Every finding on record at Cambridge Health and Rehabilitation Center

Based on observation, interviews, review of the clinical record, facility documentation, and facility policy, for 2 of 3 residents (Resident #93 and Resident #90) reviewed for abuse, the facility failed to protect residents' rights to be free from abuse and neglect. Specifically, for Resident #93, the facility failed to protect the resident from neglect when multiple nursing staff - including the supervising RN, the charge nurse, and multiple nurse aides - failed to provide or ensure timely toileting assistance despite the resident's repeated call light activations over a period of more than 2 hours, resulting in the resident experiencing a urinary and fecal incontinence accident, and causing the resident to experience significant emotional distress, including uncontrollable crying, embarrassment, sadness, and inability to eat. For Resident #90, the facility failed to protect the resident from verbal abuse when a nurse aide made a disparaging and derogatory statement to the resident during a care interaction. The facility failed to protect the resident's right to be free from verbal abuse by the Nurse aide. The findings include: 1. Resident #93's diagnoses included embolism (a broken off blood clot blocking a blood vessel) and thrombosis (blood clot) of left femoral vein, and fracture of the right femur (thigh bone). The 5-day Medicare Part A stay Minimum Data Set assessment dated [DATE] identified Resident #93 had a Brief Interview of Mental Status, score of 15, indicating intact cognition, required substantial/maximal assistance with toileting hygiene, upper and lower body dressing; and needed partial/moderate assistance with bed mobility, transfers from chair/bed to chair and experienced frequent urinary and fecal incontinence episodes. The Resident Care Plan identified that Resident #93 was a minimal/moderate assist of 2 staff members for transferring, as the second staff member would be required to maintain the resident's Toe Touch Weight Bearing (TTWB) precaution to their Right Lower Extremity (RLE), and to assist Resident #93 with donning (applying) their knee brace immobilizer (prior to transfer). An interview with Resident #93 on 5/17/26 at 10:00 AM identified on 5/16/26 during the 7:00 AM to 3:00 PM shift, he/she rang the call bell requesting assistance to have his/her knee brace placed, then to transfer to the wheelchair, and to transfer to the toilet to use the bathroom. Registered Nurse (RN #5) responded to the activated call light at approximately 7:00 AM. Resident #93 informed RN #5 of the need to use the bathroom and he responded that he would get a Nurse Aid (NA) to assist. Although several NAs had entered the room multiple times to shut off the call light stating they would get someone, none of the NA assisted him/her. Resident #93 stated that RN #5 came back to his/her room approximately 2 to 3 times to follow up but also did not assist with using the bathroom. After waiting more than 2 hours to receive assistance to use the bathroom, he/she subsequently experienced a urinary and fecal incontinent accident. RN #5 answered the call light at approximately 9:00 AM and asked if he/she had received assistance with toileting. Resident #93 informed RN #5 he/she had been waiting for staff to assist since he had initially seen come to see him/her at 7:00 AM. RN #5 proceeded to assist him/her to clean up after being incontinent of both urine and feces. While RN #5 was providing care, NA #8 entered the room stating that she was unaware she had been assigned to care for the resident. Resident #93 recounted that he/she was embarrassed, sad, and upset about being incontinent, had cried uncontrollably, and was too upset to eat lunch having very little to eat for dinner due to the emotional distress. An interview with RN #5 on 5/19/26 at 11:08 AM identified that he was the RN Supervisor on duty on 5/16/26 between 7:00 AM and 3:00 PM. He indicated Resident #93 began ringing his/her call light at the beginning of the shift, and that he answered the call bell shortly thereafter. RN #5 stated he was initially informed by the resident that he/she required assistance donning the knee immobilizer prior to transferring out of bed and then wanted to use the bathroom. He identified telling Resident #93 that he would get someone to help him/her and updated the floor nurse, (RN #6). RN #5 checked back with the resident about 2 hours later and was informed by Resident #93 that no staff had come to assist him/her since 7:00 AM, informed him that he/she had been incontinent of urine and feces due to waiting so long so RN #5 started to provide incontinence care for the resident. RN #5 indicated that the Nurse Aid (NA) #8, was assigned to Resident #93 was an agency aid but wasn't aware Resident #93 was assigned to her. He indicated he did not speak to the NA directly, nor did he follow up with the nurse (RN #6) prior to checking back with the resident to see if RN #6 informed the NA that Resident #93 required help. RN #5 also noted that it was an excessive amount of time for Resident #93 to have to wait for toileting assistance but it wasn't intentional. RN #5 also identified that everybody was responsible to answer call lights. He also indicated that he wasn't sure if RN #6 ever spoke to NA #8 to inform her that Resident #93 needed assistance, stating I don't know, I didn't follow up. An interview with RN #6 on 5/19/26 at 11:55 AM identified that she was the charge nurse on Resident #93's unit on 5/16/26 between 7:00 AM and 3:00 PM. RN #6 indicated she didn't believe that Resident #93 waited for 2 hours for assistance, the resident was overly dramatic making big deals out of small issues, and that RN #5 ended up assisting the resident because she informed RN #5 that she was dealing with a resident that was bleeding out with clots. An interview with NA #8 on 5/19/26 at 12:23 PM identified she was the NA working on Resident #93's unit on 5/16/26 during the 7:00 AM to 3:00 PM shift. NA #8 indicated that 5/16/26 was the first day she had worked in the facility, and there was only 1 nurse on the floor trying to make assignments for NAs. At the time, it was unclear who was responsible for Resident #93, but she had answered his/her call light prior to receiving her assignment and told the resident she would find out which NA was assigned to him/her and send someone to assist. NA #8 stated she informed RN #6 Resident #93 initiated the call bell and was requesting assistance. She was directed to go to another resident prior to receiving her assignment more than over an hour after she arrived at the building stating, it was so busy there that day, there was only 1 nurse, and she was helping going into rooms. After finishing with her other residents, it was 2 hours until she realized Resident #93 had been assigned to her and RN #5 was already tending to Resident #93 when she entered the resident's room. NA #8 identified Resident #93 was really sad after accidentally being incontinent that he/she was crying and stated that all they wanted was help so they could get to the bathroom. NA #8 stated she apologized profusely to Resident #93 and informed him/her that if she knew Resident #93 was on her assignment, she would have been in the room to assist him/her a lot sooner. NA #8 also identified that it was everyone's responsibility to answer call lights. An interview with the Director of Nursing (DON), and Assistant Administrator on 5/19/26 at 1:55 PM identified that neither had been notified by nursing staff about Resident #93 being left in their bed for 2 hours without staff providing assistance, resulting in the resident experiencing a urinary and fecal incontinence accident. The DON also identified that waiting for that amount of time for assistance would be considered excessive, nor was it dignified to have a resident wait that long where they experienced an incontinent accident. The DON and Assistant Administrator both indicated that the resident experienced increased distress from this incident, that they would consider this episode neglectful. A review of the facility policy for Abuse directed, in part, that neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. It further directs that staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect. 2.Resident #90's diagnoses included legal blindness, hepatic encephalopathy, and non-alcoholic cirrhosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #90 had a Brief Interview of Mental Status score of 13 indicating no cognitive impairment and required partial to moderate assistance when transferring from sitting to a standing position, was incontinent of bowel and bladder, and was at risk for developing pressure ulcers. The Resident Care Plan in effect from dated May 1, 2026, to May 17, 2026, identified that Resident #90 was legally blind and identified Resident #90 had a self-care deficit, impaired mobility, was at risk for falls, diarrhea, bowel incontinence, depression due to a decline in status and legal blindness, at risk for skin breakdown, and impaired visual function: legally blind. Interventions included supervised toileting, supervised transfers and ambulation, wearing appropriate footwear and calling for assistance with toileting, monitoring/documenting/reporting any signs or symptoms of depression, including anxiety, verbalizing, and repetitive or anxious health-related complaints and maintaining clean, dry and intact skin. (The Resident Care Plan failed to have documentation of an allegation of verbal abuse). Interview with Resident #90 on 5/17/26 at 9:23 AM, identified a concern regarding a bowel movement with incontinence he/she had at the time of a shift change. Nurse Aid (NA) #6 told the resident Blind people do more than you and he/she reported being upset about the remark. Resident #90 informed his/her family member, Person #1, of the statement indicating Person #1 lodged a complaint with the Director of Nurses (DNS). Resident #90 reported NA #6 never provided care for him/her again. Interview with Resident #90's family member, Person #1, on 5/18/26 at 11:35 AM identified he/she had spoken to the DNS to file a complaint at the time of the incident but was now unable to recall the name of the staff member who made the alleged abusive statement. A review of the facility's Reportable Event Log (used to ensure that unusual occurrences were documented and entered numerically) and Grievance Book (used to document non-abusive concerns) failed to identify that Resident #90's complaint had been written down or reported in either the log or the book. Review of Resident #90's medical record, nurses notes, social work notes from December 1, 2025, through May 2026, and the Resident Care Plan dated April and May 2026, failed to show an allegation of abuse had occurred or any interventions from the facility after the complaint was known. An interview and clinical record review with the DNS on 5/19/26 at 2:14 PM identified that the comment sounds aggressive and identified it was abusive. Although the DNS recalled the conversation with Person #1, she was unable to state why the allegation of verbal abuse did not have a Reportable Event form completed, why the incident was not submitted to the State Agency, why the incident was never investigated, why the Nurse Aid (NA #6) was not immediately suspended per the facility policy indicating I don't have a good answer for that. Subsequent to surveyor inquiry, review of a Reportable Event form dated 5/20/26, identified that the DNS reported the allegation of verbal abuse against Resident #90 to the State Agency, Department of Public Health (DPH), per the requirement, suspended NA #6 at the time of reporting per the facility policy, and began an investigation into the incident. A facility investigation was completed on 5/21/26 which unsubstantiated verbal abuse. NA #6 denied the allegation indicating Resident #90 has not been on her assignment for a few months. Corrective actions included providing the resident with emotional support via social services, and counseling NA #6 on resident rights, caring for residents with dignity and respect, and facility expectations for those employed by the facility. Review of the Abuse and Policy Procedure, Revised 12/2023 defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. The policy directs staff to be knowledgeable of the definitions listed in the abuse policy and attend mandatory in-service annually, show courtesy and respect toward residents and their families, refrain from actions considered abusive, and report violations of abuse to the facility Administrator. The Procedure for Abuse Investigation dated 12/2023 identified, in part, that when any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed or reported or suspected by any employee the following steps will be implemented including: Protect the resident from alleged abuse Report the allegation to the Administrator and Director of Nurses Immediately suspend the employee pending investigation Notify the Department of Public Health immediately but no later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily harm Interview the resident or other resident witnesses. Document, date, and sign the interview Interview the staff member implicated, have the employee document their knowledge/version of the incident in a written narrative that is dated and signed. Interview staff witnessed or other available witnesses including relevant staff on the unit; Witnesses are to document the incident in a written narrative that is dated and signed The investigation will be completed within 5 days of the incident. Reporting/Documentation Requirements directed, in part: An RMS event report must be completed immediately Documentation in the medical record is to reflect direct observable facts Update the person centered care plan with appropriate interventions. Summary included in part: The results of the in-house investigation will be assembled, and findings will be done in writing. Reporting/Documentation Requirements identified that the Administrator Director of Nursing of their designee assumes responsibility for notification of the incident and preliminary internal investigation.

Based on observations, interviews, review of the clinical record and policy review for 1 of 4 sampled residents (Resident #44) reviewed for respiratory care, the facility failed to follow infection control precautions for a resident with an unidentified respiratory illness and for 1 of 3 sampled residents, (Resident #138) reviewed for pressure ulcers, the facility failed to don (put on) Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions while providing incontinent care and for for 1 of 5 sampled residents (Resident #140) observed during medication administration, the facility failed to complete hand hygiene and wear gloves during eye drop administration. The findings include: 1. Resident #44's diagnoses included chronic obstructive pulmonary disease, congestive heart failure and anxiety disorder. A physician's order dated 5/2/26 directed to have the head of the bed elevated to prevent shortness of breath related to COPD. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 had a Brief Interview of Mental Status of 15 indicating intact cognition, and was independent for eating, upper body dressing and transferring from lying to sitting. Additionally, the MDS identified Resident #44 experienced shortness of breath when lying flat. (The MDS failed to identify Resident #44 rejected evaluation or care). Review of the APRN note dated 5/18/26 at 8:45 AM identified Resident #44 was seen for worsening cough, for which a viral panel and repeat chest x-ray were ordered. Of note the resident did have a chest x-ray showing pulmonary congestion. Previously, he/she was evaluated for cough with pulmonary edema noted on the chest x-ray dated 5/8/26. A physician's order dated 5/18/26 directed for a one-time RSV/COVID/Flu test due to cough and to initiate contact and droplet precautions for suspected unknown respiratory illness every shift for 10 days. The Resident Care Pan dated 5/19/26 identified Resident #44 had infection/respiratory symptoms. Interventions included administering antibiotics as per physician's order, follow facility policy and procedures for line listing summarizing and reporting infections and maintaining precautions when providing resident care. Observation on 5/19/26 at 7:26 AM identified a precaution cart outside of Resident #44's door, with the door open, no signage was noted outside of the room to alert staff and visitors to use Personal Protective Equipment or the type of PPE to be used. Observation and interview with Nurse Aide (NA) #2 on 5/19/26 at 7:44 AM identified she was unaware which resident required a precaution cart outside their room, or the type of precautions she should take if she entered the room. NA #2 indicated she would have to ask the nurse. Interview, observation and clinical record review with Licensed Practical Nurse (LPN) #4 on 5/19/26 7:48 AM identified she was the regular nurse on the unit, she noted that Resident #44 was on precautions but was unsure why the resident required precautions as the precautions were initiated before her shift (11:00 PM- 7:00 AM). Clinical record review identified Resident #44 presented with a cough and had a x-ray performed that showed cardiomegaly (enlarged heart) and ultimately identified a physician's order in the clinical record that stated he/she was on precautions for an unknown respiratory illness, but she could not identify what symptoms Resident #44 had presented with or what type of PPE was required prior to entering the room. Interview and observation with Resident #44 on 5/19/26 at 8:38 AM identified his/her door open, sitting in a wheelchair with baseline oxygen applied stating he/she felt good and their cough was no more than the usual. Additionally Resident #44 identified the day prior he/she felt short of breath and called for the nurse to increase his/her oxygen, which made him/her feel better. Both he/she and his/her daughter were concerned due to the x-ray and tests that were being performed, as well as being confined to his/her room. Observation and Interview with NA #3 on 5/19/26 at 8:54 AM identified her coming out of Resident #44's room, (which was open prior to her exiting) wearing a gown, gloves and mask (without the benefit of eye protection). NA #3 could not identify why Resident #44 was on precautions or what PPE she should have been wearing. Review of the Unidentified Respiratory Illness precautions signage with NA #3 identified face shields were required and there were face shields supplied in the PPE cart. NA #3 indicated that although the PPE signage directed eye protection to care for the resident and that the door should have remained closed at all times she was unable to identify why she had not followed the necessary precautions. Observation, interview and clinical record review with the Infection Prevention (IP) Registered Nurse RN #7 on 5/19/26 at 10:26 AM identified the facility policy directed to initiate precautions and perform testing if a resident was suspected of an illness due to being symptomatic; housekeeping was responsible for the precaution cart, and he was responsible for posting the signage. Observation of Resident #44's room identified the door open, a precaution cart outside the room, but without the benefit of signage identifying the type of precautions. Additionally, RN #7 identified Resident #44 was placed on precautions yesterday (5/18/26) due to being short of breath, but he could not identify if Resident #44 had other symptoms, or how staff would be alerted to the type of PPE required to care for him/her, stating signage should have been posted by him. Subsequent to surveyor inquiry RN #7 posted an Unidentified Respiratory Illness sign outside Resident #44's door. Review of the APRN progress note dated 5/19/26 at 11:30 AM identified the respiratory panel was negative, with less coughing noted. On lung auscultation, slight crackles were noted, however the resident was known to have pulmonary edema on chest x-ray. Review of the Precautions to Prevent Infections directed in part that the category of transmission-based precautions determines the type of PPE to be used. Communication (e.g. written, verbal report, signage) regarding the particular type of precaution will be utilized. It is appropriate to use the least restrictive approach possible that adequately protects the resident and others, document in the medical record the rationale for the selected transmission-based precautions. Additionally, when implementing transmission-based precautions, ensure staff have awareness of facility expectations, post clear signage on the door frame or outside the resident room indicating the type of precautions and type of required PPE. 2. Resident #138's diagnoses included hemiplegia, type 2 diabetes mellitus, and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #138 had a Brief Interview of Mental Status score of 15 indicating he/she was cognitively intact and was dependent on staff for toileting hygiene, and transfers. The Resident Care Plan dated 3/24/26 identified Resident #138 required enhanced barrier precautions related to a pressure ulcer. Interventions included to don gown and gloves when performing high contact care activities including dressing, bathing, transferring, changing linens, assisting with toileting or changing brief, care or use of indwelling medical device, and providing wound care. A physician order dated 4/19/26 for Resident #138 directed for enhanced barrier precautions and for staff to don gown and gloves when performing high contact care activities including dressing, bathing, transferring, changing linens, assisting with toileting or changing brief, care or use of indwelling medical device, and providing wound care. Review of Resident #18's care card on 5/17/26 identified he/she was on enhanced barrier precautions for a wound. Observation, interview and clinical record review with Nurse Aide (NA) #9 on 5/17/26 at 11:55 AM identified NA #9 providing incontinent care to Resident #138 without a protective gown. There was no precaution signage outside the door and no PPE supplies located in the hallway. She indicated that residents with physician orders for enhanced barrier precautions would have signage, a cart containing PPE located in the hallway next to the resident's room/door, and documentation on the Resident Care Card (NA care directive) but she had not reviewed the residents care card. NA #9 indicated that because she was used to seeing the signage and a cart located outside a room for residents with orders for precautions she had not needed to review the care card. Review of Resident #138's physician orders and care card identified the resident was on enhanced barrier precautions, and had she known she would have worn a gown during care. Interview with the Infection Preventionist (IP) Registered Nurse (RN) #7 on 5/19/26 at 7:55 AM identified that residents who were on enhanced barrier precautions should have signage and a PPE cart located outside of their room in the hallway. He stated that staff should don gloves, a gown, and eye protection for residents on enhanced barrier precautions. Although he was responsible to place signage and a PPE cart with supplies outside the resident's room, he did not explain why there was no signage or PPE for Resident #138. Interview with the Director of Nursing (DON) on 5/20/26 at 9:51 AM identified that residents who were on enhanced barrier precautions should have signage and PPE cart located outside of their room in the hallway. The DON indicated that staff were made aware of residents on enhanced barrier precautions by reviewing their physician orders, Resident Care Plan or Resident Care Card and should don gloves, a gown, and eye protection for those residents when conducting high contact care. Review of the Precautions to Prevent Infection policy revised 6/24 directed in part that enhanced barrier precautions require gown and glove use for certain residents during specific high-contact resident care activities. Residents defined as at risk are those with wounds even if the resident is not known to be infected or colonized with a multidrug-resistant organism. Example of wound is a pressure ulcer. 3. Resident #140's diagnoses included glaucoma, chronic obstructive pulmonary disease, and epilepsy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #140 was cognitively intact and required partial assistance with toileting hygiene, upper body dressing, and personal hygiene, and substantial assistance for showering/bathing, and lower body dressing. The Resident Care Plan dated 3/17/26 identified Resident #140 had impaired visual function related to glaucoma. Interventions included monitoring signs and symptoms of acute eye problems, and identifying and recording factors affecting visual function, including glaucoma, light sensitivity, and dry eyes. Physician's orders dated 5/17/25, and in effect on 5/18/26 directed to instill 1 drop of Restasis Ophthalmic drops 0.05% to each eye every 12 hours for dry eyes, and to administer saline nasal solution 0.9% 1 spray to both nostrils twice daily for nasal congestion. Observation and interview on 5/19/26 at 9:00 AM, identified Licensed Practical Nurse (LPN) #10 performed hand hygiene using an alcohol-based hand rub (ABHR) and then administered saline nasal spray to Resident #140. LPN #10 then administered Restasis Ophthalmic drops as prescribed, without the benefit of performing hand hygiene or donning gloves. LPN #10 indicated per the facility policy, she should have performed hand hygiene and donned gloves prior to administering Resident #140's eye drops. Interview with Infection Preventionist Registered Nurse (RN) #7 on 5/20/26 at 8:52 AM identified he would expect the nurse administering eye drops to perform hand hygiene and to apply gloves before administering the drops. Review of the Medication Pass policy dated 9/23/24 directed, in part, to cleanse hands before and after administration per facility policy, and that gloves must be worn when administering eye drops.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #90 and Resident #93) reviewed for abuse, the facility failed to report 2 allegations of abuse (neglect and verbal) in accordance with the requirement. The findings include: 1. Resident #90's diagnoses included legal blindness, hepatic encephalopathy, and non-alcoholic cirrhosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #90 had a Brief Interview of Mental Status score of 13 indicating no cognitive impairment and required partial to moderate assistance when transferring from sitting to a standing position, was incontinent of bowel and bladder, and was at risk for developing pressure ulcers. The Resident Care Plan in effect from dated 5/1/26, to 5/17/26, identified that Resident #90 was legally blind and identified Resident #90 had a self-care deficit, impaired mobility, was at risk for falls, diarrhea, bowel incontinence, depression due to a decline in status and legal blindness, at risk for skin breakdown, and impaired visual function: legally blind. Interventions included supervised toileting, supervised transfers and ambulation wearing appropriate footwear and calling for assistance with toileting, monitoring/documenting/ reporting any signs or symptoms of depression, including anxiety, verbalizing, and repetitive or anxious health-related complaints and maintaining clean, dry and intact skin. (The Resident Care Plan failed to have documentation of an allegation of verbal abuse). Interview with Resident #90 on 5/17/26 at 9:23 AM, identified a concern regarding a bowel movement with incontinence he/she had at the time of a shift change. Nurse Aid (NA) #6 told the resident Blind people do more than you and he/she reported being upset about the remark. Resident #90 informed his/her family member, Person #1, of the statement indicating Person #1 lodged a complaint with the Director of Nurses (DNS). Resident #90 reported NA #6 never provided care for him/her again. Interview with Resident #90's family member, Person #1, on 5/18/26 at 11:35 AM identified he/she had spoken to the DNS to file a complaint at the time of the incident but was now unable to recall the name of the staff member who made the alleged abusive statement. A review of the facility's Reportable Event Log (used to ensure that unusual occurrences were documented and entered numerically) and Grievance Book (used to document non-abusive concerns) failed to identify that Resident #90's complaint had been written down or reported in either the log or the book. Review of Resident #90's medical record, nurses notes, social work notes from December 1, 2025, through May 2026, and Resident Care Plan for April and May 2026, failed to show an allegation of abuse had occurred or any interventions from the facility after the complaint was known. An interview and clinical record review with the DNS on 5/19/26 at 2:14 PM identified that the comment sounds aggressive and identified it was abusive. Although the DNS recalled the conversation with Person #1, she was unable to state why the allegation of verbal abuse did not have a Reportable Event form completed or why the incident was not submitted to the State Agency indicating I don't have a good answer for that. Subsequent to surveyor inquiry, review of a Reportable Event form dated 5/20/26, identified that the DNS reported the allegation of verbal abuse against Resident #90 to the State Agency, Department of Public Health (DPH), per the requirement. 2. Resident #93's diagnoses included embolism (a broken off blood clot blocking a blood vessel) and thrombosis (blood clot) of left femoral vein, and fracture of the right femur (thigh bone). The 5-day Medicare Part A stay Minimum Data Set assessment dated [DATE] identified Resident #93 had a Brief Interview of Mental Status, score of 15, indicating intact cognition, required substantial/maximal assistance with toileting hygiene, upper and lower body dressing; and needed partial/moderate assistance with bed mobility, transfers from chair/bed to chair and experienced frequent urinary and fecal incontinence episodes. The Resident Care Plan identified that Resident #93 was a minimal/moderate assist of 2 staff members for transferring, as the second staff member would be required to maintain the resident's Toe Touch Weight Bearing (TTWB) precaution to their Right Lower Extremity (RLE), and to assist Resident #93 with donning (applying) their knee brace immobilizer (prior to transfer). An interview with Resident #93 on 5/17/26 at 10:00 AM identified on 5/16/26 during the 7:00 AM to 3:00 PM shift, he/she rang the call bell requesting assistance to have his/her knee brace placed, then to transfer to the wheelchair, and to transfer to the toilet to use the bathroom. Registered Nurse (RN #5) responded to the activated call light at approximately 7:00 AM. Resident #93 informed RN #5 of the need to use the bathroom and he responded that he would get a Nurse Aid (NA) to assist. Although several NAs had entered the room multiple times to shut off the call light stating they would get someone, none of the NA assisted him/her. Resident #93 stated that RN #5 came back to his/her room approximately 2 to 3 times to follow up but also did not assist with using the bathroom. After waiting more than 2 hours to receive assistance to use the bathroom, he/she subsequently experienced a urinary and fecal incontinent accident. RN #5 answered the call light at approximately 9:00 AM and asked if he/she had received assistance with toileting. Resident #93 informed RN #5 he/she had been waiting for staff to assist since he had initially seen come to see him/her at 7:00 AM. RN #5 proceeded to assist him/her to clean up after being incontinent of both urine and feces. While RN #5 was providing care, NA #8 entered the room stating that she was unaware she had been assigned to care for the resident. Resident #93 recounted that he/she was embarrassed, sad, and upset about being incontinent, had cried uncontrollably, and was too upset to eat lunch having very little to eat for dinner due to the emotional distress. An interview with RN #5 on 5/19/26 at 11:08 AM identified that he was the RN Supervisor on duty on 5/16/26 between 7:00 AM and 3:00 PM. He indicated Resident #93 began ringing his/her call light at the beginning of the shift, and that he answered the call bell shortly thereafter. RN #5 stated he was initially informed by the resident that he/she required assistance donning the knee immobilizer prior to transferring out of bed and then wanted to use the bathroom. He identified telling Resident #93 that he would get someone to help him/her and updated the floor nurse, (RN #6). RN #5 checked back with the resident about 2 hours later and was informed by Resident #93 that no staff had come to assist him/her since 7:00 AM, informed him that he/she had been incontinent of urine and feces due to waiting so long so RN #5 started to provide incontinence care for the resident. RN #5 indicated that the Nurse Aid (NA) #8, was assigned to Resident #93 was an agency aid but wasn't aware Resident #93 was assigned to her. He indicated he did not speak to the NA directly, nor did he follow up with the nurse (RN #6) prior to checking back with the resident to see if RN #6 informed the NA that Resident #93 required help. RN #5 also noted that it was an excessive amount of time for Resident #93 to have to wait for toileting assistance but it wasn't intentional. RN #5 also identified that everybody was responsible to answer call lights. He also indicated that he wasn't sure if RN #6 ever spoke to NA #8 to inform her that Resident #93 needed assistance, stating I don't know, I didn't follow up. An interview with RN #6 on 5/19/26 at 11:55 AM identified that she was the charge nurse on Resident #93's unit on 5/16/26 between 7:00 AM and 3:00 PM. RN #6 indicated she didn't believe that Resident #93 waited for 2 hours for assistance, the resident was overly dramatic making big deals out of small issues, and that RN #5 ended up assisting the resident because she informed RN #5 that she was dealing with a resident that was bleeding out with clots. An interview with NA #8 on 5/19/26 at 12:23 PM identified she was the NA working on Resident #93's unit on 5/16/26 during the 7:00 AM to 3:00 PM shift. NA #8 indicated that 5/16/26 was the first day she had worked in the facility, and there was only 1 nurse on the floor trying to make assignments for NAs. At the time, it was unclear who was responsible for Resident #93, but she had answered his/her call light prior to receiving her assignment and told the resident she would find out which NA was assigned to him/her and send someone to assist. NA #8 stated she informed RN #6 Resident #93 initiated the call bell and was requesting assistance. She was directed to go to another resident prior to receiving her assignment more than over an hour after she arrived at the building stating, it was so busy there that day, there was only 1 nurse, and she was helping going into rooms. After finishing with her other residents, it was 2 hours until she realized Resident #93 had been assigned to her and RN #5 was already tending to Resident #93 when she entered the resident's room. NA #8 identified Resident #93 was really sad after accidentally being incontinent that he/she was crying and stated that all they wanted was help so they could get to the bathroom. NA #8 stated she apologized profusely to Resident #93 and informed him/her that if she knew Resident #93 was on her assignment, she would have been in the room to assist him/her a lot sooner. NA #8 also identified that it was everyone's responsibility to answer call lights. An interview with the Director of Nursing (DON), and Assistant Administrator on 5/19/26 at 1:55 PM identified that neither had been notified by nursing staff about Resident #93 being left in their bed for 2 hours without staff providing assistance, resulting in the resident experiencing a urinary and fecal incontinence accident. The DON also identified that waiting for that amount of time for assistance would be considered excessive, nor was it dignified to have a resident wait that long where they experienced an incontinent accident. The DON and Assistant Administrator both indicated that the resident experienced increased distress from this incident, that they would consider this episode neglectful. The DON and Assistant Administrator indicated this episode should have been reported to the State Agency. Subsequent to surveyor inquiry, the facility reported the incident to the State Agency Department of Public Health on 5/19/26 at 3:23 PM. The Procedure for Abuse Investigation dated 12/2023 identified, in part, that when any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed or reported or suspected by any employee, notification to the Department of Public Health immediately but no later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily harm. Additionally, Reporting/Documentation Requirements directed.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 sampled residents (Resident # 90 and Resident #93) reviewed for allegations of abuse, the facility failed to initiate and conduct a complete and thorough investigation, failed to maintain documentation of the incident, and failed to suspend the Nurse Aid immediately after the allegations of abuse were reported per the facility policy. The findings include: 1.Resident #90's diagnoses included legal blindness, hepatic encephalopathy, and non-alcoholic cirrhosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #90 had a Brief Interview of Mental Status score of 13 indicating no cognitive impairment and required partial to moderate assistance when transferring from sitting to a standing position, was incontinent of bowel and bladder, and was at risk for developing pressure ulcers. The Resident Care Plan in effect from dated May 1, 2026, to May 17, 2026, identified that Resident #90 was legally blind and identified Resident #90 had a self-care deficit, impaired mobility, was at risk for falls, diarrhea, bowel incontinence, depression due to a decline in status and legal blindness, at risk for skin breakdown, and impaired visual function: legally blind. Interventions included supervised toileting, supervised transfers and ambulation, wearing appropriate footwear and calling for assistance with toileting, monitoring/ documenting/reporting any signs or symptoms of depression, including anxiety, verbalizing, and repetitive or anxious health-related complaints and maintaining clean, dry and intact skin. (The Resident Care Plan failed to have documentation of an allegation of verbal abuse). Interview with Resident #90 on 5/17/26 at 9:23 AM, identified a concern regarding a bowel movement with incontinence he/she had at the time of a shift change. Nurse Aid (NA) #6 told the resident Blind people do more than you and he/she reported being upset about the remark. Resident #90 informed his/her family member, Person #1, of the statement indicating Person #1 lodged a complaint with the Director of Nurses (DNS). Resident #90 reported NA #6 never provided care for him/her again. Interview with Resident #90's family member, Person #1, on 5/18/26 at 11:35 AM identified he/she had spoken to the DNS to file a complaint at the time of the incident but was now unable to recall the name of the staff member who made the alleged abusive statement. A review of the facility's Reportable Event Log (used to ensure that unusual occurrences were documented and entered numerically) and Grievance Book (used to document non-abusive concerns) failed to identify that Resident #90's complaint had been written down or reported in either the log or the book. Review of Resident #90's medical record, nurses notes, social work notes from December 1, 2025, through May 2026, and Resident Care Plan for April and May 2026, failed to show an allegation of abuse had occurred or any interventions from the facility after the complaint was known. An interview and clinical record review with the DNS on 5/19/26 at 2:14 PM identified that the comment sounds aggressive and identified it was abusive. Although the DNS recalled the conversation with Person #1, she was unable to state why the allegation of verbal abuse did not have a Reportable Event form completed, why the incident was never investigated, or why the Nurse Aid (NA #6) was not immediately suspended per the facility policy indicating I don't have a good answer for that. Review of a Reportable Event form dated 5/20/26, identified that the DNS suspended NA #6 at the time of reporting per the facility policy and began an investigation into the incident. A facility investigation was completed on 5/21/26 which unsubstantiated verbal abuse. NA #6 denied the allegation indicating Resident #90 has not been on her assignment for a few months. Corrective actions included providing the resident with emotional support via social services, and counseling NA #6 on resident rights, caring for residents with dignity and respect, and facility expectations for those employed by the facility. 2. Resident #93's diagnoses included embolism (a broken off blood clot blocking a blood vessel) and thrombosis (blood clot) of left femoral vein, and fracture of the right femur (thigh bone). The 5-day Medicare Part A stay Minimum Data Set assessment dated [DATE] identified Resident #93 had a Brief Interview of Mental Status, score of 15, indicating intact cognition, required substantial/maximal assistance with toileting hygiene, upper and lower body dressing; and needed partial/moderate assistance with bed mobility, transfers from chair/bed to chair and experienced frequent urinary and fecal incontinence episodes. The Resident Care Plan identified that Resident #93 was a minimal/moderate assist of 2 staff members for transferring, as the second staff member would be required to maintain the resident's Toe Touch Weight Bearing (TTWB) precaution to their Right Lower Extremity (RLE), and to assist Resident #93 with donning (applying) their knee brace immobilizer (prior to transfer). An interview with Resident #93 on 5/17/26 at 10:00 AM identified on 5/16/26 during the 7:00 AM to 3:00 PM shift, he/she rang the call bell requesting assistance to have his/her knee brace placed, then to transfer to the wheelchair, and to transfer to the toilet to use the bathroom. Registered Nurse (RN #5) responded to the activated call light at approximately 7:00 AM. Resident #93 informed RN #5 of the need to use the bathroom and he responded that he would get a Nurse Aid (NA) to assist. Although several NAs had entered the room multiple times to shut off the call light stating they would get someone, none of the NA assisted him/her. Resident #93 stated that RN #5 came back to his/her room approximately 2 to 3 times to follow up but also did not assist with using the bathroom. After waiting more than 2 hours to receive assistance to use the bathroom, he/she subsequently experienced a urinary and fecal incontinent accident. RN #5 answered the call light at approximately 9:00 AM and asked if he/she had received assistance with toileting. Resident #93 informed RN #5 he/she had been waiting for staff to assist since he had initially seen come to see him/her at 7:00 AM. RN #5 proceeded to assist him/her to clean up after being incontinent of both urine and feces. While RN #5 was providing care, NA #8 entered the room stating that she was unaware she had been assigned to care for the resident. Resident #93 recounted that he/she was embarrassed, sad, and upset about being incontinent, had cried uncontrollably, and was too upset to eat lunch having very little to eat for dinner due to the emotional distress. An interview with RN #5 on 5/19/26 at 11:08 AM identified that he was the RN Supervisor on duty on 5/16/26 between 7:00 AM and 3:00 PM. He indicated Resident #93 began ringing his/her call light at the beginning of the shift, and that he answered the call bell shortly thereafter. RN #5 stated he was initially informed by the resident that he/she required assistance donning the knee immobilizer prior to transferring out of bed and then wanted to use the bathroom. He identified telling Resident #93 that he would get someone to help him/her and updated the floor nurse, (RN #6). RN #5 checked back with the resident about 2 hours later and was informed by Resident #93 that no staff had come to assist him/her since 7:00 AM, informed him that he/she had been incontinent of urine and feces due to waiting so long so RN #5 started to provide incontinence care for the resident. RN #5 indicated that the Nurse Aid (NA) #8, was assigned to Resident #93 was an agency aid but wasn't aware Resident #93 was assigned to her. He indicated he did not speak to the NA directly, nor did he follow up with the nurse (RN #6) prior to checking back with the resident to see if RN #6 informed the NA that Resident #93 required help. RN #5 also noted that it was an excessive amount of time for Resident #93 to have to wait for toileting assistance but it wasn't intentional. RN #5 also identified that everybody was responsible to answer call lights. He also indicated that he wasn't sure if RN #6 ever spoke to NA #8 to inform her that Resident #93 needed assistance, stating I don't know, I didn't follow up. An interview with RN #6 on 5/19/26 at 11:55 AM identified that she was the charge nurse on Resident #93's unit on 5/16/26 between 7:00 AM and 3:00 PM. RN #6 indicated she didn't believe that Resident #93 waited for 2 hours for assistance, the resident was overly dramatic making big deals out of small issues, and that RN #5 ended up assisting the resident because she informed RN #5 that she was dealing with a resident that was bleeding out with clots. An interview with NA #8 on 5/19/26 at 12:23 PM identified she was the NA working on Resident #93's unit on 5/16/26 during the 7:00 AM to 3:00 PM shift. NA #8 indicated that 5/16/26 was the first day she had worked in the facility, and there was only 1 nurse on the floor trying to make assignments for NAs. At the time, it was unclear who was responsible for Resident #93, but she had answered his/her call light prior to receiving her assignment and told the resident she would find out which NA was assigned to him/her and send someone to assist. NA #8 stated she informed RN #6 Resident #93 initiated the call bell and was requesting assistance. She was directed to go to another resident prior to receiving her assignment more than over an hour after she arrived at the building stating, it was so busy there that day, there was only 1 nurse, and she was helping going into rooms. After finishing with her other residents, it was 2 hours until she realized Resident #93 had been assigned to her and RN #5 was already tending to Resident #93 when she entered the resident's room. NA #8 identified Resident #93 was really sad after accidentally being incontinent that he/she was crying and stated that all they wanted was help so they could get to the bathroom. NA #8 stated she apologized profusely to Resident #93 and informed him/her that if she knew Resident #93 was on her assignment, she would have been in the room to assist him/her a lot sooner. NA #8 also identified that it was everyone's responsibility to answer call lights. An interview with the Director of Nursing (DON), and Assistant Administrator on 5/19/26 at 1:55 PM identified that neither had been notified by nursing staff about Resident #93 being left in their bed for 2 hours without staff providing assistance, resulting in the resident experiencing a urinary and fecal incontinence accident. The DON also identified that waiting for that amount of time for assistance would be considered excessive, nor was it dignified to have a resident wait that long where they experienced an incontinent accident. The DON and Assistant Administrator both indicated that the resident experienced increased distress from this incident, that they would consider this episode neglectful. The DON and Assistant Administrator indicated this episode should have been investigated by the facility. Subsequent to surveyor inquiry, the facility began an investigation into the incident. Review of the Abuse and Policy Procedure, Revised 12/2023 defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. The Procedure for Abuse Investigation dated 12/2023 identified, in part, that when any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed or reported or suspected by any employee the following steps will be implemented including: Protect the resident from alleged abuse Report the allegation to the Administrator and Director of Nurses Immediately suspend the employee pending investigation Interview the resident or other resident witnesses. Document, date, and sign the interview Interview the staff member implicated, have the employee document their knowledge/version of the incident in a written narrative that is dated and signed. Interview staff witnessed or other available witnesses including relevant staff on the unit; Witnesses are to document the incident in a written narrative that is dated and signed The investigation will be completed within 5 days of the incident. Reporting/Documentation Requirements directed, in part: An RMS event report must be completed immediately Documentation in the medical record is to reflect direct observable facts Reporting/Documentation Requirements identified that the Administrator Director of Nursing of their designee assumes responsibility for notification of the incident and preliminary internal investigation.

Based on observations, review of the clinical record, facility policy and interviews for the only sampled resident (Resident #12) reviewed for activities of daily living, the facility failed to develop a comprehensive Resident Care Plan. The findings include:Resident #12 's diagnoses included rhabdomyolysis, urinary tract infection and muscle weaknessThe admission Minimum Data Set assessment dated [DATE] identified Resident #12 had a Brief Interview for Mental Status score of 8 indicating moderate cognitive impairment and required substantial maximum assistance with eating, and total assistance from staff with hygiene, dressing, toileting, bed mobility, transfer and had functional limitations in range of motion on 1 side of the upper extremities.The baseline Resident Care Plan dated 3/23/26 identified Resident #12 had a deficit in functional mobility. Interventions included ambulation with rehab only, transfer dependent on staff, bed mobility dependent on staff.The baseline Resident Care Plan dated 3/24/26 identified Resident #12 had a potential for fall with/without injury. Interventions included a physical therapy/occupational therapy evaluation and treatment as indicated.The baseline Resident Care Plan dated 3/25/26 identified Resident #12 had a deficit in self-care function. Interventions included dependent on staff for bathing/showering, dressing, eating, toileting and substantial maximum for personal hygiene.A clinical record review on 5/18/26 identified Resident Care Plans were noted to be incomplete with blanks and care areas that had been triggered on the Care Area Assessment (CAA) Summary failed to be included in any Resident Care Plan associated with the triggered care area. The admission MDS dated [DATE] was signed as completed on 4/3/26 indicating the comprehensive care plan was complete.Interview and clinical record review with RN #3 (MDS Coordinator) on 5/19/26 at 2:42 PM identified that the Resident Care Plan for Resident #12 had incomplete focus statements and triggered Care Area Assessments (CAA) failed to reflect associated care plans as indicated on the CAA summary and failed to have an explanation of why triggered CAAs were not included. Additionally, RN #3 indicated this was an oversight, the Resident Care Plan should have been completed 7 days after the completion of the MDS assessment, and the Interdisciplinary team was responsible for the completion of the Comprehensive Resident Care Plan. RN #3 further indicated that a care plan meeting was conducted on 4/9/26 and the comprehensive care plan should have been reviewed and corrected at that time.Subsequent to surveyor inquiry, on 5/19/26, the Resident Care Plan was updated to reflect Resident #12's current status and the CAAs which had triggered.A review of the Baseline/Comprehensive Person-Centered Care Plan policy revised 3/23 directed that the Comprehensive Person-Centered Care Plan will be developed after the completion of the comprehensive assessment (MDS) the Comprehensive Person-Centered Care Plan will be reviewed by an interdisciplinary team.A review of the CMS Resident Assessment Instrument 3.0 manual dated October 2023 chapter 2 page 2-43 directed, in part a final CAA(s) review and associated documentation are still required no later than the 14th calendar day of admission (admission date plus 13 calendar days). After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs.

Based on observation, interviews, review of the clinical record, and facility policy for 1 of 4 sampled residents, (Resident #131) reviewed during a dining observation, the facility failed to transcribe hospital discharge orders for a resident who was dependent on staff assistance for eating. The findings include:Resident #131's diagnoses included dysphagia, pneumonitis due to inhalation of food and vomit, and dementia.The admission Minimum Data Set assessment dated [DATE] identified Resident #131 had a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment, required setup or clean-up assistance with eating and was dependent on staff for chair/bed-to-chair transfers.A physician's order dated 5/3/26 directed a house regular diet, pureed level 4 texture, and moderately thick (honey) consistency.The Resident Care Plan dated 5/7/26 identified Resident #131 had a deficit in self-care. Interventions included partial/moderate assistance for eating/feeding with helper doing less than half the effort.Observation on 5/19/26 at 8:30 AM identified Resident #131 was in the hallway sitting across from the [NAME] Unit nurse station. Resident #131 was coughing while eating his/her pureed meal without assistance from facility staff.Review of a Hospital Summary dated 4/24/26 identified Resident #131 required 1:1 feeding assistance for all oral intakes.Review of a Nutritional Evaluation dated 4/27/26 identified Resident #131 had severe pharyngeal dysphagia and was dependent on staff for eating.Interview, observation, and clinical record review with NA #3 on 5/19/26 at 8:35 AM identified that NA's assist residents with eating if ordered by the physician and that it was the NA's responsibility to know which resident's required assistance by reviewing the Resident Care Card (directs NA care). Review of Resident #131's care card identified that the resident required partial/moderate assistance with eating/feeding. NA #3 indicated that she would observe Resident #131 while eating and assist if needed, and that since it was on the care card, that is what should have occurred.Interview and review of physician orders with Registered Nurse (RN) #1 on 5/19/26 at 8:51 AM identified that any staff can help assist a resident with eating. RN #1 indicated that any resident that required assistance with eating should have physician orders and staff can locate those orders in the Resident Care Plan or on the NA Care Card. Review of physician's orders failed to indicate that Resident #131 required staff assistance for eating.Interview with the dietitian on 5/19/26 at 9:24 AM identified that when a resident was admitted into the facility from the hospital, he would review the Hospital Summary to identify if the resident needed any assistance with eating/feeding. The dietician indicated that he would input the order directing the assistance level into the resident's clinical record and that the physician would then approve the order. The dietitian indicated that according to the Hospital Summary, Resident #131 was dependent on staff for eating due to trouble with swallowing. Although the dietitian stated that he had selected dependence on staff for eating on his Nutritional Evaluation, he was unable to explain why the order never appeared as a physician's order in the clinical record.Interview with the speech therapist on 5/19/26 at 11:30 AM identified that when a resident was admitted to the facility on hospice, they would not conduct an evaluation unless requested by the hospice provider. She indicated that they did not receive a request from hospice to evaluate Resident #131.Interview with Hospice Case Manager on 5/19/26 at 1:35 PM identified that they did not request a swallowing evaluation from the facility speech therapist. Additionally, she indicated that Resident #131 should have been assisted with eating all meals by facility staff per the Hospital Discharge Summary.Interview and clinical record review with the Director of Nursing (DON) on 5/20/26 at 9:51 AM identified that residents were evaluated by speech therapy upon admission to determine if any assistance was required for eating/feeding and that there would be orders inputted by the therapist if necessary. The DON indicated that for residents being admitted to the facility from the hospital and on hospice care, they would not be assessed by speech therapy unless requested and that they would follow the orders from the Hospital Discharge Summary which should have been reviewed by the physician. The DON reviewed Resident #131's Hospital Discharge summary dated [DATE] and could not identify why the order for 1:1 feeding assistance was not transcribed properly, but that was what the resident required.Interview and clinical record review with the Advanced Practice Registered Nurse (APRN) #1 on 5/20/26 at 10:31 AM identified that he reviewed the Hospital Discharge Summary for Resident #131 and did not identify any documentation indicating assistance was needed for eating/feeding. APRN #1 indicated that he did not know that there was a separate Hospital Summary from the hospital located in the resident's clinical record. Review of the Hospital Summary for Resident #131 dated 4/24/26 identified that Resident #131 was dependent on eating and required 1:1 feeding assistance.Subsequent to surveyor inquiry, an order for was inputted and the care card/care plan was updated for Resident #131. Review of the facilities Transcription of Orders policy, 1/24, 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. Orders can be written in the electronic health record or obtained over the phone, secured messaging system, verbally, and/or from discharge and transfer paperwork from the hospital, physician's office visit, or the consultant's recommendations.

Based on observations, review of the clinical record, facility policy, and interviews for 3 of 4 sampled residents (Resident #44, Resident #59 and Resident #91) reviewed for respiratory care, the facility failed to administer oxygen as directed per the physician's order and for Residents #44 and #59 failed to ensure oxygen tubing was changed and labeled per the facility policy. The findings include:#1.Resident #44's diagnoses included chronic obstructive pulmonary disease, congestive heart failure and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 had a Brief Interview of Mental Status of 15 indicating intact cognition, and was independent for eating, upper body dressing and transferring from lying to sitting. Additionally, the MDS identified Resident #44 experienced shortness of breath when lying flat. (The MDS failed to reflect Resident #44 rejected evaluation or care that was necessary to achieve goals for health and well-being. The Resident Care Pan in effect on 5/17/26 identified Resident #44 had a potential for altered cardiac status related to congestive heart failure, hypertension and atrial fibrillation. Interventions included oxygen as ordered and observing for/documenting potential additional symptoms of altered cardiac status such as heartburn, nausea and vomiting, excessive sweating, periorbital edema, dry cough, distended neck veins, increased heart rate, lethargy and disorientation. Physician's orders in effect on 5/17/26 directed to wean oxygen as tolerated per the cardiologist, administer oxygen at 2 Liters Per Minute (LPM) as needed for shortness of breath via nasal cannula to maintain oxygen saturations above 90%, and to change oxygen tubing every Sunday on the night shift. Observation on 5/17/26 at 7:40 AM and 5/17/26 at 11:06 AM identified Resident #44 out of bed in a wheelchair in his/her room wearing an unlabeled, undated nasal cannula tubing and was being administered oxygen at 5 liters per minute via the oxygen concentrator. An additional unlabeled, undated oxygen nasal cannula tubing was wound around the back of Resident #44's chair. Observation, interview, and clinical record review with Licensed Practical Nurse (LPN) #2 on 5/18/26 at 8:39 AM identified the facility policy directed to change oxygen tubing every other day and to follow physician's orders for oxygen, both of which were the responsibility of the charge nurse assigned to the resident. On observation LPN #2 identified Resident #44 was receiving 5 liters of oxygen per minute (physician ordered 2 LPM) and neither the oxygen tubing administering oxygen or the tubing stored around the wheelchair had the benefit of being labeled or dated. Although she could not identify the reason physician's orders were not being followed, LPN #2 stated the tubing should be labeled with the date it was changed and Resident #44 should be receiving 2 liters of oxygen per minute. LPN #2 then proceeded to exit the room without the benefit of changing the tubing, checking Resident #44's oxygen saturation (meter to indicate amount of oxygen in the blood) or changing the flow rate (which remained at 5 LPM) to reflect the physician's order. Observation, interview, clinical record review and review of facility policy with Registered Nurse Supervisor (RN) #1 on 5/18/26 at 8:56 AM identified the facility policy directed oxygen tubing to be changed and labeled weekly every Sunday night. Liter per minute flow was directed by a physician's order and the charge nurse was responsible to ensure the correct amount of oxygen was being administered. Clinical record review identified Resident #44 had a physician order to be administered 2 liters of oxygen as needed to keep oxygen saturations above 90%. Observation of Resident #44 identified the resident was receiving 5 LPM of oxygen, was not short of breath, and had a pulse oximeter (meter to indicate amount of oxygen in the blood) reading of 98%. Subsequent to surveyor inquiry RN #1 identified Resident #44 should have been receiving 2 liters of oxygen, per the physician's order and she decreased the oxygen flow rate. Resident #44 identified he/she turned the flow rate up to 5 LPM last week due to feeling short of breath. Further, Resident #44 indicated that the oxygen flow rate remained at 5 LPM since he/she turned it up last week and no staff had changed the setting back. Resident #44 identified that he/she did not call staff to assister with his/her oxygen settings because it took them too long to respond. Interview and clinical record review with APRN #1 on 5/18/2026 at 11:15 AM identified Resident #44 should have been on 2 LPM, not 5 LPM of oxygen per the physician orders. Additionally, APRN #1 stated he changed the physician's orders earlier in the day to titrate oxygen flow rate between 2 and 6 liters to keep oxygen saturation rates above 90% and adjust per comfort, which was his practice for COPD residents giving licensed staff the ability to change the oxygen administration rate. 2.Resident #59's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypoxia and obstructive sleep apnea. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had a Brief Interview of Mental Status of 14 indicating intact cognition, required partial /moderate assistance for upper and lower body dressing and supervision for toileting and transfers, and Resident #59 was on oxygen therapy. (The MDS failed to include Resident #59 rejected evaluation or care that was necessary to achieve goals for health and well-being.) The Resident Care Plan dated 5/5/26 identified Resident #59 had COPD related to a history of smoking. Interventions included changing oxygen tubing every Sunday on the night shift, keeping oxygen at 4 Liters Per Minute (LPM) continuously via nasal cannula tubing to maintain oxygen saturation rates above 92% and monitor for signs and symptoms of acute respiratory insufficiency. The physician's order in effect on 5/17/26 directed to change oxygen tubing every Sunday on the night shift and administer oxygen continuous at 4 LPM via nasal cannula to maintain oxygen saturation levels above 92% for COPD. The undated Resident Care Card (Nurse Aid care information) directed to change Resident #59's oxygen tubing every Sunday on the night shift and to keep oxygen at 4 LPM continuously via nasal cannula to maintain oxygen saturations above 92%. Observation on 5/17/26 at 6:55 AM identified Resident #59 in his/her room, up in a wheelchair without the benefit of wearing oxygen, a portable oxygen tank was noted on the back of the wheelchair with undated oxygen tubing wrapped around the back of the chair. Observation on 5/17/26 at 11:58 AM identified Resident #59 in the common dining area, up in a wheelchair without the benefit of wearing oxygen. A portable oxygen tank was noted on the back of the wheelchair with undated oxygen tubing wrapped around the back of the chair. Interview, observation and clinical record review with Licensed Practical Nurse (LPN) #2 on 5/18/26 at 8:40 AM identified the facility policy directed oxygen tubing to be changed every other day, to follow physician orders for oxygen administration, and that the resident's charge nurse was responsible for ensuring tubing was labeled and the oxygen flow rate was correct. Review of Resident #59's clinical record identified a physician order to change the oxygen tubing on Sundays, and oxygen was to be administered at 4 LPM continuously via nasal cannula tubing to keep oxygen saturations above 92%. Observation of Resident #59 with LPN #2 identified he/she was in the common dining area up in a wheelchair without the benefit of wearing oxygen, a portable oxygen tank was noted on the chair with the oxygen tubing wrapped around the back of the chair. LPN #2 identified Resident #59's oxygen saturation as 88%, stating he/she should have been on oxygen because his/her oxygen saturation was under 92%. Subsequent to surveyor inquiry LPN #2 applied Resident #59's oxygen via nasal cannula at 4 liters per minute without the benefit of obtaining new tubing. Observation on 5/19/26 at 7:29 AM identified Resident #59 in his/her room, in a wheelchair without the benefit of being administered oxygen, a portable oxygen tank was noted on the back of the wheelchair with the oxygen tubing wrapped around the back of the chair. Resident #59 denied wrapping the oxygen tubing around the back of the chair and stated he/she was unable to apply his/her own oxygen nasal cannula tubing. Interview, observation, clinical record review, and review of facility policy with Registered Nurse Supervisor (RN) #1 on 5/19/26 at 8:00 AM identified Resident #59 had physician's orders directing oxygen tubing be changed on Sundays and oxygen was to be administered at 4 LPM continuously via nasal cannula to keep oxygen saturation levels above 92%. Observation of Resident #59 identified him/her in the common dining area, up in a wheelchair without the benefit of oxygen administration, a portable oxygen tank was noted on the back of the wheelchair with the oxygen tubing wrapped around the back of the chair. RN #1 identified that Resident #59's oxygen saturation was initially 92%, when she applied the pulse oximeter (blood oxygen level monitor) which then dropped to 89%, identifying that he/she should be on oxygen. Subsequent to surveyor inquiry RN #1 proceeded to apply the nasal cannula, but Resident #59 refused the oxygen stating his/her tank was empty. RN #1 picked up the oxygen canister by the strap in order to measure the amount of oxygen. The tank level was in the red indicating 0 the oxygen canister was empty. RN #1 subsequently brought a new portable oxygen tank, and new tubing, applied the nasal cannula to Resident #59 and set the oxygen to 4 LPM, but failed to label the nasal cannula oxygen tubing. Observation and interview on 5/20/26 at 9:07 AM with Resident #59 identified him/her in a wheelchair in the common dining area without the benefit of wearing oxygen, a portable oxygen tank was noted on the back of the wheelchair as well as unlabeled oxygen tubing wrapped around the back of the chair. Resident #59 indicated that he/she had informed staff that he/she thought his/her portable oxygen tank was empty and that oxygen was required but the staff did not do anything to help. Observation with RN #1 identified Resident #59 had an initial oxygen saturation of 92%, which then dropped to 84%, leveling out between 86% and 88%. Subsequent to surveyor inquiry RN #1 applied Resident #59's tubing to administer oxygen, the tubing remained unlabeled. Interview with the Respiratory Therapist on 5/19/26 at 9:15 AM identified she followed residents on oxygen therapy and monitored them to see if they were candidates for weaning off the oxygen. She identified that residents, especially ones with preexisting respiratory illnesses such as COPD, should have the physician's orders followed to prevent respiratory distress. Review of the residents clinical record identified a physician's order to keep his/her oxygen saturation levels above 90%. Resident #59's oxygen saturations were noted in the high 90's which indicated oxygen flow might be too high. High oxygen administration levels could lead to carbon dioxide retention in residents with COPD. The Respiratory Therapist identified the resident to be on 4 LPM of continuous oxygen therapy with oxygen saturation to be above 92%. The Respiratory Therapist identified that due to the respiratory diagnoses of COPD it would be unacceptable for him/her not to wear the oxygen, especially if the saturation was below 92%. 3. Resident #91's diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and anxiety disorder. The Resident Care Plan dated 3/18/26 identified an altered respiratory status related to acute on chronic respiratory failure with hypercapnia (high carbon dioxide levels in the blood)/hypoxia (oxygen deprivation to tissue). Interventions included administering medication as ordered, monitor effectiveness and side effects, and oxygen via nasal cannula at 2 Liters Per Minute (LPM). The admission Minimum Data Set assessment dated [DATE] identified Resident #91's Brief Interview for Mental Status score was 10, indicating moderate cognitive impairment and required total assistance from staff with eating, hygiene, dressing, bed mobility and transfer, had functional limitation in range of motion on 1 side of the lower extremities and required oxygen. The Resident Care Plan dated 3/26/26 identified plan of care not followed secondary to refusal of CPAP/BIPAP, oxygen, blood sugar checks, and education was provided. Interventions included to attempt at a different time of day, approach again for re-evaluation, and social services to speak with resident to determine the cause of the refusal. A Resident Care Conference meeting note dated 4/6/26 identified Pulmonologist and Respiratory Therapist were working on decreasing nebulizer treatments which were 4 times a day. Oxygen may possibly be changed to as needed. A physician's order dated 4/13/26 directed to administer oxygen at 2 LPM continuously via nasal canula every shift for COPD, maintain oxygen saturation above 92%. A nurse's note dated 5/2/26 at 5:09 PM identified Resident #91's oxygen saturations at 91% on 2 liters of oxygen without difficulty breathing. A nurse's note dated 5/6/26 at 11:36 PM identified Resident #91 was not wearing oxygen and the oxygen saturation level was 96% on room air without respiratory distress. Observations on 5/17/26 at 2:30PM, identified Resident #91 was not wearing oxygen with no respiratory distress. Observation, interview, and review of the clinical record on 5/18/26 at 9:13 AM identified Resident #91 had a physician's order for oxygen at 2 LPM via nasal cannula, was observed without the use of oxygen, and had no respiratory distress. Resident #91 stated s/he did not need oxygen. Observation on 5/19/26 at 8:38 AM identified Resident #91 was not being administered oxygen. Interview and record review with LPN #5 on 5/19/26 at 8:38 AM identified Resident #91 refused to wear the oxygen. During an Interview with LPN #5 and Resident # 91, the resident denied s/he refused to wear oxygen. Review of the physician order for oxygen identified oxygen was to be administered continuously at 2 LPM via nasal cannula. LPN #5 stated Resident #91's oxygen saturation was 92% this morning on room air so oxygen wasn't necessary, however, the oxygen ordered for continuously should have been discontinued and changed to as needed to maintain an oxygen saturation level above 92%. Observation, clinical record review, and interview with the Respiratory Therapist (RT) on 5/19/26 at 8:48 AM identified that nursing licensed staff checked Resident #91's oxygen saturation level to ensure a level was maintained between 88 to 92%. Review of the physician order failed to identify an as needed order but directed oxygen be administered at 2 LPM continuously. The RT indicated that weaning off oxygen would have been directed in the hospital Discharge Summary. She could not remember when she started weaning Resident #91 off the oxygen. The RT stated she did not write orders but made recommendations and the nursing supervisor was responsible to bring the recommendations to the nurse practitioner to review. Subsequent to surveyor inquiry, a Physician order dated 5/19/26 directed to administer oxygen at 2 liters/minute continuously via nasal cannula as needed to maintain oxygen saturation levels between 88-92%. Review of the Oxygen Therapy Policy directed, in part, that it was the purpose of this policy to instruct how to treat hypoxemia, decrease work of breathing and decrease myocardial work in patients requiring supplemental oxygen therapy due to respiratory or cardiac insufficiency. Additionally, verify the physician's order, turn on the oxygen source and adjust the flow meter to the prescribed flow. The policy/procedure directed to verify physician's order for oxygen flow rate. Although requested, a policy for oxygen weaning was not provided.

Based on interviews, facility documentation and facility policy during a review of medication storage and labeling, the facility failed conduct bi-monthly narcotic audits per the facility policy to ensure appropriate medication reconciliation occurred. The findings include:Interview with the Assistant Director of Nursing (ADNS) on 5/20/26 at 8:30 AM identified she was responsible for performing bi-monthly narcotic audits. The facility policy directed that during bimonthly audits expiration dates, potential unusual patterns with narcotic distribution, and the accuracy of the narcotic count were reviewed. Although she was responsible, the ADNS identified she had not completed audits anytime in 2026 but should have. Interview with the Director of Nurses on 5/20/26 at 12:08 PM identified that although bi-monthly narcotic audits were not performed by the ADNS in 2026, she ensured there were no discrepancies, diversions, or issues with narcotics by matching up the blank yellow controlled substance disposition record retained and filed by nursing management on narcotic delivery with the returned white controlled substance disposition records showing signed out and completed use, or discontinuation or discharge of a resident with remaining blister pack medication.Review of the Bi-Monthly Narcotic Drug Audit Policy directed in part that medications included in the State and Federal Drug Enforcement Administration classification as Controlled Substances are subject to special handling, storage, disposal and record keeping in the nursing facility in accordance with the Federal and State laws and regulations. Additionally, the DNS or designee will monitor for compliance by completing the Narcotic Drug Audit on sampled units bi-monthly, any discrepancy will be investigated, and a corrective action plan will be implemented, copies of the audit forms will be kept for a minimum of 1 year.

Based on observations, interviews, review of the clinical record, and facility policy during the initial facility resident screening process for Resident #5 and during a review of the facility medication storage and labeling process, the facility failed to ensure medications were stored according to professional standards. The findings include: 1. Resident #5's diagnoses included end-stage renal disease, type 2 diabetes with diabetic retinopathy, and accumulation of blood in the right eye. The quarterly Minimum Data Set assessment dated [DATE] and 4/29/26 identified Resident #5 had a Brief Interview of Mental Status score of 15 indicating intact cognition and required set-up assistance for eating and oral hygiene. During the resident screening process on 5/17/26 at 8:11 AM, Resident #5 was noted in bed with the over bed table placed over the top of him/her. Two medication cups, 1 with a white tablet and the other with a pink tablet were stored on the overbed table. Interview with LPN #1 on 5/17/26 at 8:15 AM indicated she was not aware that medications were left at Resident #5's bedside. LPN #1 indicated that the medication policy directed staff to follow the 6 rights of medication administration which prohibited leaving medications at the bedside of residents who were not allowed to independently administer medications LPN #1 was unable to explain where the medications came from, but stated that she had not poured medications for Resident #5 since her shift began at 7:00 A.M. A review of the clinical record failed to identify a physician's order, a Resident Care Plan, or a medication self-administration safety screen which indicated that Resident #5 was capable of self-administering medications. Further, Resident #5 was unable to read a medication label or safely identify which medication he/she was taking and required assistance for medication administration due to visual impairment. The Clinical Services Medication Pass Policy dated 9/23/24 directs staff to observe residents until all medications are swallowed. 2. Observation and interview on 5/18/26 at 8:00 AM identified Licensed Practical Nurse (LPN) #1 walked away from her medication cart, down the hallway, and out of sight. The medication cart was unlocked, in a resident hallway, in front of a resident room, with 5 medicated patches in full view stored on top of the cart. A resident ambulated by in the hallway, and a Nurse Aid (NA) was noted to be passing out meal trays. Upon return, LPN #1 identified although the facility policy directed medication carts be locked when unattended she had not locked her medication cart when she went to get scissors, but she should have since the cart was out of sight. Observation during medication administration identified LPN #1 picked up a stack of white disposable drinking cups that had been placed upside down on the top of the medication cart. Under the cups was an unlabeled medication cup containing 4 reddish pills to be administered. LPN #1 indicated the medication was to be administered to Resident #81 and that since the mediation was covered on top of the medications cart, facility policy allowed the pills to be stored on the cart, unattended, because the medication was covered. Further, LPN #1 entered Resident #81's room, administered medication on the far side of the room behind a curtain, leaving the medication cart unlocked and the 5 medicated patches still stored, in full view, on the top of the medication cart. Continued observation of the medication pass with LPN #1 at 8:27 AM identified she next had entered Resident #44's room, leaving her medication cart out of her view. Two medicated patches and medications in a cup covered by white stacked cups remained stored on top of the medication cart. LPN #1 stated she had gone into Resident #44's room to check medication parameters, so it she was allowed to have covered medications stored on top of the medication cart. Interview with Registered Nurse (RN) #1 on 5/18/26 at 9:03 AM identified the facility policy directed medication carts be locked at all times, as soon as the nurse walked away, and that it was unacceptable to store medications on top of the medication cart, covered or uncovered, unless it was during dispensing with the nurse present. Review of the Medication Pass Policy dated 9/23/24 directed in part not to leave/store medications or resident empty containers on top of a medication cart. Additionally, medication and treatment carts are to be locked when not under direct observation.

Based on observation, interviews, review of the clinical record, and facility policy, for 1 of 2 sampled residents (Resident #59) reviewed for dental services, the facility failed to act upon a recommendation for an oral surgeon appointment. The findings include:Resident #59's diagnoses included diabetes and dysphagia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had a Brief Interview of Mental Status score of 14 indicating intact cognition and required set up assistance by staff for oral hygiene, personal hygiene, and was not experiencing dental pain or discomfort.Review of the Resident Care Plan in effect from 4/30/26 through 5/17/26 identified Resident #59 was on an antibiotic therapy due to an infection of his/her tooth. Interventions included administering the antibiotic as ordered and monitoring for adverse reactions. (The RCP failed to include any referral interventions).Interview and observation with Resident #59 on 5/17/26 at 6:45 AM identified his/her teeth on the right and left side of the mouth were painful making it challenging to eat, especially on the left side. Resident #59 exposed 1 upper left discolored molar stating although he/she received an antibiotic and had brought up mouth pain and the need for a follow up dental appointment to nursing on multiple occasions, nothing had been done to address his/her pain, and he/she had not been scheduled for a follow up. Review of the Doctor of Medicine in Dentistry (DMD) #1 note dated 4/29/26 at 6:31 PM identified Resident #59 approached this provider (dentist) today self-reporting tooth discomfort. There has been no report from nursing of issues with dental discomfort or issues with eating. Resident #59 stated his/her tooth on the upper left bothered him/her when he/she ate. A digital palpation of tooth #14 elicited verbal and non-verbal pain cues. There did not appear to be any intraoral swelling or other pathology. The tooth appeared to have suspected Class II mobility (movement) and was super erupted (extended far out from the gum line). The resident stated today he/she would like to have the tooth removed. MD #1 recommended Augmentin 875/125 milligrams (mg) twice a day for 10 days for a localized tooth infection and a referral to an oral surgeon for extraction of this tooth. A referral letter would be written and placed in the resident's miscellaneous folder of the electronic health record. The nurse, Licensed Practical Nurse (LPN) #3 was informed of the above. Further review identified a scanned referral from DMD #1 dated 4/29/26 directing a referral to an oral surgeon to remove tooth #14 (upper left molar) and that facility staff were to provide any additional information necessary for the appointment.A physician's order dated 4/30/26 written by DMD #1 directed to administer Amoxicillin-Pot Clavulanate 875-125 mg (an antibiotic), 1 tablet every 12 hours for 10 days to Resident #59. Although a physician's order for the antibiotic was written, further review of orders from 4/29/26 through 5/17/26 identified other outside vendor scheduled appointments written but failed to identify an oral surgeon referral as directed.Interview with Resident #59 on 5/18/26 at 12:50 PM identified he/she had to eat lunch on the other side (right side) of his/her mouth due to pain, and nurses still had done nothing for his/her complaints of mouth pain.Review of Resident #59's clinical record from 4/29/26 through 5/19/26 identified pain evaluations and vitals between had been signed off by nurses indicating the resident's pain level was 0 (no pain), and no pain medications had been administered, despite the resident stating he/she had complained to nursing.Review of a nurse progress dated 5/19/26 at 10:36 PM identified Resident #59 was Alert and oriented and still had gum/tooth pain. (the clinical record failed to identify any follow up for pain or notification of a supervisor or provider).Interview and clinical record review with the scheduler on 5/19/26 at 11:04 AM identified there was an inhouse dentist, DMD #1, that oversaw most residents, but any special outside dental services such as an oral surgeon for tooth extractions would be scheduled by her per the physician's orders or the nursing supervisor's directive. Review of Resident #59's clinical record indicated that DMD #1's referral letter dated 4/29/26 had been uploaded directing an oral surgeon appointment be obtained. Review of the physician's orders failed to identify a directive to schedule the appointment. Additionally, the scheduler stated since she was responsible to make outside vendor appointments, the referral for the oral surgeon appointment should have been given to her by the nursing supervisor so the appointment could have been set up. Since she had not received a referral an oral surgeon appointment was never scheduled. The scheduler indicated that she would immediately follow up on the recommendation.Interview, clinical record review and review of facility policy with Licensed Practical Nurse (LPN) #3 identified any dental recommendations be provided to the Advanced Practice Registered Nurse (APRN) for approval and then to notify the scheduler for any recommended outside appointment to be scheduled. Review of the clinical record identified that DMD #1 had verbally communicated the plan of care including the antibiotic therapy and a referral to the oral surgeon to her on 4/29/26. Although LPN #3 stated she followed up on the medications she could not explain why she had not addressed the need for Resident #59 to see an oral surgeon since 4/29/26 (20 days post DMD #1's recommendation).Re-interview with the scheduler on 5/19/26 at 11:40 AM identified she set up an appointment (23 days following the initial referral) for Resident #59 to see an oral surgeon on 5/26/26 at 10:30 AM (27 days following the initial referral and known complaints of pain) for a tooth extraction.Interview with the Director of Nurses (DNS) on 5/19/26 11:58 AM identified the policy directed consult notes to be reviewed by the nursing supervisor, who then notified the scheduler to schedule the appropriate appointments. Interview and clinical record review with the Assistant Director of Nurses (ADNS) on 5/20/26 at 8:40 AM identified she would consider a recommendation for an oral surgeon to perform a tooth extraction on a resident with an infection as a dental emergency requiring dental services. (You should have asked an acceptable time frame for referrals.) Interview and clinical record review with DMD #1 on 5/22/26 at 11:48 AM identified that she was the DMD consultant for the facility, and it was facility practice to verbally communicate any orders to the nursing staff, write a progress note, and if necessary upload a referral letter into the electronic health record so nursing staff could set up any offsite appointments. DMD #1 indicated that she would have expected that the appointment be made within 1 week of submitting the referral. Additionally, she identified that during past routine visits with Resident #59 he/she did not express any symptoms but on 4/29/26 the resident self-reported pain and expressed interest in a tooth extraction due to pain which prompted her to examine and prescribe antibiotics to the resident, and to direct a referral to an oral surgeon. DMD#1 identified she had a follow up visit with Resident #59 on 5/20/26, where he/she expressed continued discomfort with tooth #14.Review of the Dental Services Policy revised 6/23 directed in part that it was the responsibility of the facility to provide any outside resources, routine and emergency dental services to meet the needs of each resident. Additionally, in the event there is a delay in obtaining a dental appointment, the facility will document the reason for the delay and what measures were put in place to ensure that the resident can eat and drink adequately while awaiting dental services.Review of the Pain Management Policy revised 12/24 directed in part that it was the policy of this facility to monitor residents for symptoms of pain and when identified provide a detailed pain evaluation and develop a care plan to provide treatment and services to prevent, minimize and alleviate pain. Additionally, the overall goals of care of the resident with pain are prompt evaluation and diagnosis of pain.

Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #155) reviewed for smoking, the facility failed to ensure the Nursing Re/admission evaluation was completed and signed by an Registered Nurse, failed to develop a Resident Care Plan and failed to offer smoking cessation support in accordance with the facility's policy. The findings include:Resident #155's diagnoses included radiculopathy in the lumbosacral region (nerve compression in the lower back), bipolar disorder, and asthma.The Nursing Admission/readmission Evaluation dated 5/13/26 identified Resident was alert and oriented to person, place, time, and situation, and lifestyle evaluation identified positive tobacco use, however the amount, frequency, and length of time for tobacco use was left blank. Social Worker (SW) #1's evaluation dated 5/13/26 identified Resident #155 was a smoker and that a Resident Care Plan for smoking was in place.The Resident Care Plan dated 5/13/26 through 5/18/26 failed to identify that Resident #155 currently used tobacco or was offered or used options for smoking cessation.A physician orders dated 5/13/26 through 5/18/26 failed to identify smoking cessation options were in place.Observation on 5/18/26 at 1:10 PM identified Resident #155 outside the front entrance of the facility, alone and unsupervised, smoking a cigarette. The Social Worker and Director of Nurses were immediately notified.An interview with Resident #155 on 5/18/26 at 1:25 PM identified that he/she was informed on admission that the facility was non-smoking but that he/she thought it was okay to smoke outside. Resident #155 stated smoking was discussed on admission with a facility staff member who indicated he/she would receive a nicotine patch; however, he/she could not recall which staff member had indicated this to him/her and a nicotine patch was never offered. The resident went on to state he/she obtained one cigarette while out of the facility on an appointment on 5/18/26 and did not have any other cigarettes in his/her possession. Resident #155 indicated consent for a room search by staff and a staff member was holding his/her cigarette lighter until discharge.An interview with LPN #3 on 5/19/26 at 11:45 AM identified that she completed Resident #155's Nursing Admission/readmission Evaluation on 5/13/26, and that tobacco use was identified on the evaluation. LPN #3 stated the follow-up questions regarding tobacco use were not completed because LPN #3 did not believe Resident #155 was currently smoking and therefore did not feel she needed to offer a smoking cessation option. LPN #3 indicated that she had not discussed the use of a nicotine patch with the Advanced Practice Registered Nurse (APRN) or physician. Although LPN #3 did not recall the facility policy, she stated that a current smoker in a non-smoking facility should include notification of the APRN or physician for further instruction and the implementation of a Resident Care Plan, however, she had not believed Resident #155 currently smoked. An interview and review of the clinical record with the Assistant Director of Nursing (ADON) on 5/19/26 at 12:05 PM identified that since the Nursing Admission/readmission Evaluation had been completed by LPN #3 an RN needed to review the evaluation after completion on admission according to facility policy but they had not. She indicated that since it had not been signed by an RN on admission, she had signed it as an RN on 5/18/26 (5 days late). The ADON stated that a notation of positive tobacco use would mean the Resident was a current smoker and the facility should have addressed the tobacco use when Resident #155 indicated he/she smoked. Although smoking was indicated according to the assessment, the ADON was unable to locate documentation in the resident record to identify that the smoking policy or smoking cessation options had been discussed with Resident #155 or with the APRN or MD. Additionally, the ADON indicated that a Resident Care Plan should have been put in place due to Resident #155's assessment on admission, according to the facility policy.An interview with DON on 5/19/26 at 12:45 PM identified that their expectation for an RN to sign off on the Nursing Admission/readmission evaluation would be within 24 hours and that it should have been signed off by an RN supervisor or RN nurse manager on duty. The DON stated that when a yes notation for tobacco is documented on the evaluation, that the nurse completing the evaluation should have completed the follow-up questions including amount, frequency and length of time for tobacco use. She indicated that alternative interventions to smoking should have been discussed with the APRN and the resident should have been assessed for smoking. Additionally, the DON indicated that a Resident Care Plan should have been developed on admission and Resident #155 should have been educated on the no-smoking policy.An interview and review of the clinical record with SW #1 on 5/19/26 at 2:56 PM identified that she met with Resident #155 on admission and that tobacco use was discussed, however, she did not think smoking was an issue as Resident #155 told her that he/she hadn't smoked in the hospital. SW #1 also stated she thought a Resident Care Plan for smoking was put in place on 5/13/26, however on medical record review, she was unable to identify a Resident Care Plan for smoking had been initiated. Subsequent to surveyor inquiry, a Resident Care Plan was placed in the Resident #155's medical and orders were obtained for nicotine patch for smoking cessation. A review of facility's Safe Smoking (Resident) Policies and Procedures revised 5/23 identified, in part, that new admissions would be informed of the facility policy to prohibit smoking and would be offered cessation support. In addition, the procedure included completion of a smoking evaluation on admission for all residents who smoke, and for a smoking care plan to be added to the resident's clinical record.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure wound care orders were accurately transcribed and failed to provide wound care treatments to the resident's right hand in accordance with physician orders. The findings include: Resident #2 had a diagnosis of surgical amputation of the right index finger, end stage renal disease, and type 2 diabetes. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a BIMS of 15 indicating intact cognition, and had venous and arterial ulcers. The Resident Care Plan (RCP) dated 7/22/2025 identified a self-care deficit and a surgical amputation of the right index finger. Interventions directed to provide treatments as ordered. Orthopedic provider note dated 8/21/2025 at 12:46 PM identified Resident #2 was seen for a follow up visit due to cellulitis of the right index finger and underwent a right-hand disarticulation (separate bones at the joints) of the right index finger and an amputation on 8/6/2025. The note directed a wet to dry dressing to be changed daily at the facility. Physician order dated 8/21/2025 directed a wet to dry dressing to be changed daily to the right middle finger, and the order was entered into the EMR to change every shift for surgical wound until further notice from surgeon. Interview and record review with RN #4 (Wound Nurse) on 9/22/2025 at 10:31 AM identified Resident #2's orders were not transcribed correctly following his/her appointment with the orthopedic physician on 8/21/2025. The dressing was ordered to be changed daily, and the order was entered into the electronic medical record (EMR) to change it every shift in error. Interview identified although RN #4 stated she conferred with the nurse to put the order in (the EMR) the interview failed to identify if RN #4 should have checked to make sure her revision matched the physician orders. a. Orthopedic provider note dated 9/4/2025 at 12:55 PM directed soapy water soaks for 20 minutes before reapplying saline wet to dry dressing to the right hand wound site. Physician order dated 9/5/2025 directed a wet to dry dressing to be changed daily to the right middle finger every day shift for surgical until further notice from surgeon. Record review failed to identify an order was entered in the EMR to provide soapy water soaks for 20 minutes before applying the saline wet to dry dressing. Interview and record review with RN #4 (Wound Nurse) on 9/22/2025 at 10:31 AM identified the physician orders following her/his orthopedic office visit on 9/4/2025 were not transcribed correctly - they omitted the soapy water soaks for 20 minutes prior to applying the new dressing. RN #4 indicated she revised the order on 9/7/2025 to make it clearer for staff but she did not check to ensure her revision matched the physician recommendations following the resident's orthopedic office visit on 9/4/2025. Interview identified although RN #4 stated she conferred with the nurse to put the order in (the EMR) the interview failed to identify if RN #4 should have checked to make sure her revision matched the physician orders. b. Physician order dated 8/21/2025 directed a wet to dry dressing to be changed daily to right middle finger every shift for surgical until further notice from surgeon. Orthopedic provider note dated 9/4/2025 at 12:55 PM identified Resident #2 was being seen post operation for his/her right index finger. Upon physical exam, the dressing was removed, and the dressings were dated 8/31/2025 (4 days prior to the office visit). Facility incident report dated 9/4/2025 at 7:51 PM identified the facility met with Resident #2 and family regarding a concern that treatments were not completed timely. LPN #2 facility statement dated 9/5/2025 identified LPN #2 signed the Treatment Administration Record (TAR) for Resident #2 on 9/2/2025 during the 11 PM to 7 AM shift when she was not the nurse assigned to Resident #2. The statement indicated LPN #2 did not know why she signed on the TAR to indicate the resident's treatment was completed. LPN #4 facility statement dated 9/5/2025 identified she did not complete the dressing change on 9/3/2025 on the 3 PM to 11 PM shift because Resident #2 refused, but she forgot to document the resident refusal. LPN #3 facility statement dated 9/8/2025 identified she had Resident #2 on her assignment on 9/2/2025 during the 11 PM to 7 AM shift, and she did not provide the treatment to Resident #2's right middle finger because it did not come up on the TAR for her to do. Further, LPN #3 identified she did not complete the treatment on 9/3/2025 during the 7 AM to 3 PM shift because the resident was out of the facility at a medical appointment (unrelated). Review of the TAR and medical record for the month of September identified the right index finger dressing was not completed on 9/3/2025 during the 7 AM to 3 PM shift, and was not accurately documented on 9/2/2025, and on 9/3/2025 during the 3 PM to the 11 PM shift. Review of the facility Incident Summary dated 9/11/2025, Electronic Medical Record (EMR), the TAR, and interviews, identified the order was initially written correctly for the daily treatment to her/his right index finger. However, the order was entered into the electronic TAR as scheduled to complete the treatment every shift instead of daily, leading to Resident #2 refusing some of the treatments on 11-7. It was also noted there were dialysis days the treatment was not completed on the 7am to 3pm shift as she/he was not in the facility. c. Record review identified Resident #2 was transferred to the hospital for evaluation on 9/18/2025 at 12:50 PM for an unrelated issue. Hospital emergency department note dated 9/18/2025 at 3:37 PM identified Resident #2 would be discharged back to the facility. Hospital Discharge summary dated [DATE] review identified wound care directions for the right index finger were as follows: Cleanse right hand with normal saline. Primary dressing: Baci, xeroform, calcium alginate ABD secondary dressing and rolled gauze netting to be changed three (3) times a week - two (2) times at the facility and once a week at the wound care center. Nursing note dated 9/19/2025 at 12:41 AM identified Resident #2 returned to the facility at 5:03 PM. Record review failed to identify the right index finger wound care orders from the hospital were transcribed into the medical record and failed to identify the wound care was provided in accordance with the hospital physician orders. Interview and record review with RN #4 on 9/22/2025 at 12:55 PM identified Resident #2 went to the hospital on 9/18/2025 and returned on 9/19/2025 around 5 PM but when the resident came back her/his orders were not transcribed into the EMR. RN #4 stated Resident #2 was receiving the prior treatment, not the new orders from the hospital. RN #4 stated she did not know why they were not transcribed but indicated they should have been transcribed. Subsequent to surveyor inquiry (on 9/22/2025) wound care instructions following the residents visit to the emergency department on 9/18/2025 were transcribed accurately into the medical record. Interview and record review with the Director of Nursing (DNS), Administrator, and RN #2 on 9/18/2025 at 2:45 PM identified Resident #2's wound care orders were not transcribed correctly into the EMR following new orders obtained on 8/21/2025, 9/4/2025 and 9/18/2025. Interview failed to identify why the orders were not transcribed correctly. Further, the interview identified staff should sign the TAR when they perform the treatment; the TAR should not be signed if the treatment is not performed, and should be signed by the nurse assigned. Review of facility Transcription of Orders Policy dated January of 2024, directed in part, orders from an authorized licensed independent practitioner are accepted by a Registered Nurse. Orders can be written in the electronic health record, obtained over the phone, verbally, from discharge or transfer paperwork from the hospital, physician office visits, or consultant's recommendations. Review of facility Medication Error Policy dated May of 2023 directed a medication error is a discrepancy between what the healthcare provider ordered and what the resident received.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for neglect, the facility failed to ensure the medical record was complete and accurate to include accurate documentation of wound care provided. The findings include:Resident #2 had a diagnosis of surgical amputation of the right index finger, end stage renal disease, and type 2 diabetes. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a BIMS of 15 indicating intact cognition, and had venous and arterial ulcers. The Resident Care Plan (RCP) dated 7/22/2025 identified a self-care deficit and a surgical amputation of the right index finger. Interventions directed to provide treatments as ordered. Physician order dated 8/21/2025 directed a wet to dry dressing to be changed daily to right middle finger every shift for surgical until further notice from surgeon. Facility incident report dated 9/4/2025 at 7:51 PM identified the facility met with Resident #2 and family regarding a concern that treatments were not completed timely. LPN #2 facility statement dated 9/5/2025 identified LPN #2 signed the Treatment Administration Record (TAR) for Resident #2 on 9/2/2025 during the 11 PM to 7 AM shift when she was not the nurse assigned to Resident #2. The statement indicated LPN #2 did not know why she signed on the TAR to indicate the resident's treatment was completed. LPN #4 facility statement dated 9/5/2025 identified she did not complete the dressing change on 9/3/2025 on the 3 PM to 11 PM shift because Resident #2 refused, but she forgot to document the resident refusal. LPN #3 facility statement dated 9/8/2025 identified she had Resident #2 on her assignment on 9/2/2025 during the 11 PM to 7 AM shift, and she did not provide the treatment to Resident #2's right middle finger because it did not come up on the TAR for her to do. Further, LPN #3 identified she did not complete the treatment on 9/3/2025 during the 7 AM to 3 PM shift because the resident was out of the facility at a medical appointment (unrelated). Review of the Medication Administration Record (MAR) and medical record for the month of September identified the TAR was signed to indicate the treatment was completed on 9/2/2025 during the 11 PM to 7 AM shift. Further review failed to identify the residents dressing was changed on 9/3/2025 on the 7am to 3pm shift and further record review identified the residents dressing was changed on 9/3/2025 on the 3pm to 11pm shift. Review of the facility Incident Summary dated 9/11/2025, Electronic Medical Record (EMR) TAR, and interviews, identified the order was initially written correctly for the daily treatment to her/his right index finger. However, the order was entered into the electronic TAR as scheduled to complete the treatment every shift instead of daily, leading to Resident #2 refusing some of the treatments on 11-7. It was also noted there were dialysis days the treatment was not completed on the 7am to 3pm shift as she/he was not in the facility. Interview and record review with the Director of Nursing (DNS), Administrator, and RN#2 on 9/18/2025 at 2:45 PM identified LPN #2 and LPN #3 did not complete Resident #2's right finger treatment on 9/2/2025. Further, LPN #2 was not assigned to Resident #2 and should not have signed the TAR to indicate she had completed the treatment when she did not perform the dressing change. Interview failed to identify why LPN #2 signed the TAR. LPN #3 failed to sign the TAR or write a nursing note to indicate why she did not perform the scheduled dressing change. LPN #4 signed the TAR to indicate she had performed the dressing change on 9/3/2025 when she did not complete the treatment. Interview failed to identify why LPN #4 signed the TAR. Further, the interview identified staff should sign the TAR when they perform the treatment; the TAR should not be signed if the treatment is not performed, and should be signed by the nurse assigned. Review of Charting and Documentation Policy January of 2025 directed staff that documentation shall be accurate, relevant, and complete, containing sufficient details about the patients care or responses to care.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #4), reviewed for behaviors, the facility failed to ensure the physician/designee was notified timely when an antipsychotic medication was not available for administration as ordered. The findings include: Resident #4 was admitted with diagnoses that included schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behaviors), morbid obesity, and pain. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #4 had mildly impaired cognition (BIMS of 9) and had no behaviors during the prior seven (7) days. A resident care plan dated 8/20/2024 identified Resident #4 had behaviors that included negative thoughts, and refusal of care that required mood stabilizers/anti-psychotics. Interventions directed to reapproach as needed, speak calmly, and to administer medications as ordered. A physician's order dated 10/14/2024 directed Abilify (antipsychotic medication used to treat schizophrenia) 400 milligrams (mgs) injected intramuscularly (IM) one time a day every month on the first day of the month for schizophrenia. Review of manufacturer information identified Abilify Injection was directed to be stored in the refrigerator between 36 and 46 degrees Fahrenheit. A facility reportable event (RE) form dated 11/6/2024 at 8:15 AM identified Resident #4 attempted self-harm by wrapping his/her hands around his/her neck and applying pressure. Staff redirected and calmed Resident #4, and Resident #4 was placed on one-to-one (1:1) observation until he/she was transferred to the hospital. A hospital psychiatry note dated 11/7/2024 identified a call was placed to the facility and RN #2/evening supervisor verified Resident #3's Abilify was on hold for November and the resident had not received it when scheduled on 11/1/2024. Interview with LPN #1/charge nurse on 1/14/2025 at 12:00 PM identified Resident #4 was scheduled to receive Abilify 400 mgs IM on 11/1/2024 at 8 AM and she was unable to locate the medication. LPN #1 spoke with the pharmacy and was informed it was delivered. LPN #1 notified the supervisor, RN #1 and RN #1 suggested LPN re-check the refrigerator and re-check the unit. LPN #1 then signed the Medication Administration Record (MAR) to identify the medication was unavailable, and she wrote a nursing note to identify the same. LPN #1 stated she did not call RN #1 again to say she could not locate the medication, and she did not notify the APRN. LPN #1 stated she was not aware she should have notified the APRN as she had notified RN #1, and she passed the information to the next shift nurse/LPN #4 during shift report. Interview with the psychiatric APRN (APRN #2) on 1/14/2025 at 11:08 AM identified she was unaware that Resident #4 had not received the 11/1/2024 scheduled monthly dose of Abilify. APRN #2 stated she or the medical APRN (APRN #1) should have been notified the Abilify does was missed, and she would have established an alternate plan. APRN #2 stated Resident #4 had an infection identified at the hospital, and the missed Abilify dose may or may not have contributed to Resident #4's behaviors. Interview with APRN #1 on 1/14/2025 at 11:22 PM identified although she could not recall being notified of Resident #4's missed dose of Abilify on 11/1/2024, if she was notified, she would have contacted APRN #2 or the covering psychiatric service provider and she would have documented in the medical record. APRN #1 stated she would have ordered the Abilify to be given on another day and time. Further, APRN #1 was unable to identify any documentation in the clinical record to indicate she was notified of the missed dose. Interview with RN #1 on 1/14/2025 at 12:50 PM identified she was the supervisor on 11/1/2024 and stated she was notified by LPN #1 that she could not find Resident #4's 8:00 AM dose of Abilify. RN #1 stated she directed LPN #1 to recheck the medication cart and to look in the refrigerator. When LPN #1 did not call her back, she thought LPN #1 must have found the medication and administered it to Resident #4 as scheduled. RN #1 stated she did not follow up with LPN #1 again regarding the medication and she was unaware it was not given. RN #1 stated she did not know why LPN #1 did not contact her again, or contact the APRN when the dose was missed. Interview with LPN #4 on 1/14/2025 at 1:06 PM identified she was assigned Resident #4 on 11/1/2024 on the 3 to 11 PM shift and she could not recall that LPN #1 had reported Resident #4 did not receive his/her scheduled 8:00 AM dose of Abilify. LPN #4 stated if she was aware, she would have contacted the pharmacy to check to see if had been delivered. She would then have notified the supervisor and the APRN. Interview with the acting DON on 1/14/2025 at 1:30 PM identified that she would have expected LPN #1 to notify the supervisor and the APRN that she was unable to provide Resident #4's Abilify as scheduled, and she did not know why LPN #1 did not. The DON stated LPN #1 was re-educated that she needed to administer medications as prescribed and if she could not, that the supervisor and APRN needed to be notified. The facility policy Change in Condition dated 4/2023 directed in part, that the facility must consult with the resident's healthcare provider when there is a need to alter treatment. Facility documentation review identified staff education was initiated on 11/6/2024 regarding licensed nurses to administer medications as prescribed and to update the MD/APRN if medication is missing or omitted. A QAPI meeting was held on 11/6/2024 and audits were initiated on 11/15/2024. Based on review of facility documentation, past non-compliance was identified with a correction date of 11/15/2024.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #4), reviewed for behaviors, the facility failed to ensure an antipsychotic medication was administered in accordance with a physician order, and for one of four residents (Resident #2) reviewed for a change in condition, the facility failed to ensure oxygen was administered in accordance with physician orders and failed to ensure an assessment was completed timely for a resident with an identified change in condition. The findings include: a. Resident #4 was admitted with diagnoses that included schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behaviors), morbid obesity, and pain. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #4 had mildly impaired cognition (BIMS of 9) and had no behaviors during the prior seven (7) days. A resident care plan dated 8/20/2024 identified Resident #4 had behaviors that included negative thoughts, and refusal of care that required mood stabilizers/anti-psychotics. Interventions directed to reapproach as needed, speak calmly, and to administer medications as ordered. A physician order dated 10/14/2024 directed Abilify (antipsychotic medication used to treat schizophrenia) 400 milligrams (mgs) injected intramuscularly (IM) one time a day every month on the first day of the month for schizophrenia. A facility reportable event (RE) form dated 11/6/2024 at 8:15 AM identified Resident #4 attempted self-harm by wrapping his/her hands around his/her neck and applying pressure. Staff redirected and calmed Resident #4, and Resident #4 was placed on one-to-one (1:1) observation until he/she was transferred to the hospital. A hospital psychiatry note dated 11/7/2024 identified a call was placed to the facility and RN #2/evening supervisor verified Resident #3's Abilify was on hold for November and the resident had not received it when scheduled on 11/1/2024. Record review identified the Medication Administration Record (MAR) directed Abilify 400 mgs IM was due to be administered on 11/1/2024 at 8 AM. Further review identified the MAR included a code that indicated the medication was not administered. Record review failed to identify a new physician order for administration of the Abilify on a different date or time for November 2024 prior to transfer to the hospital on [DATE]. Interview with LPN #1/charge nurse on 1/14/2025 at 12:00 PM identified Resident #4 was scheduled to receive Abilify 400 mgs IM on 11/1/2024 at 8 AM and she was unable to locate the medication. LPN #1 spoke with the pharmacy and was informed it was delivered. LPN #1 notified the supervisor, RN #1 and RN #1 suggested LPN re-check the refrigerator and re-check the unit. LPN #1 then signed the Medication Administration Record (MAR) to identify the medication was unavailable, and she wrote a nursing note to identify the same. LPN #1 stated she did not call RN #1 again to say she could not locate the medication, and she did not notify the APRN. LPN #1 stated she was not aware she should have notified the APRN as she had notified RN #1, and she passed the information to the next shift nurse/LPN #4 during shift report. Interview with RN #1 on 1/14/2025 at 12:50 PM identified she was the supervisor on 11/1/2024 and stated she was notified by LPN #1 that she could not find Resident #4's 8:00 AM dose of Abilify. RN #1 stated she directed LPN #1 to recheck the medication cart and to look in the refrigerator. When LPN #1 did not call her back, she thought LPN #1 must have found the medication and administered it to Resident #4 as scheduled. RN #1 stated she did not follow up with LPN #1 again regarding the medication and she was unaware it was not given. RN #1 stated she did not know why LPN #1 did not contact her again or contact the APRN when the dose was missed. Interview with LPN #4 on 1/14/2025 at 1:06 PM identified she was assigned Resident #4 on 11/1/2024 on the 3 to 11 PM shift and she could not recall that LPN #1 had reported Resident #4 did not receive his/her scheduled 8:00 AM dose of Abilify. LPN #4 stated if she was aware, she would have contacted the pharmacy to check to see if had been delivered and notified the supervisor and APRN. Interview with the acting DON on 1/14/2025 at 1:30 PM identified that she would have expected LPN #1 to administer Resident #4's Abilify on 11/1/2024 at 8 AM as ordered. The DON stated if LPN #1 could not locate the medication she should have notified the supervisor or APRN. Medication Pass Policy dated 9/23/2024 directed in part, to administer medications per the physician's orders. Facility documentation review identified staff education was initiated on 11/6/2024 regarding licensed nurses to administer medications as prescribed and to update the MD/APRN if medication is missing or omitted. A QAPI meeting was held on 11/6/2024 and audits were initiated on 11/15/2024. Based on review of facility documentation, past non-compliance was identified with a correction date of 11/15/2024. b. Resident #2 had a diagnosis of chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] identified the Resident had a Brief Interview for Mental Status (BIMS) score of 14 (indicating alert and oriented), had a diagnosis of COPD and respiratory failure, and required oxygen use. The Resident Care Plan dated 12/5/2024 identified COPD, and respiratory failure. Interventions directed to monitor for difficulty breathing, shortness of breath at rest, and provide oxygen via nasal cannula per physician orders. Physician order dated 12/30/2024 directed oxygen at five (5) liters to keep oxygen saturation level above 90 percent. Nursing note dated 12/31/2024 at 12:30 PM, written by LPN #3, identified Resident #2 was on five (5) liters oxygen via nasal canula and complained of shortness of breath. The APRN gave new orders for oxygen at ten (10) liters via a non-rebreather (mask). Resident #2 continued to state he/she cannot breathe, and orders were obtained to transfer Resident #2 to the hospital. Record review failed to identify an RN assessment was completed when Resident #2 complained of shortness of breath. Emergency Medical Services (EMS) run sheet dated 12/31/2024 identified EMS was notified at 1:18 PM and at the resident at 1:30 PM. On EMS arrival, it appeared the oxygen tank was empty and that the resident had not been receiving oxygen. The resident blood oxygen level was 86 percent (normal 90% and above) on room air, resident anxious and breathing rate of 32 (normal 16 to 20). Placed on a non-rebreather mask and voiced ease of breathing with application. Hospital note dated 12/31/2024 at 2:54 PM identified Resident #2 was seen for COPD exacerbation, with recent Influenza A exposure and low blood oxygen levels, currently at 85% on five (5) liters of oxygen. Hospital documentation dated 12/31/2024 at 8:02 PM identified Resident #2 was admitted for acute on chronic respiratory failure secondary to COPD exacerbation triggered by influenza. Interview and record review with LPN #3 on 1/13/2025 at 11:10 AM identified she was the charge nurse during the 7 AM to 3 PM shift on 12/31/2024, and Resident #2 stated he/she was short of breath with a pulse ox (blood oxygen level) 80's on five (5) liters of oxygen. LPN #3 stated during the shift, at an unidentified time, the supervisor/RN #3 raised the head of bed upright and the resident's oxygen saturation increased to 92 percent. The APRN was notified Resident #2 continued to complain of shortness of breath and directed ten (10) liters of oxygen via a non-rebreather mask. LPN #3 stated she changed the oxygen from an oxygen concentrator to a full portable cylinder oxygen tank at around 11 AM because the concentrator could not provide ten (10) liters. Resident #2 continued to complain of shortness of breath afterwards and was transferred to the hospital. LPN #3 stated she replaced the first full portable cylinder oxygen tank with another full portable cylinder oxygen tank at an unidentified time because the first tank was empty. LPN #3 stated she did not check the oxygen level in the second tank afterwards, and then when EMS arrived, they said the portable tank was empty. LPN #3 stated she did not check the oxygen level in the tank because the bag attached to the oxygen mask was inflated. LPN #3 stated she never rechecked the second tank to ensure it still had oxygen in it, and she should have. When Resident #2 was complaining of shortness of breath she did not verify the tank had oxygen left in it, and she should have checked the tank to ensure it was not empty or running low. Interview with Oxygen Representative #1 from the facility oxygen supplier on 1/13/2025 at 12:04 PM identified they supply the facility with size E tanks for oxygen use. Oxygen Representative #1 stated a size E tank would last less than one (1) hour if the oxygen was running at ten (10) liters. Interview and observation with LPN #3 on 1/13/2025 at 1:28 PM identified the full portable cylinder oxygen tank was a size E tank. Interviews identified the first oxygen tank was placed at approximately 11 AM, and per the oxygen company the tank would last less than one (1) hour. EMS run sheet dated 12/31/2024 identified they were called at 1:18 PM (2 hours and 18 minutes after the first oxygen tank was started). Interview with RN #3 on 1/13/2025 at 12:33 PM identified she was the supervisor on 12/31/2024 during the 7 AM to 3 PM shift and was notified about 10 AM that Resident #2 was short of breath. RN #3 stated she assessed the resident, and his/her pulse ox was 88% on an oxygen concentrator set at five (5) liters, and she raised the head of the bed which increased the pulse ox to 92 to 94%. RN #3 stated although she was aware Resident #2 was placed on an oxygen mask, she did not assess the resident again because she did not know the resident was on a non-rebreather at ten (10) liters of oxygen and that LPN #3 had placed the resident on a portable oxygen tank; she stated LPN #3 did not notify her and she did not return to reassess Resident #2's respiratory status prior to Resident #2's transfer to the hospital. Interview failed to identify why RN #3 did not return to reassess Resident #2's respiratory status. Interview with the DNS and Administrator on 1/13/2025 at 2:15 PM identified Resident #2 was on ten (10) liters of oxygen and when EMS arrived, they stated the oxygen tank was empty. LPN #3 stated she just went in the resident's room to check the oxygen tank before EMS arrived, and had switched the first oxygen tank out with a second oxygen tank around 11:30 AM to 12 PM. The DNS indicated LPN #3 should have monitored the oxygen level in the tank; LPN #3 should have checked the oxygen gauge every 30 to 45-minutes to make sure the oxygen tank was not running low or empty. The DNS further indicated an RN assessment should have done after the resident was placed on ten (10) liters of oxygen via a non-rebreather mask, and she did not know why this was not completed. Facility undated Portable Oxygen Cylinder Policy directed in part, for staff to look at the pressure gauge to determine how much oxygen is in the cylinder. Facility Change in Condition Policy dated April 2023 directed in part, for a resident with a change of condition, the licensed nurse, per state regulations, conducts a complete physical/mental evaluation and documents findings in the medical record. Facility documentation review identified although education was initiated on 1/3/2025 and included use of oxygen tanks and checking to ensure the oxygen supply levels, audits and a QAPI meeting were not completed and no past non-compliance was identified.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of four (4) residents (Resident #4) reviewed for abuse, the facility failed to ensure two staff provided care for a resident with accusatory behaviors in accordance with the plan of care. The findings include: Resident #4 had diagnoses that included anxiety, hypertension, persistent mood disorder, muscle weakness, and depression. The care plan dated 9/15/2023 identified Resident #4 as a potential victim of an allegation of abuse with interventions directed assist of two (2) for all care due to accusatory behaviors. The annual MDS dated [DATE] identified Resident #4 had intact cognition, was always incontinent of bowels, frequently incontinent of bladder, and required extensive assistance with ADLs. A facility accident and incident report dated 10/1/24 at 1:10 P.M. identified Resident #4 stated that NA #2 pokes h/her in the leg and back and when Resident #4 tells NA #2 it hurts NA #2 doesn't apologize. Review of the facility's summary report dated 10/3/24 identified upon further interview Resident #4 stated NA #2 is not abusive, but when she touches me, it feels like she is poking me. Resident #4 has accusatory behaviors, is care planned, and requires 2 persons at all times for care. The nurse's note dated 10/9/24 at 9:41 A.M. written by the DNS indicated the note was a late entry note for 10/1/24. The DNS indicated she spoke with Resident #4 regarding the allegation h/she made regarding care. The DNS indicated she called Resident #4's responsible party and the APRN to update them on the allegation and that she was initiating an investigation. Interview with LPN #1 on 10/9/24 at 11:05 A.M. identified on 9/30/24 during the 3 P.M. - 11 P.M. shift Resident #4 had no complaints. LPN #1 indicated she was not aware that Resident #4 had any care concerns or that NA #2 had hurt or poked Resident #4. Interview with NA #2 on 10/9/24 at 11:20 A.M. identified on 9/30/24 during the 3 P.M. - 11 P.M. NA #2 was assigned to care for Resident #4. NA #2 identified Resident #4 asked to go to the toilet and she assisted Resident #4 to the toilet without another staff member present. NA #2 identified when she went to get Resident #4 up from the toilet Resident #4 stated you are hurting me, NA #2 stopped assisting Resident #4, and told Resident #4 she was sorry. NA #2 identified she went and to get NA #3 and NA #4 to assist Resident #4 off the toilet.NA #2 identified that she knew the resident required 2 staff for all care, but the resident had to go got the bathroom, so she did not look for another NA to assist her with care. Interview and clinical record review with the DNS on 10/9/24 at 12:00 P.M. identified based on her investigation regarding Resident #4 allegations on 10/1/24 that NA #2 poked h/her in the leg and back on 9/30/24 staff to resident abuse was not substantiated. The DNS identified on 9/30/24 NA #2 did not follow the care plan intervention when she took Resident #4 to the bathroom and placed the resident on the toilet without another staff member present. Review of facility's baseline/comprehensive person center care plan policy in part identified the person-centered care plan is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge.

Based on observation, review of facility documentation, facility policy, and interviews for 6 of 6 medication carts, the facility failed to consistently complete shift to shift narcotic/controlled drug counts. The findings include: Observation on 7/28/24 between 7:25 AM - 8:05 AM of the medication carts with LPN #3 (Discharge Planner) identified the July 2024 narcotic drug change of shift audit sheet (the narcotic count that the on-coming and off-going nurses complete to ensure the narcotic medications are counted) were missing signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the following units: The Passport A unit was missing 38 signatures. The Passport B unit was missing 44 signatures. The Passport C unit was missing 34 signatures. The [NAME] 1 unit was missing 23 signatures. The [NAME] 2 unit was missing 23 signatures. The [NAME] unit was missing 5 signatures. Interview with LPN #7 on 7/28/24 at 7:27 AM identified she has been employed by the facility for approximately [AGE] years. LPN #7 indicated it was the responsibility of all the nurses to sign the narcotic drug change of shift audit sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with LPN #2 on 7/28/24 at 7:28 AM identified she has been employed by the facility for approximately 2 months. LPN #2 indicated all the nurses are responsible for signing the narcotic drug change of shift audit sheet at the beginning of the shift and at the end of each shift. Interview with LPN #1 on 7/28/24 at 7:30 AM identified she has been employed by the facility for approximately 4 months. LPN #1 indicated it was the responsibility of all the nurses to sign the narcotic drug change of shift audit sheet at the beginning of the shift and at the end of each shift. Interview with LPN #3 (Discharge Planner) on 7/28/24 at 7:58 AM identified he was not aware of the issue. LPN #3 indicated it was the responsibility of all the nurses to sign the narcotic drug change of shift audit sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with the DNS on 7/28/24 at 8:16 AM identified she was not aware of the missing narcotic drug change of shift audit sheet signatures until now. The DNS indicated the expectation of the facility is that the on-coming and off-going nurses count the controlled substances during each shift change and sign the narcotic drug change of shift audit sheet after completing the count. Interview with the Administrator on 7/28/24 at 8:25 AM identified she was not aware of the missing narcotic drug change of shift audit sheet signatures. The Administrator indicated the expectation is that the nurses will count the narcotics at change of shift and sign the narcotic drug change of shift audit sheet. Review of the controlled substance handling policy identified all controlled drugs will be subject to special receipt, handling, storage, disposal and record keeping. A physical inventory of all controlled drugs is made at the change of each shift by two licensed nurses and is documented on an audit record. If a nurse is late, the supervisor will go to the floor and count with the nurse who is leaving. The drugs are never to leave the cabinet on the floor. The supervisor will then go to the floor and count with the nurse when she arrives.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #54 and 87) reviewed for advance directives, the facility failed to obtain the residents code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) on admission. The findings include: 1. Review of the hospital discharge paperwork dated [DATE] did not reflect the residents code status. Resident #54 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, adult failure to thrive, and heart failure. The admission MDS dated [DATE] identified Resident #54 had severely impaired cognition and almost always constant pain. The social worker note dated [DATE] at 4:53 PM indicated that Resident #54 was a full code (full code directs the medical team to take all possible measures to save the residents life in the event of a medical emergency). The social worker assessment dated [DATE] at 1:38 PM, in the electronic medical record, included a section for the advance directives, which was blank. The nurses note dated [DATE] at 1:58 PM indicated staff attempted to get Resident #54 to sign consents and advance directive. Resident #54 was confused and did not want to sign at this time. This writer called the resident representative and left a message. The advance directives form dated [DATE] identified Resident #54 was a Do Not Resuscitate (DNR means the resident does not want any life saving measures in the event of cardiopulmonary arrest). According to the form, the DNR was obtained over the phone from the resident representative and signed only by LPN #8. A physician's order dated [DATE] (17 days after admission) directed Resident #54 was DNR. The care plan dated [DATE] identified code status of DNR with interventions that included following the advance directive guidelines. Facility will honor and follow wishes of the resident/responsible party and review advance directives with resident/responsible party on admission and at least quarterly. Interview with LPN #4 on [DATE] at 7:36 AM indicated that the consent for code status is obtained on the day of admission and done by the charge nurse. LPN #8 indicated that if a nurse had to call a resident representative for the advance directive there has to be 2 nurses to witness and hear the resident representative give the directive for a full code or a DNR and both nurses have to sign the form. Interview with the ADNS on [DATE] at 8:19 AM indicated that on admission the charge nurse or supervisor gets the advance directive signed and if they have to call the resident representative then 2 RN's have to be on the phone call and get a telephone consent. The ADNS indicated the call would be made on the day of admission and if unable to reach resident representative the nurse would write a progress note indicating unable to reach for code status. The ADNS after clinical record review indicated that the advance directive dated [DATE] was only signed by 1 nurse and was not valid. The ADNS indicated that since admission [DATE] until now without a valid code status, Resident #54 would be a full code and staff would have to perform CPR if needed. The ADNS indicated that the code status should have been obtained on admission. Interview with the DNS on [DATE] at 8:37 AM indicated that the advance directives were to be done on day of admission and if unable to reach resident representative there would be a progress note identifying the nurse tried to reach the resident representative for the code status but was not able to or that the resident representative needed more time and was educated. Resident #54 would be a full code until the resident representative decided. The DNS indicated that if the family is not present that 2 nurses, one preferably an RN must co-sign the advance directive form and when resident representative comes in the next visit would sign it. The DNS indicated that the current code status form was only signed by LPN #8 on [DATE] and was not valid without a second nurses signature. The DNS indicated that Resident #54 was a full code since day of admission. Interview with the DNS on [DATE] at 9:19 AM indicated that she had just spoken with Resident #54's representative and the ADNS was present. The DNS indicated that she had gone over each area such as cardiopulmonary resuscitation, artificial respiration, and artificial nutrition with resident representative. The DNS indicated that she had informed the resident representative that he/she needed to come in and sign the form. The DNS indicated that she would get the physician's order and update the care plan. The nurses note written by DNS on [DATE] at 12:32 PM identified this writer spoke with the resident's representative to discuss advance directive who indicated Resident #54 to be a DNR. A physician's order dated [DATE] at 12:46 PM directed Resident #54 was a do not resuscitate. (61 days from day of admission). After surveyor inquiry, the advance directive form dated [DATE] directed Resident #54 requested DNR status cosigned by the DNS and the ADNS. Review of the facility Advanced Care Planning Code Status Policy identified upon admission if the resident was a DNR at the hospital it can be valid no more than 48 hours at the facility. Upon admission the option for choosing to resuscitate (CPR) or do not resuscitate (DNR) will be offered and reviewed with resident or resident representative. The consent or refusal form will be signed by the resident and witnessed. Physician orders must be written accordingly. 43032 47457 2. Resident #87 was admitted to the facility on [DATE] with diagnoses that included dissection of the ascending aorta, acute respiratory failure, and gastrostomy malfunction. The Advance Directive Consent/Acknowledgement and Release Form failed to reflect Resident #87's choices for the administration of life support systems and his/her signature. The admission MDS dated [DATE] identified Resident #87 had intact cognition. The care plan dated [DATE] identified Resident #87's code status: CPR. Interventions included to provide information to resident/responsible party to complete Advance Directives and assist as necessary, review Advance Directives with resident/responsible party on admission and at least quarterly, and honor Advance Directives as directed by resident/responsible party for guidance. The Care Plan Meeting note dated [DATE] at 3:09 PM failed to identify Resident #87's Advance Directives were reviewed. The physician's orders dated [DATE] through [DATE] failed to identify an order directing Resident #87's code status. Interview and review of the clinical record with RN #1 on [DATE] at 11:32 AM failed to identify a signed and completed Advance Directive Consent/Acknowledgement and Release Form and an order for CPR (Cardiopulmonary Resuscitation) or DNR (Do Not Resuscitate) were in Resident #87's clinical record. RN #1 indicated that she was not sure why Resident #87's code status was not in the physician's orders or why the Advance Directive consent was left blank. RN #1 further indicated that Resident #87 was responsible for self and advance directives should be reviewed and signed by the resident or responsible party on admission or readmission to the facility. RN #1 identified that it is the responsibility of the charge nurse or nursing supervisor, admitting the resident, to ensure the consent is signed and orders are entered. Subsequent to surveyor inquiry, an Advance Directive Consent/Acknowledgement and Release Form was completed and signed by Resident #87, on [DATE]. The physician's orders dated [DATE] directed full code, cardiopulmonary Resuscitation. Interview with the DNS on [DATE] at 1:32 PM identified that she would expect the charge nurse or nurse supervisor to ensure the Advance Directive Consent/Acknowledgement and Release Form was signed and the appropriate code status ordered on admission or within 24 hours of admission to the facility. The facility's Advanced Care Planning Code Status policy directs upon admission, the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident/ family/surrogate/designated representative. The consent/refusal form will be signed and witnessed. Physician orders must be written accordingly.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 residents (Resident #40) reviewed for notification of change, the facility failed to ensure the resident representative was notified when the APRN made changes to the residents medication regimen. The findings include: Resident #40 was admitted to the facility with diagnoses that included dementia, congestive heart failure, and knee pain. The care plan dated 9/22/23 identified Resident #40 had congestive heart failure with lower extremity edema and was at risk for fluid deficit because resident is on diuretic. Interventions included giving medications as ordered. Additionally, Resident #40 has chronic knee and hip pain. The social worker note dated 9/22/23 identified Person #1 was notified an increase in Trazadone (antidepressant medication) for Resident #40's insomnia and depression. Person #1 requested resident to be seen by APRN for knee pain. The quarterly MDS dated [DATE] identified Resident #40 had severely impaired cognition and required touching assistance with toileting, dressing, and personal hygiene. A physician's order dated 11/29/23 directed to administer Aspirin 81 mg once daily in the morning, Potassium Chloride ER tablet extended release 10 MEQ once a day to replace potassium, Lasix 20 mg in the morning every other day and Tylenol 650 mg every 8 hours as needed for pain. The nurses note dated 12/12/23 at 12:04 PM identified Resident #40 received Tylenol 650 mg for pain. The APRN note dated 12/12/23 at 4:36 PM identified Resident #40 was receiving the following medications Trazodone 50 mg at bedtime, Lasix 20mg every other day, Potassium Chloride ER 10 MEQ daily, and Aspirin 81 mg chewable daily. The APRN indicated that she was requested to see Resident #40 for edema. Resident #40 has back and knee pain. Resident #40 had no edema. Congestive heart failure has no signs of fluid overload. Will discontinue the Lasix and monitor residents' weight for 1 week and reevaluate. Aspirin 81 mg, called Person #1 to discuss risk versus benefit but unable to reach. Discontinue Potassium and Lasix. A physician order dated 12/12/23 directed to discontinue Lasix and Potassium. Review of progress notes dated 12/12/23 - 12/30/23 failed to reflect that Person #1 had been notified of the discontinued medications Lasix and Potassium Chloride. The APRN note dated 12/13/23 at 12:07 PM identified Resident #40 is alert, appears more confused, and frail status post emergency room visit after a fall in the shower. Resident #40 has knee and back pain. Resident #40 has no new pain. Aspirin will be discontinued due to increased risk of falls and bleeding. Attempted to reach Person #1 to updated unable to reach. A physician order dated 12/13/23 identified the discontinuation of the Aspirin 81 mg. Review of the clinical record and interview with the ADNS on 7/30/24 at 12:12 PM indicated that the APRN attempted to update Person #1 on 12/12/23 about discontinuing the medications but was unable to reach him/her. The ADNS indicated that there were notes about other things like needing urine and weights but nothing about the medications that were being discontinued. The ADNS indicated that the expectation was that the nurses would continue to try to call Person #1 and document the attempts made until Person #1 was reached. The ADNS indicated that nursing was able to reach Person #1 for other things during that time. Interview with the DNS on 7/30/24 at 12:45 PM indicated that when a resident has any medication changes the resident representative should be updated at that time the same day by the APRN or physician so they can explain why there is a medication change. The DNS indicated that on 12/12/23 and 12/13/23 when the APRN had discontinued medications she should have made multiple attempts to reach Person #1. After clinical record review, the DNS indicated that in December 2023 the APRN had reached out but did not speak with Person #1. The DNS indicated that the expectation was the APRN, or nursing would have updated Person #1 at the time the medications were being discontinued and documented when they had reached and updated Person #1. The DNS indicated that she was not aware that Person #1 was not updated about the discontinued medications until April 2024 when Person #1 had informed her that he/she had just found out that all the medications had been discontinued. The DNS indicated at that time, in April 2024, Person #1 had written a letter because Person #1 was upset he/she was never notified that of the medications were discontinued and wanted to know when and why they were discontinued. Review of the facility Change of Condition Notification Policy identified the facility will inform the resident, residents' representative, and physician when there is a change in condition. The facility will ensure that a residents change in condition is evaluated and documented properly. The facility will ensure that the change of condition is reported to the physician and resident representative. The licensed nurse per state regulations will notify the resident, physician, and resident representative of the change in condition. Repeated attempts will be made to reach the resident representative and physician until successful. The nurse will document all attempts, noting the date and time.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #181) reviewed for accidental hazards, the facility failed to ensure medication was not left at the bedside. The findings include: Resident #181 was admitted to the facility on [DATE] with diagnoses that included cerebrospinal fluid leak, surgery on the nervous system, and depression. The care plan dated 7/25/24 identified Resident #181 had a potential for pain related to back surgery. Interventions included administering medications per the physician's orders. A physician's order dated 7/24/24 directed to administer the following. 5mg Bisacodyl EC Delayed release, 1 tablet by mouth, daily, for bowel management. 300mg Gabapentin, 1 capsule, by mouth, three times daily, for pain 2mg Hydromorphone HCL (narcotic), 1 tablet, by mouth, every 6 hours, as needed for pain. 250mg Acetazolamide, 1 tablet, by mouth, twice daily, for edema. A physician's order dated 7/25/24 directed to administer the following. 150mg Bupropion HCL ER, 2 tablets, by mouth, daily, for depression. A physician's order dated 7/26/24 directed to administer the following. 25mg Topiramate, 1 tablet, by mouth, daily, for seizures. Observation on 7/28/24 at 9:13 AM identified a medicine cup, containing 7 pills, at Resident #181's bedside. Resident #181 indicated he/she wanted to wait until after breakfast to take the medications because he/she threw up the day before, after taking the medications on an empty stomach. Interview with LPN #1 on 7/28/24 at 9:16 AM identified that Resident #181 had requested Hydromorphone for pain, so she brought in Hydromorphone along with Resident #181's scheduled morning medications, about 15 minutes earlier. LPN #1 further identified that Resident #181 had reported pain but wanted to eat something because he/she felt sick after taking the medications on an empty stomach, yesterday. LPN #1 indicated that she had left the medications at the bedside and was unsure if Resident #181 had taken them. LPN #1 further indicated that she should not have left medications at the bedside and should have remained with Resident #181 until he/she had taken the medications or should have removed the medications and returned with them after Resident #181 had eaten breakfast. Interview with RN #1 on 7/28/24 at 9:20 AM identified that when medications are administered, she would expect the nurse to administer the medication using the 5 rights of medication administration and to observe that all the medications were taken. RN #1 further identified that if medications are refused, then the nurse should properly waste them and reattempt, later. Interview and review of the MAR dated 7/28/24 with LPN #1 identified the following medications were left at the bedside, at approximately 8:15 AM. 5mg Bisacodyl EC Delayed release, 1 tablet. 300mg Gabapentin, 1 capsule. 2mg Hydromorphone, 1 tablet. 250mg Acetazolamide, 1 tablet. 150mg Bupropion HCL ER, 2 tablets. 25mg Topiramate, 1 tablet. LPN #1 identified that she returned to Resident #181's room, subsequent to surveyor interview, and attempted to administer the morning medications. Resident #181 took the Hydromorphone tablet but refused the rest of the medications, as he/she was still eating breakfast. LPN #1 further identified that she discarded the other medications and later administered them after Resident #181 had eaten. Interview with the DNS on 7/29/24 at 11:21 AM identified that her expectation is that medications are not left at the bedside and that the nurse remains with the resident until all the medications are taken; if a resident refuses a medication, then the medications are to be removed from the room and offered, later. The DNS further identified that Resident #181 had not been evaluated, ordered, or care planned to self-administer medications. The facility's Medication Pass policy directs medications to be administered safely and timely per the physician's orders, always observe the resident until they have swallowed all medications that have been administered, and do not leave medication in medication cup at the bedside or on tableside. The policy further directs that medications must be re-offered before they are considered refused, and medications that are refused.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) reviewed for an for injury of unknown origin, (Resident #1), the facility failed to ensure Resident #1 was transferred in accordance with Resident #1's plan of care resulting in an injury. The findings include: Resident #1 was admitted to the facility with diagnoses that included anxiety, Alzheimer's disease, psychotic disorder with delusions, dementia, and cerebrovascular disease. The quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, was an extensive assist that required two staff for transfers and was not steady, only to able to stabilize with staff, when moved from a seated to a standing position. The care plan dated 8/12/22 identified Resident #1 had, and ADL self-care deficit related to impaired mobility with interventions that included assistance of two staff for functional transfers out of bed into wheelchair. Resident #1 also had the potential to be verbally aggressive with interventions that included to intervene before agitation escalated, guide away from source of distress, engage calmly in conversation and if response is aggressive, staff to walk away calmy and approach later. A Physician's order dated 10/1/22 directed assist of two staff for functional transfers out of bed to wheelchair, ambulation was not appropriate at this time. An Accident & Incident (A&I) report dated 10/6/22 identified Resident #1 was noted to have a bruise to left lower extremity calf, bilateral leg edema, and the staff were unable to fully test range of motion due to Resident #1 not wanted to straighten out his/her legs. The APRN was notified and ordered an ultrasound, Lasix for three (3) days and an X-ray. The A&I investigation statements identified NA #1 transferred Resident #1 by himself on 10/5/22, although the plan of care called for assistance of 2 staff. Radiology results dated 10/6/22 at 6:57 PM identified Resident #1's left knee lateral view was submitted, Resident #1's bones were osteoporotic, and no fracture, dislocation or effusion was seen. Resident #1's left foot exam was of limited diagnostic quality and the exam was not ideal and medical decision making should have been used with caution as a repeat examination may yield more useful diagnostic information. It further identified, although no obvious displaced fracture was seen, a fracture could not be excluded with certainty because of the limitations described. It further suggested to repeat with more optimized positioning and x-ray parameters would yield a more precise radiologic diagnosis. Physician's order dated 10/7/22 directed to collect urine analysis via straight catheterization one time only. A nurse's note dated 10/7/22 at 10:46 PM written by LPN #1 identified Resident #1 refused to be straight catharized and was kicking and fighting. A nurse's note dated 10/8/22 at 10:07 PM identified she was called in by the Nurse Aide (NA) to assess Resident #1's left lower extremity swelling and bruising noted. Resident #1 was combative and refusing to be touched. The APRN was notified, and Resident #1 was sent to the hospital per the APRN's request at 7:30 PM. A Hospital X-ray dated 10/9/22 identified X-ray of Resident #1's left ankle, foot and fibula found diffuse decrease bone mineralization. There was a communicated fracture of the left distal tibial shaft, oblique fracture of the fibular proximal shaft and chronic appearing fracture of the distal fibular shaft. Interview with the Occupational Therapy Director on 11/1/22 at 10:48 AM identified prior to the event on 10/6/22, Resident #1 was a transfer assist two staff members out of bed to wheelchair. Interview with NA #1 on 11/3/22 at 3:23 PM identified on 10/6/22 he transferred Resident #1 to his/her wheelchair by himself. He identified it was a quick process, he stood Resident #1 up, held onto his/her pants, Resident #1 placed his/her on his shoulders and pivoted Resident #1 into the wheelchair. He identified he usually transferred Resident #1 independently because he never wanted to ask for help or bother anyone. He identified he assumed Resident #1 was a transfer of one but never really checked. Interview with LPN #1 on 11/3/22 at 11:03 AM identified on 10/7/22 she was the nurse that attempted to straight catheter Resident #1. She identified Resident #1 was incontinent therefore needed to be straight catheterized for a urine collection. She identified she tried to open Resident #1's legs and Resident #1 began kicking. She identified Resident #1 did not kick up in the air but kicked her legs straight out on the bed. She further identified Resident #1 did not kick her or make contact with her. She identified there was no foot board at the end of the bed and did not make contact with anything hard from the bed. LPN #1 identified as soon as Resident #1 became combative she left the room. Interview with APRN #1 on 11/3/22 at 2:20 PM identified that Resident #1 presented with swelling on 10/6/22 in both legs and there was more swelling and redness in the left leg. She identified Resident #1 never really got out of his/her bed and thought it could have been a blood clot and ordered a doppler and X-ray of his/her lower extremities. She identified a doppler was unable to be done because Resident #1 refused. The X-ray was completed on 10/6/22 but was inconclusive due to Resident #1's positioning. She identified she communicated the concerns with Resident #1's POA and suggested Resident #1 go to the hospital. Resident #1's POA did not want to send Resident #1 to the hospital because he did not want to put Resident #1 through that and was educated on the implications. She identified on 10/7/22 an order was put in for a repeat X-ray because the X-ray to the left foot was inconclusive, however, Resident #1 was combative when staff tried to move his/her legs for the imaging. She identified she maintained contact with Resident #1's POA and he continued to decline transfer to the ED for Resident #1 at that time. On 10/8/22 Resident #1 had increased ecchymosis and swelling and identified he/she needed a stat work up with further imaging and the POA agreed to send Resident #1 to the hospital. APRN #1 further identified Resident #1 could have sustained a fracture from the leg turning the wrong way or a wrong movement. Interview with the DNS on 11/1/22 at 3:00 PM identified when she interviewed LPN #1 following the incident, LPN #1 told her Resident #1 kicked her during the catheterization attempt on 10/7/22 but couldn't remember which leg she kicked from. She identified they concluded the cause of Resident #1's fractures to be from when Resident #1 kicked LPN #1 because Resident #1's pain got worse the next day (10/8/22). Follow up interview with the DNS subsequent to the interview with LPN #1 identified that she was not aware that Resident #1's leg had not come into contact with LPN #1, so she was unsure how the fracture occurred. Interview with the Administrator on 11/3/22 at 3:30 PM identified NA #1 told her he had been transferring Resident #1 independently because he was strong enough. NA #1 should have been following Resident #1's care plan and transferring Resident #1 with two staff members. Subsequent to the event, the DNS is completing random audits two times a week of resident's being transferred. Review of the Care Plan policy identified the person-centered care plan is developed to include information to properly care for the resident.

Based on clinical record review, staff interview, review of facility policy and procedure, review of facility documentation, and observations for one of three residents review for abuse (Resident #158), the facility failed to immediately notify the physician and/or responsible party when the resident was identified with continued pain and swelling to an extremity resulting in an 11 day delay in getting appropriate treatment for [REDACTED]. Resident #158's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident had severely impaired cognition, no behaviors were exhibited, required total assistance of two staff members for bed mobility, and transfers, and was always incontinent of bowel and bladder. The RCP dated 8/30/16 identified that the resident was non ambulatory and required assistance of two staff members for transfers with a mechanical lift. The APRN work book identified that on 10/25/16, nursing requested R#158 be assessed due to right foot swelling. The clinical record failed to reflect an assessment had been completed when the resident was noted with right foot swelling and/or failed to reflect that the physician and/or family were notified of the change in condition immediately. An APRN progress note dated 10/26/16 noted asked to see patient for family request of right foot swelling. Assessment noted right foot with trace [MEDICAL CONDITION], no [DIAGNOSES REDACTED], positive range of motion. Assessment noted [MEDICAL CONDITION]ly positional if worsens will get ultra sound and/or or x-ray. The APRN work book identified on 10/26/16 during the 3-11 shift that the family requested an x-ray of the right leg/hip due to pain and swelling of the right foot. The clinical record failed to contain the APRN progress note dated 10/26/16. Nurse's notes dated 10/27/16 at 10:54 PM noted that the family had requested an x-ray of the right hip/leg due to the resident's complaints of pain and noticeable swelling of the right leg; Tylenol was given with positive effect. APRN to follow-up in the AM. The clinical record failed to reflect that an assessment of the right leg/hip area was completed at that time and/or that the physician was immediately notified when the resident continued to have pain and swelling of the right hip/leg area for the 3rd day. Nurse's notes dated 10/28/16 (a Friday) at 2:30 PM noted no signs or symptoms of pain/discomfort. APRN will be in facility on Monday, no new orders recommended at this time; family updated on plan of care. Nurse's notes dated 11/5/17 at 2:00 PM (8 days later) noted the family complained again that R #158 was in pain when his/her right leg was touched. an order for [REDACTED]. Nurse's notes dated 11/5/17 at 6:30 PM identified that the x-ray result noted a displaced femoral neck fracture. The physician was notified and directed to send to the hospital for evaluation. The reportable event form dated 11/5/16 identified that the resident presented with discomfort when the right leg was touched. The APRN was notified and directed to obtain an x-ray of the right leg. The x-ray report dated 11/5/16 identified a displaced right femoral neck fracture. The physician was notified and directed to send to the emergency room for evaluation. The facility investigation documentation indicated a timeline noting the right foot swollen on 10/25/16. APRN saw resident on 10/26/16. No note was present in the record and the responsible party had not been notified. On 10/27/16, a family member requested an x-ray. On 10/28/16, an RN assessment was done. The APRN did not follow up. On 11/5/16, the family member asked about the x-ray. An order was obtained and x-ray was done (11 days after pain and swelling were noted). Interview and review of written investigation documents with NA#1 on 6/2/17 at 9:42 AM identified that on 10/25/16, R#158 was grabbing his/her leg and indicating pain so s/he reported it to the nurse. NA#1 noted that s/he had the resident again a couple of days later and the resident wasn't eating and was crying out in pain. NA#1 reported it to the nurse on duty and informed the nurse that s/he had reported the same thing a couple of days ago. Interview and review of the clinical record with APRN #1 on 6/1/17 at 12:50 PM identified when a resident has a change in condition or needs to be assessed, the staff put the request in the APRN book. APRN #1 noted that the staff do not always call and/or verbally report to me. APRN #1 identified s/he is in the building Monday, Wednesday and Thursday, and s/he checks the APRN book each time s/he is in the building. The APRN identified that on 10/26/16, the APRN book noted a request to assess R#158's right foot due to swelling. S/he identified that s/he only assessed the right foot and did not assess right leg/hip because the book only requested to assess the right foot. Additionally APRN #1 noted when s/he completes a progress note, before placing the progress note in the clinical record s/he will fax the note for billing purposes. APRN #1 identified on 10/26/16 the facility fax machine was broken so the progress note remained with him/her until the fax machine was fixed, and was not sure when the APRN progress note got into the clinical record. Interview with the ADNS on 06/02/2017 at 12:35 PM identified when a resident is noted with a change in a condition, the RN supervisor should conduct an assessment of the resident and notify the physician and/or responsible party. Additionally the ADNS identified that subsequent to this issue, the facility initiated an action plan to ensure any resident with a change in condition will be assessed and treated in accordance with facility policy and procedure. Facility policy and procedure for physician notification identified when a resident experiences a change in condition, the charge nurse notifies the RN supervisor immediately, conducts a complete physical/mental assessment, and will notify the physician and family and/or responsible party. Additionally these findings will be documented and maintained in the clinical record.

Based on clinical record reviews, staff interviews, review of facility policy and procedure, review of facility documentation and reportable events, and observations for one of three residents review for abuse (Resident #158), the facility failed to ensure comprehensive assessments were completed when the resident was identified with a change in condition and/or for the only sampled resident reviewed for medication errors (Resident #189), the facility failed to ensure medications were administered in accordance with physician orders, and/or for the only resident in the survey sample reviewed for [MEDICAL TREATMENT] (R # 82), the facility failed to ensure the [MEDICAL TREATMENT] was monitored according to Physician's orders. The findings include: 1. Resident #158's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident had severely impaired cognition, no behaviors were exhibited, required total assistance of two staff members for bed mobility, and transfers, and was always incontinent of bowel and bladder. The RCP dated 8/30/16 identified that the resident was non ambulatory and required assistance of two staff members for transfers with a mechanical lift. The APRN work book identified that on 10/25/16, nursing requested R#158 be assessed due to right foot swelling. The clinical record failed to reflect an assessment had been completed when the resident was noted with right foot swelling and/or failed to reflect that the physician and/or family were notified of the change in condition immediately. An APRN progress note dated 10/26/16 noted asked to see patient for family request of right foot swelling. Assessment noted right foot with trace [MEDICAL CONDITION], no [DIAGNOSES REDACTED], positive range of motion. Assessment noted [MEDICAL CONDITION]ly positional if worsens will get ultra sound and/or or x-ray. No documentation of a full assessment of the extremity was noted. The APRN work book identified on 10/27/16 during the 3-11 shift that the family requested an x-ray of the right leg/hip due to pain and swelling of the right foot. The clinical record failed to contain the APRN progress note dated 10/26/16. Nurse's notes dated 10/27/16 at 10:54 PM noted that the family had requested an x-ray of the right hip/leg due to the resident's complaints of pain and noticeable swelling of the right leg; Tylenol was given with positive effect. APRN to follow-up in the AM. The clinical record failed to reflect that an assessment of the right leg/hip area was completed at that time and/or that the physician was immediately notified when the resident continued to have pain and swelling of the right hip/leg area for the 3rd day. Nurse's notes dated 10/28/16 (a Friday) at 2:30 PM noted no signs or symptoms of pain/discomfort. APRN will be in facility on Monday, no new orders recommended at this time; family updated on plan of care. Nurse's notes dated 11/5/17 at 2:00 PM (8 days later) noted the family complained again that R #158 was in pain when his/her right leg was touched. an order for [REDACTED]. Nurse's notes dated 11/5/17 at 6:30 PM identified that the x-ray result noted a displaced femoral neck fracture. The physician was notified and directed to send to the hospital for evaluation. The reportable event form dated 11/5/16 identified that the resident presented with discomfort when the right leg was touched. The APRN was notified and directed to obtain an x-ray of the right leg. The x-ray report dated 11/5/16 identified a displaced right femoral neck fracture. The physician was notified and directed to send to the emergency room for evaluation where the resident was admitted and underwent surgical repair. The facility investigation documentation indicated a timeline summary noting the right foot swollen on 10/25/16. APRN saw resident on 10/26/16. No note was present in the record and the responsible party had not been notified. On 10/27/16, a family member requested an x-ray. On 10/28/16, an RN assessment was done. The APRN did not follow up. On 11/5/16, the family member asked about the x-ray. An order was obtained and x-ray was done (11 days after pain and swelling were noted). Interview and review of written investigation documents with NA#1 on 6/2/17 at 9:42 AM identified that on 10/25/16, R#158 was grabbing his/her leg and indicating pain so s/he reported it to the nurse. NA#1 noted that s/he had the resident again a couple of days later and the resident wasn't eating and was crying out in pain. NA#1 reported it to the nurse on duty and informed the nurse that s/he had reported the same thing a couple of days ago. Interview and review of the clinical record with APRN #1 on 6/1/17 at 12:50 PM identified when a resident has a change in condition or needs to be assessed, the staff put the request in the APRN book. APRN #1 identified s/he is in the building Monday, Wednesday and Thursday, and s/he checks the APRN book each time s/he is in the building. The APRN identified that on 10/26/16, the APRN book noted a request to assess R#158's right foot due to swelling. S/he identified that s/he only assessed the right foot and did not assess right leg/hip because the book only requested to assess the right foot. Interview with the ADNS on 06/02/2017 at 12:35 PM identified when a resident is noted with a change in a condition, the RN supervisor should conduct an assessment of the resident and notify the physician and/or responsible party. Additionally the ADNS identified that subsequent to this issue, the facility initiated an action plan to ensure any resident with a change in condition will be assessed and treated in accordance with facility policy and procedure. Facility policy and procedure for physician notification identified when a resident experiences a change in condition, the charge nurse notifies the RN supervisor immediately, conducts a complete physical/mental assessment, and will notify the physician and family and/or responsible party. Additionally these findings will be documented and maintained in the clinical record. 2. Resident #289 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified the resident had no cognitive impairment, required limited assistance with ADL's, and did not have pain. The RCP dated 1/5/17 identified in alteration in comfort related to pain. Interventions included pain assessment per protocol, and to administer [MEDICATION NAME] medication as ordered. Physician orders dated 1/4/17 directed to apply [MEDICATION NAME] 5% patch to right. Interview with Person #2 on 6/1/17 at 10:40 AM identified that while visiting R #289 s/he noted a [MEDICATION NAME] was left at the bedside. Person #2 immediately brought it to the nurse's station and asked LPN #6 why the [MEDICATION NAME] was left at the bedside. Person #2 indicated that LPN# 6 stated that the [MEDICATION NAME] is frequently left at the resident's bedside. Interview with LPN #6 on 6/2/17 at 10:00 AM indicated he/she entered R #289's room to apply the [MEDICATION NAME] and the resident refused it until s/he was provided AM care. LPN #6 identified that a short time later, s/he went back into R #289's room to apply the [MEDICATION NAME] but had an emergency in another resident's room. LPN#6 indicated s/he left the [MEDICATION NAME] at the bedside. Review of the MAR for 1/4/17 through 1/14/17 failed to reflect documentation that R #289 had ever refused his/her [MEDICATION NAME]. Facility policy and procedure for medication administration and documentation identified medication administration and documentation occurs in a timely and accurate manner. Assures medications are not left unattended, keeps medications secured in a locked area or in visible control at all times, and documents any medication not administered (i.e. refused, etc) and documents the reason. Interview and review of the clinical record with the ADNS on 6/2/17 at 12:50 PM noted if a resident refuses a medication, the nurse should circle the medication on the front of the MAR and document on the back of the MAR the reason why it was not administered. Additionally, the ADNS indicated that no medications should be left on any resident's bedside. 3. Resident # 82's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated R # 82 had no memory problems and was independent with ADL's. A resident care plan dated 4/19/17 identified a problem related to [MEDICAL TREATMENT]. Interventions included check AV shunt bruit and thrill in right arm daily. A Physician's order dated 4/26/17 directed to monitor for bruit and thrill in shunt every shift. Review of the treatment records dated May 1-31, 2017 and June 1, 2017 indicated to check for a bruit and thrill to the shunt every shift, the documentation to indicate monitoring was completed every shift was noted to be blank. Review of nurse's notes from May 1-31, 2017 and June 1, 2017 noted documentation of a positive bruit and thrill on 5/2/17 (no time indicated), 5/9/17 at 11:00 PM, 5/13/17 at 11:00 PM, 5/23/17 (no time indicated), 5/30/17 at 11:00 PM, and 6/1/7 at 11:00 PM. Additionally, the nurse's notes indicated the AV shunt site was noted to have small amounts of blood on the dressing on 5/9/17, 5/13/17, 5/23/17, and 5/30/17. An interview on 6/2/17 at 10:00 AM with RN # 4 indicated a [MEDICAL TREATMENT] flow sheet should have been initiated to document monitoring of the AV shunt every shift. He/she was unable to provide documentation of the [MEDICAL TREATMENT] flow sheet for May 2017, and June 1, 2017. Review of the facility policy on [MEDICAL TREATMENT] indicated the licensed nurse will check the thrill and bruit every shift and document same on treatment record.

Based on review of the clinical record, facility documentation, and interviews for one of three sampled residents reviewed for accidents (Resident #93), the facility failed to ensure the resident received the necessary assistive devices to prevent an accident and an injury. The findings include: Resident #93's [DIAGNOSES REDACTED]. The Significant Change in Condition( MDS) assessment dated [DATE] identified Resident #93 had no cognitive impairment, required extensive assistance for bed mobility, transfers, locomotion on and/or off unit, dressing and personal hygiene. The physician's orders [REDACTED]. The RCP dated 4/10/15 and 6/4/15 identified an alteration in skin integrity related to potential for bruising and/or skin tears. Interventions included to observe the resident's skin during care, apply shin tubes at hour of sleep, remove the shin tubes in the morning and to apply ace wraps. The June 2015 Treatment Administration Record (TAR) identified the ace wraps were applied to Resident #93's bilateral lower extremities as ordered. The Reportable Event (RE) and facility investigation dated 7/1/15 at 10:00 PM identified NA #2 was transferring Resident #93 from the wheelchair to the bed and the resident sustained [REDACTED]. The facility investigation identified prior to the transfer to bed on 7/1/15, Licensed Practical Nurse (LPN) #1 removed the ace wraps from Resident #93's lower extremities. LPN #1 was unable to locate the shin tubes in the room and left the room to obtain the shin tubes. Before LPN #1 returned with the shin tubes, NA #2 assisted the resident from the wheelchair to the bed without the benefit of any protective leg wear. After the transfer was conducted, NA #2 noted blood on the lever of the side rail. The investigation dated 7/1/15 identified Resident #93 was transferred to the hospital for an evaluation and treatment. The documentation identified eleven sutures were required to approximate the lacerated area on the left calf. Interview with LPN #1 on 7/15/15 at 2:00 PM identified NA #1 transferred Resident #93 from wheelchair to bed without the benefit of the ace wraps and/ or shin tubes as outlined in the plan of care. Interview with NA #2 on 7/15/15 at 3:00 P.M. identified Resident #93 usually had ace wraps or shin tubes on his/her lower extremities. However on 7/1/15, when she/he transferred the resident from the wheelchair to the bed the shin tubes were unavailable. Interview and review of the clinical record with the DNS on 7/16/15 at 11:55 AM identified NA #2 did not apply Resident # 93's shin tubes in accordance with the resident's plan of care before transferring the resident from the wheelchair to the bed.

Based on clinical record review, review of facility documentation and staff interviews for one of three sampled residents reviewed for medication errors (R#247), the facility failed to ensure that the resident was free of significant medication errors. The findings included: Resident # 247's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident as cognitively impaired, had memory problems and resident required extensive assistance with personal hygiene. A physician order [REDACTED]. A nurse's note dated 7/03/13 at 8:55 AM identified that the licensed staff was called into R#247's room at 8:20 AM because the resident had cyanotic lips, was cold to touch, oxygen saturation was 92 % (Normal Range 96-100 percent) and that the resident was placed on Oxygen 2 Liters Nasal Cannula. The resident was noted with no cardiac distress and that a call was placed to the resident's physician. A nurse's note dated 7/03/13 at 10:00 AM identified that the licensed staff was called into assess R#247 a second time at 10:00 AM and identified that Resident # 247 was noted with cyanotic lips, the resident was cold to touch with increased lethargy, baseline mental status change, pinpoint non-reactive pupils,ashen skin color, cyanotic fingers and had an Oxygen Saturation of 45 %. 911 initiated and the resident was transported to the hospital for evaluation. A RE dated 7/03/13 identified R#247 received [MEDICATION NAME] (MS)[MEDICATION NAME] in error. A hospital discharge summary dated 7/07/13 identified the resident was admitted to the hospital for unresponsiveness and opiate overdose. Interview with the DNS on 7/22/13 at 3:10 PM and clinical record review identified that hospital physician telephoned the facility to review R# 247's medications and informed the facility that based on a toxicology screen the resident had received MS (opiate), at which time the facility staff informed the physician that Resident # 247 did not take any opiates. Interview with LPN#1 on 7/22/13 at 2:45 PM identified that she was informed by a nurse aide on the day shift that R#247 did not look good, and was not acting right, at which time she went in and collected data. Resident # 247 was noted to have difficulty speaking at which time she immediately notified RN #1 to come and assess the resident. Interview with RN#1 on 7/22/13 at 3:00 PM identified that after she assessed R#247 the first time, she went out to the desk to call the physician and while waiting for the physician to return the call she was called back to assess the resident a second time. The resident's pupils were non-reactive and oxygen saturation level had dropped to 45 % and she immediately initiated 911. The DNS indicated that R#247 received R# 52's [MEDICATION NAME] in error. Interview with LPN#2 on 7/24/13 at 3:40 PM identified that she could not recall if she gave R#247, R# 52's [MEDICATION NAME].

Based on review of the clinical records, review of facility policies, and interviews for one resident with an injury of unknown origin, Resident #1, the facility failed to provide care in a safe manner to prevent injury. The findings include: 1. Resident #1 (R #1) had [DIAGNOSES REDACTED].#1was cognitively impaired, had behaviors of rejection of care occurring one to three days during the assessment period, and required two person assistance for bed mobility, transfer and toilet use. The care plan dated 7/23/12 identified R #1's refusal of incontinent care and toileting related to dementia with behavior problems with interventions that included, attempting provide care at a different time of day, utilize a different staff member to encourage care, and nurses to explain benefits, risks and consequences of refusal of not being toileted or incontinent care. The care plan dated 7/25/12 addressed the resident's need for assist with Activities of Daily Living (ADLs) with interventions that included one assist for bed mobility, transfer, toilet use and personal hygiene and the use of two one half side rails. Nurse's notes dated 8/12/12 at 1:40 PM identified that R#1 sustained a raised bump on the left side of his/her forehead that measured 2.0 centimeters (cm) by 2.5 cm and 0.5 cm. after the resident became agitated during incontinent care and bumped his/her head on the siderail. Review of the Neurological/Vital Sign Check sheet identified that R #1 ' s vital signs and neurological signs were monitored for forty eight (48) hours following the incident and were within normal limits for the resident. Review of the nursing notes dated 8/12/12 through 8/13/12 lacked documentation to reflect that R #1 displayed any further agitation during care. A nurse's note dated 8/13/12 at 12:30 PM identified R #1's fourth finger of the left hand was swollen and painful to touch. A radiology report of the left hand dated 8/13/12 identified that R #1 had sustained an acute fracture of the fourth digit proximal phalanx with displacement and associated soft tissue swelling. Interview with Nursing Assistant #4 (NA #4) on 11/20/12 at 10:30 AM identified that while he/she attempted to provide incontinent care for R #1 on 8/12/12, he/she transferred the resident from the wheelchair to the bed with one assist. While on the bed, R #1 had refused to lie down, so NA #4 raised the head of the bed put up the side rails, left the resident, and returned approximately thirty (30) minutes later. After explaining to the resident that he/she was going to change him/her, NA #4 attempted to complete the incontinent care. NA #4 stated that R #1 became "out of control," was fighting and agitated, and pulled NA #4's hair. NA #4 stated that R #1 apologized, that the NA continued to provide care, but that R #1 said "leave me alone." NA #4 stated that although he/she could not finish the care because R #1 continued to fight, he/she lowered the resident's pants and briefs. NA #4 stated that he/she then got NA #1 to assist with completion of the incontinent care for R#1. Review of facility documentation of the investigation of R #1's fractured finger dated 8/17/12 identified that R #1 had a history of [REDACTED]. Subsequent to the incident, R #1's care plan was revised to include that staff use two persons to provide care when the resident was resistive. Review of facility policies directed in part, that all residents receive considerate healthcare that safeguard the right to quality of care and treatment. Facility policies further directed training for appropriate interventions to deal with aggressive and/or catastrophic reactions of residents and that healthcare workers provide effective personal care.