Every finding on record at Cherry Brook Health Care Center

Based on observation, temperature test, and interviews, the facility failed to ensure food was served at appetizing and pallatible temperatures. The findings include: Interview with Resident #91 on 7/20/26 at 10:45 AM identified the meals are served late and are cold Interview with Resident #66 on 7/21/26 at 12:39 AM identified the food is cold and sits on a cart in the hallway for 25 minutes before they bring it into my room.On 7/21/26 at 12:39 PM observation of posted mealtimes identified meal schedules as follows: Breakfast at 8:00 AM, Lunch at 12:00 PM and Dinner at 5:00 PMObservation and temperature testing of the tray line on 7/23/26 at 11:45 AM identified the meal consisting of spaghetti and meatballs or chicken parmesan, mashed potatoes, and Caeser salad. The food was temperature was taken in the kitchen at 11:55 AM and transported on an open metal cart in metal bins covered in plastic wrap. The food was transferred to the steam table on the second floor, and the first meal was plated at 12:14 PM. Meals for residents in the dining room were plated first and Nurse Aides (NAs) then fed the residents that required assistance prior to serving the residents that chose to remain in their rooms for lunch. Once those plates were cleared the NAs took the meals in metal carts to the wing that they were assigned to serve. The last plate was served at 12:49 PM and a temperature conducted by the surveyor and Food Service Director (FSD). The chicken parmesan's temperature by the surveyor was 130 degrees and the FSD was 126 degrees. The pasta temped by the surveyor was at 126 degrees.Interview with the FSD on 7/23/26 at 12:50 PM identified that food on the steam table needed to be held at 135 degrees and that food should not be served at the low temperatures that were tested at 12:40 PM. The FSD further indicated that the steam table was currently turned all the way up to 10. Although requested, facility policies for food service were not provided.

Based on tour of the dietary department, interviews, and facility policies, the facility failed to ensure food items were labeled and dated, expired food items were discarded, staff food was not stored in resident nourishment areas, and food was held in ovens in safe containers. The findings include: A tour of the Dietary Department with the Food Service Director (FSD) on 7/20/26 at 10:15 AM identified the following:1a. A stack of fresh salads plated and covered in plastic wrap, an opened box of cooked chicken breast (about 15 pieces), and hamburger patties, were on a shelf in the refrigerator undated. The FSD indicated that the salads were made each morning and thrown away at the end of the day and that anything open should be dated. b. 1/2 Pork loin covered with plastic wrap, a box of stuffed shells 1/4 full, box of omelets 1/2 full, box of square fish, and box of chicken cordon blue was located on a shelf in the walk-in freezer all opened and not dated when opened. The FSD indicated that it should be dated once opened. c. Dry goods including pasta (elbows, tricolor, ziti, and spaghetti) approximately 1/2 full, lasagna loosely wrapped in plastic wrap, sugar, bulk oatmeal (50l bs) stored in large plastic bin were open, unlabeled, and undated. The FSD indicated that it should be labeled and dated once opened. d. Panko breadcrumbs were in a plastic bin not dated and the scooper to access the breadcrumbs was located on top of the bin and was not bagged. The FSD indicated that they should be dated when opened and the scooper should be bagged. Post inquiry, the FSD placed the scooper into a bag. Interview with the FSD on 7/20/26 at 10:35 AM indicated that anything open should be dated with the date it was opened and that it was the responsibility of the cooks to complete. She was unsure why it wasn't done but indicated that they weren't used to having to do that. Observation of a sign posted on the door of the walk-in refrigerator instructing staff to date open items. Observation on 7/23/26 at 10:13 AM of the nourishment stations on 2nd and 3rd floor in the dining area identified the following:2a. 5 crispy rice single serve cereal bowls were in the upper cabinet of the nourishment station on the second floor with an expiration date of January 7th, 2026, February 7th 2026, March 14th 2026. b. 1 packet of single serve mayonnaise expired June 19th, 2026, and 5 packets had no dates, found in the cabinet of the nourishment station on the second floor. c. A Styrofoam plate with eggs and bacon covered with a second Styrofoam plate was in the cabinet on the top shelf of the nourishment station on the 2nd floor. d. A small plate with 3 crackers with peanut butter wrapped in plastic wrap not labeled or dated was located in the cabinet.e. The 3rd floor nourishment room was observed to have 2 small plastic cups with what appeared to be cinnamon crumble located in the cabinet were not labeled or dated. f. a donut shop take-out of hot coffee with a bagel and a fried egg on a Styrofoam plate covered with a second plate was in the cabinet on the top shelf of the nourishment station of the 3rd floor. Interview and observation with FSD on 7/23/26 at 1:00 PM of the nourishment stations on both the 2nd and 3rd floor identified the above listed items. The FSD indicated that there should not be expired food items in the cabinets and that the plated food was not labeled or dated. Additionally, it was the responsibility of the dietary department to maintain and stock these stations. The FSD further indicated that the plated food likely did not belong to the residents but instead the NA's because it was up on the top shelf and the residents would not be able to reach it. Upon inquiry the FSD removed all expired items and unlabeled food and discarded it. A second tour of the Dietary Department with the FSD on 7/23/26 at 11:45 AM noted 15 individual Styrofoam cups with plastic lids containing (bite sized chicken, cauliflower, and puree pasta) on a metal tray in the oven set to 200 degrees to hold temperature to serve for lunch. Lids and side of containers appeared slightly crinkled when [NAME] #1 removed the tray from the oven. Interview with the FSD at the time of observations indicated that the Styrofoam cups and lids should not be used to hold food to temperature in the oven which was set for 200 degrees. FSD further indicated that they usually are in metal dishes, but they don't have enough for 2 floors, especially because the dish washer was broken.Interview with [NAME] #1 on 7/23/26 at 11:51 AM indicated that she wasn't aware that she shouldn't heat in Styrofoam. After surveyor inquiries, the FSD discarded the 15 Styrofoam cups and prepared new chicken bites, cauliflower, and puree pasta in metal dishes. Observation of the nourishment stations on the 2nd and 3rd floor on 7/27/26 at 12:15 PM identified the following:1a. A styrofoam plate with a toasted bagel and a pastry on it covered with another Styrofoam plate on the top shelf of the cabinet in the nourishment station on the 3rd floor.b. A banana on the top shelf of the cabinet in the nourishment station on the 3rd floor.Interview and observation with Registered Nurse supervisor (RN #7) on 7/27/26 indicated she thought it belonged to a staff member because the residents couldn't reach the top shelf, and there was not fresh fruit available to the residents. Additionally, RN #7 noted that the staff should not be using the nourishment stations for their personal food and believed the plated food belonged to the NAs. She further indicated that there was a breakroom on the first floor for them to store their food and take their breaks.The Open Food Storage policy (undated), directed, in part, all open food items that are being stored in refrigerators must be properly covered and have the date it was opened labelled on it. The policy further stated that the item needed to be discarded within appropriate timeframes. Despite multiple attempts for additional policies none were provided.

Based on observation, review of facility policy and interviews for 1 of 2 residents (Resident #10) reviewed for urinary catheter, the facility failed to ensure the urine collection bag was not lying on the ground and for resident bathrooms/rooms on the third floor, failed to ensure personal care items were properly labeled, covered, stored according to facility policy for resident bathrooms/rooms on the third floor. Additionally, the facility failed to ensure there was an appropriate system preventing, identifying, investigating, and controlling infections and communicable diseases according to standards for infection control related to surveillance/tracking, identification of upticks in infections, outbreak management for COVID-19, management of undiagnosed respiratory illness, and antibiotic stewardship tracking for review of antibiotic usage rates. The findings include:1.Resident #10 had diagnoses that included Parkinsonism, urinary retention, and dementia.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was moderately cognitively impaired, had an indwelling catheter, used a wheelchair, and was dependent with eating, bed mobility, transfers, and wheelchair mobility.The Resident Care Plan (RCP) dated 6/2/26 identified Resident #10 had a newly placed suprapubic tube (SPT). Interventions included changing the suprapubic tubing per urology recommendation, providing catheter care every shift, and monitoring urinary output every shift.A physician order dated 6/22/26 directed to connect the SPT to bedside drainage (bag) and check every shift with additional directive to place inside a privacy bag.Observation on 7/20/26 at 12:36 PM identified Resident #10 sitting in an upright position in his/her custom wheelchair in the 2nd floor dining room with the urine collection bag hooked beneath the wheelchair and the bag was observed to be sitting directly on the floor beneath the wheelchair.Observation on 7/20/26 at 1:03 PM identified Nurse Aide (NA) #1 pushed Resident #10 in his/her wheelchair from the 2nd floor dining room to the 2nd floor lounge/TV room near the nurses' station.Observation on 7/20/26 at 1:06 PM identified Resident #10 sitting in the custom wheelchair which was tilted back with the urine collection bag hooked beneath the wheelchair and the bag was observed to be sitting directly on the floor beneath the wheelchair.Interview and observation with NA #1 on 7/20/26 at 1:15 PM identified that Resident #10's urine collection bag was always hooked beneath the wheelchair when he/she was out of bed to the wheelchair. She indicated that it should not touch the ground, and upon observation of the urine collection bag sitting on the floor she indicated that the tubing must have stretched out. She then donned gloves and reattached the urine collection bag onto a different location under the wheelchair and verified it didn't touch the ground even when the wheelchair was fully upright.Review of the Nurse Aide (NA) Care Card dated 3/24/26 identified that Resident #10 had an indwelling catheter (foley). This was a discrepancy as Resident #10 had a suprapubic tube. The care card failed to identify any additional directions for the NA related to care of the catheter/urinary drainage bag.Interview with the Director of Nursing (DNS) on 7/27/26 at 12:38 PM identified it was not appropriate for Resident #10's urine collection bag to touch the floor or drag on the floor. She indicated that the bag needed to hang below the level of the bladder, and that while under the wheelchair might not work for every resident, as long as there was enough clearance to keep the urine collection bag off the floor, the bag could be placed under the wheelchair.Review of the Urinary Catheter Change policy directed, in part, urinary catheters were only changed as needed unless physician order directs otherwise. The policy directed urinary drainage bags will be changed as needed due to sediment buildup, discoloration of the bag, odor, or leakage. The policy does not include direction to ensure the urinary drainage bag is kept off the floor to prevent contamination.2. Observation on 7/20/26 at 12:30 AM identified the following:room [ROOM NUMBER] -2 wash basins on the floor, not labeled with the resident's name or covered.room [ROOM NUMBER]-1 wash basin uncovered and 1 emesis basin in the bathroom not labeled with the resident's name. room [ROOM NUMBER]-bedpan and wash basin on the floor not labeled with the resident's name and not covered.room [ROOM NUMBER]-mutliple wash basins stacked together on a plastic cart in the bathroom, not labeled with a resident's name or bagged.An observation made on 7/21/26 at12:23 PM noted room [ROOM NUMBER] basin on the floor in the bathroom was not labeled with the resident's name or coveredInterview and observation on 7/22/26 at 1:50 PM of all the rooms listed above with the DNS noted the same items continued to be on floor uncovered and not labeled with the resident's name. The DNS identified that all basins, bedpans and emesis basins should be labeled, bagged and not kept on the floor or on top of a plastic cart. Also, identifying the personal care items should be kept in the resident's bedside table. Further, identifying nursing was responsible for ensuring the personal care items were stored properly and the facility needed to provide more education.Review of the bedpan/urinal policy dated 4/2015 directed, in part, after the bedpan and urinal are used the bedpan/urinal should be cleaned, dried, covered and return it to the resident's bedside stand bagged.Although requested, a facility policy for storage of personal care items was not provided. 3. Review of the facility infection prevention (IP) program documentation failed to identify a mechanism for surveillance/tracking of potential infections before they can spread to other residents through tracking and monitoring of all residents with signs and symptoms of infection of any type upon identification of initial presenting signs and symptoms (including those residents whose signs and symptoms did not lead to initiation of an anti-infective agent), what the signs/symptoms were, what monitoring was in place to monitor the resident, and the progression of the signs/symptoms if any.a. Review of the facility IP program documentation identified ICN Long Stay Resident UTI tracking reports dated June 2026 and July 2026 were used by the Infection Preventionist (Licensed Practical Nurse (LPN) #4), for tracking of residents that had a urinary tract infection (UTI) which required an antibiotic. These reports were used for surveillance of only those residents with known infectionshowever the reports failed to show what signs/symptoms the resident had, the date signs/symptoms began, the date of any testing, interventions in place (encourage fluids, vital signs, medications initiated (non-antibiotic)). b. Review of the facility IP program documentation identified an ongoing ABT, IV and Device Tracking report (last updated 7/22/26) which was used by LPN #4 for tracking of known infections requiring antibiotics, antimicrobials, antivirals, and/or antifungals for the week but it was edited throughout the week and resolved infections and/or discharged residents were removed. The report was not used for long term tracking.Interview and review of facility documentation with LPN #4 on 7/22/26 at 10:42 AM identified his method of surveillance was to attend morning report, review the electronic medical record (EMR) progress notes, assessments, diagnostic tests, vital signs for abnormal results, and to review the facility 24-hour report for new anti-infective medication orders. He indicated that he would then use the information collected to update the multi-drug-resistant organism (MDRO) list and the ABT, IV and Device Tracking report. He indicated that there was a report for tracking of UTIs, but that the report did not include signs/symptoms for the residents and did not include those residents with signs/symptoms of a UTI that did not result in initiation of antibiotic treatment, nor did it reflect the onset date of symptoms or their resolution. He indicated that he did not have any type of system in place for tracking signs and symptoms (onset, description of signs/symptoms, interventions initiated, treatments, testing, resolution of signs/symptoms) of all potential communicable diseases or infections before they could spread to other residents and/or for use with prevention, identification, control and reporting of infections.Interview with LPN #4 on 7/27/26 at 10:22 AM identified the Director of Nursing Services (DNS) oversaw the infection prevention program and would assist him as needed with directives if he had questions or concerns. He indicated that she did not assist with the writing of reports but would review them prior to the quarterly Medical Staff meetings (Med-Staff) (an interdisciplinary meeting which included outside vendors to review clinical performance and manage facility operations and practices).Interview with the DNS on 7/27/26 at 12:38 PM identified she was responsible for the oversight of the IP program, and she would review any concerns with LPN #4, make sure any outbreaks were appropriately reported, that all reports were completed.Interview with the DNS on 7/27/26 at 3:25 PM identified surveillance and tracking of infections was done through UTI 3-day monitoring, and initiation of a line list with respiratory signs and symptoms. She was unable to identify a specific policy and or how infections should be monitored but indicated that there should be some system in place or a list/report which identified all residents with signs and symptoms of infections that were being monitored and tracked for use by staff with identification and investigation of infections and for use with response to infections to prevent their spread.4. Review of the facility IP program documentation failed to identify a mechanism for identification of upticks in infections through comparing infection rates monthly, quarterly or semi-annually with documentation of facility actions to identify, investigate, control and prevent increased infections.Review of the Monthly Infection Report by Unit dated January 2026 identified 4 units (AGS, AGN, HIS, IHN) with columns for eye/ear, upper respiratory (URI), lower respiratory (LRI), UTI (with or without a catheter), gastrointestinal, skin (soft tissue), wound (surgical/non-surgical), sepsis, and other. The report indicated that for each unit, infections were further separated into rows for healthcare acquired, community acquired, chronic, and asymptomatic. The report indicated for January 2026 there were 38 healthcare acquired infections.Review of the Monthly Infection Report by Unit dated February 2026 identified there were 34 healthcare acquired infections.Review of the Monthly Infection Report by Unit dated March 2026 identified there were 17 healthcare acquired infections.Review of the Medical Staff meeting (Med-Staff) Quarter 1 infection report identified 14 eye infections, 10 upper respiratory infections, 17 lower respiratory infections, 32 UTIs, 42 skin infections, 13 wound infections, and 1 sepsis infection for a total of 129 infections which required antibiotic treatment for January 2026-March 2026. This showed a discrepancy between the total infections for January 2026-March 2026 which totaled 131.The Med-Staff Quarter 1 infection report failed to identify trends or upticks in specific infection types from month-to-month or quarterly. The report failed to identify why there were 14 eye infections for the quarter with January 2026 and February 2026 both showing twice as many eye infections as March 2026 and failed to identify why there were 12 skin (soft tissue) infections in February 2026 when there were less than that in January (8) and March (6). Additionally, the report failed to identify why the total healthcare acquired infections for March 2026 (17) was half that of January 2026 (38) and February 2026 (34) and why skin (soft tissue) infections made up 32 % of the total number of healthcare acquired infections (26) for the quarter. The report indicated Total Infection Rates and listed each month and the number of infections which did not reflect that months infection rate based on resident care days. The report did include a healthcare acquired infection rate which also indicated the previous rate but did not break that rate down by month and/or unit for use with comparison and identification of upticks.Interview and review of facility documentation with LPN #4 on 7/22/26 at 10:42 AM identified his monthly infection reports and Med-Staff meeting quarterly infection reports failed to indicate any comparison to previous months and/or quarters to identify upticks of infections, identification of high rate (spikes) of infections for specific infection type (eye/ear, respiratory, UTI, skin, wound, gastrointestinal, sepsis) and why those rates were elevated (current outbreak, high community incidence, nursing staff competency/performance which required education intervention). Review of the Med-Staff Quarter 1 infection report identified 14 eye infections for the quarter, and LPN #4 indicated that he had not identified that as a concern and therefore had not initiated any education with nursing staff to decrease the number of residents with eye infections. He indicated that he had identified UTIs as a concern and had initiated a quality improvement plan for that but that he had not identified any other concerns related to high numbers of infections.Interview with LPN #4 on 7/27/26 at 10:22 AM identified he reviewed the monthly infection reports and the quarterly infection reports and would look for trends and or upticks, but that he did not have any formal mechanism in place for documenting and/or tracking these comparisons for use with providing necessary education to assist with addressing and preventing these infections. He further indicated that he did not have any documentation of identification of why there were high numbers of skin (soft tissue) infections and what was done to address it.Interview with the DNS on on 7/27/26 at 12:38 PM identified she reviewed the monthly infection reports and quarterly infection reports but that she was not aware LPN #4 was not comparing the reports to identify trends and upticks of infections, but that he should be.5. Review of the facility IP program documentation failed to identify the COVID-19 outbreak dated 9/15/25-4/20/26 was appropriately managed. There was no mechanism in place for formulating a comprehensive report for the outbreak which pulled together all the information collected during the outbreak and identified all necessary information related to the management of the outbreak for use in the investigation and control of the outbreak and to assist with prevention of similar outbreak by improvement of the facility response. The documentation failed to show a synopsis of the start and end date, date of first and last case, total number of staff and residents affected, total number of hospitalizations related to the outbreak (if any), and the total number of deaths related to the outbreak (if any). Additionally, the documentation related to the outbreak failed to identify the actual working line lists used during the outbreak with all pertinent information documented, failed to show what education was completed and when and for who the education was provided, failed to show what implementations were put in place such as closing of dining rooms, no or limited group activities, and use of universal masking (if mandated). The outbreak documentation failed to identify what Centers for Disease Control (CDC) recommendations were followed in the management of the outbreak, when and who at the local department of public health was notified, when the medical director and attending physician/Advanced Practice Registered Nurses were notified.Interview and review of facility documentation with LPN #4 on 7/22/26 at 10:42 AM identified he was responsible for reporting any outbreak to the state and local health departments, that he followed his facility policy for reportable diseases for what required reporting and when to report. He was unaware of the Connecticut Epidemiology Newsletter which was provided by the Department of Public Health for use with identification and reporting guidelines for all infections that required reporting. He indicated that the facility had been in a COVID-19 outbreak when he first started as the Infection Preventionist which had started in September 2025 and he had closed the outbreak in April 2026. He was unable to identify why the outbreak had spanned a 7-month period. He indicated that during the outbreak the facility followed CDC recommendations but he was unable to identify what specific recommendations were followed. He indicated the facility had encouraged staff and residents to wear masks inside the facility during the outbreak, but that mask use was only mandated for those residents with known positive COVID-19 test results when they needed to leave their rooms and for the staff when they were in the rooms of COVID-19 positive residents to provide care. He indicated that staff and residents who were not positive for COVID-19 were not mandated to wear masks when on the nursing units or inside the facility during the outbreak. He indicated that during the outbreak, new admissions were tested for COVID-19 on days 1, 3, and 5 after admission, and that any roommate of a resident that tested positive for COVID-19 would also be tested on days 1, 3, 5 after identification of their roommate testing positive for COVID-19. He indicated that the facility did not perform COVID-19 tests on residents exposed to COVID-19 caregivers unless they developed signs and symptoms and then only when ordered by the Advanced Practice Registered Nurse. He indicated that those residents who were exposed to the COVID-19 staff member would be monitored but he was unable to identify how staff would know to monitor them, if orders for monitoring would be put in their medical records, or where he documented those residents that were exposed and required monitoring inside his outbreak documentation. He indicated that the facility never initiated testing of a full wing/unit even if there were multiple new COVID-19 positive residents identified within a 1-2 day span of time. He indicated that education on use of personal protective equipment (PPE) was completed during the outbreak but was unable to identify if he had documented that education or had staff sign off on completion of that education. Additionally, he was unable to identify if staff and/or residents had been educated on COVID-19 during the outbreak as the organism identified for the outbreak and how to protect themselves and prevent further infection by that organism. He further indicated there was no requirement for testing of staff during the outbreak and that they did not perform staff testing.Review of the Resident COVID Outbreak Tracking report (not dated) failed to identify documentation of signs and symptoms and treatment for residents listed on the report for September 2025, October 2025, and November 2025. Additionally, for each resident listed within the report, the report failed to identify the resident's: age, gender, date of admission, onset date of symptoms, description of signs and symptoms, testing date, treatments initiated, date of family/responsible party notification, date of physician notification, date of resolution of signs/symptoms (if any). The report identified a recovered date for each resident listed that correlated with the resident's day 10 following their positive COVID-19 test and/or the date they were taken off isolation precautions (day 11 post positive COVID-19 test) however there is no information provided to indicate if those dates also indicated the resolution of symptoms.Review of the Staff COVID Outbreak Tracking report (not dated) failed to identify documentation of positive staff for September 2025 and October 2025. This was a discrepancy from the state agency outbreak reporting portal which identified the outbreak began 9/15/25 with a staff member testing positive for COVID-19. The report failed to identify the date the staff member last worked and where the staff member worked on that date and when their signs/symptoms began. Additionally, the report failed to identify if there were exposed residents that required testing due to exposure to the staff member.Review of the facility infection prevention program documentation for the outbreak failed to identify how the facility identified staff or residents who were exposed to positive staff, residents, and visitors. The documentation failed to identify what method was used for determination of what staff or residents needed to be tested such as contact tracing, when testing was completed, how often testing was completed. There were no lists or reports identified which indicated names of staff and residents who were tested for COVID-19 and what their results were.Review of both COVID-19 Outbreak Tracking reports (staff and resident) identified 13 staff members in total were affected by the outbreak and 34 residents (including 3 who may have been positive prior to admission) in total were affected by the outbreak. Review of the initial outbreak report (9/15/25) and 31 facility weekly reports (9/22/25-4/20/26) submitted to the state agency outbreak reporting portal identified the facility reported 15 positive staff members and 25 positive residents for their COVID-19 outbreak. This indicated a discrepancy from the 2 COVID-19 Outbreak Tracking reports (staff and resident) provided by the facility as their full outbreak documentation.Interview with LPN #4 on 7/27/26 at 10:22 AM identified he confirmed that staff were not mandated to wear masks within the facility during the outbreak unless they were providing care to a resident on transmission based precautions (TBP) for COVID-19. He indicated that was in line with recommendations by the CDC. Additionally, he indicated that residents were not required to wear masks inside the facility although it was encouraged. He indicated that they limited the interaction of residents with each other on the units and prevented the mixing of residents from different floors during the outbreak. He indicated that during the outbreak the facility did not offer free testing of COVID-19 to the staff, and there was no automatic testing of staff when new positive residents were identified even if staff were not wearing masks and provided care to those residents prior to them testing positive for COVID-19. He indicated that if staff wanted to be tested they were able to go to occupational health and/or purchase their own tests. LPN #4 indicated that he did not have any additional outbreak documentation besides the staff and resident COVID-19 Outbreak Tracking reports, and what was entered into the state agency outbreak reporting portal. He indicated that he did not have documentation of education completed and that he only provided education on donning and doffing PPE. He indicated that he did not provide education on COVID-19 in response to the outbreak. He indicated that he did not have actual line lists that were used during the outbreak, did not have a list of residents and/or staff that were tested for COVID-19, when they were tested, and what those results were, he did not have documentation of what resident were cared for by staff members in the 1-2 days prior to them testing positive for COVID-19. He indicated that he was not aware that documentation was needed for the identification, investigation, prevention, control, and reporting of the outbreak and the communicable disease which resulted in that outbreak. He further indicated that he followed CDC guidelines but was unable to identify how or which guidelines he referred to and indicated that they were part of the facility policy and were located within the policy book.Interview with the DNS on 7/27/26 at 12:38 PM identified she ensured the outbreaks were reported to the state agency and that weekly reports were completed in the state agency outbreak reporting portal, but that she was not aware of what documentation was maintained for the outbreak. She further indicated that the facility followed CDC guidelines for COVID-19 management but was unable to identify which guidelines were followed.Interview with the Administrator on 7/27/26 at 3:35 PM identified the facility followed CDC guidelines for COVID-19 management, but they were not printed and were not actually physically part of the policy inside the policy book. She further indicated that LPN #4 and/or nursing staff would reference the CDC COVID-19 recommendations located online at the CDC website but was unable to reference any specific page on that website to show what was used by the facility.6. Review of the facility IP program failed to identify a policy for undiagnosed respiratory illness. The lack of a facility policy contributed to inconsistent management of undiagnosed respiratory illness.Interview and review of facility documentation with LPN #4 on 7/22/26 at 10:42 AM identified there was no undiagnosed respiratory illness policy. He indicated the response to residents with undiagnosed respiratory signs and symptoms was not the same all year round. He indicated outside of a respiratory season (influenza) if a resident had signs/symptoms of respiratory illness the floor nurse would let him, the nursing supervisor, and/or the APRN know. He indicated that if he were in the facility at that time he would check for a vital sign order and line list orders and initiate a line list. He indicated that if there was only 1 resident with signs/symptoms of respiratory illness they would not do testing. He indicated the resident would be monitored but was unable to identify for how long, or what was included in the monitoring. Additionally, he indicated the residents were not placed onto any type of transmission-based precautions. He indicated if it was a respiratory season such as influenza, they would do testing of even 1 resident with respiratory signs/symptoms, but indicated there was no standing order for testing and they would do only the test requested by the APRN, and that the residents would not be placed onto any type of transmission-based precautions unless their test was positive for a respiratory illness. He indicated that the facility had the ability to test for COVID-19 and influenza as a rapid 2-in-1 test. He further indicated that if they were inside of an active respiratory outbreak (influenza/COVID-19) and a resident had respiratory signs/symptoms they would place that resident on transmission-based precautions and test them and if the test was negative, they would stay on those precautions until additional testing was completed per the APRN or until the symptoms resolved. LPN #4 was unable to identify why there was a difference in response to residents with undiagnosed respiratory illness depending on the time of year and/or if there was an active respiratory illness outbreak in the facility.Interview with the DNS on 7/27/26 at 3:25 PM identified there was no policy for undiagnosed respiratory illness. She indicated that residents with respiratory signs and symptoms should be reported to the provider so that orders can be obtained for treatment such as cough or inhaler medication. She further indicated there was no policy for testing or initiation of any type of transmission-based precautions related to residents with undiagnosed respiratory illness and was unable to identify if that was required.Review of the Surveillance for Healthcare-Associated Infections (HAIs) policy directed, in part, surveillance was the ongoing, systematic collection, analysis and interpretation of data collected, and that all residents who show signs/symptoms of infection will be closely monitored. The policy directed the suspected infections would be recorded by the infection preventionist (IP) on the infection control log. The policy directed when a resident had signs/symptoms of infection the nurse would document the resident name, type of infection, symptoms, and any antibiotics on the 24-hour report and inside their nursing notes. The policy directed the provider would be notified and monitoring of vital signs and intake/output would be implemented. The policy directed the IP would gather all data and formulate infection control reports that would be presented at quarterly Med-Staff meetings and would be available for review by all staff. The policy directed that residents with infections and/or possible infections would be monitored and on the Monthly Infection Report by Unit. The policy directed monthly reports would be reviewed by the IP, DNS and at the Med-Staff meetings to identify issues or trends and those concerns identified would have a plan of correction to address it. Additionally, the policy directed the IP would review the Monthly Infection Report by Unit for trends and new bacteria in the facility.Review of the CT Coronavirus (COVID-19) policy directed, in part, the policy followed recommendations from CDC, Centers for Medicare and Medicaid Services, and state and local health departments. The policy directed the facility does not require staff, visitor, and vendors to wear surgical masks inside the facility from November-March, but they were available upon request. The policy directed staff may choose not to wear surgical masks unless they have signs/symptoms of respiratory illness, confirmed respiratory illness, were recently positive for COVID-19 and until day 7 posttest were able to return to work with a mask, or if they are caring for a resident with a known respiratory illness in which they are required to wear a surgical mask or N-95 mask during care. The policy directed staff and visitor will be educated on COVID-19 and visitors will be encouraged but not required to wear a mask during respiratory season. The policy further directed the facility will follow CDC recommendations for employees and visitors with known exposure, PPE use, and guidance for testing and vaccinations. The policy directed for resident's line lists will be completed every shift for residents with respiratory symptoms, and if a resident had a temperature above 100.4 F and respiratory symptoms they would be placed on TBP pending test results.Review of CDC guidance with last update of 6/24/24 identified recommendations to ensure healthcare workers (HCP), residents and visitors were encouraged to remain up-to-date with vaccinations, there was process in place for identification and management of suspected (undiagnosed) and confirmed COVID-19 infection. Implement source control measures such as masks of varying levels of protection. Source control is recommended for all individuals (resident/staff/visitor) with suspected or confirmed respiratory infection or high risk exposure to a COVID-19 positive person. More broad use of source control was recommended for those residing on or working on a unit or area of the facility experiencing a respiratory illness outbreak. The recommendations for testing included anyone with even mild symptoms of COVID-19 should be tested as soon as possible, asymptomatic people with close contact to someone positive with COVID-19 should be tested by a series of 3 viral tests (Day 1, 3, 5). For facilities experiencing an outbreak of respiratory illness testing could be done by contact tracing or by the preferred broad based approach (entire unit/floor) when potential contacts cannot be identified or managed through contact tracing.Although requested a policy for undiagnosed respiratory illness was not provided.

Based on review of the clinical record, facility policy and interviews for 1 of 1sampled residents (Resident #3) reviewed for a change in condition, the facility failed to ensure an assessment was completed by a Registered Nurse (RN) for a low oxygen saturation level and for the only sampled resident (Resident #78) reviewed for pain management, the facility failed to ensure the licensed nursing staff administered medications according to standards of practice to ensure medication dosages were not administered too close together. The findings include: 1.Resident #3 diagnoses included Parkinson's disease, chronic obstructive pulmonary disease (COPD) and dementia.The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had severe cognitive impairment, requiring total assistance from staff with ADL care/hygiene and mobility. The Minimum Data Set assessment did not identify Resident #3 utilized oxygen.Review of the physician orders dated 4/12/26 identified Resident #3 did not utilize oxygen.Nursing notes dated 4/12/26 at 10:48PM identified Resident #3 had a change in condition regarding a low oxygen (O2) saturation of 84% on room air. Licensed Practical Nurse (LPN) #6 applied oxygen and the O2 saturation increased to 97% via nasal cannula with no documentation of a clinical assessment was performed by an RN to evaluate Resident #3 change of condition with a low oxygen level and the need for oxygen administration.Interview and record review with the DNS on 7/23/26 at 8:15 AM failed to identify an RN assessment had been completed with Resident #3's drop in O2 saturation. The DNS further stated that LPN #6 should have reported Resident #3's low oxygen saturation to the RN Supervisor and a RN assessment should have been completed and documented in the medical record.Interview via phone with the RN Supervisor (RN #5) on 7/27/26 at 9:55 AM identified that she was the RN Supervisor on the 3:00 PM to 11:00 PM shift on 4/12/26 and stated she was not notified of Resident #3 low oxygen level of 84% and the application of oxygen by LPN #6. RN #5 stated that she did not assess Resident #3 on 4/12/26 and that LPN #6 did not report Resident #3 change of condition to her.Although an RN Assessment policy was requested, the facility did not provide a policy for a RN Assessment.Review of facility's policy identified that professional staff would communicate with the physician regarding changes in condition to provide timely communication of the resident's status and when there is a need for treatments to be altered, changed, or to start a new form of treatment. 2. Resident #78 had diagnoses that included quadriplegia, chronic pain syndrome, and diabetes.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was cognitively intact, was independent with use of a motorized wheelchair, and was dependent for eating, personal hygiene, bed mobility, and transfers. Additionally, the MDS assessment indicated Resident #78 was taking the following high-risk drug class medications: antidepressant, anticoagulant, antibiotic, opioid, antiplatelet, hypoglycemic, and anticonvulsant.The Resident Care Plan (RCP) dated 5/20/26 identified Resident #78 was at risk for depression. Interventions included providing emotional support as needed, encouraging verbalization, and administering medications as ordered. The RCP further indicated Resident #78 was at risk for pain and had chronic pain related to impaired mobility. Interventions included administering pain medications as ordered, discussing with Resident #78 factors that trigger pain and what may reduce it, and discussing with Resident #78 to ask for pain medications before the pain becomes severe.A physician order dated 6/22/26 directed to administer Simethicone tablet 80 milligrams (mg) by mouth every 4 hours as needed for gas/bloating/pain.1a. A physician order dated 6/22/26 directed to administer Acetaminophen Extra Strength (ES) tablet 500 mg 2 tablets by mouth every 8 hours for pain with administration times of 12:00 AM, 8:00 AM, and 4:00 PM.Review of the Medication Administration Audit Report (MAAR) dated 6/26/26 identified the 8:00 AM dose of Acetaminophen ES was documented as administered at 12:27 PM (3 hr. and 27 min late), the 4:00 PM dose of Acetaminophen ES was administered on time by LPN #11 at 3:57 PM (3 hr. and 30 min after the previous dose despite physician orders to administer Acetaminophen ES every 8 hours).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of Acetaminophen ES were held after the late administration of the previous dose.b.A physician order dated 6/22/26 directed to administer Baclofen (a skeletal relaxer) tablet 20 mg by mouth 4 times a day for spasms with administration times of 9:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM.Review of the MAAR dated 6/25/26 identified the 9:00 AM dose of Baclofen was administered by LPN #1 at 11:48 AM (1 hr. and 48 min late), the 12:00 PM dose of Baclofen was administered by LPN #1 at 3:45 PM (2 hr. and 45 min late), and the 4:00 PM dose of Baclofen was administered on time by LPN #11 at 4:01 PM (which was 16 min after the previous dose).Review of the MAAR dated 6/25/26 identified Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr. and 13 min span of time.Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose.c. Review of the MAAR dated 6/26/26 identified the 9:00 AM dose of Baclofen was documented as administered by LPN #10 at 11:03 AM (1 hr. and 3 min late), the 12:00 PM dose of Baclofen was administered by LPN #10 at 1:30 PM (30 min late and 2 hr. 27 min after the previous dose), and the 4:00 PM dose of Baclofen was administered on time by LPN #11 at 3:57 PM (2 hr. and 27 min after the previous dose). Review of the MAAR dated 6/26/26 identified Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr. and 57 min span of time.Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose.d. Review of the MAAR dated 7/3/26 identified the 9:00 AM dose of Baclofen was documented as administered at 11:32 AM (1 hr. and 32 min late), the 12:00 PM dose of Baclofen was documented as administered on time at 11:45 AM (13 min after the previous dose). Additionally, the 4:00 PM dose of Baclofen was documented as administered on time at 3:51 PM (Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr and 19 min span of time).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of Baclofen were held after the late administration of the previous dose.e. Review of the MAAR dated 7/5/26 identified the 9:00 AM dose of Baclofen was documented as administered by LPN #9 at 11:30 AM on 7/5/26 (1 hr. and 30 min late), the 12:00 PM dose of Baclofen was documented as administered by LPN #9 at 2:44 PM (1 hr. and 44 min late).Review of the MAAR dated 7/5/26 identified the 4:00 PM dose of Baclofen was documented as administered on time by LPN #11 at 3:37 PM (53 min after the previous dose).Review of the MAAR dated 7/5/26 noted Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr. and 7 min span of time.Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose. f. Review of the MAAR dated 7/16/26 identified the 9:00 AM dose of Baclofen was documented as administered by LPN #9 at 12:20 PM (2 hr. and 20 min late). This shows the first dose was documented as administered after the time for the next dose (12:00 PM) and failed to identify the nurse was aware that the medication administration for 9:00 AM was completely missed due to it being time for the next dose.Review of the MAAR dated 7/16/26 identified the 12:00 PM dose of Baclofen was documented as administered by LPN #9 at 1:19 PM (59 min after the previous dose), the 4:00 PM dose of Baclofen was documented as administered on time at 4:52 PM (3 hr. and 33 min after the previous dose).Review of the MAAR dated 7/16/26 identified Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr. and 32 min span of time.Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose.g. Review of the MAAR dated 7/17/26 identified the 9:00 AM dose of Baclofen was documented as administered by LPN #1 at 12:08 PM (2 hr. and 8 min late). This shows the first dose was documented as administered after the time for the next dose (12:00 PM) and failed to identify the nurse was aware that the medication administration for 9:00 AM was completely missed due to it being time for the next dose. Additionally, the 12:00 PM dose of Baclofen was documented as administered by LPN #1 at 2:03 PM (1 hr. and 3 min late and 1 hr. and 55 min after the previous dose) and the 4:00 PM dose of Baclofen was documented as administered on time at 4:02 PM (1 hr. and 59 min after the previous dose).Review of the MAAR dated 7/17/26 identified Resident #78 received 3 doses of Baclofen 20 mg within a 3 hr. and 54 min span of time.Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose.2. A physician order dated 6/22/26 directed to administer Bethanechol Chloride ((used to treat urinary retention) tablet 25 mg by mouth 3 times a day for bladder spasms with administration times of 8:00 AM, 1:00 PM, and 8:00 PM.a. Review of the MAAR dated 6/26/26 identified the 8:00 AM dose of Bethanechol was documented as administered by LPN #10 at 12:27 PM (3 hr. and 27 min late), the 1:00 PM dose of Bethanechol was administered on time by LPN #10 at 1:30 PM (1 hr and 3 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of Bethanechol were held after the late administration of the previous dose.b. Review of the MAAR dated 7/2/26 identified the 8:00 AM dose of Bethanechol was administered by LPN #8 at 11:04 AM (2 hr. and 4 min late), the 1:00 PM dose of Bethanechol was administered on time by LPN #8 at 1:26 PM (2 hr. and 22 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of bethanechol were held after the late administration of the previous dose.c. Review of the MAAR dated 7/16/26 identified the 8:00 AM dose of Bethanechol was administered by LPN #9 at 12:20 PM (3 hr. and 20 min late), the 1:00 PM dose of Bethanechol was administered on time by LPN #9 at 1:19 PM (59 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of bethanechol were held after the late administration of the previous dose.d. Review of the MAAR dated 7/17/26 identified the 8:00 AM dose of Bethanechol was administered by LPN #1 at 2:03 PM (5 hr. and 3 min late) and the 1:00 PM dose of Bethanechol was administered by LPN #1 at 2:41 PM (38 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose.3a. A physician order dated 6/22/26 directed to administer Buprenorphine Hydrochloride-Naloxone Hydrochloride Dihydrate (used to treat opioid disorders) sublingual tablet 2-0.5 mg by mouth sublingually 2 times a day for chronic pain with administration times of 8:00 AM and 8:00 PM.Review of the MAAR dated 6/26/26 identified the 8:00 AM dose of Buprenorphine Hydrochloride-Naloxone Hydrochloride Dihydrate sublingual tablet 2-0.5 mg was documented as administered by LPN #10 at 12:28 PM (3 hr. and 28 min late).A progress note written by APRN #2 on 7/1/26 at 1:15 PM identified Resident #78 was seen at his/her request for persistent left ankle pain. The note indicated Resident #78 had recently demonstrated escalating behavioral concerns including calling law enforcement with non-emergent calls including the reporting of delays in medication administration although the nursing documentation indicated the medications were administered on time. This note shows a discrepancy from the documented administration times of 16 medications administered late on 7/1/26 identified on the MAAR dated 7/22/26. b.Review of the MAAR dated 7/16/26 identified the 8:00 AM dose of Buprenorphine Hydrochloride-Naloxone Hydrochloride Dihydrate sublingual tablet 2-0.5 mg was administered late by LPN #9 at 12:20 PM (3 hr. and 20 min late).c.Review of the MAAR dated 7/17/26 identified the 8:00 AM dose of Buprenorphine Hydrochloride-Naloxone Hydrochloride Dihydrate sublingual tablet 2-0.5 mg was administered by LPN #1 at 12:11 PM (3 hr. and 11 min late).4. A physician order dated 6/22/26 directed to administer Gabapentin (used to treat nerve pain) tablet 800 mg by mouth 3 times a day for pain with administration times of 8:00 AM, 1:00 PM, and 8:00 PM.a. Review of the MAAR dated 6/25/26 identified the 8:00 AM dose of Gabapentin was administered by LPN #1 at 11:46 AM (2 hrs. and 46 min late), the 1:00 PM dose of Gabapentin was administered by LPN #1 at 3:45 PM (1 hr. and 45 min late).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.b. Review of the MAAR dated 6/26/26 identified the 8:00 AM dose of Gabapentin was documented as administered by LPN #10 at 12:29 PM (3 hr. and 29 min late), the 1:00 PM dose of Gabapentin was administered on time by LPN #10 at 1:30 PM (1 hour and 1 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.c. Review of the MAAR dated 6/28/26 identified the 8:00 AM dose of Gabapentin was administered by LPN #12 at 9:46 AM (46 min late), the 1:00 PM dose of Gabapentin was administered on time by LPN #12 at 12:03 PM (2 hour and 17 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.d.Review of the MAAR dated 7/2/26 identified the 8:00 AM dose of Gabapentin was administered by LPN #8 at 11:05 AM (2 hr and 5 min late), the 1:00 PM dose of Gabapentin was administered on time by LPN #8 at 1:26 PM (2 hr and 21 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.e. Review of the MAAR dated 7/3/26 identified the 8:00 AM dose of Gabapentin was administered by LPN #1 at 11:32 AM (2 hr. and 32 min late), the 1:00 PM dose of Gabapentin was administered on time by LPN #1 at 1:53 PM (2 hr. and 21 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.f. Review of the MAAR dated 7/16/26 identified the 8:00 AM dose of Gabapentin was administered by LPN #9 at 12:20 PM (3 hr and 20 min late), the 1:00 PM dose of Gabapentin was administered on time by LPN #9 at 1:19 PM (59 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.g. Review of the MAAR dated 7/17/26 identified the 8:00 AM dose of Gabapentin was administered by LPN #1 at 12:07 PM (3 hr and 7 min late), the 1:00 PM dose of Gabapentin was administered by LPN #1 at 2:41 PM (2 hr and 34 min after the previous dose).Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of gabapentin were held after the late administration of the previous dose.Review of nursing notes from 7/1/26-7/27/26 failed to identify a nursing note which indicated that several of Resident #78's medications were administered late and that the MD/APRN were contacted for direction related to the late administration of the medications and/or to obtain direction related to the administration of subsequent doses of medication. (please refer to F 580).Interview with Resident #78 on 7/20/26 at 9:43 AM in his/her room identified Resident #78 stated that when a particular nurse (LPN #1) was working he/she received medication late and sometimes it was not administered until almost 12:00 PM. Resident #78 stated he/she had reported the late administration of medication to the nurses and the Advanced Practice Registered Nurse (APRN) and they had told him/her that they would talk to her (LPN #1). Observation on 7/23/26 at 9:43 AM identified LPN #1's medication cart outside Resident #78's room and she was inside the room administering Resident #78's medication. Interview with LPN #1 on 7/23/26 at 9:45 AM identified she had just finished administering Resident #78's morning medications. She indicated the acceptable time period for medication administration was between 1 hour before the scheduled time and 1 hour after the scheduled time. She confirmed that she often administered medication to Resident #78 outside of that acceptable time range for administration because her medication pass was demanding. Additionally, she indicated that today she still had 7 residents to administer medications to after Resident #78 on her medication pass and that all those residents' medications were late. She further indicated she did not tell the nursing supervisor or APRN when she administered medications outside the allowed parameters of 1 hour before the scheduled time and 1 hour after the scheduled time. Additionally, she was unable to identify why she didn't notify them but indicated that she should have notified them.Interview and clinical record review with Registered Nurse (RN) #4 on 7/23/26 at 10:45 AM identified she had not been told by any of the nurses that they were having difficulty completing their medication administration timely. She indicated that the nurse(s) this week have not told her of any medications being given late and she was surprised to see the administration times in the computer for the medications today. She indicated that if she had been informed of the late medication administration she would have contacted the APRN to notify them and then would have looked at when the next dose was due so that it could either be retimed or held, and she would have written a note detailing what was done.Interview with Pharmacist #1 on 7/23/26 at 11:16 AM identified Buprehorphine Hydrochloride-Naloxone Hydrochloride Dihydrate sublingual tablets required consistent administration at all times to maintain appropriate pain control when used for pain. She indicated that it was advisable to administer medications spaced at the frequency ordered by the physician and it was not advisable to administer medications too close together or to take 2 doses almost concurrently. She indicated that when Gabapentin was administered too close together the resident should be monitored for tremors, digestion changes (diarrhea), breathing changes (slow, shallow breaths), double vision, drowsiness, or change in mental status. She indicated when Bethanechol was administered too close together the resident should be monitored for low blood pressure, heart rate changes, breathing changes, abdominal cramps, nausea, vomiting, diarrhea, and increased secretions. She further indicated when lactulose was administered too close together the resident should be monitored for fluid status, stool frequency, abdominal discomfort, blood sugar changes, and diarrheaInterview and clinical record review with APRN #2 on 7/27/26 at 12:17 PM identified it had been only 7/1/26 that Resident #78 informed her about late medication administration, but she had looked and thought the administration was documented as completed on time. (This is a discrepancy from the documented administration times in the MAAR dated 7/22/26) She indicated that the nurses informed her occasionally of Resident #78 refusing a medication but that she had not been informed of frequent occasions of Resident #78 receiving multiple medications significantly late. She indicated that medications should be administered consistently at the frequency and time directed within the physician orders to prevent adverse effects of administration of medication doses too close together. She indicated that baclofen, gabapentin, bethanechol, lactulose, and acetaminophen should not be administered less than 2.5 hours between doses and that administration of medication doses too close together for the same medication puts the resident at risk of serious adverse effects. She indicated she would need to review Resident #78's clinical record and the administration times to determine the potential adverse effects for Resident #78 related to his/her medications.Interview with the DNS on 7/27/26 at 12:38 PM identified the acceptable time period for medication administration was between 1 hour before the scheduled time and 1 hour after the scheduled time which provided a 2 hour window for medication administration. She indicated that when medications were administered outside that 2-hour window of time, the MD/APRN should be notified. She indicated that it was not acceptable for medications to be administered as much as 3-4 hours after the scheduled time with the next scheduled dose of medication administered less than 2.5 hours later. Additionally, she indicated that if medications were administered that late the APRN/MD should be updated so that the medication and/or their administration times could be re-evaluated to determine why they were administered late.Review of the MAAR dated 7/22/26 for 7/1/26-7/22/26 identified 19 out of 22 days medications were administered late to Resident #78 on the 7:00 AM-3:00 PM shift outside of the 1 hour before the scheduled time and 1 hour after the scheduled time acceptable administration range. The MAAR further indicated that on 7 out of 19 late administration days the medications were administered less than 1 hour late, on 6 out of 19 late administration days the medications were administered greater than 1 hour but less than 2 hours late, on 4 out of 19 late administration days the medications were administered greater than 2 hours but less than 3 hours late, and on 2 out of 19 late administration days the medications were administered greater than 3 hours but less than 4 hours late. The MAAR indicated 1 out of 22 days Resident #78 was not in the facility for medication administration and further indicated that all medications were administered to Resident #78 on time 2 out of 22 days.Review of the Medication Administration-Oral policy dated June 2015, directed, in part the nurse should verify the medication order in the Medication Administration Record matched the physician order, and verify the medication is being administered at the proper time to reduce the risk of medication errors. The policy directed to document medication administration. The policy failed to direct parameters for the acceptable range of medication administration times before and after a medication to ensure medications were administered at the proper time.

Based on interviews and review of facility documentation for 4 of 5 staffing agency staff (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #8 and #9 and Nurse Aide (NA) #6 and #9), the facility failed to ensure agency staff received orientation/training to the facility. The findings include:A review of the nursing schedule for 7/19/26 indicated that there were 2 staffing agency NA's, NA #6 and NA #9 that worked on the 3rd floor on 7:00 AM to 3:00 PM shift.A review of the nursing schedule for 7/22/26 for 11:00 PM to 7:00 AM shift indicated that all 3 licensed staff that worked, 1 Registered Nurse (RN #1), 2 NAs (NA #6 and NA #9), 2 LPNs, (LPN #8 and LPN #9) were from a staffing agency.Interview with the Nursing Scheduler on 7/23/26 at 12:15 PM noted that all staffing agency nursing staff (NAs, LPNs, and RNs) were required to complete orientation packets for the facility. Orientation packets include but were not limited to job description, fire safety/disaster/emergency preparedness, electrical safety, infection control, patient safety, resident rights, abuse, security and privacy, harassment, corporate compliance and the electronic medical record system.On 7/23/26 at 12:25 PM an interview and request was given to the Nursing Scheduler to provide the orientation packets for NA #6, NA #9, RN #6, LPN #8 and LPN #9. The scheduler was only able to provide a completed orientation packet for LPN #8 (4 out of 5 agency staff did not have an orientation completed). The Nursing Scheduler was unable to explain the reason 4 out of the 5 agency nursing staff did not have an orientation packet completed. Furthermore, she was unable to note if a packet was left for the 4 agency nursing staff to complete as they had worked in the facility on dates prior to 7/23/26. The Nursing Scheduler did indicate that she had started a spreadsheet to keep track of agency staff that had completed orientation but was unable to explain why orientation packets were not provided to the 4 agency staff to complete.A review of agency staff work history at the facility revealed that NA #6 had worked 10 shifts in July, NA #9 had worked 1 shift in July, LPN #9 had worked 5 shifts in July and RN #1 had worked 4 shifts in July. All had ample opportunities to complete orientation to the facility. Interview with the Administrator and DNS on 7/23/26 at 2:15 PM were unsure why the agency staff did not have an orientation packet completed and that they all should have had an orientation to the facility. The Administrator indicated the Nursing Scheduler was responsible for booking agency staff and ensuring they receive orientation to the facility in a timely manner.Although requested, a policy for agency staff orientation was not provided.

Based on interviews, review of the clinical record, and facility documentation for 1 of 2 sampled residents (Resident #4) reviewed for Urinary Tract Infections (UTI), the facility failed to provide incontinent care timely when Resident #4 was incontinent of urine, resulting in Resident #4's incontinent brief being saturated with urine, and causing an undignified experience. The findings include: Resident #4 was admitted to the facility in November 2023 with diagnoses that included traumatic brain injury (TBI), quadriplegia, and speech disturbances (abnormalities of speech related to TBI).The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #4 had unclear speech, could usually make self-understood and sometimes understood others. Resident #4 was unable to participate in a Brief Interview for Mental Status (BIMS) for cognition due to having unclear speech. Resident #4 was totally dependent on staff for all activities of daily living (ADLS), was fed via tube feeding, always incontinent of urine and bowel, and transferred to a wheelchair with assist of 2 staff members using of a full mechanical lift.The Resident Care Plan (RCP) dated 4/29/26 identified a communication deficit as an area of focus related to TBI with interventions that included that Resident #4 was nonverbal, use simple language in yes/no format, use yes/no board or raise left hand for yes and lower left hand for no, and will kick left leg for needs (always ask if needs toilet, if not needs to be changed) and enjoys nonlinguistic activities such as coloring and painting). The RCP also identified bladder/bowel incontinence and chronic urinary tract infections (UTI) related to urinary retention as another area of focus with interventions that included maintenance toileting program to be toileted/bedpan before and after meals, at hour of sleep and as needed if able, will raise hand to let you know has to use the bathroom and will shake leg for urgent bathroom use, observe nonverbal cues for using the bathroom, report if does not void, provide incontinent care per incontinent episode and as needed, provide a brief and use barrier cream as indicated, monitor for symptoms of UTI, offer fluids, administer medications as ordered for UTI prevention and pain to help reduce symptoms of discomfort.Physician orders dated 5/19/26 directed to ensure resident was out of bed and ready at 10:00 AM every day, offer toilet/bedpan approximately every 2 hours while awake as can void or have bowel movement on toilet to decrease UTIs, monitor for signs and symptoms (S/S) of yeast infection every shift related to frequent antibiotic use for UTI, administer Cranberry tabs 450 milligrams (mg) via feeding tube 2 times a day, administer Silodosin (urinary retention) 8 mg once a day and Methenamine Hippurate (antiseptic for urinary tract) 1000 mg twice a day. Interim physician orders dated 6/1/26 directed to administer Rocephin 1 gram (gm) intramuscular (IM) injection one time for possible UTI, Diflucan (antifungal/used for yeast infections) 100 mg one time. Physician orders dated 6/22/26 direct to administer an antibiotic Ciproflaxin 250 mg 2 times a day for 7 days (ending 6/30/26) for UTI.Physician orders dated 7/4/26 directed to administer Diflucan 100 mg at bedtime for milky, rancid urine for 7 days and physician's orders dated 7/21/26 directed to administer an antibiotic of Augmentin 875-125mg 2 times a day for 7 days (ending 7/28/26) for UTI.Interview with Person #2 on 7/22/26 at 8:21 AM noted he/she had concerns regarding Resident #4 having frequent UTIs. Person #2 stated that Resident #4 was recently treated for a UTI and was now on another course of antibiotics for a UTI. Person #2 indicated that the urologist had informed her that Resident #4's frequent UTIs were partially due to Resident #4 not being toileted and not being provided incontinent care timely. Person #2 stated that he/she had informed nursing staff and administration that Resident #4 sits in his/her incontinent brief for extended periods of time without the benefit of being provided with incontinent care. Person #2 stated that he/she was tired of telling staff and filling out grievance forms as nothing changes. Furthermore, Person #2 indicated on Sunday, 7/19/26 he/she came into the facility to take Resident #4 out on a leave of absence for the day. Resident #4 was still in bed at ll:30 AM and AM care had not yet been provided. Person #2 stated that Nurse Aide (NA) #6, who she had never seen before, was Resident #4's NA. NA #6 told Person #2 at 11:30 AM that she was behind on her assignment and had not yet provided care to Resident #4. Person #2 proceeded to inform NA #6 that he/she him/herself would provide AM care to Resident #4. Person #2 stated that Resident #4's brief was saturated with urine, that urine had soaked through the brief and the bed linens were completely wet with urine when he/she provided care to Resident #4. Person #2 indicated that NA #6 and Resident #4's charge nurse, Licensed Practical Nurse (LPN) #7 were aware that Resident #4 was saturated with urine and did not have incontinent care provided until 11:30 AM (4 1/2 hours from the start of the 7:00 AM to 3:00 PM shift).On 7/22/26 at 9:00 AM the DNS was made aware by the surveyor about the concerns Person #2 stated regarding Resident #4 not receiving incontinent care until 11:30 AM on 7/19/26 and was found saturated with urine. The DNS completed a Grievance Form and initiated an investigation on 7/22/26. In addition, Social Worker (SW) #1 was made aware. The Grievance Form and DNS summary indicated that LPN #7 stated that she had directed NA #6 to provide care to Resident #4 by 10:00 AM and that other NAs on the unit had informed NA #6 that Resident #4 needed to be up and out of bed by 10:00 AM. In addition, the DNS indicated in her summary that NA #6 was not redirectable and did not follow the charge nurse's directives regarding Resident #4's care. The DNS contact NA #6's agency (as NA #6 was employed by a nurse staffing agency) and placed her on the do not return list due to not being redirectable, poor performance, and not following the charge nurse's directives. Person #2 was made aware of the outcome of the grievance on 7/22/26 at Resident #4's RCP meeting. Interview with NA #6 on 7/23/26 at 8:17 AM noted that she was aware that Resident #4 needed to be up by 10:00 AM as the other NAs and the charge nurse had informed her in the morning. However, NA #6 stated that she had never worked at the facility on the 7:00 AM to 3:00 PM shift and there were so many things going on. NA #6 stated that it was very busy and she did her best to prioritize the needs and safety of the residents. NA #6 stated she had apologized to Person #2 that she had not been timely with Resident #4's care and that Resident #4 was extremely incontinent of urine that his/her bedlinens needed to be changed. NA #6 indicated stated that although she did not notify LPN #7 until after Person #2 provided care to Resident #4, LPN #7 knew that NA #6 was running behind on her assignment and was having difficulty in completing her assignment timely. Furthermore, NA #6 indicated that she had never received orientation to the facility nor had anyone ever approached her about completing an orientation packet.Attempts to contact LPN #7 were unsuccessful. A review of Resident Rights Policy dated 9/22/25 directed, in part, you have the right to be treated with courtesy, dignity and respect and receive care that promotes quality of life. You have the right to participate in planning your care and treatment, including the development and implementation of your person-centered care plan of care, and to be fully informed in advance regarding changes in care and treatment.

Based on observation, interview, and record review and review of facility policy for 1 of 1 sampled resident (Resident #26) observed with medication at the bedside, the facility failed to ensure a Self-Administration of Medication Assessment was completed prior to allowing Resident #26 to self-administer an inhaler. The findings include: Resident #26's diagnoses included asthma, atrial fibrillation, and coronary heart diseaseThe Quarterly Minimum Data Set assessment dated [DATE] identified Resident #26 cognitively intact, independent with activities of daily living (ADLs) cares/hygiene, and mobility.Observation on 7/20/26 at 10:25 AM and at 2:00 PM with Licensed Practical Nurse (LPN) #1 noted Resident #26 sitting on his/her bedside chair watching television and an Arnuity inhaler was located unsecured on Resident #26's bedside table. Interview with Resident #26 on 7/20/26 at 10:30 AM identified that the Arnuity inhaler was left with Resident #26 by LPN #1 to self-administer. Resident #26 stated the nurses will just leave the inhaler for him/her to take by him/herself. Resident #26 stated he/she had already used the inhaler that morning and stated that he/she takes the inhaler by him/herself once a day around breakfast time. Interview with LPN #1 on 7/20/26 at 2:00 PM indicated that she provided the inhaler to Resident #26 that morning on 7/20/26 at 8:22 AM for the resident to self-administer. LPN #1 stated she was unaware of what the facility's policy was for residents to be able to self-administer medications. LPN #1 stated that she left the inhaler with Resident #26 earlier that morning, watched Resident #26 take his/her pills but did not watch him/her take the Arnuity inhaler. LPN #1 stated that she could not provide a reason why she left the inhaler with Resident #26 but that she should not have left the inhaler with Resident #26 to self-administer.Interview with the DNS on 7/23/26 at 8:00 AM indicated that LPN #1 should not have left the Arnuity inhaler for Resident #26 to self-administer because Resident #26 did not have a Self-Administration of Medication Assessment completed allowing for the self-administer the Arnuity inhaler. The DNS further indicated Resident #26 did not have a physician's order to self-administer the inhaler and stated in order for a resident to be able to self-administer medications, the facility would need to complete a Self-Administration of Medication Assessment, obtain an MD order to self-administer the medication, and obtain a lockbox for the medication at bedside.Review of Resident #26 clinical records on 7/23/26 at 8:00 AM with the DNS revealed that no Self-Administration of Medication Assessment was completed to determine Resident #26 ability to safely self-administer the inhaler and failed to identify a physician order directing Resident #26 to self-administer medications.Review of the facility's Self-Administration of Medication Policy identified that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The results of the interdisciplinary team assessment are recorded on the Medication Self- Administration Assessment Form, which is placed on the resident's medical record. Bedside medication storage is permitted when certain conditions are met for bedside storage to occur. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #12) reviewed for discharge, the facility failed to ensure a resident had appropriate bariatric accommodations while at the facility. The findings include: Resident #12 had diagnoses that included lymphedema, morbid obesity, and diabetes.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #12 had an activities of daily living (ADL) (bathing, dressing, eating, toileting, transfers, and mobility) performance deficit related to morbid obesity and weakness. Interventions included to encourage Resident #12 to get out of bed with all meals and providing assistance of 1-2 staff members with ADLs. The RCP failed to identify Resident #12 required a bariatric bed, bariatric commode, bariatric walker/rollator, bariatric wheelchair and/or bariatric bedside chair, and a long-handled sponge related to morbid obesity and limited mobility.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact, had functional limitation in range of motion to both upper extremities and both lower extremities, used a wheelchair, was independent with eating, required substantial/maximal assistance with bed mobility, chair/bed transfers, and walking, and was dependent with toileting hygiene, lower body dressing, and toilet transfers. The MDS assessment failed to identify Resident #12's weight.Review of the clinical record identified on 4/30/26 Resident #12 weighed 533.8 pounds (lbs.) on a sitting (chair) scale.A Physical Therapy (PT) Discharge summary dated [DATE] identified Resident #12 had equipment at home prior to hospitalization of a wheelchair, rollator, rolling walker, 2 canes, and a shower chair. The summary indicated discharge from service recommendations for Resident #12 were to ambulate with nursing staff at least 1 time each day, and to use a commode for toileting instead of a bed pan.An Occupational Therapy (OT) Discharge summary dated [DATE] identified Resident #12 required minimum assistance with toileting using a raised toilet seat/3 in 1 commode. The summary indicated Resident #12 had equipment at home prior to hospitalization of a wheelchair, hospital bed, 4 wheel walker, 2 canes, and a tub seat.Review of the clinical record identified on 6/26/26 Resident #12 weighed 587.6 lbs. on a standing scale and on 7/16/26 Resident #12 weighed 601.4 lbs. on a standing scale.An Advanced Practice Registered Nurse (APRN) note written by APRN #2 on 7/14/26 at 10:15 AM identified Resident #12 asked why he/she continued to have recurrent medical issues. The note indicated Resident #12 was educated that his/her choice to remain bed bound contributed to edema, impaired skin integrity, cellulitis and increased risk for pneumonia due to the immobility when in bed. The note indicated Resident #12 was educated that it was important to get out of bed every day. The note further indicated that Resident #12 verbalized understanding and indicated he/she would try to get up to the commode that day.A (late entry) social service note written by Social Worker (SW) #1 on 7/20/26 at 10:55 AM identified Resident #12 had a wheelchair and walker at the facility that would go home with him/her on discharge and indicated that Resident #12 had a commode at home.Observation on 7/20/26 at 11:25 AM in Resident #12's room identified Resident #12 was sitting in a bariatric hospital bed with the head of bed elevated and an overbed table across the bed positioned over Resident #12's thighs. No bedside chair was observed in the room, no wheelchair was visible inside the open area of the room, a folded rollator was observed leaning against the wall, and a bariatric commode was observed behind the door at the entrance to the room.A nursing note written by Licensed Practical Nurse (LPN) #1 on 7/20/26 at 7:36 PM identified Resident #12 refused to transfer to the commode and did not ambulate this shift due to not feeling safe because his/her walker and wheelchair had a weight capacity of 500 lbs.Review of the clinical record identified on 7/21/26 Resident #12 weighed 602.0 lbs. on a mechanical lift scale.Interview and observation with Resident #12 on 7/21/26 at 11:30 AM in Resident #12's room identified Resident #12 was sitting in a bariatric hospital bed with the head of bed elevated and an overbed table across the bed positioned over Resident #12's thighs. No bedside chair was observed in the room, no wheelchair was visible inside the open area of the room, a folded rollator was observed leaning against the wall, and a bariatric commode was observed behind the door at the entrance to the room. Additionally, several clear plastic bags with belongings were noted on the floor along the left side of the bed. Resident #12 identified while at the facility the nursing staff had wanted him/her to use a commode, but the commode was too small. He/she indicated that the wheelchair he/she was using was a wheelchair from home, but it was too small and it was painful to sit in because it rubbed on the sides of his/her hips and thighs. He/she indicated that the facility told him/her that he/she couldn't get a new wheelchair until after he/she went home.Interview with SW #1 on 7/21/26 identified Resident #12 had a personal wheelchair that he/she had brought from home. He/she was unable to identify if that wheelchair remained appropriate for him/her, and again indicated it was what he/she had from home.Interview with the DNS and Administrator on 7/21/26 at 2:48 PM identified Resident #12 had a bariatric wheelchair at the facility that he/she had brought from home.Interview and observation with Nurse Aide (NA) #1 on 7/22/26 at 1:59 PM identified Resident #12 was supposed to get out of bed at least once a day and indicated that when Resident #12 got out of bed he/she sat on the commode. She indicated that there was nothing else inside the room for the resident to sit on except for the commode because Resident #12 said the wheelchair was too small. Additionally, she indicated that Resident #12 would only sit out of bed for about 5 minutes on the commode and then would go back to bed. She further indicated that Resident #12 had not gotten out of bed for her in the last 1.5 months except to get weighed. NA #1 removed Resident #12's personal wheelchair from inside the closet in Resident #12's room and it was observed to be labeled with Resident #12's name. The manufacturer label on the wheelchair indicated it came from Medline and was 24 inches wide by 18 inches deep (24x18 inches).Review of the Medline At Home website identified Resident #12's personal wheelchair in his/her room was an extra-wide bariatric wheelchair with a weight capacity of 500 lbs.Review of the clinical record identified on 4/30/26 Resident #12's weight exceeded the weight capacity of the wheelchair by 33.8 lbs. and on 7/21/26 Resident #12's weight exceeded the weight capacity of the wheelchair by 102.0 lbs.Interview with APRN #2 on 7/27/26 at 12:17 PM identified she was on vacation last week but that prior to going on vacation she had known Resident #12 was expected to be discharging soon, she had told the facility that he/she needed a larger wheelchair and that she would sign any prescription for the wheelchair that they needed. She further indicated that no one had asked her for that prescription.Interview with Physical Therapist (PT) #1, the Director of Rehabilitation on 7/27/26 at 1:23 PM identified Resident #12 had a wheelchair that was brought from home and that she had concerns regarding the wheelchair not being appropriate for use by Resident #12 due to his/her weight. She indicated that she had looked into obtaining a larger sized wheelchair with a higher weight capacity but there were none available at loaner closets and in order to purchase a new one, the current one would need to be returned and that process was only able to be done after Resident #12 discharged home, so she had recommended to the Administrator that the facility rent one while Resident #12 was in the facility. She indicated that Resident #12 was recommended to get out of bed at least once a day to maintain mobility, but that Resident #12 frequently refused. She was unable to identify where Resident #12 was expected to sit when out of bed if the wheelchair was too small and there was no chair inside the room. She indicated that she was unsure if there was any type of chair within the facility that would meet the required weight capacity for Resident #12 to sit when out of bed and indicated that she had not been requested to ensure there was an appropriate sized chair available for Resident #12 when out of bed.Interview with the Administrator on 7/27/26 at 3:17 PM identified that the facility was responsible for ensuring that all residents had the necessary equipment and supplies to meet their needs while inside the facility. She confirmed that the therapy department had recommended rental of a wheelchair, but that due to the size of the equipment it would have created a hindrance in his/her room to ambulate and move around. She indicated that Resident #12 was able to ambulate and had a rollator and if he/she wanted to sit out of bed, there was a couch down in the lounge near the nurses' station that he/she could sit on if he/she walked down the hall. She was unable to identify if Resident #12 was functionally capable of walking down the hall to sit in the lounge at this time, nor what he/she would be expected to do if he/she didn't want to sit in a public location visible to other residents and visitors and just wanted privacy to sit out of bed in his/her own room. Additionally, she indicated that having extra equipment such as a larger bariatric wheelchair or a bariatric chair in the room would have made it difficult for Resident #12 and staff to maneuver around inside the room and did not identify why the facility didn't provide additional space to accommodate the necessary equipment/chair Resident #12 needed to function out of the bed. She indicated that the commode was not an appropriate place for Resident #12 to have been expected to sit when out of bed. She further indicated that the facility should have ensured Resident #12 had an appropriate bariatric accommodation for when he/she was out of bed and indicated that without something available inside his/her room there was not much motivation for him/her to get out of bed.Subsequent to surveyor inquiry, a nursing note written by LPN #1 on 7/27/26 at 4:27 PM identified a bariatric wheelchair with leg rests was delivered for Resident #12 and indicated that the wheelchair was unable to fit through the door of Resident #12's room with the leg rests in place.Review of the Wheelchair policy, dated April 2015, directed, in part, an appropriate wheelchair will be provided for non-ambulatory residents and/or residents that need assistance with greater distances. The policy directed the wheelchair should not be too large or too small for the resident.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only resident (Resident #6) reviewed for notification of change, the facility failed to notify the resident representative of a medication change and an injury of unknown origin. Additionally, for 2 of 2 residents (Resident #52 and Resident #78) reviewed for medication omissions, the facility failed to ensure the Medical Doctor/Advanced Practice Registered Nurse (APRN) were notified when medications were omitted (Resident #52) or administered late (Resident #78). The findings include: 1.Resident #6's diagnoses included dementia, displaced mid-cervical fracture of the right femur with joint replacement surgery, cognitive communication deficit, and restlessness and agitation. a.An Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was severely cognitively impaired and was independent with bed mobility, transfers and toileting. The MDS indicated Resident #6 had 1 fall without injury since the prior assessment. Review of a re-admission Inter-agency Referral Report (W-10) dated 5/10/26 at 12:08 PM identified Resident #6 had a closed fracture of the right hip with surgical repair and to take Tylenol for pain management. If Tylenol was not adequate, discuss with provider to start Oxycodone, however would put resident at increased risk of confusion. Review of the hospital Discharge summary dated [DATE] identified Active Issues Requiring Follow-up: Pain management with Tylenol and Lidocaine, may use Oxycodone low-dose after discussion with family and PT as residents RP wanted to know how patient did at rehab before starting oxycodone. The Resident Care Plan (RCP) dated 5/11/26 identified Resident #6 had a right hip surgical wound and potential for pain related to post surgery of the right fractured hip. Interventions included assessing the characteristics of pain and administering pain medications as ordered. An Advanced Practice Registered Nurse (APRN) progress note dated 5/11/26 at 8:00 AM identified physical therapy reported pain with mobility which limited therapy participation and Oxycodone 5 milligrams (mg) by mouth every 6 hours as needed for severe pain for 7 days was ordered. A physician order dated 5/11/26 directed Oxycodone HCL oral tablet 5 mg to be given by mouth every 7 hours as needed for severe pain for 7 days. Review of the audit details of the physician order dated 5/11/26 for Oxycodone HCL oral tablet 5 mg identified the Registered Nurse supervisor (RN #7) had transcribed the order onto the Medication Administration Record (MAR) on 5/11/26 at 2:43 PM. Review of the MAR for May 2026 identified Oxycodone 5 mg tablet was administered to Resident #6 on 5/12/26 at 9:14 AM. An APRN progress note dated 5/12/26 at 3:00 PM identified Oxycodone was initiated on 5/11/26 however per resident representative's request, this was discontinued as the family did not wish for the resident to receive narcotic medications. A physician order dated 5/12/26 directed Please no narcotics per patient's responsible party's request every shift. Interview with Person #1 on 7/20/26 at 1:51 PM identified he/she was the resident representative for Resident #6 and when the resident was readmitted to the facility after his/her hip fracture/surgical repair on 5/10/26, he/she was not informed the resident was ordered Oxycodone on 5/11/26. Person #1 indicated he/she was aware it was documented in the hospital discharge records that Resident #6 was to be administered Acetaminophen for pain and if Oxycodone was needed, it should have been discussed with the resident representative first. Further, Person #1 stated when he/she came to visit Resident #1 on 5/12/26 he/she found the resident delusional and when he/she asked the nurse about it, he/she was informed the resident had been administered Oxycodone. Person #1 identified she immediately requested the Oxycodone be discontinued and a note to be put in the resident's record which indicated Resident #6 was not to be put on narcotics per his/her request. Person #1 indicated he/she was never informed by the charge nurse or the nursing supervisor prior to the Oxycodone being ordered and administered to Resident #6, and he/she should have been. Interview and review of the clinical record with the DNS on 7/23/36 at 2:50 PM identified when Resident #6 was re-admitted to the facility on [DATE] Person #1 should have been notified of the Oxycodone medication order and the medication should not have been administered to the resident without Person #1's notification. The DNS indicated it was the responsibility of the nurse (RN #7) who transcribed the Oxycodone order to ensure Person #1 was notified of the new medication order and she was usure why that was not done. Review of the hospital discharge documents with the DNS identified notations within the documents that indicated the start of narcotic pain medication should have been discussed with the resident representative first. Review of the nursing notes failed to indicate RN #7 had notified the resident representative about the Oxycodone order. Additionally, the DNS indicated she was aware Person #1 was not informed and Person #1 was upset about the Oxycodone order and the order was subsequently discontinued. Attempts to contact RN #7 (supervisor that transcribed the Oxycodone order) were unsuccessful. b.The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was severely cognitively impaired and dependent with bed mobility, transfers and toileting. The Resident Care Plan (RCP) dated 5/22/26 identified Resident #6 had impaired cognition/communication related to dementia and an activities of daily living (ADL) deficit related to cognition. The RCP indicated Resident #6 exhibited memory impairments, periods of anxiety and was prescribed aspirin (ASA). Interventions included to provide cues and encouragement to participate in ADL's, encourage participation in activities of interest as a form of diversion to reduce anxiety and to monitor for signs of bruising. Further interventions included to provide the resident with consistent, simple and directive sentences and necessary cues and to stop and return if agitated. A facility Reportable Event (RE) form dated 7/14/26 at 10:50 PM identified Resident #6 had a bruise to the right forearm that measured 5.5 centimeters (cm) x 5 cm which was red, black and blue. The RE form indicated that the bruise was observed by the Nurse Aide (NA) when PM care was provided and an investigation was initiated. The attached investigation related to the bruise (completed by RN #5) indicated Resident #6 had a risk factor of dementia and the causative factor for the bruise was unknown. An interim skin audit completed by RN #5 and dated 7/14/26 at 11:15 PM identified a skin check of Resident #6 indicated no pre-existing skin impairments but noted a new non-pressure skin impairment was described as a right forearm bruise measuring 5.5 cm x 5.0 cm. A nursing note written by RN #5 and dated 7/14/26 at 11:30 PM identified Resident #6's charge nurse reported a bruise to the resident's right forearm which was observed at 10:50 PM and the bruise was discovered during PM care. The resident was unable to verbalize how the injury happened and the bruise was measured at 5.5 cm x 5.0 cm and would be monitored every shift. The nursing note indicated Resident #6's resident representative would be notified in the morning due to the late hour of discovery, and the oncoming nursing supervisor was made aware. Interview with Person #1 on 7/20/26 at 1:51 PM identified he/she was the responsible party and emergency contact for Resident #6. Person #1 indicated he/she was not made aware Resident #6 was found to have a large bruise (injury of unknown source) to his/her right forearm on 7/14/26 and he/she was unsure why the facility did not inform him/her. Further, Person #1 stated he/she was upset and felt the facility did not communicate with him/her as they should have been and she had informed the facility he/she wanted to be contacted regarding Resident #6 at any time of the day. Interview and review of the clinical record with the Registered Nurse supervisor (RN #5) on 7/23/26 at 3:52 PM identified she was the RN supervisor working 7/14/26 on the 3:00 PM to 11:00 PM shift. RN #5 stated she recalled the incident on 7/14/26 when Resident #6 was found with a large bruise to the right forearm. RN #5 indicated it was late in her shift, and she was handling multiple incidents when the injury was reported to her, and the reason she did not inform Person #1 about the bruise was because it was so late at night. Review of RN #5's nursing note and RE form from 7/14/26 identified Resident #6 was unable to indicate how he/she sustained the injury and although RN #5 did not inform the Person #1 about the injury (due to the late hour) she did notify the oncoming RN supervisor (RN #8) about the incident and that Resident #6's resident representative still needed to be notified. Interview and review of the RE form with the DNS on 7/23/26 at 2:40 PM identified Resident #6's bruise should have been reported to Person #1 and she was unsure why that was not done. The DNS indicated regardless of the late hour on 7/14/26, RN #5 was responsible to inform Person #1 about Resident #6's right forearm bruise before the end of her shift. Further the DNS stated RN #5 should not have relied on the next shift to reportthe bruise to Person #1 and should have made the notification herself. Interview with the RN supervisor (RN #8) on 7/27/26 at 10:26 AM identified she was the RN supervisor working the 11:00 PM to 7:00 AM shift on 7/14/26. RN #8 indicated she recalled RN #5 verbally told her about Resident #6's right forearm bruise during shift report and she was aware Person #1 had not been notified. RN #8 identified she did not inform Person #1 about the injury during her shift because it was overnight and although she believed she told the oncoming RN Supervisor (RN #7) about Resident #6's right forearm bruise, she was unsure if she told RN #7 that Person #1 still needed to be notified of the injury. Attempts to contact RN #7 (nursing supervisor for 7/14/26 7:00 AM to 3:00 PM shift) were unsuccessful. Review of facility policy, Condition: Significant Change, dated 4/2015, directed the facility will communicate with the resident's family regarding changes in condition to provide timely communication of resident status change which is essential to quality care management. The responsible party will be notified by the nurse in the event of a change in condition and before order changes given by the physician are carried out and this notification will be documented in the clinical record. Review of facility policy, Resident's [NAME] of Rights, dated 9/22/25, directed the facility must notify the resident representative or interested family member within 24 hours when: the resident is involved in an accident that results in injury, there is a significant change in the residents physical, mental or psychosocial status, and there is a need to alter the residents treatment significantly (discontinue or change treatment or start a new form of treatment). 2. Resident #52 was admitted to the facility in November 2019 with diagnoses that included cirrhosis of liver, heart failure, and Type 2 diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #52 was cognitively intact and was independent with activities of daily living. The Resident Care Plan (RCP) date 3/17/26 identified hepatic cirrhosis as an area of focus with interventions that included administering medications as ordered, labs as ordered and update MD, monitoring and documenting any behavioral changes and notifying MD and monitor and reporting to MD and dietitian significant changes in nutritional status. Physician orders dated 5/16/26 directed to administer Rifaximin (used to prevent brain dysfunction caused by the liver) 550 milligrams (mg) two times a day. Interview with Resident #52 on 7/21/26 at 10:41 AM stated that he/she had missed medications because they were not available from the pharmacy. Resident #52 stated that he/she had discussed these concerns at Resident Council and with the Administrator. He/she indicated that the nursing staff have told him/her that the medication did not come in from the pharmacy. Resident #52 indicated that the medication he/she was most concerned about was the Rifaximin that it was taken for his/her cirrhosis diagnosis. The Medication Administration Record (MAR) for June 2026 identified that Resident #52 did not receive the AM and PM dose of Rifaximin 550 mg on 6/12/26 and in the AM on 6/13/26 (total of 3 doses). Documented on the MAR was a code of 9 indicating medication was not administered for other reasons such as not available from pharmacy. Nursing notes dated 6/12/26 indicated that on the 7:00 AM to 3:00 PM shift medication on order, 3:00 PM to 11:00 PM shift medication order pending and on 6/13/26 on the 7:00 AM to 3:00 PM shift medication there was no documentation that the practitioner was notified of the Rifaximin not being available for administration. (please refer to F 580). Interview with the Advanced Practice Registered Nurse (APRN) #2 on 7/27/26 at 10:00 AM indicated that she was not aware that she could sign Prior Authorization requests from the pharmacy for medications until recently and that could be the reason medication (Rifaximin) was not received from the pharmacy timely. APRN #2 indicated that she was not made aware that Resident #52 had missed 3 doses of Rifaximin in June 2026. Interview and review of the clinical record with the DNS on 7/27/26 at 12:15 PM indicated that she was aware that Resident #52 had concerns with the pharmacy and that Resident #52 had spoken to the Administrator several times regarding his/her concerns. The DNS indicated that she was not aware Resident #52 had missed doses of Rifaximin in June 2026. The DNS indicated that the supervisor should have been made aware if the medication was not administered and the provider notified regardless of the reason. The DNS stated it was the responsibility of the charge nurse to notify the supervisor of medications missed and in turn the supervisor will notify the provider and complete a medication error report if warranted. The DNS indicated that this was the facility policy when medications were omitted Interview with Registered Nurse (RN) #7 could not recall Rifaximin not being administered to Resident #52. 3. Resident #78 had diagnoses that included quadriplegia, chronic pain syndrome, and diabetes. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was cognitively intact, was independent with use of a motorized wheelchair, and was dependent for eating, personal hygiene, bed mobility, and transfers. Additionally, the MDS assessment indicated Resident #78 was taking the following high-risk drug class medications: antidepressant, anticoagulant, antibiotic, opioid, antiplatelet, hypoglycemic, and anticonvulsant. The Resident Care Plan (RCP) dated 5/20/26 identified Resident #78 was at risk for depression. Interventions included providing emotional support as needed, encouraging verbalization, and administering medications as ordered. a. A physician order dated 6/22/26 directed to administer Acetaminophen Extra Strength (ES) tablet 500 mg 2 tablets by mouth every 8 hours for pain with administration times of 12:00 AM, 8:00 AM, and 4:00 PM. Review of the Medication Administration Audit Report (MAAR) dated 6/26/26 identified the 8:00 AM dose of Acetaminophen ES was documented as administered at 12:27 PM (3hr and 27 min late), the 4:00 PM dose of Acetaminophen ES was administered on time by LPN #11 at 3:57 PM (3 hr and 30 min after the previous dose despite physician orders to administer Acetaminophen ES every 8 hours). Review of the clinical record failed to identify the Medical Doctor (MD)/Advanced Practice Registered Nurse (APRN) were notified of the significantly late administration of acetaminophen extra strength at 12:27 PM and to obtain direction related to another scheduled dose due at 4:00 PM less than 4 hours later. Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of acetaminophen extra strength were held after the late administration of the previous dose. b. A physician order dated 6/22/26 directed to administer Baclofen (a skeletal relaxer) tablet 20 mg by mouth 4 times a day for spasms with administration times of 9:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM. Review of the MAAR dated 6/25/26 identified the 9:00 AM dose of Baclofen was administered by LPN #1 at 11:48 AM (1 hr. and 48 min late), the 12:00 PM dose of Baclofen was administered by LPN #1 at 3:45 PM (2 hr. and 45 min late), and the 4:00 PM dose of Baclofen was administered on time by LPN #11 at 4:01 PM (which was 16 min after the previous dose). Review of the MAAR dated 6/25/26 identified Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr. and 13 min span of time. Review of the clinical record failed to identify the Medical Doctor (MD)/Advanced Practice Registered Nurse (APRN) were notified of the late administration of Baclofen at 11:48 AM to obtain direction related to the next scheduled dose at 12:00 PM. Additionally, the clinical record failed to identify the MD/APRN were notified of the significantly late administration of baclofen at 3:45 PM to obtain direction related to another scheduled dose due at 4:00 PM less than 15 minutes later. c. Review of the MAAR dated 6/26/26 identified the 9:00 AM dose of Baclofen was documented as administered by LPN #10 at 11:03 AM (1 hr. and 3 min late), the 12:00 PM dose of Baclofen was administered by LPN #10 at 1:30 PM (30 min late and 2 hr 27 min after the previous dose), and the 4:00 PM dose of Baclofen was administered on time by LPN #11 at 3:57 PM (2 hr. and 27 min after the previous dose). Review of the MAAR dated 7/27/26 identified on 6/26/26 Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr. and 57 min span of time. Review of the clinical record failed to identify the Medical Doctor (MD)/Advanced Practice Registered Nurse (APRN) were notified of the late administration of baclofen at 11:03 AM to obtain direction related to the next scheduled dose at 12:00 PM. Additionally, the clinical record failed to identify the MD/APRN were notified of the late administration of baclofen at 1:30 PM to obtain direction related to another scheduled dose due at 4:00 PM less than 2.5 hours later. Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose. d. Review of the Medication Administration Audit Report (MAAR) dated 7/1/26 identified the 8:00 AM dose of Acetaminophen Extra Strength (a pain reliever) tablet 500 milligrams (mg) 2 tablets by mouth was administered at 10:13 AM (1 hr. and 13 min late), the 8:00 AM dose of Apixaban (an anticoagulant) tablet 2.5 mg by mouth was administered at 10:10 AM (1 hr. and 10 min late), the 8:00 AM dose of Bethanechol Chloride (used to treat urinary retention) tablet 25 mg by mouth was administered at 10:13 AM on 7/1/26 (1 hr. and 13 min late), the 8:00 AM dose of Buprehorphine Hydrochloride-Naloxone Hydrochloride Dihydrate (used to treat opioid disorder) sublingual tablet 2-0.5 mg by mouth sublingually was administered at 10:14 AM (1 hr. and 14 min late), the 8:00 AM dose of Cinnamon capsule 500 mg 2 capsules by mouth was administered at 10:13 AM (1 hr. and 13 min late), the 8:00 AM dose of Cyanocobalamin (Vitamin B12) tablet 1000 micrograms (mcg) by mouth was administered at 10:10 AM (1 hr. and 10 min late), the 8:00 AM dose of Duloxetine Hydrochloride (an antidepressant) delayed release particles 60 mg by mouth was administered at 10:10 AM o (1 hr. and 10 min late), the 8:00 AM dose of Gabapentin (used to treat nerve pain) tablet 800 mg by mouth was administered at 10:10 AM (1 hr and 10 min late), the 8:00 AM dose of Hiprex (used to prevent urinary tract infections) tablet 1gram (GM) by mouth was administered at 10:10 AM (1 hr and 10 min late), the 8:00 AM dose of Lactulose solution (used to treat constipation or to reduce blood ammonia levels) 20 GM per 30 ml, give 30 ml, by mouth was administered at 10:15 AM (1 hr and 15 min late), the 8:00 AM dose of Levetiracetam (an antiseizure medication) tablet 500 mg by mouth was administered at 10:10 AM (1 hr and 10 min late), the 8:00 AM dose of Methocarbamol (a muscle relaxant) tablet 750 mg by mouth was administered at 10:10 AM (1 hr and 10 min late), the 8:00 AM dose of Oxcarbazepine (used to treat seizures) tablet 150 mg by mouth was administered late at 10:10 AM (1 hr and 10 min late) and the 8:00 AM dose of Sennosides (used to treat constipation) tablet 8.6 mg 2 tablets by mouth was administered late at 10:10 AM (1 hr and 10 min late). A progress note written by APRN #2 on 7/1/26 at 1:15 PM identified Resident #78 was seen at his/her request for persistent left ankle pain. The note indicated Resident #78 had recently demonstrated escalating behavioral concerns including calling law enforcement with non-emergent calls including the reporting of delays in medication administration although the nursing documentation indicated the medications were administered on time. (This note shows a discrepancy from the documented late administration times of 16 medications on 7/1/26). Review of the clinical record nursing notes failed to identify APRN #2 was notified that 16 medications were administered greater than 1 hour late (greater than 2 hours after the scheduled administration time of 8:00 AM) on the morning of 7/1/26. Interview with Resident #78 on 7/20/26 at 9:43 AM in his/her room identified that when a particular nurse (LPN #1) was working he/she received pain medication late and sometimes it was not administered until almost 12:00 PM. Resident #78 further indicated he/she had reported the late administration of medication to the nurses and the Advanced Practice Registered Nurse (APRN) and they had told him/her that they would talk to her (LPN #1). e.Review of the Medication Administration Audit Report (MAAR) dated 7/3/26 identified the 8:00 AM dose of cinnamon capsule 500mg 2 capsules by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Cyanocobalamin tablet 1000 micrograms (mcg) by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Duloxetine Hydrochloride delayed release particles 60 mg by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Gabapentin tablet 800 mg by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Hiprex tablet 1GM by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Lactulose solution 20 GM per 30 ml, give 30 ml, by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Levetiracetam tablet 500 mg by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 8:00 AM dose of Oxcarbazepine tablet 150 mg by mouth was administered at 11:32 AM (2 hr. and 32 min late), the 9:00 AM dose of Polyethylene Glycol (a laxative) 3350, one 17 gram (GM) scoop by mouth was administered at 11:32 AM (1 hr. and 32 min late), the 8:00 AM dose of Sennosides tablet 8.6 mg 2 tablets by mouth was administered at 11:32 AM on 7/3/26 (2 hr. and 32 min late), the 9:00 AM dose of Baclofen (a skeletal muscle relaxant) tablet 20 mg by mouth was documented as administered at 11:32 AM (1 hr and 32 min late), the 9:00 AM dose of Cranberry tablet 450 mg by mouth was administered late at 11:32 AM on 7/3/26 (1 hr and 32 min late), the 9:00 AM dose of Toujeo Solostar (a long acting Insulin) 300 unit/milliliter (ml) solution pen by injection 14 units subcutaneously was administered at 11:32 AM (1 hr and 32 min late), the 9:00 AM dose of Vitamin C tablet 500 mg by mouth was administered at 11:45 AM (1 hr and 45 min late), the 8:00 AM dose of Buprehorphine Hydrochloride-Naloxone Hydrochloride Dihydrate sublingual tablet 2-0.5 mg by mouth sublingually was administered at 11:45 AM (2 hr and 45 min late. f.Review of the MAAR dated 7/3/26 identified the 9:00 AM dose of Baclofen was documented as administered at 11:32 AM (1 hr. and 32 min late), the 12:00 PM dose of Baclofen was documented as administered on time at 11:45 AM (13 min after the previous dose). Additionally, the 4:00 PM dose of Baclofen was documented as administered on time at 3:51 PM (Resident #78 received 3 doses of Baclofen 20 mg within a 4 hr and 19 min span of time). Review of the clinical record failed to identify the Medical Doctor (MD)/Advanced Practice Registered Nurse (APRN) were notified of the late administration of baclofen at 11:32 AM to obtain direction related to the next scheduled dose at 12:00 PM. Review of the Medication Administration Record (MAR) for July 2026 failed to identify any doses of baclofen were held after the late administration of the previous dose. Observation on 7/23/26 at 9:43 AM identified LPN #1's medication cart outside Resident #78's room and she was inside the room administering Resident #78's medication. Interview with LPN #1 on 7/23/26 at 9:45 AM identified she had just finished administering Resident #78's morning medications. She indicated the acceptable time period for medication administration was between 1 hour before the scheduled time and 1 hour after the scheduled time. She confirmed that she often administered medication to Resident #78 outside of that acceptable time range for administration because her medication pass was demanding. She indicated that she had told nursing supervisors of the demanding medication pass, that today she still had 7 residents to administer medications to after Resident #78 on the medication pass and that all those residents' medications were late. She further indicated she did not tell the nursing supervisor or APRN when she administered medications outside the allowed parameters of 1 hour before the scheduled time and 1 hour after the scheduled time. Additionally, she was unable to identify why she didn't notify them but indicated that she should have. Interview and clinical record review with Registered Nurse (RN) #4 on 7/23/26 at 10:45 AM identified she was per diem and was currently covering for the 2nd floor supervisor who was on vacation. She indicated that she had not been told by any of the nurses that they were having difficulty completing their medication administration timely. She indicated that the nurse(s) this week have not told her of any medications being given late and she was surprised to see the administration times in the computer for the medications today. She indicated that if she had been informed of the late medication administration she would have contacted the APRN to notify them and then would have looked at when the next dose was due so that it could either be retimed or held, and she would have written a note detailing what was done. Review of the clinical record nursing notes for 7/1/26-7/27/26 failed to identify a nursing note which indicated that medications were administered late and subsequently failed to identify the nursing supervisor and MD/APRN were notified. Interview with the Director of Nursing Services (DNS) on 7/27/26 at 12:38 PM identified the acceptable time period for medication administration was between 1 hour before the scheduled time and 1 hour after the scheduled time which provided a 2 hour window for medication administration. She indicated that when medications were administered outside that 2-hour window of time, the MD/APRN should be notified. She indicated that it was not acceptable for medications to be administered as much as 3-4 hours after the scheduled time with the next scheduled dose of medication administered less than 2.5 hours later. Additionally, she indicated that if medications were administered that late the APRN/MD should be updated so that the medication and/or their administration times could be re-evaluated to determine why they were administered late. Interview and clinical record review with APRN #2 on 7/27/26 at 12:17 PM identified in her note written on 7/1/26 she was likely referring to nursing notes when she indicated that the documentation showed medications were administered on time. She further indicated that it had been that day (7/1/26) only that Resident #78 informed her about late medication administration and not on 7/3/26. She indicated that the nurses informed her occasionally of Resident #78 refusing a medication but that she had not been informed of frequent occasions of Resident #78 receiving multiple medications significantly late. Review of the Administration Procedures for All Medications policy revised August 2020, directed, in part, medications are administered in a safe, effective manner. The policy directed to review the 5 rights (of medication administration) prior to removing the medication from the medication cart, prior to removing the medication from the container, and after the dose is prepared before returning the medication to the medication cart. The policy failed to identify what the 5 rights of medication administration are. The policy further directed to notify the MD/APRN for repeated medication refusals, held medications, and suspected adverse drug reactions. The policy failed to identify to notify the MD/APRN when medications are administered late and/or too close together.

Based on interviews, review of the clinical record, and facility policy for 1 of 2 sampled residents (Resident #4) reviewed for urinary tract infections (UTIs), the facility failed to ensure an allegation related to untimely incontinent care was thoroughly investigated. The findings include: Resident #4 was admitted in November 2023 with diagnoses that included traumatic brain injury (TBI), quadriplegia, and speech disturbances (abnormalities of speech related to TBI).The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #4 had unclear speech, could usually make self-understood and sometimes understood others. Resident #4 was unable to participate in a Brief Interview for Mental Status (BIMS) for cognition due to having unclear speech. Resident #4 was totally dependent on staff for all activities of daily living (ADLs), was feed via tube feeding, always incontinent of urine and bowel, and transferred to a wheelchair with assist of 2 staff members using of a full mechanical lift.The Resident Care Plan (RCP) dated 4/29/26 identified communication deficit as an area of focus related to TBI with interventions that included Resident #4 was nonverbal, use simple language in yes/no format, use yes/no board or raise left hand for yes and lower left hand for no, and will kick left leg for needs (always ask if needs toilet, if not needs to be changed) and enjoys nonlinguistic activities such as coloring and painting). The RCP also identified bladder/bowel incontinence and chronic urinary tract infections (UT)I related to urinary retention as another area of focus. Interventions included maintenance toileting program to be toileted/bedpan before and after meals, at hour of sleep and as needed if able, will raise hand to let you know has to use the bathroom and will shake leg for urgent bathroom use, observe nonverbal cues for using the bathroom, report if does not void, provide incontinent care per incontinent episode and as needed, provide a brief and use barrier cream as indicated, monitor for symptoms of UTI, offer fluids, administer medications as ordered for UTI prevention and pain to help reduce symptoms of discomfort.Interview with Person #2 on 7/22/26 at 8:21 AM indicated she had concerns regarding Resident #4 having frequent UTIs. Person #2 stated that Resident #4 was recently treated for a UTI and was now on another course of antibiotics for a UTI. Person #2 indicated that the urologist had informed her that Resident #4's frequent UTIs were partially due to Resident #4 not being toileted and not being provided incontinent care timely. Person #2 stated that she had informed nursing staff and administration that Resident #4 sits in his/her incontinent brief for extended periods of time without the benefit of being provided with incontinent care.Furthermore, Person #2 indicated on Sunday, 7/19/26 Person #2 came into the facility to take Resident #4 out on a leave of absence for the day. Resident #4 was still in bed at ll:30 AM and AM care had not yet been provided. Person #2 stated that Nurse Aide (NA) #6 was Resident #4's NA. NA #6 told Person #2 at 11:30 AM that she was behind on her assignment and had not yet provided care to Resident #4. Person #2 proceeded to inform NA #6 that she would provide AM care to Resident #4. Person #2 stated that Resident #4's brief was saturated with urine and that urine had soaked through the brief and the bed linens were completely wet with urine when she provided care to Resident #4. Person #2 indicated that NA #6 and Resident #4's charge nurse, Licensed Practical Nurse (LPN) #7 was aware that Resident #4 was saturated with urine and did not have incontinent care until 11:30 AM (4 1/2 hours from the start of the 7-3 shift).On 7/22/26 at 9:00 AM the DNS was made aware by the surveyor about the concerns Person #2 stated regarding Resident #4 not receiving incontinent care until 11:30 AM and was found saturated with urine on 7/19/26. The DNS completed a Grievance Form and initiated an investigation on 7/22/26. In addition, the Social Worker (SW) #1 was made aware. The facility completed a grievance form related to Person #2's concerns. A review of the grievance investigation on 7/23/26 failed to reflect a thorough investigation was conducted. Although the DNS stated that she had spoken to staff, there were no staff statements attached to the grievance. The DNS stated she made one attempt to interview NA #6 but did not receive a call back. The DNS failed to contact NA #5 who was the 11-7 NA on 7/18/26 into 7/19/26 to determine the last time Resident #4 received incontinent care. The Grievance Form and DNS summary indicated that LPN #7 stated that she had directed NA #6 to provide care to Resident #4 by 10:00 AM and that other NAs on the unit had informed NA #6 that Resident #4 needed to be up and out of bed by 10:00AM. In addition, the DNS indicated in her summary that NA #6 was not redirectable and did not follow the charge nurse's directives regarding Resident #4's care. The DNS contacted NA #6's agency and placed her as Do not return due to not being redirectable, poor performance, and not following the charge nurse's directives. Person #2 was made aware of the outcome of the grievance on 7/22/26 at Resident #4's RCP meeting. Interview with the DNS on 7/23/26 at 9:20 AM indicated that she should have obtained written statements from the staff and that she should have made another attempt to contact NA #6. In addition, DNS stated that in retrospect, she should have contacted NA #5 who provide care on the 11-7 shift to determine the last time Resident #4 received incontinent care. The DNS stated that although she believed that placing NA #6 on a do not return list was sufficient, her investigation should have been more thorough, and written statements should have been obtained from all staff and that it was her responsibility to conduct a comprehensive investigation.The Grievance Policy not dated, directed, in part, upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. The grievance officer shall begin the grievance process by logging a summary of the grievance (if oral), the date the grievance received and by initiating an investigation. If the grievance involves an allegation of abuse, neglect, mistreatment, misappropriation of property, exploitation or injuries of unknown origin source, the incident or allegation shall be investigated and reported pursuant to the facility policy on abuse prohibition.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #12) reviewed for discharge, the facility failed to ensure a resident's discharge needs were identified and an effective discharge plan was developed and implemented. The findings include: Resident #12 had diagnoses that included lymphedema, morbid obesity, and chronic obstructive pulmonary disease (COPD).The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact, had functional limitation in range of motion to both upper extremities and both lower extremities, used a wheelchair, was independent with eating, required substantial/maximal assistance with bed mobility, chair/bed transfers, and walking, and was dependent with toileting hygiene, lower body dressing, and toilet transfers. The MDS assessment failed to identify Resident #12's weight.The Resident Care Plan (RCP) dated 4/20/26 identified Resident #12 had a potential for discharge to an appropriate setting with appropriate services when able. Interventions included evaluating discharge potential, home evaluation as needed, order recommended adaptive equipment, set goals to achieve an appropriate discharge, refer Resident #12 to home care agencies as needed, and conducting discharge planning meetings as needed.A Physical Therapy (PT) Discharge summary dated [DATE] identified Resident #12 had equipment at home prior to hospitalization of a wheelchair, rollator, rolling walker, 2 canes, and a shower chair. The summary indicated discharge from service recommendations were to ambulate with nursing staff at least 1 time each day, and to use a commode for toileting instead of a bed pan.An Occupational Therapy (OT) Discharge summary dated [DATE] identified Resident #12 required minimum assistance with toileting using a raised toilet seat/3 in 1 commode. The summary indicated Resident #12 had equipment at home prior to hospitalization of wheelchair, hospital bed, a 4-wheel walker, 2 canes, and a tub seat.Review of the clinical record failed to identify additional PT/OT evaluations or screens for Resident #12 to ensure he/she remained at the same functional level when it was time for discharge back home.A social services note written by Social Worker (SW) #1 on 7/15/26 at 11:28 AM identified Resident #12's Medicaid was now active and a call was placed to Resident #12's care management service provider to discuss discharge planning. The note failed to identify Resident #12 was informed of this call or that a discussion was had with him/her about discharge planning and failed to identify a tentative date for the discharge.An Advance Practice Registered Nurse (APRN) progress note written by APRN #2 and dated 7/16/26 at 10:45 AM identified Resident #12 had edema which had progressed since the previous evaluation which presented concern for worsening volume overload. The note indicated Resident #12 was assisted out of bed to obtain a weight and he/she expressed being very uncomfortable and requested to return immediately back to bed after the weight was obtained. The note indicated Resident #12 weighed 601.4 pounds (lbs.), Medical Doctor (MD) #1 was updated and in agreement with plan to start a new diuretic for 3 days in addition to the current diuretic, increased potassium supplement, and obtain repeat blood work on 7/20/26 to monitor renal function and electrolytes. The note failed to identify APRN #2 was aware of or involved in discharge planning discussions.APRN #2's progress note dated 7/17/26 at 11:15 AM identified Resident #12's edema had increased now with involvement of the abdomen and the resident was non-compliant with daily weights. The note indicated that during the attempt to weigh Resident #12 the previous day, he/she had experience significant distress with standing which made further walking unlikely. The note indicated that due to Resident #12's significant weight gain since admission (68.4 lbs.) and the new development of pitting edema to the abdomen the plan was to send Resident #12 to the hospital for evaluation.A nursing note dated 7/17/26 at 12:36 PM identified Resident #12 was sent to the hospital for abnormal lab work. A nursing note dated 7/18/26 at 4:41 PM identified Resident #12 returned from the hospital at 12:45 PM via a stretcher and was accompanied by 4 Emergency Medical Technicians. The note indicated Resident #12 was seen at the hospital for shortness of breath and abnormal lab work. The hospital indicated a chest x-ray showed no signs of fluid overload, and there were no new orders from the hospital.A (late entry) social services note written by Social Worker (SW) #1 on 7/20/26 at 10:55 AM identified Resident #12 was a 1-person assist after collaboration with the clinical team. The note identified Resident #12 would be discharging the following day as originally planned on Thursday (7/16/26). The note indicated homecare services were set up, that Resident #12 would receive care services from care management for 3 hours in the morning and 3.5 hours in the evening. Additionally, the note indicated if Resident #12 did not discharge the following day he/she would lose services from the care management company. The note indicated that Resident #12 was not incontinent medically, but that he/she had chosen not to get out of bed. The note further identified Resident #12 had a wheelchair and walker at the facility that would go home with him/her on discharge and indicated that he/she had a commode at home per the care management company. The note failed to identify that Resident #12's current weight exceeded the weight limit of the wheelchair and failed to identify that there would be oxygen in place at the home for Resident #12 who currently used oxygen. The note failed to identify Resident #12 was informed that his/her discharge was tomorrow, what time it would be, how he/she was getting home, and who would be there when he/she arrived.Interview with Resident #12 on 7/20/26 at 11:25 AM identified he/she had been at the facility for 3 months and that staff assisted him/her with toileting on the bedpan. Resident #12 indicated that during the day sometimes he/she would be incontinent of urine not because of inability to know when he/she had to go, but because he/she couldn't hold it until staff arrived to assist. He/she further indicated that at nighttime while he/she was sleeping he/she would be wet in the morning. Additionally, in the interview with Resident #12 he/she did not indicate there was any plan for discharge the following day.An APRN progress note by a covering APRN (APRN #2 was on vacation) dated 7/20/26 at 12:00 PM identified she saw Resident #12 for follow-up after the hospital visit for weight gain and edema. The note indicated Resident #12 had dyspnea on exertion and his/her pulmonary status was difficult to assess due to his/her body size. The note indicated Resident #12 was incontinent and there was concern about Resident #12's ability to care for him/herself, and that he/she was going to have 6.5 hours care at home. The note further indicated there were concerns that he/she may become deconditioned, and that a PT evaluation was requested to assess his/her transfer status. Additionally, the note indicated MD #1 made the decision to clear Resident #12 for discharge because she was covering for APRN #2 and was not familiar with Resident #12. The note failed to identify how much assistance Resident #12 required for care at home (if 6.5 hours was sufficient), failed to identify he/she needed oxygen at home, failed to identify if medications were reviewed and if Resident #12 needed any prescriptions written for medications that were running low or new.A social service note written by SW #1 on 7/20/26 at 2:28 PM identified Resident #12's care management company was contacted to update them that Resident #12 was not cleared for discharge because he/she required 2-person assistance. The note indicated Resident #12 could not be cared for safely in the community per the medical team and that he would discuss long-term options with him/her. This note shows a discrepancy from the late entry SW note dated 7/20/26 at 10:55 AM and the APRN progress note dated 7/20/26 at 12:00 PM.Review of the clinical record on 7/21/26 failed to identify a progress note by MD #1 dated 7/20/26 or 7/21/26 regarding Resident #12 being cleared for discharge on [DATE].Interview and observation with Resident #12 on 7/21/26 at 11:30 AM in Resident #12's room identified Resident #12 was sitting in a bariatric hospital bed with the head of bed elevated and an overbed table across the bed positioned over Resident #12's thighs. He/she had teary eyes and reddened cheeks when initially approached and indicated that he/she had been told today that he/she was ready for discharge and there would be 7.5 hours of care each day at home and SW told him/her it was a safe discharge. No wheelchair was visible inside the open area of the room, a folded rollator was observed leaning against the wall, and a bariatric commode was observed behind the door at the entrance to the room. Additionally, several clear plastic bags with belongings were noted on the floor along the left side of the bed proximally to the center of the room. Resident #12 identified while at the facility the nursing staff had wanted him/her to use a commode, but the commode was too small. He/she indicated that the wheelchair he/she was using was a wheelchair from home but it was too small and it was painful to sit in because it rubbed on the sides of his/her hips and thighs. He/she indicated that the facility told him/her that he/she couldn't get a new wheelchair until after he/she went home. Resident #12 expressed concern about his/her ability to care for him/herself at home and asked what was supposed to happen in the 17 hours that he/she would be alone and unable to care for him/herself. Am I just supposed to sit in urine for hours until someone comes back? Resident #12 indicated that he/she did not have a commode at home and that previously he/she was going into the bathroom at home. He/she asked if the facility had ordered a commode for him/her at home.Interview and observation of Resident #12 on 7/21/26 at 11:54 AM identified he/she was visibly distraught at the facility saying he/she was going home. At that time the Director of Recreation entered the room and to convey that Resident #12's ride had arrived, the stretcher was in the hallway, and accept that he/she was going home. Resident #12 then stated he/she was calling a family member and was asked if there was oxygen in place at home because he/she was wearing oxygen both days the surveyor saw them. He/she indicated that there was not oxygen at home because he/she had not been on it before at home.Interview and clinical record review with Registered Nurse (RN) #4 on 7/21/26 at 12:00 PM identified she was unaware Resident #12 didn't have oxygen at home, and she was unable to identify if Resident #12 required the oxygen at all times. She called SW #1 on the phone and he was informed the ride was there to take Resident #12 and did he know that Resident #12 was on oxygen, and questioned if he ordered oxygen for home. SW #1 indicated that he was not aware Resident #12 was on oxygen and had not ordered it for home. He indicated it was the responsibility of the nurses to inform him when a resident was on oxygen and that they filled out that portion of the Interagency Referral form (W-10). SW#1 indicated he had been told previously by Resident #12 that he/she wore the oxygen because he/she was hot at night. He was unable to identify if the MD would write an order for oxygen due to a resident being hot at night. He indicated that he had not had nursing perform any assessments to determine if the oxygen was required or would be covered by insurance. RN #4 identified in the physician orders that Resident #12 was to wear the oxygen at all times to maintain an oxygen saturation greater than 90%. SW #1 offered that the facility could send Resident #12 home with an oxygen concentrator until oxygen service could be set up at home.Subsequent to surveyor inquiry, interview with SW #1 on 7/21/26 at 12:45 PM identified on Thursday (7/16/26) he had told Resident #12 that he/she would discharge home on 7/21/26. He indicated MD #1 had initially thought Resident #12 required assistance of 2 people, but yesterday it was clarified that he/she needed only assistance of 1 and he/she was going to have 3.5 hours of care in the morning and 3.5 hours of care in the evening. He indicated MD #1 cleared Resident #12 for discharge when he was notified he/she was not an assist of 2. He indicated Resident #12 had no medical issues and had homecare in place. He indicated that the discharge was discussed as a team on 7/16/26 and they had talked about the oxygen and he/she had been told it would be tapered and discontinued on Friday. He indicated Resident #12 had not participated well with PT/OT but that he/she was able to stand-pivot, could use a commode, and needed only assistance of 1. He further indicated that Resident #12 was not incontinent and was just emotional and shuts down. He indicated that Resident #12 had a commode at home even if he/she said there wasn't one, and that his/her wheelchair was going home with him/her. He was unaware Resident #12's weight exceeded the weight capacity for the wheelchair and continued to indicate it was what he/she had at home previously. He indicated that although the APRN had requested a PT evaluation the previous day, MD #1 said it wasn't necessary. He was unable to identify how the facility knew without a PT and/or OT evaluation that Resident #12's functional ability hadn't declined in the month since PT/OT services ended when he/she had spent the majority of that time in bed. Additionally, SW #1 was unable to explain how Resident #12 was independent while also requiring assistance of 1 person, and how 7 hours of care was adequate for someone who required assistance of 1 person. SW #1 indicated that the stretcher was there to take Resident #12 and that after he spoke with the team he/she would be leaving.Subsequent to surveyor inquiry, interview with the Director of Nursing Services (DNS) and Administrator on 7/21/26 at 2:48 PM identified they were putting the discharge on hold until they could get an overnight pulse oximetry test completed, and that the discharge was now set for 7/23/26. They were unable to identify when Resident #12 was last seen by PT or OT and indicated that MD #1 had cleared him/her for discharge and that he/she was able to walk and transfer independently and had come off of PT/OT only due to non-participation. They indicated that it was a safe discharge due to Resident #12 having 7 hours of care in place at home, and that he/she was able to care for him/herself. They were unable to identify how they knew for certain that those statements were valid and he/she could walk, transfer, and care for him/herself. Additionally, they indicated Resident #12 had a bariatric wheelchair ordered for home and he/she could transfer and walk with the rollator independently to the bathroom, and he/she was not incontinent. They further indicated that discharges were discussed as a team and there were orders in place to show what the resident's needs were. They indicated that SW #1 should have taken the appropriate steps to ensure that oxygen was ordered if needed and to verify if the oxygen order was still in place or discontinued.A social service note written by SW #1 on 7/21/26 at 2:56 PM identified SW #1, the DNS, and the Assistant DNS met with Resident #12 who was in agreement to discharge on [DATE]. The note indicated he/she would have the oxygen test to see if he/she required oxygen and that a commode will be ordered.On 7/22/26 a review of the discharge packet inside a folder that had been prepared for Resident #12's discharge home identified the folder contained a W-10 and discharge paperwork which identified the last time medications had been given that was printed on 7/21/26. The folder contained the admission APRN note dated 4/13/26, recent blood work, an order summary report (physician orders), PT Discharge summary dated [DATE], and an OT Discharge summary dated [DATE]. None of the paperwork was signed by Resident #12 that it had been reviewed with him/her prior to the arrival of the stretcher to bring him/her home on 7/21/26.Interview with SW #1 on 7/22/26 at 10:00 AM identified Resident #12 was not in the facility due to being transported to the hospital for chest pain the night before. He indicated that it had been very difficult to get her transported out of the building due to his/her size. He indicated he/she was expected to return to the facility later that day and they would obtain the overnight pulse oximetry and he/she would go home the next day (7/23/26). Subsequent to surveyor inquiry, he indicated that the facility was ordering a new commode for Resident #12 for home since he/she didn't recall having one. He further indicated that it was his oversight for the oxygen not getting ordered for home, that he had thought it was going to be discontinued, and he should have double checked.A social service note written by SW #1 on 7/22/26 at 3:18 PM identified Resident #12 was at the hospital and decided that upon return to the facility he/she would remain in the facility for long term care to work on him/herself.A Physical Therapy (PT) Evaluation dated 7/24/26 (3 days after attempted discharge on [DATE] and 1 day after re-admission from hospital emergency department visit) identified Resident #12 would receive PT 3 times a week. The evaluation indicated Resident #12 required minimum assistance of 1 person for position change from lying supine to sitting upright and bed mobility, and required stand by assistance for sitting to standing and transfers. The evaluation indicated that Resident #12 was not evaluated for stand-pivot transfers or ambulation. The evaluation failed to identify Resident #12 was independent with mobility as indicated by SW #1, the DNS, and the Administrator on 7/21/26.Interview with APRN #2 on 7/27/26 at 12:17 PM identified that prior to her going on vacation she had notified the staff that Resident #12 would need a wheelchair ordered for discharge home, and that she would sign any prescriptions needed to ensure that happened. She indicated they had not asked her to sign a prescription for a wheelchair. She indicated that she had asked for MD #1 to make the determination that Resident #12 was ready to discharge home because she had some medical issues that required a hospital evaluation and she knew she would be on vacation when Resident #12 returned from the hospital. She indicated that Resident #12 was able to ambulate when admitted and often refused PT/OT and daily weights. She indicated that she did not think there was a chair in the facility that could support the weight of Resident #12 to help encourage him/her to get out of bed. She further indicated when asked how long it would take Resident #12, a 600 lb. person to stay in bed before he/she was deconditioned and unable to care for him/herself, that I think we are there.b. Review of the clinical record identified on 7/21/26 Resident #12 weighed 602.0 lbs. on a mechanical lift scale.Interview and observation with Resident #12 on 7/21/26 at 11:30 AM in Resident #12's room identified Resident #12 was sitting in a bariatric hospital bed with the head of bed elevated and an overbed table across the bed positioned over Resident #12's thighs. No bedside chair was observed in the room, no wheelchair was visible inside the open area of the room, a folded rollator was observed leaning against the wall, and a bariatric commode was observed behind the door at the entrance to the room. Additionally, several clear plastic bags with belongings were noted on the floor along the left side of the bed. Resident #12 identified while at the facility the nursing staff had wanted him/her to use a commode, but the commode was too small. He/she indicated that the wheelchair he/she was using was a wheelchair from home, but it was too small and it was painful to sit in because it rubbed on the sides of his/her hips and thighs. He/she indicated that the facility told him/her that he/she couldn't get a new wheelchair until after he/she went home.Interview with SW #1 on 7/21/26 identified Resident #12 had a personal wheelchair that he/she had brought from home. He/she was unable to identify if that wheelchair remained appropriate for him/her and again indicated it was what he/she had from home.Interview with the DNS and Administrator on 7/21/26 at 2:48 PM identified Resident #12 had a bariatric wheelchair at the facility that he/she had brought from home.Interview and observation with Nurse Aide (NA) #1 on 7/22/26 at 1:59 PM identified NA #1 removed Resident #12's personal wheelchair from inside the closet in Resident #12's room and it was observed to be labeled with Resident #12's name. The manufacturer label on the wheelchair indicated it came from Medline and was 24 inches wide by 18 inches deep (24x18 inches).Review of the Medline At Home website identified Resident #12's personal wheelchair in his/her room was an extra-wide bariatric wheelchair with a weight capacity of 500 lbs.Review of the clinical record identified on 4/30/26 Resident #12's weight exceeded the weight capacity of the wheelchair by 33.8 lbs. and on 7/21/26 Resident #12's weight exceeded the weight capacity of the wheelchair by 102.0 lbs.Interview with PT #1, Director of Rehabilitation, on 7/27/26 at 1:23 PM identified it was the responsibility of the whole interdisciplinary team to ensure a resident had all necessary equipment in place at home prior to discharge. She indicated she had tried to get a new wheelchair ordered for Resident #12 for home but the insurance wouldn't cover it until the old one was returned. She indicated that it was not routine to screen or re-evaluate a resident prior to discharge. She indicated that Resident #12 had not participated well with PT or OT which was why those services were discontinued, but that it had been her understanding that Resident #12 was to be discharged soon after the discontinuation of his/her PT/OT. She indicated that no one had requested for him/her to have a screen and she had not been aware that Resident #12 wasn't getting out of bed at least daily. She indicated that she was unable to say how long Resident #12 who weighed more than 600 lbs., would need to stay in bed before his/her functional ability declined enough that he/she couldn't care for him/herself. She further indicated that she had told the team that Resident #12 required assistance of 1 person for activities of daily living and that she had been unaware that Resident #12 had only 7 hours of care in place. She was unable/unwilling to identify if Resident #12's discharge plan was a safe discharge knowing there was only 7 hours of care in place.Review of the clinical record on 7/27/26 failed to identify a progress note was written by MD #1 that cleared Resident #12 for discharge scheduled for 7/21/26. Subsequent to surveyor inquiry, review of a NA care card dated 7/29/26 identified Resident #12 was incontinent of both bowel and bladder at times.Subsequent to surveyor inquiry, review of a progress note, received on 7/31/26, written by MD #1 dated 7/30/26 at 5:35 PM identified a discussion was held with MD #1, SW #1, the DNS, and the Administrator regarding Resident #12's discharge scheduled for 7/20/26 (discrepancy from original scheduled discharge of 7/21/26). The note indicated he approved the discharge based on Resident #12 had family support available, was set up for daily additional support, had a primary care appointment scheduled, and was motivated to return home. The note failed to identify that PT and/or OT staff were in the discussion and/or that they had provided clarification of Resident #12's functional mobility level, and failed to identify he had performed a physical assessment on Resident #12 to clear him/her for discharge as the covering APRN in her note on 7/20/26 at 12:00 PM indicated she was the covering APRN and she, updated Dr. Oh regarding this patient's status and potential discharge, asking him to make the decision as he/she is known to him. Review of the Discharge Planning Procedure policy, directed, in part, a written discharge plan will be created no later than 21 days after admission. The policy directed during the Discharge Planning Conference, held with a care plan meeting, which could be scheduled by the discharge coordinator to discuss a pending discharge. The policy directed the Discharge Planning Conference would include the resident, responsible party, nursing, discharge coordinator, dietary, recreation, physical therapy, and others involved in direct care and each person would sign a sheet to document attendance. The policy directed the resident's continued needs would be addressed during the discharge conference, and social services would evaluate the affects of discharge and actions to be taken to minimize disruptions, and other departments would outline areas that required teaching or followup. The policy directed the discharge coordinator would contact community agencies to provide necessary follow-up care. The policy directed the discharge plan and W-10 together were the Discharge Summary and provided the following information: diagnosis, medications, treatments, pertinent medical findings, course of treatment, continuing needs, rehabilitation potential, baseline vital signs, diet, activity. The policy directed the Discharge Coordinator would coordinate the process and make appropriate referrals and the plan would be signed by the physician.

Based on observations, review of the clinical record, facility policy and interviews for the only sampled resident (Resident #78) reviewed for pain management, the facility failed to ensure medications were administered on time per physician orders and failed to ensure medications were not administered too close together. The findings include: Resident #78 had diagnoses that included quadriplegia, chronic pain syndrome, and diabetes.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was cognitively intact, was independent with use of a motorized wheelchair, and was dependent for eating, personal hygiene, bed mobility, and transfers. Additionally, the MDS assessment indicated Resident #78 was taking the following high-risk drug class medications: antidepressant, anticoagulant, antibiotic, opioid, antiplatelet, hypoglycemic, and anticonvulsant.The Resident Care Plan (RCP) dated 5/20/26 identified Resident #78 was at risk for pain and had chronic pain related to impaired mobility. Interventions included administering pain medications as ordered, discussing with Resident #78 factors that trigger pain and what may reduce it, and discussing with Resident #78 to ask for pain medications before the pain becomes severe.Interview with Resident #78 on 7/20/26 at 9:43 AM in his/her room identified Resident #78 was in bed. He/she stated that when a particular nurse (LPN #1) was working he/she received pain medication late and sometimes it was not administered until almost 12:00 PM. He/she reported that when his/her pain medication was administered on time, the pain level was about 5 out of 10 but, when the pain medication was administered late his/her pain level was 10 out of 10. Resident #78 stated he/she had reported the late administration of medication to the nurses and the Advanced Practice Registered Nurse (APRN) and they had told him/her that they would talk to her (LPN #1). Interview with Resident #78 on 7/20/26 at 10:30 AM identified he/she was still in bed and he/she reported that he/she had not received the morning medications yet.Observation and interview with LPN #1 on 7/20/26 at 10:32 AM identified LPN #1 was standing at the medication cart 2 rooms down from Resident #78's room and on the opposite side of the hallway. When approached by the surveyor to inquire about when medications would be administered to Resident #78, LPN #1 picked up a medication cup (approximately half full) containing several tablets/capsules and replied that she had them ready to go right now and that Resident #78 was next to receive medications.Observation on 7/20/26 at 10:35 AM identified LPN #1 entered Resident #78's room to administer his/her medications. (Resident #78's medication administration times were 8:00 AM).Observation on 7/23/26 at 9:43 AM identified LPN #1's medication cart outside Resident #78's room and she was inside the room administering Resident #78's medication. (43 minutes late).Interview with LPN #1 on 7/23/26 at 9:45 AM identified she had just finished administering Resident #78's morning medications. She indicated the acceptable time period for medication administration was between 1 hour before the scheduled time and 1 hour after the scheduled time. She confirmed that she often administered medication to Resident #78 outside of that acceptable time range for administration and indicated that it may be due to her needing to complete dressing changes before she finished the medication pass so that residents could get dressed and out of bed. Additionally, she indicated that her medication pass was demanding because she had 25 or more residents to administer medication to, many of the residents had scheduled administration times for different times on the same medication pass (8:00 AM, 9:00 AM, 10:00 AM). She indicated that most resident medications were scheduled for 8:00 AM and she could not start her medication pass at 7:00 AM which was the allowed administration time of 1 hour before for the medications with an 8:00 AM scheduled time because that was her shift start time and she had to get shift report on all the residents, perform rounds to check on all of them and see who had appointments and/or urgent needs which then resulted in her starting the medication pass later than needed. She indicated that she had told nursing supervisors of the demanding medication pass but the only thing that changed was some of the dressing times. Additionally, she indicated that if she started the medication pass on the furthest room and worked her way around the residents in the closest room would be angry because their medications would be late, and if she started on the closest rooms the residents in the rooms further away would be angry. She further indicated that today she still had 7 residents to administer medications to after Resident #78 on the medication pass and that all those resident's medications were late. She indicated that she had not expressed any concerns recently because she thought this was just how it was and she had to do her best to get the medications done. She further indicated that she did not tell the nursing supervisor or APRN when she administered medications outside the allowed parameters of 1 hour before the scheduled time and 1 hour after the scheduled time, she was unable to identify why she didn't notify them but indicated that she should have.Interview and clinical record review with Registered Nurse (RN) #4 on 7/23/26 at 10:45 AM identified she was per diem and was currently covering for the 2nd floor supervisor who was on vacation. She indicated that she had not been told by any of the nurses that they were having difficulty completing their medication administration timely. She indicated that for Resident #78 she had not heard that his/her medications were frequently administered more than 2 hours late. She indicated that occasionally he/she might refuse medication or ask for the nurse to give it at a different time, but that she had not heard that recently, and it had not been for all of his/her morning medications but for only a couple of them. She indicated that the nurse(s) this week have not told her of any medications being given late and she was surprised to see the actual administration times in the computer for the medications today. She indicated that if she had been informed of the late medication administration she would have contacted the APRN to notify them and then would have looked at when the next dose was due so that it could either be retimed or held, hat she would have reviewed the medications to determine a reason for the late administration, and she would have written a note detailing what was done. She suggested a solution was for the nurses to administer medications to the cognitively intact residents first and then complete the medication pass for the remainder of the residents after that. She was unable to identify how that would assist the nurse(s) with completion of their medication administration timely.Interview with Resident #78 in his/her room on 7/23/26 at 12:56 PM identified there was never a time throughout the day when he/she did not have pain. He/she indicated that he/she accepted that there would always be some amount of pain and as long as his/her medications were administered on time, that the pain was managed appropriately, but that when he/she received the pain medication late it made the pain worse.1a. A physician order dated 6/22/26 directed to administer Acetaminophen Extra Strength tablet 500 mg 2 tablets by mouth every 8 hours for pain with administration times of 12:00 AM, 8:00 AM, and 4:00 PM.The Medication Administration Audit Report (MAAR) identified on 6/26/26 the 8:00 AM dose of Acetaminophen Extra Strength was administered (by LPN #1) at 11:45 AM on 6/25/26 (2 hours(hr.) and 45 minutes (min) late), on 6/26/26 was documented as administered (by LPN #10) at 12:27 PM (3hr and 27 min late), on 7/1/26 was documented as administered at 10:13 AM (1 hr. and 13 min late), on 7/2/26 was documented as administered (by LPN #8) at 11:04 AM (2 hr. and 4 min late), on 7/3/26 was documented as administered (by LPN #1) at 11:32 AM (2 hr. and 32 min late), on 7/7/26 was documented as administered (by LPN #1) at 11:53 AM (2 hr. and 53 min late), on 7/16/26 was documented as administered (by LPN #9) at 12:20 PM (3 hr. and 20 min late), on 7/17/26 was documented as administered (by LPN #1) at 12:11 PM (3 hr. and 11 min late) and on 7/20/26 was documented as administered (by LPN #1) at 10:20 AM (1 hr. and 29 min late).b. A physician order dated 6/22/26 directed to administer Apixaban tablet 2.5 milligrams (mg) by mouth 2 times a day for deep vein thrombosis prevention with administration times of 8:00 AM and 8:00 PM.The MAAR identified on 6/25/26 the 8:00 AM dose of Apixaban was administered (by LPN #1) at 11:46 AM (2 hr. and 46 min late, on 6/26/26 was documented as administered (by LPN #10) at 12:29 PM (3 hr. and 29 min late), on 7/1/26 was documented as administered at 10:10 AM (1 hr. and 10 min late), on 7/2/26 was documented as administered (by LPN #8) at 11:05 AM (2 hr. and 5 min late), on 7/3/26 was documented as administered (by LPN #1) at 11:32 AM (2 hr. and 32 min late), on 7/7/26 was documented as administered (by LPN #1) at 11:54 AM (2 hr. and 54 min late), on 7/16/26 was documented as administered (by LPN #9) at 12:20 PM (3 hr. and 20 min late), on 7/17/26 was documented as administered (by LPN #1) at 12:07 PM (3 hr. and 7 min late) and on 7/20/26 was documented as administered (by LPN #1) at 10:25 AM (1 hr. and 25 min late).c. A physician order dated 6/22/26 directed to administer Aspirin chewable tablet 81 mg by mouth daily for diabetic infection of right foot with an administration time of 9:00 AM.The MAAR identified on 6/25/26 the 9:00 AM dose of Aspirin was administered (by LPN #1) at 11:49 AM (1 hr. and 49 min late), on 6/26/26 was administered (by LPN #10) at 12:30 PM (2 hr. and 30 min late), on 6/30/26 was administered (by LPN #13) at 12:29 PM (2 hr. and 29 min late), on 7/7/26 was administered (by LPN #1) at 11:54 AM (1 hr. and 54 min late), on 7/16/26 was administered (by LPN #9) at 12:20 PM (2 hr. and 20 min late), on 7/17/26 was administered (by LPN #1) at 12:11 PM (2 hr. and 11 min late) and on 7/20/26 was administered (by LPN #1) at 10:27 AM (27 min late).d. A physician order dated 6/22/26 directed to administer Baclofen tablet 20 mg by mouth 4 times a day for spasms with administration times of 9:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM.The MAAR identified on 6/25/26 the 9:00 AM dose of Baclofen was administered (by LPN #1) at 11:48 AM on 6/25/26 (1 hr. and 48 min late), the 12:00 PM dose was administered (by LPN #1) at 3:45 PM (2 hr. and 45 min late which was 3 hr. 57 min after the previous dose). On 6/26/26 the 9:00 AM dose was administered (by LPN #10) at 11:03 AM (1 hr. and 3 min late), on 6/27/26 the 12:00 PM dose was administered (by LPN #10) at 1:30 PM (30 min late and 2 hr. 27 min after the previous dose), on 7/22/26 the 9:00 AM dose was administered (by LPN #8) at 11:09 AM (1 hr. and 9 min late), and the 12:00 PM dose was administered (by LPN #8) at 1:23 PM (23 min late and 2 hr. and 14 min after the previous dose). On 7/3/26 the 9:00 Am dose was administered (by LPN #1) at 11:32 AM (1 hr. and 32 min late), on 7/5/26 the 9:00 AM dose was administered (by LPN #9) at 11:30 AM (1 hr. and 30 min late), and the 12:00 PM dose was administered (by LPN #9) at 2:44 PM (1 hr. and 44 min late and 3 hr. and 14 min after the previous dose). On 7/16/26 the 9:00 AM dose was administered (by LPN #9) at 12:20 PM (2 hr. and 20 min late) and the 12:00 PM dose was documented as administered (by LPN #9) at 1:19 PM (19 min late and 59 min after the previous dose). On 7/17/26 the 9:00 AM dose was admi (by LPN #1) at 12:08 PM (2 hr. and 8 min late). On 7/17/26 the 12:00 PM dose was documented as administered (by LPN #1) at 2:03 PM (1 hr. and 3 min late and 1 hr. and 55 min after the previous dose). Additionally, on 7/20/26 the 9:00 AM dose was documented as administered (by LPN #1) at 10:26 AM (26 min late).e. A physician order dated 6/22/26 directed to administer Bethanechol Chloride tablet 25 mg by mouth 3 times a day for bladder spasms with administration times of 8:00 AM, 1:00 PM, and 8:00 PM.The MAAR identified on 6/25/26 the 8:00 AM dose was administered (by LPN #1) at 11:46 AM (2 hrs. and 46 min late), and the 1:00 PM dose was administered (by LPN #1) at 3:45 PM (1 hr. and 45 min late and 3 hrs. and 59 min after the previous dose, on 6/26/26 the 8:00 AM dose was documented as administered (by LPN #10) at 12:27 PM (3 hr. and 27 min late), on 6/27/26 the 8:00 AM dose was administered (by LPN #12) at 10:53 AM (1 hr. and 53 min late), on 7/1/26 the 8:00 AM dose was administered at 10:13 AM (1 hr. and 13 min late), on 7/2/26 the 8:00 AM dose was administered (by LPN #8) at 11:04 AM (2 hr. and 4 min late, on 7/3/26 the 8:00 AM dose was administered (by LPN #1) at 11:32 AM (2 hr. and 32 min late), on 7/7/26 the 8:00 AM dose was administered (by LPN #1) at 11:53 AM (2 hr. and 53 min late), on 7/16/26 the 8:00 AM dose was administered (by LPN #9) at 12:20 PM (3 hr. and 20 min late),on 7/17/26 the 8:00 AM dose was administered (by LPN #1) at 2:03 PM (5 hr. and 3 min late) and on 7/20/26 the 8:00 AM dose was administered (by LPN #1) at 11:30 AM (1 hr. and 30 min late).f. A physician order dated 6/22/26 directed to administer Buprenorphine Hydrochloride-Naloxone Hydrochloride Dihydrate sublingual tablet 2-0.5 mg by mouth sublingually 2 times a day for chronic pain with administration times of 8:00 AM and 8:00 PM.The MAAR dated 7/27/26 identified on 6/25/26 the 8:00 AM dose was administered (by LPN #1) at 11:43 AM (2 hr. and 43 min late), on 6/26/26 the 8:00 AM dose was documented as administered (by LPN #10) at 12:28 PM (3 hr. and 28 min late), on 6/27/26 the 8:00 AM dose was administered (by LPN #12) at 10:58 AM (1 hr. and 58 min late), on 7/1/26 the 8:00 AM dose was administered (by LPN #1) at 10:14 AM (1 hr. and 14 min late), on 7/2/26 the 8:00 AM dose was administered (by LPN #8) at 11:11 (2 hr. and 11 min late), on 7/3/26 the 8:00 AM dose was administered (by LPN #1) at 11:45 AM (2 hr. and 45 min late), on 7/5/26 the 8:00 AM dose was administered (by LPN #9) at 11:28 AM (2 hr. and 28 min late, on 7/7/26 the 8:00 AM dose was administered (by LPN #1) at 11:53 AM (2 hr. and 53 min late), on 7/16/26 the 8:00 AM dose was administered (by LPN #9) at 12:20 PM (3 hr. and 20 min late, on 7/17/26 the 8:00 AM dose was administered (by LPN #1) at 12:11 PM (3 hr. and 11 min late) and on 7/20/26 the 8:00 AM dose was administered (by LPN #1) at 10:32 AM (1 hr. and 32 min late).g. A physician order dated 6/22/26 directed to administer Duloxetine Hydrochloride delayed release particles 60 mg by mouth 2 times a day for major depression with an administration time of 8:00 AM and 8:00 PM.The MAAR identified on 6/25/26 the 8:00 AM dose of Duloxetine Hydrochloride was administered (by LPN #1) at 11:46 AM (2 hr. and 46 min late), on 6/26/26 the 8:00 AM dose was administered (by LPN #10) at 12:29 PM (3 hr. and 29 min late), on 6/27/26 the 8:00 AM dose was administered (by LPN #12) at 10:56 AM (1 hr. and 56 min late), on 7/1/26 the 8:00 AM dose was administered (by LPN #1) at 10:10 AM (1 hr. and 10 min late), on 7/2/26 the 8:00 AM dose was administered (by LPN #8) at 11:05 AM (2 hr. and 5 min late), on 7/3/26 the 8:00 AM dose was administered (by LPN #1) at 11:32 AM (2 hr. and 32 min late), on 7/7/26 the 8:00 AM dose was administered (by LPN #1) at 11:54 AM (2 hr. and 54 min late), on 7/16/26 the 8:00 AM dose was administered (by LPN #9) at 12:20 PM (3 hr. and 20 min late), on 7/17/26 the 8:00 AM dose was administered (by LPN #1) at 12:07 PM (3 hr. and 7 min late) and on 7/20/26 the 8:00 AM dose was administered (by LPN #1) at 11:25 AM (1 hr. and 25 min late).h. A physician order dated 6/22/26 directed to administer Gabapentin tablet 800 mg by mouth 3 times a day for pain with administration times of 8:00 AM, 1:00 PM, and 8:00 PM.The MAAR identified the 8:00 AM dose was administered (by LPN #1) at 11:46 AM (2 hrs. and 46 min late), and the 1:00 PM dose was administered (by LPN #1) at 3:45 PM (1 hr. and 45 min late). On 6/26/26 the 8:00 AM dose was documented as administered (by LPN #10) at 12:29 PM (3 hr. and 29 min late), on 6/27/26 the 8:00 AM dose was administered (by LPN #12) at 10:56 AM (1 hr. and 56 min late), on 7/1/26 the 8:00 AM dose was administered (by LPN #1) at 10:10 AM (1 hr. and 10 min late), on 7/2/26 the 8:00 AM dose was administered (by LPN #8) at 11:05 AM (2 hr. and 5 min late), on 7/3/26 the 8:00 AM dose was administered (by LPN #1) at 11:32 AM (2 hr. and 32 min late), on 7/7/26 the 8:00 AM dose was administered (by LPN #1) at 11:54 AM (2 hr. and 54 min late), on 7/16/26 the 8:00 AM dose was administered (by LPN #9) at 12:20 PM (3 hr. and 20 min late), on 7/17/26 the 8:00 AM dose was administered (by LPN #1) at 12:07 PM (3 hr. and 7 min late) and on 7/20/26 the 8:00 AM dose was administered (by LPN #1) at 10:25 AM (1 hr. and 25 min late).i. The MAAR also identified physician ordered directing Hiprex (treatment for urinary tract infections), Oxcarbazepine (a medication to treat seizures), Toujelo Solostar (an injectable medication to treat diabetes), and Ciprofloxacin (an antibiotic) were also administered late on several days. Review of the clinical record nursing notes for 7/1/26-7/27/26 failed to identify a nursing note which indicated that medications were administered late.Interview and clinical record review with APRN #2 on 7/27/26 at 12:17 PM identified medications should be administered spaced apart per physician orders, administering medications too close together could result in adverse effects.Interview with the DNS on 7/27/26 at 12:38 PM identified that her, the RN Manager, and/or the nursing supervisors were responsible for monitoring that medications were administered on time. She indicated the acceptable time period for medication administration was between 1 hour before the scheduled time and 1 hour after the scheduled time which provided a 2-hour window for medication administration. She indicated that when medications were administered outside that 2-hour window of time, the APRN/Medical Doctor (MD) should be notified. She indicated that she had not been aware of concerns from Resident #78 regarding late administration of his/her medications on the 7:00 AM-3:00 PM shift until identified by surveyors. She indicated that it was not acceptable for medications to be administered as much as 3-4 hours after the scheduled time with the next scheduled dose of medication administered less than 2.5 hours later. Additionally, she indicated that if medications were administered late the APRN/MD should be updated so that the medication and/or their administration times could be re-evaluated to determine why they were administered late. (refer to F 580) She further indicated that medications should never be administered less than 2.5 hours apart unless there was a physician order which directed to do so. The DNS indicated she was unaware of concerns from charge nurses working the 7:00 AM-3:00 PM shift related to the inability to complete the morning medication pass timely due to the number of residents that were assigned to the nurse for medication administration, the timing of the medications for multiple different times (8:00 AM, 9:00 AM and 10:00 AM) for the same resident, the inability to start the medication pass at 7:00 AM as allowed by the 2 hour window due to it being the shift start time. She further indicated that she would have Resident #78's medications reviewed to see if any time changes could be made so that he/she could get the medications sooner, but she was unable to identify how that would assist the nurse(s) with completion of their medication administration timely for all residents.The MAAR dated 7/22/26 for 7/1/26-7/22/26 identified 19 out of 22 days medications were administered late to Resident #78 on the 7:00 AM-3:00 PM shift outside of the 1 hour before the scheduled time and 1 hour after the scheduled time acceptable administration range. The MAAR further indicated that on 7 out of 19 late administration days the medications were administered less than 1 hour late, on 6 out of 19 late administration days the medications were administered greater than 1 hour but less than 2 hours late, on 4 out of 19 late administration days the medications were administered greater than 2 hours but less than 3 hours late, and on 2 out of 19 late administration days the medications were administered greater than 3 hours but less than 4 hours late. The MAAR indicated that all medications were administered to Resident #78 on time 2 out of 22 days.Review of the Administration Procedures for All Medications policy revised August 2020, directed, in part, medications are administered in a safe, effective manner. The policy directed to review the 5 rights (of medication administration) prior to removing the medication from the medication cart, prior to removing the medication from the container, and after the dose is prepared before returning the medication to the medication cart. The policy failed to identify what the 5 rights of medication administration are. The policy further directed to notify the MD/APRN for repeated medication refusals, held medications, and suspected adverse drug reactions. The policy failed to identify to notify the MD/APRN when medications are administered late and/or too close together.

Based on clinical record reviews, facility policy, and interviews for 1 of 3 sampled residents (Resident #16) reviewed for pressure ulcers, the facility failed to initiate treatment orders timely to the pressure ulcer upon admission. The findings include: Resident #16's diagnoses included Parkinson's disease, unspecified severe protein calorie malnutrition, and muscle weakness. The hospital Discharge summary dated [DATE] indicated Resident #16 had a healing pressure injury to the sacrum (skin over the triangular bone in the lower back). The discharge summary failed to reflect wound measurements or treatment orders from the hospital upon discharge.A nursing note dated 1/19/26 and written by the Nursing Supervisor (Registered Nurse (RN) #1) indicated Resident #16 had a Stage 2 (shallow open wound) pressure injury to the coccyx (a discrepancy from hospital documentation identifying the pressure are was to the sacrum). The note failed to reflect measurements, descriptions, or treatments for the coccyx pressure ulcer.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 had intact cognition and was dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, and putting on or taking off footwear. Additionally, Resident #16 required maximum assistance with toilet transfers, chair to bed transfer, sitting to standing and lying to sitting on the side of bed. Resident #18 was at risk for the development of a pressure ulcer and did not have a pressure ulcer at the time of the MDS assessment (despite Resident #16 being admitted on [DATE] with a pressure ulcer).A nursing note dated 1/21/26 and written by the Wound Nurse (RN #8) indicated Resident #16 had a Stage 2 pressure ulcer to the coccyx measuring 3.0 centimeters (cm) by (x) 1.0 cm x 0.1 cm. She indicated orders were obtained from Advanced Practice Registered Nurse (APRN) #2 to cleanse the wound to the coccyx with Normal Saline, pat dry, apply Silver Alginate (a wound dressing that promotes healing and prevent infection) to the wound, and cover with a foam dressing every day and every 1 hour as needed (the treatment was initiated 2 days after the pressure ulcer was identified). A physician order dated 1/22/26 and written by APRN #2 directed to cleanse the wound to the coccyx with Normal Saline, pat dry, apply Silver Alginate to the wound, and cover with a foam dressing every day and every 1 hour as needed.A review of physician orders and the Treatment Administration Record (TAR) failed to reflect wound treatment orders for Resident #16 when the pressure ulcer was identified on 1/19/26. A wound treatment order was added on 1/21/26, to days after the resident's pressure ulcer was identified.Interview on 7/23/26 at 1:01 PM with the Nursing Supervisor (RN #1) indicated that when a resident was admitted to the facility and a pressure ulcer was identified they should contact the provider, infection control, and report up the chain of command. RN #1 indicated he should also have obtained treatment orders for a resident admitted with a Stage 2 pressure ulcer by contacting the in-house APRN or the on-call APRN. Additionally, RN #1 could not recall if he had completed the resident body assessment, identified a pressure injury, notified the provider, or obtained treatment orders. Interview and clinical record review on 7/27/26 at 11:00 AM with the Director of Nursing Services (DNS), failed to reflect admission treatment orders for Resident #16's Stage 2 pressure ulcer to the coccyx. The DNS indicated when a resident was admitted and a pressure ulcer was identified the admitting nurse supervisor was responsible for assessing the wound and obtaining treatment orders. She was not aware that Resident #16 had not had treatment orders in place from 1/19/26-1/21/26. She indicated treatment orders should have been obtained and transcribed into the medical record.Review of the facility policy Prevention and Management of Pressure Injuries directed Policy: Residents with pressure injuries and those at risk for skin breakdown are identified, assessed, and provided appropriate treatment to encourage healing and/or maintenance of skin integrity. Wound Treatments: Wound treatments are done per medical doctor (MD) order. Determination of need for a dressing for a stage 1 or 2 injury is based on the individual practitioner's clinical judgement.

Based on interviews, observations, review of the clinical record, and facility policy for 1 of 2 (Resident #4) sampled residents reviewed for Urinary Tract Infections (UTIs), the facility failed to ensure Resident #4 was provided incontinent care in a timely manner and for 1 of 3 residents (Resident #12) reviewed for discharge, the facility failed to obtain a bowel and bladder assessment when Resident #12 was identified with a decline in bladder/bowel function. The findings include: 1. Resident #4 was admitted to the facility in November 2023 with diagnoses that included traumatic brain injury (TBI), quadriplegia, and speech disturbances (abnormalities of speech related to TBI). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #4 had unclear speech, could usually make self-understood and sometimes understood others. Resident #4 was unable to participate in a Brief Interview for Mental Status (BIMS) for cognition due to having unclear speech. Resident #4 was totally dependent on staff for all activities of daily living (ADLS), was feed via tube feeding, always incontinent of urine and bowel, and transferred to a wheelchair with assist of 2 staff members using of a full mechanical lift. The Resident Care Plan (RCP) dated 4/29/26 identified communication deficit as an area of focus related to TBI with interventions that included patient is nonverbal, use simple language in yes/no format, use yes/no board or raise left hand for yes and lower left hand for no, and will kick left leg for needs (always ask if needs toilet, if not needs to be changed) and enjoys nonlinguistic activities such as coloring and painting). The RCP also identified Bladder/bowel incontinence and chronic UTI related to urinary retention as another area of focus with interventions that included maintenance toileting program to be toileted/bedpan before and after meals, at hour of sleep and as needed if able, will raise hand to let you know has to use the bathroom and will shake leg for urgent bathroom use, observe nonverbal cues for using the bathroom, report if does not void, provide incontinent care per incontinent episode and as needed, provide a brief and use barrier cream as indicated, monitor for symptoms of UTI, offer fluids, administer medications as ordered for UTI prevention and pain to help reduce symptoms of discomfort. Physician orders dated 5/19/26 directed to ensure resident was out of bed and ready at 10:00 AM every day, offer toilet/bedpan approximately every 2 hours while awake as can void or have bowel movement on toilet to decrease UTIs, monitor for signs and symptoms (S/S) of yeast infection every shift related to frequent antibiotic use for UTIs, administer Cranberry tabs 450 milligrams (mg) via feeding tube 2 times a day, administer Silodosin (urinary retention) 8 mg once a day and Methenamine Hippurate (antiseptic for urinary tract) 1000 mg twice a day. Physician orders dated 6/1/26 directed to administer Rocephin 1 gram (gm) intramuscular (IM) injection one time for possible UTI, Diflucan (antifungal/used for yeast infections) 100 mg one time. Physician orders dated 6/22/26 directed to administer antibiotic Ciproflaxin 250 mg 2 times a day for 7 days (ending 6/30/26) for UTI. Physician orders dated 7/4/26 directed to administer Diflucan 100mg at bedtime for milky, rancid urine for 7 days and physician's orders dated 7/21/26 directed to administer antibiotic Augmentin 875-125mg 2 times a day for 7 days (ending 7/28/26) for UTI. Interview with Person #2 on 7/22/26 at 8:21AM revealed he/she had concerns regarding Resident #4 having frequent UTIs. Person #2 stated that Resident #4 was recently treated for a UTI and was now on another course of antibiotics for a UTI. Person #2 indicated that the Urologist had informed him/her that Resident #4's frequent UTIs were partially due to Resident #4 not being toileted and not being provided incontinent care timely. Person #2 stated that she had informed nursing staff and administration that Resident #4 sits in his/her incontinent brief for extended periods of time without the benefit of being provided with incontinent care. Furthermore, Person #2 indicated on Sunday, 7/19/26 Person #2 came into the facility to take Resident #4 out on a leave of absence for the day. Resident #4 was still in bed at 11:30 AM and morning care had not yet been provided. Person #2 stated that Nurse Aide (NA) #6, who she had never seen before, was Resident #4's NA. NA #6 told Person #2 at 11:30 AM that she was behind on her assignment and had not yet provided care to Resident #4. Person #2 proceeded to inform NA #6 that she would provide AM care to Resident #4. Person #2 stated that Resident #4's brief was saturated with urine and that urine had soaked through the brief and the bed linens were completely wet with urine when he/she provided care to Resident #4. Person #2 indicated that NA #6 and Resident #4's charge nurse, Licensed Practical Nurse (LPN) #7 was aware that Resident #4 was saturated with urine and did not have incontinent care until 11:30 AM (4 1/2 hours from the start of the 7-3 shift). On 7/22/26 at 9:00 AM the DNS was made aware by the surveyor about the concerns Person #2 stated regarding Resident #4 not receiving incontinent care until 11:30 AM and was found saturated with urine on 7/19/26. The DNS completed a Grievance Form and initiated an investigation on 7/22/26. In addition, the Social Worker (SW) #1 was made aware. A Grievance Form and DNS summary indicated that LPN #7 stated that she had directed NA #6 to provide care to Resident #4 by 10:00 AM and that other NAs on the unit had informed NA #6 that Resident #4 needed to be up and out of bed by 10:00 AM. In addition, the DNS indicated in her summary that NA #6 was not redirectable and did not follow the charge nurse's directives regarding Resident #4's care. Interview with NA #6 on 7/23/26 at 8:17AM revealed that she was aware that Resident #4 needed to be up by 10:00 AM as the other NAs and the charge nurse had informed her in the morning. However, NA #6 stated that she had never worked at the facility on the 7-3 shift and there were so many things going on. NA #6 stated that it was very busy and she did her best to prioritize the needs and safety of the residents. NA #6 stated she had apologized to Person #2 that she had not been timely with Resident #4's care and that Resident #4 was extremely incontinent of urine that his/her bedlinens needed to be changed. NA #6 indicated stated that although she did not notify LPN #7 until after Person #2 provided care to Resident #4, LPN #7 knew that NA #6 was running behind on her assignment and was having difficulty in completing her assignment timely. Furthermore, NA #6 indicated that she had never received orientation to the facility nor had anyone ever approached her about completing an orientation packet. Interview with APRN #2 on 7/27/26 at 10:45AM indicated that she was aware of Resident #4's frequent UTIs and that she had made a recent referral for Resident #4 to see a urologist. APRN #2 stated she was not aware that Resident #4's previous urologist had indicated on previous consultations that Resident #4 needed to be provided with incontinent care at least every 2 hours and that Resident #4 needed to be placed on the toilet or bedpan when awake to fully empty his/her bladder. APRN #2 was not aware that Resident #4 had current orders for being placed on the toilet/bedpan when out of bed, incontinent care every 2 hours and to be out of bed by 10:00 AM daily. APRN #2 stated that she was unsure if toileting every 2 hours would prevent incontinence; however, if Resident #4 was being left saturated in urine or not provided incontinent care timely it would contribute to UTIs. APRN #2 stated not receiving incontinent care on 7/19/26 for 6 1/2 hours after just finishing a course of antibiotics and needing to be restarted on antibiotics on 7/21/26 for a UTI was not good and incontinent care needs to be done at least every 2 hours or as needed when Resident #4 indicates he/she needs toileting using hand gestures and/or kicking his/her legs. Attempts to contact LPN #7 were unsuccessful. Urinary Tract Infections Policy dated 7/17 directed, in part, it is the policy to treat only symptomatic infections. When UTI symptoms are first noted MD/APRN and responsible party of nursing measures instituted, start a 3-day monitoring form, record accurate intake and output for at least 72 hours, institute hydration program, and offer cranberry juice or supplement at tolerated or directed. The Incontinent Care Policy not dated, directed, in part, residents who are incontinent of bowel or bladder, or who need assistance with hygiene after toileting will receive incontinent care. 2.Resident #12 had diagnoses that included depression, morbid obesity, and urge incontinence. The Resident Care Plan (RCP) dated 4/12/26 identified Resident #12 had an activity of daily living (ADL) (bathing, dressing, eating, toileting, transfers, and mobility) performance deficit related to morbid obesity and weakness. Interventions included providing assistance of 1-2 staff members with ADLs, provide assistance and/or cueing to maximize current function, and provide privacy while dressing/bathing. A Bladder and Bowel evaluation dated 4/12/26 identified the reason for the evaluation was admission and indicated Resident #12 was continent of bowel and bladder. The evaluation indicated Resident #12 was dependent with toilet use (bedpan) and indicated no trial of a toileting program was attempted or being used. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact, had no behaviors of rejection of care, had functional limitation in range of motion to both upper extremities and both lower extremities, used a wheelchair, was independent with eating, required substantial/maximal assistance with bed mobility, chair/bed transfers, and walking, and was dependent with toileting hygiene, lower body dressing, and toilet transfers. The MDS assessment further indicated that Resident #12 had occasional urinary incontinence, was always incontinent of bowel, and was not on a urinary/bowel toileting program. Review of the Documentation Survey Report for April 2026 identified for the dates of 4/11/26-4/30/26 Nurse Aide (NA) documentation was entered for 50 out of 59 opportunities. The report indicated Resident #12 was continent of urine 39 out of 50 (78%) documented opportunities, was incontinent of urine 9 out of 50 (18%) documented opportunities and was documented as not applicable (N/A) 2 out of 50 (4%) documented opportunities. The report indicated Resident #12 had urinary incontinence 18% of the time in April. Review of the Documentation Survey Report for April 2026 identified for the dates of 4/11/26-4/30/26 NA documentation was entered for 50 out of 59 opportunities. The report indicated Resident #12 was continent of bowel 9 out of 50 (18%) documented opportunities, was incontinent of bowel 3 out of 50 (6%) documented opportunities and was documented as not applicable (N/A) or no bowel movement 39 out of 50 (78%) documented opportunities. The report indicated Resident #12 had 12 bowel movements in April 2026 and was continent for 9 out of 12 bowel movements (75%) and incontinent for 3 out of 12 bowel movements (25%). The report indicated Resident #12 had bowel incontinence 25% of the time in April 2026 A Physical Therapy (PT) Discharge summary dated [DATE] identified Resident #12 required minimum assistance with bed mobility. The summary indicated a discharge recommendation for Resident #12 to use a commode for toileting instead of a bed pan. An Occupational Therapy (OT) Discharge summary dated [DATE] identified Resident #12 required minimum assistance with toileting using a raised toilet seat/3 in 1 commode. A Documentation Survey Report for June 2026 identified for the dates of 6/1/26-6/30/26 NA documentation was entered for 84 out of 91 opportunities. The report indicated Resident #12 was continent of urine 52 out of 84 (61.9%) documented opportunities, was incontinent of urine 30 out of 84 (35.7%) documented opportunities and was documented as refused (RR) 2 out of 84 (2.3%) documented opportunities. The report indicated Resident #12 had urinary incontinence 35.7% of the time in June 2026 which was an increase of 17.7% since April 2026. A Documentation Survey Report for June 2026 identified for the dates of 6/1/26-6/30/26 NA documentation was entered for 83 out of 90 opportunities. The report indicated Resident #12 was continent of bowel 21 out of 83 (25.3%) documented opportunities, was incontinent of bowel 4 out of 83 (4.8%) documented opportunities and was documented as not applicable (N/A) or no bowel movement 58 out of 83 (69.8%) documented opportunities. The report indicated Resident #12 had 25 bowel movements in June 2026 and was continent for 21 out of 25 bowel movements (84%) and incontinent for 4 out of 25 bowel movements (16%). The report indicated Resident #12 had bowel incontinence 16% of the time in June 2026 which was an increase of 9% in bowel continence since April 2026. A nursing note dated 7/5/26 at 9:34 PM identified Resident #12 was voiding during the shift with incontinent care provided and he/she refused to get out of bed to the commode. A (late entry) social services note written by Social Worker (SW) #1 on 7/20/26 at 10:55 AM identified Resident #12 was not incontinent medically, but that he/she chose to not get out of bed. Interview with Resident #12 on 7/20/26 at 11:25 AM identified he/she had been at the facility for 3 months. He/she indicated that staff assisted him/her with toileting on the bedpan. Resident #12 indicated that during the day sometimes he/she would be incontinent of urine not because of inability to know when he/she had to go, but because he/she couldn't hold it until staff arrived to assist. He/she further indicated that at nighttime while he/she was sleeping that he/she had no control of that and would be wet in the morning. Interview with NA #1 on 7/22/26 at 1:59 PM identified she regularly cared for Resident #12 on the day shift (7:00 AM-3:00 PM). She indicated Resident #12 wet the bed multiple times a day requiring the linens to be changed. She indicated that she could be in the hallway when the light rings and answer it within 30 seconds and Resident #12 will ask to be changed because he/she couldn't hold it. She indicated that Resident #12 will often need to be changed 6-7 times a day because he/she has wet the bed. She indicated that he/she will sometimes use the bedpan for a bowel movement and sometimes will need to be changed. She further indicated that Resident #12 used to ring the call bell to use the commode, but in the past month this has not happened, and he/she only got out of bed once and that was to get weighed. A Documentation Survey Report for July 2026 identified for the dates of 7/1/26-7/27/26 NA documentation was entered for 71 out of 80 opportunities. The report indicated Resident #12 was continent of urine 9 out of 71 (12.6%) documented opportunities, was incontinent of urine 57 out of 71 (80.2%) documented opportunities and was documented as resident unavailable (RU) or not applicable (N/A) 5 out of 71 (7.0%) documented opportunities. The report indicated Resident #12 had urinary incontinence 80.2% of the time in July 2026 which was an increase of 62.2% since April 2026. A Documentation Survey Report for July 2026 identified for the dates of 7/1/26-7/27/26 NA documentation was entered for 71 out of 80 opportunities. The report indicated Resident #12 was continent of bowel 6 out of 71 (8.4%) documented opportunities, was incontinent of bowel 19 out of 71 (26.7%) documented opportunities, was documented as not applicable (N/A) or no bowel movement 42 out of 71 (59.1%) documented opportunities and was documented as RU 4 out of 71 (5.6%) documented opportunities. The report indicated Resident #12 had 25 bowel movements in July 2026 and was continent for 6 out of 25 bowel movements (24%) and incontinent for 19 out of 25 bowel movements (76%). The report indicated Resident #12 had bowel incontinence 76% of the time in June 2026 which was an increase of 51% in bowel incontinence since April 2026. Review of the clinical record failed to identify completion of any additional Bladder and Bowel evaluations after 4/12/26 when Resident #12 went from continent from episodes of incontinence. Although requested on 7/27/26, a NA care card was not received. An Advance Practice Registered Nurse (APRN) progress note written by APRN #2 on 7/27/26 at 8:30 AM identified staff had reported Resident #12 had episodes on urinary incontinence at night with increase urinary urgency, and that Resident #12 had a long-standing ongoing history of urge incontinence. The note indicated Resident #12 denied pain with urination or suprapubic pain, and was on diuretics which likely contributed to the urinary urgency. The note indicated the plan was to monitor for signs and symptoms of a urinary tract infection for 72 hours. Interview with the APRN #2 on 7/27/26 at 12:17 PM identified Resident #12 had told her that he/she was continent but not able to hold his/her urine. Additionally, she indicated that Resident #12 had more of a dribbling issue. She indicated that the staff had not notified her that Resident #12's NA document the resident was incontinent multiple times a day. She indicated that she had increased Resident #12's diuretic medication which could contribute to him/her having difficulty holding their urine and indicated that Resident #12 had a history of urge incontinence (strong need to urinate that is hard to stop leading to accidental urine leakage). She further indicated that the facility could do a 3-day urinary tract infection monitoring to monitor for incontinence. Interview and clinical record review with the DNS on 7/27/26 at 12:38 PM identified the NA documentation indicated Resident #12 was incontinent, but the clinical record failed to identify any Bladder and Bowel evaluations were completed after the initial admission evaluation. The DNS indicated it was the responsibility of the MDS nurse to monitor the NA documentation and to bring forth to the interdisciplinary team when a resident's continence status changed. Additionally, she indicated the NAs should report to the nurse when a resident is incontinent if they were initially continent on admission. She further indicated that a Bowel and Bladder evaluation should have been completed for Resident #12 if the NAs were consistently documenting that he/she was incontinent. Subsequent to surveyor inquire, review of a NA care card dated 7/29/26, received on 7/30/26, identified Resident #12 was incontinent of both bowel and bladder at times. (Per the facility, NA care cards were ongoing and previous versions were not kept once the care card is updated). Review of the Activities of Daily Living policy, directed, in part, that a program of ADLs is provided to maintain the residents' maximum functional level. The policy directed a licensed nurse and/or the interdisciplinary team will assess the residents' ability to meet the needs of daily living. The policy directed a program is developed based on the assessment to encourage the highest level of functioning and is reviewed at least quarterly.

Based on interviews, review of the clinical record and facility policy for the only resident (Resident #52) reviewed for choices, the facility failed to ensure medication was available for administration. The findings include:Resident #52 was admitted to the facility in November 2019 with diagnoses that included cirrhosis of liver, heart failure, and Type 2 diabetes.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #52 was cognitively intact and was independent with activities of daily living. The Resident Care Plan (RCP) date 3/17/26 identified hepatic cirrhosis as an area of focus with interventions that included administering medications as ordered, labs as ordered and update MD, monitoring and documenting any behavioral changes and notifying MD and monitor and reporting to MD and dietitian significant changes in nutritional status.Physician orders dated 5/16/26 directed to administer Rifaximin (used to prevent brain dysfunction caused by the liver) 550 milligrams (mg) two times a day. Interview with Resident #52 on 7/21/26 at 10:41 AM stated that he/she had missed medications because they were not available from the pharmacy. Resident #52 stated that he/she had discussed these concerns at Resident Council and with the Administrator. He/she indicated that the nursing staff have told him/her that the medication did not come in from the pharmacy. Resident #52 indicated that the medication he/she was most concerned about was the Rifaximin that it was taken for his/her cirrhosis diagnosis. The Medication Administration Record (MAR) for June 2026 identified that Resident #52 did not receive the AM and PM dose of Rifaximin 550 mg on 6/12/26 and in the AM on 6/13/26 (total of 3 doses). Documented on the MAR was a code of 9 indicating medication was not administered for other reasons such as not available from pharmacy. Nursing notes dated 6/12/26 indicated that on the 7:00 AM to 3:00 PM shift medication on order, 3:00 PM to 11:00 PM shift medication order pending and on 6/13/26 on the 7:00 AM to 3:00 PM shift medication there was no documentation that the practitioner was notified of the Rifaximin not being available for administration.Interview with the Advanced Practice Registered Nurse (APRN) #2 on 7/27/26 at 10:00 AM indicated that she was not aware that she could sign Prior Authorization requests from the pharmacy for medications until recently and that could be the reason medication (Rifaximin) was not received from the pharmacy timely. APRN #2 indicated that she was not made aware that Resident #52 had missed 3 doses of Rifaximin in June 2026. (refer to F 580).Interview and review of the clinical record with the DNS on 7/27/26 at 12:15 PM indicated that she was aware that Resident #52 had concerns with the pharmacy and that Resident #52 had spoken to the Administrator several times regarding his/her concerns. The DNS indicated that she was not aware Resident #52 had missed doses of Rifaximin in June 2026. However, Resident #52 had stated that some medications were not delivered timely. In addition, the DNS was not aware that APRN #2 just recently became aware that she could sign the Prior authorization sheets from the pharmacy.Interview with the Administrator on 7/27/26 at 12:25 PM indicated that Resident #52 had expressed his/her dissatisfaction with the pharmacy on a few occasions and that medications were not always delivered timely. The Administrator did not recall any specific medications that Resident #52 had concerns with regarding delivery.Interview with Registered Nurse (RN) #7 could not recall Rifaximin not being administered to Resident #52.A request for Prior Authorization forms for Rifaximin from the pharmacy, the facility only provided one request for 2/27/25 that indicated authorized costs of $292.60 for the medication. Attempts to contact the pharmacy were unsuccessful. A review of the Ordering and Receiving Non-Controlled Medications policy dated 9/2018 directed, in part, medications and related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication orders and receipts. Reordering of medications is done in accordance with the order and delivery schedule established by the pharmacy provider. Quantities of medications sent from the pharmacy may vary in accordance with payor status, insurance plan, or law. Examples vs Medicaid, plan limitations on quantities under Medicare Part D, and quantities ordered by the provider. Reorder medications based on the estimated refill date on the pharmacy label or at least 3 days in advance, to ensure an adequate supply is on hand. When ordering medications that require special processing, order at least 7 days in advance of need.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #90) reviewed for nutrition, the facility failed to provide a complete meal that matched the meal ticket for a resident with an intellectual disability. The findings include: Resident #90's diagnoses included cerebral palsy, scoliosis with abnormal posture, abnormalities of gait and mobility with need for assistance with personal care. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 was moderately cognitively impaired and was dependent with toileting, required partial/moderate assistance with transfers, and required substantial/maximal assistance with bed mobility. The MDS indicated Resident #90 required set up or clean-up assistance with eating and required a mechanically altered and therapeutic diet. The Resident Care Plan (RCP) dated 6/22/26 identified Resident #90 had an activities of daily living (ADL) deficit related to cerebral palsy, a nutrition problem related to obesity and a lactose intolerance. Interventions included providing a low fat, level 6, soft, bite sized and thin liquid diet, providing diet as ordered, encourage self-performance and assist as needed. A physician order dated 7/14/26 directed a low fat diet Level 6- soft and bite sized texture, thin consistency liquids with no beans, no broccoli, no corn or pasta per family. Lactose restricted with large portions. Review of Resident #6's meal ticket on 7/20/26, noted for Lunch, soft and bite size with allergy to all dairy, with the following listed under daily items: diet ginger ale, crustless tuna salad sandwich on white with chicken broth and Italian ice. Listed under the main menu was listed soft and bite sized fork tender perogies (3 each) and sauteed spinach. Dining observation and interview with the Dietary Aide (DA #2) on 7/20/26 at 12:55 PM noted Resident #90 seated in a wheelchair at a dining table with 2 other residents. The resident was served small portions of cauliflower and mashed potatoes with gravy (on both items) served on a high ridge plate, with coffee and juice for beverages. The resident was taking small bites independently but was repeatedly asking the staff in the dining room what was on his/her plate. Review of Resident #6's meal ticket with DA #2 indicated the resident should have been served perogies, spinach, a crustless tuna sandwich, chicken broth, ginger ale and Italian ice with his/her meal, but none of those items were provided. DA #2 indicated the resident was not served perogies because the texture was too hard and she served the resident the soft and bite sized items (cauliflower and mashed potatoes) that she had available. DA #2 stated she was unsure where the sandwich was and why the broth, ginger ale and Italian ice were not served and although the sandwich was likely on the cart (which was no longer in the dining room), the other DA had failed to serve it to the resident. DA #2 then called down to the kitchen and asked for a crustless tuna sandwich for the resident (the resident indicated she did not want the other items now and asked to have the chicken broth with dinner) and 5 minutes later the sandwich arrived and Resident #6 proceeded to eat the entire crustless tuna sandwich while smiling. DA #2 indicated it would have been her and the other DA's responsibility to ensure the resident was served what was listed on the meal ticket and that she had made a mistake. Interview and review of Resident #6's meal ticket for lunch on 7/20/26 with the Food Service Director (FSD) on 7/23/26 at 11:37AM identified Resident #6 should have been served everything that was listed on the meal ticket for lunch on 7/20/26, and she was unsure why that was not done. The FSD indicated the food listed on the meal ticket should have first been correctly plated and prepared by the DA serving the hot food (DA #2) and then the DA on the other side of the steam table (serving the cold items) should have read the meal ticket and ensured all items listed were being served to the resident. The FSD was unsure why Resident #6 was served cauliflower and mashed potatoes (both with gravy) instead of what was indicated on the meal ticket and stated she would need to provide further education to the DA's. Although requested, a facility policy on food service/tray service was not provided.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #56) reviewed for food preferences/intolerances, the facility failed to ensure a resident received food which accommodated his/her allergies or intolerances. The findings include: Resident #56 had diagnoses that included diabetes, severe protein-calorie malnutrition, and gastro-esophageal reflux disease.The Resident Care Plan (RCP) dated 4/28/26 identified Resident #56 was at risk for impaired nutrition related to dysphagia, history of malnutrition, and allergies to wheat, citrus fruit and fruits. Interventions included providing a gluten-free diet with thin liquids and gravy on the side, providing selective menu as able, and provide snack as desired in compliance with the diet order.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 was cognitively intact, on a therapeutic diet, used a walker and wheelchair, and was independent with eating, bed mobility, transfers, and walking.A Nutrition Evaluation dated 6/29/26 identified Resident #56 was on a gluten-free diet due to a wheat allergy.A late entry Social Work note written by Social Worker (SW) #1 on 7/20/26 at 9:11 AM (date and time not reflective of the date/time note was actually created) identified SW #1 spoke with the family of Resident #56 who clarified that Resident #56 had a wheat sensitivity and not a gluten allergy. The note indicated that Resident #56 continued to receive a wheat free diet.Interview with Resident #56 on 7/20/26 at 10:38 AM in his/her room identified he/she had been at the facility about 1.5 years and his/her main concern with the facility was related to the food provided by the facility. Resident #56 indicated that he/she was gluten intolerant and was supposed to receive a gluten-free diet however there were times when he/she received foods that were not gluten-free. She indicated that she has told many staff about concerns with the food he/she received and that it still continues to occur.Observation on 7/20/26 at 12:30 PM identified Nurse Aide (NA) #1 pushing a cart containing plates of food for the lunch service out of the dining room and down the hall in the direction of Resident #56's room.Observation on 7/20/26 at 12:36 PM identified NA #1 pushing the empty cart back toward the dining room.Observation and interview with Resident #56 on 7/20/26 at 12:36 PM in his/her room identified there was a plate of food for lunch service on the overbed table that had a clear cover over the food. Resident #56 was sitting out of bed in a chair behind the table. Observation of the plate identified 4 pierogies and cooked spinach were on the plate. Resident #56 indicated that he/she was not sure what the lunch was and he/she was not aware what pierogies were. Resident #56 was informed that pierogies typically contain gluten and to wait for clarification before eating them in case the facility purchased a gluten-free option. Observation of Resident #56's meal ticket on 7/20/26 at 12:36 PM identified it was on top of the overbed table, next to the plate, and the word pierogies was handwritten in large letters on the ticket. The ticket indicated in a gray bar at the top of the ticket an allergy to wheat, and above the gray bar the diet was listed as gluten-free. The center area of the ticket below the daily items was blank and at the bottom of the ticket was a gray bar below the box with Resident #56's name and location which instructed no sauces or gravy-plain food.Interview with [NAME] #1 on 7/20/26 at 12:40 PM identified potato and cheese pierogies or beef liver were the meal options today. She indicated that there was only 1 option for pierogies and they were not gluten-free. She indicated that Resident #56 was the only resident that she was aware of that was on a gluten-free diet and that she didn't think he/she would have gotten them. She was surprised to learn that Resident #56 had in fact received the pierogies and that it was the responsibility of the dietary staff plating the food to ensure residents received the correct food items based on their diet and preferences. She indicated that if the dietary staff had any concerns related to food being served they should call down to the kitchen to clarify any questions. Additionally, she indicated that no one had called down today to ask about the pierogies.Observation of the pierogies package listed ingredients with [NAME] #1 on 7/20/26 at 12:42 PM identified the package listed ingredients of enriched flour (wheat flour, niacin, reduced iron, thiamine mononitrate, riboflavin, folic acid). The package further listed contains wheat and soy.Observation on 7/20/26 at 12:45 PM identified the plate of food was uncovered and the center of each pierogies was missing and the edges were cut away and left on the plate.Interview with Resident #56 on 7/20/26 at 12:45 PM identified the pierogies in fact did contain gluten and that sometimes gluten makes him/her itchy when it's eaten. Resident #56 indicated that he/she had tried to eat just the inside part and didn't eat the edges because there wasn't anything else to eat so eating the inside part only limited the amount of the gluten that he/she ate. He/she further indicated that if the kitchen had offered something else, he/she would have eaten that but indicated that he/she did not like beef liver.Interview with Dietary Aide #1 on 7/20/26 at 12:50 PM identified that she had plated the pierogies for Resident #56 because the food ticket listed pierogies as the meal choice that day. When asked if the pierogies contain wheat (gluten) which Resident #56 has a listed allergy to, she indicated that the pierogies did contain gluten, but she thought the wheat (gluten) allergy was more of a preference than a true allergy as listed on the meal ticket. She further indicated that she was able to tell the difference between a true allergy and a preference by what she heard people say, and indicated that she had been surprised to see pierogies on Resident #56's meal ticket but that she had still plated it for him/her and had not called anyone to verify if that was acceptable.Interview and review of meal ticket with NA #1 on 7/20/26 at 1:15 PM identified that she had passed meal trays to the residents eating their lunch in their rooms, but she could not recall if she had brought in the plate of food to Resident #56. She indicated that she knew what gluten was but did not know if pierogies had gluten in them. She further indicated that Resident #56's meal ticket showed that he/she was on a gluten-free diet, so he/she should not have gotten the pierogies if they contained gluten.Interview with Resident #56 on 7/21/26 at 10:58 AM identified after eating the pierogies the previous day at lunch, he/she had experienced a little itching but not much and had some diarrhea. He/she further indicated that he/she would not be eating those again and that he/she hadn't really liked them anyhow.Interview with Menu Clerk #1 on 7/23/26 at 12:00 PM identified that she helped Resident #56 fill out his/her menu each week. She indicated that she had heard Resident #56 received pierogies for lunch on 7/20/26 and stated she had written them down on his/her meal ticket and that it had slipped my mind that they contained gluten. She indicated for the pierogies she had forgotten they contained gluten and did not inform Resident 56 that he/she shouldn't eat those before putting them on his/her meal ticket. Interview with the Director of Dietary on 7/27/26 at 11:00 AM identified Menu Clerk #1 was responsible for ensuring items containing gluten were not put on the meal ticket, and then the dietary aide plating the food was responsible for double-checking that the resident was receiving the appropriate food items when plating the food. She indicated that she had heard Resident #56 received the pierogies last week and indicated that he/she should not have received those for lunch. She indicated that Dietary Aide #1 should have called the kitchen or checked with nursing before plating the pierogies for Resident #56, and that it was not acceptable for her to have indicated she plated the pierogies because It was on the ticket.Interview with the Director of Nursing Services (DNS) on 7/27/26 at 12:38 PM identified that it was not appropriate for Resident #56 to have been provided with pierogies for lunch on 7/20/26 and that she had not realized that Resident #56 had actually consumed some of them. She indicated that dietary should notify nursing staff when Resident #56 requested to be given food items that contained gluten so that he/she could be educated and/or monitored as needed.Subsequent to surveyor inquiry, the meal ticket received with requested documents dated 7/27/26 had the word Allergy in large gray letters that filled the entire open space beneath the Daily Items (items ordered/requested for that meal to be plated on the plate) printed on the ticket. Review of the Gluten-Free Diet policy directed, in part, food to avoid included enriched flour.

Based on a resident council meeting, resident interviews and facility policy, the facility failed to follow up on concerns brought forth by Resident Council members and accurately document concerns, resolutions, and rationale for decisions. The findings include: A Resident Council meeting was conducted as part of the re-certification survey on 7/23/26 at 2:00 PM and attended by 8 residents (Resident #5, Resident #28, Resident #35, Resident #50, Resident #52, Resident #66, Resident #86, and Resident #91). Interviews with the residents in attendance at the meeting on 7/23/26 at 2:00 PM identified if they brought a concern forward to facility staff at a Resident Council meeting that they feel their concerns were not always addressed, and they were told we are working on it but no plans or processes were discussed with them. Additionally, residents identified concerns related to staff not answering call bells when they ring, the outdoor patio being unsafe, missing items from past meetings in the meeting minutes, food carts with resident trays sitting in the hallway too long, supervisor door always closed, rooms not being cleaned properly, noise levels at night, and disappointment with the new pharmacy. The residents stated the issues above have been expressed to the supervisor on duty at a minimum.Review of Resident Council minutes from March 2026 through May 2026 identified a concern related to patio fixes being insufficient, mealtime service issues, and resident bathrooms not being as clean as they would like.Review of the Resident Council meeting minutes for 3/11/26 identified 12 residents were in attendance. The minutes identified discussion included old business, new business and updates. ice machine fixed, new food service director announced, informed new tent going up outside (weather permitting), conversation regarding pharmacy shortages, resident rights free of retaliation reviewed, updated regarding recruitment for open positions, and a new card group being created. The minutes failed to reflect any concerns from the residents.Review of the Resident Council meeting minutes for 4/29/26 identified 12 residents were in attendance. The minutes identified food had improved, more coffee carafes were being ordered by administrator, a new flag was ordered, proposed bylaws discussed, discussion regarding resident council bank account, nursing question about timing of medications and times for residents to get up in the morning, update on patio being repaired. Concerns expressed regarding the community smart TV and set up. Review of the Resident Council meeting minutes for 5/27/26 identified 12 residents were in attendance. The minutes identified discussion regarding continued work on patio, parking lot arrows being painted, introduction of nurse consultant, bill of rights and where residents can find them, fear of retaliation video, updated and proposed bylaws, resident election, update regarding recruitment and if residents have concerns about staff to bring up the chain of command. Resident concerns regarding sinks being found with stubble and toothpaste noted. Residents reminded by staff they can rinse their sinks after use. Interview with the recreation staff member ([NAME]) on 7/27/26 at 11:30 AM identified there was no recreation director at this time. She indicated she attends the Resident Council meetings monthly and records the minutes. She indicated the residents complain about staff on floor 2, pharmacy issues, call bell times, and food services regularly during resident council. The [NAME] stated she was directed to send the minutes to the administrator to review, and the administrator edits the minutes and files them in the resident council binder. The meeting minutes provided by the administrator are the official meeting minutes used for the next Resident Council meeting. The [NAME] was able to provide a copy of the minutes she had transcribed for May 2026. Review of the meeting minutes for May 2026 provided by the [NAME] identified resident concerns regarding ants in their rooms, staff making too much noise at night, staff using headphones while doing care, clothing and towels being left in resident bathrooms, and beds being left unmade. She stated the residents regularly express concerns regarding staff supervision on the second floor, pharmacy complaints, and lack of leadership follow up.Interview with the Administrator on 7/27/26 at 11:42 AM identified the administrator re-types the meeting minutes after she receives them from the [NAME]. She indicated the [NAME] was responsible for providing follow-up information to the residents and documenting within the Resident Council meeting minutes. She stated concerns are often discussed in morning report so the [NAME] can bring updates back to the resident Council. The Administrator stated residents are updated regarding education they provide to staff regarding concerns and audits that are performed and that there are informal ways they touch base with residents such as coffee and chit chat sessions that are held at least weekly between resident council meetings. The Administrator stated the meeting minutes carry over month to month regarding concerns brought forth during the meetings. Review of the Resident Council meeting minutes for May 2026, provided by the Administrator, failed to reflect the residents' concerns regarding ants in their rooms, staff making too much noise at night, staff using headphones while doing care, clothing and towels being left in resident bathrooms, and beds being left unmade (a discrepancy from the original minutes provided by the [NAME]).Subsequent to surveyor inquiry, review of actions taken for resident concerns brought forth in resident council identified education had been provided to nursing staff related to the use of cell phones and ear buds, food related concerns, and call bell wait times. Additionally, there were audits for food concerns and call bells performed but, no additional interventions were attempted to resolve the issues of call bell complaints and earbuds/cell phone usage while on the nursing unit. Facility failed to provide interventions to address resident concerns regarding ants in their rooms, staff making too much noise at night, clothing and towels being left in resident bathrooms, and beds being left unmade. Review of the facility Resident Council policy directed, Policy Explanation and Guidelines: 2. All residents are eligible to participate in the Resident Council and are encouraged by facility staff to participate. 6. The group may appoint a resident to take notes/maintain meeting minutes or may elect that the Activity Director/designated liaison to take notes/ maintain minutes. Meeting minutes may include but are not limited to: a. Names of the residents in attendance, b. Follow up from previous meetings, c. Issues discussed, d. Recommendations from the group to the facility staff, e. Names of staff members, speakers, and other guests present in the meeting (as invited by the group to attend). 7. The facility shall act upon the concerns and recommendations of the council, make attempts to accommodate recommendations to the extent possible, and communicate its decisions to the council.

Based on interviews, review of the clinical record, review of facility documentation and review of facility policy for 1 of 3 sampled residents (Resident #99) reviewed for pressure ulcers, the facility failed to ensure Resident #99's resident representative was provided copies of medical record upon request. The findings include: Resident #99 was admitted to the facility in December 2025 with diagnoses that included contusion of the left front wall thorax (chest), acute embolism (blockage of blood vessel that has traveled in blood stream) and thrombosis (blood clot) of deep veins of right lower extremity, and dementia with severe anxiety.A hospital Discharge summary dated [DATE] identified Resident #99 was severely cognitively impaired and required moderate assistance of one staff member for washing, dressing, and toileting and required assistance of 2 staff members for transfers and ambulation with a rolling walker, minimal assistance with bed mobility and cueing for meals (there was not a Nursing admission Assessment or Minimum Data Set assessment completed for Resident #99 when admitted to the facility). The Resident Care Plan (RCP) dated 12/2/25 identified nutrition as an area of focus with interventions that included allowing adequate time to consume meals, assisting with meals as needed, monitoring labs, intake and output, monitoring weights as needed, providing diet as ordered and snacks as desired, speech therapy, inspect skin for redness, irritation or breakdown, pressure reducing cushion and mattress. Physician orders dated 12/3/25 directed assistance of 1 staff member for ambulation and bed mobility, physical, occupational, and speech therapy evaluation and treatment as indicated. Provide a no added salt diet with regular consistency and med pass (protein supplement) 120 milliliter (ml) once a day for nutritional needs.Social Worker (SW) #1's notes dated 12/10/26 noted information was provided to Person #1 and Person #2 regarding the last covered insurance day and discharge due to Resident #99's cognitive impairments.Psychiatric progress notes dated 12/4/26 by a Physician's Assistant indicated that Resident #99 had severe cognitive impairment with anxiety and depressed mood. Resident #99 was forgetful, confused and disoriented to place and time on situational exam.Nursing notes dated 12/12/26 indicated that Person #1 signed discharge paperwork for Resident #99 as he/she could not comprehend information provided for discharge. Interview with Person #1 on 7/27/26 at 8:15 AM indicated that requests had been made several times for a copy of Resident #99's medical records. Person #1 stated that she had spoken to the Administrator and emails had gone back and forth but still had not received copies of the medical record. Person #1 stated that the facility was just giving the run around. Person #1 indicated that Person #2 who was the resident representative for Resident #99 even requested copies of Resident #99's medical record per the Administrator's directive and still no copies had been sent. Interview with Person #2 on 7/27/26 at 12:15 PM indicated that she had spoken to Person #1 about Resident #99's medical records and that the facility wanted Person #2 to give consent. Person #2 indicated that she had told the facility to send the medical records for Resident #99 and she believed she had sent them written consent. Person #2 indicated that she did not know why it was taking so long to get the medical records as the request started in December 2025 even before Resident #99 was discharged . A review of email correspondence between Person #1 and the Administrator noted emails on 4/24/26, 5/7/26, 5/11/26, and 5/18/26. All emails were about Person #1's formal requests for the entire medical record for Resident #99. The Administrator's responses to Person #1, was either Person #2 or Resident #99 needed to send a signed consent in order for medical records to be released as Resident #99 was considered his/her own person. Even though Resident #99's BIMS score was 7 (severely cognitively impaired) and other documents pertaining to Resident #99 such as Beneficiary Notice and discharge paperwork were provided to Person #1 or Person #2. Otherwise, provide documentation that Person #1 was power of attorney for Resident #99.On 5/7/26 Person #1 provided a document titled, Document Concerning Health Care Instruction Combined Form. The form addressed, Living Will, Appointment of Health Care Representative, Designation of Conservator of Person, Anatomical Gift and Health Insurance Portability and Accountability Act (HIPPA) Release authority. In section of Health Care Representative, the document indicated that Person #1 and Person #2 had the authority to request and receive any information, verbal, or written, regarding my personal affairs or my physical or mental health, including medical and hospital records, and to execute any release or other documentation that may be required to obtain information. This document was in effect if attending physician determined that Resident #99 is unable to understand and appreciate the nature and consequences of health care decisions and to communicate any informed decisions.Interview with the Administrator on 7/27/26 at 1:00 PM indicated that the medical record for Resident #99 had not been sent because the information provided by Person #1 was a Living Will and was only in effect if Resident #99 was deemed incapacitated despite that Resident #99 was severely cognitively impaired and all other documents had been provided to Person #1 and Person #2 for their signatures.The Medical Records policy dated 12/4/25, directed, in part, under Connecticut General Statutes 19a-490b and 19a-550(b)(9), residents, their authorized health agents, conservators, or power of attorney may review and copy all medical records in the facility's procession upon written request by a complete and authorized form. A medical record form must be completed in its entirety and signed by a person legally eligible to release the records. When form is completed, it is returned to the facility. The maximum charge is $0.65 a page for most records.

Based on staff interview and record review for 3 of 3 sampled residents (Resident #3, Resident #6 and Resident #100) reviewed for Beneficiary Notices, the facility failed to provide the necessary Medicare Beneficiary Notices when benefits were due to be exhausted. The findings include: 1. Resident #3 was readmitted to the facility on [DATE] with Medicare as the payor source. Resident #3 no longer required Medicare benefits and benefits ended on 4/27/26. Resident #3 remained in the facility after Medicare services ended with Medicare days remaining, but an Advanced Beneficiary Notice of Non-Coverage (ABN) was not provided to Resident #3 or the resident representative prior to Medicare coverage ending. 2. Resident #6 was readmitted to the facility with Medicare as the payor source. Resident #6 no longer required Medicare benefits as of 7/16/26 but Resident #6 remained at the facility. An Advanced Beneficiary Notice of Non-Coverage (ABN) was not provided to Resident #6 or the resident representative prior to Medicare coverage ending. 3. Resident #100 was admitted to the facility on [DATE] with Medicare as the payor source. Resident #100 was discharged home from the facility after Medicare coverage ended on 5/19/26, but a Notice of Medicare Non-Coverage (NOMNC) was not provided to Resident #100 or the resident representative prior to Medicare coverage ending. Interview with the Administrator on 7/27/26 at 8:45 AM identified that Social Services and the MDS Coordinator were responsible for providing Medicare Beneficiary Notices to the resident or the resident representative. The Administrator indicated that Resident #100 was not provided with a Notice of Medicare Non-Coverage (NOMNC) prior to discharging home and the Advance Beneficiary Notice (ABN) was not given to Resident #3 and Resident #6 prior to skilled servicing ending at the facility. Both Resident #3 and Resident #6 remained in the facility after skilled services ended. The Administrator stated that neither the MDS Coordinator or Social Services realized that the NOMNC and ABN letters needed to be given to the residents. The Administrator further indicated that the MDS Coordinator was not available for interview. Interview with Social Worker (SW) #1 on 7/27/26 at 8:55 AM identified that he was responsible for providing the Beneficiary Notices to the Medicare A residents at the facility. SW #1 stated that he did not provide Resident #100 a Notice of Medicare Non-coverage (NOMNC) prior to discharging home. SW #1 stated both Resident #3 and Resident #6 remained in the facility after skilled services ended and he did not provide either Resident #3 or Resident #6 with an Advance Beneficiary Notice (ABN). SW #1 stated that he was already aware of all the Medicare Beneficiary Notices that were not given because the facility had already conducted an internal audit that identified the missing notification letters.The facility did not provide a policy for the SNF Beneficiary Notification.According to CMS, for Original Medicare Part A beneficiaries, when a skilled nursing facility determines that a beneficiary no longer requires daily skilled services and will be discharged home from the facility, the facility should provide a Notice of Medicare Non-Coverage (NOMNC) to the resident or their representative at least two calendar days prior to the skilled services ending. The Advance Beneficiary Notice is not required to be given to a SNF beneficiary if the beneficiary is discharging home. Medicare beneficiaries that remain in the SNF after the Medicare Part A stay ends and the SNF believes the continued care is not medically reasonable and necessary or is considered custodial care, a Notice of Medicare Non-Coverage (NOMNC) and an Advance Beneficiary Notice of Non-Coverage (ABN) should be provided to the beneficiary or their representative at least two calendar days prior to the Medicare skilled services ending at the facility.

Based on clinical record review, interviews, and facility documentation/policies for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to follow physician orders which directed the assistance of two (2) staff for bed mobility which resulted in a dislocation of the left shoulder, and for one (1) of three (3) residents (Resident #4) reviewed for accidents, the facility failed provide adequate supervision by failing to initiate appropriate fall prevention interventions (toileting plan/schedule) and failing to implement an established care plan intervention (gripper socks) for a resident with progressive incontinence patters who was at high risk for falls. The findings included:1.Resident #1's diagnoses included hemiplegia and hemiparesis after cerebral infarct affecting the left, non-dominant side. A Nurse's note dated 12/11/25 at 10:13 PM identified Resident #1 was alert and oriented times four. A Physician's admission Assessment note dated 12/12/25 at 11:30 AM identified Resident #1 was chair bound, had left sided weakness with no ability to move the left upper or left lower extremity. The physician's order dated 12/12/25 directed an assist of two (2) with bed mobility. The Resident Care Plan dated 12/12/25 identified Resident #1 had decreased functional mobility and was at risk of falls due to hemiplegia and hemiparesis of the left, non-dominant side. Interventions directed assistance of two (2) with bed mobility and transfers in and out of the bed and chair. The Nurse Aid Care Card (summary of a resident's daily care needs and instructions used by staff to provide care) dated 12/12/25 directed an assist of 2 with bed mobility. The Nurse's note dated 12/15/25 at 2:15 PM identified RN #2 (the 7 AM to 3 PM Nursing Supervisor), was notified Resident #1 complained of shoulder pain and stated he/she heard a pop while being transferred by a nurse aide (NA). The Advanced Practice Registered Nurse (APRN) was notified and directed an x-ray of the left shoulder. Pain medication was administered. The Nurse's note dated 12/16/25 at 12:34 PM identified Resident #1 denied pain. A Physician's progress note dated 12/16/25 at 1:00 PM identified Resident #1 complained of left shoulder, arm, and hand pain. Resident #1 had intact sensation but no active movement to the left upper extremity at baseline. Resident #1 had a small area of greenish- yellow ecchymosis on the left hand. The x-ray identified a normal left humerus with an anterior dislocation of the left shoulder. Resident #1 was sent to the Emergency Department (ED) for further evaluation. Review of the facility's summary report dated 12/18/25 identified Resident #1 complained of left arm pain when NA #1 was moving Resident #1 in bed on 12/15/25. Initially an x-ray was ordered but was discontinued by the APRN because Resident #1 no longer complained of pain and was unable to give a clear report of what happened when interviewed by the nursing supervisor. The APRN followed up with Resident #1 on 12/16/25 for evaluation of the left upper extremity pain and based on symptoms re-ordered the x-ray. NA #1 was subsequently provided with education regarding safe body mechanics and following the plan of care. An interview with LPN #1 on 1/14/26 at 11:00 AM identified that on 12/15/25 NA #1 reported that when he assisted Resident #1 with the bedpan, he pulled Resident #1's arm while moving him/her in bed. LPN #1 spoke with Resident #1 who reported the incident occurred that morning and further identified he/she heard a pop when NA #1 was moving him/her in bed. An interview with the Director of Nursing (DON) on 1/14/26 at 11:45 AM identified when she interviewed NA #1, he identified he moved Resident #1 in bed without assistance. The DON identified that provider orders directed assistance of two (2) staff members for bed mobility. Interview with NA #1 on 1/14/26 at 12:00 PM identified on 12/15/25 he was in a rush and Resident #1 wanted a boost up in bed to eat breakfast. NA #1 was alone and stood at the head of Resident #1's bead, grabbed the right side of the transfer sheet that was under Resident #1 with his right hand and grabbed Resident #1's left shoulder with his left hand and pulled Resident #1 up in the bed. NA #1 further identified he was aware Resident #1 was supposed to be moved by two (2) people while in bed. Although requested, the facility was unable to provide a transfer policy. 2.Resident #4 was admitted to the facility in February of 2025 and had diagnoses that included dementia, cerebral infarction, and difficulty in walking.The Bladder and Bowel assessment dated [DATE] identified Resident #4 was continent of bowel and the bladder section indicated non applicable. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 3), was dependent with toileting hygiene and bathing, required substantial assistance with ambulation, was occasionally incontinent of urine, and utilized a wheelchair. The Resident Care Plan (RCP) dated 6/12/25 identified Resident #4 was at risk for falls secondary to an impaired sense of balance and unsteady gait. Interventions directed to apply gripper socks while in bed, instruct Resident #4 to ask for assistance prior to attempting to transfer or ambulate, place call bell within reach, and orient to surroundings. The RCP did not identify goals and interventions for incontinence care or a toileting plan/schedule.a.The Accident and Incident report (A&I) dated 7/4/25 at 3:30 AM identified Resident #4 sustained an unwitnessed fall, was found lying on the bathroom floor, and sustained a skin tear to the left elbow.b.The A&I by LPN #3 dated 8/6/25 at 2:20 PM identified Resident #4 sustained an unwitnessed fall, was found lying on the floor in his/her room with the wheelchair tipped over and reported a headache and pain to the right side, hip, and back.c. The A&I by LPN #3 dated 9/8/25 at 8:15 PM identified Resident #4 sustained an unwitnessed fall due to ambulating without assistance. Resident #4 was found next to his/her bed and sustained no injuries. d. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) of 3), required substantial assistance with toileting hygiene, personal hygiene, and ambulation, utilized a wheelchair, and was frequently incontinent of bowel and bladder. Review of the RCP dated 9/24/25 identified Resident #4 was at risk for falls secondary to an impaired sense of balance and unsteady gait. Interventions directed to apply gripper socks while in bed, instruct Resident #4 to ask for assistance prior to attempting to transfer or ambulate, offer toileting during second rounds, and to offer bathroom frequently when in bedside chair. The RCP did not identify goals and adequate interventions for incontinence care or a toileting plan/schedule.The A&I by RN #7 dated 11/19/25 at 11:45 PM identified Resident #4 sustained an unwitnessed fall and was found under the sink in his/her bathroom, sustained a right elbow and low back skin tear, and reported right rib pain. Initial x-rays resulted negative; however, Resident #4 was transported to the hospital on [DATE] for a high pain level (10 out of 10) to the right side and back.The Certified Nurse's Aide Care Card (care card) (used to identify a resident's specific care needs) dated 11/20/25 identified Resident #4 was continent of bowel and bladder. The toileting plan section of the care card directed a transfer status rather than a toiling plan to provide an assist of one for toilet transfers with use of a rolling walker or grab bar. The care card directed to ensure non-skid socks were in place. A nurse's note by RN #6 on 11/27/26 at 12:57 PM identified Resident #4 was readmitted to the facility and had fractures to ribs 8-11.Review of the clinical record failed to identify a Bowel and Bladder assessment was performed upon readmission to the facility according to facility policy.e.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) of 3), required supervision with toileting, substantial assistance with transfers, utilized a wheelchair, was frequently incontinent of urine.The Resident Care Plan (RCP) dated 12/9/25 identified Resident #4 was at risk for falls secondary to impaired sense of balance and unsteady gait and was incontinent of bowel and bladder. Interventions directed to apply gripper socks while in bed, to check placement of gripper socks at the beginning of the 11:00 PM to 7:00 AM shift, observe for non-verbal cues of needing to use the bathroom, observe for signs of redness or inflammation and apply barrier if indicated, to provide privacy and a brief. The RCP did not identify a toileting plan/schedule. The Fall Investigation Report by RN #4 dated 12/20/25 at 4:15 AM identified Resident #4 fell out of bed while attempting to use a urinal and was not wearing gripper socks.A Nursing Post Event progress note by RN #7 dated 12/20/25 at 5:11 AM identified Resident #4 sustained an unwitnessed fall out of bed and stated was trying to use the urinal and I don't know what happened, sustained a 2.5 centimeter (cm) skin tear to his/her head with a hematoma, and a bruise to the outer lower leg. The on-call provider was contacted and ordered Resident #4 to be transported to the hospital for further evaluation. A nursing note by RN #2 dated 12/21/25 at 8:55 AM identified Resident #4 returned from the hospital after receiving 2 staples for a 3 cm by 2.5 cm head laceration and additionally sustained an 11 cm by 8 cm bruise to the right elbow area from the fall. Interview with NA #4 on 1/22/26 at 10:58 AM identified he/she was seated outside Resident #4's room on 12/20/25 during the 11:00 PM to 7:00 AM shift when Resident #4 fell to the floor. NA #4 indicated Resident #4 explained he/she was sitting on the edge of the bed with both feet on the floor, attempting to position the urinal for use, when he/she lost balance and fell. NA #4 further identified Resident #4 was not wearing gripper socks at the time of the fall and that he/she was unaware Resident #4 was to have gripper socks on while in bed and checked for placement on the 11 PM to 7 AM shift.Interview with the Director of Nursing Services (DNS) on 1/22/26 at 11:33 AM identified Resident #4 should have had a toileting plan/schedule due to severe cognitive impairment and identified incontinence patterns. The DNS was unable to identify why the facility failed to implement a toileting plan/schedule despite Resident #4 sustaining three (3) falls related to toileting needs, two of which resulted in injury. The DNS further identified the facility should have performed a Bowel and Bladder assessment following the 11/22/25 to 11/27/25 hospitalization according to facility policy. The DNS identified NAs were trained to review care cards at the start of each shift because updates/changes to the level of care could occur at any time and would be updated on the care card. The DNS indicated NA #4 and NA #5 should have checked Resident #4's care card.Interview with NA #5 on 1/22/26 at 2:34 PM identified he/she was assigned to provide care for Resident #4 during the 3 PM to 11 PM shift on 12/19/25. NA #5 identified he/she provided personal care and assisted Resident #4 to bed. NA #5 identified he/she applied regular socks and was unaware that Resident #4 required gripper socks while in bed.The Falls Management policy directed the facility would utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at risk for fall status and that the interdisciplinary team would develop, initiate, and implement an appropriate individualized care plan based on the fall risk evaluation score.The Urinary Incontinence policy directed each resident would have a urinary assessment on admission, readmission, and with a significant change in continence. The policy further indicates changes in continence status would be monitored and that the bladder assessment, once completed, would determine the type of toileting plan based on the score. Although requested, the facility did not have a Resident Care Card policy to provide. The Comprehensive Care Plan policy directed the facility was committed to providing residents with all necessary care and services to enable them to achieve the highest quality of life, that care plans were oriented toward preventing avoidable decline in clinical functional levels, maintaining a specific level of functioning, and that the Comprehensive Care Plan included measurable objectives and timelines to accommodate preferences, special medical, nursing and psychosocial needs identified.

Based on observations, interviews, clinical record review, and review of facility documentation, for one resident reviewed for choking, (Resident #1), the facility failed to ensure that a resident who had a diagnosis of dysphagia received a diet that was consistent with speech therapy recommendations and physicians orders, and failed to ensure that the resident who had a choking episode was not given foods prior physician approval and a speech therapy evaluation, and further failed to ensure that Resident #1 did not receive foods that were listed as an allergy, and for three (3) out of ten (10) residents with a diagnosis of dysphagia, (Resident #2, Resident #3, and Resident #4) the facility failed to ensure that the residents received meals in accordance to physician's orders, resulting in a finding of Immediate Jeopardy. The findings include: 1. Resident #1 had a diagnosis of dysphagia, dyskinesia and [CONDITION(S)]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident was cognitively intact, required extensive assistance with activities of daily living, required oversight and encouragement of one staff person with eating, and received a therapeutic diet. The care plan dated 4/27/21 identified a history of dysphagia with upper dentition only (resident refuses bottom dentures), with interventions that included to provide feeding guidelines as indicated, speech therapy evaluation as ordered, provide diet as ordered and to have nurse aide's cut up food. Review of a speech therapy discharge summary dated 12/31/21 identified the resident was treated for a diagnosis of dysphagia from 12/8/20 until 12/31/20 with focus on bolus control with thin liquids. Resident #1 met h/her goals and was discharged with recommendations for a regular diet with thin liquids and to cut up food and provide extra sauces and gravies at mealtime. The staff was in-serviced on carry over of recommendations and the resident was able to eat independently after set up from staff. A physicians order dated 3/31/21 directed to provide a low fat, low cholesterol, regular consistency diet, no ham or pork, with extra gravy/sauces, thin liquids, and to have the nurse aides cut up food. The physician's orders for May 2021 identified a strawberry and tomato product allergy. Review of the facility menu on 5/21/21 for the supper meal identified a sausage grinder with marinated mushrooms, chicken orzo soup, and bread pudding. A nurse's note dated 5/21/21 at 11:38 PM written by Licensed Practical Nurse (LPN) #1 identified Resident #1 was heard coughing. Upon entering the resident's room the resident was displaying the universal choking sign, and was not able to speak when asked questions. The resident was then assisted to the side of the bed and the [MEDICATION(S)] maneuver was performed successfully and the resident expelled two pieces of sausage from dinner. The resident did not lose consciousness, lung sounds were clear, oxygen saturation was 94% on room air, vital signs were stable and no respiratory distress was noted. The resident complained of a sore throat but was otherwise without complaints. The resident requested a chicken salad for a snack which was provided and staff were present while the resident was eating and the resident had no difficulties swallowing. A nurse's note dated 5/21/21 at 10:55 PM written by Registered Nurse (RN) #1 identified h/she was called to the resident's room and the charge nurse had reported the [MEDICATION(S)] maneuver had been performed on the resident. An assessment identified that the lung sounds were clear, and vital signs were stable. The Advanced Practice Registered Nurse (APRN) was notified and new orders were obtained to check vital signs, pulse oxygenation and respiratory assessments every four (4) hours and to obtain a speech evaluation. A reportable event form dated 5/21/21 at 6:00 PM identified that the resident was heard coughing, the staff immediately responded to observe Resident #1 displaying the universal sign for choking. The resident was unable to speak, the [MEDICATION(S)] maneuver was performed and the food was cleared. Review of the meal ticket dated 5/21/21 for the supper meal identified that Resident #1 was to receive a high ridge plate, weighted utensils, extra-gravy, CNA to cut up food, and had a strawberry and tomato allergy, no tomato sauce. (The meal ticket failed to identify that the resident should not be served ham or pork). Interview with the Dietary Manager (DM) on 6/7/21 at 10:30 AM identified that the meals are served on the resident unit from a steam table in the dining room. The dietary staff serves the meal according to the meal ticket which lists the diet, allergies, and preferences as well as any modified equipment needed. The dietary staff then hands the meal and the meal ticket to the Nurse Aide (NA) and the NA deliver the meals to the residents. The DM identified that the extra sauces that are provided by the dietary department are served in a soufflé cup on the plate, aside from the meal, but he was unsure if Resident #1 received the extra sauce/gravy on 5/21/21 at the supper time meal. He further stated that if the resident is on a regular diet and the meal needs to be cut up, it is cut up by the NA's. The meal on 5/21/21 was sausage grinders (served in a link form) that were served with onions and peppers in a tomato sauce on a bun. The Dietary Manager identified that on 5/21/21 the resident was served tomato sauce which was a listed allergy on the meal ticket, furthermore the resident was served a sausage (pork) which h/she should not be given due to a religious preference. Review of the meal ticket from 5/21/21 with the DM failed to identify that the resident should not receive pork and the DM stated that he was unsure why this was not on the meal ticket that day. Interview with Dietary Aide (DA) #1 on 6/7/21 at 12:15 PM in the presence of the DM identified that she had been serving the meals on the 3rd floor where the resident resided on 5/21/21 for the supper meal. DA #1 identified that the sausage grinder came with tomato sauce that was mixed with onions and peppers. She stated although she read the meal ticket she did not provide the resident with the extra sauces and gravy, and failed to read the allergy to tomato sauce, and was unsure why. Interview with NA# 1 (who was from a nursing agency) on 6/7/21 at 11:32 AM identified that she had delivered the tray to Resident #1 at supper time on 5/21/21. She further stated that she remembers being short staffed that night and it was very busy, so she passed the meals to the resident's and made sure that the correct resident received the correct meal, but did not read the meal tickets any further. NA #1 stated that she could not recall if she cut up Resident #1's food, but no one told her Resident #1 needed her food cut up, and the resident appeared that she did not need assistance. NA #1 stated she would have expected the staff to tell her who which residents needed their food cut up since she was not familiar with the residents. Interview with LPN #1 on 6/7/21 at 10:30 AM identified that she was Resident #1's charge nurse on 5/21/21 on the 3:00 PM to 11:00 PM shift. LPN #1 stated that she heard the resident cough and immediately entered the room where the resident had h/her hands up to h/her throat and could not speak. LPN #1 stated that she sat the resident up at the bedside and started the [MEDICATION(S)] maneuver and after three abdominal thrusts two pieces of sausage were expelled, one piece was about 1 ¼ inch long and was described by LPN #1 as not bite sized, but more like two bite sizes. The other piece of sausage was masticated and smaller at about ½ in size. Interview with RN #1 on 6/7/21 at 11:05 AM identified that she was the nursing supervisor on 5/21/21 when the resident choked. She stated that by the time she entered Resident #1's room the airway had already been cleared and the food bolus had been expelled. RN #1 identified that she saw the remains of the sausage grinder on the plate and it was not cut up. RN #1 further identified that she interviewed NA #1 after the incident and the NA stated that she did not cut up Resident #1's meal, and had thought that if Resident #1 needed her meal cut up one of the regular staff would have told her. RN #1 identified that she in-serviced the staff on shift that evening to the importance of checking meal tickets. Interview with the Speech Therapist (ST) on 6/7/21 at 12:46 PM identified that the resident had oral dysphagia (dysphagia that takes place in the mouth). The resident had chronic dry mouth, and the extra sauces and gravy would add the moisture that the mouth lacks, and would help the resident swallow the food bolus more smoothly. The resident also required that staff cut up the food because the resident has decreased range of motion in h/her hands and is unable to cut up the food h/herself. Furthermore, the resident had a diagnosis of dyskinesia (involuntary, erratic movement of the face) which creates movement in the mouth that would decrease food bolus control, and additionally the resident lacked bottom dentition (the resident refuses bottom dentures). The speech therapist identified that if the food was not cut up and the extra sauce was not given it could put the resident at risk for a choking episode. The ST identified that after the choking incident Resident #1 indicated that the NA left the room and did not cut h/her food, the resident put the call light on to request that her food be cut, but no one answered her light so she decided to eat the food as she was hungry. Interview with the DON on 6/7/21 at 3:00 PM identified that she was informed by RN #1 that Resident #1 had received the supper meal and the NA failed to cut the food, and the resident had a choking episode on 5/21/21. The DON stated that the NA should be checking the meal ticket in its entirety prior to leaving the meal with the resident. The DON further identified that although the staff that were on the 3:00 PM to 11:00 PM shift on 5/21/21 were educated to ensure that meal tickets are checked at meal time, no other staff members were educated because she didn't think to do it because the facility determined that the resident choked. Interview with APRN #1 on 6/7/21 at 1:45 PM identified that it would be her expectation for the facility to follow speech therapy recommendations and physician orders during meal time. The APRN further identified that she was unsure about history of the allergy to tomato products, but the resident should not have received the tomato product, however, the resident did not have an adverse outcome from the consumption. Review of the NA job description identified that the NA will follow the current care plan on all the residents under h/her care. Review of the dietary aide job description identified that the dietary aide must follow the therapeutic diet cards as ordered by the physician. The facility failed to ensure that the resident was not served food items that were listed as an allergy, and failed to provide cut up food and extra sauces and gravy in accordance to physician's orders resulting in a choking episode and the finding of Immediate Jeopardy. 2. A nurse's note dated 5/21/21 at 11:38 PM written by Licensed Practical Nurse (LPN) #1 identified that Resident #1 was heard coughing, upon entering the resident's room the resident was displaying the universal choking sign, and was unable to answer questions. The resident was then assisted to the side of the bed and the [MEDICATION(S)] maneuver was performed successfully and the resident expelled two pieces of sausage from dinner. The resident did no lose consciousness, lung sounds were clear, oxygen saturation was 94 % on room air, vital signs were stable and no respiratory distress was noted. The resident complained of a sore throat but was otherwise without complaints. The resident requested a chicken salad for a snack, staff were present while the resident was eating and the resident had no difficulties swallowing. A nurse's note dated 5/21/21 at 2:15 PM written by RN #2 identified that the resident was status post abdominal thrusts on the evening shift on 5/21/21. The resident's lung sounds were clear, with no congestion noted, no shortness of breath, and no respiratory distress. The resident ate breakfast and lunch without difficulty, and speech therapy was into evaluate the resident. Review of the breakfast meal on 5/22/21 identified that oatmeal, a vegetable soufflé and cinnamon rolls were served. Review of meal intake for breakfast on 5/21/21 identified that the resident had eaten 75-100% of the meal. Interview with LPN #1 on 6/7/21 at 10:30 AM identified that the resident was hungry on 5/21/21 after the choking incident and requested chicken salad for a snack. The chicken salad was in a cup, not in a sandwich form. LPN #1 stated that she was unsure what the supervisor and APRN had discussed about the residents choking episode, but she gave the resident the chicken salad and ensured that the resident was supervised by a staff member, and the resident had no difficulties swallowing the chicken salad. Interview with RN #1 on 6/7/21 at 11:05 AM identified that she was not aware that the resident was given chicken salad after the choking event, and when she called the APRN they did not discuss a diet order or if further food intake was appropriate for the resident. Interview with RN #2 on 6/7/21 at 11:45 AM identified that she was the charge nurse on the floor on 5/22/21 for the 7:00 AM to 3:00 PM shift and had been notified in report that the resident had a choking episode. She stated that she had assessed the resident's lung sounds, and they were clear, she ensured that the resident was positioned properly, and then gave the resident breakfast. RN #2 stated that she used her nursing judgment and since the breakfast was soft, she allowed the resident to eat, with a nursing student supervising Resident #1's intake. Interview with the Speech Therapist (ST) on 6/7/21 at 12:46 PM identified that she evaluated the resident on 5/22/21 for the lunch time meal, and had changed her diet to a chopped diet. The ST identified that although the resident received the chicken salad on 5/21/21 and breakfast on 5/22/21 prior to her evaluation, the foods the resident consumed would have been appropriate for the chopped diet, however, she would expect that the nursing staff receive direction for the physician prior to allowing the resident to eat following a choking episode, if it was prior to her evaluation. Interview with APRN #1 on 6/7/21 at 1:45 PM identified that she was notified on 5/21/21 that the resident had choked on the evening meal, and gave orders for respiratory assessments every 4 hours. APRN #1 further identified that the facility did not inquire about whether the resident could eat prior to the speech evaluation the next day, but assumed there was a protocol after a choking episode that the resident would not eat prior to the speech therapy evaluation because the reason for the choking episode is unknown. Interview with the DON on 6/6/21 at 3:00 PM identified that there was no policy or protocol on meal intake after a choking episode, but it would be her expectation that the staff call the physician for direction prior to feeding a resident after a choking episode if it were prior to the speech therapy evaluation. The facility failed to consult the physician, and have a ST consult prior to feeding a resident after a choking incident. 3. Physician's orders dated 6/1/21 directed for Resident #1 to have a low carbohydrate and fat diet, no added salt, mechanical soft ground textured, and to add sauces and gravy to meals. Allergies listed on the June 2021 physician's orders were strawberries and tomato products. a. Observation on 6/7/21 at 12:30 PM of the lunch meal for Resident #1 identified the resident was on a mechanical soft ground, low fat and carbohydrate diet, no added salt, and no pork. Observation of the lunch meal was chicken in gravy, on top of egg noodles and cinnamon applesauce, the meal did not include the extra gravy. The meal ticket did not identify that extra sauce/gravy was required, and that the resident had a tomato and strawberry allergy. Interview with the Meal Ticket Clerk on 6/7/21 at 1:30 PM identified she had recognized the errors in the ticket and had called the company that the facility contracts with for the meal ticket computer program to tell them they were having issues with items left off of the meal ticket. She further identified that although she identified the error she had already printed the meal ticket, so it had gone to the floor with the missing information, although she had called the company about the issue she did not inform anyone in the nursing staff about the lack of information on the meal ticket. Interview with the Dietary Manager on 6/7/21 at 1:34 PM identified that extra gravy should be given in a soufflé' cup aside the plate, and the facility was currently working with the company to fix the issue with the meal tickets. Interview with the ST on 6/7/21 at 2:00 PM identified that the extra gravy is needed for the resident due to the lack of saliva that the resident produces, the extra gravy helps ease the resident swallowing capabilities. The ST further identified that if the meal is served with gravy, it is still expected for the resident to receive extra gravy on the side. b. Observation on 6/8/21 at 8:25 AM of Resident #1's breakfast meal ticket identified a mechanical soft ground, low fat and carbohydrate diet, no added salt, and no pork. The ticket failed to identify the need for extra gravy and sauces and failed to identify the strawberry and tomato product allergy. Observation Resident #1's of the breakfast meal at 8:25 AM consisted of scrambled eggs. Interview with the Dietary Manager on 6/8/21 at 10:00 AM identified that he was unsure of why the allergies and extra sauces and gravy were left off of the meal ticket, but he would be contacting the company that supplies the program to alert them of the issue. Interview with the ST on 6/8/21 at 12:00 PM identified that the eggs were moist enough where the extra gravy would not be necessary for the resident to swallow effectively. 4. Resident #2 had diagnoses of dysphagia and dementia. A significant change minimum data set assessment dated [DATE] identified that the resident was cognitively impaired and required extensive to total care with activities of daily living, and received a mechanically altered diet. The care plan dated 5/25/21 identified a risk for aspiration with interventions that included aspiration precautions, and to thicken liquids to honey consistency. A physician's order dated 4/21/21 directed that the resident can have regular water between meals only, and to serve honey thick liquids at meal time. Review of a ST discharge summary dated 4/26/21 identified that the resident's family wanted the resident to have regular water between meals, despite known aspiration as demonstrated in the Fiber optic Evaluation of Swallowing (FEES) study (a bedside swallowing test). The ST recommendations upon discharge were for the resident not to have straws, water between meals only, and a puree diet with honey thick liquids. A significant change minimum data set assessment dated [DATE] identified that the resident was cognitively impaired and required extensive to total care with activities of daily living, and received a mechanically altered diet. The care plan dated 5/25/21 identified a risk for aspiration with interventions that included aspiration precautions, and to thicken liquids to honey consistency. A physician's order dated 6/1/21 directed to provide a low fat, low sodium, puree consistency diet with honey thickened liquids, no straws. Observation on 6/7/21 at 12:22 PM of Resident #2 at the lunch meal identified that the resident was eating h/her puree diet with a Kennedy cup which contained un-thickened water and a straw. Observation of Resident #2's meal ticket dated 6/7/21 identified that the resident requires honey thick liquids and should not have a straw. Interview with NA # 2 on 6/7/21 at 12:30 PM identified when she passed out fluids to the residents she used a list provided by the dietary department which indicated each of the resident diets. Review of the list with NA#2 indicated that Resident #2 should not receive a straw and should be provided with honey thick liquids. NA #2 further identified that she thought that the resident could have water that was not thickened, but was unaware she could not have it at meal time. Interview with the ST on 6/8/21 at 9:45 AM identified Resident #2 was on aspiration precautions because she had a diagnosis of dysphagia. She further identified that the resident had a FEES test and it had shown that the resident aspirated on thin liquids, and aspirated with thickened liquids through a straw. The family was concerned about the resident's hydration and wanted the resident to have un-thickened water, the family was educated about the aspiration risks, and an order was written for the resident to drink un-thickened water between meals. The ST identified that the resident should not have the un-thickened water at meal time because if h/she aspirates with the un-thickened water while eating the resident has the potential to aspirate food particles into the lungs. The ST further identified that the resident should not have a straw because the FEES showed aspiration on honey thick liquids with the use of a straw. Review of the NA job description identified that the NA will follow the current care plan on all the residents under h/her care. 5. Resident #3 had a diagnosis of dysphagia. A Minimum Data Set assessment dated [DATE] identified that the resident was cognitively impaired, required total care for activities of daily living, including eating, and was on a mechanically altered diet. The care plan dated 4/13/21 identified a diagnosis of aspiration and dysphagia with interventions that included to provide the resident with the diet as ordered and thin liquids. A physician's order dated 6/1/21 directed to provide a dysphagia level 2 texture (ground) diet with thin liquids and to provide extra sauces and gravies. Observation on 6/8/21 of the lunch time meal at 12:37 PM identified that Resident #3 was being assisted by a staff member, the consistency of the meal was correct but there were no extra sauces or gravy served with the meal. The meal ticket dated 6/8/21 identified that the resident should have extra sauces and gravies at meal time. Interview with NA #3 at the time of the observation identified that she had not noticed that the meal was not provided with extra gravy. Interview with the Cook on 6/8/21 at 12:41 PM identified although he was in-serviced on meal ticket accuracy that morning, he didn't see the extra sauces/gravy on the meal ticket. He further identified that when the meal ticket identifies that extra sauces and gravies are required he places the gravy in a soufflé cup beside the meal to be added by the staff. Interview with the Speech Therapist on 6/8/21 at 2:00 PM identified that the resident should have the extra gravy and sauces on at least the vegetables to ease the residents swallowing. Review of the NA job description identified that the NA will follow the current care plan on all the residents under h/her care. Review of the cooks job description identified that the cook must follow the therapeutic diet cards as ordered by the physician. 6. Resident #4 had diagnoses of [CONDITION(S)] and dysphagia. An admission minimum data set assessment dated [DATE] identified that the resident was cognitively impaired, required total care for activities of daily living, including eating, and received a mechanically altered diet. The care plan dated 3/30/21 identified a risk for aspiration due to the disease process with interventions that included to follow feeding guidelines, and thickened liquids. A physician's order dated 6/1/21 directed to provide a puree diet with nectar thick liquids and to provide extra sauces and gravies at meal time. Observation on 6/8/21 at 12:30 PM of the resident's meal identified a puree diet, the resident was assisted by NA #4, and the meal lacked the extra sauces/gravies that were listed on the meal ticket. Interview with NA #4 on 6/8/21 at 12:30 PM identified that although she had been in-serviced that morning on meal ticket accuracy, she did not see the need for extra gravies and sauces on the meal ticket. Interview with the Cook at the time of the observation identified that although he was in-serviced that morning on meal ticket accuracy, he must not have seen the extra sauces/gravy on the meal ticket otherwise he would have placed them in a soufflé cup and put it on the resident's plate. Interview with the Speech Therapist on 6/8/21 at 2:00 PM identified that although the resident should be provided with the extra sauces/gravy at meal time, the meal that was served to the resident at lunch time had a lot of moisture and the resident would have had no problems with swallowing without the extra sauces/gravy. Review of the NA job description identified that the NA will follow the current care plan on all the residents under h/her care. Review of the cooks job description identified that the cook must follow the therapeutic diet cards as ordered by the physician. The facility failed to ensure that meal tickets were accurate and that meals were served to the residents with dysphagia diagnoses in accordance to the meal tickets and physician orders. On 6/7/21 the facility submitted an immediate action plan to ensure the accuracy of physician ordered diets. The facility immediately started education on meal ticket accuracy, which included checking the diet consistency, and liquid type, allergies and dislikes, level of assist for set up, if extra sauces or gravy are required, adaptive equipment necessary, and any restrictions. The facility initiated random weekly audits weekly. On 6/8/21 surveyor observations for Resident #3 and Resident #4 identified that the residents did not get their extra sauces and gravy with their meal in accordance with their meal ticket, physician's orders, and speech therapy recommendations. NA #4 and the cook identified that they did not see the extra sauces/gravy on the meal ticket, although both staff members were educated about meal ticket accuracy by the facility before they started their shift on 6/8/21. The facility identified they would be auditing all meals served to ensure accuracy of the food being delivered, and education to staff that assist with meals will be educated/re-educated on ensuring the meal ticket and the food being served are accurate prior to delivering the meals to the residents. On 6/10/21 a monitoring visit was conducted at 12:00 PM and 10 residents who have modified diets were observed to have meals in accordance with the meal ticket and physician orders. Immediate Jeopardy was identified as corrected.

Based on clinical record review, observations, facility documentation review, review of hospital summary and interviews for one of six sampled residents reviewed for accidents (R#148, R#17, R#96) the facility failed to implement measures to prevent a fall with injury and/or injury from a hot pack and/or failed to apply foot rests and seat belt prior to transporting the resident. The findings include: 1. Resident # 148 ' s [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified Resident # 148 with a Brief Interview for Mental Status (BIMS) score of ten out of fifteen, indicative of moderate cognitive impairment, required assistance of two staff for bed mobility and required total assistance for personal hygiene. The Resident Care Plan (RCP) dated 10/18/16 identified the resident with a pressure ulcer, a fall risk and requiring assistance with mobility due to weakness. Interventions included to use air mattress set at 220 lbs and check every shift and assist with ADL's as needed. A physician's orders [REDACTED]. Review of the clinical record identified R # 148's weight recorded on 12/07/16 as 234 lbs. A nurse's note dated 12/10/16 at 13:47 identified that R#148 was observed lying on the floor supine, the nurse aide R#148 rolled out of bed, complained of pain to right leg and lower back and was transferred to the ED for evaluation. Review of facility documentation dated 12/10/16 at 9:55 AM identified R#148 rolled out of bed onto the floor and landed on his/her back. The APRN ordered the resident to be transferred to hospital for evaluation. Additional review of facility documentation identified R#148 was admitted to the hospital with [REDACTED]. Facility documentation/investigation included a statement from NA#1 indicating he/she turned R#148 on his/her side, went to R#148's bathroom for supplies, turned and saw R#148 rolling out of the bed. Interview with NA#1 on 9/12/17 at 10:25 AM identified he/she was giving care to R#148 with no other staff assistance, when R#148 had a fall out of bed. NA # 1 indicated R#148 had an air mattress on the bed and he/she pushed a button on the air mattress to inflate the mattress before giving care. NA#1 also indicated R#148 could move his/her legs independently. NA#1 indicated he/she rolled R#148 onto his/her left side and left R#148 to obtain supplies from the resident's bathroom. NA#1 indicated that while he/she was in the bathroom, he/she heard R# 148 call out his/her name and when NA#1 looked over at R#148, he/she saw R#148 falling out of the bed, feet first and then his/her upper body followed out of the bed, landing on the floor. Interview and review of clinical record and facility documentation with RN # 1 on 9/12/17 at 1:10 PM identified that although R#148 required assistance with turning, R#148 could move his/her legs independently, had a history of [REDACTED].#148's momentum going. Phone interview with Person # 1 on 9/12/17 at 8:42 AM, identified that the air mattress had a Max Inflate button to use if a firmer surface is required for resident care, depending on the individual resident needs and the level of care of procedure to be performed. Person # 1 indicated the Max Inflate should be turned off before staff leaves a resident unattended, however the Max Inflate automatically turns off after 20 minutes for safety. Interview and review of the clinical record and facility documentation with the DON on 9/13/17 at 9:20 AM identified he/she does not know who determines the use of the Max Inflate setting for resident care and indicated nursing staff should have been with the resident when rolled onto his/her side. The DON also indicated that the use of the Max Inflate setting was not included in the plan of care, and if the Max Inflate setting was used it should be included in the plan of care. Resident # 148's care plan was updated on 12/11/16 after the fall, with a new intervention that included; staff to be present on both sides of bed during care. Review of Relief Aire Low Air Loss System Operation Manual identified in part, a warning regarding patient falls, and included air mattresses have soft edges that may collapse when patients roll to the edge. Additional review of the Manual identified in part, the Max Inflate button rapidly inflates the mattress to maximum pressure, and directed to press the Max Inflate button after the function is no longer needed to return to the Standard mode and the Max Inflate function will cancel automatically after 25 minutes if unattended. Review of facility Alternating Pressure Mattress Policy failed to identify any instructions regarding use of a Max Inflate setting. 2. Resident#17's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified moderate impairment in cognition, requiring extensive assistance of two staff for transfers, not steady with moving from a seated position, turning and walking and no recent falls. a. Facility documentation dated 8/13/17 at 7:30 PM indicated that a staff member identified Resident#17 with two superficial burns to the lower back, measuring 4.9 cm x 2.8 cm on the right and 2.1 cm x 1.5 cm on the left. Pain evaluation also dated 8/13/17 identified intermittent, nagging, burning pain to the area when material comes in contact with the open area. Although facility investigation identified actions taken for prevention that included staff education of wrapping hot packs in towel prior to placing, the 72 - hour look back of staff statements failed to identify any staff who applied a hot pack and/or when the burns occurred. Interview with the DNS on 9/15/17 at 1:50 PM indicated the facility investigation identified all staff interviewed denied placing a hot pack on Resident#17 and no one ever found or saw a hot pack on 8/13/17 when the burns were reported. Interview with RN#2 on 9/15/17 at 2:30 PM indicated on 8/11/17, (2 days prior to identification of the burns), a NA, whom RN#2 could not recall asked RN#2 if she/he could reinforce a hot pack because it was coming out from the towel. RN#2 indicated she/he reinforced the pack, did not check the resident's skin and applied the hot pack over the R#17's shirt. RN#2 further indicated she/he did not work on 8/13/17. Interview with APRN#1 on 9/15/17 at 3:00 PM indicated the injured area was consistent with a burn from a warm compress and the only cause she/he could think of is that a towel was not placed under the hot compress causing the burn. b. The resident care plan dated 7/13/17 identified the resident at risk for falls secondary to weakness and decreased endurance/strength with interventions of utilizing a self-releasing seat belt in wheelchair for pelvic positioning. Facility documentation dated 8/30/17 indicated NA#3 was transporting Resident#17 to the bathroom with a gait belt on the resident when the resident's right foot got stuck under the wheel of the wheelchair and the resident slipped forward out of the wheelchair. Facility investigation identified that Resident#17's wheelchair did not have the leg rests on and the seat belt was not fastened. Interview with NA#3 on 9/15/17 at 1:45 PM indicated 8/30/17 was the first time NA# 3 was assigned to the resident and was not aware that leg rests should have been on the wheelchair. NA#3 also indicated he/she was informed later that the resident has a seatbelt in the wheelchair but thought it was a restraint so did not want to use it. NA#3 finally indicated he/she received shift report on the resident, was aware something is posted on the closet door indicating the care needs of the resident but had not looked at it. On 9/01/17, NA#3 received on the job training/education regarding understanding of the utilization of care cards and resident safety during wheelchair transport. 3. Resident#96's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] identified short and long term memory impairments, severe impairment in cognition, requiring extensive assistance of two staff for bed mobility and transfers and one recent fall. Fall risk assessments dated 11/28/16 and 1/10/17 identified Resident#96 at risk for falls. The resident care plan revised on 12/01/16 identified the resident at risk for falls which included intervention for low bed with mats on floor. Facility documentation dated 1/10/17 indicated Resident#96 was found on the floor next to the bed with a bump on the right side of the head. Facility investigation identified the mat was missing from the bedside and intervention included to continue to place bedside mat down. Interview with the DNS on 9/14/17 at 1:30 PM indicated she/he was not the DNS at the time of the accident and the assigned NA and investigative nurse are no longer employed at the facility. Attempt to reach the NA staff was unsuccessful.

Based on review of the clinical record review, facility documentation and interviews for one of four residents (Resident #103) reviewed for accidents, the facility failed to transfer the resident with an assistive device to prevent an accident with injury. The findings include: Resident #103 ' s [DIAGNOSES REDACTED].The physician order [REDACTED].The fall risk assessment dated [DATE] identified the resident was at risk for falls.The admission MDS assessment dated [DATE] identified intact cognition and extensive assistance for transfers, personal hygiene and toilet use.The care plan dated 8/15/16 identified the resident required help with mobility due to weakness and unsteady gait and was at risk for falls secondary to decreased endurance/strength and balance with interventions that included to transfer and ambulate as ordered. The nurse ' s note dated 10/10/16 identified that while preparing for AM weight, Resident #103 stood from the wheelchair and lost balance, landing on his/her right side. Further review of the nurse ' s note identified that Resident #103 hit her/his head during the fall sustaining two linear open areas to her/his right brow, pressure and ice was applied to area, and neurological checks were initiated. The Reportable Event dated 10/10/16 identified Resident #103 stood up to stand on the scale and lost his/her balance landing on the floor. The resident sustained [REDACTED]. The fall investigation identified the resident was transferred from the wheelchair to the standup scale. The investigation identified that during the transfer on 10/10/16, the resident had on shoes, and a wheelchair and a gait belt were equipment used during the transfer. The investigation did not identify that a walker was utilized during the transfer and at the time of the fall. The fall investigation statement dated 10/10/16 from Nurse Aide (NA) #3, who was assigned to provide care to the resident identified that while assisting Resident #103 onto the scale the resident ' s hand slipped off the bar of the scale and his/her leg gave out and resident collapsed on the floor. The statement identified a gait belt was utilized for the transfer, however, there was no indication in the investigation and/or statement that a walker was used as directed by the physician order.The nurse ' s note dated 10/12/16 identified Resident #103 was transferred to the Emergency Department due to a change in mental status and subsequently admitted to the acute care hospital with a [DIAGNOSES REDACTED]. The hospital discharge summary identified that Resident #103 had a CT scan of the head on 10/12/16, which identified an acute subdural hematoma over the right cerebral convexity with 5mm of midline shift to the left. Further reviewed of the discharge summary identified that Neurosurgery was consulted and conservative management was recommended. The resident returned to the facility on [DATE]. Interview with the Director of Rehabilitation on 10/26/16 at 2:48 PM identified that Resident #103 required the use of a rolling walker with a gait belt and assistance of one for transfers. The Director of Rehabilitation further identified that when transferring the resident from the wheelchair onto the scale, the rolling walker should have been utilized per the physician's order [REDACTED].#3 on 10/27/16 at 10:05 AM identified as he/she was propelling Resident #103 in the wheelchair towards the scale, the resident verbalized he/she could stand on his/her own to be weighed. NA #3 demonstrated and identified he/she pushed the wheelchair to the edge of the scale, placed the gait belt around the resident ' s waist and assisted the resident to stand on the scale. The reenactment of the transfer identified the resident held onto a handle with the left hand, stood and as he/she was turning and taking approximately three steps to turn and pivot to grab the second handle with the right hand, Resident #103 ' s hand slipped resulting in the right leg buckling and the resident fell to the ground. NA #3 indicated a rolling walker was not utilized for the transfer because the resident stated she/he could stand on the scale. Interview with Corporate RN #1 on 10/27/16 at 1:30 PM identified the facility did not have a policy and procedure for transferring residents.

Based on clinical record reviews, facility documentation and interviews for one of three sampled residents, (Resident #58) who was reviewed for accidents and / or for one of three sampled resident's (Resident # 62) who required physical assistance with transfers, the facility failed to ensure the residents received the necessary assistance and/or supervision to prevent accidents. The findings include: Resident #58's [DIAGNOSES REDACTED]. The fall risk assessment dated [DATE] identified Resident #58 as a fall risk. A physician's orders [REDACTED]. The RCP dated 10/7/14 identified Resident #58 was a fall risk with interventions that included; to instruct the resident in the proper use of any appliance/device to aid with balance/transfer, encourage use, place call light within reach and to instruct the resident to ask for assistance prior to attempting to transfer or ambulate when needed. The Resident Care Plan dated 10/16/14 identified Resident #58 required help with mobility related to generalized weakness with interventions that included; to apply a gait belt and to transfer and ambulate the resident as ordered. The admission MDS assessment dated [DATE] identified Resident #58 with moderately impaired cognition and that the resident required limited assistance with bed mobility, transfer, walk in room, to provide extensive assistance with dressing and toilet use. The nurses's notes from 10/4/14 through 10/18/14 identified the following: on 10/4/14 at 7:56 A.M. Resident # 58 found out of bed self ambulating to the bathroom,10/4/14 at 1:25 P.M. the resident self transferred once during morning and that the resident was placed at nursing station for close observation. On 10/7/14 at 2:01 P.M. Resident # 58 was ambulating ad lib with a RW independently. On 10/8/14 at 3: 31 P.M. and 9:48 P.M. the resident was found ambulating independently with a RW around the room. On 10/12/14 at 3:48 P.M Resident # 58 was self ambulating around the room and 10/16/14 at 2:23 P.M. was ambulating ad lib with a RW in the room. On 10/17/14 at 2:51 P.M. Resident # 58 was observed ambulating in room independently with bathroom privileges and 10/18/14 at 2:04 P.M. was ambulating with RW ad lib in room independently in room, the resident was reminded that he/she needed assistance with ambulation. The nurse's notes on 10/18/14 at 11:12 P.M. identified that Resident #58 was found sitting on the floor with his/her back against the wall in the bathroom with the RW nearby at 10:40 P.M.. Resident # 58 reported to staff that he/she was going to the bathroom. On 10/19/14 at 4:44 A.M. nurses note identified Resident #58 complained of substantial pain to the right knee up to the right hip and was noted with bruising to right knee and right hip. On 10/19/14 3:23 P.M. Resident # 58's right hip X-ray was positive for fracture, Resident #58 was transferred to an acute care hospital for an evaluation . Subsequent to resident's fall the facility updated the care plan with the following interventions, dated 10/19/14; instruct to ask for assistance prior to attempting to transfer or ambulate as needed and directed facility staff to offer assistance with toileting every two hours while awake. Review of the clinical record failed to identify documentation that the facility addressed Resident #58 repeated ambulation in room and/or to the bathroom independently or to implement interventions to reduce risk of falling. Interview with the DNS on 11/6/14 at 8:45 A.M. identified that it was her/his understanding that staff would provide Resident #58 with reminders and re-education to call for assistance in response to him/her ambulating independently. The DNS indicated that she/he would have hoped to see the information documented in the medical record. DNS further identified that although, Resident #58 was being toileted every two hours the facility did not have any documentation to support additional/alternative interventions were explored and/or pursued to address resident's frequent independent ambulation and/or needs in regards to bathroom use. 2. Resident #62's [DIAGNOSES REDACTED]. Resident Care Plan ( RCP) dated 7/3/14 identified Resident #62 required assistance with mobility, transfers, bed mobility and was totally dependent on staff for toileting. Included Interventions ; to transfer the resident with 2 people using a hoyer lift out of bed into the wheelchair. A quarterly MDS assessment dated [DATE] identified that Resident #62 was moderately cognitively impaired and required extensive assistance with bed mobility, transfers and totally dependent on staff for toileting. The physician's orders [REDACTED].# 62 with a sliding board with the physical assistance of one person. Review of facility documentation on 11/5/14 of Resident # 62's Accident and Incident ( A&I) report dated 9/12/14 at 6:00 P.M. identified that Resident #62 alleged that her/ his skin tears to the Left Lower Extremities (LLE) were the result of rough handling. The report dated 9/12/14 identified that the resident was noted with a 4 Centimeter (CM) skin tear on the LLE, the Advance Practical Registered Nurse ( APRN) was notified and the licensed staff was directed to cleanse the area with Normal Saline , pat dry and to apply steri strips, to use cover site to protect the area, to change the area daily and when needed. A review of NA#1's written statement ( with no date) identified that when she/ he went to answer Resident # 62's call light , the resident requested to be changed , she/ he pulled the chair backwards so she/he could get to the bed to apply a pad. After completing the care and while transferring Resident # 62 from the bed to the wheelchair , Resident # 62's legs hit the chair where the foot pedals are located, the resident was noted with a skin tear. NA # 1 indicated that she /he reported the incident to the nurse. Interview and review of facility documentation with Licensed Practical Nurse (LPN#1) on 11/5/14 at 1:45 P.M. identified that when he/she found Resident #62 he/she was facing the head of the bed and the skin tear was on the left lower leg, the level of the bracket of where the wheelchair leg would have been attached and that the skin tear would have been consistent with the left leg hitting the bracket during a slide board transfer. Interview and review of facility documentation with NA#1 on 11/6/14 at 9:42 A.M. identified that when he/she was transferring Resident #62 back to bed the resident sustained [REDACTED]. NA#1 indicated that when she/he was fixing the resident's seatbelt, he/she saw the skin tear and reported it to the nurse.

Based on clinical record review, review of facility documentation and staff interview for one sampled resident reviewed for injuries (R#163), the facility failed to ensure the resident was free from injury. The findings include: Resident # 163's [DIAGNOSES REDACTED]. A significant change MDS dated [DATE] identified the resident as having a problem with short-term memory and no problem with long-term memory. The MDS further noted the resident required total assist of two staff members with bed mobility, dressing and toileting. A care plan dated 3/29/12 identified a problem with needing help with hygiene and dressing with interventions to provide extensive assistance with hygiene and 2 nurse aides for care (sometimes refuses care). Nurse Aide flow sheets from 3/12 to 5/12 for the 11:00 PM to 7:00 AM shift noted the resident was totally dependent and required two staff members for bed mobility. Nurses notes dated 4/19/12 at 1:45 AM identified the resident requested NA#2 provide care due to a soiled brief. While the brief was being removed, the resident sustained [REDACTED]. in length. The laceration was unable to be approximated due to subcutaneous fat protrusion and the resident was transferred to the emergency department for treatment which included 11 sutures to approximate the wound and then returned to the facility. Interview with NA #2 on 9/27/12 at 11:21 AM, identified that on 4/19/12 she provided R #163 with incontinent care by herself. NA #2 further noted that when she folded the brief to remove it from under the resident, the sticky tab "must have come undone" and stuck to the resident's abdomen, NA #2 identified that she pulled Resident #163's skin when she removed the brief from below the resident. NA #2 indicated the resident began to yell when the brief was pulled from under her/him. Further interview with NA #2 at that time noted that she was unfamiliar with the resident and did not refer to the care card in the resident's closet prior to providing incontinent care. NA #2 indicated she did not ask the NA's until after providing care whether the resident was a one or two person assist. NA #2 noted the NA's told her the resident could be handled with either one or two people depending on the condition of the resident.

Based on review of the clinical record, review of facility policies and procedures, and interviews for one of four sampled residents reviewed for hospitalization (R#22) the facility failed to reassess the resident for dehydration and/or assess the resident for signs and symptoms of dehydration, to include skin turgor and dry lips or mucous membranes and/or failed to implement new interventions when the resident failed to meet fluid requirements. The findings include: Resident #22's [DIAGNOSES REDACTED]. A Dehydration assessment dated [DATE] identified no signs or symptoms of dehydration. A Basic Metabolic Panel collected 05/10/12 identified an elevated BUN of 47 milligrams per deciliter (mg/dL) (normal range 9-20 mg/dl) and an elevated Creatinine of 1.5 mg/dL and a normal Potassium of 4.7 (normal range 3.5-5.5). A Medical Nutrition Therapy assessment dated [DATE] identified R #22's optimal fluid needs ranged from 2226 cc to 2671 cc's of fluid per 24 hrs and indicated that R #22 had been consuming 75%-100% of food served. A corresponding RCP dated 05/11/12 identified a risk for weight loss with interventions that included, in part, to provide 2226 cc to 2671 cc's of fluid per 24 hours, and that increased confusion, lethargy, increased temperature, complaints of nausea or vomiting, low blood pressure, dry lips or mucous membranes may indicate dehydration. An admission MDS assessment dated [DATE] identified a moderately impaired Brief Interview of Mental Status (BIMS) score of 8 (moderately impaired range 8-12), altered level of consciousness continuously present that does not fluctuate, multiple mood indicators including poor appetite almost daily, total dependence of 1 staff for bed mobility, transfer, toilet use, and personal hygiene and independence after set up with eating, always incontinent of bowel and bladder, scheduled and as needed pain medication, and daily anticoagulant use. Review of intake and output (I&O) from 05/14/12 though 05/25/12 (11 days) identified a fluid intake range of 1680 cc's (05/14/12) to 1080cc's (05/25/12) over a 24-hour period. The resident was below the optimal fluid needs by 400 cc's to 1500 cc's within each 24-hour period. During the time frame of 05/25/12 and until discharge to the hospital on [DATE] at 4:00 AM, intake range was 960 cc's to 670 cc's which was below the optimal fluid need by 1200 cc's to 2000 cc's per 24 hours. Output was identified by number of incontinent episodes in 24 hours with a range of 7 to 9 episodes per 24 hour period. Review of nursing notes dated 05/26/12 at 2:00 PM identified; appetite and fluids taken fairly well, fluids encouraged; 05/26/12 at 10:30 PM, poor appetite; 05/27/12 at 10:00 PM, 2 loose stools; 05/28/12 at 3:00 PM, ate nothing but 25% of lunch and 120 cc of fluid and at 11:00 PM a temperature of 99.6 degrees Fahrenheit; 05/29/12 poor oral intake of 25% of food for breakfast and lunch and poor fluid intake. An Inter-Agency Patient Referral Report (W-10) dated 05/30/12 identified a new onset of change in level of consciousness, labored breathing, low systolic blood pressure of 100 mm/Hg (normal <100 mm/Hg) and no detectable diastolic blood pressure. R#22 was transferred to Acute Care Hospital #1 on 05/30/12 at 3:00 AM for evaluation and treatment. Admission Laboratory values included normal Sodium of 140 (normal range 135-145 millequivalents per deciliter (mEq/L), elevated Potassium of 6.3 (normal range 3.5-5 mEq/L), elevated Chloride of 116 mEq/L (normal range 98-106), elevated BUN of 154 (normal range 9-20), elevated Creatinine of 6.4 (normal range of 10-20), elevated white blood count (WBC) of 11.1 (normal range 4.0-10.5), elevated [MEDICATION NAME] time of 66.9 seconds (normal range 9.5 seconds to 12 seconds) and elevated International Normalized Ratio (INR) of 30.2 (normal range of 2-3 for [MEDICAL CONDITION]). Discharge [DIAGNOSES REDACTED]. Review of nursing notes failed to identify that the the facility completed a dehydration assessment once the resident was not meeting fluid goals and/or failed to assess the resident for signs and symptoms of dehydration, to include skin turgor and dry lips or mucous membranes, lethargy etc. and/or failed to implement new interventions when the resident failed to meet fluid requirements. A facility Hydration policy identified, in part, if the resident has consumed less than estimated needs/day for 3 consecutive days, the resident is evaluated for signs and symptoms of dehydration.