Every finding on record at Civita Care Center at Milford

Based on observation, review of facility policy, and interviews, for 9 of 16 resident bathrooms reviewed for environment, the facility failed to provide a clean, homelike environment for the bathrooms utilized by Resident #5, Resident #6, Resident #14, Resident #15, Resident #16, Resident #21, Resident #29, Resident #31, Resident #34, Resident #36, Resident #47, Resident #49, Resident #51, Resident #53, Resident #60, Resident #61, Resident #62, Resident #64, Resident #65, Resident #72, Resident #78, Resident #81, Resident #83, Resident #94, Resident #102, Resident #104, Resident #108, Resident #109, Resident #110, Resident #112, Resident #123, and Resident #124. The findings include:a.Observation on 7/27/26 at 5:16 AM of the shared bathroom used by Resident #61, Resident #104, and Resident #112 identified two unlabeled capped tubes of toothpaste and one unlabeled white toothbrush on the bathroom sink, with the bristles touching the sink surface.b. Observation on 7/27/26 at 5:19 AM of the shared bathroom used by Resident #15, Resident #47, Resident #53, and Resident #78 identified two unlabeled bottles of body wash, one unlabeled bottle of shaving cream, and one can of disinfectant spray on the bathroom sink.c. Observation on 7/27/26 at 5:20 AM of the shared bathroom used by Resident #14, Resident #60, and Resident #124 identified an unlabeled kidney basin containing multiple unlabeled tubes of toothpaste, mouthwash, and a toothbrush located under the soap dispenser on the dispenser's drip tray, with the toothbrush bristles touching the wall. Additionally, an unlabeled empty urinal was observed hanging on the bathroom grab bar.d. Observation on 7/27/26 at 5:22 AM of the shared bathroom used by Resident #5, Resident #110, and Resident #123 identified a wet washcloth on the floor beneath a garbage can located under the bathroom sink and partially under a leg of the toilet seat riser. Additionally, an unlabeled bedpan was observed wedged between the wall and the wall mounted grab bar, and an empty urinal was noted hanging on the grab bar. e. Observation on 7/27/26 at 5:25 AM of the shared bathroom used by Resident #16, Resident #21, Resident #51, and Resident #108 identified two urinals hanging on the bathroom grab bar, one labeled and one unlabeled; a urine collection hat on the floor next to the toilet; a washcloth hanging from an empty glove box mounted on the wall; and an empty open bottle of body wash on the bathroom sink.f. Observation on 7/27/26 at 5:27 AM of the shared bathroom used by Resident #31, Resident #64, Resident #81, and Resident #83 identified an unlabeled tube of toothpaste, an unlabeled can of shaving cream, and an unlabeled toothbrush on the bathroom sink. Additionally, an unlabeled basin was observed placed on top of the paper towel dispenser.g. Observation on 7/27/26 at 5:30 AM of the shared bathroom used by Resident #29, Resident #34, Resident #94, and Resident #109 identified an unlabeled open bottle of body wash, a wet washcloth draped over the cold water handle of the sink, and an empty urinal hanging from the bathroom grab bar.h. Observation on 7/27/26 at 5:32 AM of the shared bathroom used by Resident #49, Resident #62, Resident #65, and Resident #72 identified an unlabeled open bottle of body wash, unlabeled deodorant, an unlabeled tube of toothpaste, and an unlabeled toothbrush on the bathroom sink.i. Observation on 7/27/26 at 5:36 AM of the shared bathroom used by Resident #6, Resident #36, and Resident #102 identified an unlabeled empty urinal hanging on the bathroom grab bar, two unlabeled tubes of toothpaste, unlabeled deodorant, and an unlabeled bottle of shaving cream on the bathroom sink.Interview and observations with LPN #6 (Infection Preventionist) on 7/27/26 at 9:30 AM of the residents' bathrooms on the 2nd floor identified the personal items found in the shared bathrooms should not have been left there. LPN #6 stated all personal items are required to be labeled with the resident's name and stored at the bedside.Review of the facility Personal Items in Common Areas policy dated 4/5/26 directed, in part, staff are to maintain a clean, safe, and sanitary environment by ensuring resident personal care items are properly stored and not left unattended in bathrooms, tubs, or shower rooms, in order to reduce the risk of infection, cross contamination, loss of personal belongings, and safety hazards. Personal items are defined as items such as toothbrushes, razors and shaving supplies, soap and body wash, washcloths and towels, and other personal hygiene supplies. The policy further directs personal items should not be placed directly on contaminated surfaces, such as sinks, where contamination may occur, and that caregiving staff are responsible for returning resident belongings and maintaining infection prevention and environmental safety practices.

Based on review of the clinical record, facility documentation, facility policies, and interviews, for 1 of 1 resident (Resident #88) reviewed for care planning, the facility failed to ensure the resident was included in the development and implementation of his or her person centered plan of care. The findings include:Resident #88 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, diabetes, acute embolism, and deep vein thrombosis.The 5 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #88 had intact cognition and participated in setting goals for discharge back to the community.The Resident Care Plan (RCP) dated 12/5/25 identified Resident #88 was at risk for psychosocial risks. Interventions directed staff to keep Resident #88 informed of progress and plans toward discharge goals.A physician's order dated 12/21/25 identified the resident care plan was reviewed and approved by the medical provider.Record review failed to identify any interdisciplinary team (IDT) meetings were conducted from admission [DATE] through 7/24/26.Although requested, the facility was unable to provide any documentation that any IDT care plan meetings were held from admission during 11/28/25 through 7/24/26.Interview with Resident #88 on 7/23/26 at 10:40 AM identified he/she had not participated in a care plan meeting since admission on [DATE]. Resident #88 identified he/she had not met with an interdisciplinary team consisting of nursing, dietary, social services, or recreation to discuss his/her plan of care. Resident #88 identified he/she would want to attend care plan meetings if they were offered.Interview with Licensed Practical Nurse (LPN) #4 (MDS Coordinator) on 7/24/26 at 8:01 AM identified she was responsible for scheduling quarterly and annual care plan meetings for second floor residents and bringing residents to their scheduled meetings. LPN #4 identified every resident should have a 72 hour interdisciplinary team (IDT) care plan meeting on admission led by the social worker. LPN #4 identified Resident #88 should have had a 72 hour IDT care plan meeting on 12/1/25 and quarterly meetings on 12/19/25 and 3/5/26. She identified that after reviewing Resident #88's clinical record on 7/24/26, there was no documentation of any care plan meetings for Resident #88 during the 72 hour period, December 2025, or March 2026. LPN #4 indicated she was on medical leave during December 2025 and March 2026 and corporate staff were assigned to cover. LPN #4 further indicated she would contact corporate to determine if any meetings were held and whether Resident #88 was invited.Interview with Social Worker (SW) #1 on 7/24/26 at 8:49 AM identified she was the only social worker and began employment on 6/15/26. SW #1 indicated she follows the MDS Coordinator's resident care plan meeting schedule, and the MDS Coordinator prepared the schedules. SW #1 identified she was responsible for seeing new admissions within 24 hours and scheduling the interdisciplinary 72 hour care plan meetings. SW #1 identified Resident #88's clinical record contained no social worker notes documenting any care plan meetings or any evidence that Resident #88 had care plan meetings from 12/1/25 through 7/24/26. SW #1 identified Resident #88 should have had a 72-hour care plan meeting and quarterly care plan meetings.A follow up interview with LPN #4 on 7/24/26 at 10:44 AM identified she contacted corporate and confirmed Resident #88 did not have care plan conferences in December 2025 or March 2026 while she was on medical leave. She identified no one covered care plan meetings during her leave and corporate staff only completed Minimum Data Set (MDS) assessments.Interview with LPN #1 (Corporate Clinical Nurse) on 7/24/26 at 11:47 AM identified when LPN #4 was on leave, a per diem corporate staff member was overseeing Minimum Data Set (MDS) assessments and should have conducted the required care plan conferences for Resident #88.Interview with the Administrator on 7/24/26 at 11:52 AM identified corporate per diem staff were used when employees were on vacation or leave. The Administrator indicated that while LPN #4 was on leave, one corporate staff member worked remotely and another came onsite once, though he did not recall the name. He identified LPN #4 was on leave from 11/25/25 through 12/29/25 and again from 3/9/26 through 5/19/26. He identified the facility was not compliant with conducting resident care plan meetings and stated this was an ongoing problem.Review of the facility Comprehensive Care Planning Policy dated 7/3/25, directed in part, the interdisciplinary team (IDT), in conjunction with the resident develops and implements a comprehensive, person-centered care plan for each resident. Each residents comprehensive person-centered care plan is consistent with the residents rights to participate in the development and implementation of his/her plan of care, including the right to participate in the planning process, identify individuals to be included, request a meeting, request revisions to the plan of care, participate in establishing the expected foals and outcomes of care, participate in determining the type, amount, frequency, and duration of care, receive the services and/or items included in the plan of care, and see the plan of care and sign it after significant changes are made. If the participation of the resident and his/her representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. The IDT reviews and updates the care plan when a resident is admitted or re-admitted to the facility and at least quarterly in conjunction with the required quarterly MDS assessments.Review of the facility Resident Rights Policy and Procedure dated 2026 directed in part, the facility will ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Planning and implementing care each resident has the right to participate in the development and implementation of his/her plan of care, including the right to participate in the planning process, identify individuals to be included, request a meeting, request revisions to the plan of care, participate in establishing the expected foals and outcomes of care, participate in determining the type, amount, frequency, and duration of care, receive the services and/or items included in the plan of care, and see the plan of care.

Based on review of the clinical record, facility documentation, facility policy, and interviews, for 3 of 3 residents (Resident #14, Resident #16, and Resident #17) reviewed for Advance Directives, the facility failed to follow and implement residents' expressed Advance Directive wishes and failed to ensure Advance Directive forms were completed upon admission. The findings include: 1.Resident #14 was admitted to the facility on [DATE] with diagnoses that include dementia, a malignant tumor, and chronic obstructive pulmonary disease (COPD). Review of Resident #14's hospital transfer documentation identified a Transfer of Do Not Resuscitate (DNR) order dated [DATE]. This transfer form indicated that Resident #14 had a previously established DNR order dated [DATE]. A Resident/Patient Health Care Instructions (Advance Directives) form dated [DATE] and signed by Resident #14's Health Care Decision Maker, directed staff to perform cardiopulmonary resuscitation (CPR), transfer the resident to a hospital, utilize artificial ventilation, and provide other life sustaining treatments as applicable. A physician's order dated [DATE] directed to honor or refer to the resident's physical chart for advanced directives or code status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was rarely or never understood and was unable to complete the Brief Interview for Mental Status (BIMS) to determine cognitive status. The MDS assessment further identified the resident had both short and long term memory impairment, and that cognitive skills for daily decision making were severely impaired. The Resident Care Plan (RCP) dated [DATE] did not include Resident #14's code status. A physician's order dated [DATE] directed a Do Not Resuscitate (DNR). Interview with Registered Nurse (RN) #2 on [DATE] at 7:25 AM identified that the official determination of a resident's code status is based on the physically signed copy of the advance directive maintained by the facility. RN #2 stated that Resident #14 should not have had an electronic DNR order in place because the Health Care Decision Maker had signed the facility's advance directive indicating full code status. RN #2 identified the DNR order transferred with Resident #14 from the hospital but should not have remained in effect because Resident #14's Health Care Decision Maker completed new documentation during the admission process on [DATE] indicating full code status. RN #2 confirmed the most recent and official advance directive for Resident #14 was the form dated [DATE] directing staff to provide CPR, artificial ventilation, hospital transfer, and other life sustaining treatments. Interview with the Director of Nursing Services (DNS) on [DATE] at 1:30 PM identified in an emergency, staff should refer to the resident's physical chart to obtain the official advance directive to guide resuscitative efforts. The DNS further identified if a resident is transferred from a hospital with a different code status, the facility should verify the code status with the resident or their Health Care Decision Maker upon admission. 2. Resident #16 was admitted to the facility on [DATE] with diagnoses that include COPD, alcoholic liver disease, Type 2 Diabetes, and dementia. A physician's order dated [DATE] directed a DNR. The admission MDS assessment dated [DATE] identified Resident #16 was moderately cognitively impaired. The RCP dated [DATE] identified Resident #16 had a code status of a DNR. Interventions included resident preferences would be honored while residing in the center. Review of Resident #16's clinical record was unable to provide documentation to reflect advanced directives were completed. Interview with RN #2 on [DATE] at 7:25 AM identified when a resident has a Do Not Resuscitate (DNR) code status, proper documentation must be signed by the resident or their legal representative, and documentation must be maintained in the resident's physical chart. RN #2 stated Resident #16's chart and electronic record contained no signed DNR documentation. Interview with the DNS on [DATE] at 1:30 PM identified any resident with a DNR status must have an official, signed document indicating their wishes and the document should be kept in the resident's physical chart or electronically scanned into the electronic medical record. Subsequent to the surveyor inquiry, the Resident/Patient Health Care Instruction (Advanced Directive) form for Resident #16 was completed and signed by the resident's Health Care Decision Maker on [DATE] and signed by APRN #1 on [DATE]. Review of the facility Advanced Directives policy dated [DATE] directed in part, if a resident does not have an advance directive, facility staff will offer assistance in developing one, and that advance directive documentation should be displayed prominently in the medical record, so it is easily retrievable by staff. 3. Resident #17's diagnoses included pulmonary edema, congestive heart failure, and chronic obstructive pulmonary disease. Review of Resident #17's hospital transfer documentation identified a Transfer of Do Not Resuscitate (DNR) order dated [DATE]. This transfer form indicated that Resident #17 had a previously established DNR order dated [DATE]. A physician order dated [DATE] directed DNR. The Resident Care Plan (RCP) dated [DATE] identified Resident #17 had a code status of DNR. Interventions included resident preferences would be honored while residing in the center. The admission MDS assessment dated [DATE] identified Resident #17 had a Brief Interview of Mental Status (BIMS) score of 15 indicative of intact cognition. Review of Resident #17's clinical record was unable to provide documentation to reflect advanced directives were completed. Interview and clinical record review with Licensed Practical Nurse (LPN) #2 on [DATE] at 9:49 AM identified Resident #17 had no completed signed advance directives in the paper chart or scanned into the electronic medical record (EMR). LPN #2 stated the charge nurse was responsible for ensuring advance directives were completed for Resident #17 during the admission process. Interview and clinical record review with RN #1 on [DATE] at 9:50 AM identified Resident #17 had no completed advance directive forms. RN #1 further identified Resident #17's advance directives should have been completed upon admission. Interview with the DNS on [DATE] at 10:08 AM identified the nursing supervisor is responsible for ensuring advance directives are completed for every resident at the time of admission. The DNS indicated in an emergency, any resident without a signed advance directive would be treated as a full code. Subsequent to the surveyor's inquiry, RN #1 assisted Resident #17 and completed the advance directive form. Review of the facility Advance Directives policy dated [DATE] directed in part, upon admission the facility will determine if a resident has executed an advanced directive. If the resident has executed an advanced directive copies of these documents will be obtained and maintained in the resident's medical record and readily retrievable by any facility staff. If the resident does not have an advance directive, facility staff will offer assistance in developing one, and that advance directive documentation should be displayed prominently in the medical record, so it is easily retrievable by staff.

Based on interviews, review of clinical records, and review of facility policy, for 1 of 5 residents (Resident #20) reviewed for hospitalizations, the facility failed to notify the Office of the State Long Term Care Ombudsman when the resident was transferred to the hospital; and for 1 of 3 residents (Resident #117) reviewed for discharge, the facility failed to notify the Office of the State Long Term Care Ombudsman when the resident left the facility against medical advice (AMA). The findings include:1.Resident #20's diagnoses included metabolic encephalopathy, urinary tract infection, and diabetes mellitus with diabetic chronic kidney disease.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status (BIMS) score of 9 indicative of moderately impaired cognition.The Resident Care Plan (RCP) dated 6/17/26 identified Resident #20 was at risk for sepsis related to a history of sepsis secondary to urinary tract infections. Interventions directed to notify physician/APRN promptly of abnormal assessment findings, laboratory results, or changes in the resident's condition.The nurse's note dated 6/29/26 at 4:16 PM identified Resident #20 was transferred to the hospital.The Hospital Discharge summary dated [DATE] at 9:55 AM identified Resident #20 was discharged back to the facility after an eight day hospital stay for sepsis.Interview and clinical record review with Social Worker (SW) #1 on 7/27/26 at 12:50 PM identified she did not notify the Office of the State Long Term Care Ombudsman on 6/29/26 that Resident #20 was transferred to the hospital. SW #1 indicated she had not been informed during training that she was required to notify the Ombudsman of hospital transfers.Interview with the Director of Nursing Services (DNS) on 7/27/26 at 12:58 PM identified the social worker is responsible for notifying the Ombudsman of all transfers and discharges. The DNS was unable to explain why the Ombudsman had not been notified on 6/29/26 of Resident #20's hospital transfer.2. Resident #117's diagnoses included chronic lower back pain, hypertension, and lung cancer.A hospital inter agency referral report dated 6/26/26 at 9:27 AM identified Resident #117 was discharged to the facility to receive skilled nursing care for rehabilitation after an L4-L5 revision laminectomy (surgical procedure that removes part of a vertebra called the lamina to relieve pressure on the spinal cord or nerves) and Transforaminal Lumbar Interbody Fusion (a spinal surgery that fuses two vertebrae in the lower back to relieve pain and stabilize the spine).The nurse's note dated 6/26/26 at 1:00 PM identified Resident #117 arrived at the facility at 12:05 PM and the resident did not want to remain in the assigned room with three additional residents and expressed a desire to leave the facility. Resident #117 was educated regarding leaving against medical advice (AMA), he/she signed the AMA paperwork, and left the facility with a family member at 12:50 PM on 6/26/26.Review of the clinical record identified AMA paperwork dated 6/26/26 at 12:41 PM was signed by Resident #117 and a nurse. The clinical record failed to identify that the Office of the State Long Term Care Ombudsman had been notified that Resident #117 left the facility AMA.Interview with SW #1 on 7/24/26 at 8:49 AM identified she was responsible for notifying the Office of the State Long Term Care Ombudsman within a few days of a resident leaving AMA. SW identified she did not notify the Ombudsman of Resident #117's AMA discharge on [DATE] because she was in training.Interview with SW #2 on 7/24/2026 at 12:40 PM identified when a resident leaves a facility AMA the Office of the State Long-Term Care Ombudsman must be notified immediately and again on the monthly report.Review of the facility Long Term Care Ombudsman policy dated 9/1/2022 directed in part, that it is the center's responsibility to report to the Ombudsman as set forth by the State of Connecticut and the Long-Term Care Ombudsman.

Based on review of clinical records, facility documentation, facility policy, and interviews for 3 of 10 residents (Resident #48, Resident #80, and Resident #90) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure referrals for Level I and/or Level II PASRR evaluations were requested following the expiration of short term approvals for Resident #48 and Resident #80, and failed to ensure a referral for a PASRR evaluation was requested following the expiration of a 30 day hospital exemption for Resident #90. The findings include:1.Resident #48 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, depression, and anxiety.A PASRR Level I screen dated [DATE] identified Resident #48 had diagnosis of schizophrenia, anxiety, bipolar, and mild or situational depression. The Level I outcome indicated a Level II evaluation was required.The Notice of Action for the PASRR dated [DATE] identified Resident #48 was admitted on [DATE] and received short term approval for 90 days ending on [DATE]. The nursing facility requested additional time. The Notice of Action further identified Resident #48 had diagnoses including schizophrenia, anxiety disorder, depressive disorder, and borderline personality disorder. The facility submitted an update on [DATE], and the resident was granted 180 day short term approval ending [DATE], with a date of action of [DATE].The annual Minimum Data Set (MDS) dated [DATE] identified Resident #48 had moderately impaired cognition and received antipsychotic, antianxiety, antidepressant, and hypnotic medications in the previous seven (7) days.The Resident Care Plan (RCP) dated [DATE] identified Resident #48 had behaviors and documented resident to resident altercations on [DATE], [DATE], [DATE], [DATE], and [DATE]. A resident to resident altercation dated [DATE] resulted in Resident #48 fracturing another resident's nose. Interventions included placing Resident #48 on one to one supervision until sent to the emergency room and cleared by psychiatry.Interview with Social Worker (SW #1) on [DATE] at 1:55 PM identified she was new to long term care and new to the PASRR process. SW #1 indicated she had recently received authorization to access the state PASRR website. SW #1 identified Resident #48 had continuously resided in the facility since admission on [DATE], aside from brief hospital transfers. During review of the state agency PASRR system with the surveyor, SW #1 identified Resident #48 received 180 day Level II approval on [DATE], but the required update was never submitted, and Resident #48 continued to reside in the facility without approval beyond [DATE]. SW #1 stated the social worker at that time should have resubmitted the PASRR update approximately one week before [DATE] but did not.Interview with Person #1 (state agency Level II PASRR representative) with SW #1 present, on [DATE] at 10:45 AM identified that Resident #48 had a Level II 180 day approval dated [DATE], and the facility was required to resubmit for continued approval by [DATE] if the resident was still residing in the nursing facility. Person #1 stated the facility could submit now, but approval might only be granted beginning [DATE], which could affect the facility's payment for the period [DATE] to [DATE]. Person #1 stated the facility should submit documentation for Resident #48 as soon as possible because the required update was due on [DATE].2.Resident #80 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety, and insomnia.The PASRR Level II dated [DATE] identified Resident #80 received short term approval for 120 days, beginning on [DATE] and expiring on [DATE]. The outcome identified that if the resident or the facility believed the resident would need to remain beyond the approved 120 day period, the facility was required to request additional authorization for an extended approval period.A physician's order dated [DATE] directed to administer Trazadone (used to treat depression) 50 milligram (mg) three times a day for restlessness, agitation, and insomnia.A physician's order dated [DATE] directed to administer Bupropion (used to treat depression) 150 mg once daily and Mirtazapine (used to treat depression) 15 mg once daily.The admission MDS assessment dated [DATE] identified Resident #80 had moderately impaired cognition.The Resident Care Plan (RCP) dated [DATE] identified Resident #80 was at risk for depression. Interventions included administering medications as ordered and monitoring for side effects; assessing reasons for anxiety, depression, and social withdrawal; encouraging participation in group activities; encouraging the resident to verbalize feelings and fears; and referring the resident for counseling or psychiatric services as needed.Interview with SW #1 on [DATE] at 11:00 AM identified that an additional PASRR Level II assessment was not submitted for continued approval after Resident #80's original PASRR Level II authorization expired. SW #1 stated she was unsure why the Level II was not resubmitted, as she was not employed at the facility at the time of expiration. SW #1 confirmed a new PASRR Level II assessment should have been completed and submitted on or before the end of the short term approval period. SW #1 further stated that following surveyor inquiry, a new PASRR Level II assessment would be completed.Review of the facility Pre admission Screening and Resident Review (PASRR) policy dated [DATE] directed in part, the facility to comply with all PASRR requirements prior to admission and throughout a resident's stay and identified that all required records must be submitted promptly. 3. Resident #90 was admitted with diagnoses that included paranoid schizophrenia and anxiety disorder.The Notice of PASRR Level I Screen Outcome dated [DATE] identified Resident #90 was granted a 30 day hospital exemption to remain at the nursing facility. The exemption identified the resident must be discharged by day 30, or the nursing facility must submit a PASRR rescreening to the state agency on or before day 30 if the resident was expected to remain in the facility beyond the approved timeframe.The MDS dated [DATE] identified Resident #90 had severely impaired cognition and diagnoses including schizophrenia and anxiety. The MDS further identified Resident #90 had received antipsychotic medications within the previous seven (7) days.The RCP dated [DATE] identified Resident #90 was receiving psychotropic medications for paranoid schizophrenia. Interventions included psychiatry referral, psychiatric evaluation for medication management, and medications as ordered.Interview with SW #1 on [DATE] at 12:29 PM identified she was responsible for ensuring a level of care was completed prior to expiration. SW #1 identified no evaluation had been submitted since the 30-day exemption expired on [DATE] for Resident #90. SW #1 stated the evaluation should have been submitted and was unsure why it had not been completed. SW #1 stated she was not employed at the facility at the time the PASRR updates were due and did not know why it was not submitted.Interview with SW #2 (social worker from a sister facility) on [DATE] at 12:34 PM identified she has been training SW #1. SW #2 identified Resident #90's PASRR was not updated after the 30 day hospital exemption and that an audit was currently being conducted.Interview with the Administrator on [DATE] at 12:35 PM identified that at the time Resident #48 and Resident #90's PASRR updates were due, the full time social worker had been terminated, and the part time social worker did not have access to the state PASRR system to complete the required updates. The Administrator indicated he was not aware that PASRR updates were not being completed timely.Review of facility Pre-admission Screening and Resident Review (PASRR) Policy dated [DATE] directed in part, to ensure compliance with federal and state requirements regarding PASRR for all residents who may have serious mental illness (SMI), intellectual disability (ID), or related conditions, and to ensure individuals receive appropriate placement and services. The facility shall comply with all applicable federal and state PASRR requirements prior to admission and throughout a residents stay. No resident requiring PASRR screening shall be admitted without the completion of the required screening process unless the admission qualifies under approval exempted hospital discharge. Exempted hospital discharge on admission directly from the hospital after acute care stay when nursing facility placement is expected to be less than 30 days and all exemption criteria are met. Responsible parties are the Administrator, Director od Nursing, Admissions Coordinator, and Social Services. Procedure for exempted hospital discharge the facility shall receive follow up PASRR review if the residents stay will exceed the permitted timeframe. Level 2 PASRR approvals the facility shall submit required records promptly.

Based on observations, review of clinical records, facility documentation, facility policy, and interviews for 2 of 7 residents (Resident #37 and Resident #59) reviewed for medication administration, the facility failed to ensure medications were administered as ordered by the physician. The findings include:1. Resident #37 had diagnoses that included hypomagnesemia, high blood pressure, coronary artery disease, constipation, and severe protein calorie malnutrition. The quarterly MDS dated [DATE] identified Resident # 37 had severely impaired cognition.The physician's order dated 6/19/26 directed to administer Calcium 600 milligrams (mg) with Vitamin D3 10 micrograms (mcg) (vitamin) give 2 tablets twice a day, Fluticasone Propionate 50 mcg (nasal spray used to treat allergies) give 1 spray in each nostril daily, Liquid Protein (dietary supplement) 1 gram 4 kcal per 6 milliliter (ml) give 30 ml twice a day, Magnesium Oxide (vitamin) 200 mg give 2 tablet to equal 400 mg daily, Metoprolol Succinate Extended Release (medication to treat high blood pressure give 25 mg daily, MiraLAX (laxative used to treat constipation) give 17 grams mixed with 8 ounces of liquid once a day, and Multivitamin tablet give one tablet daily. Observation of medication administration for Resident #37 by Licensed Practical Nurse (LPN) #3 on 7/27/26 at 7:53 AM identified LPN #3 administered Magnesium Oxide 800 mg instead of the prescribed 400 mg, and Calcium 600 mg with D3 5 mcg in one tablet instead of the prescribed two tablets (10 mcg total). LPN #3 did not administer Resident #37's MiraLAX 17 grams, Liquid Protein 30 ml, Metoprolol Succinate 25 mg, Multivitamin, or Fluticasone Propionate nasal spray. LPN #3 then proceeded back to the medication cart and stated she would begin preparing Resident #59's medications.Interview with LPN #3, with the Director of Nursing Services (DNS) present on 7/27/26 at 9:15 AM, identified she was the regular nurse assigned to the unit and stated she knew what medications the residents received daily. LPN #3 identified she did not administer Resident #37's prescribed MiraLAX because the resident had a bowel movement the day before, and she routinely holds MiraLAX for two days after a bowel movement without notifying the APRN or physician. LPN #3 indicated the Calcium 600 mg with Vitamin D3 5 mcg was house stock and the only bottle available, so she administered one tablet daily. LPN #3 identified she administered two tablets of Magnesium Oxide 400 mg because it was the only bottle available in the medication cart. LPN #3 indicated she did not realize she was administering incorrect doses of both Calcium with Vitamin D3 and Magnesium Oxide. LPN #3 indicated she did not administer MiraLAX, Liquid Protein, Metoprolol Succinate, Multivitamin, or Fluticasone because she did not see them listed in the electronic medical record.2. Resident # 59 had diagnoses that included pressure ulcer of buttock, chronic pain right shoulder, vitamin D deficiency, and diverticulosis of large intestine. The physician's order dated 6/19/26 directed to administer Vitamin D3 25 mcg give 2 tablets daily; Vitamin C 500 mg twice a day; Arginaid powder(dietary supplement) one packet daily; and MiraLAX 17 grams mixed with 8 ounces of liquid daily.The annual MDS dated [DATE] identified Resident #59 had moderately impaired cognition. Observation of medication administration for Resident #59 by LPN #3 on 7/27/26 at 8:00 AM identified LPN #3 administered one tablet of Vitamin D3 instead of the prescribed two tablets. LPN #3 did not administer Arginaid powder, Vitamin C 500 mg, or MiraLAX 17 grams. LPN #3 returned to the medication cart and indicated she would begin preparing medications for the next resident.Interview with LPN #3, with the DNS present on 7/27/26 at 9:17 AM, identified she did not administer Resident #59's MiraLAX because the resident had a bowel movement two days earlier and she routinely holds MiraLAX for two days without notifying the nursing supervisor, APRN, or physician. LPN #3 indicated the Vitamin C 500 mg and Arginaid were house stock and not available, and she did not request the nursing supervisor to check supply or obtain replacement.Interview with the DNS on 7/27/26 at 9:20 AM identified the expectation is that nurses administer medications exactly as ordered by the physician. The DNS stated that if a medication is not available, the nurse should contact the supervisor and notify the APRN or physician and the pharmacy. The DNS identified all of Resident #59's and Resident #37's medications were in the building and available, and there was no reason for LPN #3 not to administer them as ordered. The DNS stated LPN #3 cannot independently decide to hold MiraLAX without notification. The DNS identified that the Calcium 600 mg with D3 5 mcg did not match the physician's order and the order or stock supply should have been corrected. The DNS identified nurses are responsible for following the five rights of medication administration for all residents. The DNS identified LPN #3 should have followed the five rights of medication administration, and that the medication errors would not have occurred if the five rights had been followed.Interview with APRN #1 on 7/28/26 at 10:20 AM identified his expectation is the nurses administer medications in accordance with the physician's orders. APRN #1 indicated if a medication is not available, the nurse should contact the supervisor, and if the medication is not available, he expected to be notified so he could review the situation and determine whether laboratory tests or vital signs should be ordered based on the medication not available. Review of the facility Medication Administration Policy 8/2/25 directed in part, the purpose is to provide guidelines for the safe administration of medications. Verify the physician order for medication administration. The nurse must wash his/her hands then unlock the medication cart, select the medication from the unit dose, draw, or the stock supply. Check the label on the medication and confirm the medication name and dose with the medication administration record. Check the expiration date on the medication. Check the medication dose then recheck and confirm the dose. Prepare the correct dose of medication. Confirm the identity of the resident and explain the procedure. Provide the medications to the resident. Remain with the resident until all medications have been taken and perform hand antisepsis once completed. Review of the facility Physician's Order Policy dated 10/3/25 directed in part, the physician orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written orders of a person duly licensed and authorized to prescribe such medication in this state. Orders for medications must include name and strength of the drug, number of doses, start and stop date, and/or duration of therapy, dosage and frequency of administration, route of administration, and the clinical condition that medication is prescr

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #91) reviewed for elopement, the facility failed to ensure when the receptionist unlocked the front doors a resident identified at risk for elopement was not able to elope from the facility. The findings include:Resident #91 was admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety, schizoaffective disorder, depression, and post-traumatic stress disorder (PTSD). Resident #91 was conserved of person and estate. Review of the Elopement Risk Evaluation dated 3/21/26 at 2:01 AM identified Resident #91 was at risk for elopementThe quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 had moderately impaired cognition, was an elopement risk, and independent with ambulation.A physician's order dated 6/21/26 directed to apply an elopement prevention bracelet to Resident #91's left ankle, verify the device's placement every shift (7 AM-3 PM, 3 PM-11 PM, and 11 PM-7 AM), and check the functioning of the device once daily on the overnight shift.The Resident Care Plan (RCP) dated 6/22/26 identified Resident #91 was at risk for elopement related to exit seeking behaviors, independent ambulation, and history of removing the elopement prevention bracelet. Interventions directed staff to educate the resident on the purpose and importance of the device, provide frequent checks, and offer 1:1 supervision as needed.A psychiatric evaluation dated 6/23/26 at 5:36 PM identified Resident #91 removed the elopement prevention bracelet. Resident #91 understood the behavior was unacceptable, expressed remorse, and stated he/she would not remove it again.The nurse's note dated 6/24/26 at 4:00 PM identified Resident #91 initially refused the elopement prevention device but later agreed, and the device was applied to the resident's left ankle.The nurse's note dated 6/28/26 at 10:57 PM written by Registered Nurse (RN) #4 (supervisor) identified at 5:45 PM she received a call from Receptionist #1 reporting Resident #91 had exited the building after the main door was opened for a visitor. RN #4 indicated an elopement code was initiated, the police, the administrator, the Director of Nursing Services (DNS), and Resident #91's conservator were notified. RN #4 indicated she instructed staff to search the grounds, but the search was unsuccessful. RN #4 identified the administrator located Resident #91 at 7:55 PM near the medical offices adjacent to the facility. RN #4 indicated she and the DNS assessed Resident 91 upon return and no injuries were noted. RN #4 identified Resident #91 was evaluated by a provider, who ordered 1:1 supervision until he/she has a psychiatric assessment.The physician's order dated 6/28/26 directed 1:1 supervision and neurological checks every shift for three days.A facility reportable event (RE) dated 6/28/26 identified at 5:45 PM Resident #91 was witnessed by Receptionist #1 briskly walking out the front doors of the facility as a visitor exited. Receptionist #1 reported she attempted verbal redirection to stop Resident #91, but Resident #91 became resistive, used profanities, and continued speed walking. Receptionist #1 was unsuccessful in stopping Resident #91 and notified RN #4, prompting an immediate search for Resident #91. Resident #91 was located at 7:30 PM by the Administrator, walking on the sidewalk in front of the medical offices located next door to the facility and was escorted safely back to the facility. Resident #91 reported visiting a gas station and then a church around the corner.A facility written statement by Receptionist #1 dated 6/29/26 identified she witnessed Resident #91 exit the main elevator with a visitor. Resident #91 asked if the dining room was open, then Resident #91 motioned toward the dining area before running out the front doors, which she had opened for a visitor. Receptionist #1 instructed Resident #91 to return to the building, but Resident #91 did not comply and responded with profanities while increasing his/her pace. Receptionist #1 then notified RN #4 and activated the elopement code.A facility RE summary dated 7/2/26 identified on 6/28/26 at 5:45 PM, Resident #91 exited the facility through the front doors witnessed by the receptionist on duty. At 7:30 PM, the Administrator located Resident #91 walking on the sidewalk in front of the medical offices next door and safely escorted the resident back to the facility. Resident #91 reported going to a gas station and then to a church around the corner. Resident #91 was calm, allowed an RN assessment, and had no injuries or complaints. Resident #91 was immediately placed on 1:1 monitoring. The investigation determined that Resident #91 had already been identified as an elopement risk and was wearing a wander guard, last confirmed in place at 5:00 PM on 6/28/26 by the assigned charge nurse. The receptionist last saw Resident #91 at 5:45 PM exiting the main elevator with a visitor. Resident #91 asked if the dining room was open, gestured in its direction, then suddenly turned and quickly followed the visitor out of the facility. The receptionist stated she attempted to stop the resident, but the resident walked away quickly while using profanities. The receptionist immediately notified the nursing supervisor and activated Dr. [NAME] (elopement) to initiate the staff search. Interventions after the event included continued 1:1 monitoring of Resident #91, follow up with the psychiatric APRN, and social services involvement to support psychosocial well being.Interview with Receptionist #2 on 7/27/26 at 9:15 AM indicated that when a resident identified as high risk for elopement attempts to leave the building or exit the building the expectation is the receptionist follows the resident or ensures another staff member does and maintains proximity until additional staff arrive.Interview with RN #4 on 7/27/26 at 9:30 AM identified she was notified by Receptionist #1 that Resident #91 had exited the facility through the main front doors on 6/28/26. RN #4 stated that she immediately went to the main entrance, where Receptionist #1 was seated at the front desk, and an elopement code was initiated. RN #4 indicated she exited the building to search for Resident #91 but was unable to locate the resident. RN #4 further indicated she directed staff to continue searching for Resident #91, but the search was unsuccessful. RN #4 indicated she notified the police, Administrator, DNS, and Resident #91's conservator.Interview with RN #3 (Corporate Nurse) on 7/27/26 at 11:00 AM identified Resident #91 was an elopement risk and wore an elopement prevention bracelet on the left ankle. RN #3 indicated on 6/28/26 it was unclear whether the alarm was activated when Resident #91 exited the facility through the front doors. RN #3 indicated her investigation showed LPN #5 checked Resident #91's elopement-prevention bracelet at 5:00 PM on 6/28/26 and found it in place and functioning. RN #3 identified when Resident #91 returned to the facility, the bracelet was no longer on the resident's ankle. RN #3 identified that Receptionist #1 should have followed Resident #91 outside to maintain visual contact.Although attempted, interviews with Receptionist #1 and LPN #5 were not obtained. Review of facility Wandering and Elopement policy dated 2/4/26, in part, identified when a resident is at risk for wandering, the resident's care plan will include strategies and interventions to maintain the resident's safety. The policy directs that if an employee observes a resident leaving the premises, the employee should attempt to prevent the resident from leaving, obtain assistance from other staff members, and ensure that staff notify the charge nurse that a resident is attempting to leave or has left the premises. If a resident is missing, staff are to initiate the elopement/missing resident emergency procedure, determine whether the resident is out on an authorized leave, and if not, search the building and premises. If the resident is not located, the policy requires notification of the administrator, the Director of Nursing Services, the resident's legal representative, the attending physician, law enforcement officials, and others as appropriate. When the resident returns to the facility, the DNS or charge nurse is to examine the resident for injuries, contact the attending physician, notify the resident's legal representative, inform search teams that the resident has been located, complete and file an incident report, and document relevant information in the resident's medical record.

Based on observations, review of clinical records, facility documentation, facility policy, and interviews, for 2 of 2 residents (Resident #5 and Resident #88) reviewed for respiratory care, the facility failed to ensure Continuous Positive Airway Pressure (CPAP) equipment was cleaned and the tubing, filter, and mask were changed in accordance with the manufacturer's recommendations. The findings include:1.Resident #5's diagnoses included pneumonia, acute and chronic respiratory failure, and obstructive sleep apnea.The physician's order dated 10/1/25 directed to administer CPAP at 4-25 cmH O (centimeters of water) with oxygen at 3 liters per minute using a face mask at bedtime every shift and to provide CPAP basic setup with replacement supplies including humidified heated tubing and disposable filters.The Medicare 5-day MDS dated [DATE] identified Resident #5 had intact cognition.The Resident Care Plan (RCP) dated 11/14/25 does not identify that Resident #5 has a physician order for the use of a CPAP.The Resident Care Plan (RCP) dated 11/14/25 did not identify Resident #5's use of CPAP at bedtime, despite an active physician order requiring its use.A physician's order dated 11/28/25 directed to wash the face mask during 11:00 PM to 7:00 AM shift with soap and water and let air dry.Observation on 7/24/26 at 9:45 AM identified Resident #5 lying in bed with nasal cannula oxygen in place. Resident #5's CPAP machine was observed on the nightstand with the face mask draped over a large plastic bag of personal belongings. The mask was not stored in a clean bag, and the mask, humidified tubing, and water chamber were not labeled or dated.Interview and observation with Registered Nurse (RN) #2 on 7/24/26 at 10:00 AM identified CPAP masks must be bagged when not in use, and the mask and tubing should be dated when changed. RN #2 identified Resident #5's mask, tubing, and water chamber were not dated, and the mask was not bagged. RN #2 indicated she did not know when the equipment was last cleaned or changed. 2. Resident #88 had diagnoses that included obstructive sleep apnea and diabetes.The physician's order dated 11/28/25 directed to administer CPAP with pressure setting 6-10 cmH O, titrate with oxygen at bedtime daily, and wash the CPAP mask daily during the 11:00 PM to 7:00 AM shift with soap and water and allow it to air dry.The 5 day MDS dated [DATE] identified Resident #88 had intact cognition and received oxygen therapy in the prior 14 days.The RCP dated 12/5/25 identified Resident #88 had asthma and obstructive sleep apnea. Interventions directed staff to assist the resident at bedtime with CPAP.Interview with Resident #88 on 7/23/26 at 10:45 AM identified that he/she used the CPAP every night. Resident #88 reported the CPAP mask, tubing, filter, and water chamber had never been replaced since admission. Resident #88 stated nursing staff had not washed the CPAP mask daily or weekly. Resident #88 indicated that the mask is placed on the nightstand during the day.Observation on 7/23/26 at 10:46 AM identified Resident #88's CPAP mask, tubing, and water chamber were not dated, and the mask was sitting on the nightstand unbagged.Observation on 7/24/26 at 9:20 AM again identified Resident #88's CPAP mask, tubing, and water chamber were not dated, and the mask remained unbagged.Interview with Licensed Practical Nurse (LPN) #3 on 7/24/26 at 9:21 AM indicated she was the regular nurse assigned to Resident #88 for the 7:00 AM to 3:00 PM shift. LPN #3 indicated the night shift supervisor was responsible for changing CPAP or oxygen equipment and dating it. LPN #3 identified she does not wash Resident #88's mask because the order only appeared on night shift tasks. LPN #3 identified Resident #88's mask, tubing, and water chamber were not dated, and the mask was not bagged. LPN #3 indicated she did not know when any equipment was last cleaned or replaced. LPN #3 identified Resident #88's mask should have been placed in a plastic bag.Interview with RN #2 (nursing supervisor) on 7/24/26 at 9:33 AM identified Resident #88's mask should be bagged when not in use. RN #2 indicated CPAP masks and water chambers are typically replaced every three to six months. RN #2 indicated the oxygen company supplies replacement CPAP parts and the night shift charge nurse or supervisor is responsible for changing and dating equipment. RN #2 identified there were no physician orders directing staff to change Resident #88's CPAP face mask, tubing, filter, or water chamber. RN #2 indicated she could not determine whether Resident #88's equipment had ever been replaced since admission.Interview with LPN #1 (Regional Nurse) on 7/24/26 at 10:02 AM identified the CPAP water chamber and face mask should be cleaned daily. LPN #1 indicated tubing is changed only if there is a problem. LPN #1 stated the air filter should be changed every two weeks to one month, the face mask monthly, the tubing every three months, and the water chamber and headgear every six months. LPN #1 identified Resident #5 and Resident #88 did not have any physician orders for changing CPAP equipment. LPN #1 further identified that Resident #5's CPAP equipment had not been cleaned or changed since 10/1/25 (296 days) and Resident #88's equipment had not been cleaned or changed since 11/28/25 (238 days).Review of the manufacturer's guidelines indicated recommendations include changing the mask monthly, tubing every three months, water chamber and headgear every six months, and the air filter twice monthly. Guidelines further direct staff to fill the water chamber daily with distilled water, empty it after each use, wipe dry, and refill with fresh distilled water. Masks should be washed daily with warm water and mild detergent and air dried. Weekly cleaning of air tubing includes washing inside and out with warm water and mild detergent, rinsing thoroughly, and air drying. Water chambers should be washed weekly and, for mineral buildup, soaked 15-20 minutes in a solution of one-part white vinegar to nine parts water.Review of the facility CPAP/BIPAP/VPAP support equipment and Management Policy undated directed in part, to provide safe and effective Continuous Positive Airway Pressure (CPAP) therapy for residents requiring respiratory support while ensuring equipment is maintained, cleaned, inspected, and documented in accordance with physician's orders, infection prevention standards, and manufacturers recommendations. This policy incorporates the facilities clinical procedure for CPAP support and establishes ongoing equipment management requirements. Nursing staff will daily inspect the tubing, mask, humidifier, filters, and electrical cords for cleanliness and damage. Ensure the humidifier chamber containers only distilled water. Perform routine cleaning according to manufacturer recommendations. Weekly and monthly nursing will follow manufacturer recommended replacement intervals for disposable supplies. Cleaning shall be completed in accordance with manufacturer's instructions.

Based on observations, review of the clinical records, facility documentation, facility policy, and interviews for 2 of 7 residents (Resident #37 and Resident #59) reviewed for medication administration, the facility failed to ensure the medication error rate was not greater than 5% (error rate was 33.33% ). The findings include:1. Resident #37 had diagnoses that included hypomagnesemia, high blood pressure, coronary artery disease, constipation, and severe protein calorie malnutrition. The quarterly MDS dated [DATE] identified Resident # 37 had severely impaired cognition. The physician's order dated 6/19/26 directed to administer Calcium 600 milligrams (mg) with Vitamin D3 10 micrograms (mcg) (vitamin) give 2 tablets twice a day, Fluticasone Propionate 50 mcg (nasal spray used to treat allergies) give 1 spray in each nostril daily, Liquid Protein (dietary supplement) 1 gram 4 kcal per 6 milliliter (ml) give 30 ml twice a day, Magnesium Oxide (vitamin) 200 mg give 2 tablet to equal 400 mg daily, Metoprolol Succinate Extended Release (medication to treat high blood pressure give 25 mg daily, MiraLAX (laxative used to treat constipation) give 17 grams mixed with 8 ounces of liquid once a day, and Multivitamin tablet give one tablet daily. Observation of medication administration for Resident #37 by Licensed Practical Nurse (LPN) #3 on 7/27/26 at 7:53 AM identified LPN #3 administered Magnesium Oxide 400 mg 2 tablets equal to 800 mg (prescribed dose Magnesium Oxide 400 mg), and Calcium 600 mg with D3 5 mcg 1 tablet ( prescribed dose Calcium 600 mg with D3 10 mcg give 2 tablets not one) to Resident #37. LPN #3 did not administer Resident #37 the following medications: MiraLAX 17 grams, Liquid protein 30 ml, Metoprolol Succinate Extended Release 25 mg, Multivitamin, or Fluticasone Propionate 50 mcg nasal spray. LPN #3 proceeded back to the medication cart and indicated she was going to begin preparing Resident #59's medications.Interview with LPN #3, with the Director of Nursing Services (DNS) present on 7/27/26 at 9:15 AM, indicated she was the regular nurse assigned to the unit and stated she knew what medications the residents received daily. LPN #3 identified she did not administer Resident #37's prescribed MiraLAX because the resident had a bowel movement the day before, and she routinely holds MiraLAX for two days after a bowel movement to prevent loose stools. LPN #3 further identified she does not inform the APRN or physician when she chooses to hold Resident #37's MiraLAX and makes this decision independently based on the resident's recent bowel pattern. LPN #3 indicated the bottle of Calcium 600 mg with Vitamin D3 5 mcg was house stock and the only bottle available, so she administered one tablet daily to Resident #37. LPN #3 identified she administered two tablets of Magnesium Oxide 400 mg to Resident #37 because it was the only bottle she had in the medication cart. LPN #3 indicated she did not realize she was administering incorrect doses of both Calcium with Vitamin D3 and Magnesium Oxide to Resident #37.LPN #3 further indicated she did not administer Resident #37's additional prescribed medications-MiraLAX 17 grams, Liquid Protein 30 ml, Metoprolol Succinate, Multivitamin, and Fluticasone nasal spray-because she did not see them listed in the electronic medical record.2. Resident # 59 had diagnoses that included pressure ulcer of buttock, chronic pain right shoulder, vitamin D deficiency, and diverticulosis of large intestine. The physician's order dated 6/19/26 directed to administer Vitamin D3 (vitamin) 25 mcg give 2 tablets daily, Vitamin C (vitamin) 500 mg twice a day, Arginaid (dietary supplement) powder give one packet daily, and MiraLAX 17 grams mixed with 8 ounces of liquid daily. The annual MDS dated [DATE] identified Resident #59 had moderately impaired cognition. Observation of medication administration for Resident #59 by Licensed Practical Nurse (LPN) #3 on 7/27/26 at 8:00 AM identified LPN #3 placed one tablet of Vitamin D3 25 mcg (prescribed dose Vitamin D3 25 mcg give 2 tablets) into a medication cup, handed the medication cup to Resident #59 with a cup of water, Resident #59 took the medication, and LPN #3 exited the room. LPN #3 did not administer Resident #59 the following medications: Arginaid powder one packet, Vitamin C 500 mg, or MiraLAX 17 grams in 8 ounces of liquid. LPN #3 proceeded back to the medication care and identified she was going to start preparing for the next resident's medication administration. Interview with LPN #3 with the DNS present on 7/27/26 at 9:17 AM indicated she did not administer Resident #59's prescribed MiraLAX because the resident had a bowel movement two days earlier, and she routinely holds MiraLAX for two days after a bowel movement. LPN #3 stated she did not inform the nursing supervisor, APRN, or physician that she was holding Resident #59's MiraLAX. LPN #3 indicated the over the counter bottle of Vitamin C 500 mg and the Arginaid powder packet were house stock items and were not available. LPN #3 identified she did not request assistance from the nursing supervisor to check the supply area and instead chose not to administer the medications.Interview with the DNS on 7/27/26 at 9:20 AM indicated the expectation is that nurses follow the physician's orders and administer all medications as prescribed. The DNS identified if a medication is not in the medication cart, the nurse should contact the supervisor to locate the medication. The DNS further identified the medication is not available, the nurse must notify the APRN or physician and call the pharmacy to obtain the medication as quickly as possible. The DNS indicated all of Resident #59's and Resident #37's medications were available, and there was no reason for LPN #3 not to administer them as ordered. The DNS stated LPN #3 cannot independently decide to hold MiraLAX for either resident without notifying the supervisor and the APRN. The DNS identified because the over the counter Calcium 600 mg with Vitamin D3 5 mcg did not match the physician's order for Resident #37, the physician's order must be changed, or the facility's house stock supply must be corrected to match the prescribed medication. The DNS identified nurses are responsible for following the five rights of medication administration for all residents. The DNS identified LPN #3 should have followed the five rights of medication administration and the medication errors would not have happened. Interview with APRN #1 on 7/28/26 at 10:20 AM identified his expectation is the nurses administer medications in accordance with the physician's orders. APRN #1 indicated if a medication is not available, the nurse should contact the supervisor, and if the medication is not available, he expected to be notified so he could review the situation and determine whether laboratory tests or vital signs should be ordered based on the medication not available. Review of the facility Medication Administration Policy 8/2/25 directed in part, the purpose is to provide guidelines for the safe administration of medications. Verify the physician order for medication administration. The nurse must wash his/her hands then unlock the medication cart, select the medication from the unit dose, draw, or the stock supply. Check the label on the medication and confirm the medication name and dose with the medication administration record. Check the expiration date on the medication. Check the medication dose then recheck and confirm the dose. Prepare the correct dose of medication. Confirm the identity of the resident and explain the procedure. Provide the medications to the resident. Remain with the resident until all medications have been taken and perform hand antisepsis once completed. Review of the facility Physician's Order Policy dated 10/3/25 directed in part, the physician orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written orders of a person duly licensed and authorized to prescribe such medication in this state. Orders for medications must include name and strength of the drug, number of doses, start and stop date, and/or duration of therapy, dosage and frequency of administration, route of administration, and the clinical condition that medication is prescribed for.Review of the facility Medication Omission Policy dated 2/22/26 directed in part, the facility shall ensure that all medications are administered as prescribed by the licensed practitioner. Any omission of a scheduled medication dose shall be promptly identified, assessed, documented, reported, and addressed to minimize the risk of adverse resident outcomes. Medication omissions shall be investigated to determine root causes and implement corrective actions when necessary. To establish a standardized process for identifying medication omissions. Assessing resident risk following missed dose. Notifying appropriate healthcare providers. Documenting medication omissions accurately. Investigating contributing factors. Preventing reoccurrence through quality improvement activities. Medication omission is failure to administer prescribed medication as ordered, excluding a resident refusal, physician ordered a hold, or medications unavailable due to circumstances beyond facility control when appropriate actions have been taken.

Based on observation, review of facility documentation, facility policy, and interviews, for 1 of 2 medication storage rooms (second-floor medication storage room), the facility failed to ensure medication was labeled with an open date when opened. The findings include:Observation of the second-floor medication room with Registered Nurse (RN) #5 (supervisor) on 7/27/26 at 2:40 PM identified the in the medication refrigerator, a 10 milliliter (mL) vial of Insulin Lispro 100 units/1mL was standing loosely on the inside of the refrigerator door and not in any packaging. The vial of Insulin Lispro was noted to be missing the plastic flip-off cap and the white rubber stopper at the top of the insulin vial was exposed. A comparison with RN #5 of the uncapped insulin vial with an unopened Insulin Lispro 10 mL vial identified that the uncapped insulin vial had less insulin than the unopened one. Additionally, the uncapped Insulin Lispro 10 mL vial had the last name and room number of Resident #15 written on the vial with a marker, and no other pharmacy label was observed.Interview with RN #5 on 7/27/26 at 2:40 PM identified the opened 10 milliliter (mL) vial of Insulin Lispro should have been labeled with the date opened and discarded after 28 days. RN #5 indicated she did not know when the insulin had been uncapped.Interview with Licensed Practical Nurse (LPN) #6 on 7/27/26 at 2:50 PM who was assigned to care for Resident #15 identified he did not know when the vial of Insulin Lispro had been uncapped. LPN #6 indicated insulin vials were usually labeled with the date opened and discarded after 29 or 30 days. LPN #6 identified the Insulin Lispro was Resident #15 and Resident #15 self administered insulin through an insulin pump. LPN #6 further identified Resident #15 had brought in a box of Insulin Lispro vials from his/her pharmacy and facility only stored the insulin for Resident #15.Review of the manufacturer's insert for Insulin Lispro identified a 10 milliliter (mL) vial that has been opened or is in use should be used within 28 days or discarded, whether stored refrigerated or at room temperature.Interview with the Director of Nursing Services (DNS) on 7/28/26 at 9:29 AM identified insulin should be labeled after opening and discarded after 28 or 30 days, depending on the type of insulin.Review of the facility Labeling of Medications Policy, directed, in part, that labels for individual resident medications must include all necessary information, including the resident's name, the prescribing physician's name, the issuing pharmacy's name, address, and telephone number, the date the medication was dispensed, appropriate accessory and cautionary statements, the expiration date when applicable, and directions for use.

Based on clinical record review, facility policy and interviews, the facility failed to ensure medications were administered as ordered and failed to prevent significant medication errors for nineteen (19) of twenty-nine (29) sampled residents (Residents #3, 4, 8, 9, 10, 11, 13, 15, 16, 17, 18, 20, 22, 24, 26, 27, 28, 29, and 30). This resulted in missed doses of high risk medications, unsafe controlled substance handling, and a lack of timely assessment or provider notification. Specifically, LPN #1 repeatedly left the unit without notifying supervisory staff, was unavailable to administer scheduled and PRN medications, and was later found unresponsive in an employee restroom with drug paraphernalia present. Despite these concerns, nursing leadership did not remove LPN #1 from duty, did not assess residents for potential omissions, did not review the electronic Medication Administration Record (eMAR), and did not notify the provider until the following day. Following suspension, LPN #1 retained remote access to the eMAR and subsequently signed off medications she could not verify as administered. Record review identified widespread omitted medications on 5/21/26-including anticoagulants, insulin, anticonvulsants, cardiac medications, psychotropics, controlled substances, and time sensitive treatments. Required vital signs, pain assessments, diabetic monitoring, gastrostomy tube (G-tube) (a medical device inserted through the abdomen directly into the stomach) care, and treatment documentation were also missing. Controlled substance counts were inaccurate, and RN #2 permitted LPN #1 to retroactively sign out narcotics without verifying administration. Additionally, for Resident #3, the facility failed to administer multiple time sensitive medications prior to the resident's scheduled fistulogram, and nursing staff failed to identify the missed doses or notify the nursing supervisor or provider of the omissions. These failures resulted in a finding of Immediate Jeopardy. The findings included:Please cross-reference F580, F636 and F657.The Reportable Event (RE) dated 5/21/26 identified throughout the 3:00 PM to 11:00 PM shift, LPN #1 was off the nursing unit multiple times due to reportedly feeling unwell. At approximately 11:00 PM, staff located LPN #1 lethargic in an employee restroom with suspected drug paraphernalia in possession. Emergency services were called and police and Emergency Medical Services (EMS) arrived; LPN #1 was removed from the schedule pending investigation and twenty-two (22) residents were identified to have been omitted medications and/or treatments during the shift. The Medical Director was notified, and assessments were completed for affected residents with no adverse effects identified.1a. Resident #4's diagnoses included chronic pancreatitis (progressive inflammation of the pancreas), central pain syndrome and type II diabetes mellitus.The quarterly MDS assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 6) and required substantial assistance with bed mobility.The RCP dated 5/11/26 identified Resident #4 had diabetes mellitus with diabetic neuropathy and was insulin dependent, required a therapeutic diet related to compromised endocrine function and had the potential for chronic pain secondary to chronic pancreatitis. Interventions included administering medications as ordered and monitoring and recording effectiveness.Review of the Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:5:30 PM: baclofen (muscle relaxant and antispasmodic) 5 mg, give 1 tablet twice daily;6:30 PM: Creon (for the treatment of exocrine pancreatic insufficiency) 36,000-114,000-180,000 units delayed release, administer 1 capsule with meals.The May 2026 eMAR identified the 5:30 PM dose of baclofen and the 6:30 PM dose of Creon were documented as administered on 5/21/26 by LPN #1, however, review of the Audit Log (a report that identifies when charting was completed or documentation was edited) identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility).Although attempted, Resident #4 was unable to be interviewed.1b. Resident #8's diagnoses included hypertension, benign prostatic hyperplasia (enlargement of the prostate gland), adult failure to thrive, anxiety disorder and major depressive disorder.The annual MDS assessment dated [DATE] identified Resident #8 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), was independent with bed mobility and required supervision assistance for transfers.The RCP dated 4/6/26 identified Resident #8 had weight loss over the last month, was at risk for cardiac complications secondary to diagnoses of cerebral infarction, hyperlipidemia and orthostatic hypotension. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:00 PM: midodrine (for the treatment of symptomatic orthostatic hypotension) 10 mg, give 1 tablet three times daily; Ensure supplement, give 237 milliliters (mL) 4 times daily.5:00 PM: tamsulosin (for the treatment of symptoms of an enlarged prostate such as difficulty urinating) 0.4 mg, give 1 capsule daily.The May 2026 eMAR identified the 4:00 PM dose of midodrine, the Ensure supplement and the 5:00 PM dose of tamsulosin were documented as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility). The MAR further identified missing entries for a blood pressure and heart rate which were required prior to the administration of the midodrine.Although attempted, Resident #8 was unable to be interviewed.1c. Resident #9's diagnoses included Congestive Heart Failure (CHF), chronic left lower quadrant abdominal spasms, diverticulitis (inflammation of irregular bulging pouches in the wall of the large intestine), retention of urine, anxiety disorder and major depressive disorder.The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13), required setup assistance for bed mobility and was independent with transfers.The RCP dated 5/20/26 identified Resident #9 had heart failure, a history of urinary retention and a history of diverticulitis. Interventions included administering medications such as beta blockers, diuretics and antibiotics as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:5:00 PM: metoprolol succinate (for the treatment of CHF and high blood pressure) extended release 25 mg, give 3 tablets (75 mg) twice daily; Voltaren gel 1 %, administer 4 g topically three times daily.6:00 PM: check bladder ultrasound and straight catheterize as needed for more than 450 cubic centimeters (cc) in the bladder every 6 hours.The May 2026 eMAR identified 5:00 PM doses of metoprolol succinate, calcium carbonate and Voltaren gel were omitted on 5/21/26. 9:00 PM doses of rosuvastatin 20 mg, give 1 tablet daily; Eliquis 5 mg, give 1 tablet every 12 hours; gabapentin 100 mg and 400 mg tablet (500 mg dose) three times daily for chronic leg pain; metronidazole 500 mg, give 1 tablet every 12 hours for bacterial vaginosis; mirtazapine (for the treatment of major depressive disorder) 30 mg, give 1 tablet daily at bedtime; oxycodone 5 mg, give 1 tablet three times daily for chronic leg pain; tamsulosin 0.4 mg, give 2 capsules daily at bedtime for urinary retention were omitted on 5/21/26. The pain assessment scheduled to be completed each shift was blank for the 3:00 PM to 11:00 PM shift on 5/21/26. The May 2026 Treatment Administration Record (TAR) identified blank entries for the 6:00 PM bladder ultrasound. Review of nurse's notes dated 5/21/26 failed to identify LPN #1 documented regarding the omitted medications.The Controlled Proof-of-use/Disposition Form for oxycodone 5 mg identified one (1) tablet of oxycodone 5 mg was signed out at 9:00 PM on 5/21/26.Interview with Resident #9 on 6/23/26 at 11:22 AM identified he/she could not recall receiving medications on 5/21/26.1d. Resident #10's diagnoses included chronic pain, atrial fibrillation (irregular, rapid heart rhythm) and depression.The quarterly MDS assessment dated [DATE] identified Resident #10 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) required total assistance for transfers and was independent with bed mobility.The RCP dated 2/11/26 identified Resident #10 was at risk for impaired skin integrity due to Eliquis use and had a diagnosis of diabetes mellitus. Interventions included administering medications per order and monitoring for side effects.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:8:00 PM: acetaminophen (for treatment of mild to moderate discomfort/pain) 500 mg, give 2 tablets (1000 mg) every 12 hours; Eliquis 5 mg, give 1 tablet every 12 hours.The May 2026 eMAR identified acetaminophen and Eliquis were documented as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility).Interview with Resident #10 on 6/23/26 at 10:46 AM identified he/she did not receive medications from LPN #1 on 5/21/26. Resident #10 reported having increased pain and difficulty sleeping subsequent to the omissions.1e. Resident #11's diagnoses included type II diabetes mellitus, chronic kidney disease, dependence on renal dialysis, unspecified convulsions (involuntary muscle shaking or spasms but the exact cause or seizure type had not been identified) and acute embolism and thrombosis of the deep veins of the right proximal lower extremity (clotting of blood in the deep vein of the upper portion of the right leg).The annual MDS assessment dated [DATE] identified Resident #11 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance for bed mobility and was dependent on staff for transfers.The RCP dated 3/29/26 identified Resident #11 had the potential for injury due to seizure disorder, had the potential for pain/discomfort due to generalized discomfort and lymphedema wounds (slow-healing sores due to fluid buildup) and had a history of Deep Vein Thrombosis (DVT) and was on blood thinners. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:00 PM: levetiracetam (for treatment of seizures) 250 mg, give 1 tablet daily on Tuesday, Thursday and Saturday.5:00 PM: Eliquis 2.5 mg, give 1 tablet twice daily; oxycodone (for treatment of moderate to severe pain) 5 mg, give 1 tablet every 4 hours.The May 2026 eMAR identified levetiracetam, Eliquis and oxycodone were documented as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/24/26 (while suspended from employment at the facility).The Controlled Proof-of-use/Disposition Form for oxycodone 5 mg failed to identify the 5:00 PM dose was documented by LPN #1 on 5/21/26.Interview with Resident #11 on 6/24/26 at 10:34 AM identified he/she could not recall receiving medications on 5/21/26.1f. Resident #13's diagnoses included spastic hemiplegia affecting left nondominant side (a neurological condition where muscle stiffness and weakness occurred on the left side of the body due to right-brain damage), chronic pain, type II diabetes mellitus and gastro-esophageal reflux disease.The annual MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), was independent with bed mobility and was dependent on staff for transfers.The RCP dated 5/6/26 identified Resident #13 had the potential for pain/discomfort related to polyneuropathy, had diabetes mellitus and was at risk for hyper/hypoglycemia. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:5:00 PM: metformin (for treatment of hyperglycemia) 1000 mg, give 1 tablet twice daily; methocarbamol 500 mg, give 1 tablet four times daily; omeprazole delayed release 40 mg, give 1 capsule daily.8:00 PM: diclofenac sodium gel (topical pain treatment) 1 %, give 4 g topically four times daily.The May 2026 eMAR identified the metformin, methocarbamol, omeprazole and diclofenac sodium gel were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility).Further review of the eMAR identified the following 9:00 PM scheduled medications were omitted for on 5/21/26: pregabalin 200 mg, give 1 capsule every 12 hours for polyneuropathy; tramadol 50 mg, give 1 tablet daily at bedtime for chronic pain; Symbicort aerosol inhaler 80-4.5 micrograms (mcg)/actuation, administer 2 puffs by inhalation every 12 hours for asthma and calcium carbonate 500 mg, give 2 chewable tablets (1000 mg) three times daily.Review of nurse's notes dated 5/21/26 failed to identify documentation of the omitted medications.The Controlled Proof-of-use/Disposition Form for tramadol 50 mg identified one (1) tablet of tramadol 50 mg was signed out at 9:00 PM on 5/21/26.The Controlled Proof-of-use/Disposition Form for pregabalin 200 mg, identified one (1) tablet of pregabalin 200 mg was signed out at 9:00 PM on 5/21/26.Interview with Resident #13 on 6/23/26 at 10:51 AM identified he/she could not recall receiving medications during the 3:00 PM to 11:00 PM shift on 5/21/26 but reported LPN #1 was consistently late administering medications and Resident #13 often called the nursing supervisor to complain. Resident #13 identified he/she was often in increased pain after LPN #1 worked due to receiving medications late.1g. Resident #14's diagnoses included pain disorder with psychological factors, personal history of a traumatic brain injury, migraines, anxiety disorder and depression.The quarterly MDS assessment dated [DATE] identified Resident #14 had intact cognition (Brief Interview for Mental Status (BIMS) score of 14), was independent with bed mobility and transfers.The RCP dated 4/6/26 identified Resident #14 had pain. Interventions included administering pain medications as ordered.The May 2026 eMAR identified all scheduled medications were signed off as administered on the 3:00 PM to 11:00 PM shift on 5/21/26 by LPN #1.Further review identified Resident #14 received as needed (PRN) acetaminophen 500 mg on 5/21/26 at 7:27 PM by LPN #4, who was not Resident #13's assigned nurse that shift. Resident #14's pain level was not re evaluated until the next shift by LPN #6, but a re-evaluation time was not identified (the next shift was over 3.5 hours later).Interview with LPN #4 on 6/23/26 at 12:43 PM identified on 5/21/26, just before 7:30 PM, Resident #14 rang the call bell complaining of a headache. Staff alerted her they could not locate LPN #1 so she administered acetaminophen to Resident #14 and then notified the nursing supervisor (RN #1) that she had not seen LPN #1 since approximately 6:00 PM. LPN #1 was paged overhead three (3) times before returning to the unit at 8:00 PM. LPN #4 notified LPN #1 that acetaminophen was administered. LPN #4 reported LPN #1 did not notify her that she was leaving the unit.Although attempted, an interview with Resident #14 was not obtained.1h. Resident #15's diagnoses included seizures, aphasia following cerebral infarction (language disorder caused by damage to the brain's language centers following a stroke), hypercholesterolemia (high cholesterol levels) and depressive disorder.The annual MDS assessment dated [DATE] identified Resident #15 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8) and was independent with bed mobility and transfers.The RCP dated 3/16/26 identified Resident #15 had the potential for seizures. Interventions included monitoring lab values for a therapeutic level of anticonvulsant medications.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:8:00 PM: levetiracetam 250 mg, administer 6 tablets (1,500 mg) twice daily; rosuvastatin 40 mg, give 1 tablet daily at bedtime.The May 2026 eMAR identified the levetiracetam and rosuvastatin were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility).Although attempted, Resident #15 was unable to be interviewed.1i. Resident #17's diagnoses included dementia without behavioral disturbances, restlessness and agitation, palliative care, major depressive disorder and schizoaffective disorder, depressive type.The annual MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 6) and was dependent on staff for bed mobility and transfers.The RCP dated 4/13/26 identified Resident #17 had the potential for pain/discomfort related to general discomfort, had the potential for alteration in mood and/or behavior, had a history of schizoaffective disorder and depressive disorder and was on hospice care. Interventions included evaluating for pain/discomfort as indicated and administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:30 PM: acetaminophen 500 mg, give 2 tablets (1,000 mg) three times daily.5:30 PM: lorazepam (for treatment of anxiety, comfort) 0.5 mg, give 1 tablet once daily.The May 2026 eMAR identified the lorazepam was signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medication on 5/22/26 (while suspended from employment at the facility). The acetaminophen administrations at both 4:30 PM and 9:00 PM on 5/21/26 were blank.Review of nurse's notes dated 5/21/26 failed to identify documentation regarding the omitted medications.The Controlled Proof-of-use/Disposition Form for lorazepam 0.5 mg failed to identify the 5:30 PM dose of lorazepam was signed out by LPN #1 on 5/21/26.Although attempted, Resident #17 was unable to be interviewed.1j. Resident #18's diagnoses included hypertension, hypothyroidism, type II diabetes mellitus with hyperglycemia and major depressive disorder.The annual MDS assessment dated [DATE] identified Resident #18 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility, transfers and ambulation.The RCP dated 4/16/26 identified Resident #18 had a history of both hypotension and hypertension and was at risk for pain. Interventions included monitoring vital signs as necessary and administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:00 PM: pantoprazole delayed release 40 mg tablet, give 1 tablet daily; levothyroxine 137 mcg, give 1 tablet daily.5:00 PM: metformin 500 mg, give 1 tablet twice daily; midodrine 5 mg, give 1 tablet three times daily.6:00 PM: metoprolol succinate extended release 50 mg tablet, give 1 tablet twice daily.The midodrine required a pre administration blood pressure to be obtained, and the metoprolol succinate required a pre administration heart rate and blood pressure to be obtained, which were blank.The May 2026 eMAR identified the pantoprazole, levothyroxine, metformin, midodrine and metoprolol succinate were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility). The required pre-administration vitals were blank. The required pain assessment was blank for the 3:00 PM to 11:00 PM shift.Interview with Resident #18 on 6/23/26 at 11:14 AM identified he/she could not recall receiving medications on 5/21/26.1k. Resident #20's diagnoses included Atrial Fibrillation (AFIB), urinary retention, chronic interstitial cystitis with hematuria, visual hallucinations, restlessness and agitation and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #20 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), required substantial assistance for bed mobility and was dependent on staff for transfers.The RCP dated 5/15/26 identified Resident #20 had AFIB and was prescribed blood thinners, had the potential for alteration in elimination due to incontinence, constipation, and urinary retention and had the potential for alteration in mood and/or behavior and display behaviors such as yelling out and talking to self and could present as agitated and accusatory. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:30 PM: methenamine hippurate 1 gram, give 1 tablet twice daily; trazodone 50 mg, give 25 mg daily in the evening; ascorbic acid 250 mg, give 500 mg twice daily.At 5:00 PM: Eliquis 5 mg, give 1 tablet twice daily; sennosides-docusate sodium 8.6-50 mg, give 1 tablet twice daily; ferrous sulfate 324 mg delayed release, give 1 tablet twice daily.The May 2026 eMAR identified the methenamine hippurate, trazodone, ascorbic acid, Eliquis, sennosides-docusate sodium and ferrous sulfate were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/23/26 (while suspended from employment at the facility). The required pain assessment was blank.Interview with Resident #20 on 6/23/26 at 11:26 AM identified he/she could not recall receiving medications on 5/21/26.1l. Resident #22's diagnoses included CHF, hypertension, hypotension, polyneuropathy, chronic pain, anxiety disorder and adjustment disorder with depressed mood.The 5 day MDS assessment dated [DATE] identified Resident #22 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and was dependent on staff for bed mobility and transfers.The RCP dated 4/21/26 identified Resident #22 had a history of seizures, was at risk for cardiac/pulmonary complications, and had chronic generalized pain. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:5:00 PM: carvedilol 6.25 mg;8:00 PM: gabapentin 600 mg.The May 2026 eMAR identified the carvedilol and gabapentin were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility). Further review of the eMAR identified the 9:00 PM levetiracetam 500 mg and melatonin 6 mg were not signed off on 5/21/26Review of nurse's notes dated 5/21/26 failed to identify documentation of omitted medications.Interview with Resident #22 on 6/23/26 at 10:40 AM identified he/she could not recall receiving medications on 5/21/26.1m. Resident #24's diagnoses included dementia with behavioral disturbances, type II diabetes mellitus, unspecified abnormal involuntary movements, hypertension, Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, schizoaffective disorder, bipolar type, and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #24 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10) and was independent with bed mobility and transfers.The RCP dated 5/11/26 identified Resident #24 had diabetes and was at risk for hypo and hyper glycemic episodes and was insulin dependent, had pain and chest pain and had the potential for alteration in mood and/or behavior due to multiple diagnoses and a history of impulsive behavior, violent behavior and accusatory behavior. Interventions included administering prescribed medication and evaluating for the effectiveness.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:5:00 PM: benztropine (used to treat Parkinson's disease and manage symptoms caused by antipsychotic medications) 0.5 mg, give 1 tablet twice daily; Humalog (fast acting) insulin 100 units per mL, give 5 units with meals; metformin 1000 mg twice daily.8:00 PM: divalproex delayed release sprinkles 125 mg, give 8 capsules (1000 mg) three times daily; escitalopram oxalate (used to treat depression) 20 mg, give 1 tablet daily; tamsulosin 0.4 mg, give 1 capsule daily; trazodone 150 mg, give 1 tablet daily at bedtime8:30 PM: propranolol 10 mg, give 3 tablets (30 mg) twice dailyThe May 2026 eMAR identified the benztropine, Humalog, metformin, divalproex, escitalopram oxalate, tamsulosin, trazodone and propranolol were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/25/26 (while suspended from employment at the facility). The eMAR identified the required blood sugar and injection site were not documented for the Humalog administration.Although attempted, Resident #24 was unable to be interviewed.1n. Resident #26's diagnoses included hypertension, atrial fibrillation, gastrostomy status, seizures, pain, contractures of muscles, abnormal involuntary movements, depression and bipolar disorder.The quarterly MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9) and was dependent for bed mobility and transfers.The RCP dated 5/15/26 identified Resident #26 utilized a gastrostomy tube, was at risk for cardiovascular events, was on blood thinners and had the potential for alteration in mood and/or behavior. Interventions included administering medications as ordered and monitoring for side effects.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:5:00 PM: Eliquis 5 mg, give 1 tablet via Gastric tube (G-tube) twice daily; gabapentin 100 mg, give 2 capsules (200 mg) via G-tube three times daily; metoprolol tartrate 25 mg, give 0.5 tablet (25 mg) via G-tube twice daily.5:30 PM: levetiracetam 500 mg, give 1 tablet via G-tube twice daily.8:00 PM: clonazepam 0.5 mg, give 1 tablet via G-tube daily; valproic acid solution 250 mg per 5 mL, give 5 mL via G-tube every six (6) hours.The May 2026 eMAR identified the Eliquis, gabapentin, metoprolol, levetiracetam and clonazepam were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility). The pre administration heart rate and blood pressure required prior to metoprolol administration were not documented. The valproic acid administration at 8:00 PM was blank.Further review of the eMAR identified:The required pain assessment for the 3:00 PM to 11:00 PM shift was blank.The orders G-tube feeding, Peptamen AF liquid 0.0756 gram- 1.2 kilocalorie (kcal) per mL to be run at 65 mL per hour via G-tube continuously was not signed off as administered on the 3:00 PM to 11:00 PM shift on 5/21/26 and the tube feeding intake was not documented on as required;The order to flush the G-tube with 30 mL of water before and after each medication administration was not signed off as administered on the 3:00 PM to 11:00 PM shift on 5/21/26;The order to verify G-tube placement prior to administration of food, fluids, or medications was not signed off as administered on the 3:00 PM to 11:00 PM shift on 5/21/26.The Controlled Proof of use/Disposition Form identified one (1) tablet of clonazepam 0.5 mg was signed out at 9:00 PM on 5/21/26.Although attempted, Resident #26 was unable to be interviewed.1o. Resident #27's diagnoses included dementia with behavioral disturbances, type II diabetes mellitus with hyperglycemia, hypertension, epilepsy and polyneuropathy.The annual MDS assessment dated [DATE] identified Resident #27 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8) and required supervision for transfers and was independent with bed mobility.The RCP dated 5/4/26 identified Resident #27 had potential for pain/discomfort, risk for cardiac complications, a mood disorder, and risk for anxiety/depression. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:00 PM: Novolog insulin 100 units per mL, follow sliding scale and administer subcutaneously before meals.5:00 PM: carvedilol 3.125 mg, give 1 tablet twice daily; divalproex delayed release 500 mg tablet, give 1 tablet every eight (8) hours; metformin 500 mg, give 1 tablet twice daily; trazodone 50 mg, give 0.5 tablet (25 mg) twice daily.6:00 PM: Novolog insulin 100 units per mL, give 26 units subcutaneously with meals.8:00 PM, gabapentin 800 mg, give 1 tablet three times daily.The May 2026 eMAR identified the sliding scale Novolog, carvedilol, divalproex, metformin, Novolog 26 units, and gabapentin were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility). The blood sugar and injection site for the Novolog were not documented. The trazodone administration was blank at 5:00 PM. The required pain assessment for the 3:00 PM to 11:00 PM shift was blank.Review of nurse's notes dated 5/21/26 failed to identify documentation of omitted medications.Although attempted, Resident #27 was unable to be interviewed.1p. Resident #28's diagnoses included muscle spasms, functional quadriplegia, chronic pain, insomnia, adult failure to thrive, moderate protein calorie malnutrition and major depressive disorder.The quarterly MDS assessment dated [DATE] identified Resident #28 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), was dependent on staff for bed mobility and did not transfer or ambulate.The RCP dated 4/13/26 identified Resident #28 had Major Depressive Disorder and anorexia, had potential for mood alteration, had chronic pain and osteoporosis, received gabapentin twice daily, and was on tramadol and baclofen for contractures. Interventions included administering medications per order and monitoring effectiveness.The Administration Compliance Report dated 5/21/26 identified the following medications were omitted on 5/21/26:4:30 PM: gabapentin 100 mg, give 1 capsule twice daily.5:00 PM: house supplement, give 237 mL four times daily; liquid protein supplement, give 30 cc three times daily.7:30 PM: mirtazapine (for treatment of major depressive disorder) 30 mg, give 1 tablet daily at bedtime; tramadol 75 mg, give 1 tablet three times daily.8:30 PM: melatonin 3mg, give 2 tablets (6 mg) daily at bedtime.The May 2026 eMAR identified the gabapentin, liquid protein, mirtazapine, tramadol, and melatonin were signed off as administered on 5/21/26 by LPN #1, however, review of the Audit Log identified LPN #1 accessed the eMAR and signed off the omitted medications on 5/22/26 (while suspended from employment at the facility). The house supplement was not signed off at 5:00 PM or 9:00 PM as ordered. The required pain assessment for the 3:00 PM to 11:00 PM shift was blank.The Controlled Proof of use/Disposition Form for tramadol 75 mg identified one (1) tablet was signed out at 9:38 PM on 5/21/26 (over 2 hours late).Review of nurse's notes dated 5/21/26 failed to identify documentation of omitted medication

Based on review of the clinical record, facility documentation, policy, and interviews for nineteen (18) of twenty nine (29) sampled residents (Residents #3, 4, 8, 9, 10, 11, 15, 16, 17, 18, 20, 22, 24, 26, 27, 28, 29, 30) reviewed for omitted medications, the facility failed to notify the provider immediately after omitted medications were identified. As a result, affected residents were not assessed timely and providers were not notified until the next day. The findings include: The Reportable Event (RE) dated 5/21/26 identified throughout the 3:00 PM to 11:00 PM shift, LPN #1 was off the unit multiple times due to feeling unwell. At approximately 11:00 PM, staff found LPN #1 lethargic in the employee restroom with suspected drug paraphernalia in her possession. Emergency Medical Services (EMS) arrived, LPN #1 was removed from the schedule pending investigation and twenty-two (22) residents were identified to have been omitted medications and/or treatments during the shift. The Medical Director was notified, and assessments were completed for the affected residents with no adverse effects identified. 1. Resident #3's diagnoses included end-stage renal disease, dependence on renal dialysis, type II diabetes mellitus and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had intact impaired cognition (Brief Interview for Mental Status (BIMS) score of 13) and was independent with bed mobility and transfers.The Resident Care Plan (RCP) dated 3/12/26 identified Resident #3 is on dialysis. Interventions included assuring medications are administered before and after dialysis as ordered by the physician to ensure maximum effectiveness and to avoid adverse effects of the medications.The May 2026 electronic Medication Administration Record (eMAR) identified Resident #3 was omitted the following medications on 5/21/26 at 8:00 AM: sevelamer carbonate (for treatment of high phosphate levels in the blood). Resident #3 was omitted the following medications on 5/21/26 at 9:00 AM: allopurinol (for treatment of gout and high uric acid levels in the blood) 100 milligrams (mg), take two (2) tablets once daily; amlodipine (for treatment of high blood pressure) 10 mg once daily on Sunday, Tuesday, Thursday and Saturday; bumetanide (diuretic) 2 mg, give two (2) tablets (4 mg) once daily on Sunday, Tuesday, Thursday, Saturday; losartan (for treatment of high blood pressure) 25 mg, give one (1) tablet daily on Sunday, Tuesday, Thursday, Saturday; Eliquis (blood thinner that reduces blood clotting) 5 mg, give 2 tablets (10 mg) twice daily; metoprolol tartrate (for treatment of high blood pressure and heart rate control) 50 mg twice daily; rosuvastatin (for treatment of high cholesterol) 5 mg once daily; Voltaren arthritis pain gel 1 percent (%), apply 4 grams (gm) to each knee topically twice daily;Review of nurse's notes dated 5/21/26 failed to identify that the provider was notified of the omissions.Interview with LPN #6 on 6/23/26 at 12:15 PM identified Resident #1 was scheduled for a fistulogram (a test that looks for abnormal areas in a dialysis graft or arteriovenous fistula) at 8:45 AM on 5/21/26 and was picked up for transport just after 7:00 AM. She reported the medications were not transcribed to be given early that day and she did not realize the medications were not administered until after Resident #3 left. LPN #6 identified she did not notify the nursing supervisor or the provider of the omissions.Interview with Resident #3 on 6/23/26 at 11:00 AM identified he/she did not receive morning medications on 5/21/26 prior to the fistulogram and reported he/she had not seen the nurse prior to transport to the appointment.2. Resident #4's diagnoses included chronic pancreatitis (progressive inflammation of the pancreas), central pain syndrome and type II diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 6) and required substantial assistance with bed mobility.The RCP dated 5/11/26 identified Resident #4 had diabetes mellitus with diabetic neuropathy and was insulin dependent, required a therapeutic diet related to compromised endocrine function and had the potential for chronic pain secondary to chronic pancreatitis. Interventions included administering medications as ordered and monitoring and recording effectiveness.The Administration Compliance Report (a report that identifies omitted/missed medications for residents on a specified date) dated 5/21/26 identified Resident #4 was omitted the following medications on 5/21/26: At 5:30 PM, baclofen (muscle relaxant and antispasmodic) 5 mg, give 1 tablet twice daily; At 6:30 PM, Creon (for the treatment of exocrine pancreatic insufficiency) 36,000-114,000-180,000 units delayed release, administer 1 capsule with meals.Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #4 following medication omissions. Although attempted, Resident #4 was unable to be interviewed. 3. Resident #8's diagnoses included hypertension, benign prostatic hyperplasia (enlargement of the prostate gland), adult failure to thrive, anxiety disorder and major depressive disorder. The annual MDS assessment dated [DATE] identified Resident #8 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), was independent with bed mobility and required supervision assistance for transfers. The RCP dated 4/6/26 identified Resident #8 had weight loss over the last month, was at risk for cardiac complications secondary to diagnoses of cerebral infarction, hyperlipidemia and orthostatic hypotension. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #8 was omitted the following medications and orders on 5/21/26: At 4:00 PM, midodrine (for the treatment of symptomatic orthostatic hypotension) 10 mg, give 1 tablet three times daily; Ensure supplement, give 237 milliliters (mL) 4 times daily. At 5:00 PM, tamsulosin (for the treatment of symptoms of an enlarged prostate such as difficulty urinating) 0.4 mg, give 1 capsule daily.Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions. A provider note dated 5/22/26 identified they were asked to see Resident #8 following medication omissions. Although attempted, Resident #8 was unable to be interviewed. 4. Resident #9's diagnoses included Congestive Heart Failure (CHF), chronic left lower quadrant abdominal spasms, diverticulitis (inflammation of irregular bulging pouches in the wall of the large intestine), retention of urine, anxiety disorder and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13), and required setup assistance for bed mobility and was independent with transfers.The RCP dated 5/20/26 identified Resident #9 had heart failure, a history of urinary retention and a history of diverticulitis. Interventions included administering medications such as beta blockers, diuretics and antibiotics as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #9 was omitted the following medications and orders on 5/21/26: At 5:00 PM, metoprolol succinate (for the treatment of CHF and high blood pressure) extended release 25 mg, give 3 tablets (75 mg) twice daily; calcium carbonate (for the treatment of heartburn and indigestion) 500 mg, give 2 chewable tablets (1000 mg) twice daily; Voltaren gel 1 %, administer 4 g topically three times daily. At 6:00 PM, check bladder ultrasound and straight catheterize as needed for more than 450 cubic centimeters (cc) in the bladder every 6 hours. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #9 following medication omissions.Interview with Resident #9 on 6/23/26 at 11:22 AM identified he/she could not recall receiving medications from LPN #1 on 5/21/26.5. Resident #10's diagnoses included chronic pain, atrial fibrillation (irregular, rapid heart rhythm) and depression.The quarterly MDS assessment dated [DATE] identified Resident #10 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) and required total assistance for transfers and was independent with bed mobility.The RCP dated 2/11/26 identified Resident #10 was at risk for impaired skin integrity due to Eliquis use and has a diagnosis of diabetes mellitus. Interventions included administering medications per orders and monitoring for any side effects. The Administration Compliance Report dated 5/21/26 identified Resident #10 was omitted the following medications and orders on 5/21/26: At 8:00 PM, acetaminophen (for treatment of mild to moderate discomfort/pain) 500 mg, give 2 tablets (1000 mg) every 12 hours; Eliquis 5 mg, give 1 tablet every 12 hours. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #10 following medication omissions.Interview with Resident #10 on 6/23/26 at 10:46 AM identified he/she remembered not receiving medications from LPN #1 on 5/21/26. Resident #10 reported having increased pain and difficulty sleeping, which was abnormal for him/her, but denied reporting the incident to anyone.6. Resident #11's diagnoses included type II diabetes mellitus, chronic kidney disease, dependence on renal dialysis, unspecified convulsions (involuntary muscle shaking or spasms but the exact cause or seizure type has not been identified) and acute embolism and thrombosis of the deep veins of the right proximal lower extremity (clotting of blood in the deep vein of the upper portion of the right leg).The annual MDS assessment dated [DATE] identified Resident #11 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance for bed mobility and was dependent on staff for transfers. The RCP dated 3/29/26 identified Resident #11 has the potential for injury due to seizure disorder, had the potential for pain/discomfort due to generalized discomfort and lymphedema wounds (slow- healing sores due to fluid buildup) and has a history of Deep Vein Thrombosis (DVT) and is on blood thinners. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #11 was omitted the following medications and orders on 5/21/26: At 4:00 PM, levetiracetam (for treatment of seizures) 250 mg, give 1 tablet daily on Tuesday, Thursday and Saturday. At 5:00 PM, Eliquis 2.5 mg, give 1 tablet twice daily; oxycodone (for treatment of moderate to severe pain) 5 mg, give 1 tablet every 4 hours. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #11 following medication omissions. Interview with Resident #11 on 6/24/26 at 10:34 AM identified he/she could not recall not being administered medications on 5/21/26.7. Resident #13's diagnoses included spastic hemiplegia affecting left nondominant side (a neurological condition where muscle stiffness and weakness occur on the left side of the body due to right-brain damage), chronic pain, type II diabetes mellitus and gastro-esophageal reflux disease.The annual MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), was independent with bed mobility and was dependent on staff for transfers.The RCP dated 5/6/26 identified Resident #13 has the potential for pain/discomfort related to polyneuropathy, has diabetes mellitus and is at risk for hyper/hypoglycemia. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #13 was omitted the following medications and orders on 5/21/26: At 5:00 PM, metformin (for treatment of hyperglycemia) 1000 mg, give 1 tablet twice daily; methocarbamol 500 mg, give 1 tablet four times daily; omeprazole delayed release 40 mg, give 1 capsule daily. At 8:00 PM, diclofenac sodium gel (topical pain treatment) 1 %, give 4 g topically four times daily.The eMAR identified the following 9:00 PM scheduled medications were omitted for Resident #13 on 5/21/26: pregabalin 200 mg, give 1 capsule every 12 hours for polyneuropathy; tramadol 50 mg, give 1 tablet daily at bedtime for chronic pain; Symbicort aerosol inhaler 80-4.5 micrograms (mcg)/actuation, administer 2 puffs by inhalation every 12 hours for asthma and calcium carbonate 500 mg, give 2 chewable tablets (1000 mg) three times daily.Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #13 following medication omissions.Interview with Resident #13 on 6/23/26 at 10:51 AM identified he/she could not recall receiving medications on the 3:00 PM to 11:00 PM shift on 5/21/26.8. Resident #15's diagnoses included seizures, aphasia following cerebral infarction (language disorder caused by damage to the brain's language centers following a stroke), hypercholesterolemia (high cholesterol levels) and depressive disorder.The annual MDS assessment dated [DATE] identified Resident #15 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), and is independent with bed mobility and transfers.The RCP dated 3/16/26 identified Resident #15 had the potential for seizures. Interventions included monitoring lab values for a therapeutic level of anticonvulsant medications.The Administration Compliance Report dated 5/21/26 identified Resident #15 was omitted the following medications and orders on 5/21/26: At 8:00 PM, levetiracetam 250 mg, administer 6 tablets (1,500 mg) twice daily; rosuvastatin (for treatment of high cholesterol) 40 mg, give 1 tablet daily at bedtime. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #15 following medication omissions.Although attempted, Resident #15 was unable to be interviewed.9. Resident #17's diagnoses included dementia without behavioral disturbances, restlessness and agitation, palliative care, major depressive disorder and schizoaffective disorder, depressive type.The annual MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 6) and was dependent on staff for bed mobility and transfers.The RCP dated 4/13/26 identified Resident #17 had the potential for pain/discomfort related to general discomfort, has the potential for alteration in mood and/or behavior, had a history of schizoaffective disorder and depressive disorder and was on hospice care. Interventions included evaluating for pain/discomfort as indicated and administering medications as ordered.The Administration Compliance Report dated 5/21/26 and run on 5/22/26 identified Resident #15 was omitted the following medications and orders on 5/21/26: At 4:30 PM, acetaminophen 500 mg, give 2 tablets (1,000 mg) three times daily. At 5:30 PM, lorazepam (for treatment of anxiety, comfort) 0.5 mg, give 1 tablet once daily. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #17 following medication omissions.Although attempted, Resident #17 was unable to be interviewed.10. Resident #18's diagnoses included hypertension, hypothyroidism, type II diabetes mellitus with hyperglycemia and major depressive disorder.The annual MDS assessment dated [DATE] identified Resident #18 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was independent with bed mobility, transfers and ambulation.The RCP dated 4/16/26 identified Resident #18 had a history of both hypotension and hypertension and was at risk for pain. Interventions included monitoring vital signs as necessary and administering medications as ordered. The Administration Compliance Report dated 5/21/26 and run on 5/22/26 identified Resident #18 was omitted the following medications and orders on 5/21/26: At 4:00 PM, pantoprazole (used to decrease the amount of acid the stomach produces) delayed release 40 mg tablet, give 1 tablet daily; levothyroxine (used to treat low thyroid hormone by replacing the thyroxine the body lacks) 137 mcg, give 1 tablet daily. At 5:00 PM, metformin 500 mg, give 1 tablet twice daily; midodrine 5 mg, give 1 tablet three times daily. At 6:00 PM, metoprolol succinate extended release 50 mg tablet, give 1 tablet twice daily. The midodrine required a blood pressure to be taken prior to the administration and metoprolol succinate required both a heart rate and blood pressure to be taken prior to the administration, which were noted to be blank for both medications. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #18 following medication omissions.Interview with Resident #18 on 6/23/26 at 11:14 AM identified he/she could not recall not being administered medications on 5/21/26.11. Resident #20's diagnoses included Atrial Fibrillation (AFIB), urinary retention, chronic interstitial cystitis with hematuria (bladder pain syndrome with blood in the urine), visual hallucinations, restlessness and agitation and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #20 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and required substantial assistance for bed mobility and was dependent on staff for transfers.The RCP dated 5/15/26 identified Resident #20 had AFIB and was prescribed blood thinners, had the potential for alteration in elimination due to incontinence, constipation, and urinary retention and had the potential for alteration in mood and/or behavior and displays behaviors such as yelling out and talking to self and can present as agitated and accusatory. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #20 was omitted the following medications and orders on 5/21/26: At 4:30 PM, methenamine hippurate (a urinary antiseptic used to prevent urinary tract infections) 1 gram (gm), give 1 tablet twice daily; trazodone 50 mg, give 25 mg (0.5 tablet) daily in the evening; ascorbic acid 250 mg, give 500 mg (2 tablets) twice daily. At 5:00 PM, Eliquis 5 mg, give 1 tablet twice daily; sennosides-docusate sodium (for the treatment of constipation) 8.6-50 mg, give 1 tablet twice daily; ferrous sulfate (iron supplement) 324 mg delayed release tablet, give 1 tablet twice daily. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #20 following medication omissions.Interview with Resident #20 on 6/23/26 at 11:26 AM identified he/she could not recall not being administered medications on 5/21/26.12. Resident #22's diagnoses included Congestive Heart Failure (CHF), hypertension, hypotension, polyneuropathy, chronic pain, anxiety disorder and adjustment disorder with depressed mood.The 5-day MDS assessment dated [DATE] identified Resident #22 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), and was dependent on staff for bed mobility and transfers.The RCP dated 4/21/26 identified Resident #22 had a history of seizures, was at risk for cardiac/pulmonary complications secondary to diagnoses of ischemic heart disease, hypertension, CHF, anemia and chronic chest pain and had chronic generalized pain due to arthritis, polyneuropathy and chest pain. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #22 was omitted the following medications and orders on 5/21/26: At 5:00 PM, carvedilol (used to treat hypertension and manage CHF) 6.25 mg, give 1 tablet twice daily. At 8:00 PM, gabapentin 600 mg, give 1 tablet three times daily.The May 2026 eMAR identified levetiracetam 500 mg, give 1 tab every twelve (12) hours and melatonin (used to treat insomnia and help one sleep) 3 mg, give 2 tablets (6 mg) daily at bedtime, at 9:00 PM, but neither the levetiracetam nor the melatonin were signed off as administered on 5/21/26 at 9:00 PM. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #22 following medication omissions.Interview with Resident #22 on 6/23/26 at 10:40 AM identified he/she could not recall not being administered medications on 5/21/26.13. Resident #24's diagnoses included dementia with behavioral disturbances, type II diabetes mellitus, unspecified abnormal involuntary movements, hypertension, Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, schizoaffective disorder, bipolar type, and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #24 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10) and was independent with bed mobility and transfers.The RCP dated 5/11/26 identified Resident #24 had diabetes and was at risk for hypo and hyper glycemic episodes and was insulin dependent, had pain and chest pain and the potential for alteration in mood and/or behavior due to multiple diagnoses and a history of impulsive behavior, violent behavior and accusatory behavior. Interventions included administering prescribed medication and evaluating for the effectiveness. The Administration Compliance Report dated 5/21/26 identified Resident #24 was omitted the following medications and orders on 5/21/26: At 5:00 PM, benztropine (used to treat Parkinson's disease and manage symptoms caused by antipsychotic medications) 0.5 mg, give 1 tablet twice daily; Humalog (fast acting) insulin 100 units per mL, give 5 units with meals; metformin 1000 mg, give 1 tablet twice daily. At 8:00 PM, divalproex delayed release sprinkles 125 mg, give 8 capsules (1000 mg) three times daily; escitalopram oxalate (used to treat depression) 20 mg, give 1 tablet daily; tamsulosin 0.4 mg, give 1 capsule daily; trazodone 150 mg, give 1 tablet daily at bedtime. At 8:30 PM, propranolol 10 mg, give 3 tablets (30 mg) twice daily.Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #24 following medication omissions.Although attempted, Resident #24 was unable to be interviewed.14. Resident #26's diagnoses included hypertension, atrial fibrillation, gastrostomy status, seizures, pain, contractures of muscles, abnormal involuntary movements, depression and bipolar disorder. The quarterly MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9), and was dependent on staff for bed mobility and transfers.The RCP dated 5/15/26 identified Resident #26 utilized a gastrostomy tube (g-tube) for feeding and medications as needed, was at risk for cardiovascular events and was on blood thinners and had the potential for alteration in mood and/or behavior due to diagnoses of borderline personality disorder, bipolar disorder, depression, social phobia, and restlessness and agitation. Interventions included administering medications as ordered and monitoring for side effects.The Administration Compliance Report dated 5/21/26 identified Resident #26 was omitted the following medications and orders on 5/21/26: At 5:00 PM, Eliquis 5 mg, give 1 tablet via Gastric tube (G-tube) twice daily; gabapentin 100 mg, give 2 capsules (200 mg) via G-tube three times daily; metoprolol tartrate 25 mg, give 0.5 tablet (25 mg) via G-tube twice daily. At 5:30 PM, levetiracetam 500 mg, give 1 tablet via G-tube twice daily. At 8:00 PM, clonazepam 0.5 mg, give 1 tablet via G-tube daily; valproic acid solution 250 mg per 5 mL, give 5 mL via G-tube every six (6) hours.The May 2026 eMAR identified the tube feeding, Peptamen AF liquid 0.0756 gram- 1.2 kilocalorie (kcal) per mL to be run at 65 mL per hour via G-tube continuously was not signed off as administered on the 3:00 PM to 11:00 PM shift on 5/21/26 and the tube feeding intake was not documented on as required; The order to flush the G-tube with 30 mL of water before and after each medication administration was not signed off as administered on the 3:00 PM to 11:00 PM shift on 5/21/26; The order to check for tube placement prior to administration of food, fluids, or medications was not signed off as administer on the 3:00 PM to 11:00 PM shift on 5/21/26.Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #26 following medication omissions Although attempted, Resident #26 was unable to be interviewed.15. Resident #27's diagnoses included dementia with behavioral disturbances, type II diabetes mellitus with hyperglycemia, hypertension, epilepsy (chronic seizure disorder with recurrent unprovoked seizures) and polyneuropathy.The annual MDS assessment dated [DATE] identified Resident #27 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8) and required supervision assistance for transfers and was independent with bed mobility.The RCP dated 5/4/26 identified Resident #27 had the potential for pain/discomfort related to general discomfort, low back pain, foot pain and diabetes mellitus, was at risk for cardiac complications due to diagnoses of hypertension and diabetes, has a mood disorder and is at risk for anxiety and/or depression. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #27 was omitted the following medications and orders on 5/21/26: At 4:00 PM, Novolog insulin 100 units per mL, follow sliding scale and administer subcutaneously before meals. At 5:00 PM, carvedilol 3.125 mg, give 1 tablet twice daily; divalproex delayed release 500 mg tablet, give 1 tablet every eight (8) hours; metformin 500 mg, give 1 tablet twice daily; trazodone 50 mg, give 0.5 tablet (25 mg) twice daily. At 6:00 PM, Novolog insulin 100 units per mL, give 26 units subcutaneously with meals. At 8:00 PM, gabapentin 800 mg, give 1 tablet three times daily. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #27 following medication omissions.Although attempted, Resident #27 was unable to be interviewed.16. Resident #28's diagnoses included muscle spasms, functional quadriplegia, chronic pain, insomnia, adult failure to thrive, moderate protein-calorie malnutrition and major depressive disorder.The quarterly MDS assessment dated [DATE] identified Resident #28 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3) and was dependent on staff for bed mobility and identified Resident #28 did not transfer or ambulate.The RCP dated 4/13/26 identified Resident #28 had Major Depressive Disorder and anorexia, had the potential for alteration in mood and/or behavior and has a history of chronic pain and osteoporosis, receives gabapentin twice daily for neuropathy, and was on tramadol and baclofen secondary to progressing contractures. Interventions included to administer medications per order, monitoring and recording effectiveness and reporting any adverse side effects.The Administration Compliance Report dated 5/21/26 identified Resident #28 was omitted the following medications and orders on 5/21/26: At 4:30 PM, gabapentin 100 mg, give 1 capsule twice daily. At 5:00 PM, house supplement, give 237 mL four times daily; liquid protein supplement, give 30 cc three times daily. At 7:30 PM, mirtazapine (for treatment of major depressive disorder) 30 mg, give 1 tablet daily at bedtime; tramadol 75 mg, give 1 tablet three times daily. At 8:30 PM, melatonin 3mg, give 2 tablets (6 mg) daily at bedtime. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #3 following medication omissions.Although attempted, Resident #28 was unable to be interviewed.17. Resident #29's diagnoses included hypertension, GERD, schizoaffective disorder, paranoid schizophrenia, major depressive disorder and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #29 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9) and required partial assistance for bed mobility and transfers.The RCP dated 2/28/26 identified Resident #29 had the potential for cardiac\pulmonary complications, secondary to diagnoses of Chronic Obstructive Pulmonary Disease (COPD), hypertension and hyperlipidemia and has behaviors related to schizophrenia, disorganized type, major depressive disorder, generalized anxiety disorder and alcohol-related dementia. Interventions included administering medications as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #29 was omitted the following medications and orders on 5/21/26: At 5:00 PM, buspirone (used to treat anxiety disorder) 10 mg, give 2 tablets (20 mg) twice daily; valproic acid 250 mg, give 1 capsule twice daily; propranolol 10 mg, give 3 tablets (30 mg) twice daily. At 8:00 PM, famotidine (reduces the amount of acid in the stomach) 40 mg, give 1 tablet daily at bedtime.The May 2026 eMAR identified the following omitted medications on 5/21/26: At 9:00 PM, pregabalin (controlled anticonvulsant and nerve pain medication) 100 mg, give 1 capsule three times daily; sertraline (used to treat depression) 50 mg, give 3 tablets (150 mg) daily; The required pain assessment that was to be completed every shift was blank on the 3:00 PM to 11:00 PM shift on 5/21/26. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.A provider note dated 5/22/26 identified they were asked to see Resident #29 following medication omissions.Interview with Resident #29 on 6/23/26 at 11:33 AM identified there was multiple occurrences when he/she did not receive medications on the 3:00 PM to 11:00 PM shift, but could not recall who the nurse was or the date the omissions occurred.18. Resident #30's diagnoses included type II diabetes mellitus, long-term use of insulin and lymphedema (build-up of lymph fluid in the body's soft tissues causing swelling in the arms and legs).The admission Observation dated 5/18/26 identified Resident #30 was alert and oriented to person, place and time with intact memory and utilized a walker for mobility and ambulation.The RCP dated 5/21/26 identified Resident #30 had diabetes. Interventions included administering medications as ordered and obtaining finger sticks for blood glucose twice daily as ordered.The Administration Compliance Report dated 5/21/26 identified Resident #29 was omitted the following orders on 5/21/26 at 8:00 PM: obtaining and monitoring blood sugar twice daily. The required blood sugar was not documented. Review of the clinical record dated 5/21/26 failed to identify that the provider was notified of the omissions.Interview with Resident #30 on 6/23/26 at 10:30 AM identified he/she recalled 5/21/26, as it was a family member's birthday. Resident #30 reported he/she did not see LPN #1 that night and LPN #1 did not obtain his/her blood sugar or administer medications including alprazolam and pregabalin which resulted in Resident #30 having a panic attack and pain overn

Based on review of the clinical record, facility documentation, facility policy and interviews for seven (7) of eighteen (18) sampled residents (Residents #6, 11, 13, 23, 26, 27 and 30) reviewed for neglect, the facility failed to ensure Resident Care Conferences (RCCs) were completed at least quarterly. The findings include:1. Resident #6's diagnoses included dementia with behavioral disturbances, repeated falls, schizophrenia, anxiety disorder and adult failure to thrive.The quarterly MDS assessment dated [DATE] identified Resident #6 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3) and was dependent for personal hygiene and transfers.Review of the clinical record from 1/29/26 through 3/28/26 failed to identify an RCC was scheduled or held for Resident #6 following the 1/29/26 MDS.The annual MDS assessment dated [DATE] identified Resident #6 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3) and was dependent for personal hygiene and transfers.Review of the clinical record from 3/29/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #6 following the 3/29/26 MDS.2. Resident #11's diagnoses included type II diabetes mellitus, chronic kidney disease, dependence on renal dialysis, unspecified convulsions (involuntary muscle shaking or spasms but the exact cause or seizure type has not been identified) and acute embolism and thrombosis of the deep veins of the right proximal lower extremity (clotting of blood in the deep vein of the upper portion of the right leg).An RCC sign-in sheet identified an RCC was held for Resident #11 on 12/18/25.The quarterly MDS assessment dated [DATE] identified Resident #11 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was dependent for bed mobility and transfers.Review of the clinical record from 2/17/26 through 3/27/26 failed to identify an RCC was scheduled or held for Resident #11 following the 2/17/26 MDS.The annual MDS assessment dated [DATE] identified Resident #11 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and required substantial assistance for bed mobility and was dependent for transfers.Review of the clinical record from 3/28/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #11 following the 3/28/26 MDS.3. Resident #13's diagnoses included spastic hemiplegia affecting left nondominant side (a neurological condition where muscle stiffness and weakness occur on the left side of the body due to right-brain damage), chronic pain, type II diabetes mellitus and gastro-esophageal reflux disease.An RCC sign-in sheet identified an RCC was held for Resident #13 on 2/5/26.The annual MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), was independent with bed mobility and was dependent on staff for transfers.Review of the clinical record from 4/9/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #13 following the 4/9/26 MDS.4. Resident #23's diagnoses included Parkinson's disease, abnormal voluntary movements and restlessness and agitation.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) and required substantial assistance for transfers and was independent with bed mobility.Review of the clinical record from 2/23/26 through 5/23/26 failed to identify an RCC was scheduled or held for Resident #23 following the 2/23/26 MDS.A quarterly MDS dated [DATE] for Resident #23 had not yet been completed as of 6/24/26.Review of the clinical record from 5/24/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #23.5. Resident #26's diagnoses included hypertension, atrial fibrillation, gastrostomy status, seizures, pain, contractures of muscles, abnormal involuntary movements, depression and bipolar disorder.An RCC sign-in sheet identified an RCC was held for Resident #26 on 2/2/26.The quarterly MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9) and was dependent on staff for bed mobility and transfers.Review of the clinical record from 4/27/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #26 following the 4/27/26 MDS.6. Resident #29's diagnoses included hypertension, GERD, schizoaffective disorder, paranoid schizophrenia, major depressive disorder and anxiety disorder.An RCC sign-in sheet identified an RCC was held for Resident #29 on 2/5/26.The quarterly MDS assessment dated [DATE] identified Resident #29 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9) and required partial assistance for bed mobility and transfers.Review of the clinical record from 2/28/26 through 5/30/26 failed to identify an RCC was scheduled or held for Resident #29 following the 2/28/26 MDS.A quarterly MDS dated [DATE] for Resident #29 had not yet been completed as of 6/24/26.Review of the clinical record from 5/31/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #29. 7. Resident #30 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, long-term use of insulin and lymphedema (build-up of lymph fluid in the body's soft tissues causing swelling in the arms and legs).Review of the clinical record from 5/18/26 through 5/23/26 failed to identify a 72-hr RCC was scheduled or held for Resident #30 following the 5/18/26 admission.The admission MDS assessment dated [DATE] identified Resident #30 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and required substantial assistance for bed mobility and was dependent on staff for transfers.Review of the clinical record from 5/24/26 through 6/24/26 failed to identify an RCC was scheduled or held for Resident #30 following the 5/24/26 MDS.Interview with the MDS Nurse on 6/24/26 at 10:51 AM identified social services typically scheduled RCCs, but the facility lacked a social worker since 5/15/26. RCCs must be completed quarterly and within seven days of each resident's MDS ARD. The MDS Nurse reported being behind on MDS assessments and therefore unable to assist with scheduling the RCCs.Interview with the DON and Regional Nurse on 6/24/26 at 3:13 PM identified a new facility social worker started the week of 6/22/26. They reported RCCs should be completed at least quarterly and within seven days of each resident's MDS ARD, and they were unaware RCCs were not being held consistently for all residents.Review of the Resident Participation in Care Planning policy dated 9/1/22 directed, in part, the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. Facility staff supports and encourages resident/representative participation in the care planning process by: ensuring that residents, representatives and families understand the care planning process; holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best; providing sufficient notice in advance of meeting; planning for enough time for exchange of information and decision making. A comprehensive care plan is developed within 7-days of completing the resident assessment. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. The social service director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: the date, time and location of the conference; the name of each person contacted and the date he or she was contacted; the method of contact; input from the resident or representative if they are not able to attend; refusal of participation, if applicable; the date and signature of the individual making contact.

Based on review of the clinical record, facility documentation, facility policy and interviews for nineteen (19) of twenty nine (29) sampled residents (Residents #3, 4, 8, 9, 10, 11, 13, 15, 16, 17, 18, 20, 22, 24, 26, 27, 28, 29, 30) reviewed for neglect, the facility failed to ensure that the residents were provided social services support timely after alleged neglect occurred within the facility. Specifically, LPN #1 repeatedly left the assigned unit for long periods without notifying staff, and failed to ensure resident medications and treatments were administered per physician's orders resulting in significant medication errors. The findings include:The Reportable Event (RE) dated 5/21/26 identified throughout the 3:00 PM to 11:00 PM shift, LPN #1 was off the unit multiple times due to feeling unwell. At approximately 11:00 PM, staff found LPN #1 lethargic in the employee bathroom with suspected drug paraphernalia in her possession. Emergency Medical Services (EMS) arrived, LPN #1 was removed from the schedule pending investigation and twenty-two (22) residents were identified to have been omitted medications and/or treatments during the shift. The Medical Director was notified, and assessments were completed on the affected residents with no adverse effects identified. The RE was classified as neglect.1.Resident #4's diagnoses included chronic pancreatitis (progressive inflammation of the pancreas), central pain syndrome and type II diabetes mellitus.The quarterly MDS assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 6) and required substantial assistance with bed mobility.The RCP dated 5/11/26 identified Resident #4 had diabetes mellitus with diabetic neuropathy and was insulin dependent, required a therapeutic diet related to compromised endocrine function and had the potential for chronic pain secondary to chronic pancreatitis. Interventions included administering medications as ordered and monitoring and recording effectiveness.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #4 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #4 was unable to be interviewed.2. Resident #8's diagnoses included hypertension, benign prostatic hyperplasia (enlargement of the prostate gland), adult failure to thrive, anxiety disorder and major depressive disorder.The annual MDS assessment dated [DATE] identified Resident #8 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), was independent with bed mobility and required supervision assistance for transfers.The RCP dated 4/6/26 identified Resident #8 had weight loss over the last month, was at risk for cardiac complications secondary to diagnoses of cerebral infarction, hyperlipidemia and orthostatic hypotension. Interventions included administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #8 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #8 was unable to be interviewed.3. Resident #9's diagnoses included Congestive Heart Failure (CHF), chronic left lower quadrant abdominal spasms, diverticulitis (inflammation of irregular bulging pouches in the wall of the large intestine), retention of urine, anxiety disorder and major depressive disorder.The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) and required setup assistance for bed mobility and was independent with transfers.The RCP dated 5/20/26 identified Resident #9 had heart failure, a history of urinary retention and a history of diverticulitis. Interventions included administering medications such as beta blockers, diuretics and antibiotics as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #9 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #9 on 6/23/26 at 11:22 AM identified he/she could not recall receiving medications on 5/21/26. Resident #9 reported LPN #1 was consistently rude to him/her and called him/her crazy on numerous occasions so Resident #9 tried to have as little contact with LPN #1 as possible.4. Resident #10's diagnoses included chronic pain, atrial fibrillation (irregular, rapid heart rhythm) and depression.The quarterly MDS assessment dated [DATE] identified Resident #10 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13) and required total assistance for transfers and was independent with bed mobility.The RCP dated 2/11/26 identified Resident #10 was at risk for impaired skin integrity due to Eliquis use and had a diagnosis of diabetes mellitus. Interventions included administering medications per orders and monitoring for any side effects.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #10 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #10 on 6/23/26 at 10:46 AM identified he/she remembered not receiving medications on 5/21/26. Resident #10 reported having increased pain and difficulty sleeping, which was abnormal for him/her, but denied reporting the incident to anyone.5. Resident #11's diagnoses included type II diabetes mellitus, chronic kidney disease, dependence on renal dialysis, unspecified convulsions (involuntary muscle shaking or spasms but the exact cause or seizure type had not been identified) and acute embolism and thrombosis of the deep veins of the right proximal lower extremity (clotting of blood in the deep vein of the upper portion of the right leg).The annual MDS assessment dated [DATE] identified Resident #11 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and required substantial assistance for bed mobility and was dependent on staff for transfers.The RCP dated 3/29/26 identified Resident #11 had the potential for injury due to seizure disorder, had the potential for pain/discomfort due to generalized discomfort and lymphedema wounds (slow- healing sores due to fluid buildup) and had a history of Deep Vein Thrombosis (DVT) and was on blood thinners. Interventions included administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #11 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #11 on 6/24/26 at 10:34 AM identified he/she could not recall if they were administered medications on 5/21/26.6. Resident #13's diagnoses included spastic hemiplegia affecting left nondominant side (a neurological condition where muscle stiffness and weakness occurred on the left side of the body due to right-brain damage), chronic pain, type II diabetes mellitus and gastro-esophageal reflux disease.The annual MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), was independent with bed mobility and was dependent on staff for transfers.The RCP dated 5/6/26 identified Resident #13 had the potential for pain/discomfort related to polyneuropathy, had diabetes mellitus and was at risk for hyper/hypoglycemia. Interventions included administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #13 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #13 on 6/23/26 at 10:51 AM identified he/she could not recall receiving medications on the 3:00 PM to 11:00 PM shift on 5/21/26 but reported LPN #1 was consistently late administering medications and Resident #13 often called the nursing supervisor to complain. Resident #13 identified he/she was often in increased pain after LPN #1 worked due to getting his/her medications so late.7. Resident #15's diagnoses included seizures, aphasia following cerebral infarction (language disorder caused by damage to the brain's language centers following a stroke), hypercholesterolemia (high cholesterol levels) and depressive disorder.The annual MDS assessment dated [DATE] identified Resident #15 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), and was independent with bed mobility and transfers.The RCP dated 3/16/26 identified Resident #15 had the potential for seizures. Interventions included monitoring lab values for a therapeutic level of anticonvulsant medications.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #15 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #15 was unable to be interviewed.10. Resident #17's diagnoses included dementia without behavioral disturbances, restlessness and agitation, palliative care, major depressive disorder and schizoaffective disorder, depressive type.The annual MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 6) and was dependent on staff for bed mobility and transfers.The RCP dated 4/13/26 identified Resident #17 had the potential for pain/discomfort related to general discomfort, had the potential for alteration in mood and/or behavior, had a history of schizoaffective disorder and depressive disorder and was on hospice care. Interventions included evaluating for pain/discomfort as indicated and administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #17 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #17 was unable to be interviewed.11. Resident #18's diagnoses included hypertension, hypothyroidism, type II diabetes mellitus with hyperglycemia and major depressive disorder.The annual MDS assessment dated [DATE] identified Resident #18 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was independent with bed mobility, transfers and ambulation.The RCP dated 4/16/26 identified Resident #18 had a history of both hypotension and hypertension and was at risk for pain. Interventions included monitoring vital signs as necessary and administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #18 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #18 on 6/23/26 at 11:14 AM identified he/she could not recall receiving medications on 5/21/26.12. Resident #20's diagnoses included Atrial Fibrillation (AFIB), urinary retention, chronic interstitial cystitis with hematuria, visual hallucinations, restlessness and agitation and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #20 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), and required substantial assistance for bed mobility and was dependent on staff for transfers.The RCP dated 5/15/26 identified Resident #20 had AFIB and took medications that left the blood a little on the thinner side, had the potential for alteration in elimination due to incontinence, constipation, and urinary retention and had the potential for alteration in mood and/or behavior and displayed behaviors such as yelling out and talking to self and could present as agitated and accusatory. Interventions included administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #20 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #20 on 6/23/26 at 11:26 AM identified he/she could not recall receiving medications on 5/21/26.13. Resident #22's diagnoses included Congestive Heart Failure (CHF), hypertension, hypotension, polyneuropathy, chronic pain, anxiety disorder and adjustment disorder with depressed mood.The 5-day MDS assessment dated [DATE] identified Resident #22 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and was dependent on staff for bed mobility and transfers.The RCP dated 4/21/26 identified Resident #22 had a history of seizures, was at risk for cardiac/pulmonary complications secondary to diagnoses of ischemic heart disease, hypertension, CHF, anemia and chronic chest pain and had chronic generalized pain due to arthritis, polyneuropathy and chest pain. Interventions included administering medications as ordered. Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #22 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #22 on 6/23/26 at 10:40 AM identified he/she could not recall receiving medications on 5/21/26.14. Resident #24's diagnoses included dementia with behavioral disturbances, type II diabetes mellitus, unspecified abnormal involuntary movements, hypertension, Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, schizoaffective disorder, bipolar type, and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #24 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10), and was independent with bed mobility and transfers.The RCP dated 5/11/26 identified Resident #24 had diabetes and was at risk for hypo and hyper glycemic episodes and was insulin dependent, had pain and chest pain and had the potential for alteration in mood and/or behavior due to multiple diagnoses and a history of impulsive behavior, violent behavior and accusatory behavior. Interventions included administering prescribed medication and evaluating for the effectiveness.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #24 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #24 was unable to be interviewed.15. Resident #26's diagnoses included hypertension, atrial fibrillation, gastrostomy status, seizures, pain, contractures of muscles, abnormal involuntary movements, depression and bipolar disorder.The quarterly MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9), and was dependent on staff for bed mobility and transfers.The RCP dated 5/15/26 identified Resident #26 utilized a gastrostomy tube for feeding and medications as needed, was at risk for cardiovascular events and was on blood thinners and had the potential for alteration in mood and/or behavior due to diagnoses of borderline personality disorder, bipolar disorder, depression, social phobia, and restlessness and agitation. Interventions included administering medications as ordered and monitoring for side effects.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #26 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #26 was unable to be interviewed.16. Resident #27's diagnoses included dementia with behavioral disturbances, type II diabetes mellitus with hyperglycemia, hypertension, epilepsy and polyneuropathy.The annual MDS assessment dated [DATE] identified Resident #27 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8) and required supervision assistance for transfers and was independent with bed mobility.The RCP dated 5/4/26 identified Resident #27 had the potential for pain/discomfort related to general discomfort, low back pain, foot pain and diabetes mellitus, was at risk for cardiac complications due to diagnoses of hypertension and diabetes, had a mood disorder and was at risk for anxiety and/or depression. Interventions included administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #27 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #27 was unable to be interviewed.17. Resident #28's diagnoses included muscle spasms, functional quadriplegia, chronic pain, insomnia, adult failure to thrive, moderate protein-calorie malnutrition and major depressive disorder.The quarterly MDS assessment dated [DATE] identified Resident #28 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), and was dependent on staff for bed mobility and did not transfer or ambulate.The RCP dated 4/13/26 identified Resident #28 had Major Depressive Disorder and anorexia, had the potential for alteration in mood and/or behavior and had a history of chronic pain and osteoporosis, received gabapentin twice daily for neuropathy, and was on tramadol and baclofen secondary to progressing contractures. Interventions included administering medications per order, monitoring and recording effectiveness and reporting any adverse side effects.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #28 regarding the neglect incident and omitted medications on 5/21/26.Although attempted, Resident #28 was unable to be interviewed.18. Resident #29's diagnoses included hypertension, GERD, schizoaffective disorder, paranoid schizophrenia, major depressive disorder and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #29 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 9), and required partial assistance for bed mobility and transfers.The RCP dated 2/28/26 identified Resident #29 had the potential for cardiac/pulmonary complications secondary to diagnoses of COPD, hypertension and hyperlipidemia and had behaviors related to schizophrenia, disorganized type, major depressive disorder, generalized anxiety disorder and alcohol-related dementia. Interventions included administering medications as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #29 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #29 on 6/23/26 at 11:33 AM identified there had been multiple occurrences when he/she had not received medications on the 3:00 PM to 11:00 PM shift, but could not recall who the nurse was or the date the omissions occurred. Resident #29 identified when LPN #1 worked, he/she received medications altogether at once, and it was very late into the shift. Resident #29 reported he/she always had pain when LPN #1 worked and when he/she complained of pain to LPN #1, she had been dismissive.19. Resident #30's diagnoses included type II diabetes mellitus, long-term use of insulin and lymphedema.The admission Observation dated 5/18/26 identified Resident #30 was alert and oriented to person, place and time with intact memory and utilized a walker for mobility and ambulation.The RCP dated 5/21/26 identified Resident #30 had diabetes. Interventions included administering medications as ordered and obtaining finger sticks for blood glucose twice daily as ordered.Review of social service notes from 5/21/26 through 5/27/26 failed to identify social worker interaction with Resident #30 regarding the neglect incident and omitted medications on 5/21/26.Interview with Resident #30 on 6/23/26 at 10:30 AM identified he/she recalled 5/21/26, as it was a family member's birthday. Resident #30 reported he/she did not see LPN #1 that night and LPN #1 did not take his/her blood sugar or administer medications including alprazolam and pregabalin which resulted in Resident #30 having a panic attack and pain overnight. Resident #30 identified he/she was in so much pain they were unable to move in the morning, but when he/she complained to another nurse, they reported the medications were signed off.Interview with the Director of Nursing (DON) and the Regional Nurse on 6/24/26 at 3:10 PM identified following any neglect or abuse situations, all residents identified as being involved should be followed by social services daily for 3-days to provide support. They identified there was no social worker employed full-time at the facility at the time.Review of the Residents Right to Freedom from Abuse, Neglect and Exploitation policy (undated) directed, in part, the facility is to ensure residents are free from abuse and neglect and staff must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion against any resident. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including, but not limited to: Taking steps to prevent further abuse, reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations, conducting a thorough investigation of the alleged violation, taking appropriate corrective action and the facility will revise the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall: Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported in the proper time frame pursuant to this policy, have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation or mistreatment while the investigation is in progress.

Based on a review of the clinical record, facility documentation, facility policies, and interviews, the facility failed to complete a thorough investigation following an incident in which a licensed nurse left the first floor long hall unit multiple times for long periods during the shift, resulting in omitted medications. Specifically, the facility did not interview all 29 residents on the unit to determine whether they received their medications as scheduled, experienced any signs or symptoms related to missed doses or observed any unusual behavior from the licensed nurse. The findings include: The Reportable Event (RE) dated 5/21/26 identified throughout the 3:00 PM to 11:00 PM shift, LPN #1 was off the unit multiple times due to feeling unwell. At approximately 11:00 PM, staff found LPN #1 lethargic in the employee restroom with suspected drug paraphernalia in her possession. Emergency Medical Services (EMS) arrived, LPN #1 was removed from the schedule pending investigation and twenty-two (22) residents were identified to have been omitted medications and/or treatments during the shift. The Medical Director was notified, and assessments were completed for the affected residents with no adverse effects identified. Additionally, the RE was reported as neglect.Review of the facility Accident and Incident (A&I) form dated 5/21/26 failed to identify statements were obtained from the residents residing on the first floor long hall unit on 5/21/26.A statement from LPN #3 (undated) identified on 5/22/26 she conducted interviews with Residents #7, 13, 14, 15, 24 and 28 regarding medication administration by LPN #1 on 5/21/26. All the residents reported they received their medications as scheduled and voiced no concerns regarding medication administration.Review of the facility census dated 5/21/26 identified the first floor long hall unit housed 29 residents. Only six (6) of the twenty-nine (29) residents were interviewed.Interview with LPN #3 on 6/18/26 at 1:01 PM identified no one directed her to interview the residents on the first floor long hall unit following the incident on 5/21/26 but she did so to help identify what happened. She reported selecting the residents she did because they were alert and oriented but did not conduct further interviews because she assumed someone else would conduct thorough interviews with all the residents.Interview with the Director of Nursing (DON) and the Regional Nurse on 6/24/26 at 3:10 PM identified all 29 residents residing on the first floor long hall unit should have been interviewed following the incident to include if they received their medications during the 3:00 PM to 11:00 PM shift on 5/21/26, if they had any signs and symptoms related to missed doses or observed any unusual behavior from LPN #1. They identified the statements should have been obtained and included in the A&I.Review of the Incidents and Accidents- Investigating and Reporting policy dated 11/29/24 directed, in part, all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on facility premises shall be investigated and reported to the Administrator.Review of the Residents Right to Freedom from Abuse, Neglect and Exploitation policy (undated) directed, in part, staff must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion against any resident. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including, but not limited to: Taking steps to prevent further abuse, reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations, conducting a thorough investigation of the alleged violation, taking appropriate corrective action and the facility will revise the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall: Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported in the proper time frame pursuant to this policy, have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation or mistreatment while the investigation is in progress.

Based on a review of clinical records, facility documentation, facility policy, and staff interviews for two (2) of four (4) sampled residents (Residents #1 and #30) reviewed for pain management, the facility failed to ensure pain was adequately assessed, pain medications were administered and documented as ordered, and required post administration pain re evaluations were completed. Specifically, the facility failed to ensure as needed (PRN) opioid pain medication was documented as administered, monitored for effectiveness, and that pain reevaluations were completed for Resident #1 and failed to ensure scheduled pain medication was administered and accurately documented for Resident #30. These failures resulted in inadequate pain management, inaccurate medication documentation, missed reassessments, and increased risk for adverse outcomes. The findings include:1. Resident #1's diagnoses included malignant neoplasm of the bone (bone cancer), malignant neoplasm of the hypopharynx (an aggressive cancer to the lower part of the throat) and depression.The admission Observation assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time, memory was intact and required assistance with Activities of Daily Living (ADLs). Further, it identified Resident #1 reported occasional back pain.A physician's order dated 4/28/26 directed to administer oxycodone 20 milligrams (mg) every three (3) hours for severe pain as needed.A physician's order dated 4/28/26 directed to administer Oxycontin extended release tablet 20 mg daily at bedtime.A physician's order dated 4/29/26 directed to administer Oxycontin extended release tablet 10 mg twice daily at 6:00 AM and 2:00 PM (to be administered with 15 mg tablet for a total of 25 mg).A physician's order dated 4/29/26 directed to administer Oxycontin extended release tablet 15 mg twice daily at 6:00 AM and 2:00 PM (to be administered with 10 mg tablet for a total of 25 mg).The Resident Care Plan (RCP) dated 4/29/26 identified Resident #1 had pain/discomfort and required palliative care related to cancer diagnoses. Interventions included assessing for pain and intervening as necessary, observing for nonverbal signs of pain and administering medications as ordered and assessing for effectiveness.A nurse's note by RN #4 on 5/21/26 at 3:24 PM identified Resident #1 was out of bed participating with therapy when LPN #7 called her to report Resident #1 required immediate assessment due to unresponsiveness and respiratory distress. On assessment Resident #1 was hypotensive (blood pressure of 87/70) and the blood oxygen level (Sp02) was 87 percent (%) on room air. The APRN was notified and new orders were obtained to administer oxygen at fifteen (15) liters via a non-rebreather mask and PRN Narcan (a medication that rapidly reverses the effects of opioid overdoses) was administered to both nostrils. Vital signs were reassessed and both the blood pressure and SP02 levels improved. Emergency Services was called and arrived at 1:56 PM and Resident #1 was transferred to the Emergency Department (ED) for further evaluation.Review of the May 2026 Medication Administration Record (MAR) identified Resident #1 had been administered both the 6:00 AM and 2:00 PM doses of Oxycontin prior to the incident on 5/21/26. The MAR failed to identify the PRN oxycodone had been administered to Resident #1 on 5/21/26 prior to the incident.The Controlled Proof-of-use/Disposition Form (used to track the administration, waste and reconciliation of controlled substances and proves that a specific dose was administered to a resident or properly disposed of) for Resident #1's oxycodone 20 mg, identified one (1) tablet of oxycodone 20 mg was signed out at 8:30 AM and 12:00 PM on 5/21/26 by LPN #7. The oxycodone 20 mg was removed from stock but had not been signed out as administered in the MAR, therefore Resident #1's pain was not reevaluated following the administrations.Review of nurse's notes dated 5/21/26 failed to identify documentation related to pain.Re-review of the May 2026 MAR identified eighteen (18) doses of PRN oxycodone 20 mg had been signed as administered to Resident #1 in May.Re-review of the Controlled Proof-of-use/Disposition Form identified forty (40) doses of PRN oxycodone 20 mg had been signed out of stock for Resident #1 in May 2026.Only 18 (45 % of the doses) of the PRN oxycodone 20 mg doses that were removed from stock for Resident #1 had been documented as administered on the MAR, resulting in twenty-two (22) administrations (55 %) not receiving reevaluations of Resident #1's pain.Interview with LPN #7 on 6/24/26 at 12:53 PM identified although he administered PRN oxycodone 20 mg to Resident #1 on 5/21/26 at 8:30 AM and 12:00 PM for complaints of severe back pain, he did not document the administrations in the MAR or complete the required pain re evaluations one (1) hour afterwards. LPN #7 reported after the unresponsive episode, he failed to document the event in a nurse's note or notify RN #4 or a provider that Resident #1 had received two (2) doses of PRN oxycodone earlier in the shift.Interviews with APRN #2 on 6/24/26 at 1:34 PM and 3:04 PM identified on 5/21/26, she was in the hallway when Resident #1 was found unresponsive and responded immediately. Upon arrival, Resident #1 was seated in a bedside chair, slumped over, cyanotic, unresponsive, and breathing shallowly. She directed staff to administer oxygen, move Resident #1 to the floor, obtain vital signs, and apply the Automatic External Defibrillator; no shock was advised. Narcan was administered, and after the second spray, Resident #1 became alert. Although the PRN oxycodone was ordered every three (3) hours, she was not aware Resident #1 had been receiving it several times daily or that two (2) doses had been given during the shift before the incident. She identified this could have contributed to an overdose. APRN #2 reported that all PRN pain medication doses should be documented in the MAR and pain levels should be reassessed timely per facility policy, which could also identify adverse reactions, including preventing oversedation or unresponsiveness.Interview with the DON and Regional Nurse on 6/24/26 at 3:13 PM identified all PRN pain medications are expected to be documented in the MAR at the time they are administered. Staff are required to complete and document a pain re evaluation within one (1) hour after administering PRN pain medication. The DON and Regional Nurse reported they were unaware this process was not being followed consistently for Resident #1's PRN oxycodone and were unaware LPN #7 had administered two (2) doses of PRN oxycodone during the shift prior to Resident #1 becoming unresponsive. 2. Resident #30's diagnoses included type II diabetes mellitus, long-term use of insulin and lymphedema.A physician's order dated 5/18/26 directed to administer pregabalin (used to treat nerve pain in those with diabetes) 100 mg three times daily.The admission Observation dated 5/18/26 identified Resident #30 was alert and oriented with intact memory and utilized a walker.The RCP dated 5/21/26 identified Resident #30 had diabetes. Interventions included administering medications as ordered and obtaining blood glucose twice daily.The Reportable Event (RE) dated 5/21/26 identified throughout the 3:00 PM to 11:00 PM shift, LPN #1 was noted to be off the unit multiple times due to feeling unwell. At approximately 11:00 PM, staff found LPN #1 lethargic in the employee restroom with suspected drug paraphernalia in possession. Emergency Medical Services (EMS) arrived, LPN #1 was removed from the schedule pending investigation and twenty-two (22) residents were identified to have been omitted medications and/or treatments during the shift.Interview with Resident #30 on 6/23/26 at 10:30 AM identified he/she did not see LPN #1 on 5/21/26 and did not receive pregabalin which resulted in pain overnight. Resident #30 identified he/she reported this the following day and a nurse reported the medication was signed off.The May 2026 electronic Medication Administration Record (eMAR) identified Resident #30 had scheduled pregabalin 100 mg three times daily at 9:00 AM, 1:00 PM and 5:00 PM, which was signed off as administered by LPN #1 on 5/21/26 at 5:00 PM.The Controlled Proof-of-use/Disposition Form for Resident #30's pregabalin 100 mg identified the 5:00 PM dose of pregabalin was not signed out of stock on 5/21/26.Review of nurse's notes dated 5/21/26 failed to identify documentation of omitted medications. Interview with LPN #1 on 6/24/26 at 10:04 AM identified on 5/21/26 she administered medications and treatments but did not document them at the time as required. She stated she passed some medications, may have missed others, and could not explain the discrepancies between what she signed off in the eMAR and the disposition sheets. Following her suspension on 5/21/26, she admitted accessing the eMAR from home and signing off medications and treatments when she was not certain she administered them.Interview with the DON and the Regional Nurse on 6/24/26 at 3:10 PM identified medications should be signed out on the eMAR at the time of administration and documentation should be accurate. The eMAR should have matched the Controlled Proof-of-use/Disposition Form for Resident #30's pregabalin 100 mg and since not signed out of stock, it was not administered to Resident #30, although it should have been.Review of the Clinical Protocol for Pain policy dated 9/1/22 directed, in part, residents are assessed regularly and whenever there is a change in condition or new/worsening pain. Staff evaluate pain characteristics (location, severity, pattern) and how pain affects daily function, mood, sleep, and safety. For treatment, the physician sets individualized goals and orders appropriate pain management, using the simplest and lowest-risk regimen when possible. Medications are to be administered as ordered by the physician, and non-medication interventions (such as repositioning, heat/ice, and other comfort measures) are used alongside medication therapy. PRN pain medications are specifically monitored and evaluated. Staff are responsible for tracking use of PRN analgesics, assessing their effectiveness, and reporting patterns such as frequent or escalating use. PRN effectiveness and pain status are reassessed regularly and during routine monitoring (at least each shift and more frequently if needed for acute pain or changes). If PRN medications are required frequently or are insufficient, the physician may adjust the regimen, including scheduling medications, changing agents, or adding additional therapies. Ongoing monitoring is required to evaluate response to treatment, side effects, and overall pain control. The physician may modify or discontinue medications based on effectiveness, safety, and patient response, and may also consider dose reductions when appropriate.

Based on review of the clinical record, facility policy and interviews for eighteen (18) of twenty-two (22) sampled residents (Residents #1, 3, 4, 8, 10, 11, 13, 14, 17, 18, 20, 22, 23, 24, 26, 27, 28 and 30) reviewed for comprehensive assessments, the facility failed to ensure the resident comprehensive assessments were completed within fourteen (14) days of the Assessment Reference Date (ARD) as required. The findings include:1. The admission Minimum Data Set (MDS) assessment for Resident #1 had an ARD of 5/4/26 and was due by 5/18/26.Review of the admission MDS dated [DATE] identified it was not completed as of 6/24/26 (37-days late). 2. The admission MDS assessment for Resident #3 had an ARD of 5/1/26 and was due by 5/15/26. Review of the admission MDS dated [DATE] identified it was completed on 5/26/26 (11-days late). 3. The quarterly MDS assessment for Resident #4 had an ARD of 5/12/26 and was due by 5/26/26. Review of the quarterly MDS dated [DATE] for Resident #4 identified it was not completed as of 6/24/26 (29-days late). 4. The annual MDS assessment for Resident #8 had an ARD of 4/4/26 and was due by 4/18/26. Review of the annual MDS dated [DATE] identified it was completed on 5/5/26 (17-days late). 5. The quarterly MDS assessment for Resident #10 had an ARD of 5/14/26 and was due by 5/28/26. Review of the quarterly MDS dated [DATE] identified it was not completed as of 6/24/26 (27-days late). 6. The annual MDS assessment for Resident #11 had an ARD of 3/28/26 and was due by 4/11/26. Review of the annual MDS dated [DATE] identified it was completed on 4/27/26 (16-days late).7. The annual MDS assessment for Resident #13 had an ARD of 4/9/26 and was due by 4/23/26. Review of the annual MDS dated [DATE] identified it was completed on 5/6/26 (13-days late).8. The quarterly MDS assessment for Resident #14 had an ARD of 4/5/26 and was due to be completed by 4/19/26.Review of the quarterly MDS dated [DATE] for identified it was completed on 4/29/26 (10-days late).9. The annual MDS assessment for Resident #17 had an ARD of 4/11/26 and was due to be completed by 4/25/26.Review of the annual MDS dated [DATE] identified it was completed on 4/29/26 (4-days late).10. The annual MDS assessment for Resident #18 had an ARD of 4/15/26 and was due by 4/29/26. Review of the annual MDS dated [DATE] identified it was completed on 5/28/26 (29-days late). 11. The quarterly MDS assessment for Resident #20 had an ARD of 4/27/26 and was due by 5/11/26. Review of the quarterly MDS dated [DATE] identified it was completed on 5/15/26 (4-days late). 12. The 5-day MDS assessment for Resident #22 had an ARD of 5/10/26 and was due to be completed by 5/24/26.Review of the quarterly MDS dated [DATE] identified it was completed on 6/9/26 (30-days late).13. The quarterly MDS assessment for Resident #23 had an ARD of 5/24/26 and was due to be completed by 6/7/26.Review of the quarterly MDS dated [DATE] identified it was not completed as of 6/24/26 (17-days late).14. The quarterly MDS assessment for Resident #24 had an ARD of 5/14/26 and was due by 5/28/26. Review of the quarterly MDS dated [DATE] identified it was not completed as of 6/24/26 (27-days late). 15. The quarterly MDS assessment for Resident #26 had an ARD of 4/27/26 and was due by 5/11/26.Review of the quarterly MDS dated [DATE] identified it was completed on 5/15/26 (4-days late).16. The quarterly MDS assessment for Resident #27 was noted to have an ARD of 5/4/26 and was due to be completed by 5/18/26.Review of the quarterly MDS dated [DATE] identified it was completed on 6/22/26 (35-days late). 17. The quarterly MDS assessment for Resident #28 had an ARD of 4/8/26 and was due by 4/22/26. Review of the quarterly MDS dated [DATE] identified it was completed on 4/29/26 (7-days late).18. The admission MDS assessment for Resident #30 had an ARD of 5/24/26 and was due by 6/7/26.Review of the admission MDS dated [DATE] identified it was completed on 6/16/26 (9-days late).Interview with the MDS Nurse on 6/23/26 at 2:22 PM identified each resident MDS assessment is to be completed within 14-days of the ARD date. She reported that she was behind due to her coworker being on extended leave and many of the MDS's were overdue.Interview with the DON and Regional Nurse on 6/23/26 at 3:10 PM identified MDS assessments are to be completed for each resident at least quarterly and should be signed off as completed within 14-days of the ARD date. They identified they were unaware the MDS's were not being completed timely.Review of the MDS Assessment policy dated 2/6/26 directed, in part, the facility shall complete all MDS assessments using a comprehensive interdisciplinary approach. Information entered on the MDS must accurately reflect the resident's status during the Assessment Reference Date (ARD) look-back period and be supported by documentation contained within the medical record. The MDS Coordinator shall establish and maintain an MDS schedule, ensure assessments are completed according to federal and state requirements, monitor compliance with assessment due dates, communicate assessment schedules to interdisciplinary team members.Review of the Resident Participation in Care Planning policy dated 9/1/22 directed, in part, resident assessments are begun on the first day of admission and completed no later than the fourteenth day after admission.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had sustained a fall with major injury, the facility failed to administer pain medication at the time the injury was identified and after prior to transfer to the Emergency Department (ED) to ensure the resident was kept comfortable. The findings include:Resident #1's diagnoses included bilateral (both sides) osteoarthritis of the knees, muscle wasting and atrophy (thinning of muscle mass), and muscle weakness. A physician's order dated 11/12/25 directed to administer acetaminophen 325 milligrams (mg), two (2) tablets (650 mg), every six (6) hours as needed for generalized discomfort. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating Resident #1 had poor memory recall, required partial assistance for bed mobility and substantial assistance for transfers. The Resident Care Plan dated 11/26/25 identified that Resident #1 was at risk for pain due to diagnosis of arthritis. Interventions included offering pain medications as ordered. The nurse's note dated 11/28/25 at 4:48 AM identified that at approximately 1:40 AM Resident #1 was found on the floor, lying on his/her right side between two (2) beds. The note indicated Resident #1 was noted with a bump to the right temple area measuring 2.5 centimeters (cm) in diameter, was alert with baseline confusion, neurological signs were normal, passive range of motion was normal to all four (4) extremities and Resident #1 was showing no signs or symptoms of pain. The note identified Resident #1 was transferred back to bed with an assist of two (2) staff, an ice pack was applied to the head injury and the Advanced Practice Registered Nurse (APRN) was notified who advised to call Resident #1's Power of Attorney (POA) and ask if they wanted Resident #1 transferred to the hospital for evaluation. The POA was called twice, and voicemails were left requesting a call back to the facility. The Occupational Therapy (PT) encounter note dated 11/28/25 identified Resident #1 was seen in the morning and was noted with lethargy, eye closing and left lateral (to the side) lean while seated in the wheelchair. The note indicated the leg rests were removed in preparation of standing tasks, however Resident #1 was noted with edema to the right outer ankle and was observed grimacing with touch when removing the left leg rest. The note identified the standing tasks were not completed due to Resident #1 presenting with lower extremity pain and possible injury and nursing was notified and assessed Resident #1. The Physical Therapy (PT) encounter note dated 11/28/25 identified Resident #1 was noted leaning to the left with an inverted (turned inwards) right ankle while seated in the wheelchair. The note indicated Resident #1 had facial grimacing with gentle ankle palpation due to pain and nursing was aware. The nurse's note dated 11/28/25 at 1:35 PM identified the Assistant Director of Nursing reached out to the POA again with no response. The note indicated he assessed Resident #1 as part of a post fall assessment and Resident #1 showed facial grimacing when the right femur and ankle were touched and were noted to be painful and tender but without swelling. The note identified he contacted the APRN immediately to report his assessment and new orders were obtained for bilateral lower extremity x-rays and Resident #1 was not to be transferred to the hospital. Review of the November 2025 Medication Administration Record (MAR) failed to identify the acetaminophen was administered to Resident #1 for pain relief following the staff observations when Resident #1 had showed signs and symptoms of pain. The diagnostic imaging reports identified the x-rays of the right ankle, left ankle and bilateral hips and pelvis were obtained on 11/28/25. The right and left ankle x-rays results were negative for acute fractures. The bilateral hips and pelvis x-ray results on 11/29/25 at 4:44 AM showed an acute right femoral neck fracture (the upper thigh bone that connects the rounded ball of the hip joint to the main shaft of the bone). The nurse's note dated 11/29/25 at 8:13 AM identified the x-ray results of the bilateral hips and pelvis were made available on 11/29/25 at 4:44 AM and showed an acute right femoral neck fracture with complete displacement (when the broken pieces of the femur significantly shift out of alignment and can disrupt blood supply and lead to severe pain and the inability to bear weight). The note indicated the POA was notified of the results and the impending transfer to the Emergency Department (ED). The facility's hospital transfer form dated 11/29/25 identified Resident #1 was medicated with the acetaminophen 650 mg at 8:44 AM prior to the transfer to the hospital. Although the transfer note indicated Resident #1 had been medicated with the acetaminophen, review of the November 2025 Medication Administration Record failed to reflect documentation the acetaminophen was administered on 11/29/25 prior to the ED transfer. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #3, on 12/18/25 at 11:57 AM identified on 11/28/25 therapy notified him Resident #1 was unable to stand so he immediately notified the ADON, who was the nursing supervisor that day. LPN #3 explained although the ADON came to immediately assess Resident #1, the ADON did not request he administer the acetaminophen to Resident #1 for pain. LPN #3 stated he did not observe Resident #1 with signs and symptoms of pain therefore he did not administer the acetaminophen. Interview with the ADON on 12/18/25 at 1:53 PM identified on 11/28/25 when he assessed Resident #1, Resident #1 was grimacing when the right leg was checked for range of motion and when he touched the right hip, Resident #1 pulled away. The ADON stated he did not administer any pain medications to Resident #1 and LPN #3 reported he did not administer the acetaminophen. The ADON identified when he offered Resident #1 the acetaminophen and Resident #1 refused, he did not document pain management in his note. The ADON identified although Resident #1 was cognitively impaired, he did not reapproach Resident #1 and offer the acetaminophen again or notify LPN #3 Resident #1 needed to be treated for pain. Interview with the APRN on 12/18/25 at 2:00 PM identified Resident #1 should have been medicated for pain when Resident #1 was first noted to be grimacing due to possible injuries. The APRN explained Resident #1 was not a good historian due to his/her cognitive status and if Resident #1 refused the acetaminophen, nursing should have reapproached and encouraged Resident #1 to take the medication for comfort. Interview with LPN #4 on 12/18/25 at 2:34 PM identified she worked the 7AM-3PM shift on 11/29/25, and although she administered Resident #1 the morning medications, she did not administer acetaminophen as she was unaware Resident #1 had a fracture or was being transferred to the ED until after Resident #1 was already on the stretcher and being rolled down the hall. LPN #4 indicated the 7AM-3PM nursing supervisor, Registered Nurse (RN) #2, asked her as Resident #1 was leaving if she had administered pain medication and she explained she did not because she did not observe Resident #1 in pain. LPN #4 identified that had she known Resident #1 had a fracture she would have pre-medicated Resident #1 prior to transfer to prevent discomfort while being moved out of bed onto the stretcher. Interview with the Director of Nursing (DON) on 12/18/25 at 3:11 PM identified Resident #1 should have been medicated for pain when he/she was observed with signs and symptoms of pain and if Resident #1, who was cognitively impaired, refused the medication, staff should have reapproached Resident #1 and encouraged him/her to take the medication for pain relief. The DON indicated if licensed nursing staff administered the acetaminophen, it should have been documented as administered at the time of administration and that it should not be documented that the resident received medication for pain if it was not actually administered. Review of the Clinical Protocol for Pain policy dated 09/01/22 directed, in part, that the physician and staff will identify individuals who have pain or who are at risk for having pain, which includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacological treatments. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions. The staff will reassess the individual's pain and related consequences at regular intervals; at least every shift for acute pain. Review of the Charting Documentation policy dated 09/01/22 directed, in part, that all services provided to the resident and any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective, complete and accurate.

Based on clinical record reviews, facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls with major injury, the facility failed to follow through with obtaining the x-ray reports when the diagnostic provider failed to notify the facility immediately of a positive finding which resulted in a delay of care. The findings include:Resident #1's diagnoses included bilateral (both sides) osteoarthritis of the knees, muscle wasting and atrophy (thinning of muscle mass) and muscle weakness. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating Resident #1 had poor memory recall, required partial assistance for bed mobility and substantial assistance for transfers. The nurse's note dated 11/28/25 at 4:48 AM identified that at approximately 1:40 AM Resident #1 was found on the floor, lying on his/her right side between two (2) beds. The note indicated Resident #1 was noted with a bump to the right temple area measuring 2.5 centimeters (cm) in diameter, was alert with baseline confusion, neurological signs were normal, passive range of motion was normal to all four (4) extremities and Resident #1 was showing no signs or symptoms of pain. The note identified Resident #1 was transferred back to bed with an assist of two (2) staff, an ice pack was applied to the head injury and the Advanced Practice Registered Nurse (APRN) was notified who advised to call Resident #1's Power of Attorney (POA) and ask if they wanted Resident #1 transferred to the hospital for evaluation. The POA was called twice, and voicemails were left requesting a call back to the facility. The Physical Therapy (PT) encounter note dated 11/28/25 identified Resident #1 was noted leaning to the left with an inverted (turned inwards) right ankle while seated in the wheelchair. The note indicated Resident #1 had facial grimacing with gentle ankle palpation due to pain and nursing was aware. The nurse's note dated 11/28/25 at 1:35 PM identified the Assistant Director of Nursing reached out to the POA again with no response. The note indicated he assessed Resident #1 as part of a post fall assessment and Resident #1 showed facial grimacing when the right femur and ankle were touched and were noted to be painful and tender but without swelling. The note identified he contacted the APRN immediately to report his assessment and new orders were obtained for bilateral lower extremity x-rays and Resident #1 was not to be transferred to the hospital. A physician's order dated 11/28/25 directed to obtain x-rays of the bilateral hips, legs, and ankles on 11/28/25. The diagnostic imaging reports identified the x-rays of the right ankle, left ankle and bilateral hips and pelvis were obtained on 11/28/25. The right and left ankle x-rays results were negative for acute fractures. The bilateral hips and pelvis x-ray results on 11/29/25 at 4:44 AM showed an acute right femoral neck fracture (the upper thigh bone that connects the rounded ball of the hip joint to the main shaft of the bone) approximately fifteen (15) hours after the resident began showing signs and symptoms of pain and was assessed for a possible injury.The nurse's note dated 11/29/25 at 8:13 AM identified the x-ray results of the bilateral hips and pelvis were made available on 11/29/25 at 4:44 AM and showed an acute right femoral neck fracture with complete displacement (when the broken pieces of the femur significantly shift out of alignment and can disrupt blood supply and lead to severe pain and the inability to bear weight). The note indicated the POA was notified of the results and the impending transfer to the Emergency Department (ED). Review of the clinical record from 11/28/25 when the x-rays were obtained through 11/29/25 failed to reflect documentation the radiology provider notified the facility on 11/29/25 at 4:44 AM when the results of the bilateral hip and pelvis reports were available and that the facility failed to follow up obtaining the results of the bilateral hip and pelvis reports after the right ankle, left ankle x-ray results were reported to the facility as evidenced in the 11/28/25 at 10:30 PM nurse's note. Interview with the Director of Nursing (DON) on 12/19/25 at 1:18 PM identified although the diagnostic provider should have called the facility, they did not call to notify the facility of Resident #1's positive x-ray report on 11/29/25 at 4:44 AM. The DON explained she checked their website on 11/29/25 at 7:00 AM and pulled up the final results that identified Resident #1 had a right femoral neck fracture, the APRN was notified immediately, and Resident #1 was transferred to the ED. Interview with the APRN on 12/18/25 at 2:00 PM identified although Resident #1's hip and pelvis x-ray results were available at 4:44 AM on 11/29/25, she was not notified until 7:00 AM by text from the facility (over two (2) hours later). The APRN stated the diagnostic company should have notified the facility immediately of the abnormal results so she could be notified timely. Interview with the diagnostic provider, Person #2, on 12/18/25 at 3:04 PM identified the x-ray exam was completed on 11/28/25 at 5:30 PM and the hip and pelvis x-ray results were not available until 11/29/25 at 4:44 AM. Person #2 identified although the results should have been faxed and the facility should have been called immediately, the report was not faxed to the facility until 11/29/25 at 7:10 AM (approximately 2.5 hours later) and the facility was not called and notified of the abnormal results until 11/30/25 at 6:50 PM (almost 36 hours later). Although requested, the facility did not have a policy regarding obtaining x-rays results.

Based on clinical record review and resident and staff interviews for Resident #1, reviewed for a change in condition, the facility failed to ensure that licensed staff informed the provider that an alternative method of oxygen delivery was implemented to maintain adequate oxygenation. The findings include:Resident #1 was admitted with diagnoses that included moderate persistent asthma. An annual MDS assessment dated [DATE] identified Resident #1 was cognitively intact and utilized oxygen therapy.A care plan dated 6/26/2025 identified Resident #1 had impaired respiratory function related to recurrent shortness of breath and obstructive sleep apnea. Interventions included administering medications as ordered, and reporting changes/concerns to the medical provider as needed.The physician orders dated 9/2/2025 directed to administer 2L of oxygen via nasal cannula for obstructive sleep apnea as needed.A nursing note dated 9/25/2025 identified Resident #1's oxygen saturation was 90 to 92% on 3 liters of oxygen via nasal cannula and decreasing to 88% while talking despite having received an albuterol nebulizer (a medication used for treating shortness of breath). The nursing note indicated that the nursing supervisor was made aware, and Resident #1 was placed on a non-rebreather mask as requested by the nursing supervisor. The note further indicated that Resident #1's oxygen saturation increased to 97-98% on 5L oxygen delivered via a non-rebreather mask.A nursing supervisor's note dated 9/25/2025 indicated that Resident #1 complained of not feeling well with chills and shortness of breath. The note further identified that Resident #1's oxygen saturation was 88% on room air and that afterwards oxygen was administered via a non-rebreather mask. The note indicated that APRN #1 was made aware, and new orders were obtained.On 10/2/2025 at 11:00 AM, an interview with Resident #1 identified he/she had told LPN#1 about their continued shortness of breath and that the LPN took an oxygen saturation reading, and it was high 80s, low 90s. Resident #1 indicated that afterwards, LPN#1 placed a non-rebreather mask on them, and their oxygen saturation increased to 100% but they still felt short of breath. Resident #1 indicated that the mask had a bag that inflated like a balloon (the reservoir bag of a non-rebreather mask).On 10/2/2025 at 12:10 PM, an interview with LPN#1 indicated that on 9/25/2025 at 8:00 PM, Resident #1 indicated that they were short of breath and did not feel like themselves. LPN#1 indicated she notified the nursing supervisor (RN#1), who then contacted the APRN (APRN#1). LPN#1 indicated that new orders were obtained by RN#1 and that she updated the resident. LPN #1 indicated she noticed Resident #1's oxygen saturation would decrease to 88% from 94 % when talking. LPN#1 indicated she had notified the nursing supervisor, who directed LPN#1 to place a non-rebreather mask. LPN #1 indicated that she placed the non-rebreather mask and that the oxygen flow rate was set at 5 liters/minute.On 10/2/2025 at 1:18 PM, an interview with RN#1 indicated that when she had initially assessed Resident #1, the resident had been on a nasal canula at 3 liters/minute, but that the oxygen tubing prongs were not well placed in the resident's nostrils. When she adjusted it, the resident's oxygen improved. RN#1 indicated she had later told LPN#1 to place a non-rebreather mask on Resident #1 when she was informed that the resident's oxygen was decreasing to 88%. RN#1 indicated she did not recall if she had informed APRN#1 that Resident #1 was requiring oxygen through a non-rebreather mask, but thought that the mask was placed after an ambulance was called. On 10/2/2025 at 1:53 PM, an interview and review of messages from the facility with APRN#1 indicated that RN#1 communicated with her through messaging regarding Resident #1's condition. APRN #1 indicated that although RN#1 informed APRN#1 about Resident #1's shortness of breath, APRN #1 was not informed that Resident #1 was placed on a non-rebreather mask. APRN#1 indicated that when a resident needs a non-rebreather mask, it should be communicated to her; however, APRN #1 indicated that her medical management would not have changed since she would have attempted to wean the mask off with the medications she had already ordered had the resident not been transferred to the hospital.The facility policy for Change in a Resident's Condition or Status indicated that the nurse should notify a physician on call when there is a significant change in a resident's condition or if a resident's medical treatment needs to be altered significantly. Additionally, the policy indicated that the nurse should make detailed observations and gather relevant and pertinent information for the provider.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #5) reviewed for dining, the facility failed to ensure staff provided the correct diet texture and failed to ensure staff knew or verified what the diet orders were, resulting in a choking episode. The failures resulted in a finding of Immediate Jeopardy. Resident #5 was admitted with diagnoses that included dysphagia (difficulty swallowing), dementia and end stage renal disease. The nursing admission note dated 10/4/2024 at 9:26 PM identified Resident #5 was oriented to person. The Resident Care Plan (RCP) dated 10/4/2024 identified a potential for alteration in kidney function due to dialysis and nutritional status. The RCP directed treatments as ordered and diet as ordered. A physician order dated 10/4/2024 directed carbohydrate-controlled diet (CCD), renal, dysphagia advanced diet. An APRN admission note dated 10/5/2024 at 10:30 PM identified Resident #5 was alert, confused and disoriented. A speech therapy note dated 10/5/2024 identified Resident #5 had severe cognitive impairment. Speech evaluation dated 10/5/2024 identified Resident #5 held food in his/her mouth and cheeks after meals and had clinical signs of dysphagia - oral phase (excessive chewing time and leaving residue on the tongue base). Resident #5 left residue on his/her palate and tongue with clearance attempts when trialing the ordered diet. Recommendations were for dysphagia, soft diet with thin liquids, alternate liquids with solids, and medications to be crushed in puree. A speech therapy note dated 10/8/2024 identified Resident #5 fed him/herself without cueing. A facility incident report dated 10/9/2024 at 4:50 PM identified a choking episode resulting in a resuscitation event. Resident #5 requested a sandwich after return from dialysis, and NA #1 provided a ham and cheese sandwich. NA #1 was present when Resident #5 had difficulty swallowing and could not expel the food. NA #1 called LPN #3 and LPN #3 immediately performed an abdominal thrust. A small piece of ham was expelled after one thrust and Resident #5 reported feeling better. Observations during survey identified postings in the unit nourishment rooms that included diet types and foods that were/were not allowed on the specific diet types. Interview with dietician on 11/4/2024 at 11:20 AM identified diets are posted on all the units in the nourishment room. The postings include what is allowed on diet types, including Dysphagia Advanced diet. Interview and record review with the Director of Rehabilitation and Speech therapist (SL#1) on 11/04/2024 at 12:00 PM identified that a dysphagia advanced diet allows ground meats with additional sauce, and allows soft breads softened with syrup or sauce (the sauce increases moisture and enhanced cohesiveness of the food for swallowing). SL #1 stated the ham and the bread on the sandwich were not an allowable food on Resident #5's ordered diet, and there was no moisture added to the sandwich; no mayonnaise or mustard was on the bread. Interview further identified that the foods allowed on the dysphagia diet were posted on the refrigerators in the unit nourishment rooms. Interview with NA # 1 on 11/4/2024 at 12:10 PM identified she was not Resident #5's aide, but after the resident returned from dialysis about 4:30 PM on 10/9/2024, Resident #5 told her that he/she was hungry and wanted a sandwich. NA #1 took a ham sandwich from the unit refrigerator, showed it to LPN #3 and asked if she could give it to Resident #5. LPN #3 told her it was ok to provide the sandwich to Resident #5. NA #1 stated she always checked with the nurse prior to giving food to any resident to ensure it was the correct diet, and for Resident #5 she did not know what the diet order was because she was not the NA assigned to the resident. NA #1 gave the sandwich to Resident #5 in his/her room. Resident #5 quickly took the sandwich from her and took a big bite while she was in the room, and he/she began to cough. NA #1 asked the resident if he/she was ok, but Resident #5 could not talk. NA #1 called to LPN #3 who immediately came to the room, went behind Resident #5 who was sitting on the edge of the bed and provided an abdominal thrust. After one thrust, a piece of ham was expelled, and Resident #5 began to cough again. Interview with LPN #3 on 11/4/2024 at 12:56 PM identified that on 10/9/2024 she was the charge nurse assigned Resident #5 on the 3 to 11 PM shift. LPN #3 stated about 4:30 PM NA #1 asked if she could give Resident #5 a sandwich. LPN #3 stated the sandwich was wrapped in cellophane and she did not ask what kind of sandwich it was. LPN #3 stated she did not check Resident #5's diet orders to verify the sandwich was allowed on the diet prior to responding to NA#1 that she could provide the sandwich to Resident #5. A few minutes later NA #1 called her to Resident #5's room because he/she was choking. When she entered the room, Resident #5 was not coughing and looked distressed. She asked Resident #5 if he/she was ok and when he/she could not respond, she provided an abdominal thrust. Resident #5 expelled a small piece of ham and began to cough reporting he/she felt better. LPN #3 stated she should have checked the diet order before approving the sandwich, and she did not know why she did not. Interview with the DON on 11/4/2025 at 2:19 PM identified the nursing staff should always verify a resident's ordered diet, if any staff member asked if they could provide a resident any food. The DON stated NA #1 did the right thing to check with LPN #3 to verify the sandwich was allowed on the diet, and LPN #3 did not check Resident #5's diet orders prior to telling NA #1 it was ok to give the resident the sandwich, and she did not know why. The DON stated she spoke with LPN #3 on 10/9/2024 after the incident occurred, and LPN #3 knew she should have verified the diet orders prior to approving the sandwich. The facility guidelines for Dysphagia Advanced Diet directed in part, that this diet offers more advanced texture and consists of ground meats, soft fruits and vegetables and soft bread products. The Dysphagia Advanced Diet further directed that breads and cured meats are not allowed, and the diet allowed bread softened with syrup or sauce, and ground meats. Facility documentation review identified staff education was initiated on 10/9/2024 regarding verifying resident diets prior to providing food. Audits were initiated on 10/10/2024, and a QAPI meeting was held on 10/10/2024. Based on review of facility documentation, past non-compliance was identified on 10/10/2024.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 6 residents (Resident #6, 67 and 78) reviewed for pressure ulcers, the facility failed to ensure offloading devices were in place prior the development of a pressure ulcer, failed to ensure a registered nurse completed a skin assessment on admission and ongoing for a resident admitted with a pressure ulcer, and the facility failed to consistently monitor the resident 's Circulation, Motion and Sensory (CMS) and skin integrity during the utilization of bilateral knee immobilizers for potential skin impairment and pressure ulcer development. The findings included: 1.Resident #78's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated on 4/9/22 identified Resident #78 with a bilateral distal femur fracture related to a fall at home. Resident #78 underwent Open Reduction and Internal Fixation (ORIF) on the right femur on 3/30/22. The discharge summary identified that Resident #78 had a bilateral knee immobilizer was in place and directed staff to keep the bilateral lower extremities elevated. The Braden scale assessment dated on 4/9/22 at 11:08 PM. identified Resident #78 ' s score of 15 which indicated the resident was at risk for development of pressure ulcers. The Resident Care Plan (RCP) dated on 4/9/22 identified Resident #78 was at risk for development of pressure ulcer/skin breakdown secondary to: impaired mobility and incontinence of bowel and bladder. Interventions included: to apply pressure reducing mattress/cushion to the bed/chair as ordered, to provide turning and repositioning as indicated for proper body positioning, to report any skin changes to MD and responsible party as needed, to assist with toileting and hygiene as needed and skin checks and treatment as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 had severe impaired cognition and required a 2-person extensive assist for transfer, and a 1-person extensive assist for dressing, toileting, and hygiene. The assessment also noted the resident had one stage 2 pressure ulcer upon admission. Interventions included: to provide pressure reducing devices for bed and chair, turning and repositioning and to provide ulcer care. The physician's orders dated 4/9/22 directed to conduct skin checks weekly on Monday 7-3 PM and to do a complete skin observation. The physician's orders dated 4/11/12 directed to cleanse blisters on right foot, by applying xeroform dressing followed by gauze wrap with kerlix daily. The physician ' s orders dated 4/12/22 directed to cleanse blister on right foot (top, ankle and inner) then [MEDICATION(S)] dressing gauze wrap with kerlix daily. The physician ' s orders dated 4/13/22 directed to apply LAL mattress per resident ' s weight and to check for functioning every shift and out of bed to donated custom tilt in space wheelchair with ROHO cushion, upright at meals at all times, tilt at rest as tolerated. The nurse's notes 4/9/22 through 4/25/22 failed to reflect evidence that the nursing staff consistently provided CMS and observed the resident's skin integrity underneath the bilateral knee immobilizers A review of the General Administration History dated 4/9/22 through 4/25/22 failed to reflect that the nursing staff had monitored Resident # 78's CMS and skin integrity during the utilization of the bilateral splint until 4/26/22 when a physician ' s order was obtained to check CMS (Right Lower Extremities (RLE) every shift and to keep knee immobilizer loosen with right ankle once a day. The clinical record review in the wound management dated on 4/27/22 at 3:14 PM. identified on 4/26/22 the resident developed a 10 Centimeter (CM) by 10 CM Deep Tissue Injury (DTI) to the right achilles with a necrotic spot. The nurse's noted dated 5/2/22 identified the resident was seen by the MD and nurse to assess resident 's achilles area DTI, the area was noted with 100 percent epithelial tissue with moderate serosanguinous drainage. For treatment noted Santyl followed by Calcium Alginate covered with ABD pad with kerlix daily. Additionally, noted a new order for the resident ' s immobilizer to be off while in bed. Interview with LPN #4 on 5/11/22 at 12:20 PM identified she did not remove Resident #78's leg immobilizer to check for skin integrity because there was no physician order. She did place a pillow in between the legs to provide comfort. LPN # 4 further indicated the Advance Practitioner Registered Nurse (APRN) could provide the physician's order for care of the leg immobilizer. She also stated that she followed the orders in the physician orders in relation to the care of the leg immobilizer. Interview and review of clinical record on 5/11/22 at 1:40 PM. with APRN # 1 identified she was aware Resident #78 was admitted with a bilateral lower leg immobilizer. APRN#1 further indicated the nursing staff should have check the resident's skin underneath the immobilizer and perform Circulation, Motion, Sensory (CMS) assessments every shift and as needed. Clinical record review of APRN #1 ' s note dated on 4/26/22 under skin assessment indicated multiple staples in place to the right lower extremity (thigh, knee) without signs/symptoms of infection - well healed; healing blisters to dorsum right foot; and identified right achilles with purpura and open wound - appearing to be from the right knee immobilizer. APRN #1 indicated she ordered cleaning of the right achilles with [MEDICATION(S)], apply Santyl topically to the affected area, an abdominal pad, then wrap with a kerlix roll dressing and directed to have the wound team follow the case. Interview and review of clinical record with MD #1 on 5/11/22 at 2:25 PM identified he received a request for a consultation for Resident # 78 's large DTI to the Right Achilles. MD#1 indicated he believed the metal of the lower part of the leg immobilizer was the cause of the injury secondary to the metal part digging into Resident #78 ' s skin. Clinical record review of MD# 1's progress note dated on 5/2/22 identified the right achilles had a DTI and likely was from Resident # 78's leg immobilizer. The initial wound encounter measurement was 5 CM length by 3 CM width by 0 depth, with an area of 15 square cm. MD #1 subsequent follow up visit dated on 5/9/22 identified the right achilles wound was larger and had increased slough present. MD #1 further indicated he recommended a discussion with the orthopedic team about keeping the immobilizer off while in bed. Interview and review of clinical record on 5/11/22 at 2:45 PM. with RN #6 (Infection Preventionist/Wound Nurse) identified the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She updated APRN #1 and obtained a physician's order to keep the right knee immobilizer loosened at the right ankle, to check for CMS to the right leg every shift and as needed, to apply Santyl topically daily, and provide a wound evaluation. Interview with DNS on 5/12/22 at 9:30 AM identified the nursing staff is responsible for the care of a leg immobilizer. The nursing staff would be expected to check the physician's orders and follow the physician instructions as written in the discharge summary. The DNS also indicated she would expect the nurse to check the resident's skin integrity and conduct CMS every shift and as needed. The nursing supervisor who admitted Resident #78 should include all physician orders. The facility failed to consistently assess the resident's CMS and skin integrity during the utilization of bilateral knee immobilizers to prevent the development of a pressure ulcer. A review of facility nursing policy titled Prevention of Pressure Injuries notes in part for Device-related Pressure Injuries. Staff will review all procedures for select medical devices with consideration to the ability to minimize tissue damage, monitor regularly for comfort and signs of pressure-related injury. For prevention policy directs staff to obtain consultation with specific devices to ensure current clinical practice guidelines. 2. Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden Scale for Predicting Pressure Sore Risk dated 1/17/22 identified Resident #6 was at risk for the development of a pressure ulcers. The quarterly MDS dated [DATE] identified Resident #6 had intact cognition, required extensive assistance with bed mobility, total assistance with transfers and personal care, was at risk for the development of pressure ulcers, and had no unhealed pressure ulcers. The corresponding care plan (original date 7/15/21) identified Resident #6 was at risk for development of pressure ulcers due to impaired mobility, diabetes, and occasional incontinence. Interventions included to turn and reposition, perform skin checks and provide a pressure reducing mattress. A Wound Management note dated 2/18/22 identified the resident had a new area on the left heel which was a dark purple or rusty discoloration with [CONDITION(S)] (redness) that was blanchable and measured 8.0cm by 9.5cm. Physician ' s order dated 2/18/22 directed to offload the heels, podus boots to bilateral lower extremities and consult with the wound team. Interview with RN #6 on 5/11/22 at 12:25 PM identified offloading measures for heels are usually included for any resident who had interventions that included turning and positioning. RN #6 was not sure why offloading measures/devices were not included as part of Resident #6's care plan prior to the development of the left heel pressure ulcer. Interview with the DNS on 5/11/22 at 12:35 PM identified it would be her expectation that heels be offloaded for any resident identified at risk for skin breakdown prior to the development of a pressure ulcer. Interview with MD #1 on 5/11/22 at 2:15 PM identified he was the Wound Specialist for the facility who provided care for Resident #6. MD #1 indicated offloading was very important in preventing the development of the pressure ulcers and he would have expected the facility to follow a wound prevention program. The policy for repositioning directed individualized care plan to promote comfort, prevent skin breakdown promote circulation and provide pressure relief for residents. The policy for Prevention of Pressure Ulcers/Injuries directed interventions that included the provision of support devices and assistance as needed for mobility and repositioning. 3. Review of the hospital inter-agency referral report dated 10/12/21 at 11:09 AM identified Resident #67 was admitted to the hospital on 10/8/21 with a pressure injury of the skin, unspecified injury stage, unspecified location: Resident was discharge with Incontinent Associated [CONDITION(S)] to perirectal area, a medial coccyx pressure injury, and right posterior ankle unstageable pressure ulcer. Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse's note dated 10/12/22 at 3:06 PM identified Resident #67 was admitted to the facility via stretcher with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record dated 10/12/21 to 10/24/21, 13 days, failed to reflect documentation that a registered nurse performed a skin assessment and/or pressure ulcer assessment. The Braden Scale dated 10/12/21 at 6:40 PM identified Resident #67's score was 12, indicating the resident was at high risk for the development of pressure ulcers. Physician's order dated 10/12/21 directed to clean the right ankle wound with normal saline followed by foam dressing daily and as needed during the day shift, and complete a skin check weekly on Tuesday during the day shift. A physician's order dated 10/13/21 directed to provide an air mattress, check for function and setting base on weigh every shift. A nurse's note dated 10/13/21 at 3:30 PM identified an air mattress was applied due to skin issues on bilateral heels and coccyx, wound nursing team will follow up. The care plan dated 10/13/21 identified Resident #67 has a pressure ulcer on the right ankle. Interventions included a pressure reducing mattress on the bed, treatment as ordered, turning and repositioning as indicated, skin checks as ordered, and wound consult as indicated. The admission MDS dated [DATE] identified Resident #67 had severely impaired cognition, required total 2-person assistance with bed mobility, and required total 1 person assistance with personal hygiene. The MDS further identified Resident #67 has a pressure ulcer with pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of ointments/medications. Review of the Non-Pressure Wound report dated 10/18/21 identified Resident #67 was seen on 10/25/21. Resident #67 had a left heel deep tissue injury measuring 2.0cm by 1.0cm by 0.0cm, with 75% epithelial. Right lateral foot arterial ulcer measuring 3.0cm by 3.0cm by 0.0cm with 75% eschar, no drainage. Skin prep recommended. Review of the wound progress note (1st consult) dated 10/25/21 identified Resident #67 was admitted with a large Deep Tissue Injury (DTI) along the left heel and an arterial ulcer along the right lateral foot. The left heel was a stage 2 pressure injury ulcer and had received a status of not healed. Measurement are 2.0cm by 1.0cm by 0.0cm, no drainage noted, wound bed has 51% - 75% epithelialization. The right lateral foot had an arterial ulcer and had received a status of not healed. Measurements are 3.0cm by 3.0cm by 0.0cm, no drainage, wound bed has 51% - 75% eschar. Recommendations included to change the dressing on the left heel daily, facility pressure ulcer prevention protocol, and offload heels per facility protocol. Apply skin prep to the right lateral foot, change daily, change as needed for soiling, saturation, or accidental removal. Interview with MD #1 on 5/11/22 at 2:34 PM identified he was not aware that a registered nurse had not done a wound assessment when the resident was admitted to the facility. MD #1 indicated the expectation is that the facility should have had a registered nurse perform a skin assessment on admission. MD #1 indicated pressure wounds have been an issue at the facility. Interview with the DNS on 5/12/22 at 7:57 AM identified she has been employed with the facility for approximately 4 months. The DNS indicated she was not aware that a registered nurse had not done a wound assessment when the resident was admitted to the facility. The DNS identified the record lacked any wound assessments or measurements on the resident ' s admission. The DNS indicated the residents wound are to be assessed and measured on admission, weekly, and as needed. The DNS indicated there should have been a registered nurse skin assessment upon the resident's admission. Interview with the RN #5 on 5/12/22 at 7:45 AM identified he was previously the facility Infection Preventionist/Wound nurse and worked as the supervisor and most of the time he was on the floor as the charge nurse. RN #5 indicated staffing was an issue at the facility and that is the reason why he left the facility. RN #5 indicated it was very difficult to do his job as the Infection Preventionist and the Wound nurse due to the staffing issues. RN #5 indicated he was not aware of Resident #67's pressure ulcers. RN #5 indicated he did not perform a skin assessment on Resident #67 when the resident was admitted or for the following next 2 weeks. RN #5 indicated the first time he performed a skin assessment on Resident #67 was on 10/25/21 during wound rounds with MD #1 (13 days after admission). RN #5 indicated he failed do a skin assessment because the facility had him working as a supervisor and/or a floor nurse. Review of the weekly skin assessments policy identified it is a standard of practice that weekly skin assessments be done for every resident on their first shower day of each week. If a skin issue is identified, the nurse will notify the APRN/MD to obtain a treatment if applicable. The supervisor/nurse will also complete a skin event (A&I). The family is notified of the change in conditions. Review of the prevention of pressure injuries identified the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Review of the pressure injuries overview policy identified pressure ulcer/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident # 1) reviewed for abuse, the facility failed to ensure a resident with cognitive impairment was free from non-consensual sexual contact to ensure the resident's highest practicable psychosocial wellbeing was maintained The findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was independent with ambulation but required supervision at times. The Resident Care Plan (RCP) dated 3/4/21 identified Resident #1 to be at risk for wandering due to being oblivious to safety. Interventions included: to administer medications and monitor, to ensure resident has identification in place and equip with wandering device that alarms when wandering. The RCP also identified cognitive issues related to Alzheimer's disease with interventions to redirect as needed and anticipate needs. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was conserved. The annual MDS assessment dated [DATE] identified Resident #2 was without cognitive impairment, the resident did not demonstrate any behavioral symptoms and was independent with Activities of Daily Living (ADL ) skills requiring limited assist with dressing and personal care. The RCP dated 2/4/21 identified Resident #2 had a one-time incident of physical behavioral symptoms (non-sexual) towards another resident on 11/9/20 with no new behaviors since. Interventions included: to remain with resident and if staff observed agitation to obtain a psychiatric/psychosocial consultation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavior Monitoring Flow Sheets dated 3/1/21 through 3/22/21 noted Resident #2 did not demonstrate any target behaviors. A Reportable Event dated 3/22/21 at 1:25 P.M. noted Resident #1 was observed lying on her/his back on another resident's bed (Resident #2) resident's bed. Resident #2 was on top of Resident #1. Resident #2's pants were halfway down exposing his/her buttocks. The two residents were immediately separated and placed on one to one supervision with psychological support provided. Resident #1 met with psychiatry immediately following the incident and subsequently transferred to an outside acute care hospital for further evaluation after reporting she/he had been raped by Resident #2. Resident #2 was transferred to an alternate outside acute care hospital where she/he was admitted for ongoing psychiatric monitoring. Administration, physician, police, state agency and, responsible parties for Resident #1 and Resident #2 were notified timely of the incident. Resident #1 underwent a complete physical evaluation and testing for evidence of sexual assault. However the testing for evidence of sexual assault is still pending at the time of the surveyor onsite visit for the investigation. Resident #1 was unable to be interviewed due to cognitive impairment and did not recall the events. An interview on 3/24/21 at 10:25A.M. with the Advanced Practice Registered Nurse (APRN #1) identified she returned to the facility upon being notified of the incident to evaluate both residents. Resident #1 did not have any obvious signs of trauma physically but stated Resident #2 put his/her genitalia inside Resident #1's genitalia. Resident #1 was anxious shaking and noted with trembling at the feet and hands, a behavior not previously observed. APRN #1 provided emotional support and reassure Resident #1. APRN #1 further indicated she spoke with Resident #2 as well who was less engaged which was the resident's baseline. Resident #2 stated to APRN #1 that she/he tried to have sex with Resident #1. An interview on 3/24/21 at 11:20 A.M. with RN #1 identified at approximately 1:20 P.M. on 3/22/21, he entered Resident #2's room to respond to a call light (undetermined by who) and observed the curtain to be pulled around Resident #2's bed. RN #1 asked who called for assistance as he entered the room and there was no answer. RN #1 did not hear anything and pulled back the curtain to observe Resident #2, face down on top of Resident #1 with exposed buttocks making contact at the pelvis region. Resident #2 was on his/her back, legs spread with clothing on the legs but was unable to determine to what extend each resident was disrobed and if actual penetration had taken place. RN #1 stated Stop, stop! and immediately separated the two residents who quickly got off the bed, pulled their pants up and exited the room escorted by RN #1. Both residents did not look upset when RN #1 intervened, only surprised. RN #1 immediately sought the assistance of the Assistant Director of Nursing Services (ADNS) who escorted Resident #1 to an alternate area. RN #1 tried to ask Resident #2 what had occurred, but Resident #2 would not offer any information and refused a body audit as well. The Director of Nursing Services (DNS) was present and took over for RN #1 and stayed with Resident #2 so RN #1 could attend to other duties. Resident #1 made no statements to RN #1. An interview on 3/24/21 at 11:34A.M. with the ADNS identified she was just outside Resident #2's door when RN #1 came out of the room with Resident #1 and Resident #2. RN #1 looked surprised and quickly explained the incident to the ADNS who then escorted Resident #1 to an alternate area to speak with him/her. Resident #1 did not seem out of sorts according to the ADNS, only asking where they were going, a usual behavior for him/her. Resident #1 stated to the ADNS that a person she/he did not know just had sex with him/her meaning, Resident #2 put his/her genitalia inside Resident #1's genitalia but could not recall any other details. During the course of the conversation, the ADNS contacted the DNS and social worker and that the social worker stayed with Resident #1 while the DNS stayed with Resident #2. An interview and clinical record review on 3/24/21 at 12:33 P.M. with the DNS identified she was on site when notified of the incident and came to the unit to assist until Emergency Medical Service (EMS) arrived. The DNS relieved RN #1 who was providing one to one supervision for Resident #2. According to the DNS, Resident #2 was calm and quiet, at baseline. The DNS with Licensed Practical Nurse (LPN #1) present asked Resident #2 what had occurred between the two residents, Resident #2 stated that she/he asked Resident #1 if she/he wanted to have sex with him/her. Resident #1 said yes so Resident #2 escorted Resident #1 into his/her room/bed. According to Resident #2, Resident #1 took his/her own pants off and they both left their shirts on. The DNS asked Resident #2 if his/her genitalia entered into Resident #1's genitalia for which he/she replied that she/he tried but could not function. Resident #2 indicated Resident #1 did not fight, yell out or object in any way. Resident #2 had not previously engaged in any sexually inappropriate behaviors or seek out companionship in the past. Resident #2 returned to the facility on [DATE] and placed on one to one supervision on an alternate secured unit. An interview with Resident #2 on 3/25/21 at 10:15A.M. identified Resident #2 was in the hall on the unit and saw Resident #1 walking up and down the hall. Resident #2 stated she/he asked Resident #1 if s/he wanted to have sex and that Resident #1 said yes. The two residents went into Resident #2's room, took their paints off and attempted sexual intercourse but were unsuccessful as RN #1 entered into the room prior to actual penetration. Resident #2 indicated Resident #1 did not resist or say anything during the interaction. The facility Sexual Abuse policy at the time of the incident is defined as non-consensual sexual contact of any type with a resident. Sexual contact is nonconsensual if the resident either appears to want the contact to occur, but lacks the cognitive ability to consent; or they are residents with designated or legally appointed representatives.

Based on clinical record reviews, review of facility documentation, review of the facility policies and procedures, and interviews for one of three sampled residents (Resident #1) who was reviewed for an allegation of abuse, the facility failed to ensure a staff member was not verbally abusive, yelling and using profound language, when speaking to the resident. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented, had some memory recall problems, had not exhibited behavioral symptoms in the past seven (7) days and requiried extensive to total one (1) to two (2) person assistance with activities of daily living. The Resident Care Plan dated 1/16/21 identified Resident #1 exhibited verbally abusive behavioral symptoms directed towards others. Interventions directed to avoid power struggles with the resident, two (2) staff assist with care, to maintain a calm environment and approach towards the resident, and to convey an attitude of acceptance toward the resident. The Reportable Event Form dated 2/3/21 at 6:00 AM identified an allegation of verbal abuse was reported, noting the 11PM-7AM nurse aide, Nurse Aide (NA) #1, stated to Resident #1 f_ _ _ you, f _ _ _ you. The investigation identified while standing outside Resident #1's room, the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, heard NA #1 screaming and using profanity. The report noted that LPN #1 went to the room and saw NA #1 inside the room bagging soiled linens and asked the nurse aide to come out of the room. The report identified the nurse aide reported to LPN #1 that she swore at Resident #1 because the resident swore at her. The report indicated the Nursing Supervisor was made aware, the nurse aide was sent home and the appropriate parties, the police, physician, and family were notified of the incident. The nurse's note dated 2/3/21 at 6:43 AM identified the charge nurse spoke with Resident #1 related to concerns with a staff member this morning and provided emotional support. The note indicated an investigation was started, and all appropriate parties were notified. The nurse's note dated 2/3/21 at 8:29 AM written by the 11PM-7AM Nursing Supervisor identified at approximately 6:00 AM Resident #1 expressed concern regarding a staff member, and the facility abuse protocol was followed. The note indicated upon assessment the resident was emotionally upset over the incident and support was provided. The social service note dated 2/3/21 at 10:32 AM identified emotional support was provided to Resident #1 following the incident the resident had with a nurse aide this morning. The note indicated Resident #1 was upset by what happened and the language that was used. In a statement written by the Director of Nursing when Resident #1 was interviewed on 2/3/21, Resident #1 explained he/she heard the nurse aide in the room and asked the nurse aide if the nurse was with her. Resident #1 identified the nurse aide stated, I don't have to answer you because you are a nobody. Resident #1 explained that he/she opened the curtain and the nurse aide told Resident #1 to mind his/her own business and then the nurse aide called Resident #1 a mother f _ _ _ _ _ at which time Resident #1 cursed at the nurse aide. The statement indicated the nurse aide kept yelling to Resident #1, in both Spanish and English, you're a mother f _ _ _ _ _, you're a mother f _ _ _ _ _. The investigational summary report dated 2/5/21 identified the facility substantiated the allegation of verbal abuse and NA #1 was terminated. Interview with Resident #1 on 2/23/21 at 12:10 PM identified when the 11PM-7AM nurse aide came into the room, the resident asked if she was the nurse and was told by the nurse aide that she was not going to answer him/her because they were a nobody and began using profanity at him/her in both English and Spanish. Resident #1 stated that she reported this incident to the nurse and was upset over what had happened. Interview with the Director of Nursing (DON) on 2/23/21 at 1:00 PM identified that after she found out about the incident with Resident #1, she spoke to the resident who said he/she was verbally abused by NA #1. The DON stated Resident #1 reported to her that NA #1 was screaming and yelling profanity and the resident was upset over it. The DON indicated when she contacted NA #1 for a statement to what happened, the nurse aide denied yelling and using profanity towards the resident. The DON stated that NA #1 told her Resident #1 was using profanity towards her, NA #1 admitted she did raise her voice a little and then NA #1 stated she would not let anyone verbally abuse her. The DON identified verbal abuse was substantiated, and NA #1 was terminated. Interview with the 11PM-7AM charge nurse, LPN #1, on 2/24/21 at 7:00 AM identified that he was outside of Resident #1's room doing his med pass when he heard NA #1 swearing at Resident #1 in a screaming loud tone. LPN #1 stated he went to the room and saw NA #1 bagging soiled linens and had her come out of the room. LPN #1 indicated that he spoke to NA #1 and told her she could not speak to a resident that way and NA #1 told him that she swore at Resident #1 because the resident swore at her. LPN #1 stated the Nursing Supervisor came down at that time and had NA #1 leave the facility pending the investigation. LPN #1 identified when he went into Resident #1's room with the Nursing Supervisor while the supervisor assessed the resident, Resident #1 was upset over what had happened and he provided emotional support to the resident. Interview with the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1 on 2/24/21 at 7:10 AM she identified she was made aware of Resident #1 wanting to see her when the resident called the facility phone around 6:00 AM. RN #1 stated when she went to the unit she asked LPN #1 what happened and was told by LPN #1 that he heard the nurse aide swearing at the resident in a loud screaming tone. RN #1 indicated she sent the nurse aide home and went to assess the resident. RN #1 identified Resident #1 told her that the nurse aide had stated to the resident he/she was a nobody and began swearing in both English and Spanish. RN #1 stated Resident #1 was upset with what had happened and she provided the resident with support. Interview with the Social Worker on 2/24/21 at 7:15AM identified the DON reported to her that an allegation of verbal abuse occurred with Resident #1. The Social Worker stated she went to see Resident #1 who was upset over what happened and provided emotional support to the resident. The Social Service indicated Resident #1 told her the he/she was offended by what the nurse aide had said. Review of the facility's abuse policy identified the resident have the right to be free from abuse including verbal. The policy identified that all allegations will be investigated, the residents protected during the investigation and the Administrator will ensure that any potential further abuse is prevented. Several attempts were made to contact NA #1 and were unsuccessful.

Based on clinical record review, observations, review of facility documentation and staff interviews for one sample resident in the survey reviewed for accidents (Resident #56), the facility failed to ensure the resident received the necessary assistive devices to ensure the resident was positioned with two people in accordance to the plan of care and/or positioned in a safe manner to prevent an accident and /or the facility failed to maintain safe hot water temperatures. The findings include: 1. a. Resident # 56's [DIAGNOSES REDACTED]. A rehabilitation screen dated 3/22/16 indicated Resident # 56 was at baseline dependent for ADLs and mobility. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had no speech, rarely/never understood/understands, required total care with 2 people for bed mobility, and indicated the resident did not walk. An occupational therapy evaluation dated 7/14/16 indicated the resident did not exhibit any spontaneous movement with upper and lower extremity strength impairments. A Resident Care Plan (RCP) dated 7/18/16 identified a problem with self-care related to unresponsiveness and total care. Interventions included staff assistance with Activities of Daily Living (ADL) per NA assignment. The ADL Assistance and Support sheet for dated 77/3/16 through 7/24/16 noted Resident # 56 was totally dependent on staff and required two people to assist with bed mobility. A Nurse Aide (NA) care card dated 7/24/16 indicated Resident # 56 required assistance of 1 for ADL support and assistance of 2 for turning and positioning. A physician's orders [REDACTED]. A nurse's note dated 7/24/16 at 10:20 A.M. indicated Resident # 56 was on the floor on the window side of the bed lying on his/her right side. NA # 1 indicated he/she had just finished providing care to the resident, turned Resident # 56 on his/her left side and stepped outside the door to get the nurse to perform the resident ' s dressing change. When NA # 1 turned back (without the benefit of the resident being in direct eyesight) toward the resident he/she saw the resident sliding out of the bed, but could not get to the resident in time. The resident was assessed and transported to the hospital at 10:45 AM. A hospital discharge summary dated 7/31/16 indicated Resident # 56 was found to have a right lateral intraventricular hemorrhage, a comminuted right hip fracture, and right 7th rib fracture. An interview on 12/14/16 at 7:55 A.M.with (NA # 1) indicated on 7/24/16 he/she provided a bed bath and dressed Resident # 56 while the resident was in bed. NA # 1 also indicated she/he turned the resident on his/her left side in the bed. He/she put the resident on his/her left side with his/her right leg over the left leg to expose the resident's bottom for the nurse to perform the treatment. NA # 1 indicated he/she provided the care and turned the resident on his/her left side by him/herself without the assistance of another person. NA # 1 indicated he/she left the resident's bedside went out the bedroom door and saw LPN # 3 in the hallway and told him/her the resident was ready for the treatment. NA # 1 indicated when he/she turned around to go back in the room he/she saw the resident falling out of the bed, legs first and his/her body followed. The resident landed on his/her right side. NA # 1 indicated he/she had Resident # 56's right leg over the left leg to expose the resident's bottom for the treatment and the weight of the right leg may have pulled the resident out of the bed. He/she indicated he/she would not put the resident's leg over the left leg and would put a pillow behind the resident's back for the resident to lean on in a normal resting bed position. NA # 1 indicated he/she always provided care and positioning by him/herself and 2 people for transferring. NA # 1 indicated the resident was on an air mattress, but he/she did not firm the mattress prior to care and/or positioning. An interview on 12/14/16 at 11:38 AM with LPN # 3 indicated he/she was walking in the hallway toward Resident # 56's room to provide a treatment and heard NA # 1 state Resident # 56 fell out of bed. When he/she entered Resident # 56's room the resident was on the floor on his/her right side. The side rails were elevated on the bed. The bed was not in the lowest position. LPN # 3 indicated Resident # 56 required 1 person for care and 2 people for turning and positioning because he/she was difficult to position. A review of a Reportable Event form dated 7/24/16 and interview with the DNS on 12/15/16 at 10:20 A.M. indicated although he/she did not think NA # 1 was negligent, the resident was not in a safe position before he/she left the resident's bedside. The DNS indicated the air mattress may have contributed to the resident's weight shift as well. He/she indicated it was not the facility's policy to firm the air mattresses for positioning. The DNS indicated although NA # 1 was given a warning for not following the resident care card, he/she felt Resident # 56 was put in a temporary position and not a resting position. He/she indicated the care card indicates 2 people for turning and positioning and does specify temporary positioning and/or resting positioning. Review of a notice of disciplinary action dated 7/24/16 indicated NA # 1 was given a written warning for not following the resident ' s care plan. The care card stated 2 people for turning and positioning. Review of the facility's air mattress manual indicated notes it may be helpful to activate the auto firm mode to achieve a firm surface for repositioning purposes. Safety information indicated the risk for gradual movement and/or sinking into hazardous positions of entrapment and/or inadvertent bed exit may be increased due to the nature of these products. 2. During tour and observation on 12/12/16 at 11:00 A.M. to 12:00 P.M. the following rooms were identified with elevated hot water temperatures: in resident rooms # 106: 123.4 Degrees Fahrenheit, # 107: 121.4, room #115: 129.7 and # 116: 124.8. The DNS and Director of Maintenance were notified of the elevated hot water temperatures on 12/12/16 at 12:00 P.M. Subsequent to inquiry the Maintenance staff in the presence of the surveyor checked water temperatures in resident areas ago again with surveyor and adjusted the mixing valve and contacted an outside contractor. Additionally, the facility implemented a plan to ensure safe water temperatures in resident areas by directing staff to monitor hot water temperatures and posted signs alerting residents, staff and /or visitors of hot water temperatures until the equipment could be evaluated by the facility's vendor. Interview with the Maintenance staff on 12/13/16 at 2:45 P.M. identified water temperature are conducted three times a week. Additionally, the Maintenance staff on 12/13/16 indicated he/she had noticed a spike in water temperatures of greater than 120 back in March and April and indicated he/she did not document the 120 water temperatures but did adjust the mixing valve. The Maintenance Director on 12/13/16 also indicated once he/she adjusted the mixing valve in March and April 2016 to 115 Degrees Fahrenheit to decrease the water temperature and indicated he/she informed administration of the hot water temperatures but could not get a plumber in to evaluate the equipment.

Based on clinical record review and staff interview for one of three sampled residents reviewed for injuries of unknown origin (R#2) the facility failed to ensure that a resident with signs of pain including crying, was assessed, and interventions immediately initiated to relieve the resident's pain and/or for one of one sampled resident reviewed for [MEDICAL TREATMENT] (R#117), the facility failed to administer medication according to physician orders. The findings include: 1. a. Resident #2's [DIAGNOSES REDACTED]. A Fall risk assessment dated [DATE] identified R#2 a high risk for falls. An annual assessment ((MDS) dated [DATE] identified the resident as severely cognitively impaired requiring provision of all activities of daily living (ADL) including bed mobility and transfers between surface i.e. bed to chair via a mechanical device. It further identified R#2 as always incontinent of bowel and bladder. Resident care plan (RCP) dated 6/19/14 identified utilization of a custome wheelchair for positioning and comfort. Interventions included out of bed per 24-hour positioning plan. In addition, the resident is at risk for alteration in comfort related to bilateral upper and lower extremities contractures with interventions that included to complete pain assessment sheet, administer [MEDICATION NAME] per order and report ineffective pain medication to MD and observe for verbal/nonverbal cues regarding pain level. Facility investigation documentation identified that on 07/31/14 at 10:30 PM, NA #1 and NA#3 found R#2 expressing discomfort as they were providing R#2 with care. RN#5 and LPN#5 were informed, evaluated the resident and found no evidence of trauma to any part of his/her body. On 8/01/14 at 7:30 AM, R#2 was found crying and upon assessment was noted to exhibit signs of pain with movement. The resident was subsequently transferred to the hospital and diagnosed with [REDACTED]. The investigation further identified that although no problems were found with the mechanical hoyer device, NA# 2 reported that at 6:30 PM on the evening of 7/31/14, s/he had difficulty removing R#2's clothing in preparation for s/he had difficulty removing R#2's clothing in preparation for his/her showere due to immobility and contractures. Review of facility documentation (24 hour) communication and nurse's note dated 7/31/13 and 8/01/14 failed to reflect any documentation related to staff report of R# 2 crying, staff reports of resident's expression of pain and/or physician notification. Hospital discharge summary dated 8/05/14 identified that upon admission R#2 was found to have a displaced proximal left femur fracture. It further identified that although unclear as to a history of a fall, abrasions were noted on his/her left knee suggesting a fall. Interview with NA#1 on 1/12/15 identified that up until the time he/she left for dinner break on 7/31/14 at approximately 6:00 PM, R#2 did not show any signs of pain and/or discomfort. NA#1 identified hat upon return from break NA#2 and NA#3 had already given R#2 a shower and transferred R#2 back to bed. NA#1 further indicated that at approximately 9:30 PM, R#2 was acting very different from his/her normal pattern. NA#1 indicated that R#2 was crying and grimacing when touched and with movement, in a way he/she had never observed before. NA#1 further indicated he/she made LPN #5 aware of R#2's unusual crying/grimacing and that LPN# 5 and RN#5 checked on the resident. Interview with RN#2, Supervisor on 1/12/15 at 5:20 PM indicated that although the resident was maoning he/she had assessed the resident and the resident, "did not seem different". RN#2 further indicated that R#2 was to be seen by the APRN the following morning. Interview with LPN#5 on 1/13/15 at 10:30 AM indicated that although NA#1 reported R#2's crying, he/she and RN#5 touched the resident in, " different places " and had not observed any evidence of a problem. Interview with NA#3 on 1/13/15 at 10:55 AM indicated that although he/she assisted NA#3 with transferring R#2 to the shower room via CWC, he/she did not assist NA#2 with showering R#2. NA#3 indicated that he/she assisted R#2 back to bed after his/her shower and there was no indication of discomfort during the transfer. He/she indicated that later that shift around 9:30 PM while assisting NA#1 he/she observed that R#2 was crying, had a facial expression of pain and was acting, " weird " . NA#3 further indicated that he/she had never seen R#2 crying like that. Interview with LPN#4, the third shift charge nurse, on 1/13/15 at 9:15 AM indicated that although he/she was not made aware during change of shift report of significant changes, at approximately 11:05 PM he/she could hear R#2 crying from the hallway. LPN#4 identified that the crying was different for the resident and later made RN#3, the night supervisor, aware. Interview with RN#3, night supervisor with the Director of Nursing (DNS) present on 1/13/15 at 11:30 AM indicated that although he/she was unable to say who gave the report on the second shift, he/she was made aware that R#2's left leg was swollen. RN#3 indicated that at some time during the night he/she observed that the left lower extremity more swollen than the right side. He/she further indicated that he/she did not make the physician aware because the left swelling leg was identified on the previous shift. Interview with NA#4 on 1/13/15 at 6:13 AM identified that from the beginning of the shift on 7/31/14 and into the 11-7 AM shift of 8/01/14, R#2 was moaning. NA#4 indicated that the 3-11 PM nurse aide had reported to him/her that, " the resident " was like that all night " . NA#4 indicated that the resident continued through the 11-7 AM shift onto 8/01/14 to, " not act like his/her self " and was " scrunching his/her face up " grimacing and moaning when moved. NA#4 indicated he/she reported multiple times through the shift that something was not right with the resident. Review of LPN#4's (11-7 charge nurse) Witness Statement dated 8/01/14, identified that no information was relayed by LPN#5 (3-11 charge nurse) regarding R#2 at shift report. LPN#4 indicated that while making rounds LPN#5 was observed in R#2's room and reported that R#2 had been crying earlier in the shift and he/she had never heard R#2 crying like that before. RN#3, LPN#5 were unable to identify why R#2 was crying because everywhere they touched on assessment R#2 would cry. Interview with LPN# 1, Unit Manager and the ADON on 1/12/15 at 5:28 PM, identified that during rounds on the morning of 8/01/14, R#2 was found crying and upon further evaluation found his/her left leg swollen and externally rotated and was transferred to the hospital for evaluation. Interview with OT#1 and PT #1 on 1/13/15 at 8:40 AM identified that the twenty-four hour positioning plan is communicated to staff via the care plan and indicated that pushing and/or pulling on a contracted, osteopenic resident was not appropriate due to the possibility of causing pain and/or injury such as fractures. 2. Resident #117's [DIAGNOSES REDACTED]. An quarterly MDS dated [DATE] identified the resident as cognitively intact and independent with bed mobility, transfers, ambulating, eating and personal hygiene. A physician order [REDACTED]. a. A physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. December, 2014 MAR indicated [REDACTED]. Interview with RN# 2 on 1/15/15 at 10:44 AM identified that he/she did not administer [MEDICATION NAME] as identified because the resident was at [MEDICAL TREATMENT] until 3:00 PM on those days. RN# 2 further identified that she/he did not report to anyone that he/she was withholding medication because the resident was at [MEDICAL TREATMENT] during those scheduled administration times. Subsequent to surveyor inquiry, a physician order [REDACTED]. A self-administration assessment was completed on 1/14/15 and the resident deemed safe for self-administration of medication. b. A physician order [REDACTED]. A care plan dated 9/10/14 identified a problem with fluid restriction of 1200 cc in 24 hours with interventions that included to maintain fluid restriction of 1200 cc per 24 hours, divide allotted amount of cc's between dietary and nursing for medication and to monitor compliance. Review of the resident's fluid intake from 12/03/14 to 1/13/15 (43 days) identified the resident exceeded the fluid restriction by 150 cc to 600 cc, 38 out of 43 days. On 1/14/15 at 11:42 AM a review of the fluid intake flow sheets with Nursing Supervisor #1 failed to identify why the resident had been exceeding the fluid restriction and/or that an evaluation of the reason the resident was exceeding the fluid restriction (non-compliance, family bringing in fluids, lack of resident education, etc) was addressed. Further interview with Nursing Supervisor #1 identified the 11:00 PM to 7:00 AM Nursing Supervisor was to have identified that the resident was exceeding the fluid restriction because he/she tallies the fluid intake on a 3 day cycle. The 11:00 PM to 7:00 AM Nursing Supervisor is responsible to document in the APRN book and report that the resident was exceeding fluid restriction. Interview with the APRN on 1/14/15 at 12:04 PM identified that she/he could not recall if he/she was made aware of the resident exceeding the fluid restriction but if she/had been made aware, an APRN progress note would have been written. Review of the APRN progress notes at that time with Nursing Supervisor #1 failed to reflect an APRN note identifying the resident exceeded the fluid restrictions. The APRN further identified that had she/he been made aware, she/he would have assessed the resident for fluid overload and possibly order bloodwork to assess volume status. Facility policy for fluid restriction management identified the nurse will oversee documentation of the actual fluid intake on each shift and monitor to ensure that restriction is maintained.

Based on clinical record review and staff interview for 1 of 3 sampled residents reviewed for injuries of unknown origin (R#2 ), the facility failed to provide supervision and/or assistance to prevent an injury. The findings included: Resident #2's [DIAGNOSES REDACTED]. A Fall risk assessment dated [DATE] identified R#2 a high risk for falls. An annual assessment ((MDS) dated [DATE] identified the resident as severely cognitively impaired requiring provision of all activities of daily living (ADL) including bed mobility and transfers between surface i.e. bed to chair via a mechanical device. It further identified R#2 as always incontinent of bowel and bladder. Resident care plan (RCP) dated 6/19/14 identified utilization of a custom wheelchair for positioning and comfort. Interventions included out of bed per 24-hour positioning plan. The RCP further identified a self-care deficit, potential for falls and alteration in comfort secondary to impaired cognition due to [DIAGNOSES REDACTED], dependent mobility and contractures. Interventions included dependent on staff for all ADL care, transfers via Hoyer lift with assistance of two (2), and to observe for verbal and/or non-verbal cues regarding pain and to observe for crying, grimacing. A physician order [REDACTED]. Facility investigation documentation identified that on 07/31/14 at 10:30 PM, NA #1 and NA#3 found R#2 expressing discomfort. RN#5 and LPN#5 were informed, evaluated R#2 and found no evidence of trauma. On 8/01/14 at 7:30 AM, R#2 was found crying and upon assessment was noted to exhibit signs of pain with movement. The resident was subsequently transferred to the hospital and diagnosed with [REDACTED].# 2 reported that at 6:30 PM on the evening of 7/31/14, s/he had difficulty removing R#2's clothing in preparation for his/her shower due to immobility and contractures. Review of facility documentation (24 hour) communication and/or nurse's notes dated 7/31/14 and 8/01/14 failed to reflect any documentation related to staff reports of R#2's crying, staff reports of resident's expression of pain and/or physician notification. Hospital discharge summary dated 8/05/14 identified that upon admission R#2 was found to have a displaced proximal left femur fracture. It further identified that although unclear as to a history of a fall, abrasions were noted on his/her left knee suggesting a fall. Interview with NA#1 on 1/12/15 identified that up until the time he/she left for dinner break on 7/31/14 at approximately 6:00 PM, R#2 did not show any signs of pain and/or discomfort. NA#1 identified that upon return from break, NA#2 and NA#3 had given R#2 a shower and transferred him/her back to bed. NA#1 further indicated that at approximately 9:30 PM, R#2 was acting very different from his/her normal pattern. NA#1 indicated that R#2 was crying and grimacing when touched and with movement, in such a way he/she had never observed before. NA#1 further indicated he/she made LPN #5 aware of R#2's unusual crying/grimacing and that LPN# 5 and RN#5 checked on the resident. Interview with NA#2 on 1/12/15 at 5:00 PM indicated that with the assistance of NA#3 he/she had transferred R#2 to the shower room via his/her custom wheel chair (CWC). NA#2 further indicated he/she then proceeded to remove R#2's clothes while he/she was still in the CWC. NA#2 additionally indicated that he/she did not transfer the resident to a shower chair/device, and had given the resident a shower while seated in the CWC. Interview with LPN#1, Unit Manager and the ADON on 1/12/15 at 5:28 PM, identified that during rounds on the morning of 8/01/14, R#2 was found crying and upon further evaluation found his/her left leg swollen and externally rotated and was transferred to the hospital for evaluation. Interview with NA#3 on 1/13/15 at 10:55 AM indicated that although he/she assisted NA#3 with transferring R#2 to the shower room via CWC, he/she did not assist NA#2 with showering R#2. NA#3 indicated that he/she assisted R#2 back to bed after his/her shower and there was no indication of discomfort during the transfer. He/she indicated that later that shift around 9:30 PM while assisting NA#1 he/she observed that R#2 was crying, had a facial expression of pain and was acting, " weird " . NA#3 further indicated that he/she had never seen R#2 crying like that. Interview with LPN#4, the third shift charge nurse, on 1/13/15 at 9:15 AM indicated that although he/she was not made aware during change of shift report of any significant changes, at approximately 11:05 PM he/she could heard R#2 crying from the hallway. LPN#4 identified that the crying was different for the resident and later made RN#3, the night supervisor, aware. Interview with RN#3, night supervisor with the Director of Nursing (DNS) present on 1/13/15 at 11:30 AM indicated that although he/she was unable to say who gave the report on the second shift, he/she was made aware that R#2's left leg was swollen. RN#3 indicated that at some time during the night he/she observed that the left lower extremity more swollen than the right side. He/she further indicated that he/she did not make the physician aware because the left swollen leg was identified on the previous shift. Interview with NA#4 on 1/13/15 at 6:13 AM identified that from the beginning of the shift on 7/31/14 and into the 11-7 AM shift of 8/01/14, R#2 was moaning. NA#4 indicated that the 3-11 PM nurse aide had reported to him/her that, " the resident " was like that all night " . NA#4 indicated that the resident continued through the 11-7 AM shift onto 8/01/14 to, " not act like his/her self " and was " scrunching his/her face up " grimacing and moaning when moved. NA#4 indicated he/she reported multiple times through the shift that something was not right with the resident. Interview with OT#1 and PT #1 on 1/13/15 at 8:40 AM identified that the twenty-four hour positioning plan is communicated to staff via the care plan and indicated that pushing and/or pulling on a contracted, osteopenic resident was not appropriate due to possibly causing pain and/or injury such as fractures. Interview and review of R#2's clinical record and/or facility investigation documentation with the DNS on 1/13/15 at 12:15 PM indicated that the investigation concluded that the injury most likely occurred as a result of the resident's profound osteopenia. Review of NA#2's initial statement dated 8/01/14 identified that NA#3 assisted with the transfer of R#2 via a Hoyer lift into the shower chair and later recanted indicating that R#2 was showered in his/her custom wheelchair, then transferred to bed. NA#2 indicated that this practice was not common place but he/she did not have enough time during the evening. NA#2 indicated she asked NA#3 to say R#2 was washed in the shower chair. Review of NA#2's and NA#3's personnel file identified both NA's were provided a notice of disciplinary action on 8/01/14 regarding making a false statement about the manner R#2 was transferred and showered on 7/31/04, and a prior one-to-one inservice dated 9/30/13 provided to NA#2 regarding not removing dependent resident's clothes while they are sitting in the wheelchair when providing showers. Review of NA#3's Witness Statement dated 8/01/14 identified that while in the shower room while preparing R#2 to be showered NA#2 assisted in tilting the chair back to remove the resident's pants. At the time, " they used R#2's leg to assist" in taking his/her pants off. The resident was then showered in a tilt and space wheelchair. NA#3 indicated that it is likely that when they used R#2's leg to take off his/her pants, that is when the injury occurred. Review of LPN#4's (11-7 charge nurse) Witness Statement dated 8/01/14, identified that no information was relayed by LPN#5 (3-11 charge nurse) regarding R#2 at shift report. However, LPN#4 indicated that while making rounds LPN#5 was observed in R#2's room and reported that R#2 had been crying earlier in the shift and he/she had never heard R#2 crying like that before. RN#3, LPN#5 were unable to identify why R#2 was crying because everywhere they touched on assessment R#2 would cry.

Based on clinical record review, observation, and interviews for one of three residents reviewed for accidents (Resident #26), the facility failed to ensure the resident's safety during a transfer. The findings included: Resident #26's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified short and long term deficits, moderately impaired decision ability, required extensive assistant of one staff member with bed mobility and was totally dependent on two staff members for transfers. The care plan dated 7/12/13 identified a risk for falls with interventions which included to transfer out of bed to a modified tilt and space wheelchair via mechanical lift with assistance of two staff members utilizing a self-releasing seatbelt. The Accident/Incident report dated 09/29/13 identified that at 6:30 PM the resident was observed by the charge nurse lying on the right side on the floor after the fall that was witnessed by two Nursing Assistants. The resident was bleeding from a laceration on the occipital area of the head and was transferred to the hospital for an evaluation. The resident returned to the facility after receiving six staples to approximate the wound. The hospital discharge summary identified a CT scan and cervical spine x-ray was conducted that was initially negative. The nurse's note dated 09/30/13 at 4:00 PM identified that the facility was notified by the hospital to have the resident return for a repeat CT scan. The note identified that the resident had been alert but sleepy, with baseline neuro checks prior to having been send to the hospital at 5:30 PM. The note identified that Resident #26 had been admitted to hospital with a [DIAGNOSES REDACTED]. A written statement by NA#2 identified that resident received a shower and was being lifted back into bed with the crisis-cross Hoyer pad with green straps in place and that NA#1 was behind the chair and NA#2 had been in the front of resident guiding his/her legs. NA #2 statement identified that when the resident had been lifted 3-4 inches from the shower chair, the resident had been observed leaning to the right and that the Hoyer strap on the left had "popped off" the hook and the resident started to fall and hit his/her head on the floor. A review of the Report of Summary and Conclusion of the event by facility identified that contributing factors to the fall may have included the resident being lifted with a wet sling, resident leaning to right side, and the sling hook dislodging. Interview with NA#2 on 12/11/13 at 3:00 PM identified that he/she had finished showering Resident #26 and had returned the resident to the room to lift the resident back into the bed from the shower chair. He/she identified that the straps had been in place, the six hook-ups and the one between resident ' s legs. NA #2 identified that I was controlling the Hoyer, and the resident started to lean to the right and it happened so fast that Resident #26 fell off. NA#2 acknowledged that the straps may have not been put on correctly. Interview with NA#1 on 12/12/13 at 7:30 AM identified that it had been a Sunday night and had been assisting Resident #26's roommate and NA#2 had returned to the bedroom with Resident #26 in the shower chair. NA #1 identified that it happened so fast and did not know what happened and that NA#2 had indicated that he/she had the resident all hooked up. NA #1 identified that he/she had been behind the chair and could not see and had pulled the shower chair away to grab onto the Hoyer pad, and that all of a sudden the resident had fallen. Interview with the Manufacturing Company representative on 12/12/13 at 2:35 PM identified that the model of the lift identified having been used during the event did not have safety clips, as described in the investigation. He/she identified that the resident's weight would have kept the straps secured on the prongs. He/she identified that the only way the event could have happened would have been if the resident had shifted the weight in a way to cause slack on the strap allowing it to slip off the prong, or if the strap had not been applied correctly. Interview with Biomedical Consultant on 12/13/13 at 9:00 AM identified that he/she was called in to inspect the equipment following the event and found no mechanical issues and identified that the lift may have had open hooks and that the strap might have slipped off or they may have not been placed on correctly.

Based on clinical record review and interview for 4 of 6 sampled residents reviewed for pressure sores ( R#2, R#27,R#33, R#160), the facility failed to monitor the use of a splint to prevent skin breakdown and/or ensure that wounds were thoroughly and accurately assessed upon admission and/or at least weekly, and/or when a change in condition occurred and/or when the wound was treated surgically. The findings include: 1. Resident #27's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident with severe cognitive impairment, total dependence on staff for ADL's and functional limitations in the range of motion in both lower extremities. The Resident Care Plan dated 8/8/12 identified the need for splints/braces related to lower extremity contractures. Interventions directed to apply splints as ordered and monitor and report skin problems. physician's orders [REDACTED]. Nurse's Notes dated 10/4/12 at 10:30 AM identified the resident was observed with open areas under the right knee. Two open areas that measured 1 cm by 1 cm and 0.5 cm by 0.5 cm were noted and contained slough. The APRN and the rehab dept were notified and the use of the splints was put on hold until therapy could evaluate the splints. An APRN note dated 10/4/12 identified the wound had slight depth and 100% slough. A referral was made to the Wound Care Specialist. The Wound Care Specialist initial evaluation identified the presence of a popliteal wound secondary to pressure caused by the use of a brace. The wound measured 2 cm by 1.3 cm and was 95% eschar. On 10/16/12 the resident under went surgical excisional debridement of the wound. Post surgical depth was identified as 0.2 cm. The resident was evaluated and treated by the Wound Care Specialist weekly until 1/15/13 when the would was identified as healed. Interview and review of the clinical record on 1/17/13 at 10:15 AM with LPN# 1 identified that the NA's on the 3:00 PM to 11:00 PM shift applied the resident's splints/braces every evening during care. Although the NA checked the resident's skin at that time, the nurses assessed the residents skin once a week on shower days. Interview and review of the clinical record on 1/17/13 at 1:00 PM with the Director of Rehab identified that although the resident had been using the splints/braces since July 2012, the clinical record failed to reflect that the NA's were instructed on the correct application and use of the splints. A therapy evaluation dated 10/4/12 identified that the resident's splints were assessed after the wounds were identified and noted to be missing the required air bladders that would prevent skin to skin contact and the knee pad was being used incorrectly leading to skin breakdown. 2. Resident #2's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified intact cognition and required extensive assistance of one staff member for bed mobility and dressing. The quarterly MDS further identified the resident required extensive assistance of two staff members for transfers and toileting. A care plan dated 12/18/12 identified a problem with an unstageable pressure ulcer to the coccyx with interventions to utilize a specialty mattress, avoid friction and shearing while repositioning. A nursing re-admission evaluation form completed by LPN#3 dated 12/18/12 identified pressure ulcer to the coccyx measuring 7 cm by 8 cm. Nurses notes dated 12/18/12 at 7:30 PM by LPN#3 identified a pressure ulcer of 7 cm by 8 cm but failed to identify location. Both nursing re-admission evaluation form and nurses notes by LPN#3 failed to identify the stage of the wound and/or description of the wound. A pressure ulcer record document was not initiated until 12/19/12 by LPN#2/Unit Manager that identified an unstageable 10 cm by 7 cm by 0.2 cm coccyx pressure sore with a scant amount of serous drainage with slough and eschar present. The resident was transferred to the hospital on [DATE] and was re-admitted to the facility on [DATE]. A nursing re-admission evaluation form and nurses notes completed on 12/23/12 identified a coccyx pressure open area measuring 8 cm by 7.5 cm. Nurses notes and admission evaluation failed to identify the stage of the wound and/or description of the wound and/or wound bed. A pressure ulcer record document had not been initiated. The resident was then admitted to the hospital on [DATE]. Facility policy regarding pressure ulcers identified upon admission of a resident with a wound, the type,location,measurements, stage, general appearance, presence of or infection,will be documented on the designated form for pressure ulcers. Interview with LPN#2/Unit Manager on 1/16/13 at 3:10 PM noted that she measured the wound on 12/19/12 and referred to the hospital discharge summary to stage the wound as unstageable. She further failed to provide evidence that a RN assessed the pressure ulcer. LPN#2/Unit Manager further noted that when a resident is identified as having a pressure sore on the admission evaluation, the admitting nurse is to initiate a wound sheet. A wound sheet had not been initiated timely when the resident was admitted on [DATE] and had not ever been initiated on the 12/23/12 admission. 3. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Resident Evaluation Form dated 1/4/13 identified the resident with open areas, measuring 2 centimeters (cm) by 1.5 cm and 3 cm by 1 cm on the left buttock and 1.5 cm by 1 cm on the right buttock. The admission care plan dated 1/4/13 identified the resident with stage II pressure ulcer to the left buttock. Interventions included to assess skin weekly and as needed, and to update the physician with signs of infection or wound deterioration. The Advanced Practice Registered Nurse (APRN) Progress Note dated 1/7/13 identified excoriation and open areas on buttocks. Review of the Wound Care Specialist Initial Evaluation dated 1/8/13 noted a stage III left buttock pressure wound, measuring 2.5 cm by 0.6 cm with light serous exudates, 20 % thick adherent devitalized necrotic tissue and 80 % granulation tissue. Further review of the evaluation identified that on 1/7/13 the left buttock pressure ulcer was surgically debrided of subcutaneous tissue and the post debridement depth measured 0.1 cm. The Pressure Ulcer Record dated 1/16/13 identified the resident with a stage III wound on the left buttock that measured 1.5 cm by 0.6 cm with pink, pale wound bed, no depth, no exudates and normal surrounding skin. Review of the clinical record failed to reflect documentation that assessments of open skin areas were conducted and/or documented when resident was admitted with pressure ulcers. Interview with APRN# 1 on 1/17/13 at 12:00 PM identified that on 1/7/13 Resident ' s #33 buttocks looked excoriated with broken skin integrity secondary to resident ' s loose stools. Interview with LPN #1 on 1/17/13 at 1:00 PM identified that on 1/8/13 she conducted wound rounds with Wound Care physician. LPN #1 further identified that Resident ' s # 33 left buttock pressure ulcers had pink tissues, no necrosis and no drainage ... ... ... Interview and wound observation with LPN #2 on 1/17/13 at 4:00 PM identified the residents left buttock pressure ulcer with pink, fragile tissues and no drainage. LPN #2 further indicated that the pressure ulcer appears almost healed. 4. Resident #160's [DIAGNOSES REDACTED]. The wound assessment form dated 8/2/12 noted a 2 by 1 cm with a "normal for skin" wound bed. The next assessment dated [DATE] identified that the wound was a stage 3 measuring 2 by 1.8 cm with granulation tissue present. Slough and/or eschar were not checked off as being present for either assessment. Review of the wound physician's documentation dated 8/6/12 noted that upon assessment the wound was a stage 3 pressure sore measuring 2 by 1.8 by unmeasurable with 25% thick adherent devitalized necrotic tissue. The note indicated that a surgical debridement was conducted with topical [MEDICATION NAME] applied for pain control with 1 ml blood loss and residual necrosis was present and scored. The resident was assessed by the wound physician again on 8/13/12 and he documented that the wound was a stage 3 pressure sore measuring 2.4 by 1.5 by unmeasurable with 20% thick adherent devitalized necrotic tissue. The note indicated that a surgical debridement was conducted with topical [MEDICATION NAME] applied for pain control with 1 ml blood loss and residual necrosis was present and scored. The facility wound assessment dated [DATE] indicated that the wound was the same size as the physician indicated but only contained granulation tissue. Interview and review of the clinical record with the DNS and ADNS on 1/16/13 at 3:45 PM failed to provide documentation that the surgical procedures conducted on the resident were documented along with an assessment of the resident before, during and after the procedure, that the wound was reassessed for bleeding and signs of infections post operatively, and/or that the residents pain was assessed before during and / or after the procedure, or that necrosis was ever present in the wound. Further review and interview noted that facility nursing staff are not allowed to assess wounds or stage them, which was why the wound was not staged from admission on 8/2/12 until the resident was assessed by the wound physician on 8/6/12 who noted a stage 3 wound with necrosis present.