Every finding on record at Civita Care Center at West River

Based on observations, interviews, and review of facility documentation, the facility failed to monitor and maintain dishwasher water temperatures at the appropriate level. The findings include:a. Observation on 08/19/2026 from 11:45 AM to 11:55 AM identified Dietary Aide #1 was in the dish room the only staff present. Dietary Aide #1 was observed handling soiled dishes, placing dish racks into the dishwasher, and, after several dishwasher cycles, moving to the clean side of the dish room to remove clean dishes from the machine to make space for additional loads.b. Observation on 08/19/2026 from 11:55 AM and 11:59 AM of the dishwasher cycles from washing and rinsing identified at 11:55 AM, the dishwasher temperature gauge for the wash cycle read 156 Fahrenheit (F), and the rinse cycle temperature gauge displayed readings between 144 F and 148 F.Interview with Dietary Aide #1 on 08/19/2026 at 12:00 PM identified that he was not sure whether the dishwasher was a chemical sanitizing dishwasher or a high temperature dishwasher. Dietary Aide #1 identified he did not have to monitor or take any actions regarding the temperature gauges. Dietary Aide #1 indicated usually another kitchen staff member would check the gauges and document the readings on a clipboard.Interview and observation with the Director of Dietary on 8/19/2026 at 12:10 PM indicated that the dishwasher was new and that it operated as both a high temperature and chemical sanitizing dishwasher. Observation of the dishwasher failed to identify any setup for chemical sanitizer. The Director of Dietary indicated the bottles labeled Performance Plus Dishwasher Detergent and Solid [NAME] 23 Rinse Aide were the sanitizing chemicals used with the machine. A review of the Safety Data Sheets for both products failed to identify any approved disinfectant ingredients. The Director of Dietary then stated the dishwasher was a high temperature dishwasher.c. Observation on 08/19/2026 at 12:25 PM conducted with the Director of Dietary of the dishwasher identified that the wash cycle temperature was 158.0 F and the rinse cycle temperature was 144.0 F.d. Observation on 08/19/2026 at 12:35 PM of a temperature test strip conducted with the Director of Dietary identified the water temperature reaching the dishes failed to reach 160.0 F, as evidenced by the test strip not changing color.e. Observation on 08/19/2026 at 12:38 PM noted the Director of Maintenance was working on the dishwasher.A follow up interview with the Director of Dietary on 08/19/2026 at 12:59 PM identified that the dishwasher's hot water booster required adjustment. Observation of the dishwasher temperature gauges conducted with the Director of Dietary identified that the wash cycle temperature was 154.0 F and the rinse cycle temperature was 188.0 F.Although requested, a facility policy for dishwasher temperatures was not provided. The Director of Dietary provided a sign that indicated the wash temperature should be at least 150 F and the rinse temperature should be 180 F. A review of the manufacturer's operating instructions for the dish machine, observed hanging in the dish room, identified that when using hot water for sanitizing, the wash temperature should be 160 F and the sanitizing temperature should be 180 F.

Based on review of clinical records, facility documentation, facility policy, and interviews for 3 of 6 residents (Residents #13, #106, and #121) reviewed for pain management, the facility failed to ensure the residents received care in accordance with professional standards. Specifically, the facility failed to complete pain assessments prior to administering as needed (PRN) pain medications. The findings include:1. Resident #13's diagnoses included displaced intertrochanteric fracture of the right femur, vertebral fracture, and cognitive communication deficit.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had BIMS score of five (5) indicating severe cognitive impairment, required moderate assistance with bed mobility, and required supervision with eating.Physician's order dated 6/6/2026 with a stop date of 6/22/2026 directed to administer Tramadol (opioid medication used to treat pain) 50 milligrams (mg) for severe pain (pain scale of 7 to 10) every six hours as needed (PRN).The Resident Care Plan (RCP) dated 6/22/2026 identified Resident #13 had pain. Interventions directed to administer medications as ordered and assess effectiveness.Physician's order dated 6/22/2026 with a stop date of 7/6/2026 directed to administer Tramadol 50 mg for moderate pain (pain scale of 4 to 6) every six hours PRN.a. Review of the Controlled Substance Distribution Record (CSRD) (a form used in healthcare facilities to track every dose of a controlled medication from the time it is received until administered to a resident or properly discarded. It documents who received the medication, who administered it, when it was given, and how much was used, helping prevent misuse and medication errors while ensuring patient safety and legal compliance) identified Resident #13 was administered Tramadol 50 mg on the following dates and times on 6/10/2026 at 4:00 AM; 6/16/2026 at 9:00 AM; 6/24/2026 at 10:00 AM; 6/24/2026 at 8:00 PM; 6/25/2026 at 9:00 PM; 6/26/2026 at 9:00 PM; 6/30/2026 at 9:00 PM; 7/1/2026 at 9:00 PM; 7/2/2026 at 9:00 AM; and 7/3/2026 at 6:00 PM, totaling ten (10) doses.Review of the clinical record failed to identify from 6/10/2026 through 7/3/2026 that Pain Assessments were completed prior to the administration of Tramadol 50 mg on the dates and times noted above (10 pain assessments were not completed).The nurse's notes dated 6/10/2026 through 7/3/2026 failed to identify the location of the pain when pain medication was administered to Resident #13.b. Physician's order dated 8/2/2026 (with no stop date) directed to administer Tramadol 50 milligrams for moderate pain (pain scale of 4 to 6) every six hours PRN.Review of the Controlled Substance Distribution Record (CSRD) identified Resident #13 was administered Tramadol 50 mg on the following dates and times on 8/2/2026 at 8:00 AM; 08/11/2026 at 7:00 PM; 08/12/2026 at 8:00 PM; and 8/16/2026 at 7:00 PM, totaling four (4) doses.Review of the clinical record failed to identify from 8/2/2026 through 8/16/2026 that Pain Assessments were completed prior to the administration of Tramadol 50 mg on the dates and times noted above (4 pain assessments were not completed).The nurse's notes dated 8/2/2026 through 8/16/2026 failed to identify the location of the pain when pain medication was administered to Resident #13. 2. Resident #106's diagnoses included displaced intertrochanteric fracture of the right rib, wedge compression fracture of the vertebra, and fusion of spine.Physician's order dated 8/3/2026 directed to administer Oxycodone (an opioid pain medicine used to treat severe pain) 5 mg every six hours as needed for severe pain.The 5-day MDS assessment dated [DATE] identified Resident #106 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating intact cognition and was independent with eating. The MDS further identified Resident #106 received PRN pain medication.Review of the Controlled Substance Distribution Record (CSRD) identified Resident #106 was administered Oxycodone 5 mg on the following dates and times on 8/14/2026 at 9:20 AM; 8/14/2026 at 3:00 PM; 8/14/2026 at 9 PM; 8/15/2026 at 4:38 AM; 8/15/2026 at 10:30 AM, 8/15/2026 at 6:00 PM; 8/16/2026 at 1:46 AM; 8/16/2026 at 9:30 AM; 8/16/2026 at 3:00 PM; 8/16/2026 at 9:40 PM; 8/17/2026 at 4:42 AM, 8/17/2026 at 10:10 AM; 8/17/2026 at 5:30 PM; 8/18/2026 at 1:00 AM; 8/18/2026 at 10:02 PM; 8/19/2026 at 8:15 AM; and 8/19/2026 at 6:20 PM, totaling seventeen (17) doses.Review of the clinical record failed to identify that pain assessments were completed on 8/15/2026 at 6:00 PM and on 8/17/2026 at 4:42 AM prior to the administration of Oxycodone 5 mg (2 pain assessments were not completed).3. Resident #121's diagnoses included fracture of the upper end of the right tibia, pain, and type 2 diabetes.Physician's order dated 5/4/2026 with a stop date of 6/14/2026 directed to administer Oxycodone (an opioid pain medicine used to treat severe pain) 5 mg every eight hours as needed for moderate to severe pain (pain scale of 4-10).The quarterly MDS assessment dated [DATE] identified Resident #121 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating intact cognition. The MDS further identified Resident #121 received scheduled and PRN pain medication.The Resident Care Plan (RCP) dated 6/22/2026 identified Resident #121 had pain and discomfort related to chronic pain syndrome and wounds. Interventions directed to administer medications as ordered and assess effectiveness.Physician's order dated 7/8/2026 directed to administer Oxycodone (an opioid pain medicine used to treat severe pain) 5 mg every eight hours as needed for moderate to severe pain (pain scale of 4-10).Review of the Controlled Substance Distribution Record (CSRD) identified Resident #121 was administered Oxycodone 5 mg on the following dates and times 6/7/2026 at 6:00 PM; 6/21/2026 at 9:00 PM; 6/25/2026 at 1:00 PM; 6/25/2026 at 2:00 PM; 6/28/2026 at 5:00 PM 6/30/2026 at 6:00 PM; 7/9/2026 at 1:00 PM; 7/10/2026 at 3:12 AM; 7/11/2026 at 1:00 PM; 7/12/2026 at 1:00 PM; 7/14/2026 at 12:00 PM; 7/17/2026 at 12:00 PM; 7/18/2026 at 12:00 PM; and 7/19/2026 at 2:30 PM, totaling fourteen (14) doses.Review of the clinical record failed to identify on 6/7/2026 through 7/19/2026 that Pain Assessments were completed prior to the administration of Oxycodone 5 mg (14 pain assessments were not completed).Interview on 8/20/2026 at 5:44 AM with Registered Nurse (RN) #1 (nurse manager) identified she expects nurses to assess and document a resident's pain before administering pain medication.Interview on 8/20/2026 at 7:47 AM with the Director of Nursing Services (DNS), identified nurses should assess a resident's pain before giving pain medication. The DNS further identified pain assessments should have been completed each time pain medications were administered to Residents #13, #106, and #121. The DNS was unable to explain why pain assessments were not completed when pain medications were administered to Residents #13, #106, and #121.Interview on 8/20/2026 at 10:00 AM with Licensed Practical Nurse (LPN) #11 indicated she was aware a pain assessment should be completed before giving pain medication and documented in the resident's medical record. LPN #11 identified she had administered Oxycodone 5mg to Resident #121 on multiple dates, but she did not complete pre administration pain assessments. LPN #11 further identified she had administered Tramadol 50 mg to Resident #13 on multiple dates, but she did not complete pre-administration pain assessments. LPN #11 was unable to explain why she did not consistently complete pre-administration pain assessments.Interview on 8/20/2026 at 11:26 AM with LPN #10 indicated she was aware a pain assessment should be completed before administering a pain medication and documented in a resident's medical record. LPN #10 identified she had administered Oxycodone 5 mg to Resident #106 on various dates, but she did not complete pre-administration pain assessments. LPN #10 was unable to explain why she did not consistently complete pre-administration pain assessments.Review of the facility's PRN Medication Administration policy (undated) directed in part, prior to administering a PRN medication the licensed nurse will assess the resident to determine the reason for administration and verify that the medication is appropriate for the resident's current symptoms or condition. The reason or indication for administration will be documented in accordance with the facility's documentation system.

Based on review of clinical records, interviews, facility documentation and facility policy, for one 5 of 5 residents (Resident #8, Resident #13, Resident #106, Resident #121, and Resident #122) reviewed for medication administration, the facility failed to record the administration of controlled medications on the Medication Administration Records (MAR) and facility failed to document the removal of a controlled medications on the Controlled Substance Distribution Record (CSDR). The findings included:1.Resident #8's diagnoses included anxiety, schizophrenia, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, was independent with eating and required moderate with bed mobility.The Resident Care Plan (RCP) dated 5/10/2026 identified Resident #8 had schizophrenia. Interventions directed to administer medications as ordered and assess effectiveness, monitor behaviors every shift, document observed behaviors and attempted interventions.Physician's order dated 7/14/2026 at 2:45 PM with a stop date of 7/15/2026 directed to administer Alprazolam ( medication used to treat anxiety and panic disorder) 0.25 milligrams (mg) every 8 hours as needed (PRN).Physician's order dated 8/14/2026 at 2:44 PM with no stop date directed to administer Alprazolam 0.25 mg every 8 hours PRN.a. A nurse's note dated 7/14/2026 at 3:03 PM identified Resident #8 was administered Alprazolam 0.25 mg.Review of the Controlled Substance Distribution Record (CSDR) failed to identify 0.25 mg of Alprazolam was administered to Resident #8 on 7/14/2026.Review of the Medication Administration Report (MAR) dated 7/14/2026 failed to identify 25 milligrams of Alprazolam was administered to Resident #8.b. Review of the CSDR form identified Resident #8 was administered 0.25 mg of Alprazolam on 7/15/2026 at 9:00 AM, 7/22/2026 at 8:00 PM, 8/14/2026 at 2:30 PM, and 8/15/2026 at 12:00 PM.Review of the Medication Administration Report (MAR) dated 7/15/2026 at 9:00 AM, 7/22/2026 at 8:00 PM, 8/14/2026 at 2:30 PM, and 8/15/2026 at 12:00 PM failed to identify 25 milligrams of Alprazolam was administered to Resident #8. 2. Resident #13's diagnoses included displaced intertrochanteric fracture of the right femur, vertebral fracture, and cognitive communication deficit.The quarterly MDS assessment dated [DATE] identified Resident #13 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment, required supervision with eating, and moderate assistance with bed mobility.The RCP dated 6/22/2026 identified Resident #13 had pain. Interventions included administer medications as ordered and assess effectiveness.Physician's order dated 6/22/2026 with a stop date of 7/6/2026 directed to administer Tramadol (medication used to treat pain) 50 mg for moderate pain (pain scale 4-6) every six hours PRN.a.A nurse's note dated 6/24/2026 at 3:04 PM identified Resident #13 was administered Tramadol 50 mg.Review of the Controlled Substance Distribution Record (CSDR) failed to identify 50 mg of Tramadol was administered to Resident #13 on 6/24/2026.Review of the Medication Administration Report (MAR) dated 6/24/2026 failed to identify 50 mg of Tramadol was administered to Resident #13. Physician's order dated 8/02/2026 with no stop date directed to administer Tramadol 50 mg for moderate pain (pain scale 4-6) every six hours PRN.b. Review of the CSDR form identified Resident #13 was administered 50 mg of Tramadol 8/2/2026 at 8:00 AM; 8/11/2026 at 7:00 PM; 8/12/2026 at 8:00 PM; and 8/16/2026 at 7:00 PM.Review of the Medication Administration Report (MAR) dated 8/2/2026 at 8:00 AM; 8/11/2026 at 7:00 PM; 8/12/2026 at 8:00 PM; and 8/16/2026 at 7:00 PM. failed to identify 50 mg of Tramadol was administered to Resident #13. 3. Resident #106's diagnoses included displaced intertrochanteric fracture of right rib, wedge compression fracture of the vertebra, and fusion of spine.Physician's order dated 8/3/2026 directed to administer Oxycodone 5 mg (medication used to treat pain) every six hours PRN for severe pain.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and was independent with eating.Review of the CSDR form identified Resident #106 was administered 5 mg of Oxycodone on 8/15/2026 at 6:00 PM and 8/17/2026 at 4:42 AM.Review of the Medication Administration Report (MAR) dated 8/15/2026 at 6:00 PM and 8/17/2026 at 4:42 AM failed to identify 5 mg of Oxycodone was administered to Resident #106. 4.Resident #121's diagnoses included fracture of the upper end of the right tibia, pain, and type 2 diabetes.Physician's order dated 5/4/2026 with a stop date of 6/14/2026 directed to administer Oxycodone 5 mg every 8 hours PRN for moderate to severe pain (pain scale 4-10).The quarterly MDS assessment dated [DATE] identified Resident #121 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition, required set-up with eating, and was on both scheduled and PRN pain medications.Physician's order dated 6/14/2026 with a stop date of 7/8/2026 directed to administer Oxycodone 5 mg every 8 hours PRN for moderate to severe pain (pain scale 4-10).The Resident Care Plan (RCP) dated 6/22/2026 identified Resident #121 had pain and discomfort related to chronic pain syndrome and wounds. Interventions included administer medications as ordered and assess effectiveness.Physician's order dated 7/8/2026 with no stop date directed to administer Oxycodone 5 mg every 8 hours PRN for moderate to severe pain (pain scale 4-10).Review of the Medication Administration Report (MAR) dated 6/7/2026 at 2:37 PM, 6/26/2026 at 12:56 PM, and 7/8/26 at 5:42 PM identified Oxycodone 5 mg was administered to Resident #121.Review of the CSDR form identified Resident #121 failed to identify 5 mg of Oxycodone was administered to Resident #121 on 6/7/2026 at 2:37 PM, 6/26/2026 at 12:56 PM, and 7/8/26 at 5:42 PM.5. Resident #122's diagnoses included anxiety, depression, and Stage 5 chronic kidney disease.The admission MDS assessment dated [DATE] identified Resident #122 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition, required set-up assistance with eating, and required moderate assistance with rolling left and right.The RCP dated 8/20/2026 identified Resident #122 had increased anxiousness. Interventions included administer medications per ordered and monitor for side effects and effectiveness.Physician's order dated 8/07/2026 with a stop date of 8/18/2026 directed to administer Alprazolam 0.5 mg by mouth every 12 hours as needed for anxiety/mood, and hold for mental status changes, somnolence, and respiratory depression.Physician's order dated 8/18/2026 with a stop date of 9/01/2026 directed to administer Alprazolam 0.5 mg by mouth every 12 hours as needed for anxiety/mood, and hold for mental status changes, somnolence, and respiratory depression.a.Review of the CSDR identified Resident #122 was administered 0.5 mg of Alprazolam on 08/10/2026 at 11:00 AM, 08/14/2026 at 5:00 PM, 08/17/2026 at 2:00 PM, and 08/17/2026 at 6:00 PM.Review of the Medication Administration Report (MAR) dated 08/10/2026 at 11:00 AM, 08/14/2026 at 5:00 PM, 08/17/2026 at 2:00 PM, and 08/17/2026 at 6:00 PM failed to identify Alprazolam 0.5 mg was administered to Resident #122.b. Review of the MAR dated 8/11/2026 at 11:05 AM identified 0.5 mg of Alprazolam was administered to Resident #122.Review of the CSDR identified dated 8/11/2026 at 11:05 AM failed to identify Alprazolam 0.5 mg was administered to Resident #122. Interview on 08/20/2026 at 7:47 AM with the DNS identified that she expects nurses to document on the Controlled Substance Distribution Record and the MAR immediately before and after giving medications. The DNS was unable to explain why nurses were not consistently documenting when on the CSDR and MAR when administering narcotics.Interview on 08/20/2026 at 10:00 AM with Licensed Practical Nurse (LPN) #11 identified when she administers narcotic pain medications to a resident, she is responsible for documenting both the MAR and the CSDR. LPN #11 indicated she administers the medication immediately after popping it from the blister pack but does not always document because the unit was very busy and the residents were very needy.Interview on 08/20/2026 at 11:26 AM with LPN #10 identified when she administers narcotic pain medications to a resident, she is responsible for documenting in both the MAR and the Controlled Substance Distribution Record. LPN #10 indicated that her inconsistent documentation occurred because someone must have interrupted or distracted her.Review of the facility's undated Medication Disposal/Destruction policy directed in part Schedule three (III), four (IV), and five (V) medications may be disposed of at the facility by two licensed personnel, as directed by state laws, regulations, and/or the DEA. The facility will maintain a record of all discontinued medications for record keeping purposes for a period of three years.Review of the facility's undated PRN Medication Administration policy directed in part; administration of a PRN medication will be documented in the resident's electronic Medication Administration Record (eMAR/MAR).

Based on review of the clinical records, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #8 and Resident #13) reviewed for medication administration, the facility failed to obtain physician orders before administering controlled medications, resulting in significant medication errors. The findings include:1.Resident #8's diagnoses included anxiety, schizophrenia, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of ten (10), indicating moderate cognitive impairment, required moderate assistance with bed mobility, and was independent with eating.The Resident Care Plan (RCP) dated 5/10/2026 identified Resident #8 had schizophrenia. Interventions directed to administer medications as ordered and assess effectiveness, and monitor behaviors every shift, document observed behaviors, and attempted interventions.A physician's order dated 7/14/2026 at 2:45 PM with a stop date of 7/15/2026 directed to administer Alprazolam (a medication used to treat anxiety and panic disorders) 0.25 milligrams (mg) every eight hours as needed (PRN).Review of the Controlled Substance Distribution Record (CSRD) (a form used in healthcare facilities to track every dose of a controlled medication from the time it is received until administered to a resident or properly discarded. It documents who received the medication, who administered it, when it was given, and how much was used, helping prevent misuse and medication errors while ensuring patient safety and legal compliance) identified that Alprazolam 0.25 mg one (1) tablet was administered at 2:30 PM on 8/14/2026 by Licensed Practical Nurse (LPN #3).Review of the Medication Administration Record (MAR) dated 08/14/2026 identified Alprazolam 0.25 mg was not listed as an active medication on the MAR.Interview on 8/19/2026 at 12:12 PM with Registered Nurse (RN) #4 (Regional Clinical Nurse) identified medications should not be administered without an active physician's order. RN #4 further identified LPN #3 made a significant medication error when she administered Alprazolam 0.25 mg on 8/14/2026 at 2:30 PM without an active order.Interview on 8/19/2026 at 1:43 PM with Medical Doctor (MD) #2 identified she expects nurses to contact a provider to obtain an order when a resident needs medication. MD #2 further identified medications should not be administered without an active physician's order. MD #2 indicated she was not notified that Resident #8 received Alprazolam 0.25 mg without an active order.Attempts to interview LPN #3 were unsuccessful. 2. Resident #13's diagnoses included displaced intertrochanteric fracture of the right femur, vertebral fracture, and cognitive communication deficit.The quarterly MDS assessment dated [DATE] identified Resident #13 had BIMS score of five (5), indicating severe cognitive impairment, required moderate assistance with bed mobility, and supervision with eating.The RCP dated 6/22/2026 identified Resident #13 had pain. Interventions directed to administer medications as ordered and assess effectiveness.A physician's order dated 6/22/2026 with a stop date of 7/6/2026 directed to administer Tramadol (an opioid medication used to treat pain) 50 milligrams (mg) for moderate pain (pain scale of 4-6) every six hours PRN.Review of the Controlled Substance Distribution Record (CSRD) (a form used in healthcare facilities to track every dose of a controlled medication from the time it is received until administered to a resident or properly discarded. It documents who received the medication, who administered it, when it was given, and how much was used, helping prevent misuse and medication errors while ensuring patient safety and legal compliance) identified LPN #10 administered Tramadol 50 mg on the following dates and times, totaling five (5) doses, without a physician's order on:7/13/2026 at 8:00 PM7/29/2026 at 8:00 PM7/30/2026 at 8:00 PM7/31/2026 at 1:00 PM8/2/2026 at 8:00 AM Review of the Medication Administration Record (MAR) dated 7/13/2026 through 8/2/2026 8/14/2026 identified Tramadol 50 mg was not an active medication listed on the MAR.Interview on 8/19/2026 at 12:12 PM with Registered Nurse (RN) #4 (Regional Clinical Nurse) identified nurses should not give medications without an active physician's order. RN #4 indicated LPN #10 should not have administered Tramadol 50 mg to Resident #13 from 7/13/2026 through 8/2/2026 because there was no physician's order. RN #4 identified LPN #10 made significant medication errors.Interview on 8/19/2026 at 1:43 PM with MD #2 identified she expects nurses to contact a provider to obtain an order when a resident needs medication. MD #2 further identified medications should not be given without an active physician's order. MD #2 indicated she was not notified that Resident #13 received Tramadol 50 mg on multiple occasions without an active order.Interview on 8/20/2026 at 11:26 AM with LPN #10 identified she was aware medication administration should be documented in a resident's MAR. LPN #10 stated she did not know Resident #13 did not have an active order for Tramadol 50 mg when she gave the medication because she does not always check the MAR before giving medications. LPN #10 indicated she did not verify the order or document the doses because she was very busy and Resident #13 was in pain.Interview on 8/20/2026 at 12:07 PM with Advanced Practice Registered Nurse (APRN) #1 identified she expects nurses to contact her when a resident needs a renewal of a PRN medication. APRN #1 indicated medications given without an active order would not appear in the MAR. APRN #1 identified when staff give a medication without an order, it can lead her to make different clinical decisions because she assumes the resident is not receiving the medication. APRN #1 stated she was not notified that Resident #13 received five doses of Tramadol 50 mg without a physician's order on the above dates and times. APRN #1 identified she would have wanted to be notified.Review of the facility's PRN Medication Administration policy (undated) directed in part, prior to administering a PRN medication the licensed nurse will verify the medication order, including the medication name, dose, route, frequency, indication, and any applicable parameters prior to administration. The administration of a PRN medication will be documented in the resident's electronic Medication Administration Record (eMAR/MAR).

Based on observation, review of the clinical record, facility documentation, facility policies, and interviews for one (1) of eight (8) residents (Resident #60) reviewed for dining, the facility failed to ensure that when staff were feeding a resident the resident was fed in a dignified manner. The findings include:Resident #60 was admitted to the facility in June 2024 with diagnoses that included dementia and diabetes.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #60 had severely impaired cognition and required total assistance with eating, oral hygiene, toileting, and personal hygiene.The Resident Care Plan (RCP) dated 8/3/26 identified Resident #60 was at risk for an alteration in nutrition related to dementia and moderate malnutrition. Interventions included providing weighted utensils and documenting meal and fluid intake. The RCP did not identify any non care planned nicknames preferred by Resident #60.The physician's order dated 8/10/26 directed a consistent carbohydrate diet, regular consistency with thin liquids, assistance with meals as needed, supervision during all oral intake, and use of weighted utensils with all meals.a.Observation on 8/17/26 at 8:20 AM identified Resident #60 was lying in bed in an upright position, and Nurse's Aide (NA) #1 was standing on the left side of the bed preparing to feed Resident #60 his/her breakfast meal. NA #1 used the weighted fork while standing and fed Resident #60 bites of eggs and sips of juice. NA #1 repeatedly used the phrase around and around and in we go while moving the weighted fork in a circular motion in front of Resident #60's face, and Resident #60 did not open his/her mouth until NA #1 opened her own mouth. NA #1 attempted to feed additional forkfuls of eggs and called Resident #60 poppa multiple times; however, Resident #60 did not open his/her mouth. NA #1 stated Resident #60 did not want any more eggs but would eat cold cereal and proceeded to feed Resident #60 the cold cereal while again saying around and around and in we go in between bites. NA #1 completed feeding Resident #60 the breakfast meal at 9:00 AM and exited the room.Interview with NA #1 on 8/17/26 at 9:05 AM identified she worked full time and cared for Resident #60 daily. She identified she provided assistance with eating for Resident #60 for breakfast and lunch each day she worked. NA #1 identified she called Resident #60 poppa while feeding to gain Resident #60's attention so he/she would eat. NA #1 further identified while feeding Resident #60 she used the phrase around and around and in we go to help get Resident #60 to eat. NA #1 indicated she stood while feeding Resident #60 because she felt uncomfortable sitting. NA #1 identified she knew staff were required to sit while feeding a resident and she was aware there was a bedside chair available.b. Observation on 8/18/26 at 8:15 AM identified Resident #60 was lying in bed in an upright position, NA #2 was standing on the left side of the bed and started feeding Resident #60 his/her breakfast meal. At 8:20 AM, Registered Nurse (RN) #2 entered the room, greeted Resident #60, and exited without instructing NA #2 to sit feeding the resident. NA #2 stood on the left side of the bed feeding Resident #60 bites of scrambled eggs and cut up sausage links, along with sips of orange juice and coffee. NA #2 prompted Resident #60 to open his/her mouth multiple times. NA #2 proceeded to fed Resident #60 two bowls of cold cereal while standing. NA #2 finished feeding Resident #60 at 8:48 AM and exited the room.Interview with NA #2 on 8/18/26 at 8:50 AM identified she was responsible for providing assistance with eating for Resident #60 during the 7:00 AM to 3:00 PM shift. NA #2 indicated Resident #60 was marked as a feed on the work sheet at the nurse's station. NA #2 identified she stood while providing assistance with eating because she did not want to move the bedside chair. NA #2 identified she had been educated that staff were expected to sit at eye level with residents when feeding meals.Interview with Registered Nurse (RN) #2 on 8/18/26 at 8:53 AM identified nurse aides are expected to be seated next to the resident at eye level when providing assistance with eating. RN #2 indicated although she observed NA #2 standing while feeding Resident #60, she did think to instruct her to sit. RN #2 identified NA #2 should have used the bedside chair while feeding Resident #60. Interview with the Director of Nursing Services (DNS) on 8/18/26 at 9:00 AM identified nursing staff should sit in front of residents or next to residents while providing assistance with eating to be able to interact and encourage the residents to eat. The DNS indicated on 8/17/26 NA #1 informed her she had been observed standing while feeding Resident #60. The DNS indicated she initiated education for all nursing staff on 8/17/26 instructing them to sit next to residents while providing assistance with eating to maintain the residents' dignity. The DNS indicated she was not aware NA #1 called Resident #60 poppa or used the phrase around and around and in we go while feeding the resident his/her meal. The DNS indicated nurse aides are trained not to residents like children. The DNS identified residents should not be treated like a child or called nick names unless the residents preferred them.Review of the facility Dining Assistance policy (undated) directed, in part, the facility will ensure that each resident receives appropriate assistance with eating and drinking based on the residents' assessed needs, abilities, preferences, physician orders, and person-centered plan of care. Staff will encourage residents to eat and drink as independently as possible and will provide cueing, setup, supervision, or direct feeding assistance as identified in the residents' plan of care. Feeding will be provided at a safe pace, allowing adequate time for chewing and swallowing. Food Residents will be treated with dignity and respect during meals and will be provided with adequate time and appropriate assistance to safely consume meals, snacks, and fluids.Review of facilty Resident Rights policy (undated) directed, in part, employees shall treat all residents with kindness, respect, and dignity. Residents have the right to a dignified existence.Review facility Dining Assistance policy (undated) directed, in part, the facility will ensure that each resident receives appropriate assistance with eating and drinking based on the residents' assessed needs, abilities, preferences, physician orders, and person-centered plan of care. Staff will encourage residents to eat and drink as independently as possible and will provide cueing, setup, supervision, or direct feeding assistance as identified in the residents' plan of care. Feeding will be provided at a safe pace, allowing adequate time for chewing and swallowing. Residents will be treated with dignity and respect during meals and will be provided with adequate time and appropriate assistance to safely consume meals, snacks, and fluids.

Based on observations, review of clinical records, facility documentation, facility policies, and interviews, for 2 of 6 residents (Resident #82 and Resident #93) reviewed for accidents, the facility failed to ensure Resident #82's floor mats were in place on both sides of the bed and failed to ensure Resident #93's protective sleeves (Geri- Sleeves) were applied to both arms. The findings include:1.Resident #82 had diagnoses that included stroke and pubic ramus fracture from a fall.The admission Minimum Data Set (MDS) dated [DATE] identified Resident #82 had severely impaired cognition, was dependent on staff for toileting and transfers, and required maximum assistance with dressing, bathing, and personal hygiene.The physician's order dated 6/19/26 directed transfers using a mechanical lift with the assistance of two persons to a wheelchair.The Resident Care Plan (RCP) dated 7/22/26 identified Resident #82 was at risk for falls and had a fall on 7/22/26. Interventions included keeping the call light within reach, maintaining the bed in a low position, ensuring non skid socks while up, transfers with assistance of two staff, and floor mats on both sides of the bed.Observation of Resident #82 in his/her room on 8/17/26 at 8:15 AM identified Resident #82 was in bed in an upright position eating breakfast. There was a floor mat on the left side of the bed (doorway side) and no floor mat on the right of the bed.Observations of Resident #82 in his/her room on 8/18/26 at 7:30 AM, 8/19/25 at 8:00 AM, and 8/20/26 at 6:40 AM identified Resident #82 was lying in bed. There was a floor mat on the left side of the bed (doorway side) and no floor mat on the right of the bed.Interview and observation of Resident #82 with Licensed Practical Nurse (LPN) #4 on 8/20/26 at 6:42 AM identified Resident #82 was in the position detailed above (at 6:40 AM) upon room entrance. LPN #4 identified that only one floor mat was present on the left side of the bed and that a floor mat should also have been placed on the right side of the bed LPN #4 identified Resident #82 was a fall risk and had experienced a fall. LPN #4 indicated floors mats were required on both sides of Resident #82's bed as part of the resident's fall prevention measures. LPN #4 indicated she did not know why only one floor mat was in Resident #82's room.Interview and observation of Resident #82 with the Director of Nursing Services (DNS) on 8/20/26 at 6:45 AM identified Resident #82 was in the position previously described at 6:40 AM upon room entry. The DNS identified that only one floor mat was present, located on the left side of Resident #82's bed. The DNS indicated Resident #82 had experienced a fall on 7/22/26 and the fall prevention intervention implemented at that time required floor mats to be placed on both sides of the bed. The DNS identified nurse aides are expected to ensure floor mats are in place, and the nurses are responsible for confirming floor mats are correctly positioned. The DNS indicated she did not know why only one floor mat was present in Resident #82's room.2. Resident #93 had diagnoses that included cognitive communication deficit, fractured humerus, and osteoarthritis.A physician's order dated 7/9/26 directed to monitor discoloration to the right forearm on every shift until resolved.The quarterly MDS dated [DATE] identified Resident #93 had severely impaired cognition, required moderate assistance with transfers, toileting, ambulation, and set-up assistance with personal hygiene.The RCP dated 7/9/26 identified Resident #93 had discoloration to the right lower arm. Interventions included protective sleeves ( Geri-Sleeves garments worn to protect fragile skin) to both arms at all times, to be removed only for care and then applied immediately afterward.Observation on 8/17/26 at 8:30 AM identified Resident #93 was lying bed eating breakfast. Resident #93 was noted not to be wearing protective sleeves on either arm while eating breakfast, and his/her left arm was resting against the edge of the overbed table. Resident #93 was noted with a yellow bruise with a scabbed laceration above the right eye and over the right eyebrow.Observations on 8/19/26 at 8:15 AM and on 8/20/26 at 8:20 AM identified Resident #93 lying in bed with the overbed table positioned in front of him/her while eating breakfast. During both observations, Resident #93 was not wearing protective sleeves on either arm.Interview with Nurse Aide (NA) #3 on 8/20/26 at 8:21 AM identified she was responsible for caring for Resident #93 and had cared for him/her many times. NA #3 indicated she would be doing morning care and getting Resident #93 out of bed after breakfast.Observation on 8/20/26 at 10:56 AM identified Resident #93 was dressed and seated in his/her wheelchair next to the bed without the benefit of protective sleeves on either arm.Interview with NA #3 on 8/20/26 at 11:00 AM indicated she provided morning care and assisted Resident #93 out of bed into the wheelchair. NA #3 identified she was not sure whether Resident #93 required protective sleeves to be applied on either arm. NA #3 further identified she had never applied protective sleeves to Resident #93's arms before and would ask the nurse if they were needed.Interview with Licensed Practical Nurse (LPN) #6 on 8/20/26 at 11:09 AM indicated she worked the 7:00 AM to 3:00 PM shift throughout the week and was the nurse assigned to Resident #93. LPN #6 identified she did not notice whether Resident #93 was wearing Geri-sleeves. LPN #6 further identified Resident #93 should always wear Geri- Sleeves except during care. LPN #6 indicated it was the nurse's aide's responsibility to ensure the protective sleeves were applied.Interview with the DNS on 8/20/26 at 11:14 AM identified Resident #93 should always have Geri-Sleeves applied to both arms, to be removed only during care and then reapplied. The DNS indicated the Geri-Sleeves were implemented as an intervention to protect Resident #93's skin on the right arm and to prevent further bruising. The DNS identified that both nurse aides and nurses are responsible for ensuring Resident #93's Geri-Sleeves are applied.Review of the facility Comprehensive Care Planning Policy (undated) directed in part, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of resident's problem areas, and relevant clinical decision making.

Based on review of the clinical record, facility documentation, facility policies, observations, and interviews for 3 of 6 residents (Resident #13, Resident #82, and Resident #93) reviewed for accidents, the facility failed to ensure a residents neurological assessments were conducted following unwitnessed falls, and for 1 of 4 residents (Resident #65) reviewed for hospitalization, the facility failed to ensure blood pressures were obtained prior to medication administration per the physician's order. The findings include: 1. Resident #13's diagnoses included Parkinson's disease, depression, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had intact cognition and was independent with eating, oral hygiene, toileting, and transferring. The Resident Care Plan (RCP) dated 2/4/26 identified Resident #13 was at risk for falls. Interventions directed to remind the resident to wear non-skid socks at all times, ensure the call light was within reach of the resident, remind the resident to call for assistance when needed, frequent checks on the resident, and frequent rounding when the resident is in their room or not at the nurse's station or activities. The Facility Incident Report dated 3/23/26 at 8:05 PM identified that during a routine medication pass, Licensed Practical Nurse (LPN) #12 heard a loud noise as she entered Resident #13's room. LPN #12 identified upon entering the room, she observed Resident #13 on the floor on the left side of the bed, lying on his/her right side on top of the floor mat. LPN #12 identified Resident #13 was assessed and the nursing supervisor was notified, at which time a Registered Nurse (RN) assessment was conducted. The RN assessment identified abrasions on the right side of Resident #13's mid back measuring 3.0 centimeters (cm) by 1.0 cm, on the right knee measuring 1.5 cm by 1.0 cm, and on the right upper shin measuring 0.5 cm by 2.0 cm. The Facility Incident Report identified Resident #13's vital signs and neurological checks were initiated for three days. A physician's order dated 3/23/26 directed 72-hour post fall documentation on every shift. Review of the Neurological Check Flow Sheet dated 3/23/26 directed to conduct neurological checks at the initial time of the incident, then every fifteen (15) minutes for the one (1) hour, then every thirty (30) minutes for four (4) hours, then every hour (1) for two (2) hours, and then every shift for seventy-two (72) additional hours. The Neurological Check Flow Sheet identified that on 3/23/26, neurological checks were initiated at 8:05 PM and conducted every fifteen (15) minutes for one (1) hour, every thirty (30) minutes for four (4) hours, and every one (1) hour for two (2) hours. The Neurological Check Flow Sheet identified neurological checks were completed again on 3/25/26 and 3/26/26 during the 7:00 AM to 3:00 PM shifts, 3:00 PM to 11:00 PM shifts, and 11:00 PM to 7:00 AM shifts for Resident #13. The Neurological Check Flow Sheet identified Resident #13's neurological checks were not completed on 3/27/26 during the 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, or 11:00 PM to 7:00 AM shifts, and the flow sheet was blank. Interview on 8/20/26 at 12:30 PM with the second floor unit Manager, Licensed Practical Nurse (LPN) #7 indicated when a resident fell, a RN Assessment is completed, and a set of vital signs (blood pressure, pulse, respirations, and temperature) should be taken. LPN #7 identified when a fall is unwitnessed or when a resident hit his/her head, neurological checks should be completed. LPN #7 further identified on 3/27/26 that Resident #13's neurological checks should have been conducted and documented on the Neurological Check Flow Sheet on every shift. 2. Resident #82 was admitted in June 2026 with diagnoses including stroke and pubic ramus fracture. The Resident Care Plan (RCP) dated 6/11/26 identified Resident #82 was at risk for falls, with interventions including call light within reach, bed in low position, non skid socks when up, and transfer with assist of two staff. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #82 had severely impaired cognition, was dependent on staff for toileting and transfers, and required maximum assistance for dressing, bathing, and personal hygiene. A physician's order dated 6/19/26 directed staff to transfer Resident #82 with a mechanical lift and assist of two persons. a. Facility Incident Report dated 7/19/26 at 3:00 PM identified Resident #82 was observed sitting on the floor next to the bed with an abrasion to the right mid back. The nurse's note dated 7/19/26 at 7:34 PM identified at 3:00 PM Resident #82 was found on the floor on the left side of the bed in front of the wheelchair with both legs extended. Resident #82 stated, 'I was trying to get up'. Resident #82 denied hitting his/her head, an abrasion and redness was noted on the right mid back. The APRN was notified and neurological assessments were initiated. Review of the Neurological Check Flow Sheet dated 7/19/26 directed to conduct neurological checks at the initial time of the incident, then every fifteen (15) minutes for the one (1) hour, then every thirty (30) minutes for four (4) hours, then every hour (1) for two (2) hours, and then every shift for seventy-two (72) additional hours. The Neurological Check Flow Sheet identified that on 7/19/26 neurological checks were initiated at 3:00 PM and conducted every fifteen (15) minutes for one (1) hour, every thirty (30) minutes for four (4) hours, and then every one (1) hour for two (2) hours. The Neurological Check Flow Sheet form identified on 7/20/26 for the 7:00 AM to 3:00 PM shift through 7/22/26 for the 3:00 PM to 11:00 PM shift Resident #82's neurological assessments were not completed (8 neurological checks missed). b. Facility Incident Report dated 7/22/26 at 2:15 PM identified Resident #82 had an unwitnessed fall. Resident #82 was found sitting on the floor next to the bed and no injuries were noted. Review of the Neurological Check Flow Sheet dated 7/22/26 directed to conduct neurological checks at the initial time of the incident, then every fifteen (15) minutes for the one (1) hour, then every thirty (30) minutes for four (4) hours, then every hour (1) for two (2) hours, and then every shift for seventy-two (72) additional hours. The Neurological Check Flow Sheet identified that on 7/22/26 neurological checks were initiated at 2:15 PM. The Neurological Check Flow Sheet form identified on 7/22/26 at 3:00 PM the form was blank, indicating Resident #82's neurological assessments were not completed. A nurse's note dated 7/22/26 at 3:13 PM indicated Resident #82 denied hitting his/her head and neurological checks were initiated. The Neurological Check Flow Sheet form further identified on 7/22/26 at 3:45 PM the form was blank, on 7/24/26 for the 3:00 PM to 11:00 PM shift the form was blank, and on 7/25/26 for the 3:00 PM to 11:00 PM shift the form was blank indicating neurological checks were not completed (3 neurological checks missed). c. Facility Incident Report dated 8/2/26 at 5:50 PM identified Resident #82 had an unwitnessed fall in the small dining room and no injuries were noted. The Resident Care Plan (RCP) dated 8/2/26 identified Resident #82 was at risk for falls and was observed sitting on the floor in the small dining room. Interventions included call light within reach, bed in low position, non skid socks when up, transfer with assist of two staff, neurological assessments, evaluate for bleeding per facility fall protocol, and therapy to evaluate for seatbelt use in wheelchair per resident representative request. Review of the Neurological Check Flow Sheet dated 8/2/26 directed to conduct neurological checks at the initial time of the incident, then every fifteen (15) minutes for the one (1) hour, then every thirty (30) minutes for four (4) hours, then every hour (1) for two (2) hours, and then every shift for seventy-two (72) additional hours. The Neurological Check Flow Sheet identified that on 8/2/26 neurological checks were initiated at 5:50 PM. A nurse's note dated 8/2/26 at 6:45 PM indicated Resident #82's neurological checks were within normal limits. The Neurological Check Flow Sheet form dated 8/2/26 identified on 8/3/26 for the 7:00 AM to 3:00 PM shift the form was blank, indicating Resident #82's neurological check was not completed (1 missed neurological check). d. Facility Incident Report dated 8/5/26 at 5:30 PM identified Resident #82 had an unwitnessed fall and was observed sitting on the floor in the small dining room with legs extended outward. Resident #82 reported he/she slid out of the wheelchair. The nurse's note dated 8/5/2026 at 5:30 PM identified Resident #82 was observed sitting on floor in front of his/her wheelchair with legs extended in the small dining room. Resident #82 stated he/she slid off the wheelchair and landed on his/her buttocks. Resident #82 was alert, verbal, with intermittent confusion at baseline. Neurological check and vital signs were initiated. APRN #1 was updated and directed to continue with neurological checks and vital signs for 3 days. Review of the Neurological Check Flow Sheet dated 8/5/26 directed to conduct neurological checks at the initial time of the incident, then every fifteen (15) minutes for the one (1) hour, then every thirty (30) minutes for four (4) hours, then every hour (1) for two (2) hours, and then every shift for seventy-two (72) additional hours. The Neurological Check Flow Sheet identified that on 8/5/26 neurological checks were initiated at 5:30 PM. The Neurological Check Flow Sheet form dated 8/5/26 identified on 8/6/26 for the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift the form was blank indicating Resident #82's neurological assessments were not completed (2 neurological checks missed). Interview with the DNS on 8/19/26 at 10:00 AM identified the unit secretary scans the completed neurological assessment forms into the clinical record and the Assistant Director of Nursing Services (ADNS) attaches them to Reportable Event forms. Interview with Unit Secretary #1 on 8/19/26 at 10:15 AM indicated the nurses leave completed neurological assessment forms in a folder for her. Unit Secretary #1 identified she did not scan any neurological assessments for Resident #82 into the medical record. Interview with RN #1 ( supervisor for 7:00 AM to 3:00 PM shift) on 8/19/26 at 10:20 AM identified she partially completed neurological assessment form dated 8/2/26 for Resident #82's unwitnessed fall. RN #1 identified there were no other completed neurological assessments for Resident #82 found. Interview with the Director of Nursing Services (DNS) on 8/19/26 at 10:40 AM identified nurses are responsible for initiating neurological assessments for residents who experience unwitnessed falls, and the neurological checks are documented on paper forms. The DNS indicated any incomplete neurological check forms are returned to the supervisors, who are expected to have nurses complete the missing entries before the unit secretary scans the forms into the medical record. The DNS further indicated the neurological check forms are also attached to the incident report. The DNS identified she had multiple resident's neurological check forms in her folder that were incomplete, but she did not have any neurological check forms for Resident #82. Interview with the Assistant Director of Nursing Services (ADNS) on 8/19/26 at 10:41 AM indicated she was unable to locate any additional neurological check forms for Resident #82 related to the unwitnessed falls. 3. Resident #93 was admitted in February 2026 with diagnoses that included cognitive communication deficit, fractured humerus, and osteoarthritis. The Resident Care Plan (RCP) dated 2/11/26 identified Resident #93 was at risk for falls. Interventions included assistance with transfers. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #93 had moderately impaired cognition, was dependent on staff for toileting, and required moderate assistance for wheelchair transfers. A Facility Reportable Event dated 6/2/26 at 1:00 AM identified Resident #93 had an unwitnessed fall in his/her room. Resident #93 was observed sitting on the floor leaning against the bed, and no injuries were noted. Clinical record review failed to provide documentation that a neurological assessment was completed on 6/2/26 following Resident #93's unwitnessed fall. Interview with the Director of Nursing (DNS) on 8/18/26 at 2:30 PM indicated that, according to facility policy, nurses are required to complete neurological assessments for any resident who has an unwitnessed fall. The DNS stated neurological assessments are completed on paper rather than in the electronic medical record and reported she could not locate the neurological assessment form for the 6/2/26 unwitnessed fall. Follow up interviews with the DNS on 8/19/26 at 12:38 PM and 8/20/26 at 11:14 AM indicated she was unable to locate the neurological assessment for Resident #93 related to the unwitnessed fall on 6/2/26. Interview with Licensed Practical Nurse (LPN) #5 (Regional Nurse) on 8/20/26 at 11:20 AM indicated she and the DNS were unable to locate the neurological assessment for Resident #93's unwitnessed fall on 6/2/26. Review of the facility Neurological Assessment policy (un-dated) directed, in part, the purpose of this procedure is to provide guidelines for a neurological assessment directed by a physician's order, or when a resident has an unwitnessed fall, subsequent to a fall with suspected head injury, or when indicated by a resident's condition. When assessing neurological status, it always includes frequent vital signs. Particular attention should be paid to widening pulse pressure (blood pressure). This may be indictive of increasing intracranial pressure. Any changes in vital signs or the neurological status in a previously stable resident should be reported to the physician immediately. 4. Resident #65's diagnoses included hypertension, type 2 diabetes, and multiple sclerosis. The Resident Care Plan (RCP) dated 6/01/2026 identified Resident #65 was at risk for decreased cardiac output. Interventions administer medications as ordered and monitor vital signs as determined by the Medical Doctor (MD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #65 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, required maximal assistance with bed mobility and dependent with transfers. Physician's order dated 7/08/2026 with a start date of 8/04/2026 directed to administer Losartan Potassium (a blood pressure medication) 100 milligrams (mg) tablet once a day Review of the Medication Administration Record (MAR) identified at 8:00 AM on 8/04/2026, 8/05/2026, 8/06/2026, 8/07/2026, 8/08/2026, 8/09/2026, 8/10/2026, 8/11/2026, 8/12/2026, 8/13/2026, 8/14/2026, 8/15/2026, 8/16/2026, and 8/17/2026 Losartan Potassium 100 mg one tablet was signed off indicating it was administered. Review of the clinical record failed to reflect documentation Resident #65's blood pressure was obtained on 8/04/2026, 8/05/2026, 8/06/2026, 8/07/2026, 8/08/2026, 8/09/2026, 8/10/2026, 8/11/2026, 8/12/2026, 8/13/2026, 8/14/2026, 8/15/2026, 8/16/2026, and 8/17/2026 prior Losartan Potassium 100 mg being administered for 14 of 14 days. Interview on 8/18/2026 at 11:03 AM with Licensed Practical Nurse (LPN) #3 identified she would only obtain Resident #65's blood pressure before administering Losartan if a pop up in the electronic medical record prompted her to do so. LPN #3 indicated she administered Resident #65's Losartan in the past without obtaining Resident #65's blood pressure prior to administration. LPN #3 was unable to explain why Resident #65's blood pressures were not obtained on 8/04/26, 8/05/26, 8/06/26, 8/07/26, 8/08/26, 8/09/26, 8/10/26, 8/11/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, 8/16/26, and 8/17/26 prior to the administration of Losartan Potassium. Interview on 8/18/2026 at 11:05 AM with Registered Nurse (RN #3) identified Resident #65's blood pressure should have been taken prior to administering Losartan. RN #3 was not able to locate any blood pressures or medication refusals prior to medication administration of Losartan in the progress notes or Resident #65's electronic health record for the dates 8/04/2026, 8/05/2026, 8/06/2026, 8/07/2026, 8/08/2026, 8/09/2026, 8/10/2026, 8/11/2026, 8/12/2026, 8/13/2026, 8/14/2026, 8/15/2026, 8/16/2026, and 8/17/2026. Interview on 8/18/2026 at 11:47 AM with Advanced Practice Registered Nurse (APRN) #1 identified she made an error when she entered Resident #65's Losartan order, which resulted in the pop up prompt for obtaining blood pressures not appearing in the electronic medical record. Interview on 8/18/2026 at 12:10 PM with the Director of Nursing Services (DNS) identified nurses should be obtaining Resident #65's blood pressure prior to administering his/her Losartan, as directed by the physician's order, and documenting the blood pressure in the electronic health record. The DNS was unable to explain why nursing staff had not documented Resident #65's blood pressure prior to administering his/her Losartan. The DNS identified Resident #65's blood pressure should have been obtained and documented. Subsequent to surveyor inquiry, the order for Losartan was amended to include a blood pressure documentation pop-up. Review of the facility Administration of Medications policy dated 8/2/2026 directed in part, before administering medications it should be verified there is a physician's medication order for the procedure, and any pre-administration assessments should be done.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #20 and Resident #34) reviewed for hearing, the facility failed to follow up on audiology recommendations in a timely manner. The findings include:1. Resident #20 was admitted to the facility in January 2024 with diagnoses that included fracture of the right hand and high blood pressure. The quarterly MDS dated [DATE] identified Resident #20 had intact cognition. The MDS further identified Resident #20 had adequate hearing and did not use hearing aids or other hearing appliances.The Audiology Consultation note dated 1/7/26 identified Resident #20 was seen for management of cerumen (ear wax). Recommendations included to have the have wax removed from both ears because cerumen impaction left untreated may cause an appreciable hearing loss, and the removal of obstructing cerumen is essential for better hearing. Additional recommendations directed to call the physician as soon as possible to obtain orders for wax removal. The Audiology Consultation note dated 3/18/26 identified Resident #20 was seen, and some wax remains in both ears.Interview with Resident #20 on 8/17/26 at 1:00 PM identified he/she was seen by the facility's audiologist in January 2026 and again three weeks prior. Resident #20 identified the audiologist told him/her there was a buildup of wax in both ears and that something would be ordered for it. Resident #20 identified he/she had not received any treatment and his/her ears still felt blocked.Review of the clinical record dated 1/7/26 through 8/17/26 failed to identify the physician was notified of the audiology recommendations nor any orders for ear wax removal.Interview with the Director of Nursing Services (DNS) on 8/18/26 at 10:31 AM identified audiology consultation notes were sent via email identifying which residents were seen and whether there were any recommendations. The DNS identified the Unit Secretary was responsible for printing the individual reports and scanning them into each resident's medical record. The DNS identified she and the prior Assistant Director of Nursing Services (ADNS) were responsible for ensuring the Advanced Practice Registered Nurse (APRN) saw any recommendations made by the audiologist and implemented the orders the day they were sent via email or by the next day.Interview with Licensed Practical Nurse (LPN) #5, Regional Nurse, on 8/19/26 at 11:57 AM identified audiology recommendations should be implemented within one (1) week. LPN #5 indicated if an audiology recommendation required an order, staff should call the provider, obtain the order, and ensure the order was implemented. After reviewing the clinical record, LPN #5 identified from 1/7/26 to the current date, the provider was never notified, there was no provider order for Resident #20 to be seen again by the audiologist, and an order was never put in place for ear wax removal drops.Follow up interview with the Director of Nursing Services (DNS) on 8/19/26 at 12:08 PM identified if a resident wanted to be seen by the audiologist, the provider must be contacted, and the nurse must obtain an order for the resident to be seen by the audiologist. The DNS identified the resident, or the resident representative must sign consent to be seen by a consultant. The DNS identified audiology recommendations should be given to the provider the same day or the next day so the provider could put orders in at that time. The DNS identified Resident #20 did not have any nurse notes indicating the provider had been contacted, or orders were put into place.Interview with Advanced Practice Registered Nurse (APRN) #1 on 8/20/26 at 11:33 AM identified there was a communication concern regarding consultants who came into the facility to see residents. APRN #1 identified when a resident went to an outside consultant, she received the consult sheet with any recommendations within twenty four (24) hours; however, when a resident was seen in the facility by a consultant, she did not always receive notification. APRN #1 indicated she was not notified in January 2026 that Resident #20 had been seen by the audiologist, nor that the audiologist recommended ear wax removal drops. APRN #1 identified had she been notified she would have approved the recommendation and put the order in place.2. Resident #34 was admitted to the facility in April 2017 with diagnoses that included chronic obstructive pulmonary disease and cerebral palsy. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition. The MDS further identified Resident #34 had adequate hearing and used a hearing aid or other hearing appliance.Physician's order dated 4/1/26 (original order dated 6/30/25) directed audiologist consultation and treatment consultations as needed.The Resident Care Plan (RCP) dated 4/9/26 identified Resident #34 was at risk for potential hearing loss related to bilaterally impacted cerumen with interventions that directed to treat the ears as ordered by the audiologist consultation.The Audiology Consultation note dated 5/14/26 identified Resident #34 was seen for management of cerumen (ear wax). Recommendations included to have ear wax removed from both ears because cerumen impaction left untreated may cause an appreciable hearing loss, and the removal of obstructing cerumen is essential for better hearing. Additional recommendations directed to call the physician as soon as possible to obtain orders for wax removal. Review of the clinical record dated 5/14/26 through 8/17/26 failed to identify the physician was notified of the audiology recommendations nor any orders for ear wax removal.Interview with Resident #34 on 8/17/26 at 1:00 PM identified he/she had been asking for months to be seen by the audiologist, and the nurse eventually made an appointment with the facility audiologist a couple of months ago. Resident #34 identified he/she was seen by the audiologist, who recommended ear wax removal drops; however, the drops had not been received. Resident #34 identified nursing had not done anything with his/her ears since the audiologist recommended ear wax removal and he/she was upset nothing had been done.Interview with Licensed Practical Nurse (LPN) #5, Regional Nurse Consultant, on 8/19/26 at 12:00 PM indicated ear wax removal drops were available in the facility as an over the counter medication. LPN #5 identified if the ear wax removal drops were not available in the facility, the nurse could obtain them from the pharmacy. LPN #5 identified there were no nurse's notes indicating the provider had been made aware of Resident #34's audiology recommendations, and the order for ear wax removal drops was never put in place.Interview with the Director of Nursing Services (DNS) on 8/19/26 at 12:08 PM identified audiology recommendations should be given to the provider the same day or the next day so the provider could put orders in at that time. The DNS identified Resident #34 did not have any nurse notes indicating the provider had been contacted, and orders were never put into place for ear wax removal.Interview with APRN #1 on 8/20/26 at 11:37 AM indicated she was not notified in May 2026 that Resident #34 was seen by the audiologist, nor that the audiologist recommended ear wax removal drops. APRN #1 indicated on 7/23/26 she was asked to see Resident #34 and at that time she ordered ear drops. APRN #1 identified had she been notified on 5/14/26 she would have approved the recommendation and put the order in place at that time.Review of facility's Specialty Consultations policy (un-dated) directed, in part it is the policy of the facility to ensure residents have timely access to medically necessary specialty services, including podiatry, dentistry, audiology, optometry, dermatology, and other external consultants. Services will be coordinated to promote continuity of care, maintain resident health and wellbeing, and comply with federal and state regulations. The purpose is to establish a standardized process for scheduling, preparing for documentation, and following up on visits from external healthcare providers while ensuring resident rights, communication with responsible parties, and implementation of the recommendations. Residents may be referred for a specialty service by the physician, APRN, medical Director, Resident request, and routine preventative schedule. The attending physician shall authorize the consultation when required. Consultant recommendations following the consultation visit the licensed nurse shall review recommendations immediately, obtain the physician review, transcribe new physician's orders, initiate new orders promptly, and notify the residents representative of findings. The licensed nurse will document in the resident's medical record date of the consultation, significant findings, new recommendations, physician notified, resident and resident representative notified, and follow up actions initiated.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #5) reviewed for positioning and mobility, the facility failed to ensure a left-hand splint was applied per physician's order for a resident with contractures. The findings include:Resident #5's diagnoses included cerebral infarction, cognitive communication deficit, and need for assistance with personal care.Physician's orders dated 5/04/2026 directed to apply a resting hand splint to the left hand at night as tolerated, wash weekly as needed, and monitor device during use notify nursing, rehab, MD with any unusual findings. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of one (1) indicative of severely impaired cognition, did not have rejection of care behaviors, and was dependent on staff for dressing and personal hygiene.The Resident Care Plan (RCP) dated 6/09/2026 identified Resident #5 wore a left-hand resting splint. Interventions included checking skin integrity pre and post application, monitor device during use and inform therapy of unusual findings, and perform range of motion (ROM) and fasten straps on splint.Observations on 8/17/2026 at 7:17 AM and 8/18/2026 at 5:30 AM noted Resident #5 lying in bed asleep with his/her left hand positioned above the bed covers with the left fingers curled inward without the benefit of the left-hand splint in place. Interview and observation with Licensed Practical Nurse (LPN) #2 on 08/18/2026 at 5:30 AM identified Resident #5 was not wearing the left-hand splint as ordered. LPN #2 indicated it was the responsibly of the nurses to put on Resident #5's left hand splint daily as ordered. LPN #2 identified Resident #5 should have had the splint applied last night.Subsequent to surveyor inquiry, LPN #2 applied the left hand-splint to Resident #5's left hand.Interview with Registered Nurse (RN) #1 on 8/18/2026 at 5:47 AM indicated she was not aware Resident #5 was not wearing his/her left-hand splint. RN #1 identified Resident #5's splint should have been applied at bedtime, and the charge nurse was responsible for ensuring the splint was put on.Interview with Occupational Therapist (OT) #1 on 8/18/2026 at 8:13 AM identified Resident #5 required the left-hand splint because the resident kept his/her hand closed at all times. OT #1 indicated the splint should have been applied as ordered (daily at bedtime). OT #1 further indicated that if the resident was not tolerating the splint, nursing staff should have contacted her to re-evaluate Resident #5.Interview with OT #2 (Assistant Director of Rehabilitation) on 8/18/2026 at 8:20 AM indicated he had not been contacted by nursing prior to 8/18/2026 with any concern that Resident #5 was not wearing his/her splint. OT #2 identified the splint was needed for Resident #5's hand contracture and if the splint was not applied as ordered (daily at bedtime), the resident's contracture would worsen.Interview with the Director of Nursing Services (DNS) on 8/18/2026 at 8:33 AM identified the charge nurses were responsible for ensuring Resident #5's splint was applied per physician orders. The DNS identified she was not aware Resident #5 had refused to wear his/her splint. The DNS further identified it the resident refused then nursing should have documented the refusal and reported the refusal to the Nursing Supervisor and Therapy. The DNS was unsure why the splint was not being applied and indicated she would need to speak to the charge nurse. Review of the facility Adaptive Equipment/Assistive Device policy, directed in part; staff will be educated on the correct use of resident-specific adaptive equipment and will follow therapy recommendations and the resident's plan of care. Any changes in the resident's condition, function, mobility, or ability to safely use the equipment will be reported to the licensed nurse and referred to rehabilitation as indicated.

Based on observations, facility documentation, facility policy and interviews, reviewed for medication storage, narcotic destruction and reconciliation, the facility failed to secure discontinued controlled substances in a cabinet that was permanently affixed, failed to ensure that only authorized personnel had access to the narcotic keys, and failed to remove discontinued controlled medications from a medication cart . The findings include:1.Observations on 8/19/26 at 6:39 AM identified during review of discontinued narcotic storage with the Director of Nursing (DON) identified the discontinued narcotics were kept in a filing cabinet that was not permanently affixed in her office. The cards of controlled substances were located in the top drawer with only white controlled drug record wrapped around each controlled drug enabling ease of diversion by the removal of both the controlled drug and the controlled drug record. Additionally, no log of the controlled drugs was kept for which controlled drugs were on hand. The keys to the file cabinet were kept in the drawer of the DON's unlocked desk. An inventory was completed by the DON with the surveyor present which identified the following: Tramadol 50 milligram (mg) 4 tablets, with two (2) blister packs of Oxycodone 5 mg 9 tablets in each, two (2) blister packs of Oxycodone 5 mg 30 tablets in each, Pregabalin 150 mg 12 capsules, Pregabalin 150 mg 30 capsules, and Oxycontin 20 mg 8 tablets.Interview on 8/19/2026 at 10:07 AM with the DNS indicated her process for reconciling controlled substances before destruction included comparing the medications listed in a resident's electronic medical record with the narcotic book, and confirming the information on the blister pack matched the Controlled Substance Distribution Record (CSDR). The DNS identified once a medication was destroyed, she did not keep the white and yellow copies or the destruction log and placed whatever forms she had in a storage box. The DNS indicated she does always receive the yellow copies from the pharmacy and although she asked the pharmacy for them in the past, she does not receive them. The DNS further indicated that although the keys to the file cabinet were stored in her unlocked desk drawer, no one other than maintenance had access to her office.2. Observation on 08/20/2026 at 6:48 AM of the second floor medication cart identified Resident #58's Lorazepam 0.5 mg , 28 tablets were stored in the medication cart. The Controlled Substance Distribution Record identified that the pills arrived at the facility on 7/4/2025, one pill was recorded as wasted on 2/20 (no year), and a second pill was recorded as wasted on 4/26 (no year). Resident #58 did not reside on the second floor.Interview on 08/20/2026 at 7:47 AM with the DNS indicated when medications are discontinued, she removes the discontinued medications from the medication cart. The DNS identified Resident #58's Lorazepam was discontinued on 7/11/2025 and should have been removed from the cart. The DNS was unable to explain why the medication was not removed from the cart after the 7/11/2025 discontinuation date, despite conducting bimonthly audits of the medication carts. The DNS was unable to explain why the Lorazepam was removed from the blister pack on 2/20 and 4/26 or why the year was not documented.Subsequent to surveyor inquiry, the DNS removed the Lorazepam blister pack containing 28 tablets from the medication cart.Review of the facility's undated Medication Disposal/Destruction policy directed in part, Schedule three (III), four (IV), and five (V) medications may be disposed of at the facility by two licensed personnel, as directed by state laws, regulations, and/or the DEA. The facility will maintain a record of all discontinued medications for record keeping purposes for a period of three years.

Based on review of the clinical record, facility documentation and interviews for 1 of 1 sampled resident (Resident #54) reviewed for hospice services, the facility failed to accurately code the Minimum Data Set (MDS) assessments to reflect Resident #54 receiving hospice services. The findings include:Resident #54's diagnoses included Alzheimer's dementia, severe protein calorie malnutrition, and agitation.A physician's order dated 4/16/25 directed hospice services.a. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was severely cognitively impaired, required set-up assistance with meals, maximal assistance for transfers, and dependent on staff for toileting, showers, and personal hygiene.The Resident Care Plan (RCP) dated 10/23/25 identified Resident #54 was receiving hospice services. Interventions directed to administer medications and treatments as ordered, monitor for signs and symptoms of pain and discomfort, monitor the effectiveness of medications, and report any changes to the physician and hospice provider.b. The MDS dated [DATE] identified Resident #54 was severely cognitively impaired and required set-up assistance with meals, maximal assistance with transfers, showers, and oral hygiene, and dependent on staff for toileting, personal hygiene, and dressing .The RCP dated 1/22/26 identified Resident #54 was receiving hospice services. Interventions directed to administer medications and treatments as ordered, monitor for signs and symptoms of pain and discomfort, monitor the effectiveness of medications, and report any changes to the physician and hospice provider.c. The annual MDS dated [DATE] identified Resident #54 was severely cognitively impaired and required set-up assistance with meals, maximal assistance with transfers, showers, and oral hygiene, and dependent on staff for toileting, personal hygiene, and dressing.The Resident Care Plan (RCP) dated 4/28/26 identified Resident #54 was receiving hospice services. Interventions directed to administer medications and treatments as ordered, monitor for signs and symptoms of pain and discomfort, monitor the effectiveness of medications, and report any changes to the physician and hospice provider.Interview and clinical record review with MDS Registered Nurse (RN) #5 and RN #6 on 8/20/26 at 10:38 AM identified they were responsible for completing MDS assessments for all residents in the facility. RN #5 identified Resident #54's quarterly MDS assessments dated 10/23/25 and 1/22/25, and the annual MDS assessment dated [DATE], were coded incorrectly. RN #5 further identified Resident #54's MDS' assessments should have been coded to reflect that Resident #54 was receiving hospice services at those times. RN #5 indicated the incorrect coding must have been an oversight.Subsequent to surveyor inquiry, on 8/20/26 at 12:22 PM, the MDS assessments dated 10/23/25, 1/22/25, and 4/22/26 were corrected to reflect that Resident #54 was receiving hospice services.Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual dated 10/1/2025 which contained instructions the facility must follow when submitting MDS assessments directed in part, in Section O of the MDS check item (O0100K-Hospice care) to indicate the resident is receiving certified hospice services. Hospice care must be coded only if services were actively received during the specific 14-day look-back period from the Assessment Reference Date or ARD (the end point of the observation period or look back period).

Based on observations, clinical record review, facility documentation review, and interviews, for 1 of 6 residents (Resident #93) reviewed for accidents, the facility failed to ensure the resident's record was complete and accurate to include a nurse aide care card. The findings include:Resident #93 had diagnoses that included cognitive communication deficit, fractured humerus, and osteoarthritis.A physician's order dated 7/9/26 directed to monitor discoloration to the right forearm on every shift until resolved.The quarterly MDS dated [DATE] identified Resident #93 had severely impaired cognition, required moderate assistance with transfers, toileting, ambulation, and set-up assistance with personal hygiene.The RCP dated 7/9/26 identified Resident #93 had discoloration to the right lower arm. Interventions included protective sleeves ( Geri-Sleeves garments worn to protect fragile skin) to both arms at all times, to be removed only for care and then applied immediately afterward.Observation on 8/17/26 at 8:30 AM identified Resident #93 was lying bed eating breakfast. Resident #93 was noted not to be wearing protective sleeves on either arm while eating breakfast, and his/her left arm was resting against the edge of the overbed table. Resident #93 was noted with a yellow bruise with a scabbed laceration above the right eye and over the right eyebrow.Observations on 8/19/26 at 8:15 AM and on 8/20/26 at 8:20 AM identified Resident #93 lying in bed with the overbed table positioned in front of him/her while eating breakfast. During both observations, Resident #93 was not wearing protective sleeves on either arm.Interview with Nurse Aide (NA) #3 on 8/20/26 at 8:21 AM identified she was responsible for caring for Resident #93 and had cared for him/her many times. NA #3 indicated she would be doing morning care and getting Resident #93 out of bed after breakfast.Observation on 8/20/26 at 10:56 AM identified Resident #93 was dressed and seated in his/her wheelchair next to the bed without the benefit of protective sleeves on either arm.Interview with NA #3 on 8/20/26 at 11:00 AM indicated she checked Resident #93's nurse aide care card, but the care card did not indicate protective sleeves should be applied. NA #3 identified she was not sure whether Resident #93 required protective sleeves to be applied on either arm. NA #3 further identified she had never applied protective sleeves to Resident #93's arms before and would ask the nurse if they were needed.Interview with Licensed Practical Nurse (LPN) #6 on 8/20/26 at 11:09 AM indicated she worked the 7:00 AM to 3:00 PM shift throughout the week and was the nurse assigned to Resident #93. LPN #6 indicated she did not notice whether Resident #93 was wearing protective sleeves on either arm when providing care. LPN #6 identified Resident #93 should always have protective sleeves applied to both arms except during care. LPN #6 indicated it was the nurse aide's responsibility to ensure the protective sleeves were applied. LPN #6 identified Resident #93's nurse aide care card should direct application of protective sleeves, to be removed for care only, because this intervention was part of the resident's plan of care.Interview with the Director of Nursing Services (DNS) on 8/20/26 at 11:14 AM indicated nurse aides are responsible for reading the resident care card prior to providing care each day. The DNS indicated she was not aware that nurse aides did not have resident care cards available in the new electronic medical record system. The DNS identified the facility changed electronic medical record systems on 8/4/26, and since that time nurse aides no longer had access to the prior electronic medical records where resident care cards were located. The DNS further identified not all care plans had been entered into the new electronic medical record system, resulting in nurse aides not having care cards. The DNS indicated with the new electronic medical record system, care plans must be entered for a resident care card to be created for the nurse aides. The DNS identified no one had reported to her that care cards were unavailable since 8/4/26.Interviews with Licensed Practical Nurse (LPN) #5 (Regional Nurse Consultant) on 8/20/26 at 11:20 AM and 12:30 PM indicated that after reviewing the electronic health record for Residents #93 with Nurse Aide (NA) #3, there were no nurse aide care cards available for the nursing assistants to follow. LPN #5 identified because the residents' care plans had not yet been entered into the new electronic medical record system, nurse aide care cards were not generated. LPN #5 indicated the facility would need to print the residents' care cards from the prior electronic system, as nurse aides no longer had access to the old system, and update the cards accordingly. LPN #5 stated this affected all residents and reported the facility must immediately print all resident care cards from the prior system and update them from 8/4/26 to the present (16 days without nurse aide care cards) so nurse aides would have the necessary information to provide care, including transfer status, incontinent care, personal hygiene, and other daily tasks or interventions implemented due to incidents such as falls.Although requested, a facility nurse aide care card policy was not provided.

Based on review of the facility documentation, facility policy, and interviews the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention. The findings include: The Infection Preventionist (RN #1) was hired on 11/30/2015. During entrance conference on 1/26/24 at 7:45 AM the facility failed to provide documentation that RN #1 had been awarded the certification for Nursing Home Infection Preventionist with contact hours. Upon review of facility documentation, it was identified that RN #1 had completed the Nursing Home Infection Preventionist Training Course on 4/23/24 but had not completed the final test to obtain the Infection Preventionist certificate. The facility provided documentation that the ADNS had been awarded the certification for Nursing Home Infection Preventionist on 9/4/2020. Interview with RN #1 on 1/28/25 at 8:20 AM identified that she had served as the facility's Infection Preventionist (IP) for 10 months, and that she had completed the Nursing Home Infection Preventionist Training Course and obtained a certification of training course completion on 4/23/24, which she thought fulfilled all the IP requirements. RN #1 indicated that it was subsequent to surveyor inquiry on 1/26/25 that she learned that she also had to take a final test after completing the modules in order to be certified as an IP; RN #1 attempted to take the test, but she did not pass. RN #1 indicated that her last day as the facility's full time IP was 1/27/25, but she would remain at the facility, part-time and assist with training a new IP once one was hired; the ADNS would oversee the day-to-day infection control duties, in the interim. Interview with the DNS on 1/28/25 at 1:20 PM identified that RN #1's certificate reads that RN #1 had successfully completed the Nursing Home Infection Preventionist Training Course on 4/23/2024, and she thought that certificate indicated that the IP requirements had been met. The Infection Preventionist Job Description document directs the minimum qualifications of the IP was to have any combination of education and experience that would likely provide the required knowledge, skills, and abilities; as well as any required licenses or certifications. Education: primary professional training in nursing, medical technology, microbiology, epidemiology, or related field; and have completed specialized training in infection prevention and control.

Based on review of the clinical records, facility documentation, facility policies, and interviews for 6 of 10 residents (Resident #2, 18, 79, 87, 88, and 100) reviewed for immunizations, the facility failed to ensure consented residents received the ,d+[DATE] Covid vaccination, in a timely manner. The findings include: Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's clinical record identified a signed Annual Vaccinations form dated [DATE] which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty ,d+[DATE] (a vaccine that helps prevent the Covid-19 virus); 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #2 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty ,d+[DATE]; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #18 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #50 was admitted to the facility on [DATE]. Review of Resident #50's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had declined to the Covid-19 vaccine. Resident #58 was admitted to the facility on [DATE]. Review of Resident #58's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had declined to the Covid-19 vaccine. Resident #60 was admitted to the facility on [DATE]. Review of Resident #60's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directing the administration of Comirnaty ,d+[DATE]; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #60's resident representative declined the Covid-19 vaccination on [DATE] because Resident #60 was on hospice care. Resident #79 was admitted to the facility on [DATE]. Review of Resident #79's clinical record identified a signed Annual Vaccinations form dated [DATE] which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty ,d+[DATE]; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] failed to identify Resident #79 had received the Covid-19 vaccine. Resident #87 was admitted to the facility on [DATE]. Review of Resident #87's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty ,d+[DATE]; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #87 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #88 was admitted to the facility on [DATE]. Review of Resident #88's clinical record identified a signed Covid Vaccine Consent form dated [DATE], which identified he/she or the responsible party had consented the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty ,d+[DATE]; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] identified Resident #88 received the Covid-19 vaccination on [DATE], subsequent to surveyor inquiry. Resident #100 was admitted to the facility on [DATE]. Review of Resident #100's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had consented to the Covid-19 vaccine, and a physician's order dated [DATE] directed the administration of Comirnaty ,d+[DATE]; 30 mcg/0.3ml; intramuscular, one time. Review of the facility's Preventative Health Care Report dated [DATE] failed to identify Resident #100 received the Covid-19 vaccination. Resident #109 was admitted to the facility on [DATE]. Review of Resident #109's clinical record identified a signed Annual Vaccinations form dated [DATE], which identified he/she or the responsible party had declined to the Covid-19 vaccine. Interview and clinical record review with the Infection Preventionist (RN #1) on [DATE] at 8:20 AM failed to provide surveillance data on resident Covid-19 vaccinations but indicated that she pulls her reports from the electronic health record system when needed. RN #1 indicated that 2 of the 5 residents (Resident #60 and #87) initially reviewed for immunizations had consented for the Covid-19 vaccination but had not yet received the Comirnaty ,d+[DATE] vaccine. RN #1 indicated that Resident #60 and Resident #87 were scheduled to receive their Covid-19 vaccination on the upcoming Monday. RN #1 further indicated that the pharmacy dispenses Covid-19 vaccines in quantities of 10 at a time, and the next order of 10 vaccines was expected to be delivered by Monday. RN #1 was unable to provide a policy indicating that there was a limit to how many Covid-19 vaccines could be received from the pharmacy; RN #1 indicated that was the directive she was told by the pharmacy. RN #1 identified that the following residents were scheduled to receive the Covid-19 vaccine on Monday: Residents #2, 18, 50, 58, 60, 79, 87, 88, 100, and 109. RN #1 further identified that she had been the facility's Infection Preventionist (IP) for 10 months, and her last day as the facility's full time IP was [DATE], but she would remain at the facility in a part time capacity until a new IP was hired and trained. Interview with the pharmacy manager (Person #1) on [DATE] at 11:49 AM indicated that, last year during a medication review, it was identified that the facility had multiple expired Covid-19 vaccinations in the medication refrigerator. Person #1 indicated that Covid-19 vaccines have a shorter shelf life than other vaccines, and once defrosted it must be administered within 30 days. Person #1 identified that representatives from the pharmacy had a conversation with facility management and it was determined that 10 vaccines would be supplied at a time to devoid waste. Person #1 further identified that the pharmacy was not rationing Covid-19 vaccines and there was no policy in place to limit quantities supplied to the facility; if the facility had a need for more than 10 vaccines, the pharmacy would provide a larger quantity. Observation with the DNS of the medication refrigerator on [DATE] at 10:37 AM identified 5 Covid-19 vaccinations in a bag dated [DATE] and 10 Covid-19 vaccinations in a bag dated [DATE]. Interview with the Administrator on [DATE] at 10:57 AM identified that he never learned that there was a limit on ordering Covid-19 vaccinations. Interview with the DNS on [DATE] at 11:51 AM identified that she was aware that Covid-19 vaccines were routinely being supplied 10 at a time; while she was unable to recall where that directive came from, the DNS indicated that more could have been ordered if there was a need. The DNS further indicated that she was unaware that there were multiple residents that were consented to receive the Covid-19 vaccine but had not yet received it, and she was also unaware that there 15 Covid-19 vaccines in the refrigerator that were available to be given to consented residents. The DNS identified that it was her expectation that a Covid-19 vaccination would be administered right away, once you receive the vaccinations. Interview and clinical record review with the ADNS on [DATE] at 12:22 PM identified that the expectation is that once consent is obtained, if the vaccine is available then it would be administered, unless there was an issue or the resident was sick. The ADNS further identified that she had been unaware that there were Covid-19 vaccinations available at the facility while there were consented residents that had not yet received the vaccine. The ADNS indicated that Residents # 50, 58, and 109 declined the Covid-19 vaccination, and she was unsure why RN #1 had identified them as receiving the vaccination on Monday, Resident #60's resident representative declined the Covid-19 vaccination on [DATE] because he/she was on hospice care, Resident # 79's vaccine was on hold because he/she was not feeling well, Resident #100 was out of the facility on an LOA and would receive the vaccine upon his/her return, and Residents #2, 18, 87, and 88 received the Covid-19 vaccine on [DATE]. The Preventative Health Care Report dated [DATE] identified 9 residents received the Covid-19 vaccine on [DATE], subsequent to surveyor inquiry. Although attempted a second interview was not obtained with RN #1, and RN #1 was unavailable for majority of the survey process. The facility's Covid-19 Vaccination policy directs that all residents will be offered the Covid-19 vaccination. The IP will maintain surveillance data on all Covid-19 vaccinations among staff and residents. Administration of the Covid-19 vaccine will be made in accordance with current CDC recommendations. The facility's Infection Preventionist policy directs that the IP shall coordinate the development and monitoring of the facility's established infection prevention and control policies and practices. The IP will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training, and implement evidence-based infection prevention and control practices.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #60) reviewed for accidents, the facility failed to provide feeding assistance according to the physician's order to ensure a dignified dining experience. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication deficit, and diabetes. A physician's order dated 1/18/24 directed Resident #60 to receive hospice services. The quarterly MDS dated [DATE] identified Resident #60 had severely impaired cognition, was always incontinent of bowel and bladder and required set up for meals and substantial assistance from staff with dressing, bathing and toileting. The care plan dated 10/29/24 identified Resident #60 had the potential for alteration in nutritional status related to dementia. Interventions included advanced meal set up, assistance with feeding, and offering individual parts of a meal at once (i.e. yogurt, then sandwich, etc.). A physician's order dated 11/1/24 directed a regular diet. A physician's order dated 12/18/24 directed Resident #60 have 1:1 feeding with all meals. Observation on 1/27/25 at 8:50 AM identified NA #3 assisted Resident #60 to a seat at a table in the dining room. NA #3 retrieved a meal tray from the food truck, placed the tray directly in front of Resident #60, which included yogurt. NA #3 opened the yogurt, placed a spoon in it, and offered it to Resident #60, and all other food items on the tray, including a main entree, remained covered. NA #3 walked away from Resident #60 and assisted with delivering a meal to another resident at a different table, approximately 6 - 7 feet away from Resident #60, with her back turned 180 degrees from Resident #60. During this time, Resident #60 was observed making multiple attempts to self-feed, first by attempting to partially insert his/her lower face and mouth into the yogurt and attempting to lick the yogurt from the container. At 8:52 AM, Resident #60 inserted his/her right index and middle fingers into the yogurt and attempted to scoop the yogurt into his/her mouth. At 8:53 AM, Resident #60 was observed attempting to use the spoon, which had remained in the yogurt container during these attempts and began to self-feed with the spoon. NA #3 turned to look at Resident #60 and left the dining room. From 8:53 AM - 8:55 AM, Resident #60 remained unsupervised in the dining room with the meal tray position directly in front of him/her self-feeding the yogurt. At 8:55 AM, LPN #3 entered the dining room, removed Resident #60's yogurt from his/her hand, placed the yogurt on the meal tray, and removed the meal tray from the dining room and brought it to the unit pantry. During this time, NA #3 was observed entering the dining room and assisting another resident at the same table as Resident #60 and setting up the resident's meal tray, while Resident #60 remained seated at the table. Resident #60 was observed without a meal tray, with 2 other residents seated and eating in the dining room, from 8:55 AM - 8:58 AM. Interview with LPN #3 immediately following this observation identified she removed Resident #60's meal tray because the resident required 1:1 feeding assistance. LPN #3 identified that she was unsure why NA #3 would have left the tray with Resident #60. Observation on 1/27/25 at 8:59 AM identified a male staff member bringing Resident #60's meal tray back to his/her table, setting the tray up including removal of the entree lid, drink lids, and then sat directly next to Resident #60 and provided feeding prompts and assistance by offering food items. The male staff member remained with Resident #60 for the duration of his/her meal. Interview with NA #3 on 1/27/25 at 9:55 AM identified she was aware that Resident #60 had an order for 1:1 feeding with meals, however this was not a strict rule if Resident #60 was given one item at a time. NA #3 identified she believed that Resident #60 was okay to eat some items independently, while other items required 1:1 feeding, and yogurt was an item Resident #60 was fine to eat independently but other items on his/her tray required feeding assistance. Interview with the Dietitian on 1/27/25 at 10:00 AM identified Resident #60 had an order for 1:1 feeding with all meals due to his/her continued cognitive decline and need for supervision and prompts with meals. The Dietitian identified Resident #60 was on hospice services due to advanced dementia, and due to the advanced stage of cognitive decline, Resident #60 would often forget how to eat, including how self-feed and use utensils. The Dietitian identified due to the decline, Resident #60 required 1:1 assistance to have a staff member remind him/her how to use a fork, for example, and that staff should also be setting Resident #60's meal tray, including removing the lids and covers from food and drink items. The Dietitian identified that Resident #60 did not have any selective 1:1 food item list, and while Resident #60 can self-feed, he/she required a staff member to sit with him/her for the entire meal and to provide multiple prompts and reminders through the duration of the meal. Interview with the DNS and ADNS on 1/27/25 at 10:05 AM identified Resident #60 required 1:1 feeding assistance due to cognitive deficits with self-feeding and not due to risk of aspiration. The DNS identified that Resident #60 can self-feed with each meal, but a staff member must sit with him/her for the duration of the meal. The ADNS identified that someone should have been sitting with Resident #60 during his/her meal, and that she and the DNS would speak with the staff on Resident #60's unit to determine the issue. The facility policy on resident rights directed that residents of the facility had the right to a dignified existence and to be treated with respect, kindness, and dignity. The facility policy on assistance with meals directed that residents should receive assistance with meals in a manner that meets the individual needs of the residents. The policy further directed that facility staff would serve resident trays and help residents who required assistance with eating and residents who required feeding assistance would be treated with attention to safety, comfort and dignity. The facility policy on dignity, respect and neglect of care directed that facility staff could provide dignified care of residents by always checking on residents to assist with their needs during the shift and providing care in a dignified manner.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #48) reviewed for advance directives, the facility failed to ensure the physician's orders were consistent with the resident's wishes for code status. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, diabetes, and muscle weakness. The Resident/Patient Health Care Instructions for signed and dated by Resident #48's representative at admission on 5/2/24 identified Resident #48's advance directive choice was do not resuscitate (DNR). Physician's order dated 5/2/24 directed Resident #48 was a full code. Review of the clinical record identified Resident #48 was hospitalized from 11/18/24 - 11/21/24 for pneumonia. The Resident/Patient Health Care instructions form identified Resident #48 requested do not resuscitate (DNR). The form was signed and dated by Resident #48's representative on 11/21/24. The form further indicated it was not a physician's order and should be reviewed and a physician's order written. A physician's order dated 11/21/24 directed Resident #48 was a full code. Review of Resident #48's face sheet identified Resident #48's advance directive choice as DNR/DNI. The 5-day MDS dated [DATE] identified Resident #48 had severely impaired cognition. Review of the clinical record failed to identify a care plan related to Resident #48's advance directive choice. A resident care conference note dated 12/10/24 identified Resident #48's code status as DNR. Review of Resident #48's face sheet dated 1/27/25 identified Resident #48's advance directive choice as DNR/DNI. Interview with LPN #5 (Regional Nurse) on 1/27/25 at 10:39 AM identified that the admitting nurse is responsible to reconcile the resident's signed advance directive choices outlined on the health care instruction form and reconcile the choices against the physician's orders in the clinical record. LPN #5 identified she was unsure why the physician's order did not match Resident #48's choice of DNR but that it should have. Interview with LPN #1 on 1/27/25 at 10:55 AM identified that she was the admitting nurse for Resident #48 on 11/21/24. LPN #1 identified she was unsure why the physician's order directed full code when the resident's choice was DNR. LPN #1 identified that Resident #48's order did not match Resident #48's advance choices indicated on the health care instructions form. Although requested, the facility failed to provide a policy related to a clear and accurate clinical record. The policy on Advance Directives directed that information about whether or not a resident had executed an advance directive would be displayed prominently in the clinical record, and the plan of care for the resident would be consistent with the resident's documented treatment preferences and/or advance directives.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #56 and 84) reviewed for a specialty medical treatment and/or nutrition, for Resident #56 the facility failed to notify the physician and/or and the specialized treatment center when the resident was over the fluid restriction and for Resident #84 the facility failed to ensure the physician and resident representative were notified when the resident had a weight loss. The findings include: 1. Resident #56 was admitted to the facility in May 2024 with diagnoses that included end stage renal disease requiring peritoneal dialysis and a stroke affecting the right dominant side. A monthly physician's order dated 11/8/24 directed a fluid restriction of 1000 ml per day. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition and required moderate assistance with toileting and personal hygiene. The care plan dated 11/29/24 identified Resident #56 receives peritoneal dialysis for end stage renal disease. Interventions included to monitor fluid intake, 1000 ml within 24 hours. Review of the Fluid Intake Report dated 12/1/24 to 12/31/24 identified Resident #56 had gone over the fluid restriction 28 out of 31 days. Review of the Fluid Intake Report dated 1/1/25 to 1/28/25 identified Resident #56 had gone over the fluid restriction 26 out of 28 days. Review of the nursing and physician progress notes dated 12/1/24 to 1/28/25 failed to reflect that the physician had been notified that Resident #56 had gone over fluid restriction 54 days out of 59 days. Interview with LPN #4 on 1/29/25 at 9:40 AM indicated Resident #56 was on a 1000 ml fluid restriction per physician order. LPN #4 indicated that the charge nurse is responsible to document the fluid intake into the EMR every shift. LPN #4 indicated that the 11:00 PM to 7:00 AM supervisor was responsible for adding up the 24-hour totals of fluid intake to see if a resident goes over their fluid restriction and notify the physician and dialysis center. Interview with RN #4 (7:00 AM to 3:00 PM day supervisor) on 1/29/25 at 10:17 AM indicated that the 11:00 PM to 7:00 AM RN supervisor was responsible to add the 24-hour intakes for residents on a fluid restriction. RN #4 indicated that if Resident #56 went over the fluid restriction, the supervisor is responsible to notify the dialysis center and the physician and document it in the medical record. Interview with the DNS on 1/29/25 at 10:22 AM indicated that if a resident on a fluid restriction goes over the fluid restriction more than 5 - 10 ml's the APRN or physician must be notified and the nurse must write a progress note indicating such. The DNS indicated that the 11:00 PM to 7:00 AM RN supervisor was responsible to add up each day's fluid totals for residents on fluid restrictions. The DNS indicated that if the resident went over the fluid restriction the night supervisor would inform the day supervisor to call or inform the APRN that day. After review of the progress notes the DNS indicated the notes failed to reflect the dialysis center or the APRN had been notified that Resident #56 had gone over the fluid restriction. Interview with MD #1 on 1/29/25 at 10:53 AM indicated that if a peritoneal dialysis resident is on a 1000 ml fluid restriction every day nursing was responsible to calculate the 24-hour totals. MD #1 indicated that if Resident #56 went over the fluid restriction he should be notified that day and documented in the clinical record. Review of the Change in a Resident's Condition or Status identified the facility will promptly notify the resident, physician, and the resident's representative of changes in the residents medical/mental condition and/or status. The nurse will notify the residents physician if there has been a significant change in the resident's physical, emotional, or mental condition or need to alter the resident's medical treatment. Notifications will be made within 24 hours of a change occurring in the resident's medical condition or status, except in medical emergencies. The nurse will record in the medical record information related to changes. Although requested, a facility policy for dialysis residents on fluid restrictions was not provided. 2. Resident #84 was admitted to the facility in July 2024 with diagnoses that included stroke, dysphasia, and dementia. Review of the weight record dated 7/24/24 identified Resident #84 weighed 156 lbs. A physician's order dated 8/13/24 directed to weigh the resident daily and if weight loss is greater than 2 lbs. in a day or 5 lbs. in 7 days notify the physician/APRN. A physician's order dated 8/14/24 directed to provide a dysphasia puree diet but allow ground meats and soft sandwiches and thin liquids. Additionally, provide house supplement 237 ml twice a day. The quarterly MDS dated [DATE] identified Resident #84 had severely impaired cognition, was independent to eat, did not have a weight loss of 5% in the last month or loss of 10% in the last 6 months. The care plan dated 9/24/24 identified Resident #84 has the potential for alteration in nutritional status related to dementia. Interventions included evaluating the nutritional status on admission, per the MDS schedule and as needed and report any concerns or changes to the physician and resident representative. Review of the weight record dated 10/4/24 identified the resident weighed 150 lbs., (a 6 lbs. weight loss in 3 months). Review of the weight record dated 11/10/24 identified Resident #84 weighed 138 lbs., (a 12 lbs. weight loss in 1 month, 18 lbs. in 4 months). Review of the nurse's progress notes, APRN, and physician notes dated 11/10/24 - 12/11/24 failed to reflect that the APRN, physician, or resident representative were notified of the resident's weight loss. Further, review of the clinical record dated 11/10/24 to 12/11/24 failed to reflect that Resident #84 was seen by the dietitian subsequent to the weight loss. Review of the weight record dated 12/2/24 identified Resident #84 weighed 133 lbs., (a 5 lbs. weight loss in 1 month). Review of the nurse's progress notes, APRN, and physician notes dated 12/2/24 - 12/12/24 failed to reflect that the APRN, physician, or resident representative were notified of the continued weight loss. Review of the clinical record dated 12/2/24 to 12/11/24 failed to reflect that Resident #84 was seen by the dietitian for a weight loss. The dietitian progress note dated 12/12/24 at 11:19 AM identified a significant weight loss trend. Recommendations included orders for house supplement 237 ml twice daily, and liquid protein 30 ml daily remain appropriate to maximize protein and caloric intake. The APRN progress note dated 12/13/24 at 9:44 PM identified Resident #84 was seen for a significant weight loss of 11 lbs. over the past month. Resident #84 is tolerating diet order without difficulty. Resident #84 has variable oral intakes of 50-100% of meals. Assessment and plan resident has poor oral intake decreased, poor appetite, will have speech therapy evaluate resident for a diet upgrade, dietitian evaluated resident, food preferences upgraded, monitor intakes and weights. Interview with the Dietitian on 1/27/25 at 10:30 AM indicated that she had seen Resident #84 in August 2024, and not again until the quarterly MDS assessment on 12/12/24. The Dietitian indicated that it was nursing's responsibility to notify her when a resident had a weight loss right away so she could evaluate the resident. The Dietitian indicated she was not aware of the significant unplanned weight losses on 11/10/24 and 12/2/24 until she reviewed the clinical record on 12/12/24. Interview with MD #1 on 1/27/25 at 10:48 AM indicated when Resident #84 had a significant weight loss the APRN or physician, and the resident representative, and dietitian should have been notified. Further, the notification should be documented in the clinical record. Interview with the DNS on 1/27/25 at 11:07 AM indicated that when a resident has a weight loss the nurse is responsible to notify the dietitian, physician, and residents' representative. After clinical record review, the DNS indicated that Resident #84's weight loss the physician, dietitian, and resident representative should have been notified. The DNS indicated that she did not see a progress note of anyone being updated. Review of the Change in a Resident's Condition or Status identified the facility will promptly notify the resident, physician, and the resident's representative of changes in the residents medical/mental condition and/or status. The nurse will notify the residents physician if there has been a significant change in the resident's physical, emotional, or mental condition or need to alter the resident's medical treatment. A significant change of condition is a major decline or improvement in the resident's status requires interdisciplinary review and/or revision to the care plan. Notifications will be made within 24 hours of a change occurring in the resident's medical condition or status, except in medical emergencies. The nurse will record in the medical record information related to changes. Review of the Weight Monitoring Policy identified nursing was responsible for notifying the dietitian of any significant weight changes.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #70) reviewed for pre-admission screening and resident review (PASARR), the facility failed to ensure the State-designated authority was notified when the resident was diagnoses with a new mental health diagnosis (10/20/21) and again when the physician discontinued the mental health diagnosis on 10/13/23. The findings include: Review of a PASARR Level 1 screen dated 8/5/21 identified no level 2 required. Resident #70 has anxiety and depression and was receiving Klonopin (anxiety medication), Lexapro (antidepressant medication), and Wellbutrin (antidepressant). If changes occur or new information refutes these findings, a new screen must be submitted. Resident #70 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and dysthymic disorder (mild but long-term depression). The admission MDS dated [DATE] identified Resident #70 had intact cognition, no delusional or hallucinating thoughts and no physical or verbal behaviors. A physician's order dated 8/26/21 directed to administer Abilify 5 mg (anti psychotropic medication) once daily at bedtime. A PASARR Level 1 screen dated 9/22/21, conducted because the resident came off insurance on 9/4/21 identified Resident #70 has diagnosis of depressive disorder, unspecific mood disorder, anxiety, and dysthymic disorder. Approved for long-term care based on information provided. If medical conditions improve to the point that the resident can safely return to the community, the facility should assist with discharge planning with appropriate support services. The effective date is 9/4/21. The psychiatric evaluation and consultation, written by MD #3, dated 10/20/21 at 1:23 PM identified given history of symptoms it would be appropriate to add the diagnosis of schizoaffective disorder to the diagnosis list. Tapering of psychotropic medication will lead to worsening of symptoms. The Psychiatric Evaluation and Consultation, written by MD #3, dated 10/13/23 (2 years later) identified based upon symptoms, etiology of current disease, and response to recent medication trials, it would be prudent to discontinue the diagnosis of schizoaffective disorder. Will recommend a gradual dose reduction trial of antipsychotics as tolerated and if indicated. Interview with the SW #1 (Director of Social Services) on 1/27/25 at 7:20 AM indicated she was responsible to oversee all PASARRs starting with admission. Further, she was also responsible to track Level 2 PASARRs, update as needed and ensure all Level 2 recommendations are followed and care planned. SW #1 indicated that when the psychiatric provide adds or discontinues a diagnosis it is their responsibility to notify her so she can update State-designated authority. SW #1 indicated that if she was notified of the new diagnosis or discontinuation of the diagnosis of schizoaffective disorder for Resident #70, she would have notified State-designated authority. Review of the Coordination with PASARR Program Policy identified the facility coordinates assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental health disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. PASARR Level 1 is the initial pre-screening that is completed prior to admission. Negative Level 1 Screen permits admission to proceed and ends the PASARR process. Positive Level 1 Screen necessitates a PASARR Level 2 evaluation prior to admission. PASARR Level 2, a comprehensive evaluation by the appropriate state-designated authority, (cannot be completed by the facility) that determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitation services the individual needs. The facility will only admit individuals with a mental disorder or intellectual disability who the State-designated authority has determined as appropriate for admission. Recommendations, such as any specialized services, from a PASARR Level 2 determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transition of care. Any Level 2 resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Any resident who exhibits a newly evident or possible serios mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual authority for a level 2 resident review.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #24, 81 and 312) reviewed for nutrition and/or choices, for Resident #24 the facility failed to ensure the air mattress was set per the physician's order, for Resident #81 the facility failed to ensure the resident had close supervision during meals and for Resident #312 the facility failed to ensure that weights were obtained per the physician's order The findings include: 1. Resident #24 was readmitted to the facility in September 2024 with diagnoses that included stroke and a stage 4 pressure ulcer. The annual MDS dated [DATE] identified Resident #24 had severely impaired cognition and was dependent requiring total assistance for dressing, toileting, and personal hygiene. Resident #24 was always incontinent of bladder and frequently incontinent of bowel and at risk for developing a pressure ulcer. A physician's order dated 12/3/24 directed to utilize a specialty mattress with the setting at 210 lbs. Check function and settings every shift from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM The care plan dated 12/12/24 identified Resident #24 was at risk for a pressure ulcer due to impaired mobility and incontinence. Interventions included having a pressure-reducing mattress, a cushion to bed and wheelchair as ordered. Review of the weight report dated 12/5/24 identified Resident #24's weighed 210 lbs. Review of the weight report dated 1/8/25 identified Resident #24's weighed 208 lbs. Observation on 1/26/25 at 8:43 AM and 2:00 PM identified Resident #24 was lying in bed on an air mattress in a semi upright position. The air mattress was set to 270 lbs. Observation on 1/27/25 at 8:00 AM and 8:30 AM identified Resident #24 was lying in bed on air mattress in a semi upright position. The air mattress was set to 270 lbs. Interview with LPN #2 on 1/27/25 at 8:45 AM indicated that according to the physician's order, the air mattress was to be set at 210 lbs., and the nurse on each shift must check the setting and then sign off that it had been checked in the EMR that the setting was accurate. LPN #2 indicated that the air mattress is to be set according to the resident's weights to be therapeutic to prevent skin breakdown. LPN #2 indicated that Resident #24 would not be able to state if the air mattress was too soft or too hard. Observation with LPN #2 on 1/27/25 at 8:47 AM indicated that Resident #24 was lying in bed on the air mattress that was set at 270 lbs. LPN #2 indicated that the setting of 270 lbs., was not correct, and she would re-set it to the 210 lbs. as ordered by the physician. Interview with the DNS on 1/28/25 12:34 PM indicated that the air mattress is set based on the resident's weight and the physician's order. The DNS indicated that the nurses are to check the setting every shift and make sure it is set according to the physician order. The DNS indicated there is a sticker with the resident's weight and what the setting should be located on the face of the machine. The DNS indicated that the charge nurse was responsible to check the air mattress every shift to make sure the setting was the same as the physician's order and resident's weight and then sign off in the EMR. Review of the manufacturer manual for air mattress identified the pump and mattress system is indicated for the prevention and treatment of all pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Turn the machine on and determine the resident's weight and set the control knob to that weight setting on the control unit. Although requested, a facility policy for use of air mattress was not provided. 2. Resident #81 was admitted to the facility in December 2021 with diagnoses that included dementia and a stroke affecting the right dominant side. The annual MDS dated [DATE] identified Resident #81 had severely impaired cognition and was totally dependent on staff for toileting, dressing, and personal hygiene. Additionally, Resident #81 needed partial assistance with eating. A physician's order dated 12/5/24 directed a dysphagia puree diet with ground meats and soft sandwiches with close supervision during meals. The care plan dated 12/12/24 identified Resident #81 was at risk for weight loss. Interventions included to use a sippy cup with meals, diet mechanical soft with thin liquids. Aspiration precautions and monitor eating closely. Encourage to use feeding skills as much as he/she could and assist times 1 as needed. Observation on 1/26/25 at 9:00 AM identified Resident #81, who was in a semiprivate room, by the window with the curtain pulled from the head to the foot of the bed, (not able to be seen from the door) was lying in bed in upright position with breakfast tray in front of him/her with closed eyes. The breakfast tray was untouched and contained a scoop of puree eggs and scoop of puree bread. There was a built-up spoon on the side of the tray not used, the coffee was in a brown cup (not a sippy cup) and a carton of milk was opened. The orange juice cup had the metal cover peeled back halfway. NA #1 had dropped off the tray and continued passing trays. Interview with NA #1 on 1/26/25 at 9:10 AM indicated that she had given Resident #81 his/her breakfast meal this morning and indicated Resident #81 eats breakfast in his/her room daily with the privacy curtain pulled all the way and is not visible from the doorway. NA #1 indicated that Resident #81 was responsible for feeding him/herself and did not require supervision. Interview with RN #3 on 1/26/25 at 9:17 AM indicated that Resident #81 feeds him/herself to start and just needs cueing during the meal. RN #3 indicated that the nurse aides were to provide supervision and after the resident has a chance to feed him/herself then provide assist with eating to finish meal. RN #3 identified Resident #81 was behind the pulled privacy curtain and not visible from the doorway while left with the breakfast tray. RN #3 indicated that the nurse aide will come back and assist Resident #81 with eating after resident has had time to eat independently. Observation on 1/27/25 at 8:20 AM identified NA #2 entered the room with the breakfast tray. Resident #81 was sitting upright in bed with eyes closed. The breakfast tray had a flat plate with a scoop of puree eggs and a scoop of puree bread per the meal ticket. NA #2 removed the cover from the main meal and placed the weighted spoon in it. NA #2 did not uncover the hot liquid cup, did not open the 8oz milk cartoon, and did not open the disposable container of orange juice. NA #2 left the room. Resident #81's privacy curtain was pulled completely between the beds so Resident #81 was not visible from doorway. Interview with NA #2 on 1/27/25 at 8:45 AM identified she had delivered Resident #81's breakfast tray. NA #2 indicated Resident #81 could eat by him/herself and just needed to be set up. NA #2 indicated that she does not know why she did not open the drinks and set up the meal tray. NA #2 indicated that she was planning on going back after passing the rest of the breakfast trays and a resident wanted his/her coffee heated in the microwave. NA #2 indicated that Resident #81 was to have supervision during meals and eats breakfast in bed and lunch in the dining room. NA #2 indicated that the privacy curtain was pulled and Resident #81 was not visible from the hallway, but she was planning on going back to assist Resident #81 with breakfast. Interview with LPN #2 on 1/27/25 at 8:50 AM indicated that Resident #81 needed to be set up for meals. LPN #2 indicated that Resident #81 will start to feed him/herself but then staff need to assist. LPN #2 indicated that Resident #81 needed to be supervised for all meals, but staff can do that from the hallway when they pass by the room. LPN #2 identified the privacy curtain was pulled and Resident #81 was not visible from the hallway and the curtain would need to be pulled back. Interview with the Rehab Director on 1/28/25 at 10:53 AM indicated that Resident #81 required self-feeding with supervision and or cueing with meals which means the resident must be visually seen by a staff person during the meal. Interview with OTA #1 on 1/28/25 at 11:55 AM indicated that Resident #81 was last seen for therapy related to eating in December 2021, but she had worked with Resident #81 in September of 2024. OTA #1 indicated that Resident #81 must have close supervision will all meals because he/she needs cueing to eat due to dementia. OTA #1 indicated that supervision means the nurse aide must be able to visually observe the resident for entire meal. OTA#1 indicated that Resident #81 cannot be in bed with the curtain pulled for meals unless the nurse aide stays in the room behind the curtain with the resident throughout the whole meal. Interview with the DNS on 1/28/25 at 12:26 PM indicated her definition of supervision with meals means the resident would have to eat in the dining room so the nurse aides can visually see the resident. Review of the Resident Meal Pass Policy purpose is to provide appropriate assistance for residents who choose to receive meals in their rooms. Review the residents care plan and provide the special needs of the resident. Check the meal tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Ensure that the necessary non-food items are on the tray. Report or replace missing items such as silverware, napkins, special devices, etc. 3. Resident #312 was admitted to the facility in January 2025 with diagnoses that included hemiplegia following stroke, urinary tract infection, and chronic kidney disease. The physician's order dated 1/16/25 directed to obtain weights on admission and consecutively for 2 days and then to obtain monthly weights on the 3rd Monday of every month. Review of the clinical record identified Resident #312 had an admission weight of 94.6 lbs. on 1/16/25. A physician admission note dated 1/17/25 identified Resident #312 had a developmental disability, was nonverbal at baseline and admitted from the hospital due to urinary tract infection requiring daily antibiotics via a PICC line. Resident #312 had a history of diabetes requiring Insulin, and had a low grade hypernatremia with concern for malnutrition thought to be related to oral intake. The care plan dated 1/17/25 identified Resident #312 required mechanically altered diet due to dysphagia and stroke. Interventions included providing diet and supplements as ordered. The January 2025 TAR identified licensed staff signed that weights had been obtained on 1/17, 1/18 and 1/20/25 however, the clinical record failed to identify the weights for 1/17, 1/18 and 1/20/25. The admission MDS dated [DATE] identified Resident #312 had severely impaired cognition, was dependent on staff to assist with eating, bathing, and toileting. A physician's order dated 1/23/25 directed to obtain weekly weights x 4 weeks every Monday at 9:00 AM. Interview with Person #2 on 1/26/25 at 12:47 PM identified that he/she notified facility staff that Resident #312 was very picky regarding food choices. Review of the January TAR on 1/27/25 at 2:00 PM identified the weekly weight ordered to be obtained on 1/27/25 at 9:00 AM was signed off as obtained, however, no weight could be found. Review of the clinical record identified LPN #3 as the nurse who signed off that the weights on 1/16, 1/17, 1/20, and 1/27/25 had been obtained. Interview and review of the clinical record with LPN #3 on 1/27/25 at 2:21 PM identified she initially could not recall signing off the TAR for Resident #312's weights on 1/17 and 1/20/25. LPN #3 identified that while she had signed off Resident #312's weight for 1/27/25 at 9:00 AM as obtained, she had not obtained the resident's weight and identified that since Resident #312 required a hoyer lift for transfers to a motorized wheelchair, she was waiting until Resident #312 was going to be transferred back to bed to obtain the weight. LPN #3 identified she worked the 7:00 AM - 3:00 PM shift and indicated Resident #312 probably would not be transferred back to bed prior to the end of her shift. LPN #3 identified that she typically signed off the weight orders in the TAR and then made a note to herself to obtain the weight at a later time during the shift and document the weight in the clinical record. Subsequent to surveyor inquiry, Resident #312 was weighed 1/27/25 at 2:29 PM and had a weight of 98 lbs. Interview with the DNS on 1/29/25 at 12:05 PM identified it was her expectation that when a physician's order was in place related to obtaining weights, that the nurse who signs off in the MAR or TAR that the weight had been obtained, had actually obtained the weight and documented it in the clinical record. The facility policy on weight assessment and intervention directed that the nursing staff would measure and obtain weights on admission, the next 2 days, weekly for 4 weeks and then monthly if no concerns. The policy further directed that the weights would be recorded in the resident's medical record. 46040

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #37) reviewed for pressure ulcers, the facility failed to complete the Braden Scale (a tool used to assess a resident's risk of developing a pressure ulcer) weekly after admission per the physician's order, failed to ensure that a wound care physician's recommendation was implemented, and failed to ensure that a thorough RN assessment of the residents pressure ulcers was completed following re-admission. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, muscle weakness, and anemia. A physician's order dated 11/14/22 directed to complete a Braden Scale weekly for 4 weeks. A Braden Scale dated 11/14/22 identified Resident #37 had a score of 20, indicating the resident was not at risk for the development of pressure ulcers. a. Review of the clinical record failed to identify any additional weekly Braden scale documentation following Resident #37's initial assessment on 11/14/22. A nurse's note dated 11/14/22 at 1:44 PM identified the admission skin audit indicated Resident #37 had a scar on the coccyx and discoloration on the buttocks. The care plan dated 11/16/22 identified Resident #37 was at risk for skin breakdown related to bowel and bladder incontinence. Interventions included keeping the skin as clean and dry as possible and minimizing skin exposure to moisture. The admission MDS dated [DATE] identified Resident #37 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and required moderate staff assistance with bathing, toileting, and dressing. The MDS further identified Resident #37 was at risk to develop pressure ulcers. A wound care note, written by MD #4, the Wound Care Physician, dated 11/21/22 identified Resident #37 was seen for wound evaluation of coccyx and buttocks related to moisture. The note identified a wound to the coccyx had resolved and recommendations included to apply Dermaseptin (a zinc oxide-based barrier cream) daily and as needed. The plan of care was discussed with LPN #1 (Wound Care Nurse). b. Review of the clinical record failed to identify the Dermaseptin, or any other zinc-based barrier cream, according to MD #4's recommendation, had been implemented. Review of clinical record identified Resident #37 was sent to the hospital on 1/18/23 related to a possible gastrointestinal bleed. A weekly skin assessment dated [DATE] by LPN #1, completed while Resident #37 was hospitalized and outside of the facility, identified Resident #37 had clean, dry and intact skin with no alterations observed. The hospital discharge paperwork identified Resident #37 was discharged from the hospital on 1/21/23 following a gastrointestinal hemorrhage. The hospital discharge paperwork identified Resident #37 was found to have a stage IV pressure ulcer to the coccyx and deep tissue injury to the left buttock with recommendations including multiple treatments and to continue cleansing the wound with normal saline, daily dressing changes and with soiling, Silvadene ointment to the coccygeal wound bed, 40 % zinc oxide paste to the peri wound and left buttock, and to cover the coccyx/buttocks with bordered foam. A physician's order dated 1/21/23, following readmission to the facility, directed to complete a Braden Scale weekly for 4 weeks. A Braden Scale dated 1/21/23 identified Resident #37 had a score of 20, indicating the resident was not at risk for development of pressure ulcers. A nursing admission assessment, completed by LPN #2, on 1/21/23 at 1:55 PM, identified Resident #37 was always continent of urine and bowel and was observed to have an open area to the coccyx that measured 1.0 cm x 0.3 cm with no depth. The note further identified no wound care observation was performed and failed to identify documentation or an assessment of the left buttock DTI identified in the hospital discharge documentation. A nurse's note dated 1/21/23 at 3:08 PM by RN #7 identified Resident #37 was readmitted to the facility at 11:30 AM following hospitalization for GI bleed. The note further identified Resident #37 was observed to have an open area to the coccyx with treatment in place. c. Review of the clinical record failed to identify an RN assessment of Resident #37's left buttock deep tissue injury and stage IV pressure ulcer to the coccyx, including wound measurements and appearance, which had been noted in the hospital discharge paperwork had been completed on admission. Interview and clinical record review with LPN #1 on 1/28/25 at 11:24 AM identified that she completed weekly wound rounds with MD #4 after she became the wound care nurse in September 2022. LPN #1 identified that she was present when MD #4 evaluated Resident #37 on 11/21/22 and he ordered Dermaseptin to be started. LPN #1 identified it was her responsibility to place the order in the clinical record as a telephone order to ensure that the treatment was started. Review of the clinical record with LPN #1 identified the treatment was not in place following the 11/21/22 wound rounds. LPN #1 identified she also worked as a unit manager and that the new additional role of wound care nurse at that time was very overwhelming, which may have been why the order was not placed, but she should have taken care of it. LPN #1 identified she did not know why she documented a skin assessment on 1/20/23 while the resident was out of the facility and in the hospital and identified the volume of her workload in multiple roles at the facility as a possible cause. Interview with RN #7 (RN Supervisor) on 1/28/25 at 2:14 PM identified that she documented her RN admission assessments under the nurse's notes in the clinical record. RN #7 identified she usually reviewed the hospital discharge paperwork for all residents who are admitted or re admitted to the facility and ensured all orders are in place including reviewing medications. RN #7 identified that she did not remember Resident #37 having any wound treatments following the re admission, but due to the amount of time that had passed, she was not sure. RN #7 identified that she would have placed wound measurements in the note if she had assessed and measured the wounds when Resident #37 was readmitted to the facility on [DATE]. RN #7 identified that she should have reviewed Resident #37's hospital discharge paperwork from 1/21/23 and noted any pressure ulcers and treatments identified in the documentation present upon readmission and if that she did not document the details in her nurse's note, she did not complete a full assessment of the wounds. Interview with LPN #5 (Regional Nurse) on 1/29/25 at 8:15 AM identified that the facility utilized non medicated barrier creams that did not require a physician's order. LPN #5 identified that any barrier cream that was medicated, including zinc oxide-based barrier creams, required a physician's order and were to only be administered by a licensed nurse. LPN #5 identified that the order would populate on the TAR and the nurse would sign off the cream as administered based on the order in place. Interview with MD #4 on 1/29/25 at 9:48 AM identified that he had been treating Resident #37 for several years related to recurrent pressure ulcers of the coccyx and that when he saw and evaluated Resident #37 on 11/21/22, Resident #37 had a healed closed area on the coccyx from a previous pressure injury. MD #4 identified that he specifically ordered Dermaseptin daily and as needed for Resident #37 related to his/her history of being very incontinent and identified that a zinc oxide based barrier cream was needed to protect Resident #37's skin from moisture and breakdown to prevent further pressure injuries. MD #4 identified he was not aware the treatment had not been implemented. Interview with the DNS on 1/29/25 at 12:05 PM identified that it was the responsibility of the RN supervisor to review the hospital discharge paperwork and complete the initial physical exam of any resident newly admitted or readmitted to the facility. The DNS identified that the LPN assigned to care for the resident would also document following admission and readmission. The DNS identified that a resident who was admitted with a pressure ulcer or wound should have a wound assessment completed on admission under the wound observation assessment in the electronic record which would include the measurements and wound appearance at the time of admission. The DNS identified the Braden Scale assessments were ordered weekly for 4 weeks on admission by the physician and she would expect the nursing staff to ensure that the assessments were completed per the order and identified any resident with a pressure ulcer present on admission should have a risk of pressure ulcers per the Braden Scale if entered correctly. The DNS also identified it was the responsibility of LPN #1 to ensure that any treatment orders added to the resident's wound were entered into the physician's orders in the electronic record to ensure treatment was initiated. The facility policy on pressure ulcers/skin breakdown directed that incidence of new pressure ulcers would be minimized and healing of existing pressure ulcers would be optimized to the extent possible. The policy also directed that nursing staff would assess and document an individual's risk factors for developing pressure ulcers and examine the skin of newly admitted residents for evidence of existing pressure ulcers and other skin conditions. The policy further directed that the physician would help identify contributing factors to skin breakdown, including macerated or friable skin, and would order pertinent treatment for treating a wound including the application of topical agents. The facility policy on resident examination and assessment directed the purpose of the policy was to examine and assess the resident for any abnormalities in health status. The policy further directed that the skin assessment should include assessment findings related to intactness, color, texture and the presence of any pressure ulcers and all assessment data should be recorded in the resident's medical record. The facility policy on physicians' orders directed that verbal orders must be recorded immediately in the resident's chart by the person receiving the order, and must include the name and strength of the drug, the dosage, route and frequency of administration.

Based on review of facility documentation and facility policies, observations, and interviews, the facility failed to implement an effective water management plan to mitigate the risk of Legionella (originally identified in April 2021 water sampling) and other waterborne pathogens which resulted in Immediate Jeopardy that was corrected on August 4, 2021. The findings include: Review of the facility's water culture results from the Laboratory on 04/19/2021 indicated the presence of Legionella species (not pneumophila) in 4 of the 12 samples submitted to the laboratory for analysis for the presence of Legionella. The results were reported to the facility's water management committee for the April 2021 meeting. There was no action taken by the facility on the positive Legionella water sample. During an interview with the Administrator on 08/02/2021, he stated that he had been told by his corporate manager that the lab reported that the facility didn't have to act on the Legionella result but lacked any documentation to reflect this directive. Interview with the Laboratory representative on 08/02/2021 at 12:49PM, identified that he never advised the facility that they didn't have to take action on the positive results from 04/19/2021. During an onsite survey on 08/02/2021 at approximately 09:00 AM, it was identified that the facility failed to ensure that the facility's premise plumbing i.e. potable water utilized by staff and residents was free from Legionella. On 07/20/ 2021, the local health department notified the Department of Public Health (DPH) that there was a laboratory result that was positive Legionella result on a resident (Resident #1) from the nursing facility. On 07/20/21 the facility was contacted by DPH and the Administrator reported that resident (Resident #1) went to the hospital after a fall on 7/12/2021, was tested at the hospital on 7/12/21 for Legionella due to radiographic image showing possible pneumonia. The urine [MEDICATION(S)] test was negative. Follow-up imaging on 7/13/21 showed a worsening infiltration and pneumonia was diagnosed . The patient's symptoms worsened, and the resident was retested for Legionella on 7/16/21 using the urine [MEDICATION(S)] test and was positive for Legionella pneumophila, sero group 1. On 07/20/21 and 07/21/2021, the facility was advised by DPH that Resident #1 was a presumptive facility acquired legionnaires disease and was advised to go on water restrictions (not to use tap water for showering, drinking, oral care, medication administration or medical treatment) and to resample the facility every two weeks for a period of three months. On 7/23/2021 (2 days later), the facility obtained 20 water samples from various locations and water testing results are pending. On 08/02/2021 at approximately 9:30AM, during interview, the Administrator identified that all showers, ice machines, and juice machines were being outfitted with .2 Micron point of use filters, all sinks had their aerators removed and due to the cost, he was not planning to filter all sinks and elected to post signs indicating to not utilize the sinks for drinking and/or teeth brushing. All residents and staff were provided with bottled water for medication administration, medical treatment, teeth brushing and drinking. On 08/02/2021 at approximately 9:30AM, documentation was not provided to indicate that the facility had a water flushing program in low flow areas and the Administrator indicated logs for the flushing program would be started at that time. On 08/02/2021 the facility began installing 0.2 micron filters on showers, ice machines, and juice machines. Micron filter installation was completed by 08//04/2021. The Administrator was informed on 08/04/2021 that immediate jeopardy existed after a positive water sample for Legionella sample was identified (4/19/2021) and the facility failed to take corrective action to mitigate the risk of Legionella until 08/4/2021.

Based on review of clinical records, facility investigation, facility policies and procedures, and interviews for one of three, newly admitted residents at risk to fall, Resident (R) #1, the facility did not ensure that R #1 received adequate supervision and/or assistive devices to prevent an accident. The findings include: R #1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission Minimum Data Assessment ((MDS) dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 11 (moderately impaired range 8-12), extensive assistance of 1 staff for bed mobility, transfer, dressing, and toilet use; limited assistance of 1 staff for walking in room and corridor with a walker, locomotion on/or the unit, and not steady, only able to stabilize with staff assistance moving from seated to standing position, walking with assistive device, and turning around and facing the opposite direction while walking; ostomy; occasional moderate pain, a fall within the last month prior to admission, a fall with a major injury since admission, and antidepressant, anticoagulant, ant antibiotic medications. Review of an Acute Care Hospital #1 Discharge Summary dated 11/17/14 identified that the R #1 had been previously discharged from the hospital on [DATE] with urinary sepsis and a severe fall resulting in a contusion to the hip, back, and neck and was transferred to a Skilled Nursing Facility (not the facility at which the resident presently resided). A Physical Therapy initial assessment dated [DATE] identified impaired strength in bilateral hips, knees, and ankles with impaired balance, decreased endurance, poor safety awareness and decreased strength that required use of a rolling walker and transfer belt. Functional/Cognitive status on day of discharge included transfer status of moderate assistance of 1 person with transfer belt and rolling walker; ambulation distance of 120 feet with rolling walker and 1 person assist with fair tolerance. An interim Resident Care Plan dated 11/17/14 identified the problem of at risk for physical injury from falls related to a fall risk score of 2 (high risk greater than or equal to 10, however the score of 2 represented an inaccurate assessment of the resident) with no interventions identified. A Physical Therapy (PT) Evaluation/Plan of care initiated 11/18/14 identified confusion and impaired balance. On 11/18/14, R #1's ambulation status was contact guard with rolling walker and assist of 1 person for 30 feet. An Occupational Therapy (OT) Evaluation/Plan of Care initiated 11/18/14 identified alert, able to follow 2 step commands and demonstrates increased confusion. Functional mobility required minimal assist with rolling walker. R #1 required minimal assist to maintain static and dynamic standing balance. Weekly progress notes documented by Certified OT Assistant (COTA) #1 identified the goal of demonstrating a standing tolerance of minutes for Activities of Daily Living (ADL). Review of a facility conducted fall investigation coordinated by the Director of Nursing (DNS) identified that, on Saturday 11/22/14 at 2:00 PM, COTA #1 walked with R #1 from his/her room to the therapy room. While standing in front of a table, R #1 fell backwards and hit her head. The resident was immediately assessed by a Registered Nurse (RN) and a 3 centimeter (cm) by 3 cm bump with an abrasion was identified on the back of his/her head. The Advanced Practice Registered Nurse was notified and due to the fact that R #1 was on Coumadin, he/she was transferred to Acute Hospital #1 Emergency Department (ED) for an evaluation, and ultimately was admitted after a CT Scan identified an acute linear area of acute subdural blood along the anterior midline falx. A gait belt was not in use during ambulation and/or while standing at the table in the therapy room. Interview with COTA #1 and the Director of Rehabilitative Services on 02/04/14 at 2:10 PM identified that COTA #1 went to the resident's room on 11/22/14 and escorted him/her to the bathroom with the rolling walker and provided supervision for toileting. R #1 sat in a chair for a minute and then ambulated with COTA #1 to the therapy room with a rolling walker but no gait belt. The COTA #1 brought a wheelchair chair with him/her and provided supervision, but no contact guard assistance. COTA #1 identified that R #1 exhibited no difficulty with endurance, balance or ambulation and did not want a rest period. The therapy room was an approximate distance of 150 feet. R #1 approached the table with the walker and, because the resident required a chair, COTA #1 reached back to get the wheelchair with the intent of putting the chair behind the resident so he/she could be seated at the table. As COTA #1 turned away from R #1 to get the wheelchair, R #1 fell straight back onto the floor and appeared to hit his/her head with force. R #1 immediately tried to get up as COTA #1 interceded. There were no other staff members and/or residents in the therapy room at the time. The Director of Rehabilitative Services and COTA #1 identified that R #1 had made progress during the previous week and when treating a resident whose goal is independence, a therapist may trial independence with ADL's and mobility during a treatment session. Additionally R #1 had been reviewed at a Rehab meeting with the Director of Rehab Services (an OTR) on 11/19/14 and it was determined that R #1 could be trialed with an independent status. COTA #1 ambulated R #1 a greater distance then the functional goal developed by the PT for the certification period of 11/18/14 through 12/15/14 which was contact guard with rolling walker for 100 feet twice a day with stand by assistance. Contact guard assistance with a rolling walker for 30 feet was the resident's status on 11/18/15 and 11/24/14 per PT weekly progress note. Additionally, although COTA #1 had brought the wheelchair from the resident's room to the therapy room, he/she did not walk behind the resident with the wheel chair either in the hallway and/or in anticipation of the need to sit at the table in the therapy room. The clinical record identified that the resident required a brief hospitalization for observation and returned to the facility, continued rehabilitation and was discharged to home with 24 hour care on 12/16/14. Ambulation status at that time was contact guard assist of 1 with a rolling walker. A facility policy for the use of gait belts by therapy staff identified, in part, that a gait belt will be used for all residents during transfers and ambulation when assistance or close supervision is required. Residents who have been assessed to be independent to transfers and ambulation may not be required to wear one. Alternative applications or equipment maybe utilized to assure patient safety.

Based on review of the clinical record, facility documentation and/or interviews for one of three residents reviewed for an accident (R #153), the facility failed to ensure that care and/or services were provided according to a physician's orders [REDACTED]. Resident #153's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident with poor decision-making skills, non-ambulatory and requiring total assistance from staff for activities of daily living. Physician monthly orders for July 2013 directed a chair pad sensor alarm and to check for placement and function every shift. Facility documentation dated 7/27/13 at 6:30 P.M. identified that R#153 was observed lying on the floor face down with opened wounds to the left elbow, forehead and the bridge of the nose. The resident was subsequently transfer to an acute care facility for treatment and received three sutures to close the laceration to the bridge of the nose. All diagnostic testing which included a CT scan and maxillofacial x-rays were report as negative. On 8/19/13 at 10:30 A.M., an interview and review of facility documentation with NA #1 indicated that following supper he/she pushed the resident back to his/her room with the intention of preparing the resident for bed. After leaving the resident unattended and/or alone in his/her room, the aide went into the hallway to provide assistance to the resident's roommate (R #104) when suddenly he/she heard a "loud bang". Immediately the aide returned to R #153 only to find the resident lying on the floor, face down and bleeding. NA #1 further indicated that although the resident was to have had a chair alarm in place at the time of the fall, the alarm was not available. On 8/19/13 at 11:20 A.M. an interview and review of facility documentation with the DON indicated that following the event, the aide was given a final written warning for failure to follow the nurse aide assignment by ensuring that the resident's chair alarm was in place and functioning at the time of the resident's fall.

Resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note dated 10/29/10 identified the resident was transferred to the acute care hospital. The note identified that the resident's personal belongings were being stored at the facility until 10/30/10 when the responsible party retrieved the items. The Reportable Event dated 11/26/10 identified the facility was notified by the local Police Department of an allegation of misappropriation of the resident's funds and IPOD by an employee. The police investigation identified thirteen fraudulent cash advance charges and one balance inquiry was made on R #246's stolen Visa debit card between 10/30/10 and 11/8/10 totaling $2,042.95. R #246 was unaware that any money was withdrawn using the Visa debit card until the credit card company contacted him/her and advised the resident to notify the local Police Department. Interview with the Administrator on 8/31/11 at 1:30 PM identified the staff member was immediately suspended pending the investigation, subsequently arrested by the Milford Police on 12/7/10 and was terminated by the facility on 12/9/10.

Based on clinical record review and interviews for one of three sampled residents reviewed for pressure ulcers (Resident #36), the facility failed to assess the skin to prevent the development of a pressure sore according to standards of practice. The findings include: Resident #36's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified intact cognition and total care for activities of daily living. The nurse's note dated 3/24/11 at 10:55 AM identified Resident #36 reported shortness of breath and was transferred to the hospital and subsequently returned to the facility on [DATE] at 11:00 PM with a left leg air cast in place for a questionable avulsion [MEDICAL CONDITION] ankle and recommended a follow up with the Orthopedic Physician. The Orthopedic consultation dated 3/31/11 identified the resident did not have a fracture to the left ankle and recommendations included to wear the left leg air cast for two weeks (until 4/14/11) and return for a follow up visit in six weeks. The Treatment Administration Record identified the air cast was to be discontinued on 4/14/11, however, the nurse's notes dated 4/15/11 at 3:00 PM, 4/17/11 at 3:10 PM, 4/17/11 at 1:50 PM, and 4/21/11 at 2:30 PM identified the air cast was still in place. The Orthopedic consultation dated 4/26/11 identified a 5 centimeter (cm) by 3 cm foul smelling, eschar area with [MEDICAL CONDITION] on the left leg with recommendations that included to discontinue the air cast/brace, provide a wound consultation and weight bearing as tolerated. The APRN wound note dated 4/26/11 identified a left calf distal wound measuring 4.3 cm by 3 cm by 0.2 cm with 90 percent slough and a 1.8 cm by 3.3 cm left proximal calf unstageable wound. Review of the April 2011 nurses notes, physician orders [REDACTED]. Interview with the APRN on 9/1/11 at 11:20 AM identified the resident's air cast came to the mid shin and down around the mid foot, was secured by Velcro and was removable. Interview with the Orthopedic Physician on 9/1/11 at 2:30 PM identified the resident's open areas were a result of the brace/air cast not being removed and the skin monitored. The Orthopedic Physician further noted the air cast was to be removed and the condition of the skin assessed. Interview with the Director of Physical Therapy on 9/1/11 at 1:20 PM identified that the therapy department did not assess the resident for the use of the air cast because there was not a physician order [REDACTED]. Interview with LPN #1 on 9/1/11 at 1:00 PM identified she was the regular charge nurse on the 7 to 3 PM shift for R# 36 and she removed the air cast every day she worked, lotion the left leg and checked the integrity of the skin. LPN #1 noted she was on vacation the week prior to the open areas being identified. Interview with LPN #2 on 9/1/11 at 2:50 PM identified she was the regular charge nurse on the 3 to11 PM shift and although she assessed the skin around the air cast for color and temperature, she did not remove the air cast to assess the skin under the cast. According to the Lippincott Manual of Nursing Practice, Third Edition, 2006, nurses should evaluate the patient for proper body alignment and pressure from equipment (casts, splints, appliances)

Based on clinical record review and interviews for one of three sampled residents reviewed for pressure ulcers (Resident #36), the facility failed to provide care and services to prevent the development of a pressure ulcer. The findings include: Resident #36's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified intact cognition and total care for activities of daily living. The nurse's note dated 3/24/11 at 10:55 AM identified Resident #36 reported shortness of breath and was transferred to the hospital and subsequently returned to the facility on [DATE] at 11:00 PM with a left leg air cast in place for a questionable avulsion [MEDICAL CONDITION] ankle and recommended a follow up with the Orthopedic Physician. The Orthopedic consultation dated 3/31/11 identified the resident did not have a fracture to the left ankle and recommendations included to wear the left leg air cast for two weeks (until 4/14/11) and return for a follow up visit in six weeks. The Treatment Administration Record identified the air cast was to be discontinued on 4/14/11, however, the nurse's notes dated 4/15/11 at 3:00 PM, 4/17/11 at 3:10 PM, 4/17/11 at 1:50 PM, and 4/21/11 at 2:30 PM identified the air cast was still in place. The Orthopedic consultation dated 4/26/11 identified a 5 centimeter (cm) by 3 cm foul smelling, eschar area with [MEDICAL CONDITION] on the left leg with recommendations that included to discontinue the air cast/brace, provide a wound consultation and weight bearing as tolerated. The APRN wound note dated 4/26/11 identified a left calf distal wound measuring 4.3 cm by 3 cm by 0.2 cm with 90 percent slough and a 1.8 cm by 3.3 cm left proximal calf unstageable wound. Review of the April 2011 nurses notes, physician orders [REDACTED]. Interview with the APRN on 9/1/11 at 11:20 AM identified the resident's air cast came to the mid shin and down around the mid foot, was secured by Velcro and was removable. Interview with the Orthopedic Physician on 9/1/11 at 2:30 PM identified the resident's open areas were a result of the brace/air cast not being removed and the skin monitored. The Orthopedic Physician further noted the air cast was to be removed and the condition of the skin assessed. Interview with the Director of Physical Therapy on 9/1/11 at 1:20 PM identified that the therapy department did not assess the resident for the use of the air cast because there was not a physician order [REDACTED]. Interview with LPN #1 on 9/1/11 at 1:00 PM identified she was the regular charge nurse on the 7 to 3 PM shift for R# 36 and she removed the air cast every day she worked, lotion the left leg and checked the integrity of the skin. LPN #1 noted she was on vacation the week prior to the open areas being identified. Interview with LPN #2 on 9/1/11 at 2:50 PM identified she was the regular charge nurse on the 3 to11 PM shift and although she assessed the skin around the air cast for color and temperature, she did not remove the air cast to assess the skin under the cast.

Based review of the clinical record, facility documentation and interview for one of five residents reviewed for accidents (Resident #53), the facility failed to ensure a dependent resident was free from accident with injury. The findings include: Resident #53's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified the resident had severely impaired cognition, was totally dependent for bed mobility, transfers, dressing, and grooming, and had functional impairments of the upper and lower extremities. The care plan dated 6/20/11 identified an alteration in mobility with transfers, and bed mobility. Interventions included transferring with assistance of a Hoyer mechanical lift and two staff members, and providing two staff members for bed mobility. A nurse's note dated 8/14/11 identified a bruise was noted on the left arm with minor swelling and pain. The physician was notified and directed to obtain an x-ray of the left arm. An x-ray report dated 8/15/11 identified an acute left humerus fracture. Upon notification, the physician directed an orthopedic consultation with recommendations to apply a brace with shoulder cap, and not to rotate the left arm for care. A review of the clinical record failed to reflect a history of accident and/or injury. The Reportable Event dated 8/14/11 at 8:30 PM identified staff reported noting a bruise to the left arm with swelling and pain during care. Interview with Physician #1 on 9/1/11 at 1:15 PM identified the type of fracture noted on the x-ray would occur from a twisting/bending motion and was not pathological in nature, but post traumatic event. Physician #1 further indicated that this type of fracture is normally treated with surgical intervention; however, due to R #53's comorbidity the risks for surgery outweighed the benefit.