Every finding on record at Civita Care Sheriden Woods

Based on review of the clinical record, facility documentation/policy, and staff interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision was provided to prevent an accident for a resident identified as cognitively impaired and at risk for falls. Specifically, the facility failed to ensure Resident #1 was supervised during bedside urinal use when left out of staff line of sight behind a privacy curtain, resulting in a fall with injury. The findings include:Resident #1's diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time) with dyskinesia (involuntary, erratic and uncontrollable movements), dysarthria (speech disorder causing slurred, slow or quiet speech due to weakened muscles) and anarthria (severe form of dysarthria resulting in an inability to speak), generalized muscle weakness, lack of coordination, difficulty in walking and anxiety disorder.A Fall Risk Evaluation dated 1/20/26 identified Resident #1 was at risk for falls.A physician's order dated 1/20/26 directed Resident #1 required an assist of one (1) for Activities of Daily Living (ADLs) and toilet transfers.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and required moderate assistance with personal hygiene and transfers. Additionally, the MDS identified Resident #1 had a history of falls and sustained one (1) fall with injury since admission.The Resident Care Plan (RCP) dated 1/29/26 identified Resident #1 had impaired cognition, was at risk for falls due to being newly admitted to the facility, a previous history of falls, impaired sense of balance and an unsteady gait, difficulty seeing and reported blurriness on his/her left side of vision and required assistance with bathing, dressing, eating, grooming and hygiene. Interventions included using simple language, direct communication, task segmentation and speaking slowly and clearly and explaining all procedures, ensuring the call bell is within reach, instructing Resident #1 to ask for assistance prior to attempting to transfer or ambulate, reorienting Resident #1 as needed, providing an assist of 1 for ADLs, and providing an assist of 1 for toileting at wheelchair level using the grab bar.A nurse's note by RN #1 dated 2/7/26 at 7:30 AM identified she was called to assess Resident #1 following a fall. Resident #1 was found on the floor in a seated position attempting to get up and a laceration with blood was noted to Resident #1's face. The note identified Emergency Medical Services (EMS) was notified and Resident #1 remained on the floor until EMS arrival and Resident #1 was subsequently transferred to the hospital at 6:30 AM. The on-call provider and Resident #1's representative were notified of the incident.A nurse's note by LPN #1 dated 2/7/26 at 7:51 AM identified at approximately 5:55 AM she was notified by NA #1 that Resident #1 sustained a fall and upon entering the room, Resident #1 was observed on the floor in front of his/her bed with visible bleeding to the head. The nursing supervisor (RN #1) was notified and assessed Resident #1 and Resident #1 remained sitting in an upright position on the floor due to active bleeding until EMS arrived. The note identified NA #1 reported Resident #1 had been assisted with the urinal, a few minutes prior to the incident, and was left sitting upright in bed. Hospital documentation dated 2/7/26 identified Resident #1 was evaluated in the Emergency Department (ED) following a fall and sustained multiple lacerations over the forehead that were repaired with absorbable sutures.A nurse's note by RN #4 dated 2/7/26 at 6:40 PM identified Resident #1 returned to the facility at 5:00 PM. Resident #1 had slight bleeding to the lacerations on both eyebrows with absorbable sutures intact, a scrape to the left wrist, new bruises to both posterior (backside) upper thighs and old bruises to both knees, hips and the right upper arm. The note identified Resident #1 as alert and responsive with slight agitation and that a family member was at Resident #1's bedside.Interview and review of a statement dated 2/7/26 with NA #1 on 3/12/26 at 4:10 PM identified that on 2/7/26, she went into Resident #1's room and he/she requested to use the urinal. She reported she assisted Resident #1 in sitting on the bedside to use the urinal, but Resident #1 was unable to urinate, so he/she requested privacy. NA #1 identified she was aware that Resident #1 was an assist of one (1) for ADL's and toileting, had a history of falls, was confused at times and had a history of not using the call bell. NA #1 identified she requested Resident #1 use the call bell when he/she was finished, pulled the privacy curtain around Resident #1's bed and went to perform care for the roommate. NA #1 identified that about two (2) minutes later, she heard a bang and when she opened the privacy curtain surrounding Resident #1's bed, she observed Resident #1 on the floor on the side of the bed with active bleeding from his/her head. She identified she asked Resident #1 if he/she was okay and then left Resident #1 unattended while she walked two (2) doors down the hallway to notify RN #1. NA #1 identified she did not call out for help or use the call bell for assistance. NA #1 identified she should not have left Resident #1 unattended, should have alerted LPN #1 of Resident #1's request for privacy and requested additional assistance while she performed care for the roommate.Interview with OTA #1 (Director of Rehab) and PT #1 on 3/11/26 at 1:53 PM identified Resident #1 was receiving therapy services at the time of the 2/7/26 fall and required an assist of one (1) for ADLs and toilet transfers.Interview with LPN #1 on 3/13/26 at 9:28 AM identified on 2/7/26 she was alerted Resident #1 sustained a fall and when she arrived to the room, Resident #1 was in a sitting position on the floor with a moderate amount of active bleeding from the forehead and RN #1 was applying pressure to the area. LPN #1 identified Resident #1 was admitted to the facility after sustaining a fall at home, had previously sustained a fall at the facility, and was identified as a fall risk due to tremors and poor safety awareness. LPN #1 identified Resident #1 should not have been left out of NA #1's line of sight, despite a request for privacy, without first notifying her or other staff for assistance, due to a known fall risk. LPN #1 reported that following the fall, NA #1 should have used the call bell or yelled for staff assistance rather than leave Resident #1 further unattended after it was identified he/she was actively bleeding from the head.Interview with the DON on 3/13/26 at 11:38 AM identified per Resident #1's plan of care, on 2/7/26, NA #1 should not have left Resident #1 out of sight while sitting on the bedside using the urinal, behind the privacy curtain and then moving on to perform care for the roommate. The DON reported that when Resident #1 requested privacy while using the urinal, NA #1 should have explained that she could not leave for safety reasons or notified a licensed nurse of the request and requested assistance before leaving Resident #1 out of sight while sitting on the bedside. Additionally, she identified that once NA #1 observed Resident #1 on the floor actively bleeding, she should have first yelled for assistance or used the call bell to request assistance rather than leave Resident #1 unattended in the room.Interview with RN #1 on 3/13/26 at 12:21 PM identified on 2/7/26, NA #1 approached her in the nursing supervisor's office to report Resident #1 fell and was bleeding. She reported she immediately went to Resident #1's room and observed Resident #1 sitting on the floor at the bedside, the urinal was on the floor and Resident #1 was bleeding significantly from the forehead requiring application of pressure to the area. RN #1 reported Resident #1 was a fall risk, was an assist of one (1) for ADLs and toileting and NA #1 should not have left Resident #1 unattended, behind a privacy curtain and out of her line of sight without first notifying the charge nurse (LPN #1) and requesting assistance from staff.Review of the Kardex Use policy (undated) directed, in part, the Kardex information should reflect the resident's current care plan, physician orders and clinical status and is used by Certified Nursing Assistant staff to guide daily care and communication including safety risks, activity level and transfer status. Updates must occur when there are changes in physician orders, care plans, mobility status and safety precautions. Staff must verify Kardex information against the current physician orders and care plan before using it for care decisions. Although requested, a facility policy for post-fall procedure was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for falls, the facility failed to ensure Resident Care Conferences (RCCs) were completed at least quarterly. The findings include:Resident #2's diagnoses included fracture of the scaphoid bone of the left wrist (one of the carpal bones on the thumb side of the wrist important for both motion and stability), weakness, Alzheimer's disease and aphasia following a cerebral infarction (language disorder affecting expression, comprehension, reading and writing following a stroke). The Resident Care Plan (RCP) dated 11/19/25 identified Resident #2 was at risk for falls secondary to being newly admitted to the facility, cognitive impairment and generalized weakness. Interventions included placing the call light within reach and orienting to surroundings, instructing to ask for assistance prior to attempting to transfer or ambulate and instructing the proper use of any appliance/device to aid with balance/transfers and encouraging use. The Interdisciplinary Care Plan Meeting Documentation dated 11/19/25 identified that an RCC was held for Resident #2 on 11/19/25. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3) and required substantial assistance for bed mobility, transfers and ambulation. Review of the clinical record from 11/20/25 through 3/8/26 failed to identify an RCC had been scheduled or held for Resident #2 to correlate with the 2/3/26 MDS. The Interdisciplinary Care Plan Meeting Documentation dated 3/9/26 identified that an RCC was held for Resident #2 on 3/9/26 (1 month and 6 days after the MDS). Interview with the MDS Coordinator (RN #3) on 3/11/26 at 3:25 PM identified RCC's are to be completed for each resident at least quarterly and RCPs are to be reviewed. RN #3 identified Resident #2 should have had an RCC scheduled around 2/3/26 and an RCC was initially scheduled for 2/19/26 but there was no documentation in the clinical record to confirm the 2/19/26 RCC date. RN #3 was unable to provide documentation identifying an invitation was sent to Resident #2 or Resident #2's representative for the 2/19/26 meeting and identified she was on vacation prior to the 2/19/26 scheduled RCC date when the invitation should have been sent. Interview with the DON on 3/11/26 at 2:39 PM identified all residents are to have RCC's completed at least quarterly, which includes an RCP review, and should correlate with the MDS date and be documented in the clinical record. She identified that Resident #2 should have had an RCC scheduled on or around 2/3/26 before Resident #2's 2/10/26 fall which should have been documented in the clinical record, and if it was rescheduled, there should have been a note indicating why the RCC was rescheduled and to when. Review of the Comprehensive Care Planning policy dated 7/6/25 directed, in part, the resident is informed of his/her right to participate in his/her treatment and provided advanced notice of care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.Although requested, a facility policy for Resident Care Conferences was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for falls, the facility failed to ensure a Fall Risk Evaluation was completed at least quarterly. The findings include:Resident #2's diagnoses included fracture of the scaphoid bone of the left wrist (one of the carpal bones on the thumb side of the wrist important for both motion and stability), weakness, Alzheimer's disease and aphasia following a cerebral infarction (language disorder affecting expression, comprehension, reading and writing following a stroke). Cross-reference F657 A Fall Risk Evaluation dated 10/30/25 identified Resident #2 was not at risk to a low fall risk. The Resident Care Plan (RCP) dated 11/19/25 identified Resident #2 was at risk for falls secondary to being newly admitted to the facility, cognitive impairment and generalized weakness. Interventions included placing the call light within reach and orienting to surroundings, instructing to ask for assistance prior to attempting to transfer or ambulate and instructing the proper use of any appliance/device to aid with balance/transfers and encouraging use. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3) and required substantial assistance for bed mobility, transfers and ambulation. Review of the clinical record failed to identify a Fall Risk Evaluation had been completed from 10/31/25 through 2/9/26. A nurse's note written by RN #2 dated 2/10/26 at 1:31 AM identified she was called to the unit for reports that Resident #2 fell and was on the floor. When she entered the room, Resident #2 was noted to be on his/her right side on the floor, and the right hip was red from laying on it but Resident #2 denied pain. The note identified vital signs were obtained and the provider was notified. Review of the clinical record failed to identify orders were obtained for monitoring the reddened right hip. A nurse's note by the DON dated 2/10/26 at 12:16 PM identified Resident #2 sustained a fall at 12:20 AM and was found lying on the floor. The note reported that later in the day Resident #2 was noted with a bump to the right side of his/her head and was unable to move his/her neck but denied pain or discomfort. The note identified Resident #2 was evaluated by the APRN and subsequently transferred to the Emergency Department (ED) at 12:17 PM. The hospital documentation dated 2/16/26 identified Resident #2 was admitted from 2/10/26 through 2/16/26 following a fall with an acute displaced type II odontoid fracture (a break in the dens of the second cervical bone in the neck). Interview with the DON on 3/11/26 at 2:39 PM identified all residents should have a Fall Risk Evaluation completed by licensed nursing staff on admission, quarterly and with a change in condition and Resident #2 should have had a Fall Risk Evaluation completed on or around the 2/3/26 MDS date prior to the 2/10/26 fall. Review of the Falls Protocol policy dated 7/24/25 directed, in part, the staff and practitioner will review each resident's risk factors for falling and document in the clinical record. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). The staff will evaluate and document falls that occur while the resident is in the facility. Although requested a policy on Fall Risk Evaluations was not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Residents #1 and #2) reviewed for falls, the facility failed to ensure a nursing assessment was completed and documented in the clinical record at the time of the fall when the assessment was completed.1. Resident #1's diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time) with dyskinesia (involuntary, erratic and uncontrollable movements), dysarthria (speech disorder causing slurred, slow or quiet speech due to weakened muscles) and anarthria (severe form of dysarthria resulting in an inability to speak), generalized muscle weakness, lack of coordination, difficulty in walking and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11) and required moderate assistance with personal hygiene and transfers. Additionally, the MDS identified Resident #1 had a history of falls and sustained one (1) fall with injury since admission. The Resident Care Plan (RCP) dated 1/29/26 identified Resident #1 had impaired cognition, was at risk for falls due to being newly admitted to the facility, a previous history of falls, impaired sense of balance and an unsteady gait, difficulty seeing and reported blurriness on his/her left side of vision and required assistance with bathing, dressing, eating, grooming and hygiene. Interventions included using simple language, direct communication, task segmentation, speaking slowly and clearly and explaining all procedures, ensuring the call bell is within reach, instructing Resident #1 to ask for assistance prior to attempting to transfer or ambulate, reorienting Resident #1 as needed, providing an assist of 1 for ADLs, and providing an assist of 1 for toileting at wheelchair level using the grab bar. A nurse's note by RN #1 dated 2/7/26 at 7:30 AM identified she was called to assess Resident #1 following a fall. Resident #1 was found on the floor in a seated position attempting to get up and a laceration with blood was noted to Resident #1's face. The note identified Emergency Medical Services (EMS) was notified and Resident #1 remained on the floor until EMS arrival and Resident #1 was subsequently transferred to the hospital at 6:30 AM. The on-call provider and Resident #1's representative were notified of the incident. The note failed to identify that Range of Motion (ROM) was assessed for any further injuries or pain following the fall. Review of the clinical record failed to identify a Situation, Background, Assessment, Recommendation (SBAR) had been completed by RN #1 documenting a full assessment had been performed for Resident #1 on 2/7/26. Interview with RN #1 on 3/13/26 at 12:21 PM identified she performed a full assessment to include ROM and neurological signs for Resident #1 but did not document her findings. She identified that the assessment should have been documented as part of her note and completed prior to leaving her shift. 2. Resident #2's diagnoses included fracture of the scaphoid bone of the left wrist (one of the carpal bones on the thumb side of the wrist important for both motion and stability), weakness, Alzheimer's disease and aphasia following a cerebral infarction (language disorder affecting expression, comprehension, reading and writing following a stroke). The Resident Care Plan (RCP) dated 11/19/25 identified Resident #2 was at risk for falls secondary to being newly admitted to the facility, cognitive impairment and generalized weakness. Interventions included placing the call light within reach and orienting to surroundings, instructing to ask for assistance prior to attempting to transfer or ambulate and instructing the proper use of any appliance/device to aid with balance/transfers and encouraging use. Cross-reference F657 The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3) and required substantial assistance for bed mobility, transfers and ambulation. A nurse's note written by RN #2 dated 2/10/26 at 1:31 AM identified she was called to the unit for reports that Resident #2 fell and was on the floor. When she entered the room, Resident #2 was noted to be on his/her right side on the floor, and the right hip was red from laying on it but Resident #2 denied pain. The note identified vital signs were obtained and the provider was notified. Review of the clinical record failed to identify new orders were obtained for monitoring the reddened right hip and failed to identify that Range of Motion (ROM) was assessed for any further injuries following the fall. Review of the clinical record failed to identify a Situation, Background, Assessment, Recommendation (SBAR) had been completed by RN #2 documenting a full assessment had been performed for Resident #2 on 2/10/26. A nurse's note by the DON dated 2/10/26 at 12:16 PM identified Resident #2 sustained a fall at 12:20 AM and was found lying on the floor. The note reported that later in the day Resident #2 was noted with a bump to the right side of his/her head and was unable to move his/her neck but denied pain or discomfort. The note identified Resident #2 was evaluated by the APRN and subsequently transferred to the Emergency Department (ED) at 12:17 PM. The hospital documentation dated 2/16/26 identified Resident #2 was admitted from 2/10/26 through 2/16/26 following a fall with an acute displaced type II odontoid fracture (a break in the dens of the second cervical bone in the neck). Interview with RN #2 on 3/13/26 at 1:37 PM identified she performed a full assessment to include movement and ROM for Resident #2 but she did not document her findings. She identified the assessment should have been documented as part of her note and completed prior to leaving her shift. Interview with the DON on 3/11/26 at 2:39 PM identified both RN #1 and RN #2 should have documented their full nursing assessment following Resident #1 and Resident #2's falls in their nurse's notes or an SBAR prior to leaving their shift. Review of the Falls Protocol policy dated 7/24/25 directed, in part, the nurse shall assess and document the following: vital signs, recent injury, musculoskeletal function, observing for change in normal range of motion or weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit and precipitating factors and details on how the fall occurred. Review of the Charting Documentation policy dated 8/4/25 directed, in part, all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details including the assessment data and/or any unusual findings obtained.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures, and interviews for two of three sampled residents (Residents #2 and #37) reviewed for pressure ulcers, the facility failed to ensure that a resident at risk for the development of a pressure injury and had an existing pressure injury had patient-centered preventative interventions and treatments that were implemented based on the resident's diagnoses and positioning risk factors contributing to the development and worsening of a pressure injury. The findings include: Resident #2 was readmitted to the facility in September 2025. Diagnoses included Type 2 diabetes mellitus without complications, Sjogren syndrome, chronic combined systolic (congestive and diastolic (congestive) heart failure. A review of physician's orders for the period of 9/26/25 through 10/7/25 identified an order that directed to apply triad paste to the buttocks for wound/skin care. The care plan dated 10/2/25 identified Resident #2 was at risk for skin breakdown related to decreased mobility and moisture with interventions that included an alternating pressure mattress (APM) set at 200 lbs., inspect skin for redness, irritation or breakdown during care, offer turning and repositioning approximately every 2 hours and as needed (PRN) and complete weekly skin inspections. The Norton Plus Assessment (determines the risk of developing pressure ulcers), dated 10/6/25 identified Resident #2 scored 11 which indicated Resident #2 was at high risk. The annual MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition, utilized a wheelchair, was dependent for transfers, showering and toileting hygiene, was always incontinent of bladder and frequently incontinent of bowel, was at risk for developing a pressure injury but did not have any unhealed pressure ulcers/injuries, or other ulcers, wounds or skin problems and had a pressure reducing device for chair, pressure reducing device for bed, and application of nonsurgical dressings and applications of ointments/medications. The wound nurse's progress note dated 10/7/25 at 5:24 PM identified Resident #2 was seen for wound care. Buttocks inspected- blanchable erythema with small, superficial denuded areas. Presentation consistent with MASD (moisture associated skin deterioration). The note further indicated the APRN was updated and a foam dressing was added to the triad paste. The note identified the APM was in place and a ROHO cushion was requested from therapy. The physician's order dated 10/7/25 directed to apply triad paste to buttock followed by foam dressing every day on night shift for wound/skin care, apply ROHO cushion to the wheelchair and check proper cushion and placement every shift. The nursing progress note dated 11/7/25 at 3:13 PM identified Resident #2's coccyx had blanchable erythema with protective dressing in place. The nursing progress note dated 12/5/25 at 3:27 PM identified Resident #2 had loose, liquid bowel movements with malodorous odor and indicated the sacral area was noted with skin irritation consistent with incontinence associated dermatitis with an order for triad ointment in place. The physician's order dated 1/28/26 directed wound/skin care to apply triad paste to buttock followed by foam dressing every day, every night shift. Interview with Resident #2 on 2/19/2026 at 2:16 PM identified complaints of a rectal/back sore and indicated the soreness was related to having to sit in wet briefs due to staffing constraints on some days. Observation at this time noted the APM was set at 250 lbs. and identified a container of Aquaphor ointment on the side table. Resident #2 indicated that he/she had been provided with incontinent care but had not been out of bed. Resident #2 identified that she/he required the use of a Hoyer and two staff members for transfers. Observation of Resident #2 on 2/26/26 at 11:17 AM identified Resident #2 was still in bed and had not been cleaned up for the day. Resident #2 indicated that he/she had not been changed since night shift and was waiting for staff to come in. Resident #2 identified that the Aquaphor is on the bedside table, so it is readily accessible but indicated that it is not being placed on the rectum and that the rectum and back continue to have pain to the point that staff has started placing pillows on each side under his/her hips to alleviate some of the pressure at his/her request. Interview with NA #4 on 2/26/26 at 12:08 PM identified that this was the first time that day that she was providing care to Resident #2. NA #4 indicated that she approached the resident's room around 10:00 AM and a visitor was present, so she decided to reapproach later. NA #4 identified she could not identify when the resident had last been provided with incontinent care and indicated she asked the nurse for direction on patient care because the unit was so fast paced. NA #4 had provided most care prior to the nurse notifying this surveyor that care was being provided and indicated that the wound dressing had been saturated with urine. Observation of Resident #2 on 2/26/26 at 12:10 PM identified the old dressing was in the trash and it was dated 2/26/26, 11-7. Observation of Resident #2's skin identified a wound to the sacral/coccyx area on the lower back just above the buttocks that had an open area present with yellow drainage and slough (devitalized tissue) present. The wound edges were irregular and partially macerated, and the surrounding skin was discolored and scarred. Interview with LPN #6 on 2/26/26 at 12:13 PM identified Resident #2's dressing was placed on the night shift. She further noted that it needed to be changed due to being saturated with urine. LPN #6 indicated that this was the first time she had been into Resident #2's room for care. Interview with the Medical Director on 2/26/26 at 12:57 PM identified that he did not make decisions regarding wound care treatment and that if staff comes across a wound, it would be referred to the wound nurse and the wound APRN. The Medical Director indicated that he was not aware if the APM setting impacted wound healing. Interview with the Nursing Supervisor RN#2 on 2/26/26 at 1:07 PM identified that every resident in the facility gets a weekly skin check. RN#2 indicated the order should be placed on admission and would coordinate with the resident's shower day and prompt the nurse to complete the weekly skin check. RN#2 reviewed Resident #2's clinical chart which failed to identify an order for a weekly skin audit and failed to identify weekly skin audits. RN#2 identified that any new skin problem would immediately get referred to the wound nurse and indicated that although the wound nurse put a treatment order in on 10/7/25, there was not an assessment or monitoring of Resident #2's sacrum. RN #2 identified that the wound APRN had not seen Resident #2 for the sacral wound. Interview with LPN #11 on 2/27/26 at 6:35 AM identified she worked nights (11 pm to 7 am shift) and completed wound care on Resident #2. LPN #11 indicated the treatment had been in place for a long time and the nursing supervisor or the wound nurse would be notified of wound deterioration. Interview with the Staff Development Nurse (RN#1) on 2/27/26 at 6:55 AM identified new skin problems found should be reported to the nursing supervisor who would do an assessment that included measuring the wound. Interview with APRN#1 on 2/27/26 at 11:09 AM identified she referred to Resident #2's sacral area as a Stage 2 because it was in a previous note. APRN#1 indicated that when she looked at the wound, she thought it was being monitored. APRN#1 identified the wound should be monitored by nursing and should have been seen by the wound nurse. After surveyor inquiry a physician's order dated 2/26/26 directed to cleanse the stage 2 pressure wound to the sacrum with normal saline followed by triad cream and cover with a foam dressing. It further noted to change the dressing daily on the evening shift and as needed. Interview with the Corporate Nursing Director (LPN#3) identified that the initial assessment of a wound should include measurements, assessment, drainage amount and should be monitored. Interview with the wound RN on 3/2/26 at 10:59 AM identified Resident #2 was being seen for other wounds but had not been seen until 3/1/26 by the wound APRN. The wound RN indicated that every resident should have weekly skin checks by nursing and wounds should be referred to the wound nurse. The wound RN identified the original treatment was placed for a macerated area caused by incontinence. Interview with APRN #2, (wound APRN) on 3/2/26 at 3:54 PM identified she observed Resident #2's sacral area yesterday for the first time. APRN#2 indicated that she should have seen the area earlier and that the area looked like incontinence that had recurred. APRN #2 identified that people with moisture associated skin issues are 33 percent more susceptible to developing a pressure injury. Review of the clinical record failed to identify that the resident's wound(s) to the buttocks/sacral areal that was identified on 10/7/25 as MASD was monitored and assessed on a weekly basis. The record failed to note size, drainage and/or changes (deterioration) with the wound. The wound subsequently developed into a questionable stage 2 pressure injury. The dressing order was not changed from the time of its inception on 10/7/25. The wound nurse did not assess the wound and therefore the wound was not evaluated by the facility's wound APRN. The resident was also observed to not receive timely incontinent care on 2/26/26. All of these factors may have contributed to the development and worsening of a pressure injury wound. The facility policy for Pressure Ulcer Risk Assessment identified risk factors that increase a resident's susceptibility to develop or to not heal pressure injuries included impaired/decreased mobility and decreased functional ability, exposure of skin to urinary and fecal incontinence, altered skin status over pressure points, conditions such as diabetes mellitus, and indicated that documentation in the medical record addressing MD notification if a new skin alteration noted with change of plan of care and initiation of a pressure or non-pressure related to the type of alteration in skin if new skin alteration noted. The facility policy for Prevention and Management of Pressure Injuries identified assessment to include observation of the resident's skin daily with care, body audits completed weekly by the licensed staff and pressure injuries are to be assessed and documented on at least weekly and with a significant change in the wound until it is resolved. The policy indicated that an RN assessment is required weekly for all wounds (pressure and non-pressure) and identified if a wound is not showing progress toward healing within 2-4 weeks, the resident's clinical condition, interventions and treatment plan will be evaluated for possible modifications. The facility's policy for Pressure Injury/Non-pressure Wound Risk Management identified that residents who score at risk for skin impairment or have actual skin impairment are provided with care to address risk factors and goals of treatment and interventions include reposition approximately every 2 hours or more frequently and to check resident for incontinence approximately every 2 hours or per individualized plan of care Resident #37 was admitted to the facility in January of 2026 with diagnoses of Parkinson's disease, thoracogenic scoliosis, kyphosis, and severe protein calorie malnutrition. The admission nurse's progress note dated 1/21/26 at 5:57 PM identified Resident #37's skin was intact with a deep tissue injury (DTI) noted to the left heel and multiple age indeterminant compression fractures at thoracic (T) 6, T8, T10, T 11 and Lumbar (L) 1 was noted in the hospital. The Norton Plus Assessment (used to predict risk for pressure ulcer development) completed on admission dated 1/21/26 identified the resident had a score of 16 which is indicative of the resident being at medium risk for the development of a pressure ulcer. The admission MDS assessment dated [DATE] identified Resident #37 had moderate cognitive impairment, was dependent on staff for lower body dressing, and transfers, utilized a manual wheelchair and required maximal assistance for bed mobility, toileting hygiene, and upper body dressing. The assessment further identified Resident #37 was occasionally incontinent of urine and always continent of bowel and was at risk for developing pressure ulcers and had two stage 2 pressure ulcers with treatments that included pressure reducing device for chair and bed, nutrition or hydration intervention and application of a dressing to feet. The Resident Care Plan (RCP) dated 1/21/26 identified Resident #37 was at risk for skin breakdown with interventions that included inspecting the skin for redness, irritation or breakdown during care, pressure reducing cushion/mattress as needed, offload heel as tolerated, weekly skin inspections, toileting and incontinent care as needed and nutrition/hydration assessment. Review of Resident #37's initial care plan failed to identify a resident specific intervention related to the positioning of the resident and based on his/her diagnoses of thoracogenic scoliosis and kyphosis. The physician's order dated 1/21/26 directed to complete skin checks every Tuesday on shower/bath day on the 7:00 AM to 3:00 PM shift, apply protective ointment to intact skin for incontinent care by cleansing the area and pat dry thoroughly. The physician's order failed to direct care/treatment regarding positioning related to Resident #37's thoracogenic scoliosis and kyphosis diagnosis. The Norton Plus assessment dated [DATE] identified a score of 12 which is indicative of the resident being at a high risk for the development of a pressure ulcer. Review of the weekly skin audit dated 2/2/26 at 11:34 AM identified Resident #37 had no new skin impairments since the last review. Review of the initial pressure injury evaluation dated 2/3/26 at 2:40 PM identified Resident #37 had a facility acquired stage 2 pressure injury to the left inferior mandible measuring 1.2 centimeters (cm) in length by 2.0 cm in width by 0.3cm in depth with small amounts of serosanguinous drainage. The evaluation failed to identify the current treatment that was implemented. Review of the RCP dated 2/3/26 identified Resident #37 had a stage 2 pressure ulcer underneath the chin with interventions that included alternating pressure mattress at cycle 10 for 165lbs, a ROHO cushion to the wheelchair, wound treatment daily and as needed, dietary consultation and to check skin integrity every shift. However, the interventions identified on the care plan did not specifically address the pressure ulcer underneath the chin to prevent the area from worsening. The nursing progress note created by RN #6 dated 2/3/26 at 2:19 PM from the Wound APRN (APRN #2) note identified Resident #37 was seen by APRN #2 for wound care and the following impression and plan was identified: an area to the left inferior mandible that had a dusky dull red color stage 2 pressure injury measuring 1.0 centimeter (cm) in length by 2.0 cm in width and 0.3 cm in depth with scant to absent serous drainage, no odor, peri wound unremarkable without evidence of pressure and recommended to start wound care to the left anterior mandible daily and as needed with checks to rinse the area with normal saline apply hydrogel saturated gauze and cover with dry gauze, then unfold kerlix and fold so that there is at least 4-5 inches of fluff and place under mandible. The note further identified the recommendation was reviewed and approved by APRN #1. The APRN #1's progress note dated 2/6/26 at 12:30 PM identified the wound consult was appreciated and reviewed and to initiate comprehensive wound care as ordered to left inferior chin to shave daily and cleanse the wound with normal saline, dry, then apply Medihoney followed by superabsorbent dressing daily and as needed, and to apply fluffed Kerlix roll in between chest and chin for cushioning to offload pressure. Review of the physician's order dated 2/6/26 directed wound care to the left inferior chin, to shave daily and cleanse open area on chin with normal saline pat dry then apply Medihoney alginate followed by foam dressing daily and as needed, then apply fluffed kerlix roll in between chest and chin for cushion. Review of the Treatment Administration Record (TAR) from the period of 2/3/26 to 2/6/26 identified the dressing to the chin (left inferior mandible) was first started on 2/7/26 as indicated on the TAR. Therefore, the facility failed to implement the recommendation identified by the wound APRN on 2/3/36 until 2/6/26 nor had the facility implemented any other treatments when the area to the left inferior mandible was initially identified on 2/3/26. Review of the follow-up weekly Pressure Injury Evaluation dated 2/9/26 identified Resident #37 had a stage 2 pressure injury to the left inferior mandible measuring 2.0 cm in length by 3.0 cm in width by 0.4 cm in depth with small amount of serosanguinous drainage. The nursing progress note created by RN #6 dated 2/9/26 at 2:49 PM from APRN #2 note identified Resident #37 was seen by APRN #2 for wound care and the following impression and plan was identified: the left inferior mandible had a dusky dull red stage 2 pressure injury measuring 2.0 cm in length by 3.0 cm in width by 0.3 cm in depth with scan to absent serous drainage and no odor. APRN #2 recommended to continue with current wound care. The nursing progress note created by RN #6 dated 2/17/26 at 3:55 PM from APRN #2 note identified Resident #37 was seen by APRN #2 for wound care and the following impression and plan was identified: the left inferior mandible had a dusky dull red stage 4 pressure injury measuring 2.0 cm in length by 3.0 cm in width by 0.4 cm in depth with a gray center that was hard to touch and presumably bone with scan to absent serous drainage, no odor and peri wound unremarkable. APRN #2 recommended to continue with current wound care. Interview with the Wound Nurse (RN #6) on 3/2/26 at 11:08 AM identified he works 16 hours weekly as the wound nurse and oversees the infection control nurse. He identified that Resident #37 had asked him to look at his/her chin when he identified the resident had a stage 2 pressure injury to the area. RN #6 further identified he saw a travel pillow at the resident's bedside, and a neck collar which the resident uses to place around his/her neck due to his/her kyphosis. He indicated when he called the resident's family to notify them of the open area to the chin, they indicated to him it was not new and that the resident had a scab to the area and utilized a travel pillow around his/her neck. RN #6 identified that the admission assessment did not identify a scab or an open area to the mandible, so the wound was then identified as a facility acquired pressure injury. RN #6 identified the resident did not have a physician's order in place for the use of the collar nor the neck pillow. He further identified the resident did not have any interventions for his/her chin touching the chest on admission as they did not identify it as a risk for the development of a pressure ulcer until it was developed. He identified that the pressure injury dated 2/17/26 for the mandible was identified as a stage 2 but should have been a stage 4. Interview with the Nursing Supervisor (RN #4) on 3/2/25 at 1:00 PM identified that the skin check is completed on admission by the nursing supervisor and the charge nurse as the LPN's are not allowed to assess. RN 4 identified that she cannot recall seeing an open area to the resident's mandible (chin) area on admission, just skin issues to his/her heel and coccyx as indicated in the notes. She identified Resident #37 was able to hold his/her head up, and the resident neck did tilt forward but it did not rest on his/her chest. RN #4 identified the resident family member had brought in a neck pillow and collar in which the resident would position around his/her neck, however there were no physician's order or interventions in place on admission for his/her neck usage and that she had put in an order for occupational therapy (OT) evaluation. Interview with the Occupational Therapist (OT #2) in the presence of the Director of Rehabilitation (PT#2) on 3/2/26 at 12:30 PM identified that Resident #37's family member brought in a neck collar which Resident #37 wore at home but did not like to use. OT #2 indicated that the neck collar was not the appropriate size for the resident to use, and if used by the resident it would have caused pressure to the area. She identified the resident was on therapy for strengthening, and she would perform exercises and stretches to strengthen the resident's neck. OT #2 identified resident had a 2-inch gap between his/her neck and chest, and she had been trialing the resident with different adaptive wheelchairs. OT #2 further identified she was working with the resident to have an adaptive wheelchair that when tilted, gravity would prevent the neck from touching the chest. OT #3 identified she was on the third wheelchair trailing for Resident #37 when the area to the chin opened. OT #2 identified she had not written any orders for nursing to complete as it relates to positioning with the wheelchair as she was trialing the resident to identify what works well with the resident before passing it on to nursing. The nurse's note dated 1/21/26 at 5:57 PM identified Resident #37 also had a stage 2 pressure ulcer to the coccyx which the resident indicated he/she had that wound at the previous facility. The Resident Care Plan (RCP) dated 1/21/26 identified Resident #37 was at risk for the development of pressure ulcers, had a stage two community acquired pressure ulcer to the coccyx and a stage two to the left heel with interventions that included complete treatments as ordered, apply left heel lift boot while in bed, check skin integrity, turn and reposition every 2 hours, encourage food and fluids, weekly visit with the wound nurse and keep off back except for meals. The physician's order dated 1/21/26 directed for wound care to coccyx to apply triad paste followed by a superabsorbent bordered dressing on Monday, Wednesday and Thursday and as needed if soaked or dislodged. Review of the clinical records failed to identify an initial wound assessment of the coccyx area on admission. The records identified a follow-up weekly Pressure Injury Evaluation dated 2/3/26 at 2:41 PM which identified that Resident #37 had pressure injury to the coccyx that was not acquired in the facility with an origination date of 1/21/26 and an origination stage was a stage 2 pressure injury while the current stage is unstageable, measuring 1.2 centimeters (cm) by 0.7 cm by 0.0 depth with moderate amount of serosanguinous drainage. The nursing progress note created by RN #6 dated 1/27/26 at 5:13 PM from the Wound APRN (APRN #2) note identified Resident #37 was seen by APRN #2 for wound care and the following impression and plan was identified: Resident #37 had a stage 2 pressure injury to his/her coccyx measuring 1.2 centimeter (cm) in length by 0.7cm in width with no depth draining moderate amounts of serosanguinous drainage, no odor and peri wound was unremarkable and recommends when resident was out of bed to make sure the resident had a pillow between him/her and the back of the wheelchair, to continue the same wound care to the coccyx. The note further identified the recommendation was reviewed and approved by APRN #1. Review of the physician's order dated 2/11/26 directed to apply pillows to back when in wheelchair every day and evening shift for comfort. Review of the Treatment Administration Record (TAR) for the month of February 2026 identified the physician's order dated 2/11/26 directed to apply pillows to back when in wheelchair every day and evening shift for comfort, which was not signed off by the nurses, the nurse's initial would indicate that the treatment was completed, and it was not initial by a nurse until 2/15/26 on the 3:00 PM to 11:00 PM shift. Therefore, the facility failed to implement the recommendation made by APRN #2 on 1/27/26 but instead was implemented not until 2/15/26 based on the TAR documentation. The nursing progress note created by RN #6 dated 2/3/26 at 2:19 PM from APRN #2 note identified Resident #37 was seen by APRN #2 for wound care and the following impression and plan was identified: Resident #37's coccyx wound had deteriorated and is now unstageable with evidence of acute pressure on the periphery measuring 3.5 cm in length by 3.5 cm in width, and 0 cm in depth with moderate amounts of serosanguinous drainage and no odor and recommends to make sure there is a pillow between the resident and the back of the wheelchair, place a ROHO cushion in wheelchair, limit out of bed time to two hours daily, resident to be positioned side to side when in bed except for meals, discontinue current treatment to coccyx wound and start the following daily; rinse the wound with normal saline apply hydrogel saturated gauze and cover with superabsorbent dressing. The note further identified the recommendation was reviewed and approved by APRN #1. The RCP dated 2/3/26 identified Resident #37 had a stage 2 pressure ulcer underneath the chin with interventions that included alternating pressure mattress at cycle 10 for 165lbs, a ROHO cushion to the wheelchair, wound treatment daily and as needed, dietary consultation, heel boots on always and to check skin integrity every shift. Review of the physician's order dated 2/6/26 directed wound care to coccyx to rinse area with normal saline, apply hydrogel saturated gauze and cover with superabsorbent dressing on daily on Monday, Wednesday and Thursday and as needed; alternating pressure mattress to set to cycle 10, 165 pounds and to check function and setting every shift, check placement of the gauze roll in between the chin and chest every shift and replace as needed; and apply ROHO cushion to wheelchair and to check placement and inflation every shift. The physician's order and care plan failed to reflect the recommendation made by APRN #2 2/3/26 to limit out of bed time to two hours daily, resident to be positioned side to side when in bed except for meals was implemented nor did the clinical records identified the recommends were not accepted by the attending provider. The nursing progress note created by RN #6 dated 2/17/26 at 3:55 PM from the APRN #2 note identified Resident #37 was seen for wound care and the following impression and plan was identified: an unstageable pressure injury to his/her coccyx with thinning yellow eschar with early granulation buds now noted measuring 2.8 cm in length by 3.0 cm in width by 0.1 cm in depth with moderate amounts of serosanguinous drainage and no odor. APRN #2 recommended to continue with current wound care. Interview with the Wound APRN (APRN #2) on 3/2/26 at 4:01 PM identified that based on the location of the mandible pressure ulcer it would not take a long time for the pressure ulcer to worsen. She further identified the resident had a previous injury to the area prior to admission and utilized a neck pillow which was not known until after the resident was admitted to the facility. When asked if the pressure ulcers were unavoidable APRN #2 identified that there are several contributing factors that can lead to the worsening and the development of the pressure ulcer. APRN #2 identified positioning was one of the contributing factors for this resident to develop and for the worsening of the pressure injury. APRN #2 identified she had not seen a positioning plan in place for the resident as the resident was utilizing a wheelchair he/she used in another facility that was not appropriate for the resident. She further identified the cushion that was in the wheelchair as thick enough and had recommended the ROHO cushion. Review of the Prevention of Pressure Injury policy identified assessing the resident on admission (within eight hours) for existing pressure injury risk factors and repeating the risk assessment weekly and upon any changes in condition. Review of the Prevention and Management of Pressure Injuries policy identified the facility is dedicated to preventing pressure injuries and to developing a preventative plan of care based on individual needs. The policy identifies the necessary treatment, and services will be provided to promote healing, prevent infection and prevent new pressure injuries from developing. The policy further identified on admission/readmission a comprehensive assessment of the resident will be completed which will include the following: a head-to-to-toe skin assessment in a manner that respects the resident's dignity and a comprehensive clinical assessment to identify specific physical and functional risk factors associated with pressure ulcer development. In addition, the policy indicated that in Connecticut, an RN assessment is required weekly for all wounds (pressure and non-pressure) and upon identification of any new wounds.

Based on review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure a control drug reconciliation process was in place. The findings includeReview of the 2024, 2025, control drug and receipt program identified 9 yellow control drug and receipt disposition records in the 2025 binder that were not matched up with the white control drug and receipt disposition record (CDR.) Oxycodone IR tab 5mg CDR#1399084 Received 11/27/25Oxycodone IR tab 5mg CDR#1399086 Received 11/27/25Pregabalin Cap 200mg CDR#1493284 Received 1/21/26Oxycodone IR tab 5mg CDR#1505372 Received 10/25/25Morphine ER tab 30mg CDR#1399082 Received 11/27/25Morphine ER tab 30mg CDR#1399083 Received 11/27/25Oxycodone tab 10mg CDR#1399088 Received 11/27/25Lorazepam Conc. 2mg/ml 30ml CDR#1462405 8/23/25Morphine Conc. 20mg/ml 30ml CDR#1462406 8/23/25Review of the 2024 reconciled control drug receipt dispositions identified:Morphine Sol 100mg/5ml received 11/12/24 with a remainder of 14.5ml with no evidence of where the remainder of the medication was located.Lorazepam tab 1mg Received 11/26/24 with a remainder of 23 tablets with no evidence of where the remainder of the medication was located.Interview on 3/2/26 at 3:15pm with the DNS identified the process of control drug receipt dispositions has been a mess since she started in October of 2025. The process is they are supposed to get the yellow copy of the narcotic sheet and put it in a binder until the white copy comes to them in the nursing office to match up. The DNS further identified she had delegated the control reconciliation to first the RN#6(IP) who would come on the weekend to organize and then to RN#3 who is per diem who has been auditing and organizing the control drug dispositions. Some of the medications may have gone home with the residents and sometimes they take the white sheet home. The DNS further identified that she knows she is ultimately responsible for all the medication in the building but will not take responsibility for the medications before she started in October. The DNS herself has not reconciled the medication.Interview on 3/2/26 at 3:20PM with RN#3 identified she has been coming in to work on the organization of the control drug system. She completes audits and has identified several medications in which she did not have a white sheet to match the yellow sheet in the 2025 book and has not been able to locate the medication on the floor. Further RN#3 identified she could not locate the white sheet for the above medications, nor has she located the above medications on the floor. RN#3 further identified she could not locate the destruction log from 2024. Interview on 3/2/26 at 3:30PM with LPN#3(Corporate) identified she was unaware there were issues with the narcotic reconciliation as no one had brought it to her attention. When the facility changed ownership in December of 2025 LPN#3 said the DNS was in the position of DNS so there would not be a need to change ownership of the narcotic medication. Review of the medication reconciliation policy directed the narcotic book should be audited on a consistent basis.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 1 of 5 sampled resident (Resident #114) reviewed for unnecessary medication, the facility failed to follow up on the consultant pharmacist's recommendations. The findings include: Resident #114's diagnoses included neurocognitive disorder with Lewy bodies, dementia, anxiety disorder, and mood disorder.The quarterly MDS assessment dated [DATE] identified Resident #114 was severely cognitively impaired, had no behavior, independent for bed mobility, transfers, dressing, and personal hygiene. required limited assistance with bed mobility, transfers, dressing and personal hygiene. The assessment further identified that the resident ambulated short distances. The care plan dated 4/25/24 identified Resident #114 utilized psychotropic medication related to anxiety with interventions that included administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift, monitor document and report as needed any adverse reactions of psychotropic medications unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles. Review of the drug regimen review dated 4/22/24 identified a recommendation to check the valproic acid level but did not have indication that the recommendation was reviewed by the physician or APRN.Review of the clinical record failed to identify a valproic acid level for 2024 or 2025. Review of the drug regimen review dated 9/17/24 identified a recommendation for an AIMS (Abnormal involuntary movement scale) test due to the resident being on psychotropic medication.Review of the clinical record identified an AIMS test dated 12/7/24. Review of the drug regimen review dated 7/18/25 identified a recommendation for adding behavioral monitoring with appropriate target behaviors.Review of the clinical record failed to identify the initiation of behavior monitoring for target behaviors prior to 11/7/25 (approximately 3.5 months after the recommendation was made). Interview on 3/2/26 at 11:45AM with the Regional Director for the consultant pharmacist company identified the medication reviews are completed monthly. The recommendations are sent via fax or email and should be followed up on within 30 days and if the recommendation is not followed up on the pharmacist does not always place the recommendation on the next review. Interview on 3/2/26 at 12:10 PM with the DNS identified the medication reviews are received from pharmacy via email and then given to the APRN to review in her book. The reviews should be followed up on within 30 days before the next monthly review. Interview on 3/2/26 at 1:00PM with the APRN identified she receives reviews sporadically in the APRN book kept in the nursing supervisor's office. She goes through and reviews them frequently throughout the week while she is in the facility. If a review is not followed up on by her, then it would mean that she did not receive the drug review. Review of Drug Regimen Review Policy directed that the attending physician, or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly. The prescriber designee shall act upon the drug regimen review in a timely manner of 30 days or less, shall document on the drug regimen review whether he/she agrees or disagrees with the recommendation and provide a brief rationale if no change is to be made.

Based on observation, review of facility documentation, review of facility policy and interviews, the facility failed to ensure residents were provided a substantial evening snack daily. The findings include:Observation of the dietary department's dry storage room on 2/19/26 at 11:15 AM identified one box of crackers and seven 1-liter bottles of cola on a shelf identified as the snack shelf. Observation on 2/27/26 at 12:30 PM identified there were no more snacks available to residents. Observation of the snack cart identified there was a coffee carafe present, a basket with one package of crackers, but nothing else on the cart. Interview with FSD on 3/02/2026 at 2:07 PM identified that snacks were received on Thursdays and ran out by Mondays with the new budget. Observation of the snack cart on 3/02/2026 at 1:45 PM identified a coffee carafe, a ginger ale bottle and a half pack of crackers on the bottom of the cart. Interview with FSD at this time identified the kitchen aides refill the cart from the storage room but on observation of the storage room there are 6 bottles of cola and 4 bottles (liters) of ginger ale without any chips, cookies, crackers or any other snacks in the room. Observation of the refrigerator in the cafe on 3/2/26 at 2:30 PM identified there were less than 20 containers of Jello, pudding or fruit cups in the refrigerator. Interview with the Food Service Director (FSD) on 3/02/2026 at 2:50 PM identified there had been a cut in the budget for the snacks and the budget is $315 weekly for snacks for a facility resident capacity of 125. Interview with the Administrator on 3/2/26 at 3:00 PM identified they were working with alternative options for snacks with the new budget and that she was aware of the lack of snacks as the FSD had verbalized her concerns.Interview with the dietician on 3/02/2026 at 3:31 PM identified snacks have significantly declined since the ownership transition. The dietician indicated that she has spoken with the FSD regarding the lack of snacks and indicated the purchase of more snacks was not approved. The dietician identified that if there is a diabetic or if a resident didn't eat meals the alternate ways of getting the calories in the resident is essential but indicated she could add in the snacks for supplementation, but they aren't always available.

Based on observations, review of facility policy and interviews, the facility failed to ensure food items were stored or prepared in accordance with professional standards to ensure food service safety. The findings include:Observation of the walk-in refrigerator on 2/19/2026 at 10:15 AM identified the following: Two turkeys thawing on the second shelf with visible drainage from the thawing turkeys on the shelf above cartons of liquid eggs and cartons of milk. [NAME] Slaw dressing marked as received on 10/21/24 and marked as opened 11/2 without a year. Unable to locate an expiration date on the top, container, or bottom.Barbeque (Boom Boom) Sauce marked as received into the facility 10/21/24 and marked as opened 11/6 without a year listed. Unable to locate an expiration date or directions for use after opening.Ranch salad dressing received into the facility 9/22/25 and opened 11/6 without a year. Unable to locate an expiration date.An opened jar of maraschino cherries jar with visible crusting around the cap. Unable to locate an open date, expiration date, or received date.Jar of relish marked received into the facility 10/2025 and labeled as opened 10/11/25. Unable to locate an expiration date. Teriayki sauce marked as received into the facility 6/25 but not marked with an open date and not able to locate an expiration date.Interview with FSD on 2/19/26 at 10:25 AM identified that meat items should be thawed on the bottom shelf of the walk-in refrigerator. The FSD indicated that she was unaware of how long a food item, condiment, could be used after opening if there was no expiration date. The FSD identified the jars should be labeled with the date the item was opened. Interview with the FSD on 2/19/2026 at 1:01 PM identified she conducted an online search that states the condiments should be good for 6-9 months after opening but identified that since the items were marked with a month and a day without year and were received into the facility in 2024 that the items should have been discarded. The FSD indicated that the facility did not have a policy regarding shelf life of food items. The facility policy for Management of Food Items Without Manufacturer Expiration Dates identified all food items stored, prepared, and served to residents are safe, properly labeled and within appropriate time frames for use. The policy indicated that any food item received without a clearly indicated manufacturer expiration date shall be dated, monitored, and discarded according to established food safety standards to prevent foodborne illness. The policy identified that receiving staff shall immediately label the item with date received and use by date if there is no expiration date.The facility refrigerated food storage guide identified foods such as mayonnaise, BBQ Sauce, Mustard, Ketchup etc can be stored 60 days from date opened or manufacturers expiration date (whichever comes first) with special instructions to refrigerate immediately, covered securely and date 60 days or by expiration date.

Based on observation, review of facility documentation, review of facility policy, and interviews for three sampled residents (Residents #37, Resident #77 and Resident #117) reviewed for infection surveillance, failed to appropriately track and place a resident with an open wound on Enhanced Barrier Precautions (EBP), the facility failed to appropriately cohort residents with a known Multidrug Resistant Organism (MDRO) colonization per facility policy, the facility failed to review the infection prevention control program policies and procedures at least annually, the facility failed to ensure environmental rounds were conducted by the department heads on a quarterly basis, the facility failed to ensure that the infection control surveillance data collected monthly was analyzed for trends, and failed to follow the policy and procedural measures developed by the facility to prevent the growth of Legionella and other water borne pathogens in the building water system and for one sampled (Resident #49) on droplet precautions, the facility failed to ensure PPE was stocked for use on the outside of the EBP and contact precautions rooms and failed to ensure staff performed appropriate hand hygiene in between residents, failed to ensure staff utilized the proper PPE when entering droplet precautions rooms, and failed to ensure equipment was cleaned following use on a droplet precaution resident and before use on another resident. The findings include: Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews Resident #49 was admitted to the facility January 2026 with diagnoses that included unspecified fracture of the lower end of right radius subsequent encounter for closed fracture with routine healing, long term use of anticoagulants and difficulty in walking. The annual MDS assessment dated [DATE] identified Resident #49 had intact cognition, required set up/clean up assistance with position changes, and partial/moderate assistance with toileting and personal hygiene. Physician's orders dated 2/20/26 directed droplet precaution pending respiratory 4-plex result, discontinue if negative. The care plan dated 2/20/26 identified Resident #49 had new onset of cough and congestion with interventions to include droplet precautions pending result of the respiratory viral panel. Nursing progress note dated 2/20/26 at 1:44 PM identified Resident #49 was seen by the MD and was noted with congested cough with rhonchi and placed on droplet precautions. Added to the care plan 2/25/26 identified a fever and signs/symptoms of upper respiratory illness with interventions to follow facility protocol for contact/droplet precautions. Observation on 2/24/26 at 1:50 PM identified Resident #49 had a posted droplet precautions sign outside of the room to the right of the door above the room number placard. NA #10 entered the room without donning personal protective equipment (PPE) with a chair scale. NA #10 placed the chair scale next to the resident who was seated in a recliner and was actively coughing. The resident transferred to the chair scale with NA #10 touching the resident's shoulder as he/she sat on the chair scale. At 1:55 PM NA #10 exited the room and walked the chair scale to another resident's room. NA #10 did not perform hand hygiene before exiting Resident #49's room or prior to entering the next resident's room and she did not perform any cleaning or disinfection of the chair scale. The resident in the room she entered refused to be weighed. Further observations noted NA #10 enter another room and used the chair scale to weigh a resident but did not perform hand hygiene or cleaning/disinfecting of the chair scale. Interview with NA #10 on 2/24/26 at 2:10 PM identified that there were no residents on droplet precautions and would not answer questions concerning PPE and when it should be donned and doffed and when hand hygiene should be performed. Observation of LPN #2 on 2/24/2026 at 2:08 PM coming out of Resident #49's room (droplet precautions) without any PPE and placing the thermometer back into the cart without wiping it down or cleaning it. Resident #49's temperature was 100.5 degrees Fahrenheit. Interview with LPN #2, NA #10 and NA #11 on 2/24/2026 at 2:11 PM identified that PPE must be worn in droplet precaution rooms or evidence-based precaution (EBP) rooms, hand hygiene should be performed in between residents and the scale and other equipment used should be wiped down with bleach wipes after use in the droplet precaution room. NA#10 indicated that he had not put on PPE nor performed hand hygiene in between residents. NA#10 indicated that he was only pulling the scale into the resident room and did not have contact significant enough to perform hand hygiene. NA#10 identified he did not know if the scale should be cleaned in between residents but did identify that after the contact precaution room it should have been wiped down. LPN#2 indicated that the precautions carts located outside of precaution rooms should be stocked by the supervisors or the infection control nurse. Observation of precaution carts on one unit on 2/24/2026 at 2:15 PM identified the precaution cart outside of room [ROOM NUMBER] (EBP) had only gowns in the bottom drawer with no other PPE. Precaution cart outside of room [ROOM NUMBER] (EBP) only had gowns in the bottom. Precaution cart outside of room [ROOM NUMBER](EBP) only had gowns in the bottom drawer. Precaution cart outside of room [ROOM NUMBER] had one gown in the bottom drawer and one box of gloves on the top of the cart. Neutropenic precaution cart outside of room [ROOM NUMBER] had gowns in the bottom drawer and a ripped box of gloves on the top of the cart. Droplet precaution cart outside of room [ROOM NUMBER] had a box of masks on the top of the cart and 2 boxes of gloves on the shelf to the right of the room door. Interview with the Nursing Supervisor (RN#2) on 2/24/2026 at 2:20 PM identified she would expect the precaution rooms to have the appropriate PPE available for use in the precaution carts and that equipment used should be wiped down after the droplet precaution room but could not identify if equipment should be wiped down between non precaution residents. RN#2 indicated that she asked the per diem nurse, RN #9, to fill the precautions carts that morning. Interview with RN#9 on 2/24/26 at 2:25 PM identified that she had been working on the precaution carts throughout the day but had not yet finished due to having to assist the wound APRN on rounds. Interview with corporate nurse, LPN#3 on 2/24/26 at 2:31 PM indicated that the precaution carts should be stocked, not could not identify who was responsible to make sure they were stocked. Interview with the DNS on 2/25/26 at 1:10 PM identified that precaution carts should be stocked with necessary PPE. The DNS indicated in the event the facility needed additional PPE; they could obtain it from a sister facility. The DNS identified the Infection Prevention nurse, and the night (11p-7a) supervisors were responsible to stock and check that the carts are stocked appropriately. The DNS indicated that the stock closet and the DNS office contained PPE. Review of facility documentation (Inservice attendance for Covid outbreak, hand hygiene, mandatory surgical mask wearing in common and patient care areas, proper donning and doffing PPE) dated 10/27/25 identified that education had been provided to facility staff and NA#10, NA#11 and LPN#2 had been educated on these topics. Review of in-service attendance for infection control with a targeted group of all staff dated 6/2025 identified LPN#2 and NA#10 had received education on infection control and hand hygiene at that time. Facility policy for precautions to prevent transmission of infectious agents identified droplet precautions as a transmission-based precaution and indicated they may be implemented based on the clinical presentation until the infectious etiology had been determined. The policy identified that if any equipment cannot be dedicated to the room, it must be cleaned and disinfected before use on another resident. Facility policy in place prior to 2/24/26 identified protocol for hand hygiene identified In general, hand hygiene should be performed prior to and following direct contact with patients/resident and indicated examples of situations when hand hygiene is indicated included: before and after direct patient/resident contact; After completing tasks at one patient/resident area before moving to another station; After contact with items/surfaces at patient/resident areas; When working with a resident on isolation precautions. Review of the new facility policy for transmission-based precautions put in place 2/24/26 subsequent to surveyor inquiry. This policy identified that when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution and that the signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and /or instructions to see a nurse before entering the room. Signs and notifications comply with the resident's right to confidentiality or privacy. When transmission -based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident when possible, indicating that if re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. Droplet precautions section of the policy identified that residents on droplet precautions are placed in a private room if possible. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors, if single or cohorting is not available, decisions regarding resident placement are case by case after considering infection risks to other residents. New policy for hand hygiene and handwashing identified All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for the following situations to include: before and after direct contact with residents. after contact with a resident's intact skin. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident. after removing gloves. before and after entering isolation precaution settings. Review of the facility's EBP log for February 2026, failed to identify that Resident #37 was included on the EBP list even though the resident has 2 pressure injuries with drainage that requires dressing changes. Resident #37 was admitted to the facility in January of 2026 and had diagnosis of Parkinson's disease, thoracogenic scoliosis, kyphosis, and severe protein calorie malnutrition. The physician's order dated 1/21/26 directed for wound care to coccyx to apply triad paste followed by a superabsorbent bordered dressing on Monday, Wednesday and Thursday and as needed if soaked or dislodged. The Resident Care Plan (RCP) dated 1/21/26 identified Resident #37 had a community acquired pressure ulcer to the coccyx at a stage 2 and to the left heel and is at risk for pressure ulcers with intervention that included complete treatments as ordered, apply left heel lift boot while in bed, check skin integrity, turn and reposition every 2 hours, encourage food and fluids, weekly visit with the wound nurse and keep off back except for meals. The RCP dated 2/3/26 identified Resident #37 had a stage 2 pressure ulcer underneath the chin with interventions that included alternating pressure mattress at cycle 10 for 165lbs, a ROHO cushion to the wheelchair, wound treatment daily and as needed, dietary consultation, heel boots on at all times and to check skin integrity every shift. Review of the nursing progress note provided by the Wound APRN (APRN #2) dated 2/3/26 at 2:19 PM identified Resident #37 coccyx wound has a stage 2 pressure injury that has deteriorated and is now unstageable with evidence of acute pressure on the periphery and measures 3.5 cm in length by 3.5 cm in width, 0cm in depth with moderate amounts of serosanguinous drainage and no odor. The note further identified an area to the left inferior mandible that has a dusky dull red color stage 2 pressure injury measuring 1.0 cm in length by 2.0 cm in width and 0.3 cm in depth with scan to absent serous drainage, no odor, peri wound unremarkable without evidence of pressure. In addition, the note identified to start wound care for the left anterior mandible daily and as needed with checks for dressing to rinse with normal saline apply hydrogel saturated gauze and cover with dry gauze, then unfold kerlix and fold so that there is at least 4-5 inches of fluff and place under mandible. The note further identified the recommendation was reviewed and approved by APRN #1. Review of the physician's order for the period of January 21, 2025, through February 23, 2026, failed to identify an order that directed EBP for wound care. Observation and interview on 2/26/26 at 1:03PM with RN #1 failed to identify a posted signage outside of the room on the wall or door that identified the need for Enhanced Barrier Precautions (EBP) which noted the need for everyone to perform hand hygiene before entering and when leaving the room, providers, and staff to wear gloves and a gown for high-contact resident care activities such as dressing, bathing, showering, device care or care of a urinary catheter. RN #1 identified when a resident is placed on EBP a signage is place on the outside of the room indicating the type of precaution and PPE to be worn. RN #1 further identified if the signage is placed above the name plate it is for the resident at the door and below the name plate is for the resident at the window. RN #1 identified if the resident is sent to the hospital and is expected to return the signage would remain until they return and remove depending on the resident's readmission orders. Interview with the Infection Preventionist nurse (RN #6) on 2/26/26 at 1:05 PM identified when a resident is on EBP, an order for EBP would be placed in the physician's order and an EBP signage would be placed outside of the resident's room. RN #6 identified Resident #37 should have been placed on EBP due to his/her pressure ulcer which had moderate drainage. He identified it was the responsibility of the IP and wound nurse to input the order, but it just got missed. Review of the Enhanced Barrier Precautions policy and procedure identified enhanced barrier precautions will also be implemented for resident with wounds, or indwelling medical devices regardless of their MDRO colonization status that reside on a unit or wing where a resident known t be infected or colonized with a novel a targeted MDRO resides. The policy further identifies that signage will be posted on the door or wall outside of the resident room indicating the need for EBP. Review of the Enhanced Barrier Precautions policy identifies EBP may be indicated (when contact precautions do not otherwise apply) for residents with chronic wounds (4-12 weeks with minimal to no improvement with treatment) and/or indwelling medical devices regardless of MDRO colonization. The policy further identified signs are posted on the door or wall outside of the room indicating the type of precautions and PPE required. Review of the facility's EBP log for February 2026, which contains the list of residents with a MDRO, and the facility unit roster with the Infection Preventionist nurse (RN #6) on 12/24/26 at 12:31 PM identified Resident #77 and Resident # 177 were roommates with one resident colonized with a Center for Disease Control and Prevention (CDC) targeted MDRO and the other resident was identified without an MDRO. The EBP log for February 2026 identified Resident #117 had a colonization history that included extended-spectrum beta-lactamases (ESBL) and Carbapenem-resistant enterobacterales (CRE) while Resident #77 was not included in the EBP log as he/she had no history of an MDRO. The facility unit roster identified that Resident #77 shared room with Resident #117 who had a known history of a colonized MDRO of CRE and ESBL. Resident #77's diagnoses included urinary tract infection, Escherichia coli, dementia, type 2 diabetes mellitus, and bipolar disease. The admission MDS assessment dated [DATE] had moderately impaired cognition, required set-up assistance with personal hygiene, supervision with ambulation and independent with toileting hygiene, upper body dressing. The assessment further identified Resident #77 was occasionally incontinent of urine and always continent of bowel. Review of Resident #77's demographic sheet identified that Resident #77 and Resident #177 became roommates on 11/20/2025. Resident #177's diagnoses included extended-spectrum beta-lactamases (ESBL), carrier of Carbapenem resistant enterobacterales (CRE) and schizoaffective disorder the bipolar type. The annual MDS assessment dated [DATE] identified Resident #177 25 had moderately impaired cognition, required supervision with toileting hygiene, dressing, personal hygiene, transfers, and independently utilized a wheelchair for locomotion. The assessment further identified Resident #177 was occasionally incontinent of urine and frequently incontinent in bowel. Interview with RN #6 on 2/26/26 at 1:05 PM identified the EBP and MDRO log is completed by the IP nurse when a resident with an MDRO is admitted to the facility or identified with the resident stay. RN #6 identified the IP nurse is responsible for updating the EBP log and providing a copy to admissions and to each nurse's unit in the facility. RN #6 identified he had cohort Resident #77 with Resident #117 together because Resident #77 had no open wounds or indwelling devices. He identified that both residents used the same bathroom in their room but thought it was okay to cohort them together because Resident #77 did not have an open wound or an indwelling device. RN #6 identified he was not aware that the facility's policy indicated that residents with CRE should only be cohort with another resident with CRE. He further identified there is another resident with CRE in the facility who does not share room because they have indwelling devices. Review of the Multidrug-Resistant Organism (MDRO) policy identified in the room cohorting section that residents with the same MDRO and same strain (if known) may be roomed together. Review of the Cohorting Residents with Communicable Disease policy identified in the cohorting section of the policy that it is the practice of grouping residents infected or colonized with the same infectious organism together in a designated area. Review of the Control of Multidrug-Resistant Organism (MDRO) Infection and Colonization policy identifies residents with similar MDRO infections can be cohorted whenever possible, and if a cohorted room is not available, a roommate will be carefully selected. The policy further identified that residents who have CRE should be placed in a single room or cohorted with a roommate with CRE. Review of the facility's Infection Control Program Policies and Procedure manual from May 2024 through February 2026 on 2/24/26 at 12:31 PM with the Infection Preventionist (RN #6) failed to identify that the policies and procedures manual was reviewed in the year 2024 and 2025. Interview with RN #6 on 2/26/26 at 1:05 PM identified that they were unable to locate documentation that the policy and procedures manual was reviewed in the year 2024 and 2025. RN #6 indicated that he started working at the facility in April of 2025 as a full time IP nurse until October 2025. He identified that it was the responsibility of the then IP nurse to ensure that the infection control policies and procedures were reviewed and signed off annually. Interview with the DNS on 3/2/26 at 3:15 PM identified the polices and procedure manuals was reviewed annually as it is responsibility of the administration to ensure it was completed. Review of the facility environmental round documentation on 2/24/26 at 12:31 PM with the Infection Preventionist (RN #6) failed to identify quarterly environmental round documentation that was completed in January of 2026. Interview with RN #6 on 2/24/26 at 12:31 PM identified environmental rounds are completed quarterly by the department heads. He further identified it is the responsibility of IP nurse to ensure it was completed. RN #6 identified he works only 16 hours weekly as the wound nurse and provides oversight of the infection control program, as the facility has a nurse who works full as the IP nurse. He then indicated it was her responsibility to have it completed in January 2026 when it was due to be completed. Review of the Environmental Rounds policy identifies it is the policy of this facility that the Infection Preventionist or his/her designee, charge nurses or supervisors to complete unit rounds on a regular basis, but at least quarterly. The policy further identifies the IP will train and accompany department heads to do rounds of their department initially, thereafter, it will be distributed to the supervisor of each area, and the department heads will submit completed environmental rounds to the IP. Review of the infection control program for the period of April 2024 to February 2026 on 2/24/26 at 12:31 PM with the Infection Preventionist (RN #6) failed to provide documentation of monthly surveillance infection report analysis of infection trends were completed for the period of October 2024 to December 2024; January 2026 and quarterly infection reports that include first quarter of 2025. Interview with RN #6 on 2/24/26 at 12:31 PM and on 2/26/26 at 1:05 PM identified that he was unable to locate any of the monthly surveillance infection reports analysis of infection for the period of October 2024 to December 2024, January 2026 and the quarterly report for the first quarter of 2025after searching thoroughly throughout the facility. RN #6 identified the monthly infection control surveillance data is analyzed to identify the rate of healthcare/facility acquired infections and community acquired infections within the facility, and at the end of each month the total infection rate is calculated using a formula. He identified the facility had an IP nurse during 2024; however, he was unable to locate their records as it was their responsibility to track, identify and analyze infection rates within the facility monthly. RN #6 identified he works 16 hours weekly as the wound nurse and oversees the IP nurse who works full time and it was her responsibility to complete the monthly infection analysis. He identified that the IP nurse was responsible for completing an infection report quarterly and the information is presented at the quarterly medical staff meeting, however, he was unable to locate the first quarter infection control report. Review of the Surveillance for Infections policy is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associate infections, to guide appropriate interventions, and to prevent future infections. The policy further identified monthly collection of information from individual resident infection reports and enter line listing of infections by resident for the entire month; and summarize monthly data for each nursing unit by site and by pathogen and monthly/quarterly identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. In addition, the monthly/quarterly compares incidence of current infections to previous data to identify trends and patterns. Review of the Facility Water Management Plan with the Director of Maintenance on 2/27/26 at 2:07 PM identified that the facility water management plan policy included: monthly flushing of the identified low flow areas for 20 minutes and the, eyewash stations are to be flushed, quarterly cleaning of the ice machines, annually water management meeting, and annually water sampling testing. When requested documentation of the implementation of the water management plan the Director of Maintenance indicated that he had no documentation as the plan was not implemented. The facility provided a legionella water sampling testing result dated 3/3/25 which was collected on 2/19/25 that noted the following result for sample collected at the Whispering pine soiled hopper hot which detected 8.4 CFU/ml (colony forming unit) of L. anisa (Blue-white Legionella sp.). Interview with The Director of Maintenance on 2/27/26 at 2:07 PM identified the facility has a contract with an outside company who is responsible for collecting water sample testing and updating and revising the water management plan. He identified that he had received the February 2025 water sampling in January 2026 because the facility had not paid their bill with the company. The Director of Maintenance identified as well as the contracted company that missed the positive sampling result culture when reviewed in January/2026 until identified by the surveyor. He further identified the water lines in the resident's rooms and resident areas on the closed unit was only flushed on February 13, 2026, by the construction company, however, it was not flushed prior as well as any other unused or low flow area within the facility. The Director of Maintenance identified he started working at the facility in September of 2025 and was instructed if any plumbing part break that he was to retrieve the part from the closed unit then shut off the pipe in that area. In addition, he is unable to locate any documentation of the plan implementation prior to his nor did he implement the policy. The Director of Maintenance identified he had a meeting with the water management contracted company about 10 days ago, who informed him that he will need to maintain logs of the flushes of low flow/unused areas, cleaning of the ice machine, flushing of the eye washing stations and annual meeting. He indicated that he is awaiting the log from the company, had their first water management meeting in January 2026, which needs to be done annually, and the ice machine was cleaned by a company 2 weeks ago. In addition, he was able to locate water sampling results for 2024 due lack of payment by the facility, however, he identified that water samples were completed in February/2026 and the facility is awaiting the results. Interview with the Administrator and Director of Maintenance on 2/17/26 at 3:15 PM identified that they had made contact with the contracted company for the facility's water management regarding the positive result in 2025, which they provided guidance for localized remediation of the fixture, not to use the outlet, and they will test the site on 3/20/26. The Administrator identified that the medical director will be contacted as the facility is currently undergoing a respiratory outbreak for guidance. Interview with the Administrator on 2/17/26 at 3:15 PM identified that the facility will be testing for Legionella antigen urine test with anyone with a confirmed case of pneumonia who received antibiotic treatments without resolution. Review of the Facility Water Management plan and policy identified that the plan includes the management and validation of the plan, updating the water management plan and water sample culture analysis. The Water Management Plan policy further identified that the environmental assessment (which includes flushing, eye washing, ice machine), sampling and management plan and associated sampling results on the facility premises for at least three years.

Based on review of the clinical records, review of facility policy, facility documentation, and interview for three of five sampled residents (Resident #5, Resident #8 and Resident #50) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccine was administered as requested by the resident/responsible party and offered on admission. The findings include:F887 Based on review of the clinical records, review of facility policy, facility documentation, and interview for three of five sampled residents (Resident #5, Resident #8 and Resident #50) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccine was administered as requested by the resident/responsible party and offered on admission. The findings include: 1. Resident #5 was admitted to the facility in January of 2026 and had diagnoses that included chronic kidney disease, type 2 diabetes mellitus and chronic obstructive pulmonary disease. The admission MDS assessment dated [DATE] identified Resident #5 was cognitively intact. The assessment further identified that Resident #5 was not up to date with the Covid-19 vaccination. Review of Resident #5 immunization and clinical records with the Infection Preventionist (IP) nurse (RN #6) on 2/24/26 at 12:31 PM failed to identify that the Covid-19 vaccine was offered and/or assessed for past immunization. Interview with RN #6 on 2/24/26 at 12:31 PM identified that he was unable to provide any documentation of Resident #5's Covid-19 vaccine records, as the consent forms was not reviewed with the resident. RN #6 identified consents are obtained on admission by the admitting supervisor and it is then reviewed by the IP nurse. The IP nurse wound then check on the CT wiz, which is a database that maintains patients vaccination records, to ensure that the resident had not received the vaccination prior to admission. RN #6 further identified after the resident vaccination history is check then the appropriate vaccine is ordered by the physician for inoculation. He further identified the facility has a full time IP nurse who was responsible for reviewing the vaccine as he only works 16 hours weekly as the wound nurse and to oversee the IP nurse. RN #6 identified he will review the vaccine consents with the resident on 2/24/26 as it should have been completed on admission. Review of the COVID-19 Vaccination policy identifies the Covid-19 vaccination will be offered to all residents unless the vaccine has been medically contraindicated, or the resident has been previously immunized. The resident will be asked to sign a consent prior to administration. The policy further identifies that resident's and staff have the right to decline or not are not required to receive the vaccination and information will be documented in medical record. 2. Resident #8 was admitted to the facility in November of 2025 and had diagnoses that included urinary tract infection, chronic obstructive pulmonary disease and type 2 diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #8 was cognitively intact. The assessment further identified that Resident #8 was not up to date with the Covid-19 vaccination. Review of the Resident admission Vaccination Education form dated 11/28/25 identified Resident #8 provided the facility with consent and information regarding the influenza and the pneumococcal vaccine. However, the COVID-19 vaccine section of the form was not completed as to whether the resident had given consent or refused the vaccine. Review of Resident #5 immunization and clinical records with the Infection Preventionist (IP) nurse (RN #6) on 2/24/26 at 12:31 PM failed to identify that the Covid-19 vaccine was offered and/or assessed for past immunization. Interview with RN #6 on 2/24/26 at 12:31 PM identified that he was unable to provide any documentation of Resident #8's Covid-19 vaccine records, as on the Covid-19 section of the vaccination form was not reviewed or completed with the resident. He further identified the facility has a full time IP nurse who was responsible for reviewing the vaccine as he only works 16 hours weekly as the wound nurse and to oversee the IP nurse. He identified the covid-19 vaccine consent should have been followed upon to check if the resident would like to receive the Covid-19 booster vaccine when assessed on admission. Subsequently to surveyor's inquiry, a nurses note dated 2/24/26 T 5:10 PM written by RN #6 identified Resident #8 was eligible for the covid 2025-2026 vaccine and was offered and the resident declined. Review of the COVID-19 Vaccination policy identifies the Covid-19 vaccination will be offered to all residents unless the vaccine has been medically contraindicated, or the resident has been previously immunized. The resident will be asked to sign a consent prior to administration. The policy further identifies that resident's and staff have the right to decline or not are not required to receive the vaccination and information will be documented in medical record.3. Resident #50 was admitted to the facility in October of 2025 and had diagnoses that included dementia, depression, and hypertension. The admission MDS assessment dated [DATE] identified Resident #50 had severely impaired cognition. The assessment further identified that Resident #8 was not up to date with the Covid-19 vaccination. The nurse's progress note dated 11/17/25 at 2:44 PM written by RN #6 identified Resident #50 was eligible to receive Covid, influenza and PCV20 (pneumococcal vaccine) and was discussed with resident responsible party who provided the facility with verbal consent for the vaccine, APRN was updated and will stagger the vaccine administration. Review of the physician's order for the period of November 2025 through February 24, 2026, failed to identify an order that directed the administration of the covid-19 2025-2026 booster vaccine. Review of Resident #50's clinical records with the Infection Preventionist (IP) nurse (RN #6) on 2/24/26 at 12:31 PM failed to identify that he/she received the vaccination or documentation that the resident refused the vaccine. Interview with RN #6 on 2/24/26 at 12:31 PM identified he had approached Resident #50 to administer the Covid-19 2025-2026 booster vaccine and the resident had refused. He written on the consent form resident refused but failed to document on the consent that the responsible party had given consent to administer the vaccine. RN #6 identified that a physician's order should have been put in electronic record, and the administration records should have indicated that the resident had refused. He further identified the facility has a full time IP nurse who was responsible for reviewing the vaccine and to follow-up on the refusals, as he is responsible for the wounds and oversees the IP nurse with only working 16 hours weekly. Review of the COVID-19 Vaccination policy identifies the Covid-19 vaccination will be offered to all residents unless the vaccine has been medically contraindicated, or the resident has been previously immunized. The resident will be asked to sign a consent prior to administration. The policy further identifies that resident's and staff have the right to decline or not are not required to receive the vaccination and information will be documented in medical record.

Based on review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews for two of six sampled residents (Resident #9 and Resident #79) reviewed for advance directives, the facility failed to ensure a physician's order was in place and consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status. The findings include: Resident #9's diagnoses included systemic lupus erythematosus, depression and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #9 was cognitively intact and was independent with dressing, personal hygiene, bed mobility, transfers and ambulation. The care plan dated [DATE] identified Resident #9 had an established advance directive with a wish to be a DNR (do not attempt cardiopulmonary resuscitation)/ DNI (do not intubate)/RNP (Registered Nurse may Pronounce death) with interventions that directed to not administer cardiopulmonary resuscitation (CPR) and to review advance directives with resident and/or healthcare decision maker quarterly. A review of the clinical record identified an Advance Directive Declaration Code Status form signed by Resident #9's responsible party dated [DATE] and signed by the APRN on [DATE]. The form identified an elected code status of DNR and DNI. A review of physician's orders for the period of [DATE], through February 24, 2026, failed to identify the election of a code status of DNR and DNI. Interview with LPN #4 and LPN #7 on [DATE] at 1:38 PM identified that if Resident #9 had a life-threatening emergency where the decision to administer CPR or withhold CPR, they would check the resident's code status. LPN #4 identified the code status is found in the banner/dash section of the electronic medical record, in the resident's physical clinical record under the advance directive section and in the physician's orders. LPN #7 identified that code status consents are obtained on admission by the charge nurse or the nursing supervisor from the resident or the resident's responsible party. After which the Code Status form is signed by the physician or APRN. A physician's order is then placed into the electronic medical record. Review of the current physician's orders with LPN #7 identified that there were no orders addressing the resident's code status. LPN #7 identified that in an emergency the physician's order is the first place they would check and if there was no order for code status, she would start CPR while another staff member would check the code status form and if the form identified that the resident is a DNR/DNI compression would then cease. Interview with the DNS on [DATE] at 9:30 AM identified that if a resident had a life-threatening emergency, the nurse is to check the physician's orders in the electronic medical record. The DNS further identified that code status is obtained on admission and is signed by the resident or the resident's responsible party, following that a physician's order is obtained and the code status form placed in the APRN's book to be signed. The DNS identified that the physician's order should match the code status consent obtained from the resident/resident responsible party and in the event the code status was not obtained/unknown the resident would be considered a full code and in the event of an emergency, CPR would be performed. The Advance Directive policy identified that if a resident has an advanced directive, copies of the documents are obtained and maintained in the resident's medical record and are readily retrievable by any facility staff. The policy further identified that the DNS or designee notifies the attending physician of advance directives or changes to the advance directive so that appropriate orders can be documented in the resident's medical record and plan of care. Resident #79 was admitted to the facility in November of 2025 and had diagnoses that included Type 2 diabetes mellitus, multiple sclerosis, and paraplegia. The physician's order dated [DATE] directed a code status of full code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive including cardiopulmonary resuscitation (CPR)).The admission MDS assessment dated [DATE] identified Resident #79 was cognitively intact, was dependent on staff for toileting hygiene, dressing, personal hygiene, putting on/taking off footwear, transfers and was non-ambulatory. The care plan dated [DATE] identified Resident #9 had an established advance directive with a wish to receive CPR (cardiopulmonary resuscitation) with interventions that included review advanced directive with resident and/healthcare decision maker quarterly and support resident decision for CPR. Review of Resident #79's physical chart and the electronic health record failed to identify a signed Advance Directive Declaration Code Status form signed by the resident/resident representative to indicate what the resident's wishes were pertaining to code status. Interview with LPN #4 and LPN #7 on [DATE] at 1:38 PM identified that if Resident #79 had a life-threatening emergency where the decision to administer CPR or withhold CPR, they would check the resident's code status. LPN #4 identified the code status is found in the banner/dash section in the resident's electronic medical record, in the resident's physical clinical record under the advance directive section and in the physician's orders. LPN #7 identified that code status consents are obtained on admission by the charge nurse or the nursing supervisor from the resident or the resident's responsible party. After which the Code Status form is signed by the physician or APRN. A physician's order is then placed in the electronic medical record. LPN #7 reviewed the current physician's order and identified Resident #79 had an order for full code (CPR). LPN #7 could not locate a completed Advance Directive Declaration Code Status form for Resident #79.Interview with Person #1 (Resident #79's responsible party) on [DATE] at 10:45 AM identified that he/she had not received any contact from the facility regarding advance directives/code status. Person #1 identified the facility had reached out to him/her various times regarding different consents which he/she provided to the facility over the phone. Person #1 identified Resident #79's code status wishes were DNR/DNI, and he/she had no notes regarding the advance directive. Interview with the Social Worker (SW #1) on [DATE] identified she had reached out to Person #1 on [DATE] regarding the advance directive and discharge planning. She further identified that she should have reached out to Person #1 from admission regarding the advance directive if nursing was unable to obtain consent. Interview with the DNS on [DATE] at 9:30 AM identified that if a resident has a life-threatening emergency, the nurse is to check the physician's order. The DNS further identified that code status is obtained on admission and is signed by the resident if able or the resident's responsible party, a physician's order obtained and the code status form is placed in the APRN's book for it to be signed. The DNS identified the physician's order should match the code status consent obtained from the resident/resident responsible party and in the event a code status was not obtained the resident would be a full code. The DNS further identified that Resident #79 should have a consent in the chart by now, since he/she was admitted to the facility in November/2025. The admission Procedure Advance Directive policy identified that prior to or upon admission the Director of Admissions or designee will provide each resident and/or responsible party with written information regarding the resident's rights under state law to make decisions regarding his or her medical care including the right to accept or refuse treatment and to formulate an advance directive. The Advance Directive policy identified that if a resident has an advanced directive, copies of the documents are obtained and maintained in the resident's medical record and are readily retrievable by any facility staff. The policy further identified that the DNS or designee notifies the attending physician of advance directives or changes to the advance directive so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #114) reviewed for mistreatment, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #114's diagnoses included neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder.The quarterly MDS assessment dated [DATE] identified Resident #114 was moderately cognitively impaired, had no behaviors, required limited assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment further identified the resident utilized a wheelchair for mobility. The care plan dated 10/3/25 identified Resident #114 was at risk for refusing care and not waiting for assistance with transfers related to behavior problems with interventions that included assistance of two staff for care and transfers, introduce self to resident, explain what you are going to do, use calm, gentle, approach, and work slowly. A late entry nurse's note from the DNS dated 11/3/25 at 8:30AM identified Resident #114 was alleged to have been slapped on his/her left arm by a NA while providing care. The NA was removed from the schedule upon receiving report of the allegation and a body audit was performed and no injuries were noted. The Accident and Investigation report dated 11/3/25 identified statements from NA #1, #2, and #3 pertaining to the allegation of physical abuse. NA#3's statement identified that on Friday 10/31/25 at about 8:30PM, NA#3, NA#2, and NA#1 went into Resident #114's room to provide care. Resident #114 did not want to get changed and was combative swinging his/her arms and feet. NA#3 held Resident #114's arms so NA#2 could change his/her brief. NA#1 assisted in holding the resident's arms and slapped Resident #114 hard on the arm and used an expletive (F word). NA#3 identified she should have reported it on Friday when it happened. NA#2's statement identified she was providing incontinent care while NA#3 held Resident #114's left hand because he/she was agitated and cursing. NA#1 slapped Resident #114 with her hand she and NA#3 told NA#1 to calm down since they were more familiar with Resident #114. Resident #114 was on NA#3's assignment. The statement further identified that she did not report the incident because she thought NA #3 would report it because Resident #114 was on her assignment. NA#1's statement identified she was helping with Resident #114's care. She noted that the resident started fighting and she grabbed his/her hand twice to stop the resident from hitting NA #3. She further noted that she kept grabbing Resident #114's hands until the brief was changed. The statement noted that the resident continued to resist by kicking and slapping NA #3. Once the change occurred, she noted they all left the room. The Nursing Supervisor's (RN #7) note dated 11/3/25 identified that on 11/2/25 toward the end of the 3pm to 11pm shift, NA #3 reported that NA #1 slapped Resident #114 during the provision of care. The note further noted that NA #2 confirmed what NA #3 had reported. She further noted that the incident had occurred on 10/31/25 and there were no noted signs or symptoms of injury. The Social Worker's progress note dated 11/3/25 identified Resident #114 was in bed and reported he/she had a good weekend. The Social worker asked Resident #114 if he/she had any concerns or complaints related to care he/she had received over the last few days and Resident #114 reported no concerns. The social worker asked the resident if there were any staff members that had been treating him/her differently than usual or if care had not been done well, Resident #114 did not recall the reported event. The skin audit dated 11/3/25 by completed by RN#1 identified no new skin impairments.RN #1's nursing note dated 11/7/25 identified that the allegation of abuse was substantiated because it was witnessed by two staff members. Interview with NA #2 on 2/23/26 at 12:36 PM identified that during the provision of incontinent care to Resident #114, the resident was combative and refusing care. She acknowledged that she was aware that Resident #114 had the right to refuse care, but his/her brief and sheet were soaked with urine and felt it was to the resident's benefit to be cleaned up. She further identified that she witnessed NA #2 slap the resident's arm several times. Additionally, she noted that she had not reported the incident because she thought NA #3 was going to report it, although they had not discussed the reporting of the incident. She further noted that she was put on leave following the reporting of the incident and subsequently fired. Interview with the DNS on 2/27/26 at 9:14AM identified she was notified of the allegation of abuse on 11/3/25 via text message from RN #7. The DNS identified she immediately started the investigation. NA#1, NA#2 and NA#3 worked on 11/1/25, and 11/2/25 in the facility due to the fact the allegation had not been reported. Statements were obtained from NA#1, NA#2, and NA#3, who were subsequently terminated. RN#7 was given a final written counseling regarding the incident and remains employed at the facility. The facility reported the incident to the police and to the state survey agency. Review of the facility policy directed to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect or exploitation occur.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #114) reviewed for abuse, the facility failed to ensure the allegation of abuse was reported to the state survey agency in a timely manner. The findings include: Resident #114's diagnoses included neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder.The quarterly MDS assessment dated [DATE] identified Resident #114 was moderately cognitively impaired, had no behaviors, required limited assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment further identified the resident utilized a wheelchair for mobility. The care plan dated 10/3/25 identified Resident #114 was at risk for refusing care and not waiting for assistance with transfers related to behavior problems with interventions that included assistance of two staff for care and transfers, introduce self to resident, explain what you are going to do, use calm, gentle, approach, and work slowly. A late entry nurse's note from the DNS dated 11/3/25 at 8:30AM identified Resident #114 was alleged to have been slapped on his/her left arm by a NA while providing care. The NA was removed from the schedule upon receiving report of the allegation and a body audit was performed and no injuries were noted. The Accident and Investigation report dated 11/3/25 identified statements from NA #1, #2, and #3 pertaining to the allegation of physical abuse. NA#3's statement identified that on Friday 10/31/25 at about 8:30PM, NA#3, NA#2, and NA#1 went into Resident #114's room to provide care. Resident #114 did not want to get changed and was combative swinging his/her arms and feet. NA#3 held Resident #114's arms so NA#2 could change his/her brief. NA#1 assisted in holding the resident's arms and slapped Resident #114 hard on the arm and used an expletive (F word). NA#3 identified she should have reported it on Friday when it happened. NA#2's statement identified she was providing incontinent care while NA#3 held Resident #114's left hand because he/she was agitated and cursing. NA#1 slapped Resident #114 with her hand she and NA#3 told NA#1 to calm down since they were more familiar with Resident #114. Resident #114 was on NA#3's assignment. The statement further identified that she did not report the incident because she thought NA #3 would report it because Resident #114 was on her assignment. NA#1's statement identified she was helping with Resident #114's care. She noted that the resident started fighting and she grabbed his/her hand twice to stop the resident from hitting NA #3. She further noted that she kept grabbing Resident #114's hands until the brief was changed. The statement noted that the resident continued to resist by kicking and slapping NA #3. Once the change occurred, she noted they all left the room. The Nursing Supervisor's (RN #7) note dated 11/3/25 identified that on 11/2/25 toward the end of the 3pm to 11pm shift, NA #3 reported that NA #1 slapped Resident #114 during the provision of care. The note further noted that NA #2 confirmed what NA #3 had reported. She further noted that the incident had occurred on 10/31/25 and there were no noted signs or symptoms of injury. The Social Worker's progress note dated 11/3/25 identified Resident #114 was in bed and reported he/she had a good weekend. The Social worker asked Resident #114 if he/she had any concerns or complaints related to care he/she had received over the last few days and Resident #114 reported no concerns. The social worker asked the resident if there were any staff members that had been treating him/her differently than usual or if care had not been done well, Resident #114 did not recall the reported event. The skin audit dated 11/3/25 by completed by RN#1 identified no new skin impairments.RN #1's nursing note dated 11/7/25 identified that the allegation of abuse was substantiated because it was witnessed by two staff members. Interview with NA #2 on 2/23/26 at 12:36 PM identified that during the provision of incontinent care to Resident #114, the resident was combative and refusing care. She acknowledged that she was aware that Resident #114 had the right to refuse care, but his/her brief and sheet were soaked with urine and felt it was to the resident's benefit to be cleaned up. She further identified that she witnessed NA #2 slap the resident's arm several times. Additionally, she noted that she had not reported the incident because she thought NA #3 was going to report it, although they had not discussed the reporting of the incident. She noted that she should have reported the incident at the time she witnessed the incident. She further noted that she was put on leave following the reporting of the incident and subsequently fired. Interview with the DNS on 2/27/26 at 9:14AM identified she was notified of the allegation of abuse on 11/3/25 via text message from RN #7. The DNS identified she immediately started the investigation. NA#1, NA#2 and NA#3 worked on 11/1/25, and 11/2/25 in the facility due to the fact the allegation had not been reported. Statements were obtained from NA#1, NA#2, and NA#3, who were subsequently terminated. RN#7 was given a final written counseling regarding the incident and remains employed at the facility. The facility reported the incident to the police and to the state survey agency. Review of the facility policy directed to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect or exploitation occur.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of two sampled residents (Resident #45) reviewed for medication administration, the facility failed to ensure medications were passed on time. The findings include: Resident #45's diagnoses included hypertension, type 2 diabetes, cirrhosis of liver, seizures. The quarterly MDS assessment dated [DATE] identified Resident #45 was cognitively intact, had no behaviors, required limited assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified the use of a walker for mobility. The care plan dated 1/21/26 identified Resident #45 was at risk for seizures with interventions that included caution patient to lie down and push call button if experiencing a prodromal or aural warning, keep call light within reach, medications as ordered. Review of the active physician's orders for March 2026 directed to administer Keppra Oral tablet 500mg 1 tablet two times a day for withdrawal seizures, Bactrim DS oral tablet 800-160mg twice daily, Glipizide 5mg in the morning and Gabapentin oral tablet 600mg three times a day for pain. Interview on 2/19/26 at 11:00AM with Resident #45 identified that medications are passed late on a consistent basis. Some medications are given close to the time the next dose is due and morning medications can sometimes be passed in the afternoon. Review of the point click care (electronic program) order summary report for the period of 1/1/26 through 2/26/26 identified:1/1/26 Bactrim due at 9:00AM was administered at 11:52AM 1/1/26 Glipizide due at 9:00AM was administered at 11:52AM 1/1/26 Keppra due at 10:00AM was administered at 11:52AM 1/4/26 Bactrim due at 9:00AM was administered at 11:42AM 1/4/26 Glipizide due at 9:00AM was administered at 11:42AM1/4/26 Keppra due at 10:00AM was administered at 11:42AM1/6/26 Keppra due at 5:00PM was administered at 7:32PM 1/7/26 Bactrim due at 9:00AM was administered 10:47AM1/7/26 Keppra due at 5:00PM was administered at 11:44PM 1/8/26 Keppra due at 10:00AM was administered at 11:52AM 1/9/26 Keppra due at 10:00AM was administered at 1:21PM 1/10/26 Glipizide due at 9:00AM was administered at 10:30AM1/10/26 Bactrim due at 9:00AM was administered at 10:30AM1/13/26 Glipizide due at 9:00AM was administered at 12:30PM1/13/26 Keppra due at 10:00AM was administered at 12:30PM1/14/26 Bactrim due at 9:00AM was administered at 12:25PM 1/14/26 Glipizide due at 9:00AM was administered at 12:25PM 1/14/26 Keppra due at 10:00AM was administered at 12:25PM1/16/26 Glipizide due at 9:00AM was administered at 10:24PM 1/16/26 Bactrim due at 9:00AM was administered at 10:25AM 1/17/26 Glipizide due at 9:00AM was administered at 12:13PM 1/17/26 Bactrim due at 9:00AM was administered at 12:13PM 1/17/26 Keppra due at 10:00AM was administered at 12:13PM 1/20/26 Keppra due at 5:00PM was administered at 6:25PM 1/21/26 Glipizide due at 9:00AM was administered at 11:21AM 1/21/26 Bactrim due at 9:00AM was administered at 11:21AM 1/21/26 Keppra due at 10:00AM was administered at 11:21AM 1/23/26 Glipizide due at 9:00AM was administered at 10:32AM 1/23/26 Bactrim due at 9:00AM was administered at 10:34AM1/23/26 Keppra due at 5:00PM was administered at 6:42PM 1/24/26 Bactrim due at 9:00AM was administered at 1:11PM 1/24/26 Glipizide due at 9:00AM was administered at 1:11PM 1/24/26 Keppra due at 10:00AM administered at 1:11PM1/25/26 Glipizide due at 9:00AM administered at 11:30AM1/25/26 Bactrim due at 9:00AM administered at 11:30AM1/25/26 Keppra due at 10:00AM administered at 11:30AM 1/26/26 Glipizide due at 9:00AM administered at 11:17AM 1/27/26 Keppra due at 10:00AM administered at 11:28AM 1/30/26 Bactrim due at 9:00PM was administered at 11:11PM1/31/26 Glipizide due at 9:00AM administered at 12:12PM 1/31/26 Keppra due at 10:00AM administered at 12:12PM 2/2/26 Keppra due at 10:00AM administered at 11:21AM2/3/26 Glipizide due at 9:00AM administered at 11:11AM 2/5/26 Bactrim due at 9:00AM administered at 11:43AM2/5/26 Glipizide due at 9:00AM administered at 11:43AM2/5/26 Keppra due at 10:00AM administered at 11:43AM2/7/26 Glipizide due at 9:00AM administered at 12:17PM2/7/26 Keppra due at 10:00AM administered at 12:19PM 2/8/26 Bactrim due at 9:00AM administered at 10:56AM2/8/26 Keppra due at 5:00PM was administered at 7:25PM2/9/26 Keppra due at 10:00AM was administered at 2:31PM 2/9/26 Bactrim due at 9:00AM was administered at 2:31PM2/9/26 Glipizide due at 9:00AM was administered at 2:31PM 2/10/26 Keppra due at 10:00AM was administered at 11:16AM2/11/26 Bactrim due to at 9:00AM administered at 10:42AM 2/11/26 Keppra due at 10:00AM administered at 10:42AM 2/12/26 Bactrim due at 9:00AM administered at 12:10PM2/12/26 Glipizide due at 9:00AM administered at 12:10PM2/12/26 Keppra due at 10:00AM administered at 12:10PM 2/13/26 Glipizide due at 9:00AM administered at 12:32PM 2/13/26 Bactrim due at 9:00AM administered at 12:32PM 2/13/26 Keppra due at 10:00AM administered at 12:32PM 2/13/26 Keppra due at 5:00PM administered at 7:39PM 2/13/26 Gabapentin due at 8:00PM administered at 9:43PM 2:14/26 Gabapentin due at 8:00AM administered at 10:49AM2/14/26 Bactrim due at 9:00AM administered at 10:49AM 2/14/26 Glipizide due at 9:00AM administered at 10:49AM 2/14/26 Gabapentin due at 8:00PM administered at 9:15PM 2/15/26 Gabapentin due at 8:00AM administered at 9:22AM2/16/26 Gabapentin due at 8:00AM administered at 11:30AM2/16/26 Bactrim due at 9:00AM administered at 11:30AM 2/16/26 Keppra due at 10:00AM administered at 11:30AM2/16/26 Gabapentin due at 2:00PM administered at 4:37PM 2/17/26 Gabapentin due at 8:00AM administered at 2:23PM 2/17/26 Glipizide due at 9:00AM administered at 2:23PM 2/17/26 Gabapentin due at 2:00PM administered 4:16PM 2/18/26 Gabapentin due at 8:00AM administered at 12:28PM 2/18/26 Bactrim due at 9:00AM administered at 12:28PM 2/18/26 Glipizide due at 9:00AM administered at 12:28PM2/18/26 Keppra due at 10:00AM administered at 12:28PM 2/19/26 Gabapentin due at 8:00AM administered at 9:26AM2/19/26 Keppra due at 5:00PM administered at 6:23PM 2/20/26 Gabapentin due at 8:00AM administered at 11:17AM2/20/26 Bactrim due at 8:00AM administered at 11:17AM2/20/26 Glipizide due at 9:00AM administered at 11:17AM 2/20/26 Keppra due at 10:00AM administered at 11:17AM 2/21/26 Gabapentin due at 8:00AM administered at 9:45AM2/23/26 Gabapentin due at 8:00AM administered at 2:16PM 2/23/26 Glipizide due at 9:00AM administered at 2:16PM 2/23/26 Bactrim due at 9:00AM administered at 2:16PM 2/23/26 Keppra due at 10:00AM administered at 2:16PM 2/25/26 Gabapentin due at 8:00AM administered at 10:48AM 2/25/26 Bactrim due at 9:00AM administered 10:48AM 2/25/26 Glipizide due at 9:00AM administered at 10:48AM 2/26/26 Gabapentin due at 8:00AM administered at 9:37AM Observation on Resident #45's unit on 3/2/26 at 10:15AM identified LPN#1 completing the morning medication pass. Interview with LPN#1 on 3/2/26 at 10:20 AM, identified that she used to be responsible for administering medications to 38 residents but recently the unit was split up between two nurses and now she is responsible for 15 residents. She noted that she started the medication pass at 7:30 AM and still had 9 residents remaining to administer medications. LPN #1 attributed the delay in the medication administration to staff and resident interruptions. She further noted that on other days, it was most likely short staffing or interruptions. Interview on 3/2/26 at 12:00PM with the DNS identified she was unaware that medications were being passed late on a consistent basis, and if medications were late, she would expect the nursing supervisor to be made aware and the provider to be notified in case medications need to be rescheduled. Interview on 3/2/26 at 12:50PM with RN#2 (nursing supervisor) identified she was unaware that medications were being passed late on a consistent basis as she would expect the nurse to notify her if medications were going to be late. She only knew of one recent episode in which a nurse went home early due to being sick, which was on 2/27/26. She further noted that if medications are being passed late, she would need to reach out to the provider in case they needed to be rescheduled.Interview on 3/2/26 at 1:00PM with APRN#1 identified she was unaware of medications being passed late and noted that it was concerning because medications may need to potentially be rescheduled due to the potential of being given near the next dose. The medication administration protocol identified to verify orders, avoid distractions and interruptions when preparing and administering medications to reduce the risk of medication errors.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #2) who was incontinent, dependent on staff for care, and had a pressure injury, the facility failed to ensure the timely provision of care allowing the resident to go without incontinent care for over five hours. The findings include:Resident #2 was readmitted to the facility in September 2025. Diagnoses included Type 2 diabetes mellitus without complications, Sjogren syndrome, chronic combined systolic (congestive and diastolic (congestive) heart failure. The Norton Plus Assessment (determines the risk of developing pressure ulcers), dated 10/6/25 identified Resident #2 scored 11 which indicated Resident #2 was at high risk. The annual MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition, utilized a wheelchair, was dependent for transfers, showering and toileting hygiene, was always incontinent of bladder and frequently incontinent of bowel, was at risk for developing a pressure injury but did not have any unhealed pressure ulcers/injuries, or other ulcers, wounds or skin problems and had a pressure reducing device for chair, pressure reducing device for bed, and application of nonsurgical dressings and applications of ointments/medications.The care plan dated 10/2/25 identified Resident #2 was at risk for skin breakdown related to decreased mobility and moisture with interventions that included an alternating pressure mattress (APM) set at 200 lbs., inspect skin for redness, irritation or breakdown during care, offer turning and repositioning approximately every 2 hours and as needed (PRN) and complete weekly skin inspections. The wound nurse's progress note dated 10/7/25 at 5:24 PM identified Resident #2 was seen for wound care. Buttocks inspected- blanchable erythema with small, superficial denuded areas. Presentation consistent with MASD (moisture associated skin deterioration). The note further indicated the APRN was updated and a foam dressing was added to the triad paste. The note identified the APM was in place and a ROHO cushion was requested from therapy. The physician's order dated 10/7/25 directed to apply triad paste to buttock followed by foam dressing every day on night shift for wound/skin care, apply ROHO cushion to the wheelchair and check proper cushion and placement every shift.The nursing progress note dated 12/5/25 at 3:27 PM identified Resident #2 had loose, liquid bowel movements with malodorous odor and indicated the sacral area was noted with skin irritation consistent with incontinence associated dermatitis with an order for triad ointment in place. The physician's order dated 1/28/26 directed wound/skin care to apply triad paste to buttock followed by foam dressing every day, every night shift.Interview with Resident #2 on 2/19/2026 at 2:16 PM identified complaints of a rectal/back sore and indicated the soreness was related to having to sit in wet briefs due to staffing constraints on some days. Observation at this time noted the APM was set at 250 lbs. and identified a container of Aquaphor ointment on the side table. Resident #2 indicated that he/she had been provided with incontinent care but had not been out of bed. Resident #2 identified that she/he required the use of a Hoyer and two staff members for transfers. Observation of Resident #2 on 2/26/26 at 11:17 AM identified Resident #2 was still in bed and had not been cleaned up for the day. Resident #2 indicated that he/she had not been changed since night shift and was waiting for staff to come in. Resident #2 identified that the Aquaphor is on the bedside table, so it is readily accessible but indicated that it is not being placed on the rectum and that the rectum and back continue to have pain to the point that staff has started placing pillows on each side under his/her hips to alleviate some of the pressure at his/her request.Interview with NA #4 on 2/26/26 at 12:08 PM identified that this was the first time that day that she was providing care to Resident #2. NA #4 indicated that she approached the resident's room around 10:00 AM and a visitor was present, so she decided to reapproach later. NA #4 identified she could not identify when the resident had last been provided with incontinent care and indicated she asked the nurse for direction on patient care because the unit was so fast paced. NA #4 had provided most care prior to the nurse notifying this surveyor that care was being provided and indicated that the wound dressing had been saturated with urine.Observation of Resident #2 on 2/26/26 at 12:10 PM identified the old dressing was in the trash and it was dated 2/26/26, 11-7. Observation of Resident #2's skin identified a wound to the sacral/coccyx area on the lower back just above the buttocks that had an open area present with yellow drainage and slough (devitalized tissue) present. The wound edges were irregular and partially macerated, and the surrounding skin was discolored and scarred. Interview with LPN #6 on 2/26/26 at 12:13 PM identified Resident #2's dressing was placed on the night shift. She further noted that it needed to be changed due to being saturated with urine. LPN #6 indicated that this was the first time she had been into Resident #2's room for care.Interview with the Medical Director on 2/26/26 at 12:57 PM identified that he did not make decisions regarding wound care treatment and that if staff comes across a wound, it would be referred to the wound nurse and the wound APRN. The Medical Director indicated that he was not aware if the APM setting impacted wound healing.Interview with the Nursing Supervisor RN#2 on 2/26/26 at 1:07 PM identified that every resident in the facility gets a weekly skin check. RN#2 indicated the order should be placed on admission and would coordinate with the resident's shower day and prompt the nurse to complete the weekly skin check. RN#2 reviewed Resident #2's clinical chart which failed to identify an order for a weekly skin audit and failed to identify weekly skin audits. RN#2 identified that any new skin problem would immediately get referred to the wound nurse and indicated that although the wound nurse put a treatment order in on 10/7/25, there was not an assessment or monitoring of Resident #2's sacrum. RN #2 identified that the wound APRN had not seen Resident #2 for the sacral wound.Interview with LPN #11 on 2/27/26 at 6:35 AM identified she worked nights (11 pm to 7 am shift) and completed wound care on Resident #2. LPN #11 indicated the treatment had been in place for a long time and the nursing supervisor or the wound nurse would be notified of wound deterioration.Interview with the Staff Development Nurse (RN#1) on 2/27/26 at 6:55 AM identified new skin problems found should be reported to the nursing supervisor who would do an assessment that included measuring the wound.Interview with APRN#1 on 2/27/26 at 11:09 AM identified she referred to Resident #2's sacral area as a Stage 2 because it was in a previous note. APRN#1 indicated that when she looked at the wound, she thought it was being monitored. APRN#1 identified the wound should be monitored by nursing and should have been seen by the wound nurse.After surveyor inquiry a physician's order dated 2/26/26 directed to cleanse the stage 2 pressure wound to the sacrum with normal saline followed by triad cream and cover with a foam dressing. It further noted to change the dressing daily on the evening shift and as needed. Interview with the Corporate Nursing Director (LPN#3) identified that the initial assessment of a wound should include measurements, assessment, drainage amount and should be monitored.Interview with the wound RN on 3/2/26 at 10:59 AM identified Resident #2 was being seen for other wounds but had not been seen until 3/1/26 by the wound APRN. The wound RN indicated that every resident should have weekly skin checks by nursing and wounds should be referred to the wound nurse. The wound RN identified the original treatment was placed for a macerated area caused by incontinence.Interview with APRN #2, (wound APRN) on 3/2/26 at 3:54 PM identified she observed Resident #2's sacral area yesterday for the first time. APRN#2 indicated that she should have seen the area earlier and that the area looked like incontinence that had recurred. APRN #2 identified that people with moisture associated skin issues are 33 percent more susceptible to developing a pressure injury.The facility's policy for Pressure Injury/Non-pressure Wound Risk Management identified that residents who score at risk for skin impairment or have actual skin impairment are provided with care to address risk factors and goals of treatment and interventions include reposition approximately every 2 hours or more frequently and to check resident for incontinence approximately every 2 hours or per individualized plan of care

Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #79) reviewed for foot care, the facility failed to ensure the resident received podiatry services for trimming of toenails. The findings include:Resident #79 was admitted to the facility in November of 2025 and had diagnosed that included type 2 diabetes mellitus, multiple sclerosis, and paraplegia. The admission MDS assessment dated [DATE] identified Resident #79 was cognitively intact, dependent on staff for dressing, personal hygiene, putting on/taking off footwear, transfers and was non-ambulatory. The care plan dated 11/21/25 identified Resident #79 had diabetes with interventions that directed podiatry consult as ordered and skin audits per facility protocol. The care plan further identified the resident requires assistance with dressing, bathing hygiene, transfers, total care except feeding, oral care and dressing with interventions directed assist with one person for activities daily living skills at bed level and give the resident sufficient time to accomplish each task. Review of the monthly physician's order for November 2025 identified an order that directed podiatry care as needed, diabetic foot care every evening shift, and weekly skin checks on shower days every Mondays and Thursdays on the evening shift. The physician's order for December/2025 through February 23, 2026, identified an order that directed podiatry care as needed, and weekly skin checks on shower days every Mondays and Thursdays on the evening shift. Observation on 2/24/26 at 9:17 AM identified Resident #79 lying in bed with his/her feet uncovered with the toenails on the left foot that appeared to need trimming. Review of Resident #79 clinical records failed to identify the resident had been seen by the podiatrist since his/her admission. Review of the weekly skin checks for the period of November/2025 through February 24, 2026, did not identify any issues or concerns with Resident #79's toenails.Observation and interview with NA #6 on 2/26/26 at 11:50 AM identified Resident #79 [NAME] in bed with his/her overbed table in front of him/her. NA #6 let the resident know what she was about to do prior to preceding to remove his/her sock and the following was noted: on the left foot: the 1st, 2nd and 3rd toenail extended greater that 0.5 centimeters (cm) over the tip of the toe and on the right foot the 1st toenail was thick at the tip, the 2nd and 3rd toenail all extended greater that 0.5 cm over the tip of the toe. NA #6 identified she provides care to the resident and had noticed that his/her toenails needed to be trimmed. She indicated that she had reported it to the nurse two weeks ago but was unable to recall the name of the nurse who she had told about the resident's toenails. The resident interjected and indicated he/she had told one the staff about his/her toenails needing trimming and was told that he/she would need to be placed on the podiatry list. Observation and interview with the Charge Nurse (LPN #4) on 2/26/26 at 12:02 PM identified the same as the observation with NA #6. LPN #4 identified she was unaware that the resident's toenails needed trimming. LPN #4 further identified that nails are checked on the resident's weekly skin checks which are completed on their shower days, and Resident #79 is completed on the evening shift. She further indicated that if she had been made aware, she would have placed the resident on the podiatrist list. Interview with the Unit Secretary on 2/26/26 at 12:13 PM identified she is responsible for scheduling physician's appointments including podiatry for the residents since being hired 3 months ago. The Unit Secretary identified nursing communicates with her via email or verbally for any resident who needs an appointment scheduled and was only told on 2/26/26 by the morning supervisor that Resident #79 needed to be placed on the podiatry list. She identified the podiatrist who usually comes monthly and sends over a list of the residents who will be seen prior to their visit. She reviewed past podiatrist visits and identified that Resident #79 had not been seen for the period of December/2025 through February/2026.A review of the Podiatrist's service dates at the facility for the period of December 1, 2025, through February 26, 2026, identified that the Podiatrist visited the facility a total of 3 times to provide podiatry services.Review of the physician's order dated 2/24/26 identified an order that directed an appointment needed for podiatry consult.Interview with the evening shift Nursing Supervisor (RN #5) on 2/27/26 at 9:12 AM identified she was told by the ADNS to place an order for podiatry consult for Resident #79. She further identified that she was not made aware Resident #79 toenails needed trimming nor did the ADNS tell her the reason why the resident needed to have a podiatry appointment. Interview with the ADNS on 2/27/26 at 12:30 PM identified she was stopped in the hallway by Resident #79's family member asking if Resident #79 could be seen by the podiatrist as he/she has not had a visit for a while now, then she informed the supervisor to schedule a podiatrist appointment. Observation and interview with the DNS on 2/27/26 at 12:58 PM identified Resident #79 lying in bed. The DNS removed the resident's non-skid socks from both feet and the following was noted: On the right foot the great toenail tip was thick and measured approximately 1 centimeter (cm), the 2nd toenail tip measured approximately 1.0 cm, the 4th toenail tip measured approximately 1 cm. On the left foot the great toenail tip measured approximately 1.5 cm, the 2nd toenail tip measured approximately 1cm and the 3rd toenail tip measured approximately 1cm. The DNS identified resident's skin including nails are checked weekly on their shower days by the nurse and the nurse aide who provides the shower. The DNS identified that there was no way that the staff did not notice Resident #79's toenails. Interview with the evening shift Charge Nurse (LPN#5) on 3/2/26 at 9:52 AM identified Resident #79 weekly skin checks were completed on Mondays in which the nurse would look at the resident's entire body including their nails. She identified that she had completed a few of the weekly body skin checks but did not look at the resident's toenails as she did not remove Resident #79's socks when performing the skin check. She indicated that she also works the night shift and the evening shift, and none of the nurse aide reported to her that Resident #79's toenail needed trimming. Review of the Foot Care policy identified residents receive appropriate care and treatment to maintain mobility and foot heath. The policy further identified overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions, for example diabetes, peripheral vascular disease and immobility are referred to qualified professionals.

Based on review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #102) reviewed for pain, the facility failed to ensure the resident received pain medication timely. The findings include: Resident #102's diagnoses included primary osteoarthritis left shoulder, pain disorder with related psychological factors, chronic pain syndrome, unilateral primary osteoarthritis right knee. The quarterly MDS assessment dated [DATE] identified Resident #102 was cognitively intact, had no behaviors, required limited assistance with bed mobility, independent to supervision or touching assistance with transfers, partial to moderate assistance with dressing and independent with personal hygiene. The assessment further identified that the resident utilized a walker and a wheelchair for mobility.The care plan dated 2/26/26 identified Resident #102 was at risk for pain related to being on pain medication therapy with interventions that included administer analgesic medications as ordered by the physician, monitor and document side effects every shift, review following administration for pain medication efficacy, assess whether pain intensity is acceptable to resident. Physician's order active February 2026 directed to administer Morphine sulfate oral solution 20mg/ml give 0.25ml every 8 hours as needed for pain which was discontinued on 2/19/26 at 3:59PM and restarted the same date to be every 6 hours. Interview on 2/19/26 at 11:30AM with Resident #102 identified the resident had requested the as needed Morphine from LPN#9 for a pain level of 6 at 10:00AM that morning now the pain had increased and Resident #102 was still waiting for the medication.Interview on 2/27/26 at 11:30AM with LPN#9 identified he recalled Resident #102 requesting the as needed Morphine on 2/19/26 between 10:00AM and 11:00AM in fact he believed the resident may have stopped him in the hall returning from a smoke break (which started at 10:00AM.) LPN#9 identified that when resident #102 requested the medication he stopped administering medication to the next patient and went to Resident #102 to pass the medication and went within 5 minutes to pass the medication to Resident #102. Review of the MAR for February 2026 identified LPN#9 administered the as needed Morphine to resident#102 at 12:31PM on 2/19/26. Interview on 3/2/26 at 10:25AM with Resident #102 identified he/she recalls receiving the Morphine on 2/19/26 approximately two hours after initially requesting the medication which was after 12:00PM, and after the resident spoke with the surveyor. Resident #102 further identified he/she had not received the as needed Morphine from LPN#1 that morning after requesting it at 10:00AM. Interview on 3/2/26 at 10:30AM with LPN#1 identified Resident #102 had requested the as needed Morphine around 10:00AM however she had not had time to pass it and had forgotten about it. LPN#1 asked Resident #102 what his pain level was during the interview as Resident #102 was present and Resident #102 responded a 10 plus.Interview on 3/2/26 at 1:00PM with APRN#1 identified she was unaware of residents needing to wait an extended period to receive their pain medication. She would expect if the nurse were busy completing a task that the resident should not wait longer than 15 minutes unless there is an emergency in which the nurse was attending to. Review of the MAR for March 2026 identified LPN#1 passed Resident #102 the ass needed Morphine at 10:46AM on 3/2/26 for a pain level of 7. Review of the Civita Pain Assessment and Management policy implemented in the facility by RN#1 (staff development,) directed pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Implementing pain management strategies for pharmacologic interventions may be prescribed to manage pain. Strategies may be employed when establishing the regime include combining long-acting medications with as needed or breakthrough pain. Review of the Civita Pain Medications policy directed to administer pain medications as ordered.

Based on review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews for one of five sampled residents (Resident #5) reviewed for immunizations, the facility failed to ensure that the resident was offered and/assessed for pneumococcal and influenza immunization upon admission as per facility's policy. The findings include:Resident #5 was admitted to the facility in January of 2026 and had diagnoses that included chronic kidney disease, type 2 diabetes mellitus and chronic obstructive pulmonary disease. The admission MDS assessment dated [DATE] identified Resident #5 was cognitively intact and had not received the influenza vaccine as it was not offered. Review of Resident #5 immunization and clinical records with the Infection Preventionist (IP) nurse (RN #6) on 2/24/26 at 12:31 PM failed to identify that the influenza and the pneumococcal vaccine was offered and/or assessed for past immunization. Interview with RN #6 on 2/24/26 at 12:31 PM identified that he was unable to provide any documentation of Resident #5's pneumococcal and influenza vaccine records, as the consent forms was not reviewed with the resident. RN #6 identified consents are obtained on admission by the admitting supervisor and it is then reviewed by the IP nurse. The IP nurse wound then check on the CT wiz, which is a database that maintains patients vaccination records, to ensure that the resident had not received the vaccination prior to admission. RN #6 further identified after the resident vaccination history is check then the appropriate vaccine is ordered by the physician for inoculation. He further identified the facility has a full time IP nurse who was responsible for reviewing the vaccine as he only works 16 hours weekly as the wound nurse and to oversee the IP nurse. RN #6 identified he will review the vaccine consents with the resident on 2/24/26 as it should have been completed on admission. Review of the Procedure for Pneumococcal Vaccination of Residents policy identifies each resident, or their responsible party will be asked on admission if they have previously had any pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the residents also will be used to determine immunization status. The policy further identifies the pneumococcal conjugate vaccine will be offered to all eligible residents, and the risk and benefits will be provided to the resident or the resident's legal representative prior to administration of the vaccine, and the resident or resident's legal representative has the rift to refuse the vaccine. Review of the Immunization of Residents policy identifies all eligible resident will be offered the influenza and pneumococcal vaccines unless medically contraindicated. The policy further identifies the resident or the resident's legal representative will be provided education regarding the pros and cons of the vaccine prior to administration and the resident or resident's legal representative has the right to refuse the vaccine.

Based on review of Resident #1's clinical records (including Minimum Data Set assessments, care plan, admission documentation, and nursing notes), facility policies, and staff interviews, the facility failed to ensure the resident, who required two-person assistance for transfers as per the care card, was transferred per protocol on 1/16/2026. As a result, Resident #1 sustained an acute comminuted fracture of the left distal femoral shaft above the knee, confirmed by X-ray and hospital records. This constitutes a preventable accident, reflecting a breakdown in supervision and adherence to established protocols. The findings include:Resident #1's diagnoses included osteoarthritis of the knee, rheumatoid arthritis and generalized anxiety disorder.The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating Resident #1 had some memory recall deficits, required partial assistance with bed mobility and transfers and utilized a wheelchair for mobility.The Facility Reportable Incident form dated 1/16/26 at 4:15 PM identified Resident #1 was being transferred by the 3-11PM nurse aide when a pop sound was heard. Resident #1 had an increase in left knee pain. The report indicated the provider was notified and an x-ray was ordered of the left knee which later revealed a mildly comminuted fracture of the left distal shaft of the femur. The Physician's Assistant note dated 1/16/26 identified she was notified at 10:30 PM (over six (6) hours after the incident) and a telehealth appointment occurred for consultation of acute left knee pain. The note indicated per nursing during nighttime care, a crackling sound was heard coming from Resident #1's left knee and Resident #1 reported hearing a popping sound. The note identified Resident #1 was non-ambulatory at baseline. Resident #1 reported pain with attempted movement of the left leg and swelling of the left knee was noted. The note indicated APRN #1 ordered a STAT (immediate) left knee x-ray, directed to continue Tylenol administration as needed for pain and staff to apply ice to the knee.The 3-11 PM nursing supervisor's note dated 1/16/26 at 11:50 PM identified a call was placed to the on-call provider to report Resident #1 had an increase in pain to the left knee with noted edema after a cracking sound was heard during care. The note indicated an order was obtained for a STAT x-ray of the left knee, ice to be applied to the left knee for fifteen (15) to twenty (20) minutes every two (2) to three (3) hours as tolerated and to monitor for an increase in swelling, pain, new bruising or numbness.The Radiology Report dated 1/17/26 at 6:27 AM identified Resident #1 had sustained an acute comminuted fracture in the distal shaft of the left femur.The nurse's note dated 1/17/26 at 8:02 AM identified the provider was notified of the results of the left knee x-ray and Resident #1 was transferred to the hospital for further workup. The hospital Discharge summary dated [DATE] identified Resident #1 had been admitted for an acute comminuted fracture in the distal shaft of the left femur with surgical intervention, open reduction internal fixation.The nurse's note dated 1/22/26 at 11:04 PM identified Resident #1 had been readmitted to the facility.Interview with Resident #1 on 1/20/26 at 11:24 AM identified on 1/16/26 he/she was very tired, falling asleep in the wheelchair and his/her left foot had been bothering him/her, so a nurse aide, Nurse Aide (NA) #1, said she was going to put him/her into bed. Resident #1 explained he/she had not attempted to stand on his/her own without staff and although two (2) staff would always help him/her transfer from the wheelchair to the bed, NA #1 was alone that evening and without another staff present. Resident #1 identified NA #1 helped him/her stand without the use of the walker and told him/her to grab onto the side rail and then turn his/her bottom towards the bed. Resident #1 identified he/she started to turn but could barely move the left foot so NA #1 told him/her to step slowly and do it a little at a time and as he/she started to pivot the left knee he/she felt grinding in the left knee and immediate pain. Resident #1 identified NA #1 also heard the sound and the resident reported his/her left leg was touching the mattress, so NA #1 was able to pull him/her onto the edge of the bed and get him/her into bed without a fall occurring. Resident #1 indicated the transfer was very difficult and NA #1 did not utilize a gait belt.Interview with NA #1 on 1/30/26 at 1:17 PM identified as she was walking by Resident #1's room on 1/16/26, she observed Resident #1 leaning forward in the wheelchair with his/her hands on the side rail and it appeared Resident #1 was trying to stand. NA #1 indicated Resident #1 had been incontinent and although she knew Resident #1 was an assist of two (2) stand pivot with the walker for transfers, she did not call out or use the call bell to request assistance. NA #1 identified she did not place a gait belt around Resident #1 and did not utilize the walker to assist in the transfer. NA #1 explained she assisted Resident #1 in standing while Resident #1 held onto the side rail and as Resident #1 started to pivot, she heard a pop sound and Resident #1 yelled out in pain. NA #1 identified Resident #1 was close enough to the bed so she was able to get Resident #1 on the edge of the bed and lay Resident #1 into the bed and then left the room immediately to notify the nursing supervisor. NA #1 reported looking back, she should have yelled for assistance, waited so Resident #1 could safely be transferred to the bed, should have put the gait belt on and utilized the walker prior to transferring Resident #1 to bed.Interview with the 3-11PM nursing supervisor, Registered Nurse (RN) #1, on 1/30/26 at 12:18 PM identified on 1/16/26 the 3-11 PM nurse aide, Nurse Aide (NA) #1, came to her around 4:15 PM to report the incident. RN #1 indicated NA #1 reported she went to provide care to Resident #1 because Resident #1 had been incontinent and the incident occurred when she transferred Resident #1 into bed. RN #1 identified she assessed Resident #1 and although Resident #1 complained of pain with movement of the left leg and knee, she did not observe any redness or swelling so she did not report the incident to the provider immediately. RN #1 identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2, came to her just after 10:30 PM and reported Resident #1 had swelling to the left knee and continued to complain of pain with any movement of the left leg. RN #1 explained she assessed Resident #1 and then called the provider to report the initial incident and the subsequent swelling and pain. RN #1 reported NA #1 should not have transferred Resident #1 without a second staff member present and identified Resident #1 had significant lymphedema to both lower legs.Interview with Physical Therapist #1 and Occupational Therapist #1 on 1/30/26 at 2:02 PM identified Resident #1 had been on therapy services until 12/18/25, when Resident #1 was then discharged as an assist of two (2) for stand pivot transfers from the bed to the wheelchair and from the wheelchair to the bed. They indicated Resident #1 was not capable of pulling or pushing him/herself up out of the wheelchair unassisted.Interview with the Director of Nursing (DON) on 1/30/26 at 1:29 PM identified at the time of the 1/16/26 incident, Resident #1 was an assist of two (2) stand pivot transfer with the walker per the resident care card and physician's order.Review of the Use of Care Cards policy dated 3/12/25 directed, in part, that the facility utilizes Care Cards as a supplement tool to communicate essential, resident-specific care information to staff that highlights key care needs to support safe, consistent daily care and that they may include the following minimum necessary information to include mobility/transfer status. Noncompliance will be addressed through re-education and corrective action as needed.Review of the Gait Belt policy dated 9/1/22 directed, in part, that gait belts must be used for any residents who requires assistance with transfers or ambulation. A gait belt is required unless the resident is independently mobile or its use is contraindicated.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure Resident #1 was free from mistreatment. The findings include: Resident #1's diagnoses included Alzheimer's disease, diabetes mellitus, chronic kidney disease, major depression, anxiety disorder and difficulty in walking with unsteadiness. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition, required limited assistance for bed mobility and transfers, extensive assistance for dressing, toileting, and personal hygiene, was at risk for skin breakdown and was frequently incontinent of urine, and occasionally incontinent of bowel. The Resident Care Plan (RCP) dated 2/23/2023 identified Resident #1 required assistance with ADLs, had depression and anxiety, was at risk for skin breakdown, was at risk for falls, and had occasional urinary incontinence. Interventions directed to assist with care, provide emotional support as needed and to provide a calm, quiet environment, assist with toileting/incontinent care every two (2) hours and as needed, allow Resident #1 to make choices, provide privacy and promote dignity, and provide incontinent care as indicated. Observation of in-room video dated 3/24/2023 timed at 8:08 PM identified Resident #1 was dressed, lying on his/her bed with a sheet and blanket over him/her and appeared to be sleeping. LPN #1 entered the room without knocking, approached the bed and leaned over Resident #1 with her upper body/face leaning over Resident #1. LPN #1 was observed on the video to speak loudly to Resident #1 in a mocking tone and laughing while she was directing Resident #1 repeatedly to get out of bed, and Resident #1 repeatedly said no. Resident #1 asked LPN #1 to leave the room several times, and LPN #1 did not leave the room. LPN #1 was noted on the video to speak to Resident #1 by repeating the intonation of Resident #1's response in a higher pitched mocking-like manner, and NA #1 was heard laughing and making comments to LPN #1 while LPN #1 was mocking Resident #1. Further, prior to leaving the room, LPN #1 was noted on the video standing stand next to the bed while waving her arms in the air and doing a short movement with her body/feet and a jump while speaking in a mocking tone to Resident #1. Upon exiting the room, LPN #1 was heard to make comments to staff and she re-entered the room, looked into the camera and make a comment. Interview with the DNS on 3/31/2023 at 1 PM identified she was provided a copy of the video on 3/31/2023 and she watched the video. The DNS identified the staff as LPN #1 was in the room and NA #1 was in the doorway to the room, and the staff were suspended. The DNS indicated the interaction viewed on the video dated 3/24/2023 at 8:08 PM was abuse, and staff should not have treated Resident #1 (or any resident) as was observed in the video. Subsequent to the facility investigation, LPN #1 and NA #1 were terminated from employment at the facility. Attempts to contact LPN #1 and NA #1 were unsuccessful; interviews were unable to be obtained. The facility Abuse Prohibition Policy, dated May 2016, identified in part that it is the facility had the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect and misappropriation of his or her personal property. The policy defines verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #128) reviewed for catheter use, the facility failed to ensure the resident did not develop a pressure area related to the catheter use. The findings include: Residents #128's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] identified Resident #128 had moderately impaired cognition, had an indwelling catheter, and had no pressure ulcers. The Resident Care Plan (RCP) dated 7/30/2021 identified Resident #128 was at risk for skin breakdown and had a foley catheter. Interventions directed to inspect skin for redness, catheter care every shift, leg bag when out of bed, and keep foley catheter holder in place. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (French scale) with 10 milliliters (ml) balloon. Orders further directed foley catheter care with soap and water every shift and as needed, and to change the leg bag daily every 7-3 shift. Review of urology follow up visit dated 9/17/2021 identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of APRN #1 progress note dated 9/29/2021 identified nursing reported that the resident had penile drainage and a split to the penis area. Physical examination identified a foley catheter was in place, draining clear yellow urine, and a split to the head of the penis was likely related to foley catheter use. APRN #1 further identified that Resident #128 was asymptomatic at the time, and directed nursing staff to continue to monitor the area, notify the provider of any changes, and to continue foley catheter care. Review of APRN #1 Progress Note dated 10/17/2021 identified a penile split with purulent discharge and an odor noted. No [CONDITION(S)] was noted, and Resident #128 denied discomfort. APRN #1 directed nursing staff to change foley catheter, collect urine for culture, continue to monitor and notify provider of any changes and continue foley catheter care. Review of urology visit progress note dated 10/29/2021 identified Resident #128 was seen at the request of the nursing home for catheter irritation. During examination a foley catheter was present and was draining clear urine, the catheter was not properly secured, and urethral erosion was present from urinary meatus. Further review of urology progress note identified three (3) centimeters (cm) length of urethral erosion present from the meatus, extending down the corona of Resident #128's penis, likely from traction on the indwelling catheter. The note further indicated, unable to fully evaluate extent of erosion, as it extends into the penile shaft with a moderate amount of purulent drainage at site. Clinic staff called facility to obtained further history and facility RN #1 identified Resident #128 had the erosion with purulent drainage for over two (2) weeks. Resident #128 was transferred from the urology office to the hospital emergency room for further evaluation. Review of the Emergency Department Report dated 10/29/2021 identified Resident #128 was admitted secondary to penile erosion due to urinary catheter tension with requirement of [MEDICATION(S)] radiology procedure during hospital stay and antibiotics to prevent worsening of potential infection of the penile shaft. The report further identified Resident #128 was admitted for removal of foley catheter and suprapubic tube placement. Review of nurse's notes dated 11/2/2021 identified the resident was readmitted from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record failed to identify that the plan of care included directions to ensure Resident #128's foley catheter tubing was secured to his/her leg to prevent pressure on the skin. Interview and clinical record review with RN #1 on 11/18/2021 at 10:00 AM identified she was the charge nurse on the unit on 10/29/2021 when Resident #128 left the facility for the urology appointment. RN #1 indicated that she did not ensure that the foley catheter was properly secured to Resident #128's leg to prevent pulling and tugging or pressure during transport to the urology appointment, and she should have ensured the catheter was secured to Resident #128's leg. Observation with the DON, APRN #1 and NA #2 on 11/18/2021 at 3:12 PM identified Resident #128 had a healed urinary meatus with deep erosion, with a linear incision-like area observed from the tip of urethral meatus and glans measuring 4 by 0.4 by 0.5 cm. APRN #1 indicated that penile slit would only close with surgical intervention and no treatment was currently needed. NA #2 indicated that when she initially observed the split on Resident #128's penis on 9/29/2021, she notified the nurse. NA #2 further indicated that an elastic band/strap was used around Resident #128's leg in the past and identified she was aware that Resident #128 pulled on the foley at times, and she did not notify the nurse. Further, the DNS was unable to provide documentation that the catheter had been secured in place to prevent pressure on the skin. Interview with urology center APRN #2 on 11/19/2021 at 8:45 AM identified that Resident #128's penile injury was preventable if the facility secured the catheter correctly to prevent pressure. APRN #2 further identified the resident was without benefit of the foley catheter being secured upon arrival for a urology appointment on 10/29/2021, and that during prior visits Resident #128's foley was also unsecured to prevent pressure. APRN #2 explained when a catheter is not secured correctly, there is prolong traction (pressure) on the unsecured foley catheter that causes erosion of the meatus. She further indicated that an injury like Resident #128's would be caused by pressure over a duration of time, not a one-time event, and that proper securement of the catheter would prevent the erosion of the urethra (prevent the injury). Interview with DNS on 11/19/21 at 12:45 PM identified she was not aware that Resident #128 may have pulled on the foley in the past and indicated the foley catheter should have been secured to Resident #128's leg to prevent pressure. She further indicated that subsequent to Resident #128's readmission, orders were obtained to assess and secure the catheter for safety. Review of the clinical record failed to identify measures were in place to prevent traction/pressure on the meatus from the foley catheter. Review of facility Urinary Catheter Care directed staff to ensure that the catheter tubing is secured to the thigh with a leg strap and to prevent urinary tract infections caused by urinary reflux. Review of facility Pressure Injury/Non-Pressure Wound Risk Management Policy, dated July 2020, directed in part, to provide appropriate pressure redistributing devices. a. Review of the clinical record failed to identify a wound assessment to include measurements was completed on 9/29/2021 when the open area on Resident #128's penis was identified as a pressure area related to the foley catheter use. Interview and clinical record review with RN #1 on 11/18/2021 at 10:00 AM identified although wound documentation should be completed when a wound is identified, to include wound measurements, RN #1 was unable to provide documentation that included the characteristics of the penile wound and measurements when split to head of penis and drainage were identified on 9/29/2021. She further indicated that Resident #128's foley catheter should have been secured to his/her leg to prevent pressure. She indicated that the clinical record did not include any wound characteristics or measurements of the wound until Resident #128 was transferred to the hospital from the urology office on 10/29/2021 (30 days after the area was identified). RN #1 indicated that about a week prior to Resident #128's urology appointment on 10/29/21, she changed the foley catheter, however she could not recall the characteristics and measurements of the wound. RN #1 further stated, although she was the charge nurse on the unit on 10/29/2021, she did not assess the penile wound and she should have assessed the wound. Interview with APRN #1 on 11/18/21 at 1:15 PM indicated that she leaves the assessment of the wound and documentation (including measurements) for the nursing staff. Interview with DNS on 11/19/21 at 12:45 PM identified that she would expect the nurse to assess and document the wound when it was identified on 9/29/2021, and to assess and document the wound weekly. Review of facility Prevention and Management of Pressure Injuries Policy, dated July 2020, directed in part, an RN assessment is required weekly for all wounds (pressure and non-pressure) and upon identification of any new wounds.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #40) reviewed for accidents, the facility failed to ensure supervision was provided for a dependent resident to prevent a fall with injury. The findings include: Resident #40's diagnoses included Alzheimer's and a history of repeated falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #40 had severe cognitive impairment, was frequently incontinent of bowel and bladder, required extensive assistance of one (1) staff for toilet use and transfers, used a walker, and had three falls since 12/17/2020 (two of the falls were with injury). The Assessment further identified that Resident #40 was not steady and only able to stabilize with human assistance for moving from a seated to standing position, for turning, and for getting on or off the toilet. The Resident Care Plan (RCP) dated 4/12/2021 identified Resident #40 was at risk for falls. Interventions directed to instruct Resident #40 to ask for assistance prior to attempting to transfer or ambulate, provide verbal cues and hand-over-hand assistance as needed, and instruct to use assistive device to aid with balance and transfers. Physician's orders dated 5/3/2021 directed to transfer and ambulate with a rolling walker and assist of one (1) staff. Resident care card dated 5/13/2021 directed one (1) staff assist with ambulation, transfers and toileting. Review of the facility incident report dated 5/30/2021 at 11:00 AM identified Resident #40 was on the toilet and lost balance when he/she attempted to self-ambulate instead of waiting for the NA, lost his/her balance, fell and sustained a skin tear on right elbow. The report identified Resident #40 was alert and forgetful and required assist of one (1) staff for mobility. The Report identified a right arm x-ray was completed. Review of facility incident report dated 5/31/2021 at 12:00 AM identified an x-ray was obtained after Resident #40's fall on 5/30/2021 due to pain in Resident #40's right arm. The report identified a right forearm acute distal radius impacted fracture, and Resident #40 was transferred to the hospital for evaluation. The RCP was updated to direct staff not to leave Resident #40 unattended in the bathroom. Additionally, the report identified staff were in-serviced not to leave any resident alone in bathroom, unless they were independent. Nurses note dated 5/31/2021 at 12:21 AM identified Resident #40 complained of right arm pain, the physician was notified, and an order was obtained for an x-ray of the right arm and right wrist. Nurses note dated 5/31/21 at 1:31 PM identified the x-ray results were positive for an impacted fracture, and Resident #40 was transferred to the hospital. Additional facility documentaiton review and clinical record review identified Resident #40 was not admitted to the hospital, and returned to the facility. Interview with NA#1 on 11/17/2021 at 10:36 AM identified she was assigned to Resident #40 at the time of the fall on 5/30/2021. NA #1 indicated that Resident #40 required assist of two (2) staff for transfers and another staff member assisted her to placed Resident #40 on the toilet on 5/30/2021. She further indicated that although she should have stayed with Resident #40 when he/she was on the toilet, she told Resident #40 to wait for her before getting up, and then left the room to get a washcloth (she indicated that she was out of the room for about two (2) minutes). She described she saw Resident #40 lose his/her balance while holding onto the grab bar and fall to the floor in a sitting position. Resident #40 informed NA #1 that he/she had hit his/her elbow. NA #1 observed bleeding from the elbow area and called the nurse. NA#1 indicated that the fall would have been prevented if she stayed with Resident #40 while he/she was in the bathroom, and she should not have left Resident #40 alone. During an interview and clinical record review with the DON on 11/17/2021 at 11:00AM, the DON indicated that NA #2 should not have left Resident #40 alone in the bathroom.

Based on clinical record review and interviews for one of two residents (Resident# 217) reviewed for medication administration, the facility failed to ensure the resident was free from significant medication errors. The findings include: Resident #217's [DIAGNOSES REDACTED]. An interagency referral report (W10) dated 8/6/15 identified the resident was referred to the facility for hospice respite care admission. The initial care plan dated 8/10/15 indicated the resident will be at the facility for a short term stay with problems that included pain with interventions that included visit, touch, and convey concern and comfort as needed, provide support to family, and confer with hospice provider as needed. Admission physician's orders [REDACTED]. The physician further directed to administer [MEDICATION NAME] 100units/ml, give 5units sq at 8:30am and at 8:30pm and Humalog insulin pen at 7:30am, 11:30am, and 4:30pm, if blood sugar is 120-180 give 2 units, if blood sugar is 181-250 give 4 units, if blood sugar is 251-350 give 8 units, and if blood sugar is 351-400 give 10 units. Nurse notes dated 8/12/15 at 2:38pm identified the resident was weak, in no pain, afebrile, and with a small amount of vomitus on the shirt. Blood sugar was obtained and read HI. Review of the manufacturer's manual for the blood glucose device identified that if the device read HI, the blood sugar is above 600mg/dL, repeat the test with a new strip and if the message shows again, call your healthcare professional immediately. Interview and review of the clinical record with RN Supervisor #1 on 7/6/16 at 3:15pm identified that when a retest was done and the device read HI. Vital signs were: blood pressure (bp) - 128/64, heart rate - 62 beats per minute (bpm) O2 saturations- 98% room air, and Resident #217 was in no respiratory distress. The physician was called immediately and directed to administer [MEDICATION NAME]10 units subcutaneuosly (SQ) now. At 3:30pm blood sugar continued to read HI. Vital signs identified [MEDICAL CONDITION] 132 beats/minute, blood pressure 138/90, respirations at 24 and 99% on room air, and temperature - 97.6 degrees Farenheit. The resident responded sluggishly to verbal stimuli and was sleepy and pale. The physician directed staff to administer [MEDICATION NAME] 50mg at that time and [MEDICATION NAME]4 units SQ was administered per physician's orders [REDACTED]. At 4:00pm blood sugars remained high. The resident was somnolent but arousable. The physician directed to administer an additional [MEDICATION NAME]10 units SQ. The blood pressure read 98/60mm, heart rate - irregular at 114bpm, respirations at 24 and afebrile. At 4:15 pm the resident's blood pressure was 90/58 and heart rate 130 bpm and irregular. The physician directed to administer IV hydration 0.45% normal saline at 50cc/hr. At this time the resident started to become more alert, awake, and responding verbally. At 4:45pm the APRN changed the IV hydration order to 0.9% normal saline at 50cc/hr. Further review of the clinical record identified the resident's condition continued to be monitored periodically. RN Supervisor #2 indicated that he stayed with the resident at bedside constantly. At 6:20pm the blood sugar continued to read HI . BP-100/60 and heart rate -104. The APRN directed to administer [MEDICATION NAME] 20units SQ. At 6:40pm, the family asked for the facility to send the resident to the emergency department for further monitoring and evaluation and the physician gave the order. Resident #217 was sent to the emergency room at approximately 7:00pm. The Emergency Department report identified that Resident #217 was in diabetic ketoacidosis with random glucose at 608mg/dL. Normal range is 70-139 mg/dL. The resident's chest X-ray further revealed early right middle lobe infiltrate. The resident was then admitted with a [DIAGNOSES REDACTED]. Interview and clinical record review with the DNS on 7/6/16 at 9:00am identified the resident's admission orders [REDACTED]. The resident did not receive the ordered insulin medication from that time until 8/12/15 at approximately 3:00pm when the hospice nurse alerted the facility staff of the resident's mental and physical status changes. Further review identified that blood sugars were also not obtained during the same time period from 8/10/15 pm through 8/12/15 pm. The facility failed to monitor Resident #217's blood sugars and/or administer medications as ordered.

Based on review of the clinical record, review of facility documentation, review of facility policies, observations, and interviews for one of four residents reviewed for abuse/neglect, (Resident #173), the facility failed to ensure that the resident was free from neglect when the resident was not provided incontinent care for more than five hours. The findings include: 1. Resident #173 (R #173) had [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] identified that R #173 had a BIMs score of ten out of fifteen, indicative of moderate cognitive impairment, and required total assistance for transfers and toilet use, extensive assistance for personal hygeine, and was incontinent of bowel and bladder. Review of the care plan dated 5/6/15 identified that R #173 was unable to care for him/her self, and that due to the resident' incontinence, the resident was at risk for skin breakdown and urinary tract infections. Interventions included to provide incontinent care every two hours and as needed and to offer to change his/her position every two hours. Intermittent observations on 6/15/15 from 10:00 AM to 2:15 PM identified that R #173 remained seated in his/her custom wheelchair in his/her room and was facing the television. At 2:15 PM, Nursing Assistant #1(NA #1) and NA #2 entered R #173's room to return the resident to bed via mechanical lift and to provide incontinent care. Upon lifting the resident off the wheelchair, the entire back of the mechanical lift pad was observed to be heavily soaked through with a foul smelling liquid. Upon completion of the transfer into the bed, R #173 was positioned onto his/her left side. The resident was observed to have been incontinent of a large amount of loose stool. The stool was observed to have traveled up from the back of the resident's brief to the area between the resident's shoulder blades. As NA #1 began to provide incontinent care and the loose stool was cleansed away, stool was also observed to be dried onto the resident's back and required additional cleaning to be removed. In addition, R #173's back and posterior thighs were observed with deep linear demarcations that coincided with the brief and mechanical lift pad wrinkles. R #173 was subsequently turned onto his/her back. The front of R#173's brief was observed to be bloated and full of the same loose stool. Dried stool was observed to be caked onto the resident's skin beneath the loose stool at the resident's inner thighs and perineal area as NA #1 and NA #2 continued to provide incontinent care. In addition, R #173's bilateral inner thighs were observed to have deep linear demarcations that coincided with the brief edges. Interview with NA #1 on 6/15/15 at 2:40 PM identified that R #173 was out of bed when he/she first saw the resident at 7:15 AM on 6/15/15. NA #1 stated that although he/she checked the front of the resident's brief at approximately 9:15 AM,he/she checked only the front of the resident's brief and did not identify that the resident required incontinent care at that time. NA #1 stated that he/she did not check the resident for incontinence since that time. Upon further interview, NA #1 initially stated that he/she had been previously yelled at by another NA who he/she could not name, and that the aide told him/her that R #173 was provided with incontinent care only after being put back to bed after lunch. Interview with the Director of Nursing on 6/16/15 at 8:00 AM identified that during an investigation of the incident, NA #1 reported to the DNS that he/she had just lost track of time. Subsequent to surveyor inquiry, the facility initiated an investigation, reported the incident to the appropritate authorities, and suspended NA #1 pending outcome of the investigation. Facility policy on abuse/neglect identified neglect as the failure to provide goods and services necessary to avoid physical harm and/or mental anguish. In addition, facility policies on Resident Rights directed in part that residents had the right to reasonable accommodation of their individual needs.

Based on clinical record review, review of facility documentation and interviews for one of one sampled resident reviewed with at risk for [MEDICAL CONDITION] (R#84) the facility failed to provide care and services to maintain the highest practical well-being. The findings include: Resident # 84's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely cognitively impaired, and required extensive assistance with ADL's. A RCP dated 9/04/13 identified a scab to the left second toe with interventions that included to monitor and treat the area as ordered. Review of the wound documentation dated 9/04/13 identified a scab to the left second toe and the skin around the wound noted to be clean and dry. Wound documentation dated 9/09/13 identified the area as reddened, with serous drainage and the scab was noted as falling off. Wound documentation dated 9/16/13 identified that the scab had fallen off and with slough present. Wound documentation dated 9/16/13 identified the area as a venous ulcer and 100% yellow slough on the wound bed. Wound documentation dated 9/25/13 identified the wound as vascular and 100% yellow slough on the wound bed. Wound documentation dated on 9/26/13 identified the wound as moist and with serous drainage and 100% slough. A RCP dated 9/25/13 identified the wound on the left second toe as a vascular wound. Review of a Cardiology Consult dated 11/12/12 identified the resident was evaluated in the Vascular Clinic due to a history of prior severe lower extremity critical ischema. Recommendations from this visit included no further interventions unless something changes and to follow-up in 6 months. Review of the clinical record failed to reflect that the resident had the follow-up appointment and/or that the Vascular Surgeon had been notified of the change in condition. Interview with the DNS on 9/25/13 at 12:00 PM identified that a follow-up appointment had been scheduled but then was canceled by the office because the physician had left the practice and another appointment could not be made until October, 2013. The DNS further identified that she did not know if the Vascular physician's office was made aware of the change in condition but she had faxed all of the information on 9/25/13 to the office to inform them of the change. Interview with RN #2 on 9/26/13 at 2:00 PM identified that she had identified from the onset on 9/04/13 that the wound was vascular in nature but was not aware that the resident was followed by a Vascular surgeon and if she had been made aware then she would have followed up with the Vascular surgeon. Interview with MD#1 on 9/26/13 at 9:35 am identified that he was not made aware that the resident's follow-up Vascular consult was canceled and another appointment could not be made until October, 2013. MD#1 identified that he was not made aware of the Vascular wound until 9/26/13 when staff asked him to evaluate the area and if he had known he would have ordered a Vascular consult. The MD further identified that after he evaluated the vascular wound he changed the treatment and ordered a follow-up Vascular consult. Interview with APRN #1 on 9/26/13 at 2:35 PM identified that she had not been notified that the Vascular consult had been canceled. The APRN further identified that she had seen the wound for the first time on 9/25/13, when facility staff asked her to evaluate the area, and that the if she had known about the Vascular wound, and felt it had deteriorated, she would have ordered a follow-up with the Vascular surgeon.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents reviewed for pressure ulcers (R#103), the facility failed to provide appropriate interventions in the prevention and development of the pressure ulcer. The findings include: Resident # 103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident required extensive assistance of 2 people for bed mobility and transfers, is occasionally incontinent of urine, and free from pressure ulcers but is at risk for the development. A RCP dated 7/31/13 identified the resident at risk for skin breakdown due to decreased mobility. Interventions included to provide a pressure reducing mattress and cushion, assist to turn and reposition his/herself every 2 hours, and to assist to the bathroom every 2 hours. physician's orders [REDACTED]. Review of the admission assessment dated [DATE] identified the resident cannot make frequent/significant changes in body/extremity position independently. Review of the wound tracking dated 8/20/13 identified an unstageable wound to the right buttock with the wound bed covered with 50 % slough, measuring 0.5 cm by 1.0 cm. Wound tracking dated 8/21/13 identified the right buttock wound bed with 100% slough/eschar, measuring 0.5 cm by 0.5 cm by 0.1 cm and on 8/26/13 the documentation identified a stage 2 on the right buttock with partial thickness and loss of skin layers and measuring 0.5 cm by 1.0 cm. An updated RCP on 8/30/13 identified the resident with an unstageable wound on the right buttock, and at risk for breakdown due to long periods of sitting at [MEDICAL TREATMENT]. Interventions included on 8/29/13 identified to provide a rojo cushion, and to encourage the resident to bring the cushion to [MEDICAL TREATMENT] so he/she can sit on it during treatment. Interview with [MEDICAL TREATMENT] RN #1 (DRN #1) on 9/25/13 at 2:30 PM identified that the resident's [MEDICAL TREATMENT] treatment last approximately 3.75 hours, and during this time he/she is only repositioned when requested by the resident and the resident rarely requests repositioning. DRN #1 further indicated that she was aware or the resident's open area on her right buttock and that the resident had been sitting on 2 pillows in the [MEDICAL TREATMENT] chair before the facility implemented the rojo cushion, which DRN #1 identified the resident refuses to sit on while in the [MEDICAL TREATMENT] chair. Interview with RN#2 on 9/26/13 at 3:00 PM identified that on admission the resident was at risk for skin breakdown and was provided with a pressure reducing mattress and cushion as per facility protocol. RN#2 further identified that after the area developed the facility had been provided with a rojo cushion while in the wheelchair and also to take to [MEDICAL TREATMENT]. RN#2 indicated that the 9 day delay in obtaining the rojo cushion was most likely due to the cushion not being readily available. RN#2 also indicated she was unaware that the resident was refusing the rojo cushion at [MEDICAL TREATMENT]. Additionally, review of the clinical record failed to reflect that the resident was provided education as to the benefits of utilizing the rojo cushion .

Based on clinical record reviews, review of facility documentation, and interviews for 12 of 25 sampled residents (Residents #8, #79, #80, #92, #114, #156, #167, #173, #180, #189, and #196) who were reviewed for medication regime, the facility failed to obtain laboratory testing and/or administer medications according to the physician's orders [REDACTED]. 1. Resident #8's [DIAGNOSES REDACTED]. The laboratory results dated [DATE] indicated Resident #8 had an elevated [MEDICATION NAME] Time (PT) of 44.9 seconds (normal value 10.5 to 13.3 seconds) and an INR value of 4.4 (normal 0.8 to 1.1). A physician's orders [REDACTED]. Review of the September MAR indicated [REDACTED]. Upon further review the MAR indicated [REDACTED]. On 10/4/12 Resident #8 was noted to have bruising under the left arm and the right inner eye. The facility's investigation on 10/4/12 identified that the medical record lacked documentation the laboratory had been notified of the 9/25/12 PT/INR order to be drawn on a day that was not a usual laboratory draw day and the unit charge nurse did not verify with the laboratory if the blood work had been drawn and/or notify the Nursing Supervisor that the blood work was not drawn. Subsequent to physician notification Resident #8 was transferred to the emergency department on 10/4/12 for evaluation. In the ED Resident #8 received Vitamin K intravenously for an elevated PT/INR. The resident returned to the facility with no further negative results. Since the incident the resident has been removed from [MEDICATION NAME] therapy. During an interview with the Director of Nurses (DON) on 12/3/12 at 11:25 AM, the DON identified that on 9/17/12 RN #1 had taken the order for the PT/INR to be drawn on 9/25/12. The DON indicated a blood work slip had not been made out and upon review with the laboratory; the laboratory had not been notified of the order. The DON indicated upon questioning RN #1 she had documentation that she notified the laboratory of the order but was unable to produce the documentation. During an interview with RN #1 on 12/5/12 at 3:30 PM, RN #1 indicated that on 9/17/12 she had called Resident #8's physician because she identified an ordered PT/INR for 9/17/12 had not been drawn. RN #1 indicated she then took orders for the [MEDICATION NAME] dosing and PT/INR to be drawn 9/25/12. Upon surveyor inquiry RN #1 indicated she had entered the order in the computer, placed the blood work slip in the laboratory book and called the laboratory to book the PT/INR for 9/25/12. RN #1's interview conflicts with the laboratory results dated [DATE] in which the PT/INR blood work was drawn at 9:09 AM, reported to the facility, then faxed to the physician and the physician faxed orders back to the facility at 3:02 PM. 2. Review of facility documentation, medical record reviews, and interviews with staff related to diabetic monitoring and medication administration, the following was ascertained: a. Resident (R) #79 was admitted with [DIAGNOSES REDACTED]. Documentation of blood sugar monitoring on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon facility identification of the inaccurate blood sugar documentation R#79's blood sugar was checked at 8:00 AM. The 8:00 AM blood sugar result was 74. Subsequent monitoring indicated R#79 had blood sugar readings of 198 at 4:30 PM, 308 at 9:00 PM and received [MEDICATION NAME] (short acting) insulin coverage as indicated by physician order. b. R#80 was admitted with [DIAGNOSES REDACTED]. Documentation of BS monitoring on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon facility identification of the inaccurate blood sugar documentation and subsequent medication omission R#80's blood sugar was checked at 11:00 AM. The 11:00 AM BS result was 420. R#80 received [MEDICATION NAME]8 units SC. c. R#92 was admitted with [DIAGNOSES REDACTED].#92's blood sugar was less than 200. Documentation of blood sugar monitoring on the MAR by LPN#1 indicated on 10/14/12 at 6:30 AM R#92 had a blood sugar of 194 and received no [MEDICATION NAME]coverage. Upon facility identification of the inaccurate blood sugar documentation and medication omission subsequent blood sugar monitoring indicated R#92 had blood sugar readings of 241 at 11:30 AM and received 6 units [MEDICATION NAME] insulin. R#92's blood sugar at 4:30 PM was 250. d. R#114 was admitted with [DIAGNOSES REDACTED].#1 indicated on 10/14/12 at 6:30 AM R#114 had a blood sugar of 98. Upon facility identification of the inaccurate blood sugar documentation R#114's blood sugar was checked at 8:00 AM. The 8:00 AM blood sugar result was 73. R#114 received a routine dose of [MEDICATION NAME] 2.5 milligrams (mg) by mouth (PO) at 9:00 AM. Subsequent blood sugar monitoring indicated R#114 had blood sugar readings of 115 at 4:30 PM. e. R#156 was admitted with [DIAGNOSES REDACTED]. Documentation of blood sugar monitoring on the MAR by LPN#1 indicated on 10/14/12 at 6:30 AM R#156 had a blood sugar of 92. Upon facility identification of the inaccurate blood sugar documentation R#156's blood sugar was checked at 11:00 AM. The 11:00 AM blood sugar result was 153. f. R#167 was admitted with [DIAGNOSES REDACTED].#1 indicated on 10/14/12 at 6:30 AM R#167 had a blood sugar of 92. Upon facility identification of the inaccurate blood sugar documentation R#167 received his/her routine dose of Glimepiride 3 mg PO at 9:00 AM. Subsequent blood sugar monitoring indicated R#167 had a blood sugar reading of 194 at 10:00 AM and 317 at 4:40 PM. g. R#173 was admitted with [DIAGNOSES REDACTED]. Documentation of blood sugar monitoring on the MAR by LPN#1 indicated on 10/14/12 at 6:30 AM R#173 had a blood sugar of 112. The MAR indicated [REDACTED]. Upon facility identification of the inaccurate blood sugar documentation and medication omission subsequent blood sugar monitoring indicated R#173 had blood sugar readings of 119 at 2:00 PM, 220 at 6:00 PM and 204 at 10:00 PM and R#173 received [MEDICATION NAME]on a sliding scale as indicated by physician orders. h. R#180 was admitted with [DIAGNOSES REDACTED]. Documentation of blood sugar monitoring on the MAR by LPN#1 indicated on 10/14/12 at 6:30 AM R#180 had a blood sugar of 126. R#180 received his/her routine dose of [MEDICATION NAME] 750 mg. PO at 9:00 AM. Subsequent blood sugar monitoring indicated R#180 had blood sugar readings of 261 at 4:30 PM. i. R#189 was admitted with [DIAGNOSES REDACTED].#1 indicated on 10/14/12 at 6:30 AM R#189 had a blood sugar of 82. According to the MAR indicated [REDACTED]. Upon facility identification of the inaccurate blood sugar documentation and medication omission subsequent blood sugar monitoring indicated R#189 had blood sugar readings of 190 at 11:30 AM, 319 at 6:00 PM and 275 at 10:00 PM and received [MEDICATION NAME](short acting) on a sliding scale as indicated by physician order. j. R#196 was admitted with [DIAGNOSES REDACTED].#1 indicated on 10/14/12 at 6:30 AM R#196 had a blood sugar of 142. According to MAR indicated [REDACTED]. Upon facility identification of the inaccurate blood sugar documentation and medication omission R#196 received [MEDICATION NAME]12 units SC. Subsequent blood sugar monitoring indicated R#196 had blood sugar readings of 440 at 2:00 PM, 298 at 6:00 PM and 421 at 10:00 PM and received [MEDICATION NAME]coverage as indicated by physician order. During an interview with the Director of Nurses (DON) on 12/6/12 the DON indicated on 10/14/12 she received a call from the night shift supervisor who indicated she was concerned that LPN#1 did not appear to be as busy doing tasks consistent with the time of the shift. The supervisor had asked LPN#1 if he/she needed assistance and LPN#1 indicated he/she did not. The DON indicated she had previously asked supervisors to monitor skin dressing changes and when the supervisor checked a resident's dressing she noted it had been noted as completed but the date on the dressing was the previous date. The DON and supervisor were concerned other care had not been completed therefore they began to check the documented 6:30 AM blood sugar results against the memory in the glucometer (blood sugar monitoring machine) and noted the results in the glucometer did not match what was documented in the medical record. The DON indicated upon questioning LPN#1 he/she admitted to documenting false blood sugar results in addition to documenting the administration of insulin that had not been administered. During an interview with LPN #1 on 12/6/12, LPN#1 indicated he/she had become overwhelmed with the amount of work he/she needed to complete and had attempted to notify the supervisor but was unsuccessful. Upon surveyor inquiry LPN#1 indicated he/she had not checked the 6:30 AM blood sugars, had falsified the blood sugar results in the medical record and had not administered insulin as ordered, but had documented that he/she had. Upon completion of the facility investigation LPN#1's employment at the facility was terminated

Based on clinical record review, review of facility documentation and interviews for one of eleven sampled residents (Resident #36) who had diabetes mellitus, the facility failed to ensure that the resident received the correct insulin in accordance with the physician's orders [REDACTED]. Resident #36's [DIAGNOSES REDACTED]. The Accident & Incident Report dated 6/13/12 at 11:30 AM identified that Licensed Practical Nurse (LPN) #2, who was a new hire undergoing orientation, had administered [MEDICATION NAME]66 units at 8:00 AM instead of [MEDICATION NAME] 66 units. Interview with Registered Nurse (RN) #2 (the preceptor for LPN #2) on 12/3/12 at 11:45 AM identified that LPN #2 was instructed to only obtain the [MEDICATION NAME] for Resident #36 from the medication room. RN #2 indicated LPN #2 was only observing the medication pass and was not administering medications. RN #2 indicated LPN #2 took it upon himself to administer the insulin without direction. RN #2 stated the incident was discovered at 11:30 AM when Resident #36's finger stick was 37. The nurse's note dated 6/13/12 identified that subcutaneous [MEDICATION NAME] was administered, the blood sugar increased to 39, a second dose of [MEDICATION NAME] was administered and the resident's blood sugar increased to 67, then 70. Subsequent to physician notification Resident #36 was transferred to the emergency department for an evaluation and was admitted for blood glucose monitoring due to [DIAGNOSES REDACTED] secondary to an accidental insulin injection and a high white count related to a urinary tract infection. The hospital discharge summary dated 6/18/12 indicated Resident #36's blood sugars were stable and the resident was returned to the facility. Interview with LPN #2 on 12/5/12 at 9:50 AM he indicated that he was instructed by RN #2 to obtain the [MEDICATION NAME] from the medication room. LPN #2 identified that he took the short acting [MEDICATION NAME]instead of the [MEDICATION NAME] and took it upon himself to draw up the insulin and administer it to Resident #36. Review of facility policy for medication administration directed to read the label three times, comparing to the Medication Administration Record.

Based on clinical record reviews, review of facility policies and practices, review of facility documentation, observations, and interviews, the facility failed to adequately supervise nine of nine residents (Resident's #1, 2, 3, 4, 5, 6, 7, 8, and #9), who were at risk for elopement, per assessment, physician orders [REDACTED]. The finding includes: a. Resident #1 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The physician order [REDACTED]. The Minimum Data Set (MDS) admission assessment dated [DATE] noted that the resident had severe cognitive impairment and required supervision with ambulation when off of the unit. The plan of care dated 4/25/12 to 6/28/12 indicated that the resident was an identified wanderer and to check identification bracelet and Wanderguard. The facility incident and investigation documentation dated 6/28/12 through 6/29/12 identified that Resident #1 walked 0.4 miles to a family member's home, unsupervised on 6/27/12 at approximately 5:30 PM. The documentation further noted that facility staff was made aware of the resident's elopement via a phone call from the resident's family on 6/27/12 at approximately 6:30 PM, and the Resident did not have a Wanderguard in place. The resident was returned to the facility by family at 8PM on 6/27/12 without injury. The resident was placed on 15 minute checks and a Wanderguard was placed on the resident on 6/28/12. Interviews with the Director of Nurses, Registered Nurse (RN) # 1, #2, #5 and Licensed Practical Nurse (LPN) #1 on 7/10/12 and 7/11/12, review of the resident's treatment record and review of supervisor report sheets indicated that the resident was without the benefit of a Wanderguard bracelet from 6/17/12 through 6/28/12. However, during that same time frame, nurses on all 3 shifts documented that the Wanderguard was in place. Further interview with the DON on 7/11/12 at 10AM indicated that the supervisors on the night shift were required to perform the daily testing of the Wanderguards; however, this was not done consistently. b. In addition, the 6/28/12 investigation for Resident #1 identified that Receptionist #1 was seated at the front desk when the resident exited the front doors during a facility picnic. Review of facility documentation on 7/11/12 identified that a folder was kept at the front desk and contained pictures of nine residents who were at risk for elopement and utilized Wanderguards. Interview with Receptionist #1 on 7/11/12 at 9:30 AM noted that following Resident #1's elopement on 6/27/12, s/he saw a picture of the resident and believes s/he saw the resident exit the building with a group of people on 6/27/12 at approximately 6PM. S/he further identified that s/he was covering for the usual receptionist on 6/27/12 and was not aware of the folder containing the pictures of residents at risk for elopement. c. In addition, review of the supervisor work sheets, review of a facility purchasing requisition, and interview with RN #1 on 7/10/12 at 1PM all identified that Wanderguard bracelets and transmitting devices were unavailable in the facility beginning 6/17/12. Additional Wanderguards were ordered and purchased by the facility on 6/28/12, but were not available in the facility until 7/3/12. Interview with the Assistant Director of Nursing (ADON) and DON on 7/10/12 at 1:20 PM and 1:45 PM respectively noted that they first became aware that the facility lacked replacement Wanderguard devices and bracelets on 6/28/12 and the order was placed. Further interview with the DON on 7/10/12 at 1:50 PM indicated that the supervisor worksheets were not routinely reviewed by Administration as they were intended as a communication device between supervisors. Although nursing supervisors were aware of the facility ' s lack of supply of Wanderguard bracelets, s/he was not aware that the facility did not have the actual Wanderguard devices available in the facility until 6/28/12. d. In addition, manufacturer's recommendations for the Wanderguard (Secure Care) system instructed that a documented test of each transmitter at the facility be made each day. Review of the facility Wanderguard check sheet on 7/11/12 identified that during June 2012, wanderguard usage fluctuated between 8 and 10 residents. According to the check sheet, Wanderguard checks were only conducted on 9 out of 30 days. Interview with the DON on 7/11/12 at 10AM indicated that the supervisors on the night shift were required to perform the daily testing of the Wanderguards; however, this was not done consistently. Interview with one of two night supervisors, RN #5, on 7/11/12 at 10:40 AM noted that s/he was not aware that it was the night supervisor's responsibility to check the functioning of Wanderguard devices until 7/1/12. e. Resident #4's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident had severe cognitive impairment and required a wheelchair (W/C) for locomotion. The wandering/elopement risk assessment dated [DATE] indicated that the resident wandered out of the facility and was at risk of wandering. The physician's orders [REDACTED]. Wanderguard check sheets noted that Resident #4 was intermittently checked for Wanderguard functioning for 21 out of 30 opportunities during 6/2012 and checks were not conducted between 7/1/12 and 7/9/12. Observation on 7/10/12 at 2:27 PM identified the resident in the W/C with the Wanderguard on the resident's right ankle. Interview with the DON on 7/10/12 at 2:45 PM noted that the ADON and 2 LPNs assessed that the resident no longer required the Wanderguard on 6/28/12, removed it from Resident #4 and placed it on Resident #1, as there were no available Wanderguard devices in the facility at that time. Resident #4's clinical record lacked the 6/28/12 wandering assessment. S/he further identified that a Wanderguard was reapplied to Resident #4's right ankle the morning of 7/10/12 (after determining that an assessment was not documented when the device was removed on 6/28/12). Review of the resident's record and interview with the DON on 7/11/12 at 7:55 AM identified that Resident #4 was assessed as a wander/elopement risk by the evening supervisor on 7/10/12 subsequent to surveyor inquiry and required the continued use of the Wanderguard. The wandering/elopement risk policy directed to evaluate the risk of wandering/elopement on admission and when clinically indicated. f. In addition, interview with the DON on 7/10/12 at 8:57 AM identified that each shift nurse was required to check the placement of Wanderguards and document the checks on the treatment record. Review of Resident #4's treatment records with the DON on 7/10/12 at 2:45 PM noted that between 6/28/12 and 7/10/12, each shift nurse had initialed that Resident #4's Wanderguard was in place despite the fact that it had been removed on 6/28/12. Interview with the DON on 7/10/12 at 2:45PM indicated that although staff had been educated on 7/3/12 to visually check the placement of the Wanderguards, nursing staff continued to document that the devices were in place without visualizing/checking the resident between 7/3/12 and 7/10/12. g. Resident #2 ' s was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Wander/elopement risk assessments dated 7/8/11 to 10/3/11 (last/yearly) identified that the resident was at risk for wandering/eloping. The quarterly assessment dated [DATE] identified that the resident wandered. Physician orders [REDACTED]. Although the treatment record dated 6/2012 noted that staff documented that placement of the Wanderguard was checked, the night shift Supervisor ' s documentation dated June 2012 failed to identify consistent documentation to reflect that the Wanderguard was checked for proper functioning nightly for 21 out of 30 opportunities. Observation of the resident on 7/10/12 at 8:55 AM noted that the resident ambulated independently and had a Wanderguard in place on the left ankle. h. Resident #3 ' s [DIAGNOSES REDACTED]. The wander/elopement risk assessment dated [DATE] identified that the resident was at risk for wandering/eloping. The care plan for wandering/elopement risk dated 5/14/12 directed to check Wanderguard every shift 11-7 shift, 7-3 shift and 3-11 shift. Although the treatment record dated May, June and July 2012 noted that staff documented that placement of the Wanderguard was checked, the night shift Supervisor ' s documentation dated June 2012 failed to identify consistent documentation to reflect that the Wanderguard was checked for proper functioning nightly (21 out of 30 opportunities not documented). Observation of the resident on 7/10/12 at 8:57 AM noted that the resident ambulated independently and had a Wanderguard in place on the right ankle. i. Resident #5 ' s [DIAGNOSES REDACTED]. The wander/elopement risk assessment dated [DATE] identified that the resident was at risk for wandering/eloping. The significant change assessment dated [DATE] indicated that the resident ' s cognition was moderately impaired. Physician orders [REDACTED]. Although the treatment record dated 6/2012 noted that staff documented that placement of the Wanderguard was checked, the night shift Supervisor ' s documentation dated June 2012 failed to identify consistent documentation to reflect that the Wanderguard was checked for proper functioning nightly for 21 out of 30 opportunities. j. Resident #6 ' s [DIAGNOSES REDACTED]. The wander/elopement risk assessment dated [DATE] identified that the resident was at risk for wandering/eloping. Physician orders [REDACTED]. Although the treatment record dated 6/2012 noted that staff documented that placement of the Wanderguard was checked, the night shift Supervisor ' s documentation dated June 2012 failed to identify consistent documentation to reflect that the Wanderguard was checked for proper functioning nightly for 21 out of 30 opportunities. k. Resident #7 ' s [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] indicated that the resident ' s cognition was moderately impaired. The wander/elopement risk assessment dated [DATE] identified that the resident was at risk for wandering/eloping. Physician orders [REDACTED]. Although the treatment record dated 6/2012 noted that staff documented that placement of the Wanderguard was checked, the night shift Supervisor ' s documentation dated June 2012 failed to identify consistent documentation to reflect that the Wanderguard was checked for proper functioning nightly for 21 out of 30 opportunities. l. Resident #8 was readmitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The wander/elopement risk assessments dated 5/18/12 identified that the resident was at risk for wandering/eloping, expressed the desire to leave the building and had exit seeking behaviors. The care plan for wandering/elopement risk entry dated 5/18/12 noted that the resident sometimes wandered and to continue with the plan of care (to include the Wanderguard). The treatment records dated 5/18/12 through 6/25/12 did not identify that a Wanderguard was in place and/or checked for placement. The night shift Supervisor ' s documentation dated June 2012 identified that the Wanderguard was checked and functioning on 6/5, 6/6, 6/7 and 6/8/12. Interview with the Corporate Nurse (RN #3) on 7/13/12 at 2:30 PM noted that although the resident required the Wanderguard, the placement checks would not be populated on the treatment record because it was not written as a physician's order [REDACTED]. m. Resident #9 [DIAGNOSES REDACTED]. The wander/elopement risk assessment dated [DATE] identified that the resident was at risk for wandering/eloping. physician's order [REDACTED]. Although the treatment record dated 6/2012 noted that staff documented that placement of the Wanderguard was checked, the night shift Supervisor ' s documentation dated June 2012 failed to identify consistent documentation to reflect that the Wanderguard was checked for proper functioning nightly for 7 out of 12 opportunities. Interview with the DON on 7/11/12 at 10AM indicated that the supervisors on the night shift were required to perform the daily testing of the Wanderguards; however, this was not done consistently. The facility policy for wandering/elopement risk did not direct staff regarding Wanderguard documentation, the manufacturer's recommendations for the Wanderguard (Secure Care) identified that each transmitter should be tested daily to ensure the transmitter is working properly. The deficiencies cited above were found to constitute immediate jeopardy on 7/11/12. The facility submitted an immediate action plan on 7/11/12 to include reeducation of staff and Administration's monitoring of those residents who require Wanderguard use, as well as monitoring charge nurse and supervisor checks for Wanderguards.

Based on clinical record review, observations, review of facility documentation, and interviews for one of two sampled residents (Resident #2) who required a mechanical lift for transfers, the facility failed to utilize and/or supervise the proper functioning of the lift during a transfer. The findings include: Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident had no memory and/or cognitive deficit, did not display any psychotic behaviors, and required two person extensive assistance with transfers. A physician's orders [REDACTED]. The nurse's note dated 1/28/12 at 7:26 PM identified that Resident #2 had experienced a fall at 6:35 PM in the room and complained of right shoulder pain. Subsequent to physician notification an x-ray was ordered. The x-ray reported dated 1/28/12 identified the presence of osteoporosis and an acute impacted humeral neck fracture. The nurse's note dated 1/28/12 at 11:14 PM identified that the physician was updated with the x-ray results and directed that Resident #2 be transferred to the hospital for an evaluation and returned to the facility on [DATE] at 3:15 AM with a sling on the right arm. The Reportable Event Form dated 1/28/12 at 6:35 PM identified that Resident #2 was being transferred by two nurse aides via the Sara lift. On transport back to the chair, the Nurse Aide (NA) reported that Resident #2 became unresponsive and slid from the Sara lift onto the floor, hitting the forehead on the lift and the right arm was caught in the sling. Review of the investigation dated 1/28/12 identified that while transferring, Resident #2's feet slipped off the Sara lift and the resident began to faint. The report indicated that the buttons on the remote froze and the lift would not go up and/or down. Interview with the NA #3 on 4/25/12 at 2:40 PM identified that during the transfer from the bathroom to the bed via the Sara lift, Resident #2's eyes rolled back and the resident fainted slowly. NA #3 identified that she had been controlling the lift and tried to get the lift to go down but the button did not work and the resident's leg started to slide off the lift. Interview with the NA #2 on 4/25/12 at 2:50 PM identified that during the transfer Resident #2's left foot started to slip off the footrest and the resident fainted while trying to get the lift down. NA #2 indicated that she was behind the resident and after unhooking the sling Resident #2 was lowered down to the floor utilizing NA #2 as a brace. NA #2 identified that she was not aware of an emergency hydraulics release button on the lift and although she had utilized Sara lifts, this one was new to her. During the interviews neither nurse aide explained how they were able to release the leg straps while Resident #2 was lowered to the floor. Review of the facility's investigation dated 1/30/12 identified that the Sara lift was removed from the room, the battery was tested and the lift did function going up and down, there was no indication that the battery was low. Subsequent to the incident the vendor of the Sara lift conducted an inservice to review the utilization of the lift and trouble shooting techniques.

Based on clinical record reviews, review of facility documentation, and interviews for one of four sampled residents (Resident #5) who had a change in gastro-intestinal status, the facility failed to ensure that the resident's fluid status and/or requirements were monitored and/or reassesses to maintain adequate hydration. The findings include: Resident #5's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that the resident had mild cognitive impairment, no behavioral symptoms, and required supervision with eating. A physician's orders [REDACTED]. Review of the Intake and Output (I/O) records and the clinical records identified that the resident had a twenty-four hour total oral intake between 1580 cc to 2140 cc and had eleven bowel movements from 5/2/12 through 5/4/12. The record indicated that Resident #5 was evaluated by Advanced Practice Registered Nurse (APRN) #1 on 5/4/12 for restlessness and agitation, and a psychiatric consult and I/O monitoring was recommended. The record failed to reflect that the resident was assessed by APRN #1 for dehydration. Review of the I/O records noted that Resident #5 had seventeen or more bowel movements and the total fluid intake was 4820 cc from 5/5/12 through 5/7/12 7:00 AM. A hydration assessment conducted by the Licensed Practical Nurse (LPN) dated 5/7/12 at 3:45 PM identified that the resident's output was not significantly greater than the intake and the resident showed no signs of dehydration. Resident #5 was evaluated by APRN #1 on 5/7/12 for [MEDICAL CONDITION], the resident's blood pressure was 98/60 on 5/6/12, diarrhea, general weakness and poor appetite. An appetite stimulant, antiemetic as needed and encourage oral fluids was ordered with blood work scheduled for 5/9/12 to assess hydration status. The laboratory report identified that the stool specimen collected on 5/5/12 was positive for [MEDICAL CONDITION]. The resident had nine plus loose stools from 5/7/12 through 1:00 PM on 5/8/12, vomited on 5/8/12 at 2:59 AM, the morning blood pressure was 90/60 on 5/8/12 and APRN #1 ordered Intravenous (IV) hydration. Although the resident received IV hydration beginning 5/8/12 at 5:30 PM, the resident continued to have loose stools, [MEDICAL CONDITION], vomiting and was transferred to the hospital on [DATE]. The hospital blood work results dated 5/9/12 indicated that the resident's Blood Urea Nitrogen (BUN) was 71mg/dl (the normal range 7-17mg/dl,was 16mg/dl on 4/30/12), the creatinine was 2.4mg/dl (was 0.6 mg/dl on 4/30/12, normal range 0.5 to 1.0mg/dl) and the resident was dehydrated. Review of the facility's hydration policy identified that residents at risk for hydration (three consecutive loose stools in twenty-four hours), the Dietician and/ or nurse will determine the fluid needs when there is a change in condition. Review of the clinical record fielded to reflect that the resident was reassessed by the APRN, Registered Nurse and/or Dietician to ascertain whether or not the resident was meeting his/her fluid intake needs after the resident had a change in condition with the increase in loose stools. Interview with the Director of Nurses on 5/16/12 noted that the twenty-four hour output totaled the urine output however the output did not include the number of loose, watery stools and/or vomitus. Interview with APRN #1 on 5/17/12 at 8:15 AM identified that she was not aware of the resident's increased stool output on 5/4/12 or she would have assessed the resident for dehydration. APRN #1 further noted that to assess a resident's total I/O and hydration status, she would have to go into approximately four different areas in the computerized record system. Although interview with APRN #1 on 5/17/12 at 11:00 AM indicated that the reason she delayed the blood work to be drawn for 5/9/12 to assess for dehydration was because she wanted to first hydrate the resident with IV fluids, IV fluids were not ordered until 5/8/12 when the resident showed further decline.

Based on clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #3), the facility failed to ensure that a significant medication error did not occur. The findings include: Resident #3's [DIAGNOSES REDACTED]. Review of the Reportable Event Form dated 10/17/11 identified that Licensed Practical Nurse (LPN) #1 had administered the wrong 9:00 AM medications to Resident #3. The medications were to be administered to Resident #3's roommate, Resident #4. Review of Resident #4's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #3's MAR indicated [REDACTED]. Review of the vital signs record from 9/30/11 through 10/17/11 identified that Resident #3's blood pressure normally ranged from 92/56-170/92. Subsequent to physician notification Resident #3's blood pressure was monitored every fifteen to thirty minutes until 8:00 PM, normal saline by mouth was provided hourly and a peripheral intravenous access site was placed for maintenance. Review of the nurse's note dated 10/17/11 at 11:23 AM identified that Resident #3's blood pressure was initially stable at 88/64 with a pulse of 104, the resident was able to take fluids well and the blood pressure elevated to 104/78 with a pulse of 104. At 11:31 AM Resident #3's blood pressure dropped to 64/40, the resident was put to bed in trendelenburg position. Although the blood pressure improved to 78/54, the resident complained of feeling tired and sleepy. At 2:45 PM intravenous fluids, Normal Saline at 125 milliliters/hour times 24 hours was initiated. The nurse's note dated 10/18/11 at 11:38 PM identified that Resident #3's blood pressure was 127/78 with a pulse of 74 and the intravenous fluids had been discontinued. Interview with LPN #2 on 04/24/12 at 10:30 AM identified that she had prepared Resident #4's 9:00 AM medications, walked into the room, at which time Resident #3 stopped her and questioned her about a medical appointment. LPN #2 stated that she was distracted by Resident #3 and the nurse aide providing care. Without checking LPN #2 handed Resident #3 the medication cup intended for the roommate, and before she realized the event, Resident #3 had taken the mediations. LPN #2 indicated that she realized the error immediately and notified the Nursing Supervisor.