Every finding on record at Colonial Health & Rehab Center of Plainfield, LLC

Based on a tour of the Dietary Department, observations, review of facility policy, and interviews, the facility failed to ensure food temperatures were monitored, documented, and maintained in accordance with professional standards for safe food handling. The findings include:Interview and review of food temperature logs with the Food Service Director (FSD) on 6/4/26 at 12:30 PM identified multiple missing food temperature entries. Review of temperature logs dated 5/1/26 through 6/4/26 revealed puree food temperatures were missing for at least one meal on 13 of 35 days reviewed. In addition, no temperatures were documented for cold entree items during the review period. Further review of the temperature log form revealed there was no designated space to document temperatures for alternative entree selections. The FSD identified cooks are responsible for obtaining and documenting temperatures for all food items, including pureed foods, at breakfast, lunch, and dinner. The FSD further indicated he reviews the temperature logs for completeness; however, he had not identified the missing temperature entries noted during the review.Interview with [NAME] #1 on 6/12/26 at 11:00 AM identified she obtains food temperatures when food is removed from the oven and again prior to plating. [NAME] #1 stated she temperatures all food items to ensure hot foods are around 165 degrees Fahrenheit and do not fall below 145 degrees Fahrenheit. [NAME] #1 identified when two entree options are served, she documents the lower of the two temperatures. [NAME] #1 was unable to identify where temperatures for alternate meal selections are documented and was unable to explain the blank spaces noted on the temperature logs.Review of the facility Food Preparation Policy revised on 2/2026, directed, in part all food will be held at appropriate temperatures, greater than 135 degrees for hot holding and less than 41 degrees for cold holding.

Based on review of clinical record, facility documentation, facility policy and interviews, for 3 residents (Resident #9, 1 and 50), the facility failed to administer medications and/or monitor blood sugar according to professional standards and physician's orders. For 1 resident (Resident #9) reviewed for medication errors, the facility failed to ensure staff followed the physician's order for Xanax (antianxiety medication) administration after a change in the dose. For 1 of 5 residents (Resident #1) who were reviewed for unnecessary medications, the facility failed to ensure blood glucose monitoring was performed as prescribed by the provider. For 1 of 7 residents (Resident #50) reviewed for medications, the facility failed to hold the Metoprolol (a medication that lowers your blood pressure and heart rate) according to the physician's order, when the residents heart rate was below the identified parameters. The findings include: 1. Resident #9 was admitted in November 2018 with diagnoses that include dementia with behavioral disturbances, intellectual disabilities and anxiety disorder. The quarterly MDS dated [DATE] identified that Resident #9 had severely impaired cognition, was totally dependent on staff for all activities of daily living (ADLS) except requiring supervision with eating and received antianxiety medication 7 days a week. Review of the June 2025 physician's orders directed to administer Xanax (antianxiety medication) 0.25mg two times a day. The care plan dated 6/24/25 identified the resident receives antianxiety medications related to anxiety disorder with interventions that included to administer antianxiety medications as ordered by the physician and monitor and document any adverse reactions and unexpected side effects to antianxiety therapy. The physician's order dated 6/28/25 directed to discontinue Xanax 0.25mg twice daily and begin Xanax 0.5 mg (antianxiety medication) twice a day and Xanax 0.25mg as needed every 8 hours for agitation, anxiety, and yelling for 14 days. A nurse's note dated 7/5/25 at 10:26 AM by RN #8 indicated that Resident #9 received the wrong dose of Xanax. Resident #9 had an increase in Xanax from 0.25mg two times a day to Xanax 0.5mg two times a day. The nurses administer the wrong dose on 6/30/25, 7/1/25, 7/2/25, and 7/3/25. The RCP dated 7/5/25 identified that Resident #9 had a medication error and received the incorrect dose of Xanax. The intervention related to the medication error was to monitor for any adverse effects for 72 hours. Review of the nurse's notes dated 7/5/25 through 7/9/25 identified no changes in behaviors or vital signs. Interview with LPN #8 on 6/8/26 at 10:30AM identified she did not recall administering the wrong dose of Xanax to Resident #9 but indicated that the DNS was on top of it and she certainly would have received education related to the medication error. Interview with LPN #7 on 6/8/26 at 10:45AM identified she recalled the medication errors related to the Xanax for Resident #9. LPN #7 identified that she received education related to ensuring medication label on the medication blister pack is compared to the medication order and the importance of re-reading the dosage to ensure it is correct prior to administering medications. Interview with LPN #10 on 6/8/26 at 10:55AM identified she recalled the medication errors with the Xanax with Resident #9. LPN #10 indicated that she had become distracted and did not read the label properly. LPN #10 indicated that the medication error was reviewed with her, but she did not recall who reviewed the error with her. Interview with the Pharmacy Consultant on 6/8/26 at 11:15AM indicated that adverse reactions to certain medications are patient specific and that the medication error was not significant in nature. The Pharmacy Consultant stated that Resident #9 may have experienced an increase in behaviors or his/her anxiety related to receiving a lower dose. Interview with the DNS on 6/8/26 at 12:00PM indicated that education was provided to nursing staff after the medication error and random audits of medication orders/medication administration but could not locate the audits at the time of inquiry. A review of Medication Errors and Drug Reaction policy dated 6/30/22 directed that the facility will report and record medication errors, drug interactions and/or adverse effects of any medication in accordance with State and Federal regulations. If a medication error occurs a Medication Error report will be completed and a Change in Resident Condition form. The supervisor will notify the DNS, the physician, and responsible party. The resident will be monitored for a minimum of 72 hours or until symptoms subside for 24 hours. The charge nurse is responsible for updating the resident's care plan with all the appropriate information and documenting the resident's condition every shift for the next 72 hours or longer until the problem is resolved. 2. Resident #1's diagnosis included Type 2 diabetes mellitus. The care plan dated 9/25/25 identified Type 2 diabetes as an endocrine status focus. Interventions included monitor/document/report as needed for signs and symptoms of hyperglycemia and hypoglycemia. The quarterly MDS dated [DATE] identified Resident #1 had intact cognition, had an active diagnosis of Type 2 diabetes and was prescribed medications to treat high blood sugar. A physician's order dated 3/9/26 directed blood glucose checks to be performed twice weekly, morning and evening on Tuesday and Friday with results reported to provider for blood glucose less than 70 milligrams per deciliter (mg/dl), or greater than 400 mg/dl. An interview and clinical record review with RN #2 on 6/5/26 at 10:45 AM failed to reflect documentation that blood glucose monitoring had been done, as ordered, from 3/10/26 through 6/5/26, 3 months. Further interview with RN #2 noted that blood glucose monitoring was not completed because the physician's order was transcribed on the Diagnostic Imaging Administration Record (DIAR) rather than the Medication Administration (MAR)/Treatment Administration Record (TAR) therefore, blood glucose monitoring was not completed. Interview with the DNS on 6/5/26 at 11:20 AM indicated the order for blood glucose monitoring should have been transcribed in the MAR rather than the DIAR. The DNS indicated the providers were responsible for reviewing orders for accuracy and completion monthly. Interview with Advanced Practice Registered Nurse, APRN #1 on 6/5/26 at 12:54 PM indicated she failed to review Resident #1's blood glucose levels after the order was placed. APRN #1 stated she typically reviews blood glucose monitoring during resident visits however, if the visit was not pertaining to Type 2 diabetes, she may not review them. Additionally, she indicated she was not aware that blood glucose testing had not been completed since March 10, 2026. She indicated there would be potential for hyperglycemia (elevated blood sugar levels), and hypoglycemia (low blood sugar levels), with a variety of different outcomes related to not obtaining the blood glucose as ordered. Interview with RN #5 on 6/8/26 at 11:04 AM indicated she failed to enter the order properly into the Electronic Health record (EHR). Subsequent to surveyor inquiry, RN #2 communicated with the provider and transcribed the blood glucose order to the correct location in the EHR. Review of the Medication Administration and Documentation policy directed Licensed Nursing staff to review provider orders and compare against the MAR. Review of the Physicians Orders – Transcribing EHR (Electronic Health Record) policy dated 06/05/2023 directed Responsibility to the RN Supervisor for transcribing orders including medication/ treatment to the MAR/TAR from the provider order sheet or other referring documentation source. The policy directed orders are to be transcribed to MAR/TAR and if required, supplementary documentation or instructions as indicated by provider or per facility policy established process. The policy also directed all orders to be reviewed and transcribed to the appropriate locations (MAR/TAR, etc.). 3. Resident #50's diagnoses included hypertensive heart disease with heart failure, cardiomyopathy and atrial fibrillation. A significant change in status MDS dated [DATE] identified Resident #50 had severely impaired cognition, was dependent with bed mobility, toileting and transfers and had diagnoses of heart failure, hypertension, cardiomyopathy, and atrial fibrillation. The care plan dated 11/18/25 identified Resident #50 had an altered cardiovascular status related to congestive heart failure, hypertension and hyperlipidemia. Interventions included to administer medications as ordered and to monitor vital signs prior to giving Metoprolol and to notify the physician of significant abnormalities. The care plan further directed Metoprolol was to be held (not administered) for a systolic blood pressure below 90 or a heart rate below 55. A physician's order dated 12/11/25 directed to administer Metoprolol Succinate ER extended release 24 hour, 25mg daily and 50 mg daily (for a total dose of 75mg daily) for essential hypertension. Hold for systolic blood pressure less than 90 or heart rate less than 55. Review of the MAR's dated 12/11/25 through 5/11/26 identified Metoprolol 75mg had been administered outside of the physician's ordered parameters 12 times on the following dates: 12/23/25 heart rate 52. 12/25/25 heart rate 50. 12/30/25 heart rate 53. 2/18/26 heart rate 44. 2/25/26 heart rate 52. 2/28/26 heart rate 53. 3/2/26 heart rate 41. 3/4/26 heart rate 45. 3/14/26 heart rate 52. 3/15/26 heart rate 54. 4/15/26 heart rate 52. 5/10/26 heart rate 48. Interview and review of the clinical record with the DNS on 6/5/26 at 3:11 PM identified the following: LPN #2 administered the Metoprolol 75 mg dose outside of the physician's ordered parameters on 3/14/26 and 3/15/26. LPN #3 administered the Metoprolol 75 mg dose outside of the physician's ordered parameters on 2/18/26, 2/25/26, 2/28/26, 3/2/26, and 3/4/26 and was no longer employed at the facility. LPN #4 administered the Metoprolol 75 mg dose outside of the physician's ordered parameters on 12/23/25. The remaining staff (3 LPN's) who administered the Metoprolol 75 mg dose outside of the physician's ordered parameters on 12/25/25, 12/30/25 and 4/15/26 and 5/10/26 worked for a nursing agency. The DNS further identified per the physician's order, if Resident #50's heart rate was below 55 the medication should have been held, and the MAR should have reflected that. In addition, the nursing supervisor or physician should have been notified. Review of Resident #50's MAR with the DNS indicated the Metoprolol had been administered to Resident #50 despite the resident's heart rate being below 55 for all dates identified. The DNS indicated she was not aware of the medication errors, and the nurse responsible for administering medications should have followed the physician's order and held the Metoprolol for Resident #50 on all dates identified. Interview and review of the clinical record with licensed practical LPN #2 on 6/8/26 at 10:28 AM identified she was the charge nurse for Resident #50 and had administered morning medications to the resident on 3/14/26 and 3/15/26. LPN #2 indicated she was new at the facility and not familiar with the system being used and indicated she may have given the Metoprolol in error because of that. Review of the MAR with LPN #2 indicated on 3/14/26 the residents heart rate was recorded as 52 and on 3/15/26 the residents heart rate was recorded as 54. LPN #2 indicated that had she held the medication she would have notified her supervisor and written a progress note. Review of the clinical record with LPN #2 failed to identify she wrote a progress note in the clinical record for 3/14/26 or 3/15/26. LPN #2 further stated if she signed the Metoprolol as administered on the MAR then she had administered the medication but should not have. Interview with APRN #1 on 3/8/26 at 11:29 AM identified she was not aware Resident #50 had received the Metoprolol dose in error when his/her heart rate was below 55. APRN #1 indicated if Resident #50 received Metoprolol 75 mg when his/her heart rate was below 55, it could have caused the residents heart rate to go lower and resulted in hypotension (low blood pressure), dizziness, syncope or cardiac arrest. APRN #1 identified the nurse responsible for administering medications should not have administered the Metoprolol if the residents heart rate was below 55, and the physician's order clearly stated that. APRN #1 was unsure why the physician's order for the Metoprolol was not followed and indicated she would need to follow-up with the DNS. Attempts to contact LPN #3 and LPN #4 were unsuccessful. Review of the Medication Administration and Documentation policy, undated, directed medication administration and documentation occurs in a timely and accurate manner. The medication administration record (MAR) is the form on which all medication orders are poured and administered and on which medication doses are charted. The MAR is a permanent part of the resident's medical record. Vital signs are to be monitored and recorded when appropriate prior to medication administration and if any medications are not administered a reason should be documented. All held or refused medications should be documented on the MAR and the physician should be informed in a timely manner when medications are held, refused, or otherwise unavailable for administration.

Based on review of clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #19/victim and Resident #71/victim) reviewed for abuse, the facility failed to protect Resident #19 from physical abuse by Resident #9/perpetrator, who had a history of pinching and for Resident #71 the facility failed to protect Resident #71 from physical abuse by Resident #68/perpetrator. The findings include: 1a. Resident #19's diagnoses included chronic obstructive pulmonary disease, anxiety disorder and post-traumatic stress disorder The admission MDS dated [DATE] identified Resident #19 had intact cognition, and required partial to moderate assistance with transfers, toileting, and bed mobility. The care plan dated 8/26/25 identified Resident #19 had a potential for social isolation and depression. Interventions included to invite/encourage the resident to attend activities, provide monthly activity calendar, and assist the resident in developing a program of activities that was meaningful and of interest. A nurses note written by RN #4 dated 9/22/25 at 11:45 AM identified Resident #19 was self-propelling in the dining room and was close to another resident. The other resident proceeded to reach out and pinch Resident #19 twice on the right upper arm. Resident #19 told the other resident (that's not nice, and you can't do that). The other resident proceeded to reach out and pinch Resident #19 again. The note indicated Resident #19 denied pain or discomfort and did not have any redness or swelling to his/her skin. APRN #1 and Resident #19's responsible party were notified. b. Resident #9's diagnoses included dementia with psychosis, and intellectual disabilities. The change in condition MDS dated [DATE] identified Resident #9 had severely impaired cognition and was dependent with transfers, toileting and bed mobility. Review of the clinical record dated 6/17/25 to present identified Resident #9 had multiple episodes of pinching other residents. The care plan dated 7/14/25 identified Resident #9 had a behavior problem related to pinching, scratching, hitting, refusing care and throwing items. Interventions included the resident was to be 1:1 with staff for supervision when out of bed, in the wheelchair in the hallway, and not to be in arms reach of other residents. A nurses note, written by RN #4 dated 9/22/25 at 11:45 AM identified Resident #9 was involved in a resident-to-resident altercation. Another resident was self-propelling in the dining room and was close to Resident #9 who proceeded to reach out and pinch the other resident twice on the right upper arm. The resident that was pinched told Resident #9 (that's not nice and you can't do that) and Resident #9 proceeded to reach out and pinch the resident again. The care plan was updated to include intervening as necessary to protect the rights and safety of other residents and to remove Resident #9 from situations as necessary. A nurses note written by RN #4 dated 9/22/25 at 2:33 PM identified Resident #9 had a virtual appointment with the behavioral health advanced practice registered nurse (APRN), and a new order was received for Resident 9 to continue on 1:1 staff supervision while out of bed and remove from 1:1 staff supervision while in bed. A social service progress note dated 9/22/25 at 5:00 PM identified Resident #9 was met with after being involved in a negative peer interaction. Resident #9 presented as remorseful and stated he/she wanted to stay in his/her room and that he/she liked people. A physician's order dated 9/22/25 directed Resident #9 was to be 1:1 until cleared by behavioral health. The Reportable Event Report dated 9/22/25 at 11:47 AM identified Resident #19 as the alleged victim and Resident #9 as the alleged perpetrator. The event description indicated Resident #19 was in the dining room and when Resident #9 came close to Resident #19 and he/she reached out with his/her left hand and pinched Resident #9 on the upper right arm. Resident #19 was on 1:1 staff supervision at the time and was removed from the situation (this is in conflict with the interview with NA #3 who was assigned the 1:1 staff supervision with Resident #9. NA in an interview indicated she was on the computer charting and had her back to Resident #9 at the time of the incident). The Summary Report dated 9/24/25 at 12:00 AM identified upon investigation, the nurse aide (NA #3) assigned 1:1 supervision with Resident #9 at time of the incident indicated she felt the conversation between the two residents was pleasant in nature so she did not feel the need to separate Resident #9 and Resident #19 prior to the incident. Interview with RN #4 on 6/8/26 at 11:53 AM identified she was the RN Supervisor on duty when the incident between Resident #9 and Resident #19 occurred on 9/22/25. RN #4 indicated Resident #19 was on 1:1 staff supervision at the time of the incident and NA #3 was the assigned nurse aide. RN #4 stated NA #3 was in the dining room charting on the computer and was not focused on and did not have eyes on Resident #9 when he/she pinched Resident #19. RN #4 identified NA #3 should have been aware of Resident #19's surroundings and not allow any residents to come within arm's reach of Resident #9 (due to his/her history of pinching). RN #4 further indicated NA #3 was given a written warning after the incident and although NA #3 was apologizing after the incident occurred, NA #3 stated she was busy and charting and did not see it happen. Interview and review of reportable event documentation with the Director of Nurses (DNS) on 6/8/26 at 12:29 PM identified she was working in the facility but was not present when the resident-to-resident altercation between Resident #9 and Resident #19 occurred on 9/22/25. The DNS indicated although NA #3 was assigned to provide 1:1 supervision for Resident #19, she did not have eyes on the resident and was focused on completing her charting at the time the incident occurred. The DNS stated when Resident #19 came within arms reach of Resident #9, NA #3 should have asked Resident #19 to move away or backed Resident #9 away from Resident #19 (as per the plan of care, Resident #19 was not to be in arms reach of other residents). In a subsequent interview with the DNS on 6/8/26 at 1:00 PM the DNS indicated she had located a facility employee warning notice for NA #3 which was completed by RN #4 on 9/22/25. The notice identified NA #3 was assigned 1:1 supervision for Resident #19 and failed to follow protocol for 1:1 supervision. The notice indicated NA #3 was re-educated by RN #4 on the importance of complying with 1:1 supervision protocol. Interview and review of witness statement with NA #3 on 6/9/26 at 4:08 PM identified she was assigned 1:1 supervision of Resident #9 on 9/22/25 when the incident occurred. NA #3 indicated although she was aware Resident #9 had a history of pinching people and was not to be within arms reach of other residents, she was on the computer charting and had her back to Resident #9 when the incident occurred. NA #3 identified she was aware Resident #19 was close to and talking to Resident #9, but she did not separate them and only knew Resident #9 had pinched Resident #19 when she heard Resident #19 say something which then made her turn around. Additionally, NA #3 indicated RN #4 gave her a written warning after the incident and she was told her main focus should have been Resident #9 and she should not have been charting on the computer, but NA #3 stated she was busy and just trying to get her work done. Review of the Abuse Prohibition policy dated 7/27/23 directed to prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: Training of employees and prevention of occurrences. The center will ensure staff are doing all that is within their control to prevent occurrences of abuse. Staff actions to prevent abuse will include identifying, correcting and intervening in situations in which abuse is more likely to occur. Definition of abuse-the willful infliction of physical, verbal, mental, sexual injury or harm, that may or may not include mental anguish or discomfort associated with such actions. Mental anguish is defined as mental suffering which includes fright, feeling of distress, anxiety, depression, grief and/or psychosomatic physical symptoms. Discomfort is defined as something that disturbs one's comfort, an annoyance. 2a. Resident #71 was admitted on [DATE] with diagnosis that included hepatic encephalopathy, and respiratory failure with hypoxia. The significant change MDS dated [DATE] identified Resident #71 had severely impaired cognition, required partial to moderate assistance with transfers, used a wheelchair and was independent for eating, bathing, dressing, toileting and personal hygiene. The care plan dated 5/19/26 identified Resident #71 has chronic alteration in pulmonary function related to asthma. Interventions included to monitor sign/symptoms of respiratory insufficiency, anxiety, confusion, restlessness, monitor lungs sounds and vitals as needed. A nurse's note dated 5/25/26 at 10:45 AM written by RN #4 identified Resident #71was a victim involved in a resident-to-resident altercation. Resident #71 yelled help for the nurse. A staff member arrived in Resident #68 and Resident#71's room and Resident #68 was behind Resident #71. Resident #71 was yelling that Resident #68 choked him/her and told the staff she/he was going toward the bathroom when Resident #68 came up behind him/her and grabbed the hospital gown at the neck area, pulling back on it. RN #4 completed an assessment of Resident #71 who had light red marks noted on her/his neck which quickly dissipated. A Social Worker note dated 5/26/26 at 10:22 AM by the social worker identified she met with Resident #71 after a negative peer interaction (victim). Resident #71 was able to express that another resident came up behind him/her and pulled his/her hospital gown from the back. Also, identifying Resident #71 was initially frightened by the incident but was now verbalizing he/she felt safe. b. Resident #68 was admitted in April 2026 with diagnosis including Alzheimer's disease, anxiety and depression. The care plan dated 4/14/26 identified potential for social isolation related to personal preference to remain in the room and not participate. Interventions included to invite/encourage the resident to attend activities with residents in order to support participation, provide monthly activity calendar, and assist/escort resident to activities. The admission MDS dated [DATE] identified Resident #68 had severely impaired cognition, required partial moderate assistance for toileting and showering, required set-up assistance for eating, independent for transferring, supervision for dressing and personal hygiene. A nurse's note dated 5/22/26 at 7:15 AM, written by the DNS identified Resident #68 was wandering the halls and in other residents' rooms without his/her walker frequently throughout the night. Resident #68 was very restless. A nurse's note, written by RN #4 dated 5/25/26 at 10:28 AM identified Resident #68 was the aggressor in a resident-to-resident altercation. Resident #68's roommate, Resident #71, was in her/his wheelchair going towards the bathroom and Resident #68 went behind Resident #71 grabbing at the neck of the hospital gown and was pulling back on it. Resident #71 yelled for help from the nurse and told the staff member Resident #68 had choked her/him. The residents were separated and Resident #68 was placed on 1:1 and sent to the emergency room for evaluation. Interview on 6/5/26 at 10:34 AM with LPN #1 identified she was on duty when the resident-to-resident altercation transpired on 5/25/26. LPN #1 indicated Resident #68 was acting calm, sitting in his/her chair and taking all his/her medications. Resident #71 came out of the room upset, stating that Resident #68 choked him/her. Interview with NA #2 on 6/5/26 at 11:13 AM identified she did work on 5/25/26. NA #2 indicated Resident #68 had angry outburst in the past but was calm, quiet, lying in the bed the last time she saw him/her before the incident. NA #2 indicated Resident #68 had not ever been physically aggressive before this resident-to-resident altercation. Interview with the DNS on 6/5/26 at 11:51 AM identified she was not working on the day of the resident-to resident altercation. The DNS indicated Resident #68 has had no other resident-to-resident altercations since the altercation on 5/25/26. Resident #68 was sent to the emergency room and cleared of being a danger to herself or others. Interview with RN #4 on 6/8/26 at 12:59 PM identified she was working on 5/25/26 when the resident-to resident altercation occurred and the floor nurse, LPN #1, told her that Resident #71 was yelling that Resident #68 choked him/her. RN #4 indicated no one witnessed the incident but when she assessed Resident #71 he/she had red marks on his/her neck from where the hospital gown had been pulled. RN #4 indicated when she last observed Resident #68, he/she was sleeping and identified Resident #68 had no prior history of being aggressive but was a wanderer. Interview with NA #4 on 6/8/26 at 1:15 PM identified she was 2 rooms down the hall when she heard Resident #71 yelling for help. Resident #68 was behind Resident #71 who was stating that Resident #68 choked him/her. When she looked at Resident #71's neck it was red. Further, she separated Resident #71 from Resident #68 who was confused but not acting aggressive and had never acted aggressive before this incident. Review of the Abuse Prohibition dated 7/27/23 directed to prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: prevention of occurrences. Definition of abuse-the willful infliction of physical, verbal, mental, sexual injury or harm, that may or may not include mental anguish or discomfort associated with such actions. Mental anguish is defined as mental suffering which includes fright, feeling of distress, anxiety, depression, grief and/or psychosomatic physical symptoms. Discomfort is defined as something that disturbs one's comfort, an annoyance.

Based on interviews, review of the clinical record and facility policy for 1 of 3 sampled residents (Resident #7) reviewed for pressure ulcers, the facility failed to ensure a Deep Pressure Injury (DTI) wound was accurately assessed, measured, and documented, and failed to ensure a treatment order for the DTI was obtained upon readmission to the facility. The findings include:Resident #7 was re-admitted in February 2026 (original admission December 2025) with diagnoses that included injury on the right hip, pressure ulcers, and type 2 diabetes.The significant change comprehensive Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status score of 13 indicating Resident #7 was cognitively intact, was totally dependent on staff for all Activities of Daily Living (ADLS) except he/she ate with minimal assistance, was at high risk for pressure ulcer development, and had one stage 2 (partial thickness of skin loss/blister) and one unable to stage, Deep Tissue Injury (DTI).The Resident Care Plan (RCP) dated 2/14/26 identified pressure ulcers as an area of focus with interventions that included treatment to the buttocks and hip blister as ordered, follow facility policies and procedures for the prevention and treatment of skin breakdown, monitor nutritional status, wound care consultant, and pressure relieving surface air mattress settings 5/8 alternating every 15 minutes. The Nursing admission Skin assessment dated [DATE] completed by Licensed Practical Nurse (LPN) #6 identified that Resident #7 had an open blister to left outer thigh measuring 6.5 centimeters (cm) in length by 5 cm width and had redness to coccyx. The treatment to the outer blister included xeroform (petroleum impregnated gauze) and a Dry Protective Dressing (DPD) daily. LPN #6's assessment was reviewed and signed by Registered Nurse (RN) #3 as being accurate.Physician's orders dated 2/14/26 directed, in part, to cleanse the left outer thigh open blister with wound cleaner or normal saline, apply xeroform gauze and cover with a dry, protective dressing (DPD) and may be seen by the wound physician (Physician #1) for evaluation and treatment. No treatment orders were identified for Resident #7's coccyx/buttock area.Review of RN #1's (Infection Control Preventionist) wound assessment conducted with Physician #1 dated 2/17/26 identified Resident #7 had a DTI to the right buttock which was noted with maceration (skin white/gray in color from increased moisture) to the peri wound. The treatment order was changed to calcium alginate (highly absorbent seaweed fibers for wounds with drainage) to the wound bed followed by a DPD daily and as needed. Continue with the current treatment for DTI present on admission. The left hip area was identified as a stage 2 measuring 7.6 cm length by 6.2 cm width and 0.1 cm depth with mild redness. Treatment to the left thigh was calcium alginate followed by DPD daily and as needed.Interview with RN #1 on 6/3/26 at 11:10 AM identified that Resident #7 had a DTI on admission and she had spoken to RN #3 (nursing supervisor) on 2/14/26 when Resident #7 was readmitted . RN #3 had described the wound as a dark area that was bleeding, and the wound partially began at the coccyx going into the right buttock. RN #1 could not explain why RN #3 or LPN #6 did not obtain a treatment order for the coccyx/buttock area; however, she believed that xeroform was being applied to the area prior as that was the treatment in place when Resident #7's wound was assessed by RN #1 on 2/17/26. Further, RN #1 could not explain why the wound description to the coccyx/buttock on admission by LPN #6 was inaccurate and described that only redness was present. Interview with the Director of Nursing (DNS) on 6/3/26 at 11:30 AM was unable to explain why Resident #7's coccyx/buttock wound was not identified as a DTI pressure ulcer on admission or why no treatment order was obtained. The DNS indicated that it was the responsibility of the RN supervisor to ensure pressure ulcers were accurately described, even if the pressure ulcer was unable to be staged, and that treatment orders were put in place. In addition, the DNS stated it was the policy that wounds were accurately assessed/evaluated and that a treatment order was put in place on readmission and when a wound was identified by nursing.Interview with LPN #6 on 6/8/26 at 12:45 PM identified that she recalled Resident #7's coccyx was red on readmission and there was a blister to his/her hip. She indicated that she normally assessed a wound with the RN present; however, RN #3 was busy and RN #3 assessed Resident #7's wounds later. LPN #6 also indicated that she did not obtain treatment orders from the physician because that was the responsibility of the RN supervisor (RN #3).Interview with RN #3 on 6/8/26 at 3:30 PM indicated that she recalled assessing the wounds for Resident #7 on readmission and that she wrote a brief nursing note. RN #3 indicated that LPN #6 was not present when she assessed Resident #7's wounds. She indicated that Resident #7 had an open area to the coccyx/buttock and a blister to his/her left hip. RN #3 stated that she did not put measurements of the wounds in her nursing note, but she believed she had measured the coccyx/buttock area and the blister to the left hip. She indicated that she thought LPN #6 had put the buttock/coccyx wound measurements for Resident #7's wound on the admission Skin Assessment form in the electronic medical record. RN #3 identified that she was not aware there was no treatment order obtained for the buttock/coccyx area on readmission as she believed Resident #7's treatment to the coccyx/buttock area was being completed with xeroform. RN #3 indicated that an LPN could have written a physician's order for a treatment and was unable to explain why an order was not never written. Further, RN #3 stated if a resident had a DTI or open area it was the policy of the facility to measure the wound, document the measurements, and put a treatment order in place. The Wound Policy & Procedure dated 5/15/2023, directed, in part, residents are examined for the presence of wounds, ulcers or other open areas including but not limited to upon admission, and readmission to the facility. Treatment for wounds, ulcers or other open areas are to be carried out per the resident's attending physician orders. Physician's orders should be specific and include but not limited to: Type of topical solution to be used, frequency of treatment as well as any other specific instructions the physician deems necessary for treating the wound, ulcer or open area. Documentation in the resident's medical record identifies the process of healing and the reduction/elimination of cause and may include but not limited to size, extent of tissue damage, type of wound, anatomical location, type of tissue in wound base, color of wound, exudate, presence of infection, edge of the open wound and presence of foreign bodies. Documentation is completed by a RN except if resident receives consultation by Wound Physician, the RN may review and acknowledge the Wound Physician documentation.

Based on constant observation, review of the clinical record, facility policy, and interviews for 1 of 5 sampled residents (Resident #67) reviewed for nutrition, the facility failed to ensure adequate supervision of meals occurred, per the physician's order, for a resident with a diagnosis of dysphagia (difficulty swallowing). The findings include:Resident #67 had diagnoses that included hemiplegia (partial reduction of movement on 1 side) and hemiparesis (almost total to total reduction of movement on 1 side) affecting the right side following a stroke, vascular dementia, and oropharyngeal dysphagia.The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was moderately cognitively impaired and required setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, and was dependent for bed mobility and transfers. Additionally, the MDS assessment indicated Resident #67 had signs and symptoms of a possible swallowing disorder with a loss of liquids/solids from the mouth while eating or drinking and was on a mechanically altered therapeutic diet.The Resident Care Plan (RCP) dated 5/11/26 identified Resident #67 had a self-care performance deficit for activities of daily living related to right-sided hemiplegia and a right hand contracture. Interventions included assistance of 1 staff member for eating with direct supervision and Resident #67 was required to be out of bed for meals.A change of condition nursing note dated 5/11/26 at 10:03 AM identified Resident #67 had weight loss, had recently returned from the hospital, required staff assistance with eating, and recommendations were for staff assistance while eating. The Advanced Practice Registered Nurse (APRN) was updated.A physician order dated 5/11/26 directed to provide assistance of 1 staff member with direct supervision for eating.A physician order dated 5/27/26 directed to provide a regular dysphagia advanced texture diet with regular (thin) consistency liquids with additional directions to allow toasted bread.A nursing note dated 5/27/26 at 8:04 AM identified a meeting of the interdisciplinary teams had taken place to discuss Resident #67. The note indicated Resident #67 was receiving speech therapy services and his/her current order for diet required a dysphagia advanced texture with thin liquids to ensure safe consumption.Interview with Licensed Practical Nurse (LPN) #5 on 6/2/26 at 1:00 PM identified assistance of 1 staff member with direct supervision with eating indicated the staff member should stay with the resident and not leave them unattended.Interview with Nurse Aide (NA) #1 on 6/2/26 at 1:22 PM identified she utilized the resident Kardex (care card) to determine if they needed assistance or direct supervision with eating. She indicated that she could not remember if she had received education on direct supervision and what was expected for residents who required direct supervision.Interview and review of facility policy with Speech Therapist (ST) #1 on 6/3/26 at 11:05 AM identified he was the speech therapist and had worked with Resident #67 regarding his/her diet. The resident required a dysphagia advance diet texture which meant the consistency was 1 step down from a regular diet, that the resident should not receive a salad, and that all meats should be chopped or ground. ST #1 indicated that Resident #67's current order requiring the assistance of 1 staff member with direct supervision while eating remained appropriate and he had consulted with occupational therapy for this order. Resident #67 struggled with eating due to difficulty moving his/her upper extremities following a stroke, indicating Resident #67 should be supervised while eating due to problems with chewing and swallowing. ST #1 stated that the facility policy for direct supervision meant that if a resident was doing okay with no observed difficulties eating, he/she could be left unsupervised for a short period of time. ST #1 was unable to define the amount of time that a a short period of time meant, only that it was a commonsense kind of thing. ST #1 indicated that he had never been asked to define a short period of time which would indicate how long it was safe to leave Resident #67 unsupervised.A continuous observation of Resident #67 on 6/3/26 starting at 12:47 PM identified Resident #67 in bed with the head of bed elevated greater than 45 degrees, but less than 90 degrees. The privacy curtain was closed halfway, and Resident #67 was observed eating pasta unsupervised. At 12:48 PM an x-ray technician arrived to obtain x-rays for Resident #67. At 12:53 PM a staff member walked by the room and stopped at the doorway to speak to x-ray technician but did not enter the resident's room. When the x-ray technician returned, he/she closed the door. At 12:57 PM the x-ray technician exited the room and left the door open, leaving Resident #67's left hand visible holding a utensil and continuing to eat. No staff were identified to get the resident out of bed to eat, to supervisor, or to assist Resident #67, and the continuous observation concluded at 1:07 PM (20 minutes later) with Resident #67 unsupervised, still taking occasional bites using his/her left hand. Greater than 50% of the meal was observed uneaten.Interview with the Director of Nursing (DNS) on 6/4/26 at 12:50 PM identified a physician order for direct supervision meant staff were to directly supervise the resident while eating, but if the staff identified the resident was doing well with eating, not having any difficulty, they were allowed to leave the resident to eat independently unsupervised for a period of time from 5 to 10 minutes. A physician order directing the assistance of 1 staff for eating meant the resident required staff presence at all times allowing the resident to eat independently as much as possible to maintain dignity and staff would assist as needed. The DNS stated that leaving Resident #67 to eat unsupervised by staff for 20 minutes during the continuous observation on 6/3/26 was unacceptable. She further indicated that a staff member should have stayed with the resident at all times per the physician order while Resident #67's ate his/her meal. Review of the Eating Assistance and Supervision Protocol policy directed, in part, for resident meal consumption assistance of 1 staff means a resident requires physical assistance for intake of solids or liquids. For safe swallowing direct supervision means the resident requires cues related to their dysphagia needs (caregiver education required). The policy directed that directed supervision was not the same as 1 to 1 supervision and that the staff member may supervise multiple residents at the same time and could have short periods of vacancy if no difficulties were noted by the caregiver during meal consumption.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #28) reviewed for infection, the facility failed to monitor and flush a peripherally inserted central catheter (PICC) line according to professional standards for a resident with methicillin resistant staphylococcus aureus (MRSA). The findings include: Resident #28's diagnoses included MRSA infection, sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), bacteremia (bacteria in the bloodstream), and pyogenic arthritis (joint infection). A physician's order dated 4/30/26 directed normal saline 10 Milligram (MG) flush intravenously every 8 hours for maintaining patency and to assess PICC site for complications, if any document in nurses note. A physician's admission history and physical progress note dated 5/1/26 at 9:45 AM identified Resident #28 was recently hospitalized and treated for sepsis, MRSA, and septic arthritis. A PICC line was placed at the hospital for intravenous antibiotic therapy, and the resident would be receiving IV Vancomycin (antibiotic) for 6 weeks. The admission Minimum Data Set (MDS) assessment dated [DATE] identified the resident as severely cognitively impaired and noted dependent with toileting, transfers, and bed mobility. The MDS indicated Resident #28 had a multidrug resistant organism (MDRO) with septicemia, and bacteremia and indicated the resident was receiving (Intravenous Therapy) IV medications and had IV access. The MDS failed to indicate Resident #28 had central (PICC) IV access. The Resident Care Plan (RCP) dated 5/18/26 identified Resident #28 had MRSA and sepsis due to MRSA related to pyogenic arthritis. Interventions included observing standard precautions for infection control and administering antibiotics as per physician's order. The RCP failed to indicate Resident #28 was receiving antibiotics intravenously and had a PICC line in place. Review of the facility intravenous (IV) therapy log identified Resident #28 was admitted with a 40 Centimeter (CM) PICC line and would be receiving Vancomycin (antibiotic) 1000 Milligram (MG) daily. The physician's orders dated 5/16/26 directed to discontinue Normal Saline 10 Milligram (MG) flush intravenously every 8 hours for maintaining patency and to assess PICC site for complications, if any document in nurses note. Review of the medication administration record (MAR) for 5/2026 and 6/2026 for Resident #28 identified Vancomycin 750 mg/ml intravenously one time a day (at 8:30 AM) for MRSA treatment had been administered 5/17/26 through 6/2/26. The MAR failed to indicate a physician's order was in place for normal saline 10mg flush intravenously every 8 hours for maintaining patency and to assess PICC site for complications, if any document in nurses note during this time (from 5/17/26 through 6/3/26). After surveyor inquiry, a physician's order dated 6/4/26 directed Normal Saline 10mg flush intravenously every 8 hours for maintaining patency and to assess PICC site for complications, if any document in nurses note. Interview and review of the clinical record with the Infection Prevention Registered Nurse (RN #1) on 6/5/26 at 11:30 AM identified Resident #28 had received IV Vancomycin and a PICC line had remained in place from 5/3/26 through 5/17/26. Review of the physician's orders and MAR with RN #1 indicated the physician's order for a normal saline flush and monitoring of the PICC site every 8 hours had been discontinued on 5/16/26 and had not been renewed until 6/4/26. RN #1 identified RN #7 had accidentally discontinued the physician's order and then did not get it renewed after Resident #28 had completed IV hydration on 5/16/26. RN #1 further indicated she would have expected the charge nurse or RN supervisors to have noticed the normal saline flush and site monitoring order was not in place (from 5/3 through 5/17/26) because that was a standard of care for a resident with a PICC line. RN #1 stated although the PICC line for Resident #28 was discontinued on 6/5/26 it should have been flushed and the site monitored for the duration of its placement, and she was unsure why that was not done. Interview and review of the clinical record with the Director of Nursing Services (DNS) on 6/5/26 at 3:03 PM identified Resident #28 had received IV Vancomycin and the PICC line had remained in place from 5/3/26 through 5/17/26. Review of the physician's orders and MAR with the DNS indicated the physician's order for a normal saline flush and monitoring of the PICC site every 8 hours had been discontinued on 5/16/26 and it was not renewed until 6/4/26. The DNS stated it was a standard of care for a resident with a PICC line to have site monitoring and for the catheter to be flushed every shift and the order should not have been discontinued while Resident #28 still had a PICC line in place. The DNS further identified although RN #7 had made a mistake by discontinuing the order on 5/16/26 she would have expected the charge nurse or RN supervisors to have picked up on it and renewed the order before 6/4/26. Interview with the Advanced Practice Registered Nurse (APRN #1) on 6/8/26 at 11:45 AM identified she was not aware Resident #28 did not have a physician's order for the PICC line flush and site observation from 5/16/26 through 6/3/24. APRN #1 indicated if the PICC line was not flushed every shift it could have caused the catheter to clot off and if the site was not observed every shift the site could have become infected or the catheter could have been migrating or infiltrating. APRN #1 stated it was an error that the physician's order for the normal saline flush and monitoring of the PICC site was discontinued, and she would have expected the charge nurse or RN supervisors who were administering the Vancomycin daily to have noticed the order was not there. Further, APRN #1 indicated as a standard of care the physician's order should have been in place for the entirety of Resident #28's IV antibiotics and while the PICC line was still in place. Interview and review of the clinical record with the RN Supervisor (RN # 6) on 6/8/26 at 11:22 AM identified she works the 7:00 AM to 3:00 PM shift when Resident #28 received the IV Vancomycin dosage via the PICC line. RN #6 indicated she had not noticed Resident #28 was lacking a physician's order for the normal saline flush and monitoring of the PICC site, but the order should have been in place. RN #6 further identified if the site was not being flushed or monitored during the other shifts the PICC line could have lost patency, become dislodged, infected, or migrated. RN #6 indicated it would have been her or the nursing staff responsibility to notice the physician's order was not there and to obtain a new physician's order and she was unsure why that was not done. Interview with the RN Supervisor (RN #7) on 6/8/26 at 1:15 PM identified she works the 11:00 PM to 7:00 AM shift and was not aware Resident #28 did not have a physician's order for the PICC line flush and site observation from 5/16/26 through 6/3/24. RN #7 indicated she discontinued the order in error when she was auditing physician's orders because she failed to read the complete order and thought it was the normal saline IV hydration order. RN #7 identified although the normal saline flush and PICC site monitoring every shift was a standard of care and the physician's order should have remained in place, she had made a mistake, and it was her responsibility she discontinued the wrong order. Further, RN #7 indicated she would have expected the other nursing staff to notice the physician's order was not there and to obtain a new order and she was unsure why that was not done. Review of facility policy, Midline/Extended Dwell Catheter Flushing, dated 1/22, directed to maintain patency of the midline or extended dwell catheter, a prescriber order is required for vascular access device (VAD) flushing, and the order will be specific with regards to flush solution, volume and frequency. The VAD will be flushed before and after medication administration and routinely at established intervals and a thorough site and a catheter assessment should be performed at established intervals when not in use. Review of the facility policy, Midline/Extended Dwell Catheter Dressing Change, dated 1/22, directed VAD assessment should occur at a minimum of once each shift, when not in use and at prescribed intervals if complications are observed.

Based on observation, facility documentation, facility policies and interviews for review of the medication storage and reconciliation program, the facility failed to reconcile discontinued controlled substance medications upon receiving the medications from the nursing units. The findings include: An observation, interview and review o facility documentation made on 6/04/2026 at 11:59 AM with the Director of Nursing Services (DNS) of the Controlled Substance Disposition Record forms (proof of use sheets) dated from 11/15/25 through 5/20/26 (a total of 15 forms), identified the Controlled Substance Disposition Record was not signed and dated by the unit nurse when returning the medication to the DNS, nor was the Controlled Substance Disposition Record signed and dated by the DNS upon receiving the controlled medications from the nursing units. Also, the DNS identified she, herself and the nurses on the units have never signed/dated the Controlled Substance Disposition forms when the medication was turned into her. A review of facility policy notes for nurses on the unit turning in the medication for disposal should sign/date the form as should the DNS. The DNS identified she stores the medications in a locked file cabinet with the double copy of the Controlled Substance Disposition form with the medication all together in a locked closet until the Controlled Substance was disposed of without signing, dating, and counting of the medication and recording the number on the form.Review of the facility Drug Destruction (Narcotic) Policy and Procedure dated 11/1/17 directed, in part, when a narcotic prescribed for a specific resident by their attending physician, was no longer being used by that resident, either due to discontinuation or the resident being discharged from the facility without the medication, or the narcotic has reached the assigned expiration date, the narcotic is destroyed. The DNS will confirm the number of narcotics remaining against the Proof of use sheets (Controlled Substance Disposition Record) from the nursing unit and shall match up the appropriate narcotic sheets from the nursing unit with those kept by the DNS. The DNS shall confirm the date and number of narcotics received for destruction on the individual Proof of Use sheets for each narcotic destroyed along with the date of destruction, with both of their signatures.

Based on clinical record review, facility documentation, and interviews for 1 of 5 sampled residents (Resident #1) reviewed for unnecessary medications, the facility failed to ensure that the pharmacist consultant identified that blood glucose monitoring for a diabetic resident was completed for the period of March 10 through June 5, 2026. The findings include:Resident #1's diagnoses included Type 2 diabetes mellitus, peripheral vascular disease, and peripheral neuropathy.The Resident Care Plan dated 9/25/25 identified Type 2 diabetes as an endocrine status focus with an intervention to monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition, was dependent on staff for showers/bathing, upper/lower body dressing and personal hygiene. The physicians' orders dated 9/24/25 directed administration of Glimepiride (used to lower blood sugar levels) 2mg daily in the morning, glargine insulin 16 units injected under the skin daily at bedtime, Jardiance (medication used to lower blood sugar levels) 10 mg tablet daily in the morning, glucagon (used to treat severe low blood sugar) 1mg emergency kit to be administered as needed for blood glucose level below 70, insta-glucose gel 40%, give 15 grams by mouth as needed for blood sugars less than 70, and provide 15 grams of carbohydrates and 5 grams of protein if more than 1 hour until meal for hypoglycemia.A pharmacy consultant Medical Record Review (MRR) dated 3/5/26 recommended a sliding scale for insulin coverage and blood glucose monitoring to be completed twice weekly in the AM and PM, with instructions to notify the physician if blood glucose level is below 70, or greater than 400A physicians' orders dated 3/9/26 directed to obtain blood sugars twice a week on Tuesdays and Fridays and to report to the Medical Doctor (MD) if below 70 or greater than 400. A review of the clinical record, the medication administration record, and the treatment administration record for the period of 3/10/2026 through 06/05/2026 failed to reflect documentation that blood glucose levels had been completed. Interview with RN #5 on 6/8/26 at 11:04 AM indicated that she failed to properly enter the physician's order regarding blood glucose monitoring into the Electronic Health record (EHR) She identified that she mistakenly placed the order on the diagnostic flow sheet but should have entered the order on the flow sheet labeled other which has a supplementary documentation space to record the blood sugars.A review of MRR records for the time period of March 5, 2026, through June 2026 identified that the Pharmacist Consultant did not identify that blood glucose monitoring was not being done.Interview with the Pharmacist Consultant on 6/8/26 at 11:21 AM identified that she failed to identify the lack of blood glucose monitoring following her recommendation made on March 5, 2026. She further noted that the physician's order and the MAR should have been reviewed as part of her monthly review of the drug regimen to ensure that blood glucose monitoring was being completed.The Medication Review Policy and Procedure identified that resident medication records are reviewed to enhance the resident's quality of life. The pharmacist consultant conducts a monthly review of the resident's medication regimen to determine its efficacy, actual or potential adverse effects, consideration of laboratory, diagnostics, and other measures. The policy further identified that in the event of a significant finding, the pharmacist consultant is to notify staff immediately so the issue may be addressed in a timely fashion and should document who they spoke to regarding the findings.

Based on clinical record review, and interviews for 1of 5 sampled residents, (Resident #1) reviewed for unnecessary medications, the facility failed to ensure that a resident receiving psychoactive medications was monitored for target behaviors. The findings Included:Resident #1 diagnosis included depression, anxiety, and insomnia.The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had alterations in mood and sleep patterns during resident mood interview, however, did not indicate the diagnosis of depression, anxiety, or insomnia.The Resident Care Plan (RCP) in effect on 12/29/25 identified a psychosocial well-being problem related to depression, anxiety, insomnia, and adjustment disorder. The RCP failed to include interventions to monitor Resident #1's behavior.Review of the physician orders dated in effect from 12/29/26 through 6/5/26 directed Resident #1 be administered Ramelteon 8 milligrams (mg) nightly for insomnia, Lexapro 15mg daily for depression, Buspirone 10mg daily for anxiety, and Lorazepam 0.5mg as needed for anxiety. No behavior monitoring/target behaviors documented.An interview and clinical record review with Registered Nurse (RN) # 2 on 6/5/26 at 11:00 AM failed to reflect documentation of behavior monitoring. RN #2 indicated behavior monitoring should have been in place for each psychoactive medication prescribed to Resident #1.Interview with Director of Nursing Services (DNS) on 6/5/26 at 11:21 AM indicated the facility failed to implement behavior monitoring for Resident #1 and that the wing nurse or nursing supervisor was responsible to ensure behavior monitoring flow sheets were initiated. The DNS was unable to identify why Resident #1 did not have behavior monitoring sheets.Review of the Medication (Psychotropic) Policy and Procedure dated 9/12/2017 directed Attending Physician (MD) / Physician's Assistant (PA) / Advanced Practical Registered Nurse (APRN) to b) document rationale and diagnosis for use and identify target symptoms. The policy directed licensed nurses to: a) monitor psychotropic drug use daily noticing adverse effects such as increased somnolence or functional decline and b) monitor for the presence of target behaviors daily.

Based on observation(s), review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 residents (Resident #4) reviewed for obtaining of blood sugar via a glucometer, the facility failed to ensure personal protective equipment (PPE) was donned during obtaining of a blood sugar for a resident on transmission based precautions (TBP) for respiratory illness. The findings include:Resident #4 had diagnoses that included diabetes, asthma, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, required setup or clean-up assistance with eating, and was independent with bed mobility, transfers, and ambulation.The Resident Care Plan (RCP) dated 6/3/26 identified Resident #4 had a chronic alteration in pulmonary function related to asthma and allergic rhinitis and on 6/3/26 had coughing and congestion. Interventions included to monitor lung sounds as needed, obtain blood work and a chest x-ray related to cough/asthma on 6/3/26. The RCP further identified Resident #4 had diabetes. Interventions included check blood sugar per physician orders and administer diabetic medications per physician orders.A physician order dated 6/3/26 directed contact/droplet precautions related to an unknown respiratory status every shift for respiratory symptoms for 2 days until finished.Observation on 6/4/26 at 6:24 AM of Licensed Practical Nurse (LPN) #11 obtaining a blood glucose reading for Resident #4 noted LPN #11 gathered supplies and placed them on top of the medication cart. LPN #11 indicated Resident #4 was not on contact/droplet precautions. As LPN #11 approached the room, she observed the transmission-based precaution signage posted at the doorway and stated, I think that's for the roommate. LPN #11 entered the room without donning a gown, mask, or gloves. LPN #11 greeted Resident #4 and explained the procedure. LPN #11 placed the glucometer on a tissue on the bedspread, performed hand hygiene with alcohol-based hand rub (ABHR), donned a pair of gloves, and cleansed Resident #4's finger with an alcohol wipe. LPN #11 obtained a blood sample using a lancet and completed blood glucose testing. The result was 198 mg/dL. LPN #11 disposed of the lancet and test strip in a sharps container and placed the glucometer on top of the medication cart on a tissue. LPN #11 removed gloves, performed hand hygiene with ABHR, and obtained disinfecting wipes. LPN #11 donned gloves and disinfected the glucometer using two wipes on all sides, then placed the glucometer on the second wipe to dry air.Interview and clinical record review with LPN #11 on 6/4/26 at 6:32 AM identified she was not aware of the physician order for contact/droplet precautions for Resident #4. LPN #11 indicated she had not been informed during shift-to-shift report that Resident #4 was on transmission-based precautions for respiratory symptoms. LPN #11 further indicated she believed the signage applied to the roommate, Resident #67, who had been transported to the hospital earlier in the shift. LPN #11 stated she would have verified which resident the signage applied to prior to entering the room if both residents had been present.Interview with Registered Nurse (RN) #7 on 6/4/26 at 6:58 AM identified she was aware Resident #4 was on transmission-based precautions. RN #7 indicated she was not aware LPN #11 had not been informed during shift report. RN #7 identified when Emergency Medical Technicians (EMTs) arrived to transport Resident #67 to the hospital, she informed them that the transmission-based precaution signage applied to Resident #4 and not Resident #67 and LPN #11 was present. RN #7 further identified LPN #11 should have donned a gown and mask when entering the room and performing blood glucose testing on Resident #4.Review of the facility Transmission-Based Precautions Policy & Procedure directed, in part, they are used for residents known or suspected of being infected or colonized with an infectious agent and they are in place as long as necessary to prevent infection transmission. The policy directed there are 2 categories, contact precautions and droplet precautions, and the TBP signage is posted outside of the room with the type of precaution and the required PPE items to wear inside the room. The policy further directed for contact precautions a gown and gloves should be worn, and for droplet precautions a mask should be worn.

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pain management, the facility failed to manage Resident #1's pain in accordance with facility policy and the resident's care plan. Specifically, licensed nurses failed to reassess pain within one (1) hour after administration of as-needed pain medication on multiple occasions; failed to recognize observable signs of significant pain during post-fall transfers as a change in condition requiring provider notification; and failed to administer pain medication in a timely manner following a fall that resulted in a major injury. Resident #1 subsequently sustained an acute intertrochanteric fracture of the right proximal femur requiring surgical repair.Resident #1's diagnoses included dementia without behavioral disturbances, chronic pain syndrome, aphasia, and generalized muscle weakness. The RCP dated 3/13/26 identified Resident #1 had chronic pain related to chronic pain syndrome and on 4/20/26 had pain and spasms to the right calf. Interventions included administering analgesia per orders, anticipating the resident's need for pain relief, responding immediately to any complaints of pain, and evaluating the effectiveness of pain interventions. The RCP further identified Resident #1 had a communication deficit related to aphasia, requiring the use of alternative communication tools and allowing adequate time to respond. Physician's orders dated 8/30/25 directed acetaminophen 650 mg by mouth every four (4) hours as needed for pain and oxycodone-acetaminophen 5-325 mg by mouth every four (4) hours as needed for pain. The Pain Management policy dated 1/8/25 directed, in part, that residents receiving pain medication on an as-needed basis are to have their pain level assessed before administration and approximately one (1) hour after receiving the medication, and that if pain medication is deemed ineffective and other care-planned interventions are ineffective, the attending physician is to be notified.Failure to Reassess Pain Within One Hour of As-Needed Medication Administration: A Medication Administration Note dated 4/20/26 at 3:16 AM identified oxycodone-acetaminophen was administered for pain; however, the follow-up pain assessment was not documented until 5:33 AM - two (2) hours and fifteen (15) minutes later - exceeding the one (1) hour reassessment requirement established by facility policy. A Medication Administration Note dated 4/21/26 at 8:16 PM identified oxycodone-acetaminophen was again administered for pain; the follow-up pain assessment was not documented until 11:10 PM - two (2) hours and fifty-four (54) minutes later - after Resident #1 had already sustained a fall. That follow-up identified the medication was ineffective, with a pain level of eight (8) out of ten (10). Review of the clinical record dated 4/21/26 further failed to identify that methocarbamol 1000 mg, administered at 10:23 PM, was reassessed within one (1) hour of administration as required by policy. Interview with RN #3 on 5/20/26 at 10:30 AM confirmed she administered oxycodone-acetaminophen at approximately 8:00 PM for right leg pain and did not reassess Resident #1's pain within one (1) hour, acknowledging she should have done so and, if the medication was ineffective, should have administered acetaminophen and notified the supervisor. Interview with the DON on 5/19/26 at 2:51 PM confirmed that when pain relief medications are administered, licensed nurses should reassess the resident's pain level within one (1) hour, and if ineffective, administer an additional pain relief medication and notify the supervisor and provider.Failure to Recognize Observable Pain During Post-Fall Transfers as a Change in Condition: The Change/Event note by RN #1 dated 4/21/26 at 10:39 PM identified Resident #1 complained of pain to the right knee and leg following the fall at 10:15 PM. Interview with RN #1 on 5/19/26 at 12:37 PM and interview with RN #3 on 5/20/26 at 10:30 AM both confirmed that Resident #1 displayed facial grimacing, clenched his/her teeth, and complained of severe pain throughout transfers that required four (4) staff members. Despite these observable signs of significant pain, neither licensed nurse identified them as a change in condition requiring provider notification or a halt to the transfer. Interview with APRN #1 on 5/19/26 at 1:52 PM confirmed that the increased pain with movement and the shortening of Resident #1's right leg should have been identified and reported to a provider at the time it was identified, and that licensed nurses should reevaluate the effectiveness of pain medication per policy and notify the provider of unrelieved pain. The DON confirmed on 5/19/26 at 2:51 PM that staff should have stopped the transfer, lowered Resident #1 to the floor, and notified the on-call provider for direction.Failure to Provide Timely Pain Medication Following a Fall with Identified Pain: The Change/Event note by RN #1 dated 4/21/26 at 10:39 PM identified Resident #1 complained of pain to the right knee and leg following the fall at 10:15 PM. Review of the clinical record failed to identify that pain medication was administered until 11:12 PM - approximately fifty-seven (57) minutes after the fall and the identification of pain. Interview with RN #1 on 5/19/26 at 12:37 PM confirmed Resident #1 should have been medicated for pain immediately following the fall. The DON confirmed on 5/19/26 at 2:51 PM that Resident #1 should have been medicated with pain relief medication immediately following the fall with identified pain.On 4/22/26, Resident #1 was transferred to the Emergency Department following continued complaints of right hip and leg pain and an observed shortening of the right leg by approximately 1.5 to 2 inches compared to the left leg. Hospital documentation confirmed an acute, impacted intertrochanteric fracture of the right proximal femur. An Open Reduction and Internal Fixation was completed on 4/27/26.Review of the Pain Management policy dated 1/8/25 directed, in part, all residents will be evaluated as part of the nursing assessment process for the presence of pain with change in condition or a new onset of pain. Assess the resident for recurring, chronic or uncontrolled pain. Unrelieved pain has negative physical and psychological consequences including the potential for threatening functional ability. Whenever a resident's pain medication is deemed to be ineffective for controlling the resident's pain and other care planned interventions are ineffective, the resident's attending physician is to be notified. The licensed nurse may administer medications or other non-pharmacological interventions as indicated and initiate a pain assessment for a new onset of pain or pain that is not relieved with treatment and notify the attending physician. Residents receiving pain medication on an as needed basis are to have their pain level assessed before giving the medication and about one (1) hour after receiving pain medication indicating the relief received by utilizing the pain scale zero (0) to ten (10) or cognitively impaired scale. This information is to be documented in the Electronic Medication Administration Record (EMAR). The licensed nurse is to update the attending physician for resident's identified with unmanageable pain management. Chronic uncontrolled pain may be referred to additional resources upon attending physician order. All staff are to report any observations or communications of pain to the assigned nurse as soon as practical.

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure adequate supervision and assistance during transfers. Specifically, staff failed to recognize and respond to signs of increasing transfer instability in the weeks prior to a fall; failed to recognize that Resident #1 was unable to bear weight at the initiation of a transfer and continued the transfer without seeking assistance; left Resident #1 unattended on the floor following a fall with a head strike; and transferred Resident #1 off the floor despite observable signs of significant pain. Resident #1 subsequently sustained an acute intertrochanteric fracture of the right proximal femur requiring surgical repair.Resident #1's diagnoses included dementia without behavioral disturbances, chronic pain syndrome, aphasia, generalized muscle weakness, right-sided hemiplegia, right-hand contracture, and atrial fibrillation managed with anticoagulant therapy (apixaban). The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 required substantial assistance for transfers, reported frequent pain, and had a history of falls within the facility. The Resident Care Plan (RCP) dated 3/13/26 identified Resident #1 as a moderate fall risk related to gait and balance problems, right-sided hemiparesis, and a history of falls, and noted that on 1/29/26, Resident #1 had increased difficulty with transfers secondary to increased lower extremity weakness. Interventions included providing an assist of one (1) for transfers and monitoring for fatigue. A physician's order dated 3/23/26 directed a one (1) person assist stand pivot transfer with a grab bar for toileting.Failure to Report and Respond to Increasing Transfer Instability: Interview with NA #1 on 5/19/26 at 12:15 PM identified that for at least two (2) weeks prior to the 4/21/26 fall, Resident #1 was increasingly difficult to transfer during evening and night hours and required an assist of two (2) due to increased weakness, and that she never reported this change to a licensed nurse. Interview with RN #3 on 5/20/26 at 10:30 AM identified she observed Resident #1 had increased intermittent fatigue at least two (2) days prior to the fall. Despite these observable changes, no licensed nurse was notified and no update to the plan of care or transfer approach was made. Interview with the DON on 5/19/26 at 2:51 PM confirmed that if NA #1 observed Resident #1 had been increasingly weak and difficult to transfer in the weeks leading up to the fall, she should have notified the charge nurse of the change in condition. Interview with the Rehab Director on 5/19/26 at 2:11 PM confirmed that if Resident #1 was having pain, spasms, or increased weakness, NA #1 should have requested a second person to assist with the transfer.Failure to Recognize Inability to Bear Weight and Abort the Transfer: Interview with NA #1 on 5/19/26 at 12:15 PM identified that on 4/21/26, as soon as Resident #1 attempted to stand during a transfer to the toilet, she could tell Resident #1 was increasingly weak and had to support most of Resident #1's weight and help pull Resident #1 up. NA #1 acknowledged she should have sat Resident #1 back down and requested assistance. Instead, she continued to assist Resident #1 to a fully upright position, at which point Resident #1's right knee gave out, NA #1 was unable to hold Resident #1, and Resident #1 fell forward, striking the right side of his/her face on the wall next to the toilet before falling to the floor.Failure to Maintain Supervision Following a Fall with Head Strike: Interview with NA #1 on 5/19/26 at 12:15 PM identified that following the fall, Resident #1 was grimacing and moaning in pain. Rather than engaging the bathroom call bell and calling for assistance, NA #1 removed the gait belt from Resident #1's waist, placed it on the wheelchair, and left Resident #1 unattended on the bathroom floor to seek assistance at the nurse's station. NA #1 acknowledged she should have left the gait belt on Resident #1, engaged the bathroom call bell, and yelled for assistance immediately. The DON confirmed on 5/19/26 at 2:51 PM that following a fall, NA staff are not to leave residents unattended and that NA #1 should have engaged the bathroom call bell and yelled for assistance rather than leaving Resident #1 alone on the floor following a head strike.Failure to Cease Transfer in the Presence of Observable Significant Pain: The Change/Event note by RN #1 dated 4/21/26 at 10:39 PM identified Resident #1 complained of pain to the right knee and leg following the fall. Interview with RN #1 on 5/19/26 at 12:37 PM identified it took four (4) staff to stand Resident #1 and transfer Resident #1 first to the wheelchair and then to the bed, and that Resident #1 displayed facial grimacing throughout both transfers and complained of severe pain. Interview with RN #3 on 5/20/26 at 10:30 AM confirmed Resident #1 was clenching his/her jaw, displayed facial grimacing, and complained of pain during the transfers, and stated staff should have found a way to reposition Resident #1 to utilize the mechanical lift or notified the APRN to report the increase in pain and difficulty transferring Resident #1. Interview with APRN #1 on 5/19/26 at 1:52 PM confirmed that if four (4) staff were needed to transfer Resident #1 and he/she complained of pain upon standing and bearing weight, staff should have stopped and found a way to use the mechanical lift or notified the provider immediately for further direction. The DON confirmed on 5/19/26 at 2:51 PM that if four (4) staff were needed to transfer Resident #1 from the floor, staff should have stopped, lowered Resident #1 back to the floor, and notified the on-call provider for additional direction.On 4/22/26, Resident #1 was transferred to the Emergency Department following continued complaints of right hip and leg pain and an observed shortening of the right leg by approximately 1.5 to 2 inches compared to the left leg. Hospital documentation confirmed an acute, impacted intertrochanteric fracture of the right proximal femur. An Open Reduction and Internal Fixation was completed on 4/27/26.Review of the Change in Condition policy dated 8/1/22 directed, in part, the facility is to notify the resident and/or healthcare decision maker and the attending physician of changes in the resident's medical condition. Changes in condition shall be properly documented in the resident's medical record in accordance with policies, procedures and protocols of the facility and the resident's treatment and plan of care is updated timely. The RN supervisor is responsible for monitoring and ensuring appropriate policies, procedures, protocols and standards of care are put into practice for all residents with potential for and/or actual changes in condition. The RN supervisor contacts the attending physician or covering physician timely regarding the change in condition and provides assessment. Update the resident's plan of care and treatments as ordered by the attending physician and monitor for effects of treatment plan. The licensed nurse conducts rounds on all residents throughout the shift and interacts primarily with NAs for resident's current status as a standard of practice. Rounds include observing residents and communicating with the NAs as appropriate. NAs identify changes in the resident's status and reports to the licensed nurse a change in ADL status, altered mental status or other medical conditions not consistent with the resident's normal plan of care. NA staff are responsible for knowing the appropriate care to give and what to report on their resident as noted on the NA assignments, care card and communicated during shift report.Review of the Pain Management policy dated 1/8/25 directed, in part, all residents will be evaluated as part of the nursing assessment process for the presence of pain with change in condition or a new onset of pain. Assess the resident for recurring, chronic or uncontrolled pain. Unrelieved pain has negative physical and psychological consequences including the potential for threatening functional ability. Whenever a resident's pain medication is deemed to be ineffective for controlling the resident's pain and other care planned interventions are ineffective, the resident's attending physician is to be notified. The licensed nurse may administer medications or other non-pharmacological interventions as indicated and initiate a pain assessment for a new onset of pain or pain that is not relieved with treatment and notify the attending physician. Residents receiving pain medication on an as needed basis are to have their pain level assessed before giving the medication and about one (1) hour after receiving pain medication indicating the relief received by utilizing the pain scale zero (0) to ten (10) or cognitively impaired scale. This information is to be documented in the Electronic Medication Administration Record (EMAR). The licensed nurse is to update the attending physician for resident's identified with unmanageable pain management. Chronic uncontrolled pain may be referred to additional resources upon attending physician order. All staff are to report any observations or communications of pain to the assigned nurse as soon as practical.

Based on clinical record, facility documentation, and facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure resident was transferred safely to prevent an injury. The findings include: Resident #1's diagnoses included dementia and osteoporosis. Physician order dated 9/8/2025 directed assist of two (2) with mechanical lift for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment and was dependent for transfers. The Resident Care Plan (RCP) dated 9/29/2025 identified Resident #1 had and alteration in mobility. Interventions directed transfer with assistance of two (2) with mechanical lift. Review of the Nurse Aide (NA) care card dated 10/3/2025 directed transfers with assist of two (2) with mechanical lift. Review of facility Reportable Event dated 10/4/2025 at 4:05 PM identified Resident #1 was being transferred from the bed to wheelchair via mechanical lift by two (2) NAs when the left top strap came off the loop, causing Resident #1 to partially slip from the mechanical lift pad and strike his/her head and shoulder on the ground. Resident #1 sustained a 5 centimeter (cm) by 4 cm hematoma (accumulation of blood) to the back right side (parietal region) of his/her head. New orders were obtained that directed transfer to the hospital for evaluation. The NA care card was updated to use green middle loops all the way around sling when transferring with mechanical lift. Review of facility Summary Report dated 10/7/2025 identified initial hospital report indicated a L3 (lumbar vertebrae number #3) acute (new) fracture, re-review by radiology requested for clarification, results indicated no acute fracture of L3, however there was an L2 acute fracture. The Summary further identified orthopedic follow was recommended but was declined by responsible party. Interview and record review with NA #2 on 10/22/2025 at 12:06 PM identified on 10/4/2025 when transferring Resident #1, she secured the lower mechanical lift pad/sling straps while NA #1 secured the upper pad/sling straps to the mechanical lift. NA #2 stated she was standing behind Resident #1's wheelchair, while NA #1 operated the lift. Resident #1 was lifted off the bed and while NA #1 was moving the lift and Resident #1 over the floor toward the wheelchair, the upper left strap jumped/jerked and came off the mechanical lift hook. Resident #1 slipped out of pad/sling and landed on his/her shoulder and head. NA #2 stated Resident #1 was cooperative and did not move during the transfer. NA #2 further stated she did not check the straps NA #1 had attached, and wondered if NA #1 had secured the straps fully down on the hook. Interview and record review with NA #1 on 10/22/2025 at 12:39 PM identified she and NA #2 transferred Resident #1 out of bed on 10/4/2025. NA #2 applied the lower straps of the pad/sling to the mechanical lift, while she applied the upper straps using the middle loop. Resident #1 was lifted off the bed, and next thing she knew resident fell down and landed on head and shoulder. NA #1 further stated that prior to moving Resident #1 off the bed, she did not pull on the straps or check that straps were all the way in the lift hook, and she should have made sure the pad/sling was tight and connected to the lift correctly prior to moving Resident #1 off the bed. Interview, clinical record and facility documentation review on 10/22/2025 at 1:51 PM with the DNS identified Resident #1 was being transferred by NA #1 and NA #2 from his/her bed to wheelchair via mechanical lift on 10/4/2025. During the transfer one (1) of the upper straps came off the mechanical lift hook and Resident #1 fell out of the sling and hit his/her right parietal (side) region of his/her head. Although interview identified Resident #1 was transferred with two (2) staff, interview failed to identify why NA #1 did not verify the sling straps were properly in place prior to moving the resident. Review of the undated facility Transfer Policy & Procedure directed in part, residents will be transferred safely. Mechanical-Hoyer lift: special care and attention needs to be used when transferring any resident using a Hoyer Lift as injuries and even death may result from improper techniques or use of the lift. Lift resident slowly, maintaining control of both the sling and the lift. Review of facility documentation identified staff education was initiated on 10/4/2025 for the NAs involved. Additional education was initiated on 10/7/2025 for all nursing staff regarding mechanical (Hoyer) lift safety and to confirm all straps are securely attached to the swivel bar before lifting. Audits were initiated on 10/5/2025, and a QAPI meeting was held on 10/7/2025. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure resident was free from mistreatment. The findings include: Resident #2's diagnoses included dementia with behavior disturbances, anxiety and depression. The quarterly Minimum Data Set (MDS) dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of five out of fifteen, indicative of severe cognitive impairment and was dependent for ADLs. The Resident Care Plan (RCP) dated 10/10/2024 identified Resident #1 had a self-care performance deficit. Interventions directed two (2) staff for ADLs. Review of facility reportable event dated 11/16/2024 at 4:49 PM identified Resident #2 was alert and confused. Two NAs were providing care when NA #2 was scratched by Resident #2. The other NA reported NA #2 then grabbed Resident #2's arm and hit him/her on the chest with an open hand. When interviewed, Resident #2 stated the NA hit him/her. Review of the facility summary dated 11/19/2024 identified Resident #2 became combative while care was being provided by NA #2 and #5 on 11/16/2024 and began scratching and slapped NA #2 on the arm. NA #5 reported that NA #2 grabbed the resident's arm and hit the resident on his chest with an open palm. NA #2 was alleged to have told Resident #2 no, you don't hit. The summary indicated NA #2 denied the allegation described by NA #5. A resident skin assessment was completed, and the resident was observed with self-inflicted scratches to the chest and no additional evidence of injury to the area. Additionally, a pain assessment was conducted without findings and no negative effects were noted. The summary further indicated the facility substantiated the event and NA #2's employment was terminated. Review of NA #2's written statement dated 11/16/2024 identified when NA #2 provided care, Resident #2 scratched NA #2. NA #2 told the resident to stop doing that and it's not nice to do that to the NAs. held his/her hand while asking the other NA to help to be able to provide care. Review of NA #5's written statement dated 11/16/2024 identified while she and NA #2 were providing care, Resident #2 scratched and slapped NA #2's arm. After NA #2 was scratched, she quickly glanced at her arm and then proceeded to slap the resident on the chest very hard. NA #2 told Resident #2, no, you don't hit and NA #5 reported the incident to the supervisor. Review of local police Summary Report dated 11/16/2024 at 7:56 PM identified that when police spoke to resident, he/she remembered NA #2 hitting him/her. Interview and review of facility documentation on 11/26/2024 at 8:46 AM with NA #2 identified that Resident #2 was on her assignment on her 11/16/2024 shift. Resident #2 required two (2) staff for care and NA #5 was assisting her to provide care when the Resident #1 scratched her and she said, not nice to do that to the NA giving you care and NA #2 put the resident's hand down. NA #2 stated she removed Resident #2's shirt and Resident #2 scratched his/her chest, and then scratched her again. She told Resident #2, no don't do that and told him/her to put his/her hand down and don't scratch. NA #2 stated they completed care (trimmed nails, shaved and transferred Resident #2 into bed. NA #2 denied that she hit Resident #1 at any time during care. She further indicated that when the resident was resistive to care, he/she will calm down and relax when staff talk to him/her and explain what they are doing. Interview, clinical record review and review of facility documentation on 11/26/2024 at 10:50 AM with DNS identified that on 11/16/2024 NA #5 reported that while she and NA #2 were providing care to Resident #2, the resident became combative and scratched NA #2. NA #5 alleged that NA #2 told the resident, no don't hit and NA #2 hit the resident with an open hand on the chest. The DNS stated when attempt to redirect Resident #2 when he/she becomes combative because that works to calm him/her down; Resident #2 responds well to redirection and has a history of pinching and scratching staff. When Resident #2 was interviewed by staff and interviewed by the local police, Resident #2 indicated NA #2 had hit him/her. The facility substantiated abuse and NA #2's employment was terminated (NA #2 had already given her notice two (2) weeks prior 11/16/2024 was her last scheduled workday). Although several attempts were made, NA #5 was unable to be interviewed during the survey. Review of Conduct and Behavior policy directed in part, to adhere to professional practices in matter of conduct and behavior and exhibit high degrees of personal integrity at all times. Employees are required and expected to maintain professional conduct and attitudes as well as treating residents, their families and visitors and fell ow coworkers courteously. Review of Abuse Prohibition policy directed in part, to prohibit abuse for all residents. Abuse was defined as the willful infliction of physical, verbal, mental, sexual injury or harm, that may or may not include mental anguish or discomfort associated with such actions. Facility documentation review identified staff education was initiated on 11/14/2024 regarding resident abuse and the facility policy regarding abuse. A QAPI meeting was held on 11/18/2024, and audits were initiated on 11/22/2024. Based on review of facility documentation, past non-compliance was identified.

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 staff reported an allegation of abuse timely. The findings include: Resident #1's diagnoses included dementia, anxiety and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment, required assistance with toilet use, ADLs, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 9/27/2024 identified Resident #1 had impaired cognitive function/impaired though processes related to diagnosis of dementia and functional bladder incontinence. Interventions directed to provide incontinent care. The facility reportable event dated 11/11/2024 at 8:15 PM identified Resident #1 alleged a male NA (NA #1) touched him/her inappropriately during the night and gave a description of the NA. Resident #1 was unable to give a time of the incident, and stated the male NA did not work on 11/11 or the night prior. Assessment identified no injuries were noted, and the accused NA was suspended pending investigation. Review of RN #10 statement dated 11/11/2024 identified RN #10 was approached by NA #4 with NA #3 in tow about 8:20 PM. NA #4 reported NA #3 told her that last week Resident #1 alleged a male staff member touched him/her inappropriately. NA #4 stated she was reporting it immediately after the conversation with NA #3 because she told NA #3 she should have reported it when she was initially informed of the alleged abuse. NA #3 confirmed that she was told about the alleged abuse last week but she thought the resident was not in her right mind. Interview and record review with NA #3 on 11/25/2024 at 11:34 AM identified that Resident #1 reported the allegation of abuse to her (NA #3) on 11/8/2024, however she did not report the allegation to the facility when it was reported to her. Interview with NA #4 on 11/25/2024 at 11:45 AM identified when NA #3 told her about the allegation made by Resident #1, and she encouraged NA #3 to report the allegation. Interview with the DNS on 11/25/2024 at 1:47 PM identified Resident #1 made an allegation of abuse to NA #3 on 11/8/2024 and NA #3 did not report the allegation until 11/11/2024. The DNS stated NA #3 should have reported the allegation when Resident #1 made the allegation to her on 11/8/2024 and an investigation was initiated upon notification on 11/11/2024. Facility documentation review identified NA #3 completed the facility NA training and abuse training during 9/2024, and had not taken the NA state exams. Further review identified a employee warning was given and signed by NA #3 on 11/14/2024 for NA #3 due to she failed to report a potential allegation of abuse in a timely manner. Review of facility Personnel Policies - Resident Abuse directed in part, employees must immediately report any incident or suspected incident of resident neglect, abuse. Review of facility Abuse Prohibition Policy directed in part, anyone who receives a report of an allegation of abuse is to report the incident to his/her supervisor immediately. Review of facility Reportable Event policy in part directs regardless of how minor an actual or suspected accident, incident, abuse or neglect situation may be, it must be reported to the department supervisor immediately/at the time of occurrence. Facility documentation review identified staff education was initiated on 11/14/2024 regarding resident abuse and the facility policy regarding abuse, to include reporting of allegations timely. A QAPI meeting was held on 11/18/2024, and audits were initiated on 11/22/2024. Based on review of facility documentation, past non-compliance was identified.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure foods were dated when opened and staff personal food/fluids were not stored in the facility walk-in refrigerator. The findings include: On 11/4/24 at 10:40 AM, a tour of the Dietary Department with the Food Service Director (FSD) identified the following: A. In the dry storage area, opened and undated: one box of oatmeal cookies, one box of Oreo cookies, and a 5-gallon bucket of chicken base. B. In the main freezer- opened and undated: one bag of fried steak and one bag of Salisbury steak, two uncooked pie shells, 5 cooked apple pies, and 6 boxes of frozen cookies. C. In the walk-in refrigerator: opened and undated one 5-gallon bucket of pickles and a staff's lunch bag was noted to be stored on a shelf with facility supplied resident food items. Interview with the FSD on 11/4/24 at 10:40 AM indicated that he or the chef were responsible for dating items when the packaging was opened. He was unable to explain why the identified items were opened and undated. The FSD was unable to explain the reason Dietary Aide #1 had stored her lunch bag with resident food, the facility policy prohibited staff storing items in the walk in refrigerator, and subsequent to surveyor inquiry, he stated he would have the lunch bag removed. Interview with Dietary Aide #1 on 11/7/24 at 10:50 AM identified she was working on 11/4/24 and had stored her lunch bag in the main walk-in refrigerator of the facility's kitchen. Dietary Aide #1 indicated that she normally did not bring a lunch bag, but she brought extra drinks to work and put everything in there on that day. Dietary Aide #1 further identified that she was aware that facility policy prohibited the storage of personal food in the main walk in refrigerator and should not have put her lunch bag there. Review of the facility food storage policy directed that dry storage foods would be dated as appropriate and cold foods would be labeled and dated.

Based on interviews and record reviews for 2 of 2 residents, (Resident #40 and Resident #46) reviewed for advance directives, for Resident #40, the facility failed to transcribe advance directives according to the signed resident's wishes and for Resident #46, the facility failed to ensure the advance directive consent had been signed and available in the medical record. The findings include: 1. Resident #40's diagnoses included chronic obstructive pulmonary disease, type 2 diabetes mellitus and hypertension. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #40 was severely cognitively impaired, and was independent for eating, toileting, and transfers. The Resident Care Plan dated [DATE] identified Resident #40 had a status of DNR and a Registered Nurse (RN) may pronounce death. Interventions included not to resuscitate. The physician's orders dated [DATE] directed that Resident #40's advance directive was for a full code indicating cardiopulmonary resuscitation (CPR) was to be performed. The Do Not Resuscitate (DNR) consent form dated [DATE], signed by Resident #40, indicated not to resuscitate Resident #40. Interview with Registered Nurse (RN) #7 on [DATE] at 6:30 AM identified facility policy for signed advance directives was to ensure the document was in the chart as well as in the electronic health record (EHR). RN #7 was unable to locate Resident #40's signed advance directives form in the EHR or paper chart and could not identify who was responsible to ensure the document was available. Furthermore, RN #7 stated that in the event of an emergency which would require advance directive information, (resuscitation status), she would follow the physician's order in the EHR whick directed that Resident #40 was to receive CPR. Interview and record review with the Director of Nursing (DNS) on [DATE] at 6:43 AM identified the facility policy stated the advance directive form be signed by the resident or responsible party, the physician's order match the signed advance directive, and the information be accurately reflected in the EHR. During a review of the clinical record with the DNS the signed advance directive dated [DATE] reflected a DNR status while the EHR physician order dated [DATE] directed a full code (CPR). The DNS indicated that in the event of an emergency the nurse would follow physician's orders directing Resident #40 receive CPR. Subsequent to survey inquiry, the DNS indicated she would investigate the inconsistency. Re-interview with the DNS on [DATE] at 8:21 AM, identified the nurse who had entered the readmission orders on [DATE] had mistakenly transcribed that Resident #40 was a full code from the hospital discharge paperwork, however, the DNR signed in 2015 should have been honored. The DNS indicated it was the facility policy to fill out a new advanced directive consent form upon admission or readmission. Further, the DNS indicated that Resident #40's responsible party identified Resident #40 should have never been listed as a full code, he/she had always been a DNR, and the responsible party was on the way in to sign a new DNR consent to ensure Resident #40 remained a DNR. 2. Resident #46 was admitted to the facility in [DATE] with diagnoses that included vascular dementia with unspecified psychotic disturbances and other behavioral disturbances, anxiety disorder, and unspecified mental disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was severely cognitively impaired, was able to eat independently after set up for meals, and required assistance of 1 for transfers. The Resident Care Plan dated [DATE] identified Resident #46 was a Do Not Resuscitate (DNR) and Registered Nurse Pronouncement of Death (RNP). Interventions included that the resident or appointed family member would sign the appropriate paperwork and would be filed in the chart. Additional interventions included to obtain a copy of a living will, conservator appointment, advance directives, healthcare agent appointment, and/or power of attorney. The physician's order currently in effect and originally dated [DATE] directed Do Not Resuscitate (DNR) and Registered Nurse Pronouncement of Death (RNP). A review of the clinical record on [DATE] at 12:30 PM with RN #1 identified a signed Advanced Directive consent form was unable to be located in Resident 46's chart. Review of a new physician's order dated [DATE] identified Do Not Hospitalize (DNH), Do Not Intubate (DNI) and Do Not Transfer (DNT). Re-interview with RN #1 on [DATE] at 11:45 AM indicated that the nurses would check physician's orders in the electronic record for code status for cardiopulmonary resuscitation (CPR) or for DNR, then double check for verification by looking at the Advance Directive consent form in the clinical chart which was still unable to be located. Interview with the DNS on [DATE] at 11:50 AM identified that Resident #46's Healthcare Agent had come into the facility on the evening of [DATE] and signed a new advance directive indicating that Resident #46's status was to be a DNR, DNI, DNT, and DNH. The DNS indicated she was not sure if there had been a signed advance directive prior to surveyor inquiry. A review of the Advance Directive policy dated [DATE] directed, in part, that on admission the facility would provide the resident or responsible party with information to make advance directive decisions, the nurse would complete the form and ensure that the Advance directive was placed in the medical record, and that the facility would honor the advance directive wishes of residents, which included not performing CPR on residents who had a valid DNR. 51756

Based on staff interview, observations, review of the clinical record, and facility policy for 1 of 8 residents (Resident #13) reviewed for accidents, the facility failed to implement fall prevention interventions as per the Resident Care Plan (RCP). The findings include: Resident #13's diagnoses included dementia, lack of coordination, and abnormality of gait and mobility. The RCP dated 9/3/19 through 11/7/24 identified Resident #13 had a history of falls with no serious injury (fell on [DATE], 7/11/22, 11/2/22, 5/22/23, 10/25/23, 11/13/23, and 9/24/24). Interventions implemented to prevent future falls included the placement of a floor mat to the door side of the bed at nighttime, wearing proper footwear, placement of skid strips in front of the dresser and next to his/her bed on the door side of the bed. An Advanced Practice Registered Nurse (APRN) progress note dated 11/13/23 directed skid strips in front of the dresser. The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #13 had moderately impaired cognition, was independent in achieving a sit to stand position from a bed or his/her wheelchair and required moderate assistance in walking 10 feet. Additionally, the MDS identified Resident #13 had no falls within the previous month. A Fall Risk assessment dated [DATE] identified Resident #13 was at a moderate risk for falls. Observation on 11/6/24 at 12:01 PM failed to identify skid strips were applied to the floor in front of the dresser as per APRN orders. Additionally, skid strips were present on the door side of the bed, but there were no floor mats next to the bed or located anywhere in the room. An interview with Nurse Aide (NA) #1 on 11/7/24 at 9:18 AM identified that fall prevention interventions for NA's to follow were listed on the electronic Kardex. Review of the Kardex with NA #1 identified that floor pads and skid strips were not included on the Kardex. NA #1 noted that Resident #13 was not a fall risk because he/she did not have anything listed on the Kardex identifying Resident #13's fall risk. NA #1 further indicated for residents with floor pads listed on the Kardex, the NAs would be responsible for placing the floor mats next to the bed at night and removing them in the morning. NA #1 noted for all residents who use a floor mat for fall prevention, the floor mats were stored behind the resident's bed or next to their closet and never removed from their room. An observation of Resident #13's room with NA #1 during the interview failed to locate floor mats for Resident #13 within his/her room and NA #1 stated she had never placed or removed floor mats from Resident #13's floor as she was not aware of the need for floor mats. Further, NA #1 also failed to identify the placement of skid strips in front of Resident #13's dresser. An interview with Licensed Practical Nurse (LPN) #1 on 11/7/24 at 9:30 AM identified that the Nurse Supervisor was responsible for transcribing information from a RCP to the Kardex. During a review of Resident #13's RCP with LPN #1, it was noted Resident #13 should have floor mats, skid strips, and proper footwear as part of his/her fall mitigation interventions. An observation of Resident #13's room with LPN #1 during the interview failed to locate floor mats or the placement of skid strips in Resident #13's room per the RCP. Subsequent to surveyor inquiry, LPN #1 notified the Nursing Supervisor of the intervention of floor pads and skid strips for Resident #13. An observation of Resident #13's room on 11/7/24 at 9:35 AM with RN #1 identified that neither floor pads nor skid strips in front of the dresser were in the room. RN #1 failed to identify the reason neither the floor pads nor skid strips were being used for Resident #13. Post-surveyor inquiry, the Kardex Report dated 11/7/24 was updated for Resident #13 to include placement of skid strips in front of the dresser and next to his/her bed on the door side of the bed, and the placement of a floor mat to the door side of the bed at nighttime. Review of the facility's Falls Mitigation policy identified that nurses are responsible for updating the RCP after a resident fall with interventions to prevent future falls.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #30), reviewed for a change in condition, the facility failed to follow the physician order for blood sugars and blood pressures, and for 1 of 2 residents (Resident #34), reviewed for accidents and hazards, the facility failed to administer medications to the appropriate resident. The findings include: 1. Resident #30's diagnoses include type 2 diabetes, hypertension, and vascular dementia. The Resident Care Plan (RCP) dated 7/24/24 identified Resident #30 had hypertension with an intervention to monitor vital signs per physician (MD) order and notify the MD of abnormalities in the vital signs. Furthermore, the RCP identified Resident #30 had a history of abnormal glucose levels for which the intervention was to perform blood glucose checks and MD notification per provider orders. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #30 had severe cognitive impairment, required insulin injections for diabetes management, and required maximal assistance with chair/bed to chair transfers. a. An order from MD #1 dated 10/1/24 directed blood glucose levels were to be completed two times a week, on Monday and Thursday both in the morning (AM) and night (PM), and to notify the MD if levels were below 70 or above 350. A Weights and Vitals Summary identified on Thursday 10/10/24 at 4:50 PM, Resident #30's blood glucose level was 417 milligrams (mg)/deciliter (dl) (physician orders directed to notify MD if levels were above 350). Additionally, on Thursday 10/24/24 at 10:27 PM, Resident #30's blood glucose level was 402 mg/dl (physician orders directed to notify MD if levels were above 350) and on Monday 10/28/24 at 4:50 AM, Resident #30's blood glucose level was 69 mg/dl (physician orders directed to notify the MD if levels were below 70). An interview and record review on 11/7/24 at 12:11 PM with RN #1 failed to identify the MD or Advanced Practice Registered Nurse (APRN) was notified on 10/10/24, 10/24/24, or 10/28/24 regarding Resident #30's blood glucose levels being above 350 or below 70. RN #1 further indicated that nursing document when calls are made to providers within their progress notes. An interview on 11/7/24 at 1:25 PM with MD #1 identified that he could not recall if he was notified on 10/10/24, 10/24/24, or 10/28/24 of Resident #30's blood glucose results. MD #1 indicated if he were notified, he would have wanted to ask staff if Resident #30 had any symptoms related to an abnormal blood glucose and would have asked staff to monitor him/her for such symptoms. An interview with Registered Nurse (RN) #4 on 11/7/24 at 3:03 PM failed to identify that she notified the nursing supervisor or MD #1 of any abnormalities in Resident #30's blood glucose levels on 10/10/24 after her documentation of an abnormal blood glucose level of 417 mg/dl. She further indicated that a progress note should have been written and the nursing supervisor should have been notified of a blood glucose level to contact the MD per the 10/1/24 MD blood glucose orders. b. A progress note from APRN #1 dated 10/10/24 identified Resident #30 was being evaluated for a change in condition for a weight gain of greater than 5% within a 30-day timeframe after a medication change. As an intervention, documented within the progress note, APRN #1 directed staff to monitor Resident #30's blood pressure daily. Review of physician orders from 10/10/24 through 11/8/24 failed to identify that a RN transcribed APRN #1's order for daily blood pressure monitoring into the electronic medical record (EMR). Resident #30's Weights and Vitals Summary from 10/10/24 through 11/2/24 identified no blood pressure readings were recorded on 10/10/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/16/24, 10/17/24, 10/18/24, 10/19/24, 10/20/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/27/24, 10/28/24, 10/29/24, 10/30/24, and 10/31/24 (missing 21 of 24 opportunities). An interview with APRN #1 on 11/8/24 at 11:26 AM identified that the RN supervisor for 10/10/24 was responsible for transcribing APRN #1's order for daily blood pressures into the EMR as she enters orders into the progress note then verbally provides the RN manager with the order to be entered. APRN #1 stated she was not physically present in the facility at 4:50 PM on 10/10/24 when the order was given, so the order was given to the RN supervisor over the telephone. An interview with RN #5 on 11/8/24 at 11:45 AM, (the nursing supervisor working on 10/10/24 at 4:50 PM), failed to identify that she transcribed the daily blood pressure order into the EMR. An interview and record review with the Director of Nursing Services (DNS) on 11/8/24 at 11:49 AM failed to identify that an order for daily blood pressures for Resident #30 was entered into the EMR. Subsequent to surveyor inquiry, the DNS transcribed the orders for daily blood pressures into the EMR. Review of the Policy identified that it is the responsibility of the RN Supervisor to transcribe orders from the Physician's order sheet or other referring documentation source to the EMR. 2. Resident #34's diagnoses included dementia, chronic kidney disease, atrial fibrillation and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was severely cognitively impaired and required physical assistance of 1 person for bed mobility, toileting and transfers. The Resident Care Plan dated 9/13/24 identified an impaired cognitive function. Interventions included to administer medications as ordered and monitor and document for side effects and effectiveness. A nursing progress note dated 10/30/24 at 5:00 AM identified Resident #34 had received the wrong medications during morning medication pass. The progress note indicated that an Advanced Practice Registered Nurse (APRN) was notified and recommended to monitor Resident #34's vital signs and monitor for sedation or a change in mental status. The facility's medication error report dated 10/30/24 identified that Resident #34 was administered Baclofen 10 mg, Hydralazine 25 mg, Gabapentin 300 mg and Levothyroxine 112 mcg in error on 10/30/24 at 5:00 AM by LPN # 2. The medication error report indicated that Resident #34 should have been administered Omeprazole 20 mg and Synthroid 88 mcg on 10/30/24 at 5:00 AM but was administered the wrong medications. The medication error report further identified that an on-call advanced practice registered nurse (APRN) was notified of the error along with Resident #34's responsible party. An APRN (APRN #1) progress note dated 10/30/24 at 2:35 PM identified Resident #34 was evaluated after a medication error where he/she received another resident's medications. The progress note indicated that after Resident #34 received the wrong medications he/she was very drowsy but was able to briefly open his/her eyes. Additionally, the progress note identified that due to Resident #34's fatigue and weakness he/she was to be monitored closely for any adverse effects due to the medication error. APRN #1 indicated in her progress note that she would follow-up with the nursing staff regarding correct medication administration as well as prevention of recurrence in the future. An APRN (APRN#1) progress note dated 11/1/24 at 12:00 PM identified Resident #34 was evaluated status post episode of lethargy and somnolence after being administered the wrong medications. The progress note indicated that Resident #34 was more awake and alert without any complaints. APRN#1 identified in her progress note that Resident #34 would continue to be monitored for any delayed adverse effects. Interview with APRN #1 on 11/7/24 at 10:40 AM identified she was aware of the medication error on 10/30/24 when Resident #34 received Baclofen 10 mg, Hydralazine 25 mg, Gabapentin 300 mg and Levothyroxine 112 mcg in error. APRN#1 indicated that she evaluated Resident #34 on 10/30/24 and was concerned about the resident's sedation because he/she was sleeping a lot that day. APRN #1 further identified that Resident #34 was closely monitored and was not found to be unstable. APRN #1 indicated that LPN #2 had not correctly identified Resident #34 before she administered him/her Resident #9's medications in error. Interview with DNS on 11/7/24 at 11:00 AM identified that on the morning of 10/30/24, LPN #2 administered Resident #9's medications to Resident #34 in error. The DNS indicated that after the medication error, LPN#2 received re-education at the facility and has not been back to work at the facility. The DNS identified that, although she was unable to indicate if the facility's investigation had concluded that Resident #34 identification band was in place the morning of 10/30/24, LPN #2 had other methods to identify Resident #34 before she administered the wrong medications. The DNS indicated other identification methods would have included review of the resident's photo in the administration record or the resident's name posted above the bed as well as other facility staff could have assisted LPN #2 with identification of Resident #34. Subsequent to surveyor inquiry on 11/7/24 at 2:00 PM the DNS identified that the nursing agency which employed LPN #2 had been contacted and informed her that LPN #2 was counseled by the nursing agency after the medication error occurred. The DNS further indicated that LPN #2 had been placed on the facility's do not return list. Interview with LPN #2 on 11/7/24 at 3:00 PM identified that she was working at the facility on 10/30/24 and was responsible for administering morning medications to Resident #34. LPN #2 indicated that she dispensed Gabapentin, Baclofen, Hydralazine and Levothyroxine for Resident # 9 and then went into the wrong room and administered the medications to Resident #34 in error. LPN #2 identified that when she went to dispense Resident #34's medications and saw the resident's picture in the administration record, she realized she had already given the wrong medications to Resident #34. LPN #2 further indicated that she failed to identify Resident #34 before she administered medications to the resident on 10/30/24 and she should not have done that. Review of the facility policy, Medication Administration and Documentation, undated, directed that medication administration occurs in an accurate manner and residents are to be identified before medications are administered. 51182 Based on observations, interviews, and record review for 1 of 2 residents, (Resident #40), reviewed for respiratory care, the facility failed to obtain a physician's order to administer oxygen to a resident with Chronic Obstructive Pulmonary Disease (COPD). The findings include: Resident #40's diagnoses included chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #40 was severely cognitively impaired, and independent for eating, toileting, and transfers. Additionally, Resident #40 had no shortness of breath but was receiving respiratory treatments. The Resident Care Plan dated 10/8/24 identified Resident #40 had COPD. Interventions included to give aerosol and bronchodilators as ordered and monitor for difficulty breathing on exertion. The care plan did not indicate oxygen use. Observations on 11/4/24 at 11:40 AM, 11/5/24 at 10:02 AM, and 11/7/24 at 9:25 AM identified Resident #40 was receiving oxygen at 1 liter per minute from a concentrator (not an emergency tank), via a nasal canula (tubing). Interview and record review with Registered Nurse (RN) #1 on 11/7/24 at 9:30 AM identified licensed nurses were responsible to check the physician's order for oxygen use to identify how much oxygen to administer and ensure any orders to titrate (increase or decrease) the oxygen flow rates were implemented. Although the facility policy indicated that oxygen could have been put in place as a nursing measure, review of the documentation with RN #1, failed to identify oxygen use in the physician's orders, nursing progress notes, or the care plan for the 3 days Resident #40 was observed to be receiving oxygen therapy. Interview with APRN #1 on 11/7/24 at 10:39 AM identified she was familiar with Resident #40, his/her diagnosis of COPD, and that parameters for oxygen saturations should have been maintained between 88% and 92%. APRN #1 indicated although she would assess Resident #40 for oxygen use, his/her saturations were in the 90's so oxygen use would be unlikely. Additionally, she stated she tried to avoid giving residents with COPD oxygen if it was unnecessary as oxygen use caused retention of carbon dioxide in the lungs and increased the bicarbonate in the body which impeded breathing. Subsequent to surveyor inquiry, Resident #40 was assessed by APRN #1, and an order was placed to administer oxygen at 1 liter per minute via nasal canula, every shift, as needed, to maintain oxygen saturations greater than 88% and to titrate oxygen by 0.5 liters per minute via nasal canula to maintain oxygen saturations greater than 88% every shift. The Oxygen Administration Policy and Procedure dated 4/15/23 identified that it was the policy of the facility to ensure residents requiring oxygen were administered oxygen per the physician's orders. In addition, when an emergency arouse, the nurse may administer oxygen at 2 liters per minute via nasal canula and obtain physician orders within 24 hours.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #34) reviewed for nutrition, the facility failed to appropriately supervise a resident during mealtime per the physician's order and during the initial facility tour, the facility failed to ensure water temperatures were maintained within acceptable parameters of 105 to 120 degrees Fahrenheit for 17 of 50 rooms. The findings include: 1. Resident #34's diagnoses included dementia, dysphagia, gastro-esophageal reflux disease and pneumonia with respiratory failure. A physician's order dated 8/8/24 directed supervision and out of bed with upright posture for meals. A Speech Therapy (ST) #1 progress note dated 8/8/24 at 3:03 PM identified that staff were reminded Resident #34 would benefit from eating his/her meals in the dining room and supervision for meals was required. The progress note further indicated that Resident #34's physician's orders for eating had been changed to supervision and to be out of bed with upright posture for meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was severely cognitively impaired and required physical assistance of 1 person for bed mobility, toileting and transfers. The MDS further indicated signs and symptoms of a possible swallowing disorder as evidenced by loss of liquids/solids from the mouth when eating or drinking with nutritional approaches applied as mechanically altered/therapeutic diet. The Resident Care Plan dated 9/13/24 identified a nutritional problem related to dysphagia and a self-care performance deficit. Interventions included to monitor, document and report any signs and symptoms of dysphagia with supervision and to be out of bed with upright posture for meals. A nursing progress note dated 9/28/24 at 5:30 PM identified that Resident #34 had a foreign body airway obstruction during mealtime and was unable to communicate for a short period of time due to persistent coughing. The progress note further indicated that Resident #34's diet was downgraded and a speech therapy consult was ordered. A physician's order dated 9/28/24 directed to provide Resident #34 with a regular diet with dysphagia puree texture and regular liquid consistency. A physician's order dated 9/30/24 directed a speech therapy dysphagia evaluation and treatment for management of dysphagia. ST #1's progress note dated 9/30/24 at 2:30 PM identified Resident #34 was seen for a swallowing evaluation after an episode of coughing while eating spaghetti over the weekend which resulted in his/her diet being downgraded to puree. The progress note included that skilled speech therapy was indicated for delivery of education and training with staff caregivers related to diet recommendations and the use of safe swallowing strategies to minimize the risk of aspiration. ST #1's progress noted dated 10/16/24 at 12:51 PM identified that Resident #34 was complaining of a hard time swallowing and was spitting up brown mucous prior to any oral intake. The progress note indicated that Resident #34 was eating moderate portions of breakfast without overt signs or symptoms of aspiration despite intermittent complaints of difficulty with swallowing. Advanced Practice Registered Nurse (APRN) #1's progress note dated 10/17/24 at 1:30 PM identified Resident #34 was seen for follow-up of possible cough with brown tinged sputum. The progress note indicated that Resident #34 was seen on 10/16/24 for brown sputum and the resident reported trouble swallowing with his/her diet downgraded due to dark brown tinged sputum observed that morning. APRN #1's progress note dated 10/30/24 at 2:45 PM identified Resident #34 continued to be followed by ST for dysphagia and should continue to be monitored for swallowing ability with diet adjustments made as needed. Observation 11/04/24 at 12:30 PM identified Resident #34 was in his/her room sitting in the bedside recliner and was independently eating a pureed meal of meat and vegetables. Resident #34 was unsupervised and alone in his/her room while eating lunch. Observation on 11/6/24 at 7:45 AM identified Resident #34 was in his/her room and was sitting up at the side of the bed when NA# 2 delivered his/her breakfast tray and left the room. Resident #34 was independently eating her pureed meal of cheese omelet and toast. Resident #34 was seated behind the privacy curtain and was unsupervised and alone in his/her room while eating breakfast. Interview with ST #1 on 11/7/24 10:20 AM identified he was familiar with Resident #34 and had frequently worked directly with him/her for a diagnosis of dysphagia. ST #1 indicated that Resident #34 was to be supervised by staff during all meals and staff were to monitor and assist if he/she had any swallowing difficulty during the meal. ST #1 further identified that the reason for Resident #34's meal supervision was to minimize his/her risk of aspiration or choking. Additionally, ST #1 identified when Resident #34 was dining in his/her room, staff should have been present in the room and supervised the resident while he/she was eating. ST #1 indicated that he would need to remind the nursing staff regarding Resident #34's required supervision during meals. Interview and record review with APRN #1 on 11/7/24 at 10:30AM identified that Resident #34 had a current order for supervision during meals. APRN #1 indicated that the order for supervision meant that staff was present and monitored Resident #34 while he/she ate and drank during his/her mealtimes. APRN #1 identified that if Resident #34 was dining in his/her room, the nursing staff should have been present in the room while Resident #34 was eating. Additionally, APRN #1 indicated that, due to a diagnosis of dysphagia, Resident #34 required supervision by the nursing staff in order to be monitored for aspiration or choking during meals. APRN #1 further identified that she would need to address the lack of supervision further with the nursing supervisor on that unit. Interview with NA #2 on 11/7/24 at 3:18PM identified that on the morning of 11/6/24 she had served Resident #34 his/her breakfast tray. NA #2 indicated that since Resident #34 was independent and just a set-up, Resident #34 ate breakfast unsupervised. Additionally, NA #2 identified she was not in the room with Resident #34 while he/she was eating, and only went back into the room to pick up the breakfast tray. NA #2 further indicated that although the NA care card directed that Resident #34 was to have supervision during meals, she was not aware the resident needed to be supervised because she had not referenced the NA care card before providing care. Review of the Supervison Resident Dignity During Mealtimes Policy and Procedure, dated 12/29/12, directed, in part, that residents requiring supervision while eating in their room may be observed by the nurse assigned to the unit. 2. Observations of water temperatures on 11/4/24 at 12:00 PM identified the following: A. room [ROOM NUMBER] the water temperature was 124 degrees. B. room [ROOM NUMBER] the water temperature was 125.6 degrees. C. room [ROOM NUMBER] the water temperature was 124.5 degrees. D. room [ROOM NUMBER] the water temperature was 125.8 degrees. E. room [ROOM NUMBER] the water temperature was 126.3 degrees. F. room [ROOM NUMBER] the water temperature was 126.7 degrees. G. room [ROOM NUMBER] the water temperature was 124.0 degrees. H. room [ROOM NUMBER] the water temperature was 121.1 degrees. I. room [ROOM NUMBER] the water temperature was 128.1 degrees. J. room [ROOM NUMBER] the water temperature was 123.8 degrees. K. room [ROOM NUMBER] the water temperature was 123 degrees. L. room [ROOM NUMBER] the water temperature was 128.5 degrees. M. room [ROOM NUMBER] the water temperature was 121.3 degrees. N. room [ROOM NUMBER] the water temperature was 122.5 degrees. O. room [ROOM NUMBER] the water temperature was 126.3 degrees. P. room [ROOM NUMBER] the water temperature was 126.0 degrees. Q. room [ROOM NUMBER] the water temperature was 130 degrees. An interview on 11/4/24 at 12:30 PM with the Maintenance Director identified that he thought the water temperature acceptable parameters were to be maintained between 105 degrees to 125 degrees. Additionally, he indicated that the mixing valve was set at 145 degrees. Review of the temperature logs from 2/29/24 to 10/30/24 identified that for 133 days out of 168 days the water temperatures were logged at 121 degrees or higher, with the highest temperature being 130 degrees on 9/3/24. An interview on 11/4/24 at 12:35 PM with the Administrator identified that the water system could be bled and purged to force the water temperatures to be lowered and that the buildings high water temperatures could be fixed in minutes using this method. Subsequent to surveyor inquiry, the water temperatures were adjusted. Review of the facility Water Temperature Policy and Procedure identified water that water temperatures were to be maintained between 105 and 120 degrees Fahrenheit and were not to exceed 120 degrees Fahrenheit at all water sources to ensure individual safety for those with access. Additionally, staff were trained and aware that temperatures could rise or fall due to seasonal changes and circulation devices and that the Maintenance Director was responsible to review variances and adjust the mixing valve to proper temperatures as needed.

Based on clinical record review, observation, review of facility documentation and interview for one of three sampled resident reviewed for pressure ulcers (R#95), the facility failed to properly assess and/or measure the wound and/or provide wound tracking to ensure appropriate treatment and promote healing. The findings include: Resident #95's [DIAGNOSES REDACTED]. A 14-day MDS assessment dated [DATE] identified Resident #95 as moderately cognitively impaired, required extensive assistance with bed mobility, transfers and eating, always incontinent of stool, did not have a current pressure ulcer and at risk for pressure ulcer development. A care plan dated 8/04/14 identified the resident with impaired tissue integrity related to pressure on coccyx. Interventions included to assess condition of tissue, assess for signs and symptoms of infection, assess for pain, off load pressure, dietary consult as needed follow up with wound care consultant as needed, and use an air mattress. Intermittent observations throughout the day on 10/07/14 and 10/08/14 identified R#95 slouched in his/her wheelchair and resting on his/her coccyx. Observation with RN#2 on 10/08/14 at 1:30 PM identified that Resident #95, while working with PT was inappropriately positioned in the wheelchair and was noted to be slouched down and resting on a pressure reducing cushion on his/her coccyx. RN#2 identified that he/she thought Resident #2 was sitting on a ROHO cushion, however on closer inspection the cushion was noted to be a pressure reducing cushion which was creased in the center where the coccyx rests and was thinner at the creased areas than on the sides of the cushion. Interview with RN#2 on 10/09/14 at 11:15 PM and review of the clinical record identified the wound was first identified in a nurse's note as a Stage 2 on 7/29/14 at 3:00 AM by the LPN Charge Nurse and documented on a change of condition form signed by the supervisor, on 7/29/14 at 8:00 AM. Review of change in condition form dated 7/29/14 at 10:00 AM identified RN#2 evaluated the coccyx area and determined it was fungal infection as a result of loose stools. However, RN#2 was unable to locate any documentation of his/her assessment and/or documentation of the resident experiencing loose stools. RN#2 identified that he/she was not aware of Resident #95's repetitive loose stools which began on 7/20/14, that the house barrier cream used was A&D ointment, and that if he/she had been made aware, he/she would have used a more appropriate barrier cream. Review of the clinical record with RN#2 failed to reflect any documentation of R#95's loose stools. RN#2 identified that on 7/31/14 he/she obtained a physician's orders [REDACTED].#95's coccyx wound had become macerated. RN#2 identified he/she first documented on R#95's coccyx wound when the wound care consultant identified that the coccyx wound as a stage 3 pressure ulcer measuring 3.8 cm x 2.3 cm x 0.3 cm, 50% thick adherent devitalized necrotic tissue and 50% yellow necrotic tissue and the area was debrided.

Based on clinical record review, review of facility documentation and interviews for two of three sampled residents reviewed for alleged mistreatment (R#58, R#118), the facility failed to ensure resident care was provided in a timely manner. The findings include: 1. Resident #58's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely cognitively impaired, requiring extensive assistance with bed mobility and 2 person support, totally dependent for personal hygiene and always incontinent of bowel and bladder. A RCP dated 10/15/13 identified the resident with an alteration in elimination related to incontinence of bowel and bladder. Interventions included to provide incontinent care every two hours and as needed. Physician order [REDACTED]. Review of facility documentation dated 12/1/13 at 2:30 PM identified that R#58 was found in bed laying on a heavily urine soiled incontinent pad with a dark, dry, urine stains outlining the soiled edges. Review of facility documentation and review of a written statement from NA#4, identified Resident # 58 failed to provide incontinent care in a timely manner. According to the statement the last time incontinent care was provided was at 11:00 AM. The resident was found 3.5 hours later, laying in a urine soaked pad. Although, NA#4 was aware that residents should be checked every 2 hours and provided with incontinent care, NA#4 indicated in her statement that R#58 was not checked for incontinence and/or provided incontinent care. A telephone interview with NA#4 on 12/19/13 at 3:30 PM identified that she/he did not check the resident every 2 hours as per the plan of care indicating that she/he was aware of the needs of the resident. NA#4 indicated she was swamped with work and failed to inform the charge nurse that she/he was unable to provide R#58 with the appropriate care. Interviews with NA#6, NA#7, LPN#6 and RN#6 identified that R#58 was found in bed on 12/01/13 at 2:30 PM with an adult brief that was heavily soaked with urine and that the bed linen was also soaked with urine. A brown stain was observed on the incontinent pad and it appeared as though the urine stain was on the pad for a long time. The resident's buttocks was observed with linen demarcations. Interview with the Administrator and review of NA#4 personnel file on 12/18/13 at 2:00 PM identified the nurse aide was terminated for substantiated allegation of neglect on 12/01/13. Review of Facility Abuse and Neglect Policy defined neglect in part as an omission of care to a resident. 2. Resident # 118's [DIAGNOSES REDACTED]. A five-day PPS Assessment dated 8/31/13 identified the resident was without cognitive impairment, required extensive assistance with ADL's, including toilet use and personal hygiene. The Resident Care Plan dated 9/4/13 identified a potential and actual impaired skin integrity, a self care deficit, and a risk for diarrhea related to obesity and [MEDICAL CONDITION]. Interventions directed the staff to provide assistance with perianal care after each bowel movement. Nurse's note dated 9/07/13 identified the resident reported that on 9/06/13 from approximately 7:20 to 8:15 PM, NA#1 was aware of the resident's need for assistance with toileting and was asked to wait until after the NA returned from a break. Review of facility documentation dated 9/07/13 identified that NA#1 was aware that the resident had been incontinent of bowel and informed the resident that she was hungry and after her lunch break she would provide him/her with incontinent care. The NA returned at 8:15 PM to provide the resident with assistance, 55 minutes after the resident had requested. Interview with the DNS and review of the clinical record, and facility documentation on 12/18/13 at 10:30 AM identified that the allegation of neglect was substantiated and the NA was terminated. Attempts to contact NA# 1 were unsuccessful.

Based on clinical record review, review of reportable events, observations, and review of facility policies, and interviews for two of three sampled residents (Resident #45 and #51) who required supervision and/or assist of one with transfers, the facility failed to ensure that an assistive device was utilized as per the facility's protocol and/or an alarm device was on and/or functioning and/or fifteen minute checks were conducted as outlined in the plan of care. The findings included: 1. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #51 had no memory or cognitive deficits, required supervision with transfers and ambulation, limited range of motion to the neck, both arms and legs, was continent of bowel and bladder, and with no history of falls. The Occupational Therapy Evaluation dated 7/1/10 through 7/30/10 identified that Resident #51 had limitations in range of motion and strength, chronic back pain, and the upper extremities were impaired with passive range of motion. The Resident Care Plan dated 7/25/10 and updated through 8/6/10 identified activities of daily living potential and altered mobility. Interventions directed to assist resident with upper extremity exercise program, supervision with transfers and gait with rolling walker, and to provide close supervision with toilet transfers with rolling walker. The Reportable Event Form dated 8/8/10 at 4:30 PM identified that the Resident #51 was found lying on the bathroom floor in front of the toilet. The report indicated that the resident had sustained an open abrasion to the left forehead, an ecchymotic area to the left lower eye that measured 1.0 inch x 1/4 inch, a raised area the size of a ping pong ball to the left scalp and complained of bilateral lower leg discomfort. Upon further review, the report identified that Resident #51 did not wait for assistance to go to the bathroom and lost his/her balance. Resident #51 was transferred to the emergency department and diagnosed with [REDACTED]. Interview with Resident #51 on 9/9/10 at 11:30 AM identified that the resident was unable to recall who had assisted him/her to the bathroom on 8/8/10 at 4:30 PM. Resident #51 stated that the high seat had been removed from the toilet without his/her knowledge and she/he lost his/her balance when going to use the toilet. Resident #51 stated that when he/she went to sit down the toilet seat was not there, the resident tried to reach for the grab bar but the resident reached with his/her bad arm and fell . Observations on 9/9/10 at 11:45 AM identified a commode with armrests over Resident #51's toilet. Interview with the Physical Therapist (PT) on 9/9/10 at 2:15 PM identified that although there is no written policy, the standard protocol is that all new admissions to the facility are given a commode for over the toilet because the toilets are too low. The PT identified that on 8/8/10 the commode was not in Resident #51's bathroom at the time of the fall. Interview with the 3-11 PM Nursing Supervisor on 9/10/10 at 9:30 AM identified that the commode was not in the bathroom at the time Resident #51 fell . The Nursing Supervisor stated that the toilet seat was too low and Resident #51 needed the higher commode seat. Interview with a Nurse Aide (NA) #5 on 9/10/10 at 2:10 PM identified that she was on duty 8/8/10 during the 2-10PM shift. NA #5 stated that she had assisted Resident #51 to the bathroom around 2:15 PM but NA #5 could not recall if the commode was over the toilet. 2. Resident #45's [DIAGNOSES REDACTED]. The risk of falls assessment dated [DATE] identified that Resident #45 was scored at seven, indicating the resident was at a minimal risk for falls. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #45 had short term memory loss, no long term memory deficits, moderate cognitive impairment, no behavioral symptoms, required supervision with transfers and ambulation, was continent of bowel and bladder and had no history no of falls within the past 180 days. The Resident Care Plan dated 9/20/09 identified a potential for falls. Interventions directed to ambulate and transfer with assist of one, checks every fifteen minutes, and the use of a bed alarm. The physician's October 2009 orders identified that a bed alarm, check function and placement every shift had been initiated on 3/30/09, and every fifteen minute checks were initiated on 7/05/09. The nursing progress note dated 10/27/09 at 10:00 AM identified that Resident #45 had reported that he/she had fallen the previous night, a bruise next to the right eye was noted on the forehead by the 11PM-7AM shift and that the physician was notified. A subsequent nursing note at 2:20 PM identified increased swelling to the forehead, ecchymosis spreading to the right side and some noted on left with peri-orbital edema and the resident's speech was slightly unclear. Subsequent to physician notification, Resident #45 was transferred to the hospital. A noncontrast CAT scan dated 10/27/09 identified that there was a superficial frontal scalp hematoma and edema and no intracranial findings were noted. The hospital discharge instructions identified [DIAGNOSES REDACTED]. Interview and review of the clinical record with the Director of Nursing (DNS) on 9/10/10 at 11:00 AM failed to reflect that the every fifteen checks were completed on 10/26/09 from 8:30 PM through 10:00 PM and/or that the alarm had sounded. Interview with the 2:00-10:00 PM Nurse Aide (NA) #1 on 9/10/10 at 2:30 PM identified that the every fifteen minute checks had not been completed. Review of facility documentation regarding the incident identified that NA #7, assigned to R #45's care on the night of 10/26/09, and NA #8, the aide working the wing on the night of 10/26/09, that between approximately 10:00-11:00 PM during their first rounds, R #45 was observed without the alarm on. Although documentation on the treament kardex identified that the bed alarm was checked and functioning and in place on the 3 PM- 11 PM shift on 3/26/09 and the 11 PM - 7 AM shift on 3/27/09, review of the facility policy identified that the Wing Charge Nurses are responsible for signing off in the MAR that devices are intact and functioning unless otherwise notified by the CNA.