Every finding on record at Davis Place

Based on observations, interviews, and policy review, the facility failed to ensure exposed hair was restrained during food preparation and service and failed to ensure food contained in a Styrofoam container was not reheated in the microwave. The finding include: 1. Observation and interview on 7/1/26 at 11:52 AM identified [NAME] #1 preparing to plate resident food by the steam table in the kitchen. [NAME] #1 was wearing a baseball cap and his hair was hanging freely down to his shoulders without a hair restraint. [NAME] #1 indicated that the facilities policy was that staff wearing baseball caps did not need to wear a hair restraint even if their hair was not contained outside of the cap. [NAME] #1 indicated that he had always worn a baseball cap without a hair restraint.Observation and interview with the Director of Dining at 11:53 AM on 7/1/26 identified that she did not know the facility policy or requirement regarding hair restraints with baseball caps. The Director of Dining indicated that it would make sense for staff to have to wear a hair restraint with a baseball cap if the hair was not completely restrained under the cap.Subsequent to surveyor inquiry, [NAME] #1 applied a hair restraint2.Observation and interview on 7/1/26 at 12:14 PM in the kitchen identified [NAME] #1 removed a Styrofoam container when the microwave cycle completed and placed the item on a food truck to be delivered to a resident. [NAME] #1 indicated that he normally would reheat food on a microwave safe plate, but since the dishwasher was broken and no microwave safe plates were readily available, it was easier and quicker to reheat the food in the Styrofoam container rather than look for a different plate.Interview with the Director of Dining of 7/1/26 at 12:17 PM identified that staff should use a microwave plate when reheating food for residents and that a Styrofoam container is not microwave safe due to the possibility of it melting and chemicals getting into the resident's food. The Director of Dining indicated that she did not know why [NAME] #1 decided to use the Styrofoam container to reheat food as there were microwave safe plates available. Additionally, she indicated that she would educate facility staff on the facility policy and how to properly and safely reheat resident food. Subsequent to surveyor inquiry, the Director of Dining discarded the reheated food.Review of facility Hair Restraint (Hairnet) Policy not dated directed in part that all individuals entering food preparation areas shall wear an effective hair restraint whenever engaged in food preparation or whenever entering an area where exposed food is prepared. Hair restraints shall be worn in a manner that completely contains the hair and prevents hair from contacting exposed food or food-contact surfaces. Baseball caps are acceptable hair restraints if all hair is fully contained. Review of the On-Unit Reheating of Resident Food Policy dated 12/1/25 directed in part to use microwave-safe containers and to not use Styrofoam, foil, or non-approved plastics. According to Serv-Safe (food safety certification company), reheating food in standard Styrofoam should be avoided because it melts and releases toxic chemicals contained in the Styrofoam to the food being heated.

Based observations, interviews, review of facility documentation and the clinical record for 3 of 5 sampled residents (Resident #3, Resident #70, and Resident #138) reviewed for choices, the facility failed to ensure requested menu choices were honored. The findings include: 1. Resident #3's diagnoses included acute respiratory failure with hypercapnia (high carbon dioxide in the blood), congestive heart failure, and protein calorie malnutrition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status score of 14 indicating no cognitive impairment and required substantial maximum assistance with dressing, partial moderate assistance with personal bed mobility, and transfers, and set up assistance with eating. The Resident Care Plan dated 4/16/26 identified potential nutritional problem related to therapeutic diet, and body mass index (BMI) indicated obesity. Interventions included providing and serving diet per the physician's order, and the registered dietitian would evaluate and make diet changes as needed, and monitor intake. A physician's order dated 6/9/26 directed staff to provide a low fat, low cholesterol, no added salt, and a heart healthy diet. A comprehensive Nutritional Evaluation dated 6/24/26 identified diet as heart healthy diet, Resident #3 wanted Greek yogurt with every meal, had very specific requests and completed menus weekly. Observations of Resident 3's ticket on the lunch tray on 6/29/26 at 12:05 PM, identified he/she requested Greek yogurt, mandarin oranges, and decaf tea. The lunch tray received had chocolate cream cake, a tea bag without water to make the tea and a diet cranberry juice (which was not requested), and no fruit. Resident #3 indicated she had checked fruit and not chocolate cream cake. Additionally, his/her family member had to supply the Greek yogurt because it was not supplied by the facility. Observation of Resident #3's ticket on the lunch tray on 6/30/26 at 12:34 PM, identified that double vegetables had been requested as well as Greek yogurt, Sanka, sweet and low, and peaches. The lunch tray received, failed to have double vegetables (in addition to the salad ordered), and had ice cream in place of peaches. Interview with LPN #2 on 7/2/26 at 11:30 AM indicated that she checked the meal ticket to ensure the name, diet and liquids were correct and matched what was on the tray. LPN #2 further indicated if items were missing from the tray, she had to go to the kitchen to retrieve the missing items or she was offered another alternative. Interview with NA #5 on 7/2/26 at 11:36 AM indicated that she looked at the meal ticket and the tray to make sure it was correct. If items were missing from the tray, she would have to go to the kitchen and replace the missing item or offer something else if the item was not available. Interview and review of dietary information with the Dietary Manager on 7/2/26 at 12:08 PM, identified Resident #3 received chocolate cream pie instead of mandarin oranges on 6/29/26, and on 6/30/26 received ice cream rather than peaches. The Dietary Manager indicated that staff would not open number 10 cans of peaches and mandarin oranges for just 1 resident. Additionally, Resident #3 received a tea bag without hot water and ordered a banana and did not receive this either. The Dietary Manager indicated that Resident #3 did fill out the menu, but the bananas were brown so that was not substituted. Another fruit could have been substituted if it was available but not from an unopened number 10 can. The Dietary Manager could not explain why Resident #3 did not receive the items s/he ordered but suggested the staff member in the middle of the line and the line staff did not pay attention to the tickets. She further indicated that she has had complaints about distributing wrong items this a few times. Interview with the Dietitian on 7/2/26 at 12:30 PM identified that that chocolate cream pie was an appropriate substitute fruit as well as ice cream because ice cream was made with low fat milk and allowed on a heart healthy diet. The Dietitian further indicated that she heard about Resident #3 not receiving the items s/he ordered on the tray about a week later. She indicated that fruit should be available at all times even if the fruit was a banana. Additionally, the Dietitian indicated that the staff should open a number 10 can of fruit for 1 resident and the staff should be able to substitute any fruit they have available. The ala carte menu indicated seasonal fruit was available. The Dietitian indicated that Greek yogurt was not part of the facility generated menu, but regular yogurt was available. The Greek yogurt may have to have been ordered as a special-order item. Interview with the Administrator on 7/2/26 at 2:05 PM indicated that the staff should have absolutely opened a number 10 can of peaches and mandarin oranges despite only 1 resident request. 2. Resident #70's diagnosis included anemia, muscle weakness and aphasia. The admission Resident Care Plan dated 6/16/26 identified Resident #70 would have no unavoidable weight loss. Interventions included Registered Dietitian evaluation as needed, monitor dietary intakes, and determine likes and dislikes. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment, was dependent on staff to transfer, walked with partial/moderate assistance, could eat independently, and was on a therapeutic diet. Physician orders dated 6/16/26 directed a heart healthy diet, regular texture with thin liquids. A Nutritional assessment dated [DATE] identified Resident #70 disliked beets. Interview with Resident #70 on 6/30/26 at 9:32 AM identified that within the past week he/she had received beets for a meal and had previously notified the kitchen he/she disliked beets. 3. Resident # 138's diagnosis included hypoglycemia, hypomagnesemia, anticoagulant use and dysphagia. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #138 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment and was dependent on staff to transfer and set up assistance with eating The Resident Care Plan dated 6/25/26 identified unintentional weight loss prior to admission. Interventions included that staff would update food preferences with the kitchen and offer substitutions as requested or indicated. Interview with Resident #138 on 6/29/26 at 2:27 PM identified that he/she had an alert noted on her dietary slip that beets were not to be served, but he/she continued to receive beets. Additionally Resident #138 identified that he/she had crossed off menu items indicating the item that was not to be served, but the crossed off items were still being received. Review of the Nutrition assessment dated [DATE] identified that Resident #138 disliked beets. Review of the resident's meal ticket for 7/6/26 indicated Resident #138 disliked beets. Re-interview with Resident #138 on 7/6/2026 9:30 AM identified that frequently the facility did not provide what was requested on the selective menu. Resident #138 identified that he/she had crossed off oatmeal this morning and received oatmeal on his/her tray, stating he/she only liked oatmeal with cinnamon which the kitchen provided in an extra cup, but cinnamon had not been provided this morning. Last week he/she ordered grilled cheese and received fish instead. Resident #138 was told by the Nurse Aid (NA) that the kitchen had run out of grilled cheese sandwiches. A few weeks ago, Resident #138 indicated that he/she had ordered cinnamon oatmeal and only received an English Muffin with no oatmeal or other hot cereal and was told by the NA that the kitchen had not made enough food. Resident #138 indicated that his/her choices often were not met and that he/she had informed the NAs when this happened. Interview with NA #8 on 7/6/26 at 9:30 AM NA #8 indicated that the NAs try to accommodate what the resident requests on his/her selective menu. When Resident #138 indicated that he/she had not received what was ordered and she went to the kitchen, she was often told by kitchen staff that they ran out of an item because there was not enough food made. NA #8 indicated that although Resident #138 crossed off oatmeal he/she often received it and will sometimes eat what she is given, despite crossing it off. Interview with NA #6 on 7/6/26 at 9:37 AM identified that residents in general often don't get what they asked for because the kitchen states they ran out or the item was not available in the kitchen due to not being received on the truck. Interview with Supervising Registered Nurse (RN) #4 identified that often the kitchen ran out of food or the item was not available. RN #4 indicated that residents who were not receiving their choices was an on-going issue. Interview with NA #7 on 7/6/26 at 9:55 AM identified when residents don't receive what was ordered, the NA has to return to the kitchen to see if the items that were chosen on the menu were available to bring to the resident. Often the kitchen runs out of particular food items, they don't have the item, and/or they automatically provide substitutions. Additionally, many of the residents have started making copies of their food choices so they can give it to NA staff so when they return to the kitchen for a missing item the kitchen staff have to verify what they sent was wrong. An interview was conducted on 7/6/26 at 10:10 AM with the Food Service Supervisor (FSS) and the Administrator. The FSS identified that the reason for the errors being made from selective menus might have been due to the staff not seeing the item chosen on the ticket. The FSS identified if the item was not in the building, it would be ordered and scheduled for the next delivery, and nursing staff should not have been told that the kitchen ran out of grilled cheese because the item was always available on the ala carte menu. The FSS indicated that she had not been aware that residents were not receiving the requested items, that the facility has a food committee, and she had not heard about this issue from the food committee. The Administrator identified that running out of an item should not be a problem and that the facility had the means to go out and purchase items at will. The Administrator indicated it had previously been identified that kitchen staff had been providing the wrong items 3 to 4 months ago, that the facility had conducted an audit, and that there were very few issues. The Administrator indicated that the problem was occurring due to errors in the kitchen and that they did not have a policy for selective menus and did not have a policy for calling out dietary tickets. Review of the ala carte menu (always available menu) identified items available included, in part, fresh seasonal fruit, assorted cereals, seasonal fruit plate served with cottage cheese, and grilled cheese during the hours of 7:00 AM to 6:00 PM. An additional notation indicated to please remember that some items may take longer to prepare and should be ordered in advance, availability was subject to change due to dietary restrictions, and substitutions may be made. Review of therapeutic house diets directed a heart healthy diet translates to low fat, low cholesterol, and no added salt. Review of Resident's [NAME] of Rights directed, you have the right to quality care and services with reasonable accommodation of your individual needs and preferences, except when your health or safety or the health or safety of others would be endangered by such accommodations. Although requested, the facility did not have a policy for selective menus. Subsequent to surveyor inquiry, the facility created a Food Request Policy which stated that the Residents who have decision-making capacity maintain the right to make informed choices regarding food selection and that a QAPI process will be used going forward.

Based on interviews, facility documentation and facility policy for 1 of 3 sampled residents (Resident #30) reviewed for falls, the facility failed to ensure gait belt use according to the manufacturer's directions for a resident who required the assistance of 2 staff members to transfer. The findings include:Resident #30's diagnoses included muscle weakness, difficulty in walking, and chronic obstructive pulmonary disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #30 had a Brief Interview of Mental Status of 15 indicating intact cognition and was dependent on staff for all transfers. Additionally, the MDS identified Resident #6 did not have any rejections of care.The Morse Fall Scale (fall risk assessment) dated 3/20/26 identified Resident #30 was at high risk for falls.A physician's order dated 3/21/26 directed to transfer Resident #30 out of bed to the wheelchair as tolerated with the assistance of 2 staff members.The Reportable Event form dated 3/25/26 at 10:00 AM identified Resident #30, during a transfer with the assistance of 2 staff and a rolling walker, was lowered to the floor when his/her knees gave out. Resident #30 complained of right ankle pain. A staff statement by Nurse Aid (NA) #1 dated 3/25/26 identified she and a coworker (NA #2) were on either side of Resident #30 to transfer him/her with a rolling walker. As he/she stood up and started to turn toward the chair, his/her knees gave out, and they lowered Resident #30 to the floor.A staff statement by NA #2 dated 3/25/26 identified she was transferring Resident #30 with NA #1 from the bed to the wheelchair, with the resident holding onto the walker. NA #2 identified that while they were pulling up his/her pants, the resident was turning to the chair, his/her leg gave out, and they lowered Resident #30 to the floor.The nurses note dated 3/25/26 at 11:03 AM identified Resident #30 stated that while holding onto the walker, his/her knees gave out resulting in a fall to the floor. Resident #30 complained of pain to the right ankle upon palpitation and was sent to the hospital for a possible ankle fracture.The Summary of Findings report submitted to the State Agency on 3/26/26 at 11:38 AM identified that on 3/25/26 at 10:00 AM, Resident #30 was being transferred from the bed to the wheelchair with a rolling walker and 2 NA's. Resident #30's knees gave out and he/she was lowered to the floor; the Advanced Practice Registered Nurse (APRN) was in the facility at that time and responded to the fall. According to the Summary of Findings report an APRN progress note referenced identified that Resident #30 reported during the fall his/her ankle turned underneath, with the ankle turned posteriorly (toward the back) with a small amount of swelling. Resident #30 was unable to perform a range of motion due to pain and was sent to the Emergency Department for evaluation. An x-ray of the right ankle was completed at the hospital and identified fractures of the distal tibia (lower inner shinbone) and fibula (outer calf bone); there was a non-displaced medial malleolar fracture (lower part of the tibia), distal fibular fracture and a small fracture from the posterior malleolus also nondisplaced. The impression was a non-displaced tri-malleolar fracture.The Resident Care Plan was updated on 4/2/26 identifying Resident #30 had limited physical mobility related to weakness and low activity tolerance. Interventions included providing supportive care, assistance with mobility as needed and physical and occupational therapy referrals as ordered.Interview with NA #1 on 7/1/26 at 10:03 AM identified that on 3/25/26 she was transferring Resident #30 from the bed to the wheelchair with NA #2, and as he/she stood up while holding onto the rolling walker, his/her knees buckled. NA #1 stated she then grabbed the back of Resident #30's head for support and NA #2 grabbed the back of his/her pants and they lowered the resident to the floor. Additionally, NA #1 identified that they did not apply a gait belt (an assistive device used for transfers to reduce the risk of falls) prior to the transfer because the gait belt put too much strain on his/her breasts, which Resident #30 did not like.Interview with NA #2 on 7/1/26 at 10:10 AM identified that on 3/25/26 she was transferring Resident #30 with NA #1 from the bed to the wheelchair, without a gait belt, since the resident stated it felt too tight on his/her chest. As the resident stood up, his/her legs gave out, and she grabbed the back of the resident's pants as NA #1 held his/her head while lowering the resident to the floor. NA #2, who was a regular on Resident #30's unit, also identified all NA's including herself always had a gait belt on, however she was unable to produce her gait belt upon request stating that it was in the hallway. Additionally, NA #2 identified that although she usually placed the gait belt around the waist/under the breast, for anyone that was heavier such as Resident #30, they applied the belt on and over Resident #30's breasts/chest area.Interview with Physical Therapist (PT) #1 on 7/1/26 at 10:35 AM identified he was unaware of the facility's policy on gait belts for nursing but that the therapists always used them when transferring and ambulating residents. PT #1 indicated he had worked with Resident #30 in the past due to falling. PT #1 stated Resident #30 never had any issues in therapy when staff applied a gait belt around his/her waist. Additionally, the resident had never refused to have a gait belt applied in therapy and Resident #30 had never complained about tightness or pain when applied to the waist, due to gait belt use when transferring or ambulating.Interview and record review with the Unit Manager Registered Nurse (RN) # 2 on 7/1/26 at 11:28 AM identified that it was the facility's policy for NAs to always have gait belts on their person and apply them to residents during transfers unless the resident refused. If the resident refused, a Resident Care Plan would be developed to address the refusals and include modified interventions as needed to reduce the risk of falling. Review of Resident #30's fall on 3/25/26 identified he/she was being assisted from bed to the chair by 2 staff members, his/her knees buckled and the resident was lowered to the floor. RN #2 stated she called the APRN who was in house at the time, sent the resident to the hospital, and he/she ended up with right ankle fractures. Additionally, RN #2 identified the NA' did not apply a gait belt to Resident #30 because he/she did not like to wear it, even though staff was educated on gait belt application during transfers. Although RN #2 was aware Resident #30 did not like to wear his/her gait belt, she was unable to identify a Resident Care Plan for gait belt refusals and stated other safety measures could have been explored such as a different type of gait belt or therapy involvement when the refusals were identified.Interview with the Director of Nursing (DNS) on 7/1/26 at 11:39 AM identified that although the facility did not have a policy on gait belt use, it was a standard of care for use during transfers. If the resident refused to wear a gait belt, a Resident Care Plan would have been initiated addressing the refusal. The DNS indicated Resident #30 did not have a Resident Care Plan for gait belt refusals since refusals had not occurred during physical therapy or at any other time prior to his/her fall on 3/25/26. Following Resident #30's fall NA #1 and NA #2 received education on 3/30/36 and 3/31/26 as to what should be done for gait belt refusals, the need to follow the Resident Care Plan and NA Care Card, that a gait belt was used as a safety tool and any refusals needed to be reported to the charge nurse immediately. Additionally, the DNS identified each NA had their own gait belt which was required to be kept on their person at all times, and if needed, extra gait belts were located in central supply.Interview with Resident #30 on 7/1/26 at 11:47 AM identified he/she recalled the fall on 3/25/26, stating that's when this happened, pointing to the boot on his/her right leg. The resident stated 2 NA's were helping him/her from the bed to the chair when his/her knee buckled and he/she fell. Although Resident #30 could not recall if he/she had a gait belt on at the time of the fall, he/she stated, I always let them, referring to the application of the gait belt. Further, Resident #30 indicated that he/she did not refuse gait belt application, but disliked when NA's placed the gait belt around his/her chest and over his/her breasts as it would ride up and caused discomfort to his/her breasts and under the arms.Interview with NA #3 on 7/1/26 at 12:01 PM, who was assigned to Resident #30's unit stated that she had a gait belt, however she could not produce it upon her person because it was currently located in her purse.Re-interview and facility documentation review with the DNS on 7/1/26 at 12:20 PM identified gait belt education was provided in the form of annual competencies, which included gait belt placement to be under the breasts, not over the breasts, even in heavier set individuals. Additionally, the DNS indicated she did not feel gait belt use could have prevented Resident #30 being lowered to the floor, that he/she would have gone down to the floor even with a gait belt, and possibly still sustained a fracture due to his/her diagnoses. Review of the Nursing Assistant Clinical Checklist and Competency Evaluation, Skill #24 transfers from bed to wheelchair using a transfer belt directed to apply a transfer belt securely at the waist over clothing/gown before assisting the resident to a standing position. Additionally, on signal, gradually assist the resident to stand by grasping the transfer belt on both sides with an upward grasp maintaining stability of client's legs by standing knee to knee or toe-toe with the resident.Interview with the Director of Rehabilitation (PT) #2 on 7/1/26 at 1:19 PM identified he did not have the facility's policy on gait belts, but gait belt placement varied from person to person, ideally the gait belt should be placed on the resident's natural wait, however for larger women the gait belt placement might be more comfortable around the breasts. Additionally, PT #2 identified that it would be situational whether the lack of gait belt placement would contribute to a resident being lowered to the floor, and a gait belt might not prevent lowering to the floor for both the safety of the resident and the staff.Although requested, the facility did not have a Gait Belt Policy and/or the facility did not have a Transfer Policy or failed to provide a transfer policy.Review of the Fall Prevention Policy directed in part that the policy established evidence-based strategies for prevention assessment intervention and staff accountability. According to manufacturer application instructions which were in the new gait belt packaging, the gait belt should be placed around the patient's clothed waist with the buckle open at the front and the labels facing the patient. The manufacturer's directions did not indicate that a gait belt could be placed over a resident's breast area.

Based on observations, interviews, review of the clinical record and facility policy, for 2 of 3 sampled residents (Resident #72 and #91) reviewed for infection control practices, for Resident #72 the facility failed to ensure adherence to Enhanced Barrier Precautions, and for Resident #91, failed to perform appropriate hand hygiene according to infection control practices. The findings include:1. Resident #72's diagnoses included bone cancer, and hydronephrosis (swelling of the kidneys) caused by kidney stones, and had indwelling nephrostomy tubes (kidney drainage tubes.) The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #72 had a Brief Interview for Mental Status score of 15 indicating intact cognition, and required total staff assistance for personal hygiene, and upper and lower body dressing. The MDS identified Resident #72 had an indwelling catheter for urinary drainage and was always incontinent of stool. A physician's order dated 6/17/26 directed staff to follow Enhanced Barrier Precautions (EBP) prevents infection transmission) due to bilateral nephrostomy tubes. The Resident Care Plan in effect from 4/23/26 through 6/29/26 identified Resident #72 was on EBP due to bilateral nephrostomy tubes. Interventions included directing staff to wear gowns and gloves when providing direct patient care. Observation on 6/29/26 at 10:30 AM identified a sign posted outside Resident #72's room door indicating EBP and directed Personal Protective Equipment (PPE) during direct patient care. A storage bin stocked with gloves and gowns to comply with PPE requirements was available directly outside of the resident's room. On 6/29/26 at 10:29 AM 2 Nurse Aids (NA) #2 and NA #3 entered Resident #27's room without the benefit of placing on PPE. At 10:35 AM NA #2 and NA #3 were observed to be leaning over the bed, (with uniforms touching the bed and bed linens,) and were assisting Resident #72 to be repositioned. A wash basin with water was observed on the over-bed table, and Resident #72 was noted with his/her hospital gown raised to the waist, and wearing an incontinence brief. An interview with NA #2 on 6/29/26 at 10:40 AM identified she was aware of Resident #72's for EBP and that she should have followed the precautions. An interview with NA #3 on 6/29/26 at 10:45 AM identified she was aware of Resident #72's need for EBP and that she should have followed the precautions but that she had forgotten. An interview with Infection Control Nurse Registered Nurse (RN) #1 on 7/1/26 at 9:50 AM identified Resident #72 required the use of EBP and PPE during direct care activities due to having bilateral nephrostomy tubes. The NA's providing care during the observation on 6/29/26 should have worn PPE. Review of the Enhanced Barrier Precautions (EBP) Policy dated 4/16/26 directed in part that the facility would implement Enhanced Barrier Precautions (EBP) for residents identified as high risk for targeted multi-drug-resistant organism (MDRO) transmission and that EBP would be used during high-contact care activities including dressing, bathing, or showering, transferring or repositioning, and changing linens. Additionally, EBP would apply to any resident with a urinary catheter or drain and that staff must wear gloves and gowns during high-contact care activities. 2. Resident #91's diagnoses included cellulitis of the right lower extremity (RLE), pressure ulcers of the sacral region, buttock, and right lower back, generalized muscle weakness, and Type II diabetes mellitus. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #91 had a Brief Interview of Mental Status score of 15 indicating intact cognition, was completely dependent for bed mobility, chair/bed to chair transferring and upper/lower body dressing and had 1 or more unhealed pressure ulcers A physician's order dated 6/16/26 directed to cleanse the external genitalia with Dakins 0.125% (quarter strength), apply Dakins 0.125% moistened gauze and cover with ABD pad twice daily and PRN (as needed). A physician's order dated 6/17/26 directed to cleanse the right buttock wound with wound cleanser, apply collagen with silver to wound bed, apply house barrier cream to surrounding tissue, cover with foam silicone border dressing, followed by ABD pad, change daily and PRN. Observation and interview with RN #5 on 6/29/26 at 11:33 AM during Resident #91's external genitalia wound care identified that RN #5 performed hand hygiene prior to placing on clean gloves. RN #5 then removed the resident's soiled dressing and discarded it in the trash, along with her gloves. RN #5 was then observed to place a new pair of gloves on without performing hand hygiene. The surveyor stopped Resident #91's treatment. RN #5 indicated she was aware that hand washing should have occurred when discarding old gloves and prior to putting on new gloves. RN #5 stated that she was preoccupied with finding the correct glove size during the wound care and it must have slipped her mind. Interview with RN #1 (Infection Preventionist) on 7/1/26 at 10:47 AM identified per the facility policy, staff should be performing hand hygiene between taking off the first set of gloves and placing on a second pair. Review of the Enhanced Barrier Precautions Policy directed in part that hand hygiene must be performed before placing on and after personal protective equipment (gloves).

Based on a clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure appropriate pain management and documentation. Specifically, licensed nursing staff did not document administered pain relief medication, did not complete a pain reassessment within one (1) hour of administration, and did not provide additional pain relief or interventions despite Resident #1 experiencing ongoing severe pain and having a confirmed fracture prior to transfer to the Emergency Department (ED). The findings include:Resident #1's diagnoses included low back pain, type I diabetes mellitus with diabetic neuropathy (nerve damage caused by persistently high blood sugars), long term use of anticoagulants (medication that prevents blood clots), absence of the left leg above the knee, and anxiety disorder.A Physician's order dated 10/8/25 directed to administer acetaminophen 325 milligrams (mg), two (2) tablets by mouth every four (4) hours as needed for pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance with bed mobility, and was dependent on staff for toileting hygiene and transfers.The Resident Care Plan (RCP) dated 2/20/26 identified Resident #1 had chronic pain related to a cerebral infarction (an ischemic stroke caused by reduced blood flow to brain tissue) due to thrombosis of the right carotid artery (a blood clot in the primary artery supplying blood to the right side of the face and brain), and a left above knee amputation following hemiparesis (muscle weakness/partial paralysis affecting one side of the body) and hemiplegia (paralysis of one entire side of the body). Interventions included administering analgesia per order, anticipating Resident #1's need for pain relief and responding immediately to any pain complaint, evaluating the effectiveness of pain interventions and Resident #1's satisfaction with results, monitoring and recording pain characteristics, and notifying the physician if interventions were unsuccessful or represented a significant change from Resident #1's past pain experience.An Summary Background Assessment and Recommendation (SBAR) note by RN #1 dated 5/8/26 at 12:37 AM identified NA #1 reported on 5/7/26 at 10:45 PM that Resident #1 rolled out of bed onto the floor mat during repositioning. On arrival, Resident #1 was on his/her back on the window side of the bed with his/her head at the footboard and feet toward the headboard, reporting seven (7) out of ten (10) right knee pain. Acetaminophen was documented as administered for pain relief. No changes in mentation were noted. The on call provider was notified, and new orders were obtained for a STAT right knee x ray and for staff to monitor Resident #1's pain.The May 2026 Medication Administration Record (MAR) failed to identify acetaminophen administration following the 5/7/26 fall until 5/8/26 at 9:00 AM, approximately eleven (11) hours and fifteen (15) minutes later. A pain level of eight (8) out of ten (10), indicative of severe pain, was documented at that time.The clinical record failed to identify a pain reassessment following the 10:45 PM fall when Resident #1 reported severe pain rated seven (7) out of ten (10).A Medication Administration note by LPN #3 dated 5/8/26 at 9:00 AM identified acetaminophen 650 mg was administered to Resident #1.A pain level of eight (8) out of ten (10), indicating severe pain, was documented at 9:00 AM on 5/8/26.The clinical record failed to identify a pain reevaluation within one (1) hour of the 9:00 AM acetaminophen administration.An SBAR note by RN #3 dated 5/8/26 at 12:18 PM identified intermittent right knee pain, edema, and decreased mobility. Ice and acetaminophen were administered. The STAT x ray was completed, revealing an acute right patella fracture (a break in the kneecap). APRN #1 assessed Resident #1 and new orders were obtained to transfer Resident #1 to the ED for further evaluation.Review of the clinical record identified a pain level of eight (8) out of ten (10) at 12:47 PM (three (3) hours and forty seven (47) minutes after the 9:00 AM administration) and a pain level of three (3) out of ten (10) at 1:36 PM, both documented by LPN #3. No additional pain relief medication was documented as administered.A Change in Condition note by LPN #3 dated 5/8/26 at 1:36 PM identified Resident #1 complained of right knee pain and had been given acetaminophen at 9:00 AM with fair effect. A mobile x ray confirmed a right patella fracture, and Resident #1 was transferred to the ED.The Radiology Result Report dated 5/8/26 identified a right knee x ray obtained at 11:00 AM and reported at 11:18 AM, confirming a mid to inferior patella pole fracture with distracted fragments.A Provider note by APRN #1 dated 5/8/26 at 2:15 PM identified she evaluated Resident #1 following notification that the x ray confirmed a right patella fracture. Resident #1's right knee was swollen, and Resident #1 reported ten (10) out of ten (10) pain with movement. Resident #1 was transferred to the ED for further evaluation.Review of the clinical record failed to identify pain medication administration following the confirmed fracture and prior to ED transfer, despite Resident #1 experiencing severe pain.Review of the Prehospital Care Report (ambulance run sheet) dated 5/8/26 identified they were notified of a fall with injury. Upon arrival at 1:47 PM, Resident #1 was lying in bed and staff reported Resident #1 rolled out of bed at approximately 10:30 PM on 5/7/26. Nursing staff identified Resident #1 had an x-ray of the right knee completed at the facility which resulted with a right patella fracture. Resident #1 complained of eight (8) out of ten (10) right knee pain on assessment. Resident #1's right knee was swollen with mild bruising. Nursing staff reported they last medicated Resident #1 with acetaminophen for pain at approximately 8:00 AM on 5/8/26.Hospital documentation dated 5/8/26 identified a pain assessment at 3:30 PM with a pain level of seven (7) out of ten (10).Interview with LPN #1 on 6/3/26 at 11:57 AM identified she thought she administered acetaminophen to Resident #1 around 11:00 PM (fifteen (15) minutes after the fall) on 5/7/26 after Resident #1 was transferred back to bed, but did not document the administration. LPN #1 identified she should have signed the MAR so the oncoming licensed nurse would re evaluate Resident #1's pain for effectiveness.Interview with RN #1 on 6/3/26 at 12:16 PM identified she documented in her 5/8/26 SBAR note that acetaminophen was administered following the fall; however, she did not administer or witness its administration. She instructed LPN #1 to administer the medication and identified Resident #1's pain should have been reassessed within one (1) hour.Interview with LPN #3 on 6/3/26 at 2:54 PM identified she administered acetaminophen at 9:00 AM and should have reevaluated Resident #1's pain within one (1) hour but was unable to do so for approximately three (3) hours and seventeen (17) minutes due to a heavy medication pass. When she reevaluated, Resident #1 continued to report right knee pain. She did not administer additional pain relief because Resident #1 was being transported to the ED and she assumed the ED would medicate Resident #1 upon arrival. She identified she should have administered pain relief prior to transport given the severe pain with movement.Interview with RN #2 on 6/3/26 at 3:09 PM identified she could not recall being notified by LPN #1 that acetaminophen was administered at approximately 11:00 PM. She did not complete a pain assessment within one (1) hour and only remembered Resident #1 experiencing pain with movement.Interview with the Director of Nursing (DON) on 6/3/26 at 3:41 PM identified Resident #1 should have been medicated for pain relief immediately following identified severe pain. The acetaminophen should have been signed in the MAR when administered. Once pain relief medication is administered, pain should be reassessed within one (1) hour, and if ineffective, additional pain interventions should be implemented or the provider should be notified. The DON identified that due to the confirmed fracture and severe pain with movement, Resident #1 should have been offered and/or administered pain medication prior to transfer to the ED.Interview with APRN #1 on 6/3/26 at 3:46 PM identified licensed nurses should evaluate pain and reassess pain following medication administration per facility policy. If pain interventions are ineffective, nurses should notify the provider. On 5/8/26 she assessed Resident #1 following notification of the fracture, identified severe pain with movement, and directed staff to transfer Resident #1 to the ED. She identified Resident #1 should have been offered and/or administered pain relief prior to ED transfer.Resident #1 was unavailable for interview.The Pain Clinical Protocol policy dated 3/2018 directed staff to assess pain upon admission, at quarterly review, with a significant change in condition, and with onset or worsening of pain. Staff were to identify pain characteristics, use a standardized pain assessment instrument, reassess pain at regular intervals (each shift for acute pain), and evaluate the effectiveness of standing and PRN analgesics. If pain was complex or unresponsive, the Attending Physician may consider additional consultation.The Charting and Documentation policy directed all services provided, progress toward goals, changes in condition, and medications administered be documented in the medical record.A policy on pain medication reevaluation was unavailable.

Based on a clinical record review, facility documentation, facility policy, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for falls with major injury, the facility failed to ensure a STAT x ray was obtained in a timely manner by not contacting the diagnostic provider when they failed to arrive within the required four (4) to six (6) hour timeframe. As a result, the x ray was not performed for approximately eleven (11) hours, and the provider was not notified of the delay, resulting in delayed diagnosis and treatment. The findings include:Resident #1's diagnoses included low back pain, type I diabetes mellitus with diabetic neuropathy, long term use of anticoagulants, absence of the left leg above the knee, and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance with bed mobility, and was dependent on staff for toileting hygiene and transfers.The Resident Care Plan (RCP) dated 2/20/26 identified Resident #1 had actual falls and was at risk for falls related to confusion, deconditioning, psychoactive medication use, and a left above knee amputation. Interventions included anticipating and meeting Resident #1's needs and following the facility fall protocol.A Summary Background Assessment and Recommendation (SBAR) note by RN #1 dated 5/8/26 at 12:37 AM identified NA #1 reported on 5/7/26 at 10:45 PM that Resident #1 rolled out of bed onto the floor mat during repositioning. RN #1 notified the on call provider and received new orders for a STAT right knee x ray.A Physician's order dated 5/8/26 directed to obtain a STAT right knee x ray.The clinical record dated 5/8/26 failed to identify documentation that the diagnostic provider was contacted to inquire about the delayed arrival of the technician for the STAT x ray.A Nurse's note by RN #2 dated 5/8/26 at 5:23 AM identified the right knee x ray was scheduled for the morning.The Radiology Result Report dated 5/8/26 identified the right knee x ray was obtained at 11:00 AM (approximately twelve (12) hours and fifteen (15) minutes after the fall) and resulted at 11:17 AM confirming a mid to inferior patella pole fracture with distracted fragments.An SBAR note by RN #3 dated 5/8/26 at 12:18 PM identified the STAT x ray had been completed and confirmed an acute right patella fracture. APRN #1 assessed Resident #1 and ordered transfer to the Emergency Department (ED) for further evaluation.Interview with RN #1 on 6/3/26 at 12:16 PM identified she was the nursing supervisor from 7:00 PM on 5/7/26 to 7:00 AM on 5/8/26. She reported calling the STAT x ray order to the diagnostic provider at approximately 11:00 PM on 5/7/26. Although STAT orders should be completed within four (4) to six (6) hours, she reported overnight delays of eight (8) hours or more were not uncommon. She did not follow up with the diagnostic provider when the technician failed to arrive, and she did not notify the on call provider of the delayed STAT order.Interview with Person #1 (diagnostic provider account representative) on 6/3/26 at 1:45 PM identified the x ray order was received on 5/7/26 at 11:47 PM. STAT exams should be obtained within four (4) to six (6) hours. The technician arrived on 5/8/26 at 10:29 AM and the exam was resulted at 11:17 AM. Person #1 could not identify whether the facility called to inquire about a delayed arrival.Interview with RN #3 on 6/3/26 at 2:41 PM identified she was the nursing supervisor from 7:00 AM to 3:00 PM on 5/8/26. She was aware the STAT x ray had not been completed at the start of her shift. When she attempted to call the diagnostic provider at approximately 11:00 AM, the technician had just arrived. RN #3 identified the overnight shift should have contacted the diagnostic provider once the STAT order exceeded six (6) hours.Interview with RN #2 on 6/3/26 at 3:09 PM identified she was the charge nurse on the overnight shift from 5/7/26 into 5/8/26. Despite the diagnostic provider not arriving by 6:00 AM, she did not call to inquire about their arrival, stating it was not uncommon for the technician to arrive after the start of the 7:00 AM to 3:00 PM shift.Interview with the Director of Nursing (DON) on 6/3/26 at 3:41 PM identified the facility had ongoing concerns with the diagnostic provider's response times. Nursing supervisors were responsible for contacting the diagnostic provider when a STAT order exceeded four (4) to six (6) hours and were expected to notify the provider and request further direction. The DON identified there was no documentation to show the physician was notified of the delay.The diagnostic provider's Standard Service Terms and Conditions policy dated 2026 directed STAT x rays were available upon request and that customers could call the provider at any time for an update on any order, including STAT orders.Although requested, a facility policy on STAT diagnostic test timeframes was not available.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) reviewed for resident rights, the facility failed to ensure resident rights were protected and free from interference from the facility in exercising their rights for Leave of Absence (LOA) from the facility, as per facility practice for physician orders for no LOA for all resident admissions. The findings include: Resident #4 was admitted to the facility during the beginning of 2/10/2026 with diagnoses that included a right femur fracture and diabetes. Nursing admission note dated 2/10/2026 at 11:56 AM identified Resident #4 was admitted from the hospital after a fall and surgical repair of a right hip fracture. Resident #4 was alert, oriented to person, place, time and situation, and required assistance with personal hygiene and mobility, and was able to make his/her needs known. Discharge was planned to return to the community. Nursing elopement risk assessment dated [DATE] identified Resident #4 was not a risk for elopement from the facility. Record review identified Resident #4 signed the Admissions Agreement for his/her admission to the facility. A physician order dated 2/10/2026 directed resident may not go out on leave of absence (LOA). The Resident Care Plan (RCP) dated 2/11/2026 identified discharge to the community (home) was anticipated in three (3) to four (4) weeks. Interventions directed to assist with community support resources and services. The admission Minimum Data Set (MDS) assessment dated [DATE], Section F - Preferences for Customary Routine and Activities, section F500, Activity Preferences, identified it was somewhat important to Resident #4 to go outside to get fresh air when the weather was good. Nursing note dated 2/17/2026 at 11:58 AM identified Resident #4 was alert and oriented to person, place, time and was noted to have short term memory impairment. APRN note dated 2/24/2026 at 9:30 AM identified Resident #4 was alert and oriented times three (3) and continued with physical and occupational therapy, with an improvement in mobility noted. Interview with Resident #4 on 2/26/2026 at 10:42 AM identified he/she would like to go on a LOA on a day to spend some time visiting with his/her grandchildren. And he/she was not aware the facility allowed any LOA for residents. Interview and record review with LPN #1 on 2/26/2026 at 12:59 PM identified she was a full-time nurse at the facility and had worked there for over 15 years. LPN #1 stated Resident #4 had a standard physician order that directed Resident #4 may not leave the facility on a LOA. LPN #1 stated orders are entered in the clinical record for all residents upon admission that direct no LOA. LPN #1 stated if a resident requests to go on a LOA, they need to ask permission and then the nurse calls the physician or APRN to get orders for a one-time (1) LOA from the facility. LPN #1 further stated LOA orders are only obtained if a resident or family member requests to go on an LOA, and only obtained for one-time LOAs, then if they want to go on another LOA, they again have to ask again. Interview and record review with RN #1 on 2/26/2026 at 1:05 PM identified she was the RN supervisor/unit manager that covered both short-term and long-term care units. RN #1 stated the electronic medical record system automatically defaults to directed no LOA for all short-term and long-term care residents. RN #1 stated if a resident wants to leave the building on a LOA, the resident has to ask (staff), and then staff would call the physician/APRN to obtain an order. Once a physician order is obtained, the resident must be assessed by physical therapy before they are allowed to leave on a LOA. RN #1 stated the reason for automatic no LOA orders and not allowing residents to leave on LOA was due to insurance reimbursement, and any request would be addressed on a case-by-case basis. Interview with RN #2 on 2/26/2025 at 1:15 PM with RN #2 identified she was a facility RN supervisor/unit manager for one of the nursing units and stated all residents are admitted with physician orders that direct no LOA. RN #2 stated short- or long-term residents need to request an order for an LOA each time they want to leave the facility. When a resident requests and order, the physician/APRN may (or may not) give an order. If an order for LOA is obtained, the resident must be assessed by physical therapy before they are allowed to leave on a LOA. RN #2 stated it usually takes a day or a couple of days to obtain the order. Interview and record review on 2/26/2026 at 1:26 PM with the Director of Social Services/SW #1 identified all residents are admitted with physician orders for no LOA. If a resident would like to go on a LOA from the facility, nursing needs to obtain an order from the physician/APRN. Then, once an order was obtained, the resident must have a physical therapy evaluation before able to leave on a LOA. Interview and record review with PT #1 (Rehab Manager) on 2/26/2025 at 2:03 PM identified all residents are admitted with an automatic no LOA order. PT #1 stated residents must be cleared medically prior to any LOA order. PT #1 stated nursing has to obtain a doctors order first, then physical therapy evaluates if resident can safely transfer with/without a responsible party before cleared for LOA. Interview and review of facility documentation with the Administrator on 2/26/2026 at 2:55 PM identified the facility admission Welcome Book discusses LOAs from the facility and it refers residents and/or their responsible parties to pages 2-3 in the Admissions Agreement for any questions regarding LOAs. Review of the facility admission Welcome Book directed in part, for leave of absences please speak with the business office manager or refer to pages 2 and 3 in the Admissions Agreement for any questions regarding leave of absence(s). Requests for leave of absence require a physician approval. Please be sure to notify nursing supervisor at least 24 hours prior. Review of the Admissions Agreement failed to identify a page 2 and page 3 that referred to LOA from the facility; the pages were not numbered. Additional review of facility Resident Admissions Agreement packet identified item number 7 (seven) Leaves of Absence directed in part; the facility and its owners assume no responsibility for any personal injury, illness or deterioration in the resident's condition that may occur when the resident is temporarily absent from the facility, with or without physician or facility approval. The resident and responsible party release the facility, its owners, directors, officers and employees from all liability for any personal injury, illness, or deterioration in the resident's condition that may occur while resident is temporarily absent from the facility. However, the Admissions Agreement packet pages were not numbered, and no page 2 or 3 was provided, and failed to identify the Agreement directed there were no LOA privileges provided unless a request was made for an LOA at least 24 hours prior. Interview and record review with ADNS and DNS on 2/26/2026 at 3:03 PM identified the facility did not have a LOA policy but instead followed a LOA process. Upon admission, all residents receive orders marked no LOA, indicating the resident may not go on LOA. If a resident requests to go on a LOA, the physician/APRN would be notified to obtain an order, and the resident must be assessed by physical therapy before they are allowed to leave on a LOA. Although the DNS stated residents receive an admission Welcome Book and welcome speech covering LOAs, a copy was not provided for surveyor review. Review of facility Resident's [NAME] of Rights Policy dated 2/6/2026 directed in part, you have the right to exercise your rights as a citizen. The facility must protect and promote your rights and encourage and assist you in exercising them. Although requested Leave of Absence policy or policy evaluation/assessment before LOAs were allowed were not provided for surveyor review.

Based on observations, review of clinical records, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for accidents, staff failed to move the food service cart in a safe manner to ensure no residents were in the path. The failure resulted in a resident fall with injury. The findings include: Resident #1's diagnoses included dementia, glaucoma, and schizoaffective disorder. The Resident Care Plan (RCP) dated 6/11/2025 identified Resident #1 ambulated independently with a cane. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen, indicative of severe cognitive impairment, and required supervision with ambulation. Physician order dated 8/14/2025 directed independent ambulation in room and hall with or without single point cane (SPC). Facility Reportable Event dated 8/27/2025 at 9:30 AM identified Resident #1 was alert and forgetful and ambulated independently with a cane. Resident #1 exited his/her room at the same time the food service cart was passing by the room. Resident #1 made contact with the food service cart and fell on his/her left side. Resident #1 was transferred to the hospital and identified to have a left femoral fracture (broken upper leg bone). Review of the hospital x-ray results dated 8/27/2025 identified diffuse osteopenia (decreased bone density), and a left intertrochanteric (upper thigh bone) femoral fracture. Hospital Discharge summary dated [DATE] identified Resident #1 underwent a surgical Open Reduction Internal Fixation (ORIF) and directed weight bearing as tolerated (WBAT) and use of a Sara lift with two (2) staff for transfers. Resident #1 was readmitted to the facility on [DATE] and Resident #1 used a wheelchair (was non-ambulatory). Facility Reportable Event Summary dated 9/3/2025 identified Resident #1's cane came into contact with the bumper of the food service cart when he/she exited his/her room. Resident #1 stumbled and fell onto his/her left side with the upper torso (body) landing in the room. The food service cart was 6 foot, 2 inches tall and 23.5 inches wide with a bumper that extends outward four (4) inches. NA #1 looked to his left and right to be sure no one was in his pathway as he proceeded to push the food cart forward. A re-enactment identified Resident #1's cane would have come into contact with the food service cart bumper which caused Resident #1 to lose his/her balance and fall. Interview and record review with NA #1 on 9/9/2025 at 1:02 PM identified he started to push the food service cart back to the kitchen and checked both sides of the cart to be sure no one was in his path. As he was pushing, he felt something on the left side of the cart and saw that the cart made contact with a resident who had just come out of his/her room. NA #1 stated Resident #1 was stumbling and fell. NA #1 stated he could not see over the food service cart when he was pushing it. Although attempted, an interview with LPN #1 was not obtained during the survey. Interview, and record review with the DNS on 9/9/2025 at 1:37 PM identified Resident #1 ambulated independently and had no prior history of falls. As NA #1 was pushing the food cart Resident #1 came into contact with the bumper of the cart, lost his/her balance and fell. The DNS stated staff should ensure they are looking when moving carts to ensure the pathway remains clear of residents. Review of the facility Accident/Incident Prevention Policy directed in part, to make the environment as free from accident hazards as possible. Review of facility documentation identified staff education was initiated on 9/3/2025 that directed transportation of meal carts must prioritize safety, dietary staff will bring food service carts to the units and then NAs are responsible for maneuvering the cart into the appropriate serving area, an audible alert and/or light mechanism will be attached to each cart to alert staff/residents the cart is moving, all staff must be trained in safe cart handling, and when returning meal carts to the kitchen, the meal carts must be accompanied by two (2) staff members. Audits were initiated on 9/3/2025 and a QAPI meeting was held on 9/3/2025. Based on documentation review a finding of past-non-compliance was identified.

Based on review of the clinical record, facility documentation, facility policy, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure wheelchair footrests were in place to support a safe transfer. Resident #1, who was severely cognitively impaired, was directed by staff to lift his/her feet during the transfer; subsequently, the resident fell from the wheelchair and sustained multiple fractures. The findings include: Resident #1 's diagnoses included dementia with behavioral disturbances, mood disorder and muscle weakness. Review of the Morse Fall Scale assessment dated [DATE] identified that Resident #1 had a history of falls, exhibited an impaired gait (abnormal walking pattern) and overestimates or forgets his/her own limits, categorizing the resident as a high risk for falling. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and was dependent on staff for bed mobility and transfers. Additionally, the MDS identified Resident #1 had not exhibited any behaviors. The Resident Care Plan (RCP) dated 5/26/25 identified Resident #1 was at risk for falls due to confusion, deconditioning and gait/balance problems. Interventions included anticipate and meet needs, appropriate footwear, and attempt to determine root cause of falls. The RCP identified Resident #1 had impaired cognition, a self-care deficit and was an assist of 1 with transfers. The facility Reportable Event (RE) dated 5/30/25 identified at 9:00 PM NA #1 was transporting Resident #1 in his/her wheelchair in the hallway when Resident #1 put his/her feet down to the ground, stopping the wheelchair abruptly, and caused Resident #1 to fall forward out of the wheelchair sustaining a lump to the forehead. The RE identified the family and provider were notified and an order was obtained to transfer Resident #1 to the Emergency Department (ED) for further evaluation. Resident #1 further sustained a mildly displaced odontoid neck fracture (fracture of the bony projection from the second cervical vertebrae) and a fracture of the first cervical vertebrae. The RE identified that following the incident, footrests were to be applied to the wheelchair for all staff transports outside of the room. Review of staff statements failed to identify statements from LPN #1 (assigned nurse) and LPN #2 (additional unit nurse). Review of the hospital documents dated 5/30/25 identified Resident #1 was transported to the ED from the facility and the facility reported Resident #1 was agitated, did not want to be moved, staff moved him/her anyways and Resident #1 did what he/she always does, stuck his/her right foot out straight, leading to a fall forward. The note indicated Resident #1 had a small laceration to the upper forehead, denied pain and a cervical collar was intact to the neck. It identified head and cervical spine imaging was obtained and resulted in a prominent anterior (front) scalp hematoma (a closed wound where blood collects and fills a space because it cannot flow out or drain), a mildly displaced fracture of the odontoid neck (a fracture through the bony projection from the second cervical vertebrae where the fragment shifted out of alignment) and non-displaced fractures (when the bone fragment remains aligned and in normal position) of both sides of the posterior (backside) arch of the first cervical vertebrae (C1). The RCP revised 5/30/25 identified Resident #1 was at risk for falls due to confusion, deconditioning and gait/balance problems and had an actual fall out of the wheelchair resulting in cervical fractures (vertebrae in the neck). Interventions included anticipating and meeting the resident's needs, observing/documenting/reporting to the provider any changes in mental status and ensuring footrests are in place to the wheelchair during transport and removing them after transport so that the resident may self-propel. Interview with NA #1 on 6/16/25 at 11:14 AM identified that on 5/30/25, Resident #1 was given a trash bag necklace consisting of a ribbon attached to a small plastic bag that Resident #1 was proudly wearing around his/her neck. NA #1 identified that between 8:00 PM and 9:00 PM, Resident #1 self-propelled in his/her wheelchair down to the West-Unit and was showing LPN #2 (agency nurse) the necklace. Resident #1 was heard yelling and NA #2 was pushing Resident #1 back to his/her room. She reported Resident #1 immediately went back into the hallway and self-propelled back to the West-Unit and yelled at LPN #2. NA #1 identified LPN #2 stated she did not have time for Resident #1 and directed her (NA #1) to bring Resident #1 back to his/her room again. NA #1 identified Resident #1's behavior continued to escalate but LPN #2 was insistent Resident #1 be brought back to his/her room. NA #1 then instructed Resident #1 to lift his/her feet and then she started to push Resident #1 in the wheelchair until Resident #1 abruptly placed his/her feet down on the ground, causing the wheelchair to stop and Resident #1 fell forward out of the wheelchair to the floor. NA #1 identified that LPN #2 taking the necklace off Resident #1, throwing it in the garbage in front of him/her without calmly explaining why, then continuing to dismiss Resident #1 when he/she reapproached LPN #2 angrily, caused an escalation in Resident #1's behaviors. NA #1 indicated the incident could have been avoided if LPN #2 was respectful to Resident #1. Interview with NA #3 on 6/16/25 at 11:29 AM identified she was in the hallway when LPN #2 took the necklace off Resident #1, causing Resident #1 to become angry and yell. NA #3 indicated LPN #2 dismissed Resident #1 and directed staff to get Resident #1 away from her which caused Resident #1's behaviors to escalate and Resident #1 became fixated on LPN #2. NA #3 identified she observed LPN #2 direct NA #1 to assist Resident #1 back to his/her room as Resident #1 was still yelling at LPN #2. Resident #1 allowed NA #1 to start pushing him/her in the wheelchair but then abruptly placed his/her feet down to the ground and fell forward out of the wheelchair to the floor. Interview with NA #2 on 6/16/25 at 11:37 AM identified Resident #1's baseline mood was either very happy or very upset, and although she knew the necklace Resident #1 was wearing on 5/30/25 was a safety hazard and needed to be removed, the necklace made Resident #1 happy as he/she self-propelled the hallway in the wheelchair showing those who walked by. NA #2 identified she was watching Resident #1 and planned to take the necklace off when she assisted Resident #1 to get ready for bed. She reported Resident #1 self-propelled to the West-Unit from the East-Unit and started to show LPN #2 his/her necklace. LPN #2 became upset about Resident #1 wearing the necklace, immediately took the necklace off Resident #1 without explaining why she was doing so and then threw the necklace in the garbage in front of Resident #1. NA #2 reported Resident #1 immediately became angry and started yelling at LPN #2, and LPN #2 stated Resident #1 was becoming too disruptive and directed her (NA #2) to push Resident #1 back to his/her room. Interview with LPN #2 on 6/16/25 at 1:59 PM identified that on 5/30/25, Resident #1 self-propelled in his/her wheelchair down to the West-Unit, where she was passing medications. She reported Resident #1 approached her, and she observed Resident #1 wearing a plastic bag attached to ribbon around his/her neck like a necklace. LPN #2 indicated the necklace was a safety hazard, and although she had never met Resident #1, and did not inquire with other staff (NAs) for assistance, while the assigned nurse (LPN #1) was on break, she removed the necklace and threw it in the garbage. She reported Resident #1 became agitated, so she asked NA #2 to bring Resident #1 back to his/her room but Resident #1 returned and was disruptive so she asked NA #1 to bring Resident #1 back to his/her room but as NA #1 started to push Resident #1, Resident #1 put his/her feet down causing a fall forward out of the wheelchair. LPN #2 identified she should not have thrown away the necklace in front of Resident #1 and further identified Resident #1 was confused and appeared to be sundowning. LPN #2 indicated she did not play into Resident #1's behaviors which is why she did not respond to Resident #1 when he/she spoke to her. LPN #2 identified the facility never requested that she write a statement regarding the incident. Review of the Medication Administration Record (MAR) for May 2025 failed to identify any documented incidents of agitation leading up to the 5/30/25 incident. Interview with the DNS on 6/16/25 at 3:00 PM identified staff should treat residents with dignity and respect and LPN #2 should not have approached Resident #1 the way she did and should not have thrown the necklace away in front of Resident #1. The DNS identified that when Resident #1 became upset, LPN #2 should have addressed Resident #1's concerns prior to directing the NA's to bring Resident #1 back to his/her room. The DNS indicated Resident #1 had dementia and LPN #2 should have had empathy and allowed Resident #1 to communicate his/her feelings and/or concerns. She further indicated that although Resident #1 self-propelled independently in the wheelchair, the NA's should have applied footrests prior to transporting Resident #1 back to his/her room. Additionally, the DNS identified statements should have been obtained from LPN #2 and LPN #1 following the 5/30/25 incident. Although attempted, Resident #1 was unable to be interviewed. Review of the Quality of Life- Dignity policy dated 08/2009 directed, in part, that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times and staff shall speak respectfully to residents at all times. Staff shall treat cognitively impaired residents with dignity and sensitivity by addressing the underlying motives or root causes for behavior and not challenging or contradicting the residents' beliefs or statements. Although requested, a policy for wheelchair footrests with wheelchair transfers was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure a resident was treated in a respectful and dignified manner which caused an escalation of behaviors resulting in a fall with fractures. The findings include: Resident #1 's diagnoses included dementia with behavioral disturbances, mood disorder and muscle weakness. Review of the Morse Fall Scale assessment dated [DATE] identified that Resident #1 had a history of falls, exhibited an impaired gait (abnormal walking pattern) and overestimates or forgets his/her own limits, categorizing the resident as a high risk for falling. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and was dependent on staff for bed mobility and transfers. Additionally, the MDS identified Resident #1 had not exhibited any behaviors. The Resident Care Plan (RCP) dated 5/26/25 identified Resident #1 was at risk for falls due to confusion, deconditioning and gait/balance problems. Interventions included anticipate and meet needs, appropriate footwear, and attempt to determine root cause of falls. The RCP identified Resident #1 had impaired cognition, a self-care deficit and was an assist of 1 with transfers. The facility Reportable Event (RE) dated 5/30/25 identified at 9:00 PM NA #1 was transporting Resident #1 in his/her wheelchair in the hallway when Resident #1 put his/her feet down to the ground, stopping the wheelchair abruptly, and caused Resident #1 to fall forward out of the wheelchair sustaining a lump to the forehead. The RE identified the family and provider were notified and an order was obtained to transfer Resident #1 to the Emergency Department (ED) for further evaluation. Resident #1 further sustained a mildly displaced odontoid neck fracture (fracture of the bony projection from the second cervical vertebrae) and a fracture of the first cervical vertebrae. The RE identified that following the incident, footrests were to be applied to the wheelchair for all staff transports outside of the room. Review of staff statements failed to identify statements from LPN #1 (assigned nurse) and LPN #2 (additional unit nurse). Review of the hospital documents dated 5/30/25 identified Resident #1 was transported to the ED from the facility and the facility reported Resident #1 was agitated, did not want to be moved, staff moved him/her anyways and Resident #1 did what he/she always does, stuck his/her right foot out straight, leading to a fall forward. The note indicated Resident #1 had a small laceration to the upper forehead, denied pain and a cervical collar was intact to the neck. It identified head and cervical spine imaging was obtained and resulted in a prominent anterior (front) scalp hematoma (a closed wound where blood collects and fills a space because it cannot flow out or drain), a mildly displaced fracture of the odontoid neck (a fracture through the bony projection from the second cervical vertebrae where the fragment shifted out of alignment) and non-displaced fractures (when the bone fragment remains aligned and in normal position) of both sides of the posterior (backside) arch of the first cervical vertebrae (C1). The RCP revised 5/30/25 identified Resident #1 was at risk for falls due to confusion, deconditioning and gait/balance problems and had an actual fall out of the wheelchair resulting in cervical fractures (vertebrae in the neck). Interventions included anticipating and meeting the resident's needs, observing/documenting/reporting to the provider any changes in mental status and ensuring footrests are in place to the wheelchair during transport and removing them after transport so that the resident may self-propel. Interview with NA #1 on 6/16/25 at 11:14 AM identified that on 5/30/25, Resident #1 was given a trash bag necklace consisting of a ribbon attached to a small plastic bag that Resident #1 was proudly wearing around his/her neck. NA #1 identified that between 8:00 PM and 9:00 PM, Resident #1 self-propelled in his/her wheelchair down to the West-Unit and was showing LPN #2 (agency nurse) the necklace. Resident #1 was heard yelling and NA #2 was pushing Resident #1 back to his/her room. She reported Resident #1 immediately went back into the hallway and self-propelled back to the West-Unit and yelled at LPN #2. NA #1 identified LPN #2 stated she did not have time for Resident #1 and directed her (NA #1) to bring Resident #1 back to his/her room again. NA #1 identified Resident #1's behavior continued to escalate but LPN #2 was insistent Resident #1 be brought back to his/her room. NA #1 then instructed Resident #1 to lift his/her feet and then she started to push Resident #1 in the wheelchair until Resident #1 abruptly placed his/her feet down on the ground, causing the wheelchair to stop and Resident #1 fell forward out of the wheelchair to the floor. NA #1 identified that LPN #2 taking the necklace off Resident #1, throwing it in the garbage in front of him/her without calmly explaining why, then continuing to dismiss Resident #1 when he/she reapproached LPN #2 angrily, caused an escalation in Resident #1's behaviors. NA #1 indicated the incident could have been avoided if LPN #2 was respectful to Resident #1. Interview with NA #3 on 6/16/25 at 11:29 AM identified she was in the hallway when LPN #2 took the necklace off Resident #1, causing Resident #1 to become angry and yell. NA #3 indicated LPN #2 dismissed Resident #1 and directed staff to get Resident #1 away from her which caused Resident #1's behaviors to escalate and Resident #1 became fixated on LPN #2. NA #3 identified she observed LPN #2 direct NA #1 to assist Resident #1 back to his/her room as Resident #1 was still yelling at LPN #2. Resident #1 allowed NA #1 to start pushing him/her in the wheelchair but then abruptly placed his/her feet down to the ground and fell forward out of the wheelchair to the floor. Interview with NA #2 on 6/16/25 at 11:37 AM identified Resident #1's baseline mood was either very happy or very upset, and although she knew the necklace Resident #1 was wearing on 5/30/25 was a safety hazard and needed to be removed, the necklace made Resident #1 happy as he/she self-propelled the hallway in the wheelchair showing those who walked by. NA #2 identified she was watching Resident #1 and planned to take the necklace off when she assisted Resident #1 to get ready for bed. She reported Resident #1 self-propelled to the West-Unit from the East-Unit and started to show LPN #2 his/her necklace. LPN #2 became upset about Resident #1 wearing the necklace, immediately took the necklace off Resident #1 without explaining why she was doing so and then threw the necklace in the garbage in front of Resident #1. NA #2 reported Resident #1 immediately became angry and started yelling at LPN #2, and LPN #2 stated Resident #1 was becoming too disruptive and directed her (NA #2) to push Resident #1 back to his/her room. Interview with LPN #1 on 6/16/25 at 1:42 PM identified she was the nurse assigned to provide care for Resident #1 on 5/30/25 and was on break during the fall incident. She further identified Resident #1 exhibited no agitated behaviors prior to her break. Additionally, she identified the facility never requested that she write a statement regarding the incident. Interview with LPN #2 on 6/16/25 at 1:59 PM identified that on 5/30/25, Resident #1 self-propelled in his/her wheelchair down to the West-Unit, where she was passing medications. She reported Resident #1 approached her, and she observed Resident #1 wearing a plastic bag attached to ribbon around his/her neck like a necklace. LPN #2 indicated the necklace was a safety hazard, and although she had never met Resident #1, and did not inquire with other staff (NAs) for assistance, while the assigned nurse (LPN #1) was on break, she removed the necklace and threw it in the garbage. She reported Resident #1 became agitated, so she asked NA #2 to bring Resident #1 back to his/her room but Resident #1 returned and was disruptive so she asked NA #1 to bring Resident #1 back to his/her room but as NA #1 started to push Resident #1, Resident #1 put his/her feet down causing a fall forward out of the wheelchair. LPN #2 identified she should not have thrown away the necklace in front of Resident #1 and further identified Resident #1 was confused and appeared to be sundowning. LPN #2 indicated she did not play into Resident #1's behaviors which is why she did not respond to Resident #1 when he/she spoke to her. LPN #2 identified the facility never requested that she write a statement regarding the incident. Review of the Medication Administration Record (MAR) for May 2025 failed to identify any documented incidents of agitation leading up to the 5/30/25 incident. Interview with the DNS on 6/16/25 at 3:00 PM identified staff should treat residents with dignity and respect and LPN #2 should not have approached Resident #1 the way she did and should not have thrown the necklace away in front of Resident #1. The DNS identified that when Resident #1 became upset, LPN #2 should have addressed Resident #1's concerns prior to directing the NA's to bring Resident #1 back to his/her room. The DNS indicated Resident #1 had dementia and LPN #2 should have had empathy and allowed Resident #1 to communicate his/her feelings and/or concerns. She further indicated that although Resident #1 self-propelled independently in the wheelchair, the NA's should have applied footrests prior to transporting Resident #1 back to his/her room. Additionally, the DNS identified statements should have been obtained from LPN #2 and LPN #1 following the 5/30/25 incident. Although attempted, Resident #1 was unable to be interviewed. Review of the Quality of Life- Dignity policy dated 08/2009 directed, in part, that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times and staff shall speak respectfully to residents at all times. Staff shall treat cognitively impaired residents with dignity and sensitivity by addressing the underlying motives or root causes for behavior and not challenging or contradicting the residents' beliefs or statements.

Based on review of clinical records, interviews, facility documentation and facility policy for one (1) of three (3) residents (Resident #3) reviewed for medication errors, the facility failed to prevent a significant medication error by failing to accurately transcribe and verify Provider's orders for a resident readmitted to the facility. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #3 received 30,000 mg of Hydroxyurea in excess from the hospital order which resulted in a hospitalization due to critical lab values (lab value date range: 3/14/25 through 3/28/25) which identified decreasing white blood cell (WBC) values from 12.62 to 0.99 (normal range 4.5 to 11) and decreasing platelet values from 962 to 129 (normal range 150 to 450). Resident #3 was admitted to the facility in February of 2025 with diagnoses which included dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) score of seven (7) indicative of severely impaired cognition and required substantial assistance with eating, oral and personal hygiene and was dependent with transfers. The Resident Care Plan dated 3/13/25 identified decreased cognition related to dementia and short term and/or long-term memory deficit. Interventions included to review the following for possible causes of decline in cognition: medications, medical problems, diabetes, and cardiac disease, to administer medication per physician order, and monitor resident for therapeutic effect of medication. A hospital Discharge summary dated [DATE] identified the following orders: -Hydroxyurea, 100 milligrams (mg)/milliliter (ml) suspension, ten (10) ml (1,000 mg total) by gastrostomy tube route four (4) times a week on Saturday, Sunday, Tuesday, and Thursday. -Hydroxyurea, 100 mg/ml suspension, five (5) ml (500 mg total) by gastrostomy tube route three (3) times a week on Monday, Wednesday, and Friday. Facility Physician's orders dated 3/13/25 identified the following orders: -Hydroxyurea oral capsule, 500 mg, give one (1) capsule via gastrostomy tube three (3) times a day every Monday, Wednesday, and Friday for chemotherapy. -Hydroxyurea oral capsule, 500 mg, give two (2) capsules via gastrostomy tube four (4) times a day every Tuesday, Thursday, Saturday, and Sunday for chemotherapy. Review of the March 2025 Medication Administration Report identified Resident #3 was administered 500 mg of hydroxyurea three (3) times daily (1,500 mg per day) on 3/14/25, 3/17/25, 3/19/25, 3/21/25, 3/24/25, and 3/26/25 and 1000 mg of hydroxyurea four (4) times daily (4,000 mg per day) on 3/15/25, 3/16/25, 3/18/25, 3/20/25, 3/22/25, 3/23/25, 3/25/25, and 3/27/25. (A total of 41,000 mg of hydroxyurea was administered over a 14-day period which was 30,000 mg in excess of what the hospital ordered.) A Nursing note by RN #2 on 3/30/25 at 2:21 PM identified Resident #3 had a change of condition, a rectal temperature of 102.5, ten (10) out of ten (10) gastrointestinal discomfort, a non-productive cough, and pale appearance. Resident #3 requested to be sent to the hospital as he/she didn't feel well, the physician was informed, and Resident #3 was transferred to the hospital. The hospital Discharge summary dated [DATE] identified Resident #3 was admitted to the hospital on [DATE] with a neutropenic fever and diagnosed with Covid-19, Norovirus, recurrent Clostridium Difficile, and diverticulitis. Labs drawn on 3/30/25 identified a WBC count of 1.2, platelet count of 119, and notation that Resident #3 was critically ill with a high probability of imminent or life-threatening deterioration. The summary indicated Resident #3 was administered Nivestym twice (to stimulate WBC production) with improvement in WBC count and was treated with both IV and oral antibiotics for neutropenic fever. Resident #3 was discharged from the hospital on 4/8/25 to home with palliative care. Interview with RN #1 (Nurse Supervisor on the 3:00 PM to 11:00 PM shift) on 4/14/25 at 12:21 PM identified he/she entered the medications listed on Resident #3's hospital discharge summary into the electronic medical record (EMR) on 3/13/25 after verifying the medications on the hospital discharge summary with the facility physician. Upon entering the orders into the EMR, RN #1 indicated he/she correctly matched the dose of hydroxyurea with the day of the week it was supposed to be administered, however failed to enter the correct number of doses to be administered (instead of one (1) 500 mg dose of hydroxyurea on Monday, Wednesday, and Friday it was entered as three (3) 500 mg doses on those days and instead of one (1) 1000 mg dose of hydroxyurea on Tuesday, Thursday, Saturday, and Sunday it was entered as four (4) 1000 mg doses on those days). Interview with MD #1 on 4/14/25 at 3:06 PM identified he/she signed Resident #3's medication orders following his/her readmission to the facility on 3/13/25 and believed the orders were entered accurately prior to signing them. MD #1 further identified that he/she was unaware Resident #3 was receiving that much hydroxyurea at the facility and that the difference between what the hospital ordered and what was being administered at the facility was a significant medication error for a toxic drug that was known to have significant side effects. Interview with the Assistant Director of Nurses (ADNS) on 4/15/25 at 10:15 AM identified that when entering admission/readmission orders into the EMR, the nurse supervisor should confirm the hospital discharge summary orders with a provider, enter the orders into the EMR, and a second nurse should reconcile the hospital discharge summary orders and EMR to verify accuracy. The ADNS further indicated that expanding the EMR order to view the entire order detail was part of the verification process (to verify dose, frequency and schedule) and should have been done when verifying each order. Interview with the Hematology/Oncology Advanced Practice Registered Nurse (APRN #1) on 4/15/25 at 10:45 AM identified the hydroxyurea doses administered to Resident #3 were administered at a toxic and excessive dose, suppressed Resident #3's bone marrow production of WBCs and platelets, and weakened Resident #3's immune system, making him/her susceptible to infection. Review of the Physician's Orders-Oral, Telephone, and Written policy directed the nurse would transcribe oral, telephone, and written orders from the Physician's orders sheet into the electronic medical record (EMR), orders would be noted on the Physician's Orders sheet by the nurse after entering them (unless the document was a Hospital Transfer sheet), and that the nurse would question, and not accept any order which was perceived as unsafe, contra-indicated or was not clear, and would raise the issue with the ordering physician, advanced practice registered nurse or physician assistant. Although requested, the facility was unable to provide a transcription/verification process policy. The Immediate Jeopardy template was presented to the Administrator by the State Agency on 4/15/25 at 2:44 PM. The facility submitted a removal plan which included education of all nursing staff to include medication transcription and verification, timely communication of lab results to the provider(s) and documentation of provider response/new order, enhanced auditing of new admission medication orders thirty (30) days prior to the event (March 1, 2025 to March 31, 2025), biweekly QAPI meeting for ninety (90) days or until substantial compliance was achieved, development of a list of residents currently prescribed chemotherapy medications and validation of current accuracy of medications in relation to orders, policy development related to the management and monitoring of residents on chemotherapy drugs, and policy development related to communication of lab results to Provider(s) and consultants which was accepted by the State Agency on 4/15/25 at 5:22 PM during an on-site visit.

Based on review of clinical records, interviews, facility documentation and facility policy for two (2) of three (3) residents (Resident #2 and Resident #3) reviewed for Resident Care Plans (RCPs), the facility failed to update comprehensive RCPs to address the residents needs. The findings included: 1. Resident #2 was admitted to the facility in March of 2025 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, pain in the left knee, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severely impaired cognition and required substantial assistance with eating, oral and personal hygiene and was dependent with transfers. The RCP dated 3/19/25 identified the potential for altered mood state and psychosocial well-being related to diagnoses of depression and adjustment to short term rehabilitation and administration of psychoactive medications. Interventions directed to administer medications per physician's orders, behavior tracking each shift, and monitoring for the therapeutic effect of medication. The RCP failed to identify Resident #2 had pain or was at risk for pain. A physician ' s order dated 3/19/25 directed Oxycodone HCl oral tablet, 5 milligrams (mg) one (1) tablet every three (3) hours as needed for moderate pain and two (2) tablets every three (3) hours as needed for severe pain. A physician's order dated 3/19/25 directed Morphine Sulfate ER oral tablet, 15 mg, give one (1) tablet every twelve (12) hours for pain. A note by APRN #2 dated 3/19/24 at 9:00 AM identified Resident #2 was found with Klonopin, Dialudid, and Percocet in his/her room that were not administered by the facility and staff reported Resident #2 had been more lethargic. A room search was completed (after obtaining permission) and controlled drugs were removed from the room. APRN #2 further identified Resident #2's morning dose of Klonopin was held, there was no current order for Dilaudid, the order for Oxycodone was reduced to one (1) tablet every three (3) hours for pain as needed to one (1) tablet every four (4) hours for pain as needed, and Resident #2 was educated on facility policy regarding unauthorized medications. A physician's order dated 3/20/25 directed Gabapentin 300 mg tablet three (3) times a day for pain. A physician's order dated 3/21/25 directed Percocet, 5-325 mg tablet (Oxycodone with acetaminophen), give one (1) tablet by mouth every three (3) hours as needed for pain. May use until oxycodone is available. A physician's order dated 3/24/25 directed Percocet, 5-325 mg tablet (Oxycodone with acetaminophen), give one (1) tablet every four (4) hours as needed for pain. The March 2025 Medication Administration Report (MAR) identified Morphine Sulfate was administered 3/19/25 through 3/21/25 for a pain report of nine (9) [on a pain scale of one (1) to ten (10)], gabapentin was administered three (3) times a day 3/20/25 through 3/31/25, oxycodone was administered 3/19/25 through 3/22/25 for pain report of five (5) to nine (9) [on a pain scale of one (1) to ten (10)], and Percocet was administered 3/21/25 through 3/31/25 for pain report of four (4) to eight (8) [on a pain scale of one (1) to ten (10)]. A physician's order dated 4/7/25 directed Hydromorphone HCl oral tablet, 2 mg, one (1) tablet every six (6) hours as needed for pain report of four (4) to seven (7) [on a pain scale of one (1) to ten (10)], and two (2) tablets by mouth every six (6) hours as needed for pain greater than seven (7) [on a pain scale of one (1) to ten (10)]. Review of Resident #2's April 2025 MAR identified gabapentin was administered three (3) times a day 4/1/25 through 4/9/25, Hydromorphone 2 mg was administered once on 4/7/25 for a pain report of seven (7) [on a pain scale of one (1) to ten (10)], Hydromorphone 4 mg was administered 4/7/25 through 4/10/25 for pain report of eight (8) to ten (10) [on a pain scale of one (1) to ten (10)], and Percocet 5-325 mg was administered 4/1/25 through 4/6/25 for pain report of four (4) to eight (8) [on a pain scale of one (1) to ten (10)]. Review of the RCP failed to identify goals and interventions for pain management and failed to identify Resident #2 ' s use of unauthorized controlled drugs within the facility and coinciding interventions for monitoring. 2. Resident #3 was admitted to the facility in February of 2025 with diagnoses of dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies. Hospital discharge documents dated 3/13/25 identified Resident #3 was hospitalized and treated for seizures and from 3/8/25 to 3/13/25 and treated for chronic myeloproliferative disorder/essential thrombocythemia (increased number and size of platelets in the blood). Review of the facility Nursing admission assessment dated [DATE] identified Resident #3 was transported from the hospital via stretcher with admitting diagnoses of seizures, diabetes mellitus, and dementia, was alert to person and place, verbally appropriate, anxious, and required extensive assistance with bed mobility, transfers, and toilet use. The RCP dated 3/13/25 identified decreased cognition related to dementia, short term and/or long-term memory deficit, and administration of psychoactive medications. Interventions directed to review the following for possible causes of decline in cognition: medications, weight loss, medical problems, constipation, diarrhea, diabetes, and cardiac disease, and to administer medication per physician order. The RCP failed to identify goals and interventions for seizures and chronic myeloproliferative disorder (which required a new order for the administration of hydroxyurea and monitoring of blood cell and platelet counts) that were identified on the 3/13/25 hospital discharge record. Interview with the Director of Nursing Services (DNS) on 4/10/25 at 1:56 PM identified the RCP for Resident #2 should have been updated for pain management and unauthorized use of outside medications to prevent the risk of overdosing or drug to drug interactions. The DNS further identified updating the RCP would ensure continuity of care. Review of the Change in the Resident's Condition or Status policy directed a significant change of condition was a major decline or improvement in the residents' status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) and requires interdisciplinary review and/or revision of the care plan. Review of the Care Plans, Comprehensive Person-Centered policy identified the comprehensive, person-centered care plan will describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, would incorporate risk factors associated with identified problems, reflect treatment goals, timetables, and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, and aid in preventing or reducing decline in the resident's functional status and/or functional needs.

Based on review of clinical records, interviews, facility documentation and facility policy for eleven (11) of sixteen (16) residents (Resident #8, #9, #10, #11, #13, #14, #15, #16, #18, #19, and #20) reviewed for physician's orders, the facility failed to ensure residents orders were reviewed and signed by the physician/advanced practice registered nurse monthly. The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included heart failure, anxiety and vascular dementia. Review of physician orders identified medical orders were reviewed and signed on 10/1/24, 12/31/24, and 3/11/25, however failed to identify medical orders were reviewed in 11/2024, 1/2025, and 2/2025 in accordance with facility practices. 2. Resident #9 was admitted to the facility on [DATE] with diagnoses that included systolic congestive heart failure, dementia, and anxiety. Review of physician orders identified medical orders were reviewed on 4/24/24, 7/17/24, 8/11/24, 9/11/24, 11/14/24, 1/22/25, and 3/18/25, however failed to identify medical orders were reviewed in 5/2024, 6/2024, 10/2024, 12/2024, and 2/2025 in accordance with facility practices. 3. Resident #10 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, spinal stenosis, and anxiety. Review of physician orders identified medical orders were reviewed on 4/24/24, 7/19/24, 8/11/24, 9/19/24, 1/22/25, and 3/18/25, however failed to identify medical orders were reviewed in 5/2024, 6/2024, 10/24 through 12/2024, and 2/2025 in accordance with facility practices. 4. Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, major depressive disorder, and vascular dementia. Review of physician orders identified medical orders were reviewed on 4/8/24, 5/7/24, 7/8/24, 8/11/24, 9/19/24, 12/18/24, 1/14/25, and 3/11/25, however failed to identify medical orders were reviewed in 6/2024, 10/20245, 11/2024, and 2/2025 in accordance with facility practices. 5. Resident #13 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, vascular dementia, and recurrent major depressive disorder. Review of physician orders failed to identify medical orders were reviewed monthly from date of admission to current date (4/16/25). 6. Resident #14 was admitted to the facility on [DATE] with diagnoses that included transient cerebral ischemic attacks, dementia, and anxiety. Review of physician orders identified medical orders were reviewed on 7/29/24, 10/4/24, 2/25/25, and 4/8/24, however failed to identify medical orders were reviewed in 4/2024 through 6/2024, 8/2024, 9/2024, 11/2024 through 1/2025, and 3/2025 in accordance with facility practices. 7. Resident #15 was admitted to the facility on [DATE] with diagnoses that included myotonic muscular dystrophy, cardiomyopathy, and chronic pulmonary embolism. Review of physician orders identified medical orders were reviewed on 5/16/24, 6/18/24, 8/11/24, 10/4/24, and 2/18/25, however failed to identify medical orders were reviewed monthly in 7/2024, 9/2024, and 11/2024 through 1/2025, and 3/2025 in accordance with facility practices. 8. Resident #16 was admitted to the facility in 2017 with diagnoses that included heart failure, anxiety, and dementia with other behavioral disturbances. Review of physician orders identified medical orders were reviewed on 4/15/24, 5/16/24, 6/4/24, 8/11/24, 10/3/24, 1/17/24, and 2/18/24, however failed to identify medical orders were reviewed monthly in 7/2024, 9/2024, 11/2024, 12/2024, and 3/2025 in accordance with facility practices. 9. Resident #18 was admitted to the facility on [DATE] with diagnoses that included chronic ischemic heart disease, vascular dementia, and other recurrent depressive disorders. Review of physician orders identified medical orders were reviewed on 4/3/24, 5/7/24, 6/3/24, 8/11/24, 10/2/24, 2/18/25, and 4/9/25, however failed to identify medical orders were reviewed monthly in 7/2024, 9/2024, 11/2024 through 1/2025, and 3/2025 in accordance with facility practices. 10. Resident #19 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, complete atrioventricular block, and adjustment disorder. Review of physician orders identified medical orders were reviewed on 4/8/24, 5/7/24, 6/13/24, 8/11/24, 9/13/24, 12/31/24, 2/4/25, and 4/15/25, however failed to identify medical orders were reviewed monthly in 7/2024, 10/2024, 11/2024, 1/2025, and 3/2025 in accordance with facility practices. 11. Resident #20 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder, dementia, and unspecified mood disorder. Review of physician orders identified medical orders were reviewed on 8/11/24, 11/19/24, 1/3/25, 2/4/25, and 3/11/25, however failed to identify medical orders were reviewed monthly in 9/2024, 10/2024, and 12/2024 in accordance with facility practices. Interview with the Assistant Director of Nurses (ADNS) on 4/14/25 at 11:00 AM identified either the physician or advance practice registered nurse were responsible for reviewing medical orders monthly and the facility's standard of practice was to have the physician's review and sign the resident's medical orders monthly. The ADNS failed to identify the reason why this did not occur. The facility was unable to provide a policy detailing the frequency the physician's orders were to be reviewed.

Based on review of clinical records, interviews, and review of facility documentation and policies for one (1) of five (5) residents (Resident #3) reviewed for orders, the facility failed to ensure a physician's inquiry to a lab result was responded to timely and that lab results were forwarded to all pertinent physician's in a timely manner, and for one (1) of three (3) residents reviewed for medication administration, the facility failed to ensure that a resident was administered an antibiotic in accordance with physician's orders. The findings included: 1. Resident #3 was admitted to the facility February 2025 with diagnoses of dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of severely impaired cognition and required substantial assistance with eating, oral and personal hygiene and was dependent with transfers. (If an assessment is needed that was closer to the readmission date of 3/13/25, we can use the Nursing admission Assessment). Review of the Nursing admission assessment dated [DATE] identified Resident #3 was transported from the hospital via stretcher with admitting diagnoses of seizures, diabetes mellitus, and dementia, was alert to person and place, verbally appropriate, anxious, and required extensive assistance with bed mobility, transfers, and toilet use. Review of Resident #3's revised Care Plan dated 3/13/25 identified decreased cognition related to dementia, short term and/or long-term memory deficit, and administration of psychoactive medications. Interventions directed to review the following for possible causes of decline in cognition: medications, weight loss, medical problems, constipation, diarrhea, diabetes, and cardiac disease, and to administer medication per physician order. Review of Resident #3's hospital discharge record dated 3/13/25 identified Resident #3 was treated for chronic myeloproliferative disorder/essential thrombocythemia (increased number and size of platelets in the blood) and directed continued administration of Hyroxyurea at the facility. Review of APRN #2's note dated 3/14/25 at 11:30 AM identified Resident #3 was found to have leukocytosis during his/her 3/8/25 to 3/13/25 hospitalization, was followed by hematology for myeloproliferative disorder and thrombocytopenia, had his/her hydroxyurea (medication used to reduce platelet count) reinstated at home doses, and that his/her CBC (complete blood count) and BMP (basal metabolic panel) would be drawn with results forwarded to hematology/oncology. A physician's order dated 3/14/25 directed CBC and BMP on every night shift, every Monday, Wednesday, and Friday for anemia and thrombocytopenia. Review of Resident #3's labs records identified CBC and BMP labs were drawn on 3/14/25, 3/17/25, 3/19/25, 3/21/25, 3/24/25, 3/26/25, and 3/28/25. a. Review of Resident #3's 3/26/25 lab report identified the facility had faxed the lab results [which included a white blood cell count (WBC) of 1.46 and platelet count of 225] to MD #1, noting the facility had initiated neutropenic precautions and that labs were faxed to the Hematologist/Oncologist. Interview with MD #1 on 4/16/25 at 9:14 AM identified he/she had asked the facility for Resident #3's current hydroxyurea dose via fax at 2:52 PM on 3/26/25 as Resident #3's WBC count was 1.46 and platelet count was 225, and did not receive a response to his/her request. MD #1 further indicated, upon receiving the results from labs drawn on 3/28/25, which indicated a WBC count of 0.99 and platelet count of 129, he/she chose to call the facility with orders to hold the hydroxyurea instead of faxing the request. MD #1 indicated a WBC count of less than 2.0 would be concerning and that a drop in Resident #3's WBC count was a side effect of hydroxyurea. b. Interview with APRN #1 (Hematology and Oncology Advanced Practice Registered Nurse) on 4/15/25 at 10:45 AM identified the facility did not always forward lab draw results timely. APRN #1 further indicated the lab draw results dated 3/14/25 and 3/17/25 were received on 3/19/25, lab results dated 3/24/25 were received on 3/26/25, lab results dated 3/26/25 were received on 3/27/25, and that the lab results for lab draws dated 3/19/25, 3/21/25, and 3/28/25 were never received. Interview with the Assistant Director of Nurses on 4/16/25 at 8:31 AM identified the facility's standard of practice was for the nursing supervisor to respond to the physican's faxes immediately regarding any resident related concern or information requested and that the response should occur during the shift the fax was received. The ADNS further identified it was the responsibility of the nursing supervisor on 1 [NAME] to receive faxes and distribute them as addressed. Although requested, the facility was unable to provide a policy regarding physician communications/faxes. 2. Resident #4 was admitted to the facility in May 2020 and had diagnoses that included unspecified dementia, Type 2 diabetes mellitus, and recurrent major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderate cognitive impairment. The MDS further identified Resident #4 required substantial assistance with upper body dressing, personal hygiene and was dependent with transfers. Review of Resident #4's Care Plan dated 9/18/24 identified impaired cognition related to the diagnoses of alcohol-induced persisting dementia and diagnoses of vascular dementia, and arteriosclerotic heart disease, hyperlipidemia, hypertension, and advanced kidney disease/failure. Interventions directed to provide assistance with activities of daily living as needed, and administer medications as ordered. A physician's order dated 10/10/24 directed Levaquin oral tablet, 750 milligrams, one tablet by mouth at bedtime for pneumonia for seven (7) days. Review of the Medication Error Report dated 10/11/24 identified Resident #4 was not administered his/her 750 milligrams dose of Levaquin the evening of 10/10/24 and was left unattended on his/her bedside table. Interview with the Assistant Director of Nurses (ADNS) on 4/15/25 at 10:30 AM identified Resident #4 was supposed to be administered his/her first dose of Levaquin on 10/10/24 at 9:00 PM and wasn't as the medication was found on Resident #4's bedside table the following morning by LPN #2. The ADNS identified the standard of practice was to administer medications in accordance with physician's orders, to watch the resident take the medication and not leave his/her bedside until the medication was swallowed. The ADNS further indicated that Resident #4 was not able to self-administer medications and that the Levaquin 750 milligram order was extended to allow for the full seven (7) day course to be administered. Interview with LPN #2 on 4/16/25 at 8:42 AM identified he/she noticed a medication cup on Resident #4's bedside table on 10/11/24 with an unfamiliar medication in it and suspected it was Levaquin, which Resident #4 was to have taken on second shift the night before. LPN #2 indicated he/she removed the medication from Resident #4's room, identified that it was Levaquin, and had reported the incident to the nurse supervisor. Review of the Medication Administration policy directed medications to be administered in a safe and effective manner.

Based on observation, review of facility documentation, and interviews, the facility failed to ensure the residents had the opportunity to experience their choice of in-person community dining. The findings include: During the resident council meeting with the residents on 8/12/24, it was identified that the residents had previously brought up the concern during their resident council meetings that there was no in person dining in the main dining rooms. They identified that it had been approximately a year since they'd had in person dining and that the concern had been raised several times in resident council, however they still did not have in person dining in place. Review of the Resident Council meeting minutes dated 6/27/24 identified the food service director spoke about the plans for the dietary department including satellite dining and main dining. Recreation spoke about the action plan for resident dining. Review of the Resident Council meeting minutes dated 7/25/24 identified dietary spoke about the action plan on the dining room and finalizing the new list of who is eating in the dining area and what that looked like. Observation of lunch service on 8/12/24 at 12:45 PM identified residents in their rooms eating lunch on the 2West unit. Some residents who were being assisted to eat were in a small dining space located on the 2West unit. Interview with Resident #36 on 8/12/24 at 10:45 AM identified Resident Council has talked about wanting to open up the main dining room on countless occasions and they still do not have in-person dining going on in the main dining rooms. It really would be great to be able to sit at a table of people and interact with them while you eat. The socialization is something that a lot of people want to have back in place. Interview with Resident #103 on 8/12/24 at 10:50 AM identified that this issue has been brought up several times during resident council and that it would be wonderful to sit and chat and interact with others while you eat. Resident #103 identified that it hasn't been done for a very long time and they really missed it. Interview with NA#1, and NA#2 on 8/13/24 at 12:10 PM identified that the dining rooms had not been open since the previous year and that the satellite dining areas on the units were utilized for residents who needed assistance or supervision with eating and that residents who were independent stayed in their rooms to eat. Interview with the Dietician on 8/14/24 at 8:55 AM identified that, the main dining room had been closed for some time, however they had just opened the satellite dining areas for people who needed supervision or assistance with eating. She further identified that; although, she knows there could have been a negative impact on the residents from the dining areas being closed for that long of a period of time, she hasn't seen any negative impact on the residents and that if there were any changes identified the resident may be moved to the supervised dining area on the unit. Interview with the Dietary Manager on 8/14/24 at 9:00 AM identified the main dining rooms had been closed for some time however he started in his position in July of 2024 and as of August they had been working on making a seating chart and finding out who wanted to eat in the dining rooms. He further identified there were many moving parts as once the seating chart was made then they needed to ensure the trays were arranged in the kitchen carts and the tickets updated. He noted that 27 residents had made it known that they wanted to eat in the main dining room and that he really wanted in person dining to occur. Interview with RN#4 on 8/14/24 at 2:08 PM identified she worked on getting the units open back in June of 2024, and they were working on the plan for the main dining areas to open and that they were hoping to open them this week. Interview with the Administrator on 8/14/24 at 3:10 PM identified that the dining rooms had been closed for a period of time, he started in September of 2023, and they have basically been closed since then. He identified that not only were they closed due to the outbreaks of illness throughout the facility, but staffing has been a consistent issue in the dietary department. With the illnesses and with kitchen staffing between the two issues the stars never aligned for the dining rooms to open. The Administrator further identified; it was brought up in June 2024 at a resident council meeting he attended that the residents wanted the main dining room open to in-person dining for meals and noted things were in the works such as seating arrangements but that there were many moving parts to making it happen. Interview with the Director of Nursing on 8/15/24 at 9:30 AM identified that she has been in outbreak mode from 8/23/23 to 6/10/24 then on 7/11/24 to present was the next COVID outbreak. If there is an outbreak on a unit, they would not have dining in the main dining rooms and isolate the unit to stop the spread of infection such as COVID. This would limit activities as well to just being done on the unit and residents would not be able to participate in group activities. However, during these times not all units were affected throughout the whole outbreak. There were breaks in time in which some units were not affected. The most recent COVID outbreak that started on 7/11/24 did not affect unit 2East or 2West. The previous wave of COVID affected Unit 1 and 2East and 2West however did not affect Unit #3. Unit #1 and #2 were clear from their 14-day period as of 5/21/24. Dining in the main dining areas had not been done since the 8/23/23 outbreak. Interview with Recreation on 8/15/24 at 2:00 PM identified that in person recreation activities have been occurring in the building. At times due to COVID they have had to limit the activities to the units, but most recently they have been doing in person activities, such as entertainment the previous day in the large group setting in the Dining room [ROOM NUMBER]. Although a policy for Resident Council/Committees was requested none was provided. Review of the Outbreak of Communicable disease policy reviewed April 2024 directed an outbreak of most communicable disease can be defined as one of the following: One case of an infection that is highly communicable, trends that are 10 percent or more above the historical rate of infection for the facility; or occurrence of three or more cases of the same infection over a specified period of time and in a defined area. The infection preventionist and Director of Nursing will discontinue group activities as indicated. Review of the Meal service policy directed it is the policy of the facility to provide a dining experience that is conducive to meal acceptance, residents will be interviewed at the time of admission and thereafter as needed as to their preference to eat in the dining room or their room. The resident's eating preference will be obtained and entered into their resident profile so that their preference will print on the tray cards. Residents will be assisted to the dining room as needed by the nursing staff.

Based on observations and interviews the facility failed to ensure an outdoor concrete patio (smoking area) was safe and free of accident hazards. The findings include: Observation of the smoking area on the unit three patio on 8/15/24 at 10:00 AM noted that the concrete patio contained multiple holes causing the surface to be uneven. After observing the unit three patio with the Administrator on 8/15/2024 at 10:15 AM, the Administrator identified that staff and Residents utilize the patio for smoking, and noted he was unaware of the status of the patio. The Administrator further indicated it was a safety issue and would be fixed that day. An interview with the Maintenance Director on 8/15/24 at 10:45 AM indicated he had been aware of the condition of the patio since 8/8/24 but had not notified the Administrator or the DNS. The Maintenance Director further indicated he had been busy and had planned to get the supplies to make the repairs. On 8/15/24 at 10:48 AM the Administrator was made aware that the Maintenance Director had known of the condition of the patio since 8/8/24. An observation on 8/15/24 at 11:10 AM noted a sign on the porch door and caution tape across the porch exit. An interview with the Administrator on 8/15/24 at 11:13 AM indicated the porch was closed off, a blast fax sent to all employees that it was closed until further notice and recreation would inform all residents.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #133) reviewed for missing property, the facility failed to follow up on a resident reported concern related to missing items in a timely manner. The findings include. Resident #133's diagnoses included dementia and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #133 had severe cognitive impairment and required one to two person assist with activities of daily living (ADL). The Resident Care Plan dated 5/5/24 identified Resident #133 had decreased cognition related to dementia and an ADL deficit. Interventions directed to provide safety measures in all activities and provide assistance with ADL care as needed. An interview with Person #2 on 8/11/24 at 12:20 PM identified that Resident #133's prescription glasses were reported missing to Corporate Admission Staff #1 about a month prior and was told the matter would be investigated and every time the status of the glasses has been inquired about, Person #2 was told they were not found. Further, there had been no follow-up to discuss future action. A review of nursing progress notes dated 7/1/24 through 8/10/24 did not include documentation concerning missing items. A review of social service progress notes dated 7/1/24 through 8/10/24 did not include documentation for any missing items. An interview with the Director of Social Services on 8/13/24 at 10:14 AM identified that for reports of missing property, he would be responsible for interviewing the resident/family, conducting a room search, and if necessary, refer to other disciplines such as nursing, housekeeping and laundry to attempt to locate the missing item. If the missing item is not located, the item would be replaced, or reimbursement provided based on resident/family preference, which would be determined that day. The Director of Social Services further identified it was just reported to him one hour earlier on 8/13/24 that Resident #133 had a pair of missing glasses along with other missing items. It was the first time he had learned of the missing items and had not been previously notified. An interview and facility documentation review with Corporate Admissions Staff #1 on 8/13/24 at 10:24 AM identified it was reported by Person #2 that Resident #133 had missing items that included a pair of prescription glasses. Corporate Admissions Staff #1 generated an electronic communication dated 7/19/24 to administrative staff that included the Director of Social Services to notify him of the missing item(s). A subsequent interview and (handwritten) clinical record review with the Director of Social Services on 8/13/24 at 10:30 AM identified on 7/22/24, he did refer the matter to Transportation Staff #1 who was responsible for scheduling community provider specialty services for replacement. The Director of Social Services identified he did follow up with Resident #133 several times and offered cheater glasses but that s/he declined and likely could not recall. The Director of Social Services did not follow up with Person #2 regarding the missing item and should have. An interview with the Director of Nursing (DNS) on 8/13/24 at 11:08 AM identified the report of the missing item(s) should have been responded to and replaced if not found at the time it was reported. An interview and facility documentation review with Transportation Staff #1 on 8/15/24 at 11:40 AM identified she was responsible for scheduling community provider specialty services. Transportation Staff #1 was contacted by the Director of Social Services to schedule Resident #133 for glasses; however, it was not communicated that the glasses were just a replacement for a lost pair rather than a full exam. Transportation Staff #1 did schedule Resident #133 for glasses but was informed by the provider Resident #133 would not be able to be seen sooner than 9/2024, subsequent to surveyor inquiry, Transportation Staff #1 better understood the glasses were for replacement only and not a new prescription therefore could be replaced much sooner. Transportation Staff #1 identified the Director of Social Services never followed up with her to find out the status of the glasses, otherwise the matter could have been clarified. A review of the policy for Reported Losses/ Missing Items directed the facility to actively investigate and mitigate occurrences of lost or missing items of value. [NAME] an item is reported missing, the Nursing Supervisor will be notified, and a Missing Item Report completed. The Nursing Supervisor will conduct an initial investigation and the loss reported to DNS, ADNS social services and Administrator. An investigation will be conducted in conjunction with the local police department if indicated.

Based on clinical record reviews, observations, review of facility policy and interviews for one of three sampled residents (Resident #6) reviewed for respiratory care, the facility failed to develop and implement a comprehensive care plan for a resident utilizing oxygen therapy and for one of four sampled residents (Resident #138) reviewed for accidents, the facility failed to revise the comprehensive care plan to ensure safe food consumption for a resident who was repeatedly provided unsafe food items with a known swallowing disorder. The findings include: 1. Resident #6's diagnoses included chronic obstructive pulmonary disease (COPD), metabolic encephalopathy, and muscle wasting and atrophy. The quarterly MDS assessment dated [DATE] identified Resident #6 was cognitively intact, was totally dependent on staff for toileting, transfers, and personal hygiene. It further identified Resident #6 had shortness of breath or trouble breathing when lying flat and required oxygen therapy. The resident care plan (RCP) dated 7/20/24 did not address Resident #6's use of oxygen or interventions related to the use of oxygen therapy. Review of the physician's orders for the month of August/2024 failed to identify an order for the use of oxygen therapy. Observation on 8/12/24 at 2:35 PM identified Resident #6 was lying in bed wearing a nasal cannula connected to an oxygen concentrator set at 3 liters per minute (LPM). Interview with the Nursing Supervisor (RN #1) on 8/13/24 at 11:34 AM identified that a care plan should be developed and implemented for a resident utilizing oxygen. RN #1 was asked who was responsible for developing the care plan and she indicated that the nurses on the unit develop care plans for falls, and skin, but the MDS Coordinator does all other care plans. Interview with the MDS Coordinator (LPN #8) on 8/13/24 at 11:42 AM identified that the care plan dated 7/20/24 failed to identify Resident #6 had a care plan developed and implemented for oxygen therapy. LPN #8 identified that it was her responsibility to review Resident #6's care plans after completing the MDS to ensure that all areas of the resident's care were included in the plan of care. LPN #8 identified if the oxygen care plan was included it would have had interventions such as monitor for sign or symptoms of respiratory distress and report to MD, pulse oximetry, and oxygen as ordered. Subsequent to surveyor's inquiry Resident #6's care plan was updated (8/13/24) to reflect the focus area of oxygen therapy related to COPD with interventions that included monitor for sign or symptoms of respiratory distress and report to MD, respirations, pulse oximetry, accessory muscle usage, oxygen settings via nasal prongs/mask at 1-3 liters continuously and promote lung expansion and improve air exchange by positioning with proper body alignment. Interview with the DNS on 8/14/24 at 3:18 PM identified that the nurses on the unit would develop and implement care plans but it was the MDS nurse's responsibility for the overall care plan to ensure that it was completed. The DNS indicated that if the resident was on oxygen a care plan should be included in the resident's plan of care. Review of the Care Plans, Comprehensive Person-Centered policy identified that the facility is to develop an individualized comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed. It further identified that the comprehensive person-centered care plan will incorporate identified problem areas and their causes and develop interventions that are targeted and meaningful to the resident. Additionally, the policy identified that assessments of residents are ongoing, and the care plans are to be revised as information about the resident's condition changes. 2. Resident #138 had diagnoses that included hemiplegia/hemiparesis (weakness and paralysis) following a cerebral infarction (stroke) affecting the left non-dominant side and dysphagia (swallowing disorder). The Admission MDS assessment dated [DATE] identified Resident #138 had moderate cognitive impairment, mobility impairment to one side of the body, and required partial to total assist with eating. The resident care plan (RCP) dated 7/31/24 identified an alteration in nutrition related to being on an altered textured diet related to dysphagia. Interventions directed to explain and reinforce the importance of maintaining the diet as ordered, comply with nutrition recommendations and provide set up/assistance as indicated. An observation on 8/11/24 at 1:17 PM identified Resident #138 with a plate of ground/minced in appearance food plated in front of him/her, holding a broken off chocolate covered wafer like cookie in his/her right hand and chewing. Person #3 was noted at bedside. An interview with LPN #5 on 8/11/24 at 1:17 PM identified Resident #138 was not approved to eat the cookie and proceeded into Resident #138's room to intervene. An interview and clinical record review with the (acting) Director of Rehabilitation on 8/13/24 at 12:58 PM identified Resident #138 was prescribed a minced/ground diet due to dysphagia with no exceptions, was currently receiving therapy related to poor attention, wet vocal quality and the need for continuous cueing for bolus (food) retrieval. Resident #138 required total supervision with meals. The Director of Rehabilitation was not aware Resident #138 was being provided unsafe food items but further noted that on 8/9/24, the caregiver was provided education on offering the resident smaller bites. A subsequent observation on 8/13/24 at 1:44 PM identified Person #3 offering Resident #138 a donut. LPN #10 was notified and immediately intervened. An interview with LPN #10 on 8/13/24 at 1:55 PM identified RN #7 reported that Resident #138 was provided unsafe food items, and this was the first occasion where LPN #10 made a direct observation. Person #3 was subsequently provided education on the provision of unsafe food items. An interview with the DNS on 8/14/24 at 9:51 AM identified the care plan could have been more specific to include the provision of unsafe food items with interventions that reduced the risk of an accident hazard. An interview with RN #8 on 8/14/24 at 10:45 AM identified she was the assigned RN supervisor for the 7:00 AM to 3:00 PM shift. RN #8 identified she was notified, believing it was some time the preceding week that [NAME] #3 was feeding unsafe food items to Resident #138. RN #8 provided education to Person #3 at that time. RN #8 identified that she was notified a second time on 8/11/24 that Resident #138 was again being provided unsafe food items. RN #8 was given a list of approved food items from speech therapy. RN #8 identified she was, in part, responsible for updating the care plan and did not. RN #8 further identified she should have updated the care plan with interventions to reduce the accident risk when the concern was first identified and education unsuccessful. An interview with RN #7 on 8/14/24 at 10:39 AM identified she had made at least two observations within the previous two weeks prior to 8/11/24 where on one occasion, she observed Person #2 feeding cream pie to Resident #138 and on another occasion, a donut. RN #7 reported both incidences to RN #8. RN #7 further identified that she educated Person #3 and completed a referral to speech therapy. An interview with (interim) the Speech Therapist, SLP #1 on 8/14/24 at 1:46 PM identified Resident #138 was prescribed a minced ground moist diet since readmission in 4/2024. Formed foods such as cookies were not permitted. SLP #1 became aware the preceding week when Person #2 complained that snacks were removed from Resident #138's room that were not appropriate. SLP #1 identified that snacks should not have been in Resident #138's room in the first place and that staff were not checking. SLP #1 provided education to Person #3 and Resident#138 about the risks of eating unsafe food items. SLP #1 identified there needed be increased in servicing around monitoring for safe food items. SLP #1 further identified that the provision of unsafe food items placed Resident #138 at risk for aspiration and choking and the continued provision of unsafe foods was placing Resident #138's life at risk. The RCP failed to identify Resident #138 was repeatedly being provided unsafe food items, failed to include interventions for safe food consumption and monitoring after Resident #138 was repeatedly provided unsafe food items when attempts to educate were unsuccessful. A review of the facility policy for Care Plans dated 12/2016 directed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet a resident's physical, psychological and functional needs is developed and implemented for each resident. Care plans are revised as information about the resident and resident condition changes.

Based on review of the clinical record and interviews for one sampled resident (Resident #57) receiving insulin, the facility failed to ensure that physician orders for blood sugar monitoring/parameters were congruent with the administration of the morning dose of insulin. The findings include. Resident #57 had a diagnosis of diabetes A physician's order dated 4/24/24 directed to administer Tresiba Flex touch solution 100 units/ml pen injector, 24 units subcutaneously in the AM and to 21 units subcutaneously in the PM. A physician's order dated 6/13/24 directed to hold Tresiba if blood sugar is less than 90 every day and evening shift for diabetes. The annual MDS assessment dated [DATE] identified Resident #57 had severe cognitive impairment, could feed self with supervision, and received insulin daily. The care plan dated 7/18/24 indicated Resident #57 was an insulin dependent diabetic with interventions that included: administer insulin and blood sugar checks as ordered and staff to provide diet as ordered. Interview on 8/13/24 at 8:50 AM with LPN #8 indicated Resident #57 was a brittle diabetic and had a low blood sugar at 8:30 AM, the RN supervisor (RN #3) was notified, and the hypoglycemic protocol was followed with elevation of blood sugar to a normal level. Interview and record review on 8/13/24 at 10:30 AM with RN #3 identified that the 4/24/24 order to administer Tresiba was ordered to be given in the AM was scheduled to be given at 6:00 AM. A separate order dated 6/13/2024, directed to hold the Tresiba if the blood sugar level was below 90 was scheduled for the AM on the 7-3 shift, after the Tresiba was actually given at 6:00 AM. No blood sugar was scheduled to be performed at 6:00 AM prior to administering the Tresiba but a blood sugar was scheduled for 7:30 AM (an hour and half after the Tresiba was given at 6:00AM without the benefit of checking the blood sugar level to ensure it was within the physician's ordered parameter to be safely administered (64 days after the order to hold was written). RN #3 indicated she would contact the APRN for further orders. On 8/13/24 at 12:42 PM an interview with Pharmacist #1 indicated Tresiba would start working to lower a blood sugar level in about an hour and continues to be long acting over 24 hours. An interview with the DNS on 8/14/24 at 2:20 PM indicated the APRN writes the orders in the electronic system and the charge nurse notes the orders, third shift does a double check of new orders every night to ensure the orders are transcribed correctly onto the medication and/or treatment records. The DNS further indicated the staff involved will be reeducated. The facility policy labeled Physician's orders-Oral, telephone and Written indicated in part all orders will include the name of the drug, dosage, form, route and length of time to be administered (stop date) the policy does not indicate how physician orders are double checked by nursing staff for accuracy of transcription to the medication and/or Treatment administration record. The facility failed to ensure that the blood sugars were monitored prior to the administration of morning dose of insulin.

Based on observations, facility documentation review, facility policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. The findings include: Observations during a tour of the kitchen on 8/11/24 at 10:05 AM with [NAME] #1 identified the following: The kitchen floor had an excessive amount of dried spillage brown/tan buildup under all counters and work prep areas in front of oven and back counter Dried white/tan/brown spillage along the side and front of ovens (4). 1/2 bag thawed mango loosely covered and placed on top of bin of pineapple also loosely covered. Leakage from the mango into the pineapple with the outside of bag directly making contact with the pineapple. 1/2 bag of opened mozzarella cheese balls with no date. 1/2 bag shredded of opened mozzarella cheese with no date. Three ceiling vent covers in the dishwashing station with moderate amount brown/grey matter buildup. Three red sanitizing buckets were stacked alongside the sink empty with cleaning supplies stored inside. The top of the Dishwasher with moderate amount of brown crumb-like debris. An interview with [NAME] #1 on 8/11/24 at 10:05 AM identified there were no set cleaning schedules for staff to follow and that staff were only responsible for cleaning immediate surface areas after use. All food items should have been dated and not stacked on top of each other. The cleaning of the ceiling vents was the responsibility of maintenance staff. [NAME] #1 further identified that although she had been switching food prep tasks on surface areas for breakfast and lunch, she did not use a sanitation solution and should have. Instead, [NAME] #1 used a towel with warm soapy water. An interview with the Director of Maintenance on 8/11/24 at 10:34 AM identified the kitchen staff were responsible for the cleaning of the ceiling vents covers in the dishwashing station. An interview with the Food Service Director, FSD on 8/11/24 at 11:05 AM identified he had been employed at the facility for one month and was responsible for overseeing staff in ensuring a clean and sanitary kitchen. The FSD was aware that the kitchen was not being maintained in a clean and sanitary manner, did not have any cleaning schedules that staff followed and was attempting to clean smaller areas of the kitchen at a time to address the issue. The FSD identified foods should be dated and not stacked to prevent leakage and that a sanitization bucket should have been set up and used to sanitize between food prep tasks. A review of the facility policy for Dietary Cleaning and Sanitation dated 8/2022 directed that the facility must maintain the sanitization of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination. Although requested a policy on dating foods was not provided.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to ensure that leg rests were applied to the wheelchair prior to transporting the resident to prevent a fall with injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #1 had severe cognitive impairment, vision was highly impaired, required extensive two person assistance with transfers, was non-ambulatory and utilized a wheelchair for transportation. The resident care plan dated 7/10/14 identified a risk for falls related to unaware of safety needs, psychoactive medications and confusion. Interventions directed two person mechanical lift transfers and leg rests on the adaptive wheelchair. A physician's order dated 7/24/14 directed out of bed to adaptive wheelchair with an assist of two via mechanical lift. The Reportable Event Form dated 8/15/14 at 8:00 am identified that Resident #1 fell forward from wheelchair while a nurse aide was pushing the resident out of the room and the resident hit his/her head on the floor. The nurse's note dated 8/15/14 identified Resident #1 was observed lying on the floor face down. The resident sustained [REDACTED]. The hospital summary dated 8/15/14 identified Resident #1 sustained a fracture to the left nasal bone and a four centimeter laceration to the left eye that required seven sutures. The care plan revised dated 8/18/14 directed when transferring to the adaptive wheelchair from the bed tilt the chair back until the leg rests are applied. Interview with Nurse Aide (NA) #1 on 4/7/15 at 10:00 am stated that she knew Resident #1 required leg rests to wheelchair. NA #1 identified that there was not enough space in the resident's room to apply the leg rests, so she wheeled the resident out of the room to apply the leg rests and all of a sudden Resident #1 fell forward out of the chair hitting the floor. NA #1 stated the resident was not agitated during care. Interview with the Occupational Therapist (OT) on 4/7/15 at 11:30 am identified that Resident #1 was being fitted for a custom wheelchair and on the current wheelchair required the leg rests to keep him/her hips back in the chair. The OT stated that the leg rests should have been applied to Resident #1's wheelchair prior to transporting the resident. Interview with the Director of Nursing on 4/1/15 at 9:40 am identified that although there was no physician's order for leg rests, the leg rests were part of the care plan and the nurse aide should have applied them prior to moving the resident.

Based on clinical record review, observation, interview and for one of three sampled residents reviewed for accidents (R#9), the facility failed apply a positioning foot device to ensure the safety of the resident. The findings include: Resident #9 [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident with cognitive impairment and required extensive assistance of two for transfers, and required two person assistance with bed mobility. A RCP dated 1/11/12 identified the resident with a self care deficit related to Dow[DIAGNOSES REDACTED] and dementia. Interventions included to provide assistance of two for transfers, two staff to reposition and turn in bed, daily skin inspections and on bath day, observe for redness, open area, scratches, cuts, bruises and report changes to the nurse. A physician's orders [REDACTED]. A 24-hour positioning plan dated 12/23/11 identified R#9 required two foot rests on wheelchair with two foot placement straps over the feet. A nurse's note dated 4/16/12 identified the resident was crying out, the right ankle was assessed, edema was present and very tender to touch. The right foot was elevated on a pillow, ice was applied and the physician was notified. A "stat" X-ray was ordered and Tylenol was administered for pain and discomfort. A nurse's note dated 4/17/12 at 11:00 AM identified R#9 as crying out and complaining of right ankle foot pain, Tylenol was administered with positive effect and foot tender to touch on palpitation. A nurse's note dated 4/17/12 at 10:00 PM identified the right ankle tender to touch, R#9 was noted as crying at times and Tylenol administered with fair results. A nurse's note dated 4/18/12 at 4:45 AM identified R#9's right leg, shorter than the left, increased pain in the hip area with on palpation and the physician updated. R#9 was identified with right hip fracture and transferred to the hospital. Review of the hospital summary dated 4/19/12 identified a displaced right intertrochantor hip fracture. Interview with NA#1 on 5/7/12 at 2:15 PM identified she went into R#9's to provide assistance and noted that resident's right foot was crossed over the left and when she attempted to move the resident's wheelchair she noticed the resident's right foot stuck between the bed frame. NA#1 indicated she removed the resident's foot from the bed frame and then transferred the resident to the commode with assistance. NA#1 identified R#9 yelled out in pain when attempts were made to have the resident bear weight and when she placed resident's foot back on the foot rest. NA#1 indicated she did not report incident immediately to staff nurse however, she informed the nurse after the resident complained of pain when weight bearing. NA#1 indicate that although R#9's feet should have been strapped in the foot rest, utilizing the foot strap, she did not apply them. Interview with LPN#2 on 5/7/12 at 1:40 PM identified NA#1 reported that R# 9 was having difficulty standing up in the bathroom and she then assessed R#9. LPN#2 also indicated that an X-ray of the right ankle was obtained with results indicating no fracture and some edema. Interview with RN#4 on at 3:00 PM identified she worked the 3-11 shift on 4/16/12 and resident's right foot was on a pillow, and the ankle swollen. RN#4 also indicated she administered Tylenol and only assessed the resident from the knee down. Interview with OT#1 on 5/8/12 at 10:20 AM indicated that the foot rest on R#9's wheel chair helps to keep the resident's legs in alignment and foot straps help to keep resident's hip back and leg in good position. OT#1 also indicated that the wheelchair is customized for resident use and current positioning plan should be utilized by staff. OT#1 also indicated that positioning plan for residents are located in resident room. Interview with RN#5 on 5/8/12 at 3:25 PM indicated she worked the 3-11 shift on 4/17/12 and at the beginning of the shift R#9 demonstrated a lot of pain and Tylenol was given. RN#5 also indicated she only assessed the resident's ankle. Interview with MD#1 on 5/9/12 at 8:55AM indicated that the resident's hip fracture occurred as a result of a fall and/or trauma. MD#1 further indicated that there is no evidence to illustrate the fracture as spontaneous and/or pathological.

Based on observation, clinical record review, review of facility documentation, policies and interviews for R#2 who was found on the floor and/or was struck by the mechanical lift, the facility failed to provide adequate supervision and/or assistive devices to prevent accidents. The findings include: 1. R#2 ' s [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified impaired cognition with severely impaired decision-making, communication problems, total dependence for all mobility activities and activities of daily living, did not use bedrails for mobility or transfers, incontinence of bowel and bladder and full side rails on all open sides of the bed. A physician's order [REDACTED]. A Restraint assessment dated [DATE] identified 2 full side rails, padded, related to dementia/inability to remember directions, anxiety, and lack of awareness of limitations/safety awareness. A Fall Risk assessment dated [DATE] identified a score of 15 with a score above 10 representing a high risk. Review of the clinical record dated 04/05/10 at 7:30AM, identified that R#2 was found on the floor, next to the bed, face down, in a pool of blood. One side rail was noted to be down. NA#12 who worked the 11:00PM through 7:00AM shift identified that he/she had provided care one half hour prior to the resident being found on the floor, and had put both side rails up, adding, that R#2 shakes the rails continuously. Review of facility investigative report identified that NA#12 was interviewed on 04/05/10 and identified that he/she had provided care to R#2 at approximately 6:00AM, elevated the head of the bed, slightly, so R#2 could watch television, and placed both side rails up. NA#12 left the room between 6:15AM and 6:20AM. Review of the facility investigative report and the Emergency Department Department Record dated 04/05/10 identified [DIAGNOSES REDACTED]. A CAT Scan of the head identified no bleed or fracture. The deep laceration of the forehead required four sutures for closure. Review of the facility Maintenance Log dated 04/05/10 identified that RN#3, the 11:00 PM through 7:00 AM supervisor, requested that the side rails on R#2 ' s bed be checked. They were checked the same day and determined to be functioning properly. Interviews with LPN#3, LPN#4, NA#9, NA#10, and NA#11 on 09/16/10 and 09/17/10 identified that in order to ensure that the side rails were properly engaged, they must be pulled up until there was an audible " click." The rails should be re-checked to ensure that they were firmly locked in place. Interview with the Director of Maintenance on 09/21/10 at 1:00 PM identified that it was not possible for a resident to disengage the side rail if it was properly placed in the locked position. 2. Resident #2's care plan dated 04/05/10 identified that a fall occurred on 04/05/10 with interventions that included bedside mats, low bed, and bolstered mattress. Review of the clinical record identified that on 04/23/10 at 6:45 PM, R#2 was struck below the right eyebrow by the mechanical lift, following transfer into bed, as NA#13, and NA#14 attempted to dislodge the lift from underneath the low bed. Review of facility documentation dated 04/23/10 identified that after transferring R#2 back to bed by mechanical lift, NA#14 began unhooking the leg straps from the lift as NA#13 attempted to remove the lift from under the bed. NA#13 started moving the lift back and forth to dislodge it, and the lift moved forward, striking R#2 above the eyebrow. R#2 was closely monitored, and subsequently, vomited and was transferred to the Emergency Department for evaluation and was discharged with new [DIAGNOSES REDACTED]. Review of the facility procedure for Mechanical Lift Transfer identified that while moving a resident by mechanical lift; one NA must ensure that the resident ' s arms, head and legs are protected. Interview with NA#14 on 09/21/10 at 3:15 PM identified that he/she guided R#2 ' s legs while NA#13 maneuvered the lift. The lift got stuck under the bed and, as NA#14 released the final hook on the sling, NA#13 moved the lift back and forth under the bed in an attempt to dislodge it. The lift moved forward, suddenly, and struck R#2 above the right eyebrow. Interview with NA#13 on 09/16/10 at 3:15PM identified that he/she had received mechanical lift transfer training at least annually since hire, but could not recall the circumstances of the transfer with R#2. Subsequent to the incident, the facility staff was re-inserviced on the use of the mechanical lift.