Every finding on record at Evergreen Center for Health & Rehabilitation

Based on observations, review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews, for nine of twelve sampled residents (Residents #5, #9, #91 #105, #107, #115#122, #142, #151) reviewed for facility acquired pressure injuries, the facility to accurately assess, treat, and implement timely interventions for residents at risk for the development of pressure injuries, resulting in the development of avoidable pressure injuries and the worsening of the pressure injuries resulting in harm. The findings include:Resident #122's diagnoses included cellulitis of left and right lower limbs, generalized muscle weakness, and difficulty walking. The Braden Scale Assessment (used to predict risk for pressure ulcer development) dated 7/30/26 identified Resident #122 had a score of 16 which was indicative of the resident being at high risk for the development of a pressure ulcer The initial nurse assessment dated [DATE] identified lower leg venous ulcer. Review of the clinical record identified there were no additional nurse skin checks completed until 8/16/26 and it reflected there were no skin concerns. The physician's orders dated 7/30/26 identified that skin checks were to be performed weekly on the day of the resident's shower. The admission MDS assessment dated [DATE] identified Resident #122 had no cognitive impairment, was dependent on staff for bed mobility, toileting, transfers, and was non-ambulatory unless with therapy. The assessment further identified the resident was occasionally incontinent of both bladder and bowel. The wound specialist's evaluation dated 8/13/26 identified Resident #122 was evaluated for right lower leg dermatologist-rash, groin rash and left shin venous ulcer. The wound assessment noted measurements were 0.1 centimeters (cm) in length by 0.1cm in width with no measurable depth and no tunneling noted. There is no drainage noted and the skin around the wound is normal in texture, moisture, and color. The left shin has a full thickness venous ulcer that was not healed. The measurements were 3.1cm in length, 2.3cm in width and 0.1cm in depth. No other wounds were noted at this time. A wound specialist consultation on 8/19/26 failed to identify any additional wounds. A review of the clinical record identified the facility failed to conduct weekly skin checks as per physician orders from 7/31/26 through 8/20/26 (total of 19 days). A nursing skin check dated 8/21/26 (21 days later) identified a pressure injury on the right buttocks as a Stage 2 or partial thickness with exposed skin. A second pressure ulcer was also discovered under the right gluteal fold, determined as a Stage 2 or partial thickness with exposed skin. A review of the care plan on 8/20/26 from 7/31/26 to 8/20/26 failed to identify any turning and repositioning until 8-21-26. Wound specialist rounds completed on 8/27/26 identified an unstageable right perineum wound with a light amount of liquid drainage and a right buttock Stage 2 pressure injury that was not healed that measured 1.4 cm in length and 0.8 cm in width and 0.1cm in depth with no tunneling noted. An additional right buttock stage 2 pressure injury was identified that measured 0.8cm in length, 0.6cm in width, and 0.1cm in depth. A review of the physician's orders on 8/27/26 from 7/31/26-8/16/26 failed to identify any treatment recommendation. Wound care observation conducted with Licensed Practical Nurse (LPN #1) wound nurse on 8/27/26 at 1:15 PM identified Resident #122 was lying in bed on an alternating low air loss mattress. The resident had no dressings in place on the right buttock. LPN #1 identified a Stage 2 pressure injury to the right buttock and right groin. The wound bed was noted to have a light-yellow covering with granulation tissue visible. Interview with LPN #1 on 8/25/26 at 1:40 PM identified she was recently hired as the facility's wound nurse and began her role in July 2026. She reported that she is responsible for monitoring wounds weekly and assisting the wound specialist during weekly wound rounds. She also identified she is responsible for ensuring the wound specialist's treatment recommendations are transcribed into the physician's orders. LPN #1 identified the Wound Specialist verbally informed her of treatment recommendations and sent the wound evaluation, assessment, and treatment recommendations via email. She acknowledged that treatment orders should be reviewed and transcribed on the same day or, at minimum, the following day Interview and clinical record review with the Assistant Director of Nursing Services (ADNS) on 8/25/26 at 2:15 PM identified the nursing supervisor and/or the wound nurse are responsible for ensuring that treatment was implemented once a wound and/or pressure ulcer injury is identified. She identified the nursing supervisor as responsible for assessing a resident's wound or pressure ulcer injury when noted, obtaining a physician's order for treatment, and transcribing the physician's treatment order into the electronic physician order system. The ADNS further identified the charge nurse is responsible for signing off the Treatment Administration Record (TAR) once the treatment is administered. Interview and record review with Physician Assistant (PA #1) wound specialist on 8/27/26 at 2:15 PM indicated she was newly assigned as the facility's wound specialist. She identified that any resident with a new onset of moisture associated skin damage (MASD) or a pressure injury required immediate treatment intervention to prevent worsening and promote healing. She also identified that Resident #122 was at high risk for pressure ulcer development due to cognitive impairment, occasional incontinence, and limited bed mobility. She further indicated she would expect to see documentation for turning and repositioning, heel off loading and low-air loss mattress in the plan of care. PA #1 indicated her expectation would be for weekly skin checks and the facility to communicate any identified wounds to the provider for treatment recommendations. The lack of timely treatment could have contributed to the progression of pressure ulcers. She identified that the expectation was for treatment recommendations to be implemented immediately, and that delays of up to five days for treatment initiation were not acceptable. Interview with Nurse Aide (NA # 4) on 8/28/26 at 12:06 PM identified Resident # 122 is on a turn and reposition scheduling every 2 hours which was not documented in the electronic medical record. NA # 4 further indicated she/he knew to turn and reposition every 2 hours from nursing school. The facility's Pressure Injury Prevention Protocol reviewed on-site identified that every resident must receive care that follows professional standards. If a resident has a pressure injury, the facility must provide treatment to help it heal, prevent infection, and stop new pressure injuries from forming. The policy also explains the difference between avoidable and unavoidable pressure injuries: Avoidable: A pressure injury is avoidable if the resident develops one because the facility failed to do one or more of the following: Check the resident's clinical condition and risk factors. Create and follow a care plan that matches the resident's needs and accepted clinical standards. Monitor whether the care plan is working. Change the care plan when needed. Unavoidable: A pressure injury is unavoidable if the resident develops one even though the facility: Assessed the resident's condition and risk factors. Created and followed a care plan based on the resident's needs and professional standards. Kept track of how well the plan was working. Updated the plan when necessary. The facility failure to conduct weekly skin assessments resulted in the resident developing two newly acquired pressure ulcers to the groin and buttocks. Resident #5 was admitted to the facility in September of 2025 with diagnoses that included moderate protein-calorie malnutrition, type 2 diabetes mellitus, traumatic subdural hemorrhage, hemiplegia and hemiparesis hemorrhage affecting the left non-dominant side. The admission MDS assessment dated [DATE] identified Resident #5 had severe cognitive impairment, was totally dependent on staff for toileting hygiene, bed mobility, transfers, dressing, was non-ambulatory, always incontinent of bladder and bowel, was at risk for development of a pressure injury but had no pressure injury. The assessment further identified that the resident used a pressure-reducing device while in bed and when seated in chair but was not on a turning and repositioning program. The Braden Scale assessment (used to predict risk for pressure ulcer development) dated 9/19/25 identified Resident #5 had a score of 10 which was indicative of the resident being at high risk for the development of a pressure ulcer. The Resident Care Plan (RCP) dated 9/26/25 identified Resident #5 had the potential for skin breakdown due to prolonged pressure. The care plan interventions directed staff to offload the resident's heels with boots when in bed and/or at all times, pressure redistribution mattress, complete weekly skin evaluations, and administer treatments as per physician's orders. The physician's order dated 9/19/25 directed staff to complete weekly skin checks and document findings in the total body skin assessment every evening shift weekly on Mondays. The physician's order dated 9/20/25 directed to apply barrier cream to buttocks for protection every shift and as needed. The admission nurse's note dated 9/19/25 at 11:52 PM written by the ADNS identified Resident #5's coccyx/sacrum was red and blanchable, and noted triad paste to area. The note further identified the resident had an air mattress in place and to reposition in bed every two hours. The admission nursing note dated 9/19/25 at 11:33 PM written by the charge nurse (LPN #12) identified Resident #5's buttock was red, blanchable and barrier cream was applied. Review of the admission skin assessment completed on 9/19/25 and 9/20/25 by the ADNS failed to identify that the coccyx/sacrum area was red on admission nor were there any measurements included in the admission nursing documentation. Review of the hospital discharge records (after visit summary) dated 9/19/ noted a wound to the right medial gluteal that was last assessed on 9/18/25, and noted the area was dry, intact and base of the wound was pink. The documentation further identified that a sacral foam dressing was in place. A review of the Nurse Aide (NA) care card, effective 9/20/25, revealed that it did not indicate that Resident #5 was to be turned and repositioned every two hours. Interview with the ADNS on 8/25/26 at 2:14 PM identified that on admission she noted a foam dressing to Resident #5's coccyx/sacrum area, the dressing was removed and she noted the red blanchable area, so she obtained a physician's order for barrier cream. The ADNS also identified that she should have documented the redness on the admission skin assessment but did not because the redness was not a redness that was significant .The ADNS further noted that turning and repositioning a resident every 2 hours is a standard of care practice, so the nurse aide does not document when the resident is turned and repositioned, however, she should have included it in the care plan as she was responsible for developing the care plan at the time of the admission. In addition, she identified that the facility's wound prevention protocol should have been implemented given that the resident's Braden score indicated that Resident #5 was at a high risk for developing a pressure injury. Review of the Pressure Injury Prevention Management Program policy in the Admission/re-admission Protocol section identified that the licensed nurse is responsible for updating the nurse's aide care card (information on how to care for the resident) on admission/readmission with appropriate preventative measures. This update should include information such as the established turning and positioning schedule, out-of-bed schedule, preventative mattress and/cushion, offloading and adaptive/assistive devices. The nursing note dated 10/5/25 at 1:08 PM written by LPN #6 identified Triad paste was applied to the MASD on Resident #5's sacrum. Review of the skin/wound documentation and skin issues for Resident #5 for the period of 9/29/25 through 10/10/25 failed to identify that Resident #5 had a skin issue to his/her sacrum. Review of the physician's order and the treatment administration record for the period of 9/19/25 through 10/10/25 failed to identify a physician's order directing the use of Triad paste to Resident #5's sacrum. The weekly skin check completed on 9/29/25 documented no skin issues for Resident #5. The weekly skin check completed on 10/6/25 documented no skin issues for Resident #5 even though the nurse's note dated 10/5/25 identified that the resident had MASD (moisture associated skin damage) to the sacrum. A review of the Treatment Administration Record for the period of 10/5/25 to 10/11/25 failed to identify a treatment in place for Resident #5's MASD to the sacrum as identified on 10/5/25, the resident only had a treatment order for barrier cream to be applied to the buttocks, which is not the sacrum. Further review of the clinical records failed to identify that the identified skin issue to the sacrum was reported to the nursing supervisor for assessment nor did the records note that the APRN/physician was updated regarding the change in the resident's skin condition. Interview with Charge Nurse (LPN #6) on 8/28/26 at 10:18 AM identified the area to Resident #5's sacrum was an MASD because it was a red unopened and non-blanchable area, so she applied the Triad paste as it was listed in the resident admission paperwork on 9/19/25. LPN #6 reviewed the discharge paperwork dated 9/19/25 and identified that Triad paste was used to the lower buttocks/perineum and not to the sacrum. She further identified the facility had a list of treatment/protocol that can be used based on the skin issue and since it was not opened Triad paste was appropriate, however, she identified that she would have needed to have a physician's order prior to applying the Triad paste. She further identified that she could not recall if she had notified the supervisor of the MASD area on the sacrum as whenever a skin issue is identified a risk management documentation needs to be completed by the charge nurse or the supervisor. Interview with the DNS on 8/25/26 at 2:14 PM identified that whenever a skin issue is identified the nurse should report the issue to the supervisor who would then assess the area, obtain treatment orders, and notify the family. The DNS further identified that a physician's order is needed for Triad paste to be administered to a resident. The facility's Pressure Injury Prevention Protocol policy indicated that, based on a comprehensive evaluation of the resident, the facility was to ensure that each resident received care consistent with professional standards of practice. The policy indicated that a resident with pressure ulcer was to receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing. The Situation, Background, Assessment, and Response (SBAR) notes dated 10/11/25 at 2:20 PM written by LPN #6 identified she was called to Resident #5's room and noted an open area to the sacrum. The area was cleansed with normal saline; calcium alginate was applied followed by a foam dressing. The note further identified vital signs were obtained and the supervisor was notified. Review of the physician's orders and the MAR failed to reflect an order for the calcium alginate. The progress note dated 10/11/25 at 4:04 PM written by APRN #3 identified Resident #5 was evaluated for a newly identified sacral wound that was noted during routine care. The note identified RN #8 (a nursing supervisor) provided the details of Resident #5's sacral wound to APRN #3. The note further identified that the open area was located on the resident's sacrum measuring 2.69 centimeters (cm) by 2.73 cm, and noted the wound was a full thickness ulceration with visible subcutaneous tissue, a moist red wound bed with partial slough, no bone, tendon or muscle exposure. The note further identified there was minimal serosanguinous drainage, the peri wound had mild erythema no odor and was staged as a stage 3 pressure ulcer (injury). In addition, the note indicated that APRN #3 ordered the wound to be cleansed with normal saline, pat dry, then apply barrier film to peri-wound skin and dress with Triad paste or foam dressing (per formulary) and to change daily and as needed for saturation. The skin and wound evaluation dated 10/11/25 at 2:51 PM completed by RN #9 identified Resident #5 had a facility acquired unstageable pressure injury to his/her sacrum which was first identified on 10/11/25 and measured 2.7 cm in length by 1.3 cm in width, no depth. The evaluation further identified the wound bed had eschar, with moderate amount of serosanguinous exudate (drainage) with no odor or evidence of infection. The treatment included an enzymatic debridement with primary dressing of calcium alginate followed by a secondary dressing of dry foam dressing. A review of the physician's orders from 10/11/25 through 10/13/25 failed to identify that the barrier film to peri-wound skin and dress with Triad paste or foam dressing or an order directing the application of calcium alginate to the sacral wound had been ordered and implemented for the sacral wound. The RCP dated 9/26/25 identified the potential for skin breakdown due to prolonged pressure with an intervention dated 10/11/25 for an air mattress to improve skin breakdown. The progress note dated 10/13/25 at 10:30 AM written by APRN #2 identified Resident #5 was seen for an acute follow-up for the coccyx wound, and reported the wound was uncomfortable. The note further identified that the resident was being followed by the wound nurse and the resident declined to get out of bed over the weekend. It further noted that the current treatment would remain in place. The wound specialist progress note dated 10/14/25 identified Resident #5 had a sacral wound which is an unstageable pressure injury with an initial wound encounter measurements of 2.4 cm in length by 1.5 cm in width by 0.2 cm in depth with a moderate amount of serosanguineous drainage, with no odor noted and wound pain of 0 out of 10 on the scale of 0 to 10, (0 indicate no pain and 10 the highest pain). The note further identified the wound bed had 30 percent (%) granulation, 50% slough, 20% eschar with no epithelialization present. The treatment recommendation included cleanse the sacral wound with wound cleanser, then apply Santyl to wound and calcium alginate and cover with foam dressing daily and as needed. A review of the Treatment Administration Record (TAR) identified Resident #5 had no recorded wound treatments administered to the sacrum from 10/5/25 through 10/13/25. The first recorded and signed treatment administration was on 10/14/25, which was 10 days after the sacrum area was initially noted by the charge nurse (LPN #6) as MASD, then later as a stage 3 pressure injury on 10/11/25 by APRN #3, which was later identified by the wound specialist to be an unstageable pressure injury on 10/14/25. Interview with the DNS and ADNS on 8/25/26 at 3:00 PM identified that the APRN's assessment of the wound should take precedent over the registered nurse's assessment of a wound. They noted that the APRN's assessment was completed via telehealth and that should be considered. They further identified that when the telehealth on-call physician/APRN is notified, they have access to the pictures of the wound, and the nurse provides their assessment information to the physician/APRN when they are notified. However, the nurse who documented the skin and wound evaluation/assessment was not the nurse who provided the details to APRN #3, hence the APRN would be assessed based on the picture seen and the RN's assessment information provided to them at the time of the notification. The wound specialist's progress note dated 10/20/25 identified Resident #5's sacral wound was an unstageable pressure injury with a subsequent encounter measurement of 2.3 cm in length by 1.3 cm in width by 0.2 cm in depth with moderate amount of serosanguineous drainage. The wound specialist's progress note dated 11/3/25 identified Resident #5's wound assessment of the sacral wound noted the sacral wound was an unstageable pressure injury, which measures 4.5 cm in length by 6.5 cm in width by 0.2 cm in depth, from the previous measurements on 10/27/25 which noted to be 2.9cm in length by 1.7cm in width by 0.2 cm in depth. The note further identified the wound has moderate amount of serosanguineous drainage which had a strong odor and the resident noted to have a 3/10 pain. The note further identified the wound bed had no granulation, 60% slough, 40% eschar with no epithelialization present and that the wound is deteriorating. The treatment recommendation included an x-ray of the sacrum and to cleanse the sacral wound with Dakin's 1/4 strength wet to moist and apply silicone bordered foam dressing twice daily and as needed. The wound specialist's progress note dated 11/10/25 identified Resident #5 wound assessment of the sacral wound noted the sacral wound is an unstageable pressure injury, which measures 4.7 cm in length by 2.4 cm in width by 0.2 cm in depth, no tunneling, no sinus tract and no undermining. The note further identified the wound has heavy amount of serosanguineous drainage which had a mild odor and the resident reports to have a wound pain level of 3/10. The wound specialist's progress note dated 11/17/25 identified Resident #5's wound assessment of the sacral wound noted the sacral wound is an unstageable pressure injury, which measures 6.0 cm in length by 4.5 cm in width by 4.2 cm in depth, no tunneling and sinus tract noted and undermining noted at 9:00 and ends at 1:00 with a maximum distance of 2 cm and muscle is exposed. The note further identified the wound has heavy amount of serosanguineous drainage which had a strong odor and the resident reports to have a wound pain level of 3/10. The note further identified the wound bed had no granulation, 30% slough, 40% eschar with no epithelialization present and the wound is deteriorating. The x-ray result dated 11/4/25 identified there was probable bone erosions involving the lower sacrum with a conclusion that there are findings suspicious for osteomyelitis involving the lower sacrum, and an MRI scan might be of benefit for further evaluation. APRN #2's progress note dated 11/5/25 at 12:30 PM identified a diagnosis of osteomyelitis, and noted the resident was seen for a follow-up x-ray of the sacral area for a question of osteomyelitis and noted the MRI (Magnetic Resonance Imaging) results were pending and resident is on intravenous antibiotics. The Situation, Background, Assessment, and Response (SBAR) note dated 11/19/25 at 11:02 AM identified Resident #5 presented with increased pain to the sacrum pressure ulcer with worsening of his/her wound bed. The note further identified that the resident's pain is not managed and the wound is worsening without clear indication of etiology. The resident was evaluated by the APRN with order to send the resident out to the hospital. The hospital Discharge summary dated [DATE] identified the computed tomography scan (CT) of the abdomen pelvis revealed a deep decubitus ulcer in the sacrococcygeal region and osteomyelitis of proximal coccyx with no soft tissue abscess. The wound specialist's progress note dated 12/8/25 identified Resident #5's initial wound assessment of the sacral wound since readmission noted the sacral wound was a stage 4 pressure injury, which measured 7.0 cm in length by 11.2 cm in width by 2 cm in depth, no tunneling and sinus tract noted and undermining noted at 9:00 and ends at 1:00 with a maximum distance of 2 cm and necrotic ligament, tendon, muscle, joint, bone and adipose are exposed. The note further identified the wound has heavy amount of serosanguineous drainage which had a strong odor and the resident reports to have a wound pain level of 3/10. The note further identified no tunnelling, sinus tract noted and undermining noted at 10:00 and ends at 3:00 with a maximum distance of 3cm. The wound margin is not attached to wound base, the wound bed has no granulation, no slough, eschar and no epithelialization present and the wound is deteriorating. A wound treatment observation conducted with LPN #1 (wound nurse) on 8/27/26 at 10:20 AM identified Resident #5 lying in bed facing the door. The resident had a foam dressing applied to sacrum which was removed and observed to have a stage 4 pressure injury to the sacrum. The wound bed of the sacrum had small sections of slough, eschar and approximately 70% granulation. Interview with the ADNS on 8/25/26 at 2:14 PM identified that when a skin issue is identified a treatment should be implemented immediately to treat the area. She further identified that an assessment should have been completed and a picture taken of the MASD area on 10/5/25, which captures measurements of the area. The ADNS further identified the supervisor should have been notified on 10/5/25 and a treatment order should have been in place on 10/11/25 when the wound opened. Interview with NA #6 and NA #7 on 8/26/26 at 2:20 PM identified that they apply barrier cream to residents when peri-care is provided. Interview with LPN #2 on 8/26/26 at 2:30 PM identified she was unable to recall if she had checked the resident's buttocks on 10/6/25 when she completed the skin check, even though she identified that when a skin check is completed the resident's entire body is checked for any skin issues. She further identified that the nurse aides apply barrier cream with care and the nurses apply the Triad paste. Interview with LPN #10 on 8/27/26 at 3:10 PM identified that skin checks are completed weekly on the resident's shower day and new skin issues are reported to the supervisor and documented. LPN #10 identified she did not recall noticing any skin issues to Resident #5's sacrum nor was she aware that the resident had MASD to the sacrum. She further identified that the nurse aide applies barrier cream to the resident buttocks and nurse only apply barrier cream if there is an issue with the area. Interview with Nursing Supervisor (RN #8) on 8/26/26 at 4:47 PM identified that she is an agency nurse and when third eye/on call APRN/physician is to be notified the supervisor typically does the notification. She further identified it was the responsibility of the supervisor who spoke with the APRN/Physician to input the order as it is given verbally or in the chat feature, so she is not sure why the order was not in the computer. Interview with PA #1 (wound specialist) and LPN #3 (wound care assistant) on 8/27/26 at 3:15 PM identified that she was newly assigned to the facility as the wound specialist, so she was not working at the facility at the onset of the wound. She further identified that when the resident was identified with MASD to the sacrum, the resident should have been evaluated by the wound specialist for the appropriate treatment and interventions to be implemented to prevent worsening and to promote healing. She further identified it is difficult to state what treatment should have been in place without seeing the wound but typically she recommends zinc oxide cream for MASD. LPN #3 identified she was familiar with Resident #5's sacral wound as she started working at the facility around the time the wound was identified. LPN #3 identified Resident #5's sacrum was known to be red, but she was unaware that the resident had MASD first, and then the sacrum opened. PA #1 and LPN #3 identified that the resident's diagnosis of osteomyelitis with bone loss appears to have started prior to the resident's admission to the facility, given the fact that the resident was hospitalized from May/2025 through September/2025. PA #1 was asked if osteomyelitis had started prior to being admitted to the facility what are some of the clinical presentations that would be seen/displayed by the resident, which she responded the resident could have elevated temperature, pain to the area, abnormal laboratory findings of C-reactive protein (CRP), which are not typically drawn unless the resident is suspected to have osteomyelitis and changes in the skin where it can start as being pink, then red or deep tissue injury (DTI), then opens into a small or a large wound, so the resident skin at the time would need to be assessed by the wound specialist. The facility failed to provide timely treatment interventions to prevent the worsening of the moisture associated skin damage (MASD) on the sacrum, identified on 10/5/25, which subsequently progressed to a Stage 3 pressure ulcer injury then to unstageable on 10/14/25. The facility also failed to implement timely treatment for the MASD to the sacrum and the stage 3 pressure ulcer injury to the sacrum, identified on 10/11/26 by the APRN, which progressed to an unstageable pressure ulcer injury on 10/14/26 as identified by the wound specialist. These delays in treatment contributed to the worsening of the pressure ulcer injury. The facility's Pressure Injury Prevention Protocol identified that every resident must receive care that follows professional standards. If a resident has a pressure injury, the facility must provide treatment to help it heal, prevent infection, and stop new pressure injuries from forming. The policy also explains the difference between avoidable and unavoidable pressure injuries: Avoidable:A pressure injury is avoidable if the resident develops one because the facility failed to do one or more of the following: Check the resident's clinical condition and risk factors. Create and follow a care plan that matches the resident's needs and accepted clinical standards. Monitor whether the care plan is working. Change the care plan when needed. Unavoidable:A pressure injury is unavoidable if the resident develops one even though the facility: Assessed the resident's condition and risk factors. Created and followed a care plan based on the resident's needs and professional standards. Kept track of how well the plan was working. Updated the plan when necessary. Resident #107's diagnoses included type 2 diabetes, pressure ulcer of sacral region stage 3, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #107 had severe cognitive impairment, was totally dependent on staff for toileting hygiene, bed mobility, transfers, and dressing, the assessment further noted the resident was non-ambulatory, always incontinent of bladder and bowel, and was at risk for developing pressure ulcer, but did not have a pressure injury and was not on a turning repositioning program. The Resident Care Plan (RCP) dated 6/19/26 identified Resident #5 had the potential for skin breakdown due to incontinence and immobility. The care plan interventions directed staff to complete skin checks with care for changes and report any changes to the nurse, use of an alternative air special mattress, update physician with changes as

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews the facility failed to maintain an effective system of controlled substance receipt, accountability, reconciliation, storage, disposition, destruction, and documentation. The facility failed to ensure that controlled substance disposition records (CSDRs) were reconciled and accurately reflected the electronic health record (EHR); failed to maintain required signatures documenting receipt, shift-to-shift accountability, return and/or destruction of controlled substances; failed to maintain adequate security of emergency controlled substance keys; and failed to maintain complete and accurate controlled substance records. The findings include:Unreconciled Yellow CSDRsReview of the facility's process for controlled substance biweekly audits with the ADNS on 8/26/26 at 11:05 AM identified she is the facility designee for completing the biweekly audits. The ADNS presented a binder full of papers (one paper containing two audits check-off lists). The ADNS indicated that she filled out a paper for each of the carts that she completed the audit at. The check list included:The ADNS had 4 separate binders in her office, separated by unit (First floor, Maple/subacute, 2nd floor and house stock) that contained yellow CSDR sheets. Observation of these yellow CSDRs identified dates dating back to 2023. There was not any indication on the yellow CSDRs that they had been reconciled. There were a handful of more recent yellow CSDRs that had dates of 7/10/26 and 7/30/26 as having been audited in the facility and indicated the remaining dose of the medication at the time of the audit. However, these two dates were the only dates noted on the yellow CSDRs dating back to 2023.Interview with the ADNS during this observation identified that she did not take the binders with the yellow CSDRs to verify which controlled substances were in use in the facility. Additionally, the ADNS indicated that not all of the yellow CSDRs were active in the facility and could not identify where the corresponding white CSDR sign off sheets were located in order to reconcile the controlled substances.Interview with the ADNS on 8/26/26 at 11:45 AM identified that the ADNS duties/responsibilities prevent her from having enough time to reconcile the controlled substances, and while she does complete a count with each nurse biweekly, she does not have time to verify all of the narcotics. The ADNS indicated that she had been working at the facility since 2022 and took the ADNS position in 2023, which is when she assumed responsibility for the biweekly reconciliations.Interview with the DNS on 8/26/26 at 11:50 AM identified that there was a drug control agent who came to investigate missing narcotics in March 2026.A facility wide controlled substance audit was conducted with the ADNS on 8/26/26 from 1:22 PM to 3:30 PM. During this audit, all active medications in use in the facility with white CSDR administration record sheets and medications present in the corresponding medication cart or room were found to have corresponding yellow CSDRs. All of the yellow CSDRs for medications in use in the facility were removed from the binders which identified an outstanding 529 yellow CSDRS dated 5/4/23 through 8/26/26 that did not have a corresponding white CSDR administration record, nor actual medication. Interview with the DNS on 8/26/26 at 3:37 PM identified that she had taken over as DNS in June 2026 and explained to the ADNS her process of biweekly audits specifically letting her know that the yellow CSDRs in the binder should all match up with the binders on the carts. The DNS was not sure if this was received as direction or just a conversation with the ADNS but indicated that the expectation is that all narcotics should be accounted for. At this time, the destruction logs from the last EID through today were requested from the DNS. Interview with the DNS on 8/27/26 at 6:44 AM identified facility staff had located white CSDR administration records and brought in binders with destruction logs and the most recent destruction log dated 8/26/26. The DNS indicated that when attempting to reconcile the outstanding yellow CSDRs, it was easier to destroy the bubble packs when reconciling and did not think to wait to show to the surveyor. All yellow CSDRs prior to the facility last EID date 11/19/24 were removed identifying a remaining seventy-four (74) yellow CSDRs that did not have a corresponding white CSDR administration record or actual medications.The outstanding yellow CSDRs that did not have a corresponding white CSDR administration record or actual medication includes medications listed below:CSDR #1370125 Tramadol 50 mg tablet (#30 of 90) received into the facility 11/27/24.CSDR #1346678 Oxycodone 5mg tablet (#30) received 11/5/24.CSDR #1364344 Lorazepam 0.5 mg tablet (#28) received 11/15/24.CSDR #1369185 Oxycodone 5 mg tablet (#30) received 11/20/24.CSDR #1369094 Lorazepam 0.5 mg tablet (#30) received 11/20/24.CSDR #1355549 Pregabalin 100 mg capsule (#30 of 90) received 11/24/24.CSDR #1355548 Pregabalin 100 mg capsule (#30 of 90) received 11/24/24.CSDR #1355546 Hydromorphone 2 mg tablet (#30) received 11/24/24.CSDR #1362292 Pregabalin 75 mg capsule (#30 of 60) received 12/7/24.CSDR #1362291 Pregabalin 75 mg capsule (#30 of 60) received 12/7/24.CSDR #1356638 Lorazepam 0.5 mg tablet (#15) received 12/5/24.CSDR #1394344 Clonazepam 0.5 mg tablet (#10 of 30) received 2/1/25.CSDR #1394345 Clonazepam 0.5mg (#20 of 30 half tabs) received 2/1/25.CSDR #1391549 Tramadol 50 mg tablet (#30) received 1/11/25.CSDR #1385418 Clonazepam 0.5 mg tablet (#30) received 12/20/24.CSDR #1403455 Modafinil 200 mg tablet (#30 of 60) received 1/22/25.CSDR #1394946 Clonazepam 1 mg tablet (#30) received 2/1/25.CSDR #1396273 Alprazolam 0.25 mg tablet (#30) received 1/28/25.CSDR #1393395 Zolpidem 5 mg tablet (#15) received 1/23/25.CSDR #1387758 Hydrocodone/APAP 5/325 mg tablet (#30) received 1/12/25.CSDR #1396849 Oxycodone 5 mg tablet (#30) received 1/26/26.CSDR #1388537 Lorazepam 2 mg tablet (#30) received 1/9/25.CSDR#1394805 Tramadol HCL 50 mg tablet (#30) received 2/9/25.CSDR #140273_ Clonazepam 0.5 mg tablet (#30 of 60) received 2/14/25.CSDR #14062_8 Morphine ER 20 mg capsule (#30) received 2/19/25.CSDR #1410858 Tramadol HCL 50 mg tablet (#30 of 90) received 2/23/25. (documented audit on 4/3/25 with 29 tablets remaining)CSDR #1428232 Clonazepam 1 mg tablet (#14) received 3/15/25.CSDR #1447125 Morphine ER 30 mg tablet (#30) received 4/8/25.CSDR #1362548 Pregabalin 75 mg capsule (#30) received 6/30/25.CSDR #1459841 Oxycodone IR 5 mg tablet (#30 of 60) received 6/5/25.CSDR #1459840 Oxycodone IR 5 mg tablet (#30 of 60) received 6/5/25.CSDR #1460978 Eszopiclone 2 mg tablet (#30) received 5/28/25.CSDR #1474227 Clonazepam 0.5 mg tablet (#30 of 60) received 8/28/25. CSDR #1451742 Pregabalin 75 mg capsule (#30) received 6/16/25.CSDR #1362546 Pregabalin 50 mg capsule (#14) received 6/30/25.CSDR #1362547 Oxycodone/APAP 5/325 mg tablet (#14) received 6/30/25.CSDR #1362545 Lorazepam 0.5 mg tablet (#30) received 6/30/25.CSDR #1442279 Eszopiclone 2 mg tablet (#14) received 6/30/25.CSDR #1472804 Fentanyl Patch 37.5 mcg/hr (#5 of 10) received 7/10/25.CSDR #1465098 Oxycodone/APAP 5/325 mg tablet (#30) received 8/9/25.CSDR #1464610 Oxycontin 30 mg tablet (#30) received 8/10/25.CSDR #1476932 Oxycodone/APAP 5/325 mg (#30 of 120) received 9/23/25.CSDR #1390855 Pregabalin 25 mg capsule (#30 of 60) received 9/29/25.CSDR #1512678 Pregabalin 100 mg capsule (#30 of 90) received 11/19/25.CSDR #1374128 Tramadol 50 mg tablet (#9) received 11/29/25.CSDR #1374126 Oxycodone IR 5 mg tablet (#12) received 11/29/25.CSDR #1373806 Morphine ER 15 mg tablet (#1) received 12/2/25.CSDR #1518999 Clonazepam 0.5 mg tablet (#30) received 1/11/26.CSDR #1493532 Morphine ER 30 mg tablet (#30 of 90) received 1/23/26.CSDR #1516953 Oxycontin 10 mg tablet (#2) received 12/29/25.CSDR #1485757 Pregabalin 150 mg capsule (#6) received 1/18/26.CSDR #1532284 Lorazepam 0.5 mg tablet (#30 of 60) received 2/27/26.CSDR #1542677 Lorazepam concentrate 2 mg/ml (30 ml) sent 3/13/26 but does not received signature at all or a date received.CSDR #1579385 Lorazepam 0.5 mg tablet (#30) received 4/29/26.CSDR #1577625 Morphine concentrate 20 mg/ml (30 ml) received 6/30/26.CSDR #1548181 Pregabalin 25 mg capsule (#30) received 5/20/26.CSDR #1573828 Lorazepam 0.5 mg tablet (#28) received 4/27/26.CSDR #1562417 Oxycodone 10 mg tablet (#15) received 5/12/26.CSDR #1557485 Tramadol 25 mg tablet (#30) received 7/14/26.CSDR #1585515 Lorazepam concentrate 2 mg/ml (30 ml) received 6/21/26.CSDR #1585726 Tramadol 50 mg tablet (#15) received 6/22/26.CSDR #1578175 Oxycodone 5 mg tablet (#30) received 7/2/26.CSDR #1556678 Tramadol 25 mg tablet (#30) received 7/16/26.CSDR #1599059 Lorazepam 1 mg tablet (#30) received 8/4/26.CSDR #1556248 Morphine concentrate 20 mg/ml (30 ml) received 7/17/26.CSDR #1598638 Tramadol 25 mg tablet (#30) received 8/4/26.CSDR #1645141 Lorazepam 0.5 mg tablet (#1) received 8/9/26.CSDR #1894861 Oxycodone 5 mg tablet (#30) received 8/11/26.CSDR #1601532 Morphine concentrate 20 mg/ml (30 ml) received 8/12/26.CSDR #1601292 Lorazepam 1 mg tablet (#16) received 8/12/26.CSDR #1593063 Eszopiclone 2 mg tablet (#3) received 8/21/26.CSDR #1593451 Morphine concentrate 20 mg/ml (30 m) received 8/21/26.Review of the yellow Controlled Substance Disposition Records (CSDRs) revealed multiple records that had not been reconciled. The facility was unable to provide documentation demonstrating that the controlled substances identified on the records had been completely accounted for and that discrepancies, if any, had been identified, investigated, and resolved.Interview with the DNS on 8/31/26 at 2:00 PM identified that facility staff have been working to marry the outstanding CSDRs but have not been able to locate the white CSDR administration records, nor any medication that would reconcile the outstanding yellow CSDRs. Controlled Substance InvoicesReview of the controlled substance invoices in the binder in the ADNS office on 8/26/26 and again on 8/31/26 at 1:14 PM identified invoices that did not contain the signature or other documentation identifying the licensed staff member who received the controlled substances when they were delivered to the facility. Review back to January 2026 identified a sample including the following invoices of received controlled substances without signatures and/or received dates:7/23/26 Morphine Concentrate 20mg/mo (30ml)7/23/26 Lorazepam Concentrate 2mg/ml (30ml)7/23/26 Oxycodone 5mg tablets (#30)7/23/26 Tramadol 50 mg tablets (#90) 3 cards 7/24/26 Lorazepam 1 mg tablet (#30)7/24/26 Tramadol 25mg tablet (#30)7/24/26 Lorazepam 0.5 mg tablets (#30) 1 card of 25 and 1 card of 5.7/24/26 Morphine ER 15 mg tablet (#30)7/24/26 Oxycodone 5 mg tablet (#30)7/24/26 Tramadol 25 mg tablet (#30) and Tramadol 50 mg tablet (#30)8/17/26 Oxycodone 5 mg tablet (#30) and Xtampa ER 9 mg capsule (#28)8/17/26 Clonazepam 0.5 mg tablet (#60) 2 cards8/22/26 Oxycodone 5mg tablet (#30)8/22/26 Tramadol 50 mg tablet (#30) and Pregabalin 200 mg capsule (#30)8/22/26 Pregabalin 75 mg capsule (#30)8/22/26 Oxycodone 5 mg tablet (#30)8/29/26 Tramadol 25 mg tablet (#30)8/29/26 Clonazepam 0.5 mg tablet (#14)9/29/26 Lorazepam 0.5 mg tablet (#30)8/29/26 Clonazepam ODT 0.25 mg (#30)8/29/26 Oxycodone 5 mg tablet (#30)8/29/26 Oxycodone 5 mg tablet (#12)8/29/26 Oxycodone 5 mg tablet (#30)8/29/26 Lorazepam 1 mg tablet (#30)8/30/26 Tramadol 50 mg tablet (#30)8/30/26 Alprazolam 0.5 mg tablet (#30) Interview with the ADNS on 8/26/26 at 11:30 AM identified that when controlled substances are delivered to the facility the receiving staff sign the delivery slip which is taken by the delivery person. The ADNS indicated that some of the invoice slips were signed but could not identify if the facility received a copy of the signed invoice slip for their records. Additionally, the ADNS could not identify if the facility received an overview of all medications delivered to compare to the received medications and the medications in use in the facility. The ADNS indicated that verifying the presence of the controlled substances against the deliveries was not part of her reconciliation process. Interview with the DNS, ADNS and the Regional Director of Clinical Operations (RN#2) on 8/28/26 at 11:52 AM identified that it has not been the facility practice to sign the delivery invoices but indicated the invoices are kept in a binder in the ADNS office. The DNS could not identify who received the pharmacy control invoices that should be received by the facility weekly and indicated that neither the pharmacy control invoices nor the delivery invoices were used to reconcile the controlled substances in the facility. [NAME] CSDR Administrative Sign-OffReview of a sample of 10 white CSDR administrative sign-off records and comparison with the residents' electronic health record Medication Administration Records (MARs) over the course of the survey identified that the administrative sign-off (5 of the 10 MARs) for 4 residents (Resident #22, Resident #140, Resident #176 and Resident #177) did not accurately reflect the medication administration information documented in the EHR. Despite discrepancies between the CSDR documentation and the EHR, the records indicated that the controlled substance records had been reconciled.Resident #22 was admitted to the facility with diagnoses including alcoholic cirrhosis of liver with ascites and chronic pain syndrome.The care plan dated 8/1/26 identified Resident #22 had actual/potential for pain relating to ascites with interventions including administer medications per orders.The Physician's orders dated 8/10/26 directed administration of Oxycodone HCL oral tablet 5 mg with directions to give 2 tablets by mouth every 6 hours as needed for severe pain for 14 days (through 8/17Review of the Medication Administration Record (MAR) dated August 2026 identified Oxycodone HCL 5 mg oral tablet give 2 tablets by mouth every 6 hours as needed for severe pain was administered 8/11 (2 administrations), 8/12 (2 administrations), 8/13 (1 administration), 8/15 (3 administrations), 8/16 (1 administration) and 8/17 (1 administration). Additional order identified administration on 8/24/26 (1 administration).Review of the white CSDR administration (CSDR #1604861 received in the facility 8/11/26) sign-off dated 8/11 through 8/24/26 identified administration of 2 tablets on 8/11 (2 administrations), 8/12 (3 administrations) which does not accurately reflect the EHR MAR where only 2 administrations were documented on 8/12. Additional administrations identify 8/13 (2 administrations) which does not accurately reflect the EHR MAR where only 1 administration was documented. One administration on 8/14 does not accurately reflect the EHR MAR as no administrations were documented for 8/14. Administrations on 8/15 (3 administrations), 8/16 (1 administration), 8/17 (1 administration) all accurately reflect the EHR MAR. Administration documented on 8/18 does not accurately reflect the EHR MAR as no administrations were documented for 8/18. One administration on 8/24 accurately reflects the EHR MAR documentation.Resident #140 was admitted to the facility with diagnoses including nondisplaced fracture of lateral end of left clavicle, fracture of one left side rib, and spondylolisthesis of the lumbosacral region.The physician's order dated 8/4/26 directed administration of Tramadol HCL oral tablet 50 mg to give one tablet by mouth every 8 hours as needed for moderate to severe pain for 14 days. The care plan dated 8/4/26 identified Resident #140 has and actual/potential for pain rlating to fracture of the left clavicle and left 3rd rib with interventions including the resident prefers to have pain controlled by medication and treatment.Review of the MAR dated August 2026 identified Tramadol HCL oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain for 14 days identified administrations on 8/4 (1 administration), 8/5 (2 administrations), 8/6 (1 administration), 8/7 (2 administrations), 8/8 (1 administration), 8/9 (2 administrations), 8/10 (2 administrations), 8/11 (2 administrations), 8/12 (1 administration), 8/14 (2 administrations), 8/15 (2 administrations), 8/16 ( 1 administration), 8/17 (2 administrations) and 8/18 (1 administration).Review of the white CSDR administration (CSDR#1599057 received in the facility 8/4/26) sign-off dated 8/5/26 through 8/18/26 identified administration on 8/5 (2 administrations), 8/6 (2 administrations) which does not accurately reflect the EHR MAR as only 1 administration was documented. The white CSDR identified administrations on 8/7 (2 administrations), 8/8 (2 administrations) which does not accurately reflect the 1 administration documented in the EHR MAR, 8/9 (2 administrations), 8/10 (2 administrations), 8/11 (2 administrations), 8/12 (2 administrations) which does not accurately reflect the 1 documented administration in the EHR MAR, 8/13 (1 administration) which does not accurately reflect no documented administrations for 8/13 in the EHR MAR, 8/14 (2 administrations), 8/15 (2 administrations), 8/16 (2 administrations) which does not accurately reflect the 1 administration documented in the EHR MAR, 8/17 (2 administrations) and 8/18 (1 administration).Resident #176 was admitted to the facility with diagnoses including cellulitis of right lower limb, Type 2 diabetes mellitus with foot ulcer, stage 2 pressure ulcer of sacral region and generalized anxiety disorder.The care plan dated 5/19/25 identified Resident #176 had actual/potential for pain relating to impaired mobility.The physician's orders dated 5/10/25 directed administration of Hydromorphone HCL oral tablet 2mg give 1 tablet by mouth every 4 hours as needed for foot pain and Lorazepam oral tablet 0.5 mg give 0.25 mg (1/2) tablet by mouth every 6 hours as needed for anxiety for 14 days.Review of the EHR MAR dated May 2025 identified Hydromorphone HCL oral table 2 mg give 1 tablet by mouth every 4 hours as needed for foot pain was administered on 5/11 (3 administrations), 5/12 (3 administrations), 5/13 (2 administrations), 5/14 (2 administrations), 5/15 (2 administrations), 5/16 (3 administrations), 5/17 (3 administrations)Review of the white CSDR administration sign-off (CSDR #1448081 received 5/11/25) for Hydromorphone HCL identified the first administration was 5/11 at 4:55 pm and shows 2 administrations which accurately reflects the EHR MAR. Administrations on 5/12 (3 administrations), 5/13 (3 administrations) which does not accurately reflect the 2 administrations documented in the EHR MAR, 5/14 (2 administrations), 5/15 (3 administrations) which does not accurately reflect the 2 administrations documented in the EHR MAR, 5/16 (4 administrations) which does not accurately reflect the 3 administrations documented in the EHR MAR, and 5/17 (1 administration) which would zero the amount of medications received.Review of the EHR MAR dated May 2025 identified Lorazepam oral tablet 0.5 mg was administered on 5/11 (1 administration), 5/12 (2 administrations), 5/13 (2 administrations), 5/14 (2 administrations), 5/15 (1 administration), 5/16 (3 administrations), 5/17 (2 administrations) 5/18 (2 administrations), 5/19 (3 administrations), 5/20 (3 administrations).Review of the white CSDR administration sign-off (CSDR #1448080 received 5/11/25) for Lorazepam oral tablet 0.5 mg (24 half tablets) identified administrations on 5/11 (1 administration), 5/12 (2 administrations), 5/13 (3 administrations) which does not accurately reflect the 2 administrations documented in the EHR MAR, 5/14 (2 administrations), 5/15 (2 administrations) which does not accurately reflect the 1 administration documented in the EHR MAR, 5/16 (3 administrations), 5/17 (2 administrations), 5/18 (3 administrations) which does not accurately reflect the 2 administrations documented in the EHR MAR, 5/19 (3 administrations) and 5/20(3 administrations).Resident #177 was admitted to the facility with diagnoses including pneumonitis due to inhalation of food and vomit and dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.The physician's order dated 7/2/26 directed administration of Lorazepam oral tablet 0.5 mg 1 tablet by mouth every 8 hours as needed for spasm for 14 days.Review of the EHR MAR dated July 2026 identified Oxycodone HCL oral tablet 5 mg give 1 tablet by mouth every 6 hours as needed for pain was administered 7/4 (1 administration), 7/5 (1 administration), 7/8 (1 administration) and 7/18 (1 administration).Review of the white CSDR administration sign-off (CSDR #1578175 received 7/2/26) for oxycodone 5 mg tablet identified administrations on 7/4 (1 administration), 7/5 (1 administration), 7/8 (1 administration), 7/15 (1 administration) which does not accurately reflect the EHR MAR where there was no documented administration, and 7/18 (1 administration).Interview with the DNS on 8/31/26 at 2:00 PM identified that she had not ever taken a white CSDR administrated sign-off sheet and compared the administrations to the resident's MAR in the EHR. Without this practice the facility was unable to demonstrate that the white CSDR administration sign-off documentation provided a complete, accurate, and verifiable reconciliation of the applicable controlled substance records with the electronic medication administration documentation. Emergency Controlled Substance Box KeysObservation of the EBox (emergency medication box) with the ADNS on 8/26/26 at 11:45 AM identified the ADNS requested the EBox keys from the nurse supervisor. The keys were on separate small metal key rings but then fastened together by one stretchy wrist keychain.Observation of the EBox with the DNS on 8/31/26 at 1:41 PM identified the DNS requested the EBox keys from the nurse supervisor. The keys were on separate small metal key rings but then fastened together by one stretchy wrist keychain.Interview with the DNS on 8/31/26 at 1:43 PM identified that the 2 keys that open the emergency-controlled substance box should not be fastened together but stored separately.Maintaining both access keys together failed to provide separate control of the keys and created the potential for simultaneous loss or unauthorized access to both keys and the controlled substances maintained within the emergency supply. Controlled Substance Destruction RecordsReview of the facility's controlled substance destruction documentation from 11/2024 through 4/24/26 identified that destruction records did not provide a clear and readily auditable record distinguishing the source and ownership of controlled substances that were returned or destroyed. Additionally, destruction records did not clearly separate facility stock medications from resident/patient-specific controlled substances.Observation on 8/27/26 at 6:00 AM of 2 binders containing controlled substance destruction forms with patient specific medications and facility house stock medications that had been destroyed failed to include the white CSDR administration records and the yellow CSDR forms that reflected the medications that had been destroyed. Additionally, the house stock medications and resident specific medications were destroyed in the same destruction log. Interview with the DNS on 8/27/26 at 6:44 AM identified a new destruction log dated 8/26/26 including facility house stock and resident specific medications.Interview with the ADNS on 8/27/26 at 10:47 AM identified that the only destruction information she had knowledge of was the destruction logs included in the 2 binders provided. The ADNS indicated that she does not know where the white and yellow CSDRs for the destroyed medications on the log were located.Interview with the DNS on 8/28/26 at 10:39 AM identified that she had additional destruction logs kept in the filing cabinet in her office and indicated that since she took over as the DNS her process for destruction included marrying the white and yellow CSDRs and attaches them to the destruction logs and keeps them in her office. Shift-to-Shift Controlled Substance Count signaturesReview of the shift-to-shift controlled substance counts for the EBox dated from March 2026 through August 2026 identified missing staff signatures which prevented the facility from demonstrating that the required controlled substance inventory had been jointly counted, verified and transferred between licensed staff at each change of shift.[NAME] of the shift-to-shift signatures for March 2026 identified signatures were missing on 3/27 for the 3-11p oncoming nurse and off-going nurse.Review of the Shift to shift signatures for April 2026 identified signatures were missing on 4/16 7a-3p oncoming nurse and off-going nurse and the 3p-11p oncoming and off-going nurse; 4/17 for 11p-7a oncoming and off-going nurse and the 7a-3p oncoming and off-going nurse; 4/20 7a-3p oncoming and off-going nurse; 4/21 7a-3p oncoming and off-going nurse; 4/22 7a-3p oncoming and off-going nurse and 3p-11p oncoming and off-going nurse; 4/30 7a-3p oncoming and off-going nurse; 4/31 7a-3p oncoming and off-going nurse and 3p-11p oncoming and off-going nurse.Review of the shift-to-shift signatures for May 2026 identified missing signatures for 5/30 aap-7a oncoming and off-going nurse.Review of the shift-to-shift signatures for June 2026 identified missing signatures for 6/18 7a-3p oncoming and off-going nurse and 3p-11p oncoming and off-going nurse; 6/19 7a-3p off-going nurse; 6/25 7a-3p off-going nurse.Review of the shift-to-shift signatures for July 2026 identified missing signatures for 7/16 3p-11p oncoming and off-going nurse; 7/18 7a-3p off-going nurse and 3p-11p oncoming nurse; 7/25 7a-3p off-going nurse.Review of the shift-to-shift signatures for August 2026 identified missing signatures for 8/23 3p-11p off-going nurse.Additionally, review of the unaccounted for yellow CSDRs identified CSDR #1542677 Lorazepam concentrate 2 mg/ml (30 ml) sent 3/13/26 does not have a received signature at all or a date received into the facility. There should be 2 nurses' signatures on the CSDRs as receipt and confirmation that the medication as listed was received into the facility.Additionally, Review of CSDR #1559361 Oxycodone 5mg tablets (#30) received into the facility 7/4/26 identified the remaining #16 tablets were returned to the office on 7/22/26. The received by signature is only one signature, although 2 signatures are required. This medication was not able to be located and is not included in the destructions through 8/26/26.Interview with the ADNS on 8/26/26 at 11:05 AM identified that the shift to shift sign off sheets should be signed at every change of shift. The ADNS indicated that when she completes the biweekly audit, the signatures are checked and staff is aware the sheet needs to be signed. The ADNS indicated that 2 signatures are required when a medication is delivered into the facility, one from the receiving nurse and then one from the nurse who is putting the medication on their medication cart. The ADNS identified that medications returned for destruction also have two signatures to verify the amount returned to be destroyed. Interview with the DNS on 8/31/26 at 1:14 PM identified that shift-to-shift signatures are required when the narcotics are counted and indicated that staff had been educated on this. Additionally, the DNS indicated that when narcotics are counted or moved, they should be signed by two nurses.The facility Opioid Medication Policy and Procedure identified that nursing administers scheduled dose of the opioid medication, including oxycodone, and documents in the patient's medical record including pain level before and post medication administration. The facility policy for Controlled Substance Destruction identified that unused or expired controlled substances will be destroyed in a manner consistent with CT DCP (CT Dept. of Consumer Protection) regulations to ensure that medications are rendered unrecoverable, prevent diversion and protect privacy.The facility policy for Controlled Substance Handling identified a licensed nurse shall sign for and take possession of controlled substances delivered to the facility and will check the packing slip against the contents and report any discrepancies. The policy indicated all stocks of controlled substances shall be logged into the official count by two nurses. The policy identified that all controlled drugs shall be stored in a 2 door double-locked cabinet with 2 separate keys designed for that purpose. This policy additionally indicated that immediately after a dose is administered, the licensed nurse administering the drug enters the administration on the accountability record. The policy identified that if a dose of controlled substance is removed from the administration container it cannot be returned to the container or taped back into the blisterpack.The facility policy for Bi-Monthly Narcotic Drug Audit identified Controlled Substances are subject to special handling, storage, disposal and record keeping in the nursing facility in accordance with Federal and State laws and regulations and is the responsibility to ensure the integrity of the process of storing, dispensing and documentation of controlled substances is maintained. Federal requirements (21 CFR 1317.80)When disposing of such controlled substances by transferring those substances into a collection receptacle, such disposal shall occur immediately, but no longer than three business days after the discontinuation of use by the ultimate user. Discontinuation of use includes a permanent discontinuation of use as directed by the prescriber, as a result of the resident's transfer from the long-term care facility, or as a result of death.Sec. 21a-254.(e) Pharmacies, hospitals, chronic and convalescent nursing homes, rest homes with nursing supervision, clinics, infirmaries, freestanding ambulatory surgical centers and laboratories shall keep records of all controlled substances, received and disposed of by them in accordance with the provisions of subsections (f) and (h) of this section, except that hospitals and chronic and convalescent nursing homes using a unit dose drug distribution system may instead keep such records in accordance with the provisions of subsections (g) and (h) of this section, and except that hospitals and freestanding ambulatory surgical centers shall not be required to maintain separate disposition records for schedule V controlled substances or records of administering of individual doses for ultra-short-acting depressants, including but not limited to, Methohexital, Thiamylal and Thiopental.(f) The form of record to be kept under subsection (c), (d) or (e) of this section shall in each case show the date of receipt, the name and address of the person from whom received, and the kind and quantity of controlled substances received, or, when applicable, the kind and quantity of controlled substances produced or removed from process of manufacture and the date of such production or removal from process of manufacture; and the record shall in each case show the proportion of controlled substances. The record of all controlled substances sold, administered, dispensed or otherwise disposed of shall show the date of selling, administering or dispensing, the name of the person to whom or for whose use, or the owner and species of animal for which, the substances were sold, administered or dispensed, the address of such person or owner in the instance of records of other than hospitals, chronic and convalescent nursing homes, rest homes with nursing supervision and infirmaries, and the kind and quantity of substances. In addition, hospital and infirmary records shall show the time of administering or dispensing, the prescribing physician and the nurse administering or dispensing the substance. Each such record of controlled substances shall be separately maintained apart from other drug records and kept for a period of three years from the date of the transaction recorded. Sec. 21a-262(b) For each long-term care facility, two or more of the following persons may jointly dispose of excess stock of controlled substances: A nursing home administrator, a pharmacist consultant, a director of nursing services or an assistant director of nursing services. Such facility shall maintain documentation of any such destruction a

Based on clinical record reviews, review of facility documentation, review of facility policies and procedures, and staff interviews, the facility failed to develop and/or implement an effective training program to ensure nursing staff received education necessary to provide care and services related to the prevention, identification, and treatment of pressure ulcers/injuries. The findings inlcude:The review of the Facility Assessment, last updated 4/1/26, found that at any given time, 15 to 20 residents in the facility were dependent on staff for all mobility needs, which increased their risk of pressure ulcer/injury development. Review of the annual mandatory staff education found that body mechanics was included; however, required education on pressure ulcer/injury prevention was not.A review of the mandatory annual nursing competency list, provided by the Regional Director of Clinical Operations, found that competencies related to skin and wound care included only clean and aseptic dressing-change techniques. The mandatory annual competency list did not include education or competency evaluation related to skin assessment or pressure ulcer/injury prevention, identification, staging, or management.Review of facility training and education records from 1/1/25 through 8/24/26 identified 88 nursing staff members, including 10 registered nurses (RNs), 32 licensed practical nurses (LPNs), and 46 certified nurse aides (CNAs), who were responsible for providing direct care to residents. Further review identified that 27 of 88 (30.8%) nursing staff members reviewed did not have documented training and/or education related to pressure ulcer/injury prevention, identification, assessment, treatment, and/or implementation of pressure ulcer/injury interventions.Further review identified that the staff members without documented training included 4 registered nurses, 4 licensed practical nurses, and 19 nurse aides. Clinical record review for Residents #5, #9, #91, #102, #105, #107, #115, #142, and #151 identified failures related to the timely identification, assessment, treatment, and/or implementation of interventions for identified skin conditions, which resulted in the development or worsening of pressure ulcers/injuries for these residents. (See also F686.) A review of the deficient practices identified at F686 determined that the facility failed to ensure the appropriate assessment, prevention, identification, and/or treatment of pressure ulcers/injuries. These deficient practices resulted in the development or worsening of pressure ulcers/injuries for nine (9) of twelve (12) residents reviewed for facility-acquired pressure ulcers/injuries. During an interview on 9/2/26 at 11:10 AM, RN #3 stated that she had not received formal education related to the assessment or staging of pressure ulcers/injuries. RN #3 stated that education on pressure ulcers/injuries was available voluntarily but not mandatory. RN #3 further stated that she deferred to the wound nurse for assistance with staging and treatment when skin conditions were identified. During an interview on 9/2/26 at 11:44 AM, the Assistant Director of Nursing Services (ADNS) stated that nursing staff was expected to assess residents' skin using the Braden Scale upon admission, quarterly, and whenever a new skin condition was identified. The ADNS further identified that Resident #107 did not have required Braden Scale assessments completed in December 2025, March 2026, or June 2026 and stated that she did not know why the assessments had not been completed. The ADNS stated that staff education related to pressure ulcer/injury prevention and management was initiated subsequent to surveyor inquiry on 8/25/26.During an interview on 9/2/26 at 12:50 PM, when informed that 27 of 88 (30.8%) clinical staff members' training records reviewed lacked documented evidence of pressure ulcer/injury training, the Director of Nursing Services (DNS), ADNS, and Staff Development Nurse (RN #1) acknowledged that clinical staff were not required to attend pressure ulcer/injury in-services offered from 1/1/25 through 8/24/26. The DNS, ADNS, and RN #1 stated that the required annual skin care training consisted of basic skin care for nurse aides and dressing changes for licensed nursing staff. They further acknowledged that periodic in-services addressing the identification, assessment, staging, and treatment of pressure ulcers/injuries were offered, but attendance was not mandatory for all clinical staff. During the same interview, RN #1 stated that interim education reflected a previously identified need for staff education related to pressure ulcer/injury identification and care; however, the training had been offered as refresher education and had not been required for all clinical staff. The DNS stated that education had been provided on an as-needed basis to applicable staff when areas of opportunity were identified. The DNS further stated that, subsequent to surveyor inquiry regarding multiple resident pressure ulcers/injuries, the facility initiated education for all clinical staff, including competency evaluations, as part of its corrective action.During an interview on 9/2/26 at 1:45 PM, LPN #7 stated that she had been hired approximately three (3) months earlier and had received training related to performing skin checks on residents on shower days, including completion of a head-to-toe skin assessment. LPN #7 stated that she notified the nursing supervisor when she identified new skin conditions, but had received no formal training in the identification or management of pressure ulcers/injuries. LPN #7 further stated that she had documented no skin issues for Resident #107, who was subsequently identified later that same day with a facility-acquired pressure ulcer/injury. LPN #7 stated that she was subsequently notified of the pressure ulcer/injury and received education related to the appropriate assessment and documentation of skin conditions. The review of the Facility Assessment and the facility training program failed to identify evidence that the facility had developed and implemented sufficient training related to pressure ulcer/injury prevention, identification, assessment, and management to ensure that nursing staff possessed the knowledge and skills necessary to provide care and services to the facility's resident population.

Based on review of clinical records, review of facility policy/procedures and interviews for one sampled resident (Resident #5) with a significant change MDS assessment, the facility failed to ensure that the comprehensive care plan was revised to reflect that the resident was not receiving intravenous medications and for two of twelve sampled residents (Residents #91 and #105) reviewed facility acquired pressure injuries, the facility failed to ensure that the care plan contained measures to prevent the occurrence or reoccurrence of a pressure injury. The findings include: Resident #5's diagnoses included moderate protein-calorie malnutrition, type 2 diabetes mellitus, traumatic subdural hemorrhage without loss of consciousness, and hemiplegia and hemiparesis following other non-traumatic intracranial hemorrhage affecting left non-dominant side. The significant change MDS assessment dated [DATE] identified Resident #5 had severe cognitive impairment and was totally dependent on staff for toileting hygiene, bed mobility, transfers, dressing and was non-ambulatory. Review of the care plan dated 8/14/26 identified concerns that were no longer relevant, they included the resident is on intravenous medications (IV) dated 5/8/26. Review of the physician's order and Medication Administration Record (MAR) for the period of 7/29/26 through 8/10/26 did not identify intravenous medications that were ordered or administered to Resident #5. Interview with RN #7 (MDS Coordinator Nurse) in the presence of the other MDS staff on 8/26/26 at 2:35 PM identified that the interdisciplinary team is responsible for reviewing and updating the resident's care plan. She identified that the charge nurse updates and adds nursing interventions when a new problem is identified. RN #7 identified that the MDS nurse is responsible for removing care plans and interventions that are no longer in effect for residents after the completion of each MDS assessment to ensure the care plan remains current. After RN #7 reviewed Resident #5's current care plan dated 8/14/26 she identified that the intravenous care plan should not be a part of the resident's current care plan because the resident was not on intravenous medication at the time of the review and it was an oversight. Review of the Baseline/Comprehensive Person Centered Care Plan (CPCCP) policy showed that the care plan must be kept up to date by all disciplines at all times. Each discipline is responsible for updating the care plan whenever a new problem is identified that requires their intervention. They must ensure the CPCCP remains current and add new problems or interventions as they arise. Resident #91's diagnoses included retention of urine, type 2 diabetes, and dementia. The Resident Care Plan (RCP) dated 5/29/26 identified Resident #91 had the potential for skin breakdown related to decreased mobility. Care plan interventions directed to offload heels when in bed, treatments as ordered, turn a reposition every 2-3 hours, update MD with changes as needed. The admission MDS assessment dated [DATE] identified Resident #91 had severe cognitive impairment, was dependent on staff for toileting, and transfers, utilized an indwelling catheter for the bladder and was occasionally incontinent of bowel, was at risk for the development of pressure ulcers but did not currently have a pressure ulcer. The skin check dated 6/30/26 identified Resident #91 had a new skin issue on the genitalia that was facility acquired and had 100% granulation, light exudate, and serosanguinous fluid. Review of the RCP identified resident specific interventions related to the wound on the genitalia were updated on 6/30/26 upon identification of the meatus however the care plan was resolved and taken out of the plan of care as of 7/6/26. No new interventions or plans of care were put into place to prevent re-occurrence of the wound to the genitalia at that time. Review of the Renew Wound Care physicians note dated 7/1/26 identified the wound was a full thickness flaying and had received the outcome of resolved. Wound measurements were 0cm length x 0cm width and no measurable depth. Review of the skin check dated 7/22/26 from former wound LPN#9 identified there is a new skin issue acquired in house described as a traction induced injury on the genitalia acquired on 7/22/26. Measuring 1cm width, 1cm length, and 0.1cm undermining with light exudate and serosanguinous fluid cleanse with generic wound cleanser twice daily. The Renew Wound Care physicians note dated 7/22/26 identified the wound on the genitalia that was a partial thickness traction induced injury and has received a status of not healed. Initial wound encounter measurements are 1cm length x 1cm width x 0.1cm depths. There is a small amount of sero-sanguinous drainage noted which has no odor, 100% dermis. Treatment was with wound cleanser and apply barrier cream/ointment twice daily and as needed. The RCP was updated at this point on 7/23/26 following the identification of the wound on the genitalia identified on 7/22/26. Interview on 8/27/26 at 2:45PM and 8/28/26 at 10:00AM with the Renew Wound PA#1 identified that the area on the genitalia was caused by the catheter. The area was identified as a medical device related to pressure. The injury could potentially have been prevented if the resident had preventative measures that were continued following the identification on 6/30/26 of the original wound identified on the genitalia. Furthermore PA#1 identified that a securement device should be in place on Resident #91 which could have potentially prevented the wound from occurring in the first place which she noted on her 8/28/26 wound note. Interview on 8/27/26 with LPN #3 Corporate Wound Nurse identified the care plan should be updated with interventions in place to prevent the reoccurrence of the issue at the time of the identification of the wound. The nurse or supervisor can put in the interventions. Interview on 8/31/26 at 9:55AM with Facility wound LPN #1 identified the supervisor or the wound nurse updates the care plan. Interview on 8/31/26 at 10:40AM with ADNS identified the supervisor should at the time a wound is identified put interventions in place. The ADNS identified prior to the breakdown on 7/22/26 she did not see a care plan in place following the issue that was resolved on 7/1/26. The ADNS identified there should have been interventions in place following the first time Resident #91 broke down on the genitalia area. Review of the Pressure Injury Prevention Program directed that based on the resident evaluation process an individualized comprehensive care plan will be implemented by the interdisciplinary team, residents will have a preventative care plan implemented upon admission that is interdisciplinary and residents with an actual pressure injury identified will have a care plan implemented that documents an interdisciplinary approach to the healing of the pressure injury follow facility protocols as well as preventative measures. The licensed nurse may update the NA Kardex with addition preventative measures as needed if a pressure injury is identified. Review of the Baseline/Comprehensive Person-Centered Care Plan (CPCCP) policy directed the CPCCP will be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the care plan when there is a new problem that requires that disciplines to intervene. Each discipline will be responsible to maintain the CPCCP current and updating the care plan when new problems/interventions have been identified. Resident #105 had diagnoses that included dementia with psychotic disturbance, atrophy, and moderate protein malnutrition. A physician's order dated 5/5/26 directed staff to complete weekly skin checks and document the assessment. The quarterly MDS assessment dated [DATE] identified Resident #105 had severe cognitive impairment, was totally dependent on staff for bed mobility, toileting, transfers, and was non-ambulatory. The assessment further identified Resident #105 was always incontinent of bladder and frequently incontinent of bowel, was at risk for the development of pressure ulcers and had no pressure ulcer injury at that time. The assessment also documented that the resident used a pressure-reducing device while in bed but was not on a turning and repositioning program. The weekly skin checks completed on 5/4/26, 5/11/26, and 5/19/26 documented no skin issues for Resident #105. A review of the Nurse Aide (NA) care card, effective 5/24/26, revealed that it did not indicate that Resident #105 was to be turned and repositioned every two hours and/or that the heels were to be offloaded as measures to prevent the development of pressure ulcer injury. The Braden Scale assessment (used to predict risk for pressure ulcer development) dated 5/25/26 identified Resident #105 had a score of 14 which indicated a moderate risk to developing a pressure ulcer. The skin-issue nurse's notes dated 5/25/26 at 10:44 PM identified a new unstageable pressure ulcer injury to the right heel. The wound measured 2.1 cm in length, 2.16 cm in width, and 0 in depth. There were no signs or symptoms of infection. There was no undermining, tunneling nor odor noted. The Situation, Background, Assessment, and Response (SBAR) notes dated 5/25/26 at 11:46 PM identified Resident #105 had a new skin wound/ulcer, described as an open area with a darkened area on the right heel noted at bedtime. The resident exhibited no pain. The physician was notified and provided an order to apply betadine, cover with gauze, and offload the heel while in bed. A physician's orders dated 5/25/26 directed staff to apply betadine to the right heel cover with non-stick dressing and wrap with gauze daily and elevate heel off the bed. The Resident Care Plan (RCP) dated 5/25/26 identified Resident #105 had a pressure ulcer to the right heel related to decreased mobility and sensory impairment. The care plan interventions directed staff to apply bilateral foam boots while in bed as tolerated, dietician to evaluate resident nutrition as needed, treatment per physician's order, weekly wound evaluation per protocol, monitor for signs and symptoms of infection, and notify the physician of any changes in skin condition. A review of the resident care plan revealed that despite Resident #105 being at moderate risk for pressure ulcer development, a preventive pressure ulcer care plan had not been developed or implemented until after the resident developed an unstageable pressure injury to the right heel. A physician's orders dated 5/26/26 identified directed to administer medical honey to the right heel, to apply foam boot while in bed The wound specialist's evaluation dated 5/27/26 identified Resident #105 had an unstageable pressure injury to the right heel related to pressure, with obscured full thickness skin and tissue loss. The wound measured 1.6 cm in length, 1.1 cm in width, and 0.1 cm in depth. A slight amount of serous drainage was present, with no foul odor, and the resident reported no pain. The wound bed was described as consisting of approximately 60 percent eschar (necrotic tissue) and 40 percent granulation tissue. The treatment plan included cleansing the right heel with wound cleanser, applying medical honey, and covering with a dry, clean dressing daily and as needed. Additional orders included following facility pressure injury prevention protocols, offloading the heels per facility protocol, and avoiding direct pressure to the wound site. The revised Resident Care Plan (RCP) dated 8/20/26 identified that Resident #105 had a potential for skin breakdown related to decreased ability to perform activities of daily living (ADLs), a history of pressure ulcers, and sensory impairment. The care plan interventions directed staff to offload the heels when the resident was in bed as tolerated, provide a pressure redistribution mattress and chair cushion, turn and reposition the resident every two to three hours and/or as tolerated, complete weekly skin evaluations, and update the physician with any changes as needed. Interview with NA #1 on 8/25/26 at 2:40 PM identified Resident #105 was totally dependent on staff for bed mobility, toileting, and transfers, and was incontinent of bowel and bladder. She identified that the nurse aide care card could be accessed through the computer kiosk located in the nursing unit hallway. She explained that not all residents required frequent turning and repositioning or heel elevation. She further identified that the care card indicated whether a resident needed to be turned and repositioned and/or whether the heels needed to be elevated using pillows or foam boots. She identified that the current nurse aide care card for Resident #105 included directions for frequent turning and repositioning and required that the resident's feet be elevated with foam boots. Interview with RN #7 (MDS Coordinator nurse) on 8/26/26 at 2:35 PM identified that the interdisciplinary team was responsible for reviewing and updating the resident care plan. She identified that the charge nurse updated and added nursing interventions when a new problem was identified, and the MDS nurse reviewed and updated the resident care plan after completion of each MDS assessment to ensure the care plan remained current. She also identified that a resident who was at risk or had the potential to develop a pressure ulcer should have had a care plan developed and implemented that included frequent turning and repositioning, offloading of bilateral heels as tolerated, and weekly skin assessments. She identified that the nurse aide care card in the computer kiosk would indicate whether a resident was required to be turned and repositioned and/or whether the heels were to be offloaded. She acknowledged that Resident #105 was at risk for developing a pressure ulcer and should have had a care plan in place that included preventive measures to reduce the likelihood of pressure ulcer development. She further identified that it was an oversight that the facility failed to develop a preventive pressure ulcer care plan for Resident #105 despite the resident being at high risk. Interview with the DNS on 8/27/26 at 9:00 AM identified that she conducted at risk meetings that included any residents with wounds and/or pressure ulcers. She reported that she ran an evaluation report that identified residents at high risk for developing pressure ulcers. She identified that for any residents who appeared on the evaluation report, she reviewed their care plans to ensure appropriate interventions were in place to prevent the development of pressure ulcers. The DNS reported that on August 20, 2026, Resident #105 appeared on the evaluation report as being at high risk for developing a pressure ulcer. She identified that upon review; Resident #105 did not have a care plan addressing pressure ulcer prevention. She identified that this review process was her current method to ensure residents at high risk had prevention interventions in place, but she was unsure what the previous DNS's process had been. The DNS also identified that the nursing supervisor and/or MDS nurse were responsible for reviewing and updating resident care plans. She identified that the resident's care plan should be reviewed regularly, at least quarterly, to ensure that it remains current and to determine whether the interventions in place are effective. She further identified that Resident #105 was at risk for developing a pressure ulcer and should have had interventions developed and implemented once identified as high risk. A wound treatment observation conducted with LPN #3 (wound nurse assistant) on 8/27/26 at 11:25 AM identified that Resident #105 was lying in bed with the feet elevated and foam boots in place. The resident had a foam dressing applied to the right heel dated 8/26/26. Resident #105 was observed to have an unstageable pressure ulcer injury to the right heel. The wound bed of the right heel was covered with slough (yellow dead tissue). Interview with Physician Assistant (PA) #1 (wound specialist) on 8/27/26 at 2:15 PM identified she was newly assigned as the wound specialist for the facility. She reported that residents with cognitive impairments, dependence with bed mobility, toileting, bowel and bladder incontinence, and low Braden Scale scores were considered at high risk for developing pressure injuries. PA #1 identified that preventive measures should be implemented immediately once a resident was identified as high risk. She identified appropriate preventive interventions to include frequent turning and repositioning at least every two hours, offloading bilateral heels, providing timely incontinent care, and using a specialty mattress when indicated. She identified that Resident #105 would have been considered at high risk for developing a pressure injury due to mobility impairment, incontinence, and cognitive impairment. The Pressure Injury Prevention Protocol policy indicated that the facility would provide a comprehensive head to toe skin evaluation when a resident was admitted or re admitted . This evaluation assisted the facility in identifying risk factors and implementing appropriate individualized preventive measures. Review of the Baseline/Comprehensive Person Centered Care Plan (CPCCP) policy showed that the care plan must be kept up to date by all disciplines at all times. Each discipline is responsible for updating the care plan whenever a new problem is identified that requires their intervention. They must ensure the CPCCP remains current and add new problems or interventions as they arise. The facility did not develop or implement adequate preventive measures to protect the resident's right heel, which resulted in the development of an unstageable pressure ulcer.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews the facility failed to ensure all expired medications were removed from the in use medication storage carts and medication rooms and failed to ensure controlled substances were stored according to guidelines and under two locks. The findings include:Observations of medication storage over the survey period 8/24/26 through 8/31/26 included observation of 2 out of 4 medication rooms and 4 out of 7 medication carts. Observation of the 1st floor medication room with LPN#2 on 8/24/26 at 2:00 PM identified a separate area designated for expired items. Observed in the active supply area were the following expired items:Juven supplement for wound healing 25 pouches expired 3/1/26Kangaroo epump feeding tube bag expired 1/31/25Straight catheter kit expired 2/1/26Interview with LPN#2 on 8/24/26 at 2:03 PM identified although she was unsure if there were residents who would need the expired items, they were located in an active use supplies in the medication room.Observation of the second floor 1 medication cart with LPN#7 on 8/26/26 at 9:45 AM identified a bubble pack medication containing Clonazepam 0.5 mg with 6 remaining tablets with one of the bubbles containing an orange colored round scored tablet with the back area not intact but containing a piece of tape over the opening.Interview with LPN#7 on 8/26/26 at 9:47 AM identified the medication should be wasted because the back had been opened. LPN#7 indicated that she had not seen that when the shift to shift count was completed, but identified that the controlled substance packaging should not be altered. Observation of the 2nd floor medication room with LPN#7 on 8/26/26 at 10:09 AM identified a bag of catheter stabilization devices (11 pieces) expired 8/19/26. Interview with LPN#7 on 8/26/26 at 10:10 AM identified LPN#7 did not know if there were residents who had catheters and would need the expired items but indicated that they were located in an active use supply area. Interview with the DNS on 8/31/26 at 1:14 PM identified expired items should be removed from active use areas. The DNS indicated that all staff would be responsible and that there was a stock person who stocked the supply closets.The facility policy for handling controlled substances identified that if controlled substances are removed from the container for administration but not given for any reason, the dose cannot under any circumstances be returned to the container or taped back into the blister pack and must be destroyed in the presence of two licensed nurses.The facility policy for medication storage indicated that outdated/expired items should be immediately removed from inventory and disposed of according to procedures for disposal.

Based on review of the clinical record, review of facility documentation, facility policy/procedures, and interviews for 2 of 5 residents (Resident #56, and Resident #62) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination was offered to residents. The findings include:Resident #56 was admitted to the facility in 1/20/24 with diagnoses that included idiopathic peripheral autoimmune neuropathy, transient ischemic attack, malignant melanoma of the right upper limb. The 5-day MDS assessment dated [DATE] identified Resident #56 had intact cognition. The assessment further identified that Resident #56 was not up to date with his/her covid-19 vaccine. Review of Resident #56's immunization report and clinical record failed to identify a covid-19 vaccination consent was obtained for the 2025 to 2026 formula. In addition, the clinical records failed to identify that he/she had received the covid-19 vaccination outside of the facility or at the facility or had refused the vaccine. Consent was obtained by the facility from the resident on 7/11/25 with the resident requesting to receive the vaccine for the 2024-2025 formula. Interview with the Infection Preventionist (IP) (RN #6) on 8/27/26 at 10:30 AM identified the resident was had a history of receiving the last COVID vaccine 6/14/22. RN #1 further identified that Resident #56 had returned from hospitalization in July of 2025 and when the resident returned they returned on antibiotics then went back out 8/15/25 and spent 13 days in the hospital. There was a correspondence send to out via their messaging system to request consent on 9/22/25 and there was no response hence why he/she was not offered the vaccine. RN#6 further identified that the resident needs a new consent signed following a discharge and re-admission, however the clinical record did not identify a discharge return not anticipated during that time frame. RN#6 identified it was her responsibility to follow up with the resident and administer the vaccination when it is requested and due, however she had not heard back from the message sent on 9/22/25. RN#6 could not provide any documentation that there was follow up with Resident #56 nor did the resident receive the vaccination. Resident #56 would have been due for the 2025-2026 booster during that time. Resident #62 was admitted to the facility on [DATE] and diagnoses included hemiplegia and hemiparesis, cerebral infarction, and dementia. The admission MDS assessment dated [DATE] identified Resident #62 had moderately impaired cognition. The assessment further identified that Resident #62 was not up to date with his/her covid-19 vaccine.Review of Resident #62's immunization report and clinical record failed to identify a covid-19 vaccination consent was obtained for the 2025 to 2026 formula. In addition, the clinical records failed to identify that he/she had received the covid-19 vaccination outside of the facility or at the facility or had refused the vaccine. The clinical record did include a consent for the 2024-2025 covid vaccine that was requested and signed on 6/20/25.Interview with the Infection Preventionist (IP) (RN #6) on 8/27/26 at 10:40 AM identified the resident had decline the covid vaccine. However, when the declination was requested RN#6 identified Resident#62 had requested the vaccine on 6/20/25 and that the resident did not receive it. RN#6 identified that the resident should have received the vaccine and that she would have been the one to administer but that it must have been an oversight. Review of the Resident Covid-19 Vaccination policy identified the facility will educate and offer the COVID-19 vaccine to all eligible resident as per recommendations of the ACIP/CDC. Review of the COVID updates and Interim Guidance dated 9/9/25 from the CT DPH directed adults 65 years and older should receive 2 or more doses and all adults should be vaccinated with at least two doses separated by 6 months.

Based on review of the clinical record, review of facility policy and procedures, review of facility documentation, and interviews for one of three sampled residents (Resident #70) reviewed for allegation of mistreatment, the facility failed to ensure that a grievance report was filed and completed when a resident expressed concern regarding care. The findings include:Resident #70's diagnoses included lymphedema, atrial fibrillation, morbid obesity, and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #70 had intact cognition, dependent on care for toileting hygiene, lower body dressing, transfers, maximal assistance with rolling left and right on the bed and non-ambulatory.Interview with Resident #70 on 8/24/26 at 11:00 AM identified that he/she had sustained a bruise to the left lower abdominal area, which was caused by a nursing aide (NA #1) that was rough during care. Resident #70 identified he/she had reported the incident to the facility about a week ago, and the nurse aide has not returned since. Resident #70 identified the incident occurring on the 11:00 PM to 7:00 AM shift with the nurse aide who cared for him/her on that shift but was unable to recall her name but would know the name if she heard the nurse aide's name. The allegation was reported to the DNS and the ADNS on 8/24/26 at 11:20 AM regarding the alleged rough care which caused the bruised. Review of the clinical records identified an incident report completed on 8/17/26 at 11:15 AM by RN #3 noted a large bruise to the left flank secondary to the Sara lift (mechanical lift device) pad positioning. The resident had minor pain with palpation with actions taken to change to a mechanical lift and to be assisted by two staff until physical therapy evaluation and to monitor the bruise until resolve. The incident report, further identities that the APRN was updated of the incident and the resident who responsible for self. The nursing note dated 8/24/26 at 1:30 PM written by the DNS regarding a comment made about rough care identified that Resident #70 clarified that the nurse aide was unaware that the resident was receiving a diuretic and that during repositioning the resident felt that he/she was turned more quickly than preferred. The nurse further identified that the resident stated that he/she did not believe the nurse aide was attempting to cause harm and felt the nurse aide was simply moving quickly while providing care and denied any concerns regarding the nurse aide interaction and he/she had no objections to the nurse aide continuing to provide him/her with care. Interview with NA #9 on 8/27/26 at 9:57 AM identified that if she had noticed any discoloration to a resident skin, she would report it to the nurse, but if it looks old, she would not have reported it as she would have thought that they would have already known about the issue. She further identified the last time she provided care for Resident #70 the nurse was present as she required two staff to assist with turning and a draw sheet was used when turning the resident. NA #7 also identified she was never called by the facility regarding an incident of bruising to the resident left flank. Interview with RN #3 on 8/27/26 at 1:20 PM identified the incident report completed on 8/17/26 regarding a bruise area noted to the left flank and at the time the resident did not indicate that it was caused by a nurse aide. She further identified that Resident #70 reported that the bruise was caused by a nurse aide about 2 days after this was reported in which the ADNS was made aware. RN #3 identified that she went into Resident #70's room with the ADNS as a witness because the DNS and Administrator were away. RN #3 identified after the conversation with the resident they had determined that it was not an incident of abuse but a customer service issue, and a grievance report was to be done by the ADNS and education to be provided to the nurse aide who the resident described which was NA #9. Review of the grievance book/binder for the period of July 2026 through 8/27/26 failed to identify a grievance report form completed for Resident #70 regarding the reported incident to the ADNS and RN #3 as it relates to care. Interview with the ADNS and the DNS on 8/27/26 at 2:20 PM identified that the ADNS had interviewed the resident following the alleged report of rough care, that was reported to her 2 days (8/19/26) after the bruise incident was reported to ask more questions. The ADNS identified during the interview with the resident that it was more of a customer service issue as the resident had indicated the rough care was the nurse aide turning him/her too fast. The ADNS identified at the time that she had determined that it was more of a grievance and nurse aide needed to be educated, she should have filed the grievance form to address the resident's concern. The ADNS further identified that she had not provided the education to the nurse aide as yet because she was trying to identify the staff based on the description in which the resident provided. However, when she had identified the nurse aide, she should have called the nurse aide to schedule the education instead of waiting on when the staff returns to work to provide the education.Subsequent to the surveyor's inquiry a grievance/concern form was completed on 8/28/26 for the concern reported on 8/19/26. Therefore, it took the facility 9 days after a concern was reported to file a grievance report from its first initial report.Interview with Resident #70 on 8/28/26 at 12:55 PM identified at the time when the incident was reported they did not file the grievance until now when they brought him/her paperwork to sign. Resident #70 identified they review his/her concern and indicated that they would provide education to the nurse aide involved. Resident #70 further identified he/she is waiting for the nurse aide to care for him/her again to ensure the education was done and the nurse aide practice has improved.Review of the Grievance policy identified that the facility would support the resident/responsible party to voice grievances/concerns regarding treatment, care, management of funds, lost articles and or any violation of residents' rights. The policy further identifies that upon receipt of the grievance/concern the facility will take the appropriate measures to seek a resolution to the concern.Review of the Residents' [NAME] of Rights Policy identifies that residents have the right to voice grievances without discrimination or reprisal and the right to have prompt efforts made by the facility to resolve any grievances he/she may have, including those about the behavior of other residents, staff, or other concerns regarding their stay.

Based on clinical record review, observation, facility policy review, and staff interviews, the facility failed to develop and implement a comprehensive care plan with preventive measures to prevent skin breakdown for 1 of 13 residents (Resident #105) who developed a facility acquired pressure ulcer. The finding includes:Resident #105's diagnoses included dementia with psychotic disturbance, muscle wasting and atrophy, and moderate protein malnutrition.A physician's order dated 5/5/26 directed staff to complete weekly skin check and document that assessment.The quarterly MDS assessment dated [DATE] identified Resident #105 had severe cognitive impairment and was totally dependent with bed mobility, toileting, transfer, and non-ambulatory. The assessment further identified Resident #105 was always incontinent of bladder and frequently incontinent of bowel, was at risk for the development of pressure ulcers and had no pressure ulcer injury at that time. The assessment also documented used of a pressure-reducing device while in bed but did not direct a turning and repositioning program.The weekly skin check completed on 5/4/26, 5/11/26, and 5/19/26 documented no skin issues for Resident #105.A review of the Nurse Aide (NA) care card, effective 5/24/26 did not direct for Resident #105 to be turned and repositioned every two hours and/or the heels to be offloaded as measures to prevent the development of pressure ulcer injury.The Braden Scale assessment (used to predict risk for pressure ulcer development) dated 5/25/26 identified Resident #105 had a score of 14 which indicated a moderate risk to developing a pressure ulcer.The skin-issue nurse's notes dated 5/25/26 at 10:44 PM identified a new unstageable pressure ulcer injury to the right heel. The wound measured 2.1 Centimeters (CM) in length, 2.16 cm in width, and 0 in depth. Additionally noted no sign and symptoms of infection. There was no undermining, tunneling nor odor were noted.The Situation, Background, Assessment, and Response (SBAR) notes dated 5/25/26 at 11:46 PM identified Resident #105 had a new skin wound/ulcer, described as an open area with a darkened area on the right heel noted at bedtime. The resident exhibited no pain. The physician was notified and provided an order to apply betadine, cover with gauze, and offload the heel while in bed.A physician's orders dated 5/25/26 directed staff to apply betadine to the right heel cover with non-stick dressing and wrap with gauze daily and elevate heel off the bed.The Resident Care Plan (RCP) dated 5/25/26 identified Resident #105 had a pressure ulcer to the right heel related to decrease mobility and sensory impairment. Interventions directed staff to apply bilateral foam boots while in bed as tolerated, dieticians evaluate resident nutrition as needed, treatment per physician's order, weekly wound evaluation per protocol, monitor for sign and symptoms of infection, and notifying the physician of any changes in skin condition.A review of the resident care plan identified despite Resident #105 being at high risk for pressure ulcer development, a preventive pressure ulcer care plan had not been developed or implemented until after the resident developed an unstageable pressure injury to the right heel.A physician's orders dated 5/26/26 identified directed to administer medical honey to the right heel, to apply foam boot while in bedThe wound specialist's evaluation dated 5/27/26 identified Resident #105 had an unstageable pressure injury to the right heel related to pressure, with obscured full thickness skin and tissue loss. The wound measured 1.6 cm in length, 1.1 cm in width, and 0.1 cm in depth. A slight amount of serous drainage was present, with no foul odor, and the resident reported no pain. The wound bed was described as consisting of approximately 60 percent eschar (necrotic tissue) and 40 percent granulation tissue. The treatment plan included cleansing the right heel with wound cleanser, applying medical honey, and covering with a dry, clean dressing daily and as needed. Additional orders included following facility pressure injury prevention protocols, offloading the heels per facility protocol, and avoiding direct pressure to the wound site.The revised Resident Care Plan (RCP) dated 8/20/26 identified Resident #105 had a potential for skin breakdown related to decreased ability to perform activities of daily living (ADLs), a history of pressure ulcers, and sensory impairment. Interventions directed staff to offload the heels when the resident was in bed as tolerated, provide a pressure redistribution mattress and chair cushion, turn and reposition the resident every two to three hours and/or as tolerated, complete weekly skin evaluations, and update the physician with any changes as needed.Interview with Nurse Aide (NA) 1 on 8/25/26 at 2:40 PM identified Resident #105 was totally dependent on staff for bed mobility, toileting, and transfers, and was incontinent of bowel and bladder. She identified the nurse aide care card could be accessed through the computer kiosk located in the nursing unit hallway. She explained that not all residents required frequent turning and repositioning or heel elevation. NA#1 further identified the care card indicated whether a resident needed to be turned and repositioned and/or whether the heels needed to be elevated using pillows or foam boots. She identified the current nurse aide card for Resident #105 included directions for frequent turning and repositioning and required the resident's feet be elevated with foam boots.Interview with RN #7 (MDS Coordinator nurse) on 8/26/26 at 2:35 PM identified the interdisciplinary team is responsible for reviewing and updating the resident care plan. She identified the charge nurse updated and added nursing interventions when a new problem was identified, and the MDS nurse reviewed and updated the resident care plan after completion of each MDS assessment to ensure the care plan remained current. RN# 7 also identified that a resident who was at risk or had the potential to develop a pressure ulcer should have had a care plan developed and implemented that included frequent turning and repositioning, offloading of bilateral heels as tolerated, and weekly skin assessments. She identified that the nurse aide care card in the computer kiosk would indicate whether a resident was required to be turned and repositioned and/or whether the heels were to be offloaded. RN# 7 acknowledged Resident #105 was at risk for developing a pressure ulcer and should have had a care plan in place that included preventive measures to reduce the likelihood of pressure ulcer development. She further identified that it was an oversight that the facility failed to develop a preventive pressure ulcer care plan for Resident #105 despite the resident being at high risk.Interview with the Director of Nursing Services ( DNS) on 8/27/26 at 9:00 AM identified she conducted at risk meetings that included any residents with wounds and/or pressure ulcers. She reported that she ran an evaluation report that identified residents at high risk for developing pressure ulcers. The DNS identified for any residents who appeared on the evaluation report, she reviewed their care plans to ensure appropriate interventions were in place to prevent the development of pressure ulcers. The DNS reported on August 20, 2026, Resident #105 appeared on the evaluation report as being at high risk for developing a pressure ulcer. She identified that upon review; Resident #105 did not have a care plan addressing pressure ulcer prevention. She identified this review process as her current method to ensure residents at high risk had prevention interventions in place, but she was unsure what the previous DNS's process had been. The DNS also identified the nursing supervisor and/or MDS nurse were responsible for reviewing and updating resident care plans. She identified the resident care plan to be reviewed regularly, at least quarterly, to ensure that it remains current and to determine whether the interventions in place are effective. She further identified Resident #105 as at risk for developing a pressure ulcer and should have had interventions developed and implemented once identified as high risk.A wound treatment observation conducted with Licensed Practical Nurse ( LPN) #3 wound nurse assistant on 8/27/26 at 11:25 AM identified Resident #105 was lying in bed with the feet elevated and foam boots in place. The resident had a foam dressing applied to the right heel dated 8/26/26. Resident #105 was observed to have an unstageable pressure ulcer injury to the right heel. The wound bed of the right heel was covered with slough (yellow dead tissue).Interview with Physician Assistant (PA) 1 wound specialist on 8/27/26 at 2:15 PM identified she was newly assigned as the wound specialist for the facility. She reported residents with cognitive impairments, dependence with bed mobility, toileting, bowel and bladder incontinence, and low Braden Scale scores were considered at high risk for developing pressure injuries. PA #1 identified preventive measures should be implemented immediately once a resident was identified as high risk. She identified appropriate preventive interventions to include frequent turning and repositioning at least every two hours, offloading bilateral heels, providing timely incontinent care, and using a specialty mattress when indicated. She identified Resident #105 would have been considered at high risk for developing a pressure injury due to mobility impairment, incontinence, and cognitive impairment. Review of the Baseline/Comprehensive Person Centered Care Plan (CPCCP) policy given during the survey notes the care plan must be kept up to date by all disciplines at all times. Each discipline is responsible for updating the care plan whenever a new problem is identified that requires their intervention. They must ensure the CPCCP remains current and add new problems or interventions as they arise.

Based on review of the clinical records, review of facility policy and procedures, review of facility documentation, and interviews one of twelve sampled residents (Resident #5) reviewed for facility-acquired pressure injuries, and for one of five sampled residents (Resident #56) reviewed for infection control, the facility failed to ensure that medication and treatments were administered in accordance with professional standards of practice. The findings include: Resident #56's diagnoses included malignant melanoma, autonomic neuropathy, and history of transient ischemic attack and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #56 was cognitively intact, required substantial/maximal assistance with bed mobility, and set up clean up assistance with personal hygiene. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 6/11/26 identified Resident #56 has a diagnosis of malignant melanoma of right upper limb including shoulder with interventions that directed to medicate as ordered for adverse reactions and monitor for effectiveness and side effects and report to physician as needed. Monitor skin condition at treatment site and report to physician as needed, and treatment for melanoma as ordered by MD. Physician's orders for the month of August 2026 directed: Heparin Sodium Lock flush intravenous solution 100unit/ml use 5ml intravenously every day shift every 30 days for maintaining patency. Instill after saline flush. Apply transparent membrane dressing and leave in place for 24 hours after flushed monthly. Review of the MAR and TAR for the month of August 2026 identified that the flush had not been documented as completed. Review of the Nurses notes for the Month of August 2026 identified there was a note entered on 8/20/26 that the supply kit for the implanted port was not available and the pharmacy was called and a kit was ordered. Interview and review of the MAR/TAR and progress notes for August 2026 on 8/31/26 at 10:40AM with the ADNS identified that there was no documentation of the implanted port flush present in the MAR/TAR or progress notes for the month of August 2026. The area on the MAR/TAR for the Heparin and Saline flush were blank. The ADNS identified that she recalled doing the flush however must have gotten pulled away to something else and did not document that it was completed. Her procedure usually would include writing a progress note as well as signing the MAR/TAR. Interview on 8/31/26 at 11:10AM with Pharmacy#1 identified the supply was ordered on 8/20/26 and delivered on 8/21/26 around 4am. Subsequent to surveyor inquiry the orders received in the MAR/TAR for the month of August 2026 were signed by the ADNS. A late entry was placed in the progress notes dated 8/31/26 from 8/21/26 stating that the port had been flushed. Review of the Medication Pass Policy directed it is the policy of this facility that medications are administered safely and timely per the physician's orders. Review of the Implanted Venous Port Accessing Policy directed to document the procedure at a minimum site assessment, non-coring needle gauge and length, number of attempts to access, brisk blood return verified, flush and volume, medication, residents' response to procedure and any resident/caregiver education. Resident #5 was admitted to the facility in September of 2025 and had diagnoses that included moderate protein-calorie malnutrition, type 2 diabetes mellitus, traumatic subdural hemorrhage without loss of consciousness, and hemiplegia and hemiparesis following other non-traumatic intracranial hemorrhage affecting left non-dominant side. The admission MDS assessment dated [DATE] identified Resident #5 had severe cognitive impairment and was totally dependent on staff for toileting hygiene, bed mobility, transfers, dressing and non-ambulatory. The assessment further identified Resident #5 was always incontinent of bladder and bowel, was at risk for development of pressure injury and had no pressure injury at that time. The assessment also identified that the resident used a pressure-reducing device while in bed and when seated in chair but was not on a turning and reposition program. The Resident Care Plan (RCP) dated 9/26/25 identified that Resident #5 had a potential for skin breakdown due to prolonged pressure. The care plan interventions directed staff to offload the resident's heels with boots when in bed and or at all times, pressure redistribution mattress, complete weekly skin evaluations, and administer treatments as per physician's orders. The nursing note dated 10/5/25 at 1:08 PM written by LPN #6 identified Triad paste was applied to the moisture associated skin damage (MASD) on Resident #5's sacrum. Review of the physician's order for the period of 9/19/25 through 10/10/25 failed to identify a physician's order directing the use of Triad paste to Resident #5's sacrum. Interview with the Charge Nurse (LPN #6) on 8/28/26 at 10:18 AM identified the area to Resident #5's sacrum was an MASD because it was a red unopened and non-blanchable area, so she applied the Triad paste as it was listed in the resident admission paperwork on 9/19/25. LPN #6 reviewed the discharge paperwork dated 9/19/25 and identified that Triad paste was used to the lower buttocks/perineum and not to the sacrum. She further identified that the facility had a list of treatment/protocol that can be used based on the skin issue and since it was not opened Triad paste was appropriate, however, she identified that she would have needed to have a physician's order prior to applying the Triad paste to Resident #5's sacrum. Interview with the DNS and the ADNS on 8/25/26 at 2:14 PM identified a physician's order is needed for Triad paste to be administered to a resident, that is the practice. The physician's order dated 9/20/25 directed to apply barrier cream to buttocks for protection every shift and as needed. Review of the treatment orders and treatment administration record (TAR) for the period of September 21, 2025, through August 27, 2026, identified the order directed to apply barrier cream to buttocks for protection was signed off by nurses assigned to the resident on the schedule administration time. This would indicate that the treatment was administered by the licensed nurse on duty. Interview with NA #6 and NA #7 on 8/26/26 at 2:20 PM identified that they apply barrier cream to residents when peri-care is provided. Interview with LPN #2 on 8/26/26 at 2:30 PM identified that the nurse aides would apply barrier cream with care and the nurses would administer/apply Triad paste treatment. When asked when she signs off the TAR what does that indicate, when she responded that it was done by her (the nurse) the treatment ordered. She then identified that she should have applied the barrier cream and not the nurse's aide. Interview with LPN #10 on 8/27/26 at 3:10 PM identified that the nurse aide applies barrier cream to the resident buttocks for protection and nurse only apply barrier cream if there is an issue with the area. When asked when she signs off the TAR what does that indicate, when she responded that it was done by her (the nurse) the treatment ordered. She then identified that she should have applied the barrier cream and not the nurse aide because she is the one signing off the TAR. Interview with the DNS and RN #2 (Regional Director of Clinical Operations) on 8/31/26 at 10:21 AM identified that a nurse aide can apply a barrier cream to resident for skin protectant but if it is written as a physician's order the nurse has to administer/apply the barrier cream and not the nurse aide. Also, they identified it as the standard that when a treatment administration record and the medication administration record are signed, it indicates that the task was completed by the individual signing the record. Review of the Charting and Documentation policy identifies that documentation shall be accurate, relevant and complete, containing sufficient details about the patient's care and/or response to care and false information shall not be documented. The policy further identifies that licensed staff, and interdisciplinary team members shall document all assessments, observations, evaluations, and services provided in the patient's medical records in accordance with state law.

Based on observations, review of clinical records, review of facility documentation, review of facility policy and interviews for two sampled residents (Residents #117 and #172) reviewed for skin conditions the facility failed to ensure upon identification of as impaired skin integrity that assessments and treatments were implemented timely. The findings include: Resident #172 was admitted to the facility on [DATE] with diagnoses that included dementia, encounter for palliative care, and muscle weakness. The skin and wound evaluation dated 8/18/26 identified that Resident #172 was admitted with skin tears to the left outer forearm, right outer forearm, and left dorsum hand. The wound measurements were documented as follows: the left outer forearm skin tear measured 8 cm in length and 3 cm in width; the right outer forearm skin tear measured 0.71 cm in length and 1.1 cm in width; and the left dorsum hand skin tear measured 0.5 cm in length and 0.5 cm in width. A physician's order dated 8/18/26 directed staff to cleanse the left forearm with wound cleanser, apply xeroform, and cover with a dry, clean dressing every two days. admission nurse's notes dated 8/18/26 at 8:48 AM documented that Resident #172 had been admitted after midnight following an unwitnessed fall at home with diagnoses of altered mental status and urinary tract infection. The resident exhibited garbled, incomprehensible speech, severe agitation, and restlessness related to dementia. The Resident Care Plan (RCP) dated 8/19/26 identified skin tears to the left and right forearms and the left hand. Care plan interventions directed staff to use protective clothing (Geri sleeves) as tolerated, administer treatments per physician orders, monitor for signs and symptoms of wound infection, and notify the physician of any changes. A physician's order dated 8/24/26 directed staff to cleanse the right forearm with wound cleanser, apply xeroform to the wound bed, and cover with a dry, clean dressing every two days. A physician's order dated 8/25/26 directed staff to cleanse the left hand/thumb with wound cleanser, apply xeroform, and cover with a dry, clean dressing every two days. A review of the Treatment Administration Record (TAR) from 8/18/26 through 8/27/26 identified that Resident #172's skin tears to the right forearm and left hand did not have active treatment orders in place. Further review of the TAR showed that the skin tear to the right forearm was acknowledged and signed off by nursing staff on 8/25/26, seven days after it was identified, and the skin tear to the left hand/thumb was acknowledged and signed off on 8/27/26, nine days after identification on 8/18/26. Interview with LPN #1 (wound nurse) on 8/25/26 at 1:00 PM identified that Resident #172 was admitted on [DATE] with skin tears to the left and right forearms and the left dorsum hand. She identified that she documented these wounds in the skin and wound evaluation section of the electronic clinical record. She further identified that she was responsible for ensuring that all open wounds had corresponding physician's treatment orders in place once they were identified. She identified that she entered a treatment order for the left forearm on 8/18/26 but failed to enter treatment orders for the right forearm and the left dorsum hand, which also should have been initiated on 8/18/26. The Prevention of Non Pressure Wounds policy indicated that the facility was to provide necessary treatment and services consistent with professional standards of practice in order to promote healing, prevent wound infection, and prevent the development of new wounds. The facility did not obtain physician's treatment orders for all wounds at the time they were identified and did not ensure that the treatments ordered were implemented promptly. Resident #117's diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbations, peripheral vascular disease, and pain. The quarterly MDS assessment dated [DATE] identified Resident #117 had severely impaired cognition, required supervision or touching assistance with personal hygiene, lower body dressing, moderate assistance with putting on/taking off footwear and independent with ambulating 10feet. The assessment further identified resident was at risk for pressure injuries, had no wounds, or skin problems with a treatment for pressure reducing device for bed. The care plan dated 7/14/26 identified Resident #117 has a potential for skin breakdown related to decrease mobility and ability to perform activities of daily living (ADL) with interventions that included to inspect skin for redness, irritation or breakdown during care, to complete weekly skin evaluations, update physician and responsible party with changes as needed. The physician's order for the month of August 2026 directed for skin integrity checks weekly on Tuesdays on the day shift and document in the skin and wound total body skin assessment. Observation on 8/24/26 at 10:15 AM identified Resident #117 was seated in his/her wheelchair without socks and noted slight swelling with redness to the right lateral malleolus (ankle bone area). Resident #117 identified he/she did not hit the area and had just woken up with this redness and pain in the right lateral malleolus and had reported it already to the staff. The weekly skin check note dated 8/25/26 at 1:31 PM completed by LPN #2 on Resident #117 identified a foot evaluation was completed and no new skin issues were identified. Observation on 8/26/25 at 11:50 AM identified Resident #117 was seated in his/her wheelchair wearing a sock on feet with responsible party at bedside. Resident #117 was asked if he/she had received any treatment to the area to the right malleolus, when the resident indicated no and it is still red. Resident #117 noted that he/she had a shower yesterday (8/25/26) and thinks the nurse may have seen the area. Interview with LPN #2 on 8/26/26 at 11:57 AM identified she had noted the redness to the right lateral malleolus when she had completed the resident's weekly skin check on 8/25/26, however, did not report the skin issue to the supervisor. LPN #2 further identified the area was chronic and even though the facility had implemented various interventions such as boots, offloading, the area would still reoccur. She further identified when the area does recur, they would take a picture, notify the supervisor and he/she would call the physician/APRN to obtain a treatment order to treat the area and update the resident representative. LPN #2 further identified she should have reported the area to the supervisor on 8/25/26, when it was first identified, and that she also did not pass her observation on to the on-coming shift when asked. In addition, LPN #2 identified that her documentation should not have indicated that there was no issue as there was redness to the right lateral malleolus when she did the resident skin check on 8/25/26. Interview with the Nursing Supervisor (RN #3) on 8/27/26 at 1:06 PM identified she was only made aware on 8/26/26 that Resident #117 had a skin issue, which was chronic by the change nurse on the unit, so she went and assessed the resident, took a picture of the area, obtain a physician order for treatment and notified the family. She identified the area was not red and she had updated the care plan for the family to provide a different type of shoe for the resident. Review of the records failed to identify that a measurement, treatment, and assessment by the registered nurse was completed of the right lateral ankle malleolus until 8/27/26. Interview on 8/31/26 at 1:14 PM with RN #3 identified she was given the incorrect information by the charge nurse as she had assessed the resident's left ankle area instead of the right ankle area which was in fact red. She further identified since then she had corrected her nursing note to reflect the accurate area with the skin issue. The wound progress note dated 8/27/26 written by PA #1 identified the area to the right lateral ankle malleolus measured 1.9 centimeters (cm) in length by 2.5 cm in width, no depth area with noted blanchable erythema. Interview with the DNS and ADNS on 8/27/26 at 1:54 PM identified they expect when a skin issue is identified that the nurse notifies the supervisor immediately, so that an assessment is completed, a picture is taken, a physician order for treatment is obtained. They also expect that treatment is implemented upon identification and it was not acceptable for the treatment order to be obtained and implemented the next day, and if the nurse was busy, it should have been passed on to the oncoming shift. Review of the Change of Condition Notification policy identified that the facility would inform the resident, resident's healthcare provider, and the resident's family/legal representative when there is a change of condition. The policy further identifies that this notification should be done when there is: an incident involving the residents which may result in an injury or require medical treatment or commence a new form of treatment. Also, that the physician/family notification must be documented in the electronic health record.

Based on clinical record review, review of facility documentation, review of facility policies and procedures, interviews for one of six sampled residents (Resident #79) reviewed for unnecessary medications, the facility failed to adequately monitor for the effects associated with the use of multiple opioid and benzodiazepine medications, resulting in the resident experiencing over sedation requiring the use of naloxone (opioid antagonists). Resident #79's diagnoses included fusion of the cervical region of the spine, hypertension, traumatic brain injury (TBI), anxiety disorder, muscle weakness, difficulty walking, C6 level cervical spine injury, and traumatic ischemia of muscle.An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #79 was cognitively intact, received antipsychotic, antianxiety, antidepressant, anticoagulant, opioid, and anticonvulsant medicationsReview of medication orders identified the following orders: 8/21/26, Lorazepam 1mg daily for anxiety, morphine sulfate 15mg extended release (as part of a total dose of 45mg) and morphine sulfate extended-release 30 mg (as part of a total 45 mg) every 12 hours for pain, oxycodone 5mg every six hours as needed for moderate pain and 10mg every 6 hours as needed for severe pain. 8/25/26, Lorazepam 1mg every 24 hours for breakthrough anxiety Further review of physician's orders identified that the morphine extended-release dosage was increased to 45 mg every 12 hours on 8/21/26, from the prior dose of 30 mg every 12 hoursReview of the clinical record following the medication changes failed to identify evidence of recommendations for monitoring Resident #79 for sedation, respiratory depression, or other side effects possible from the cumulative effects of the increased opioid dosage and concurrent administration of opioid, and benzodiazepine medication which can suppress the central nervous system. The pharmacy consultant's medication regimen review dated 8/22/26 did not identify concerns with the combination of opioid and benzodiazepine medications ordered. Review of the MAR for 8/26/26 identified Resident #79 was administered morphine sulfate extended release 45 mg, oxycodone 10 mg, and lorazepam 1 mg between 9:12 AM and 10:00 AM.Review of a health status change progress note dated 8/26/26 at 1:48 PM identified that at approximately 11:00 AM, a nurse aide notified RN #3 that Resident #79 appeared more tired and depressed. The APRN was notified and requested to evaluate the resident during rounds. The note identified that Resident #79 had received medications that morning, including oxycodone 10 mg at 9:12 AM for pain, and identified a recent increase in pain medication related to increased pain.At approximately 12:30 PM, RN #3 was notified of a change in Resident #79's vital signs, including a decrease in oxygen saturation to 88%. Supplemental oxygen was increased from 2 liters via nasal cannula, with an oxygen saturation of 90%, to 4 liters via nasal cannula, with improvement in oxygen saturation to 96-98%. PA #2 notified RN #3 that Resident #79 was difficult to arouse, demonstrated altered mental status, and required transport to the emergency department for evaluation.PA #2 administered naloxone 4 mg on two occasions, with a positive response that included improved alertness, return to baseline orientation, stable vital signs, and improved oxygen saturation. Resident #79, who was responsible for his/her own decision-making, declined transport to the hospital for further evaluation. Subsequently, psychiatric evaluation and 1:1 staff monitoring at the bedside for two shifts were ordered to ensure continued stability.Review of PA #2's progress note dated 8/26/26 at 1:00 PM identified that Resident #79 was evaluated urgently for lethargy, acute change in mental status, obtundation, and decreased oxygen saturation to 88% while receiving oxygen at 2 liters via nasal cannula. PA #2 documented that the resident had previously demonstrated tolerance to multiple opioid medications without evidence of sedation or lethargy and had tolerated an increase in the morphine dose during the preceding five days without reported concerns.PA #2 further documented that, given the acute change in mental status and concern for medication-related sedation in the setting of multiple opioid medications, opioid-related sedation was considered. Naloxone was administered on two occasions, resulting in a positive clinical response and improvement in the resident's level of alertness. The resident was subsequently monitored closely, medications were held as clinically indicated, and alternative causes of encephalopathy were evaluated through laboratory testing and chest X-ray.PA #2 further documented that Resident #79 had received oxycodone, morphine sulfate extended release (MS Contin), and lorazepam simultaneously that morning, which raised concern for opioid-induced oversedation. The resident's medication regimen also included gabapentin 800 mg three times daily and baclofen 15 mg three times daily. PA #2 documented that the resident had received an additional dose of lorazepam 1 mg the previous day for anxiety related to the resident's mother's death and that the resident's morphine extended-release dosage had been increased to 45 mg every 12 hours the prior week.Review of the psychiatric APRN progress note dated 8/26/26 at 9:36 PM identified that Resident #79 experienced acute respiratory depression requiring two doses of naloxone 4 mg. The psychiatric APRN identified that the resident received multiple CNS depressant medications, including lorazepam, quetiapine, perphenazine, hydroxyzine, morphine extended release, oxycodone as needed, gabapentin, baclofen, and clonidine.The psychiatric APRN further identified that, given Resident #79's history of prior suicide attempt and intentional ingestion, the combination of multiple CNS depressant medications with opioids presented an elevated risk and warranted ongoing monitoring. One-to-one monitoring was ordered for two shifts.Following the 8/26/26 event, provider orders included monitoring Resident #79's oxygen saturation and respiratory status following naloxone administration and holding oxycodone and lorazepam pending reassessment of the resident's sedation level and medication regimen. The oxycodone 10 mg dose was discontinued, and the oxycodone order was changed to 5 mg every 6 hours as needed for pain, with instructions not to administer oxycodone within 2 hours of morphine. The resident's pain medication regimen and the risks associated with concurrent opioid and benzodiazepine use were to be reevaluated following stabilization.Additional interventions included psychiatric follow-up, close monitoring of neurological status, and 1:1 monitoring for two shifts through 11:59 PM on 8/26/26, along with vital signs every 4 hours tapering to every shift for 3 days following the event.During an interview on 8/27/26 at 2:00 PM, RN #3 indicated that Resident #79 had chronic and severe pain and had no prior incidents of respiratory depression or altered mental status; therefore, the resident had not been under any additional monitoring related to these medications. RN #3 indicated that the incident on 8/26/26 revealed an opportunity for nursing education regarding the timing of medication doses and monitoring associatedwith these medications. RN #3 further indicated that the incident demonstrated good communication among the team, including the nurse aide, licensed practical nurse, herself, and mid-level providers, in intervening with the resident.An interview with NA #2 on 8/31/26 at 8:41 AM revealed that she observed Resident #79 mid-morning on 8/26/26 and that the resident appeared off from his/her usual baseline and was not as alert as usual. She notified the nurse in charge, who accompanied her to see the resident. At that time, the resident could not remain awake while being spoken to, prompting the nurse to request that a provider evaluate the resident.During an interview with RN #5 on 8/31/26 at 10:28 AM, she reported that Resident #79 was alert and oriented in the morning before medications were administered and complained of pain rated 8 out of 10. RN #5 indicated that she administered the resident's typical medications, which had not caused an issue in the past; however, she noted that the resident did not eat breakfast that morning because he/she remained very upset about the death of a family member. She further indicated that she did not have concerns about the doses of medications she administered because the resident had received this combination of medications at these doses on prior occasions without incident. RN #5 further noted that when she assessed Resident #79 with NA #2, she was concerned about his/her presentation and requested that both the psychiatric APRN and medical PA, who were in the building, assess the resident. She contacted EMS at the direction of PA #2; however, the resident refused to transfer to the emergency room for evaluation and subsequently became agitated with staff for intervening and waking him/her for 1:1 monitoring.An interview with Person #2, the consultant pharmacist, on 8/31/26 at 10:49 AM identified that Resident #79's medications would not have triggered an alert or recommendation for reduction because the resident had only been at the facility for approximately one month at the time of the event (admitted [DATE]). However, upon reviewing the list of medications the resident was receiving, Person #2 stated that the resident was receiving a large numberof CNS medications that, although not contraindicated for concurrent use, could have additive effects, including dizziness, sedation, and altered mental status. Person #2 further reported that tolerance to the medications could develop over time, that the medications Resident #79 was receiving affected the CNS through multiple mechanisms, and that the goal would be to gradually reduce the doses or number of medications over time to reduce the burden on the CNS.During an interview on 8/31/26 at 11:18 AM, PA #2 stated that she increased Resident #79's extended-release morphine dose approximately 2 weeks prior when the resident reported ongoing, significant, and unrelieved pain that interfered with sleep. PA #2 indicated that the discussion included options for increasing morphine versus oxycodone breakthrough medication; however, the long-term goal discussed was to reduce the need for as-needed medications by increasing the long-acting medication. She followed up with the resident on two occasions after the increase, at which time the resident reported improved pain control without negative side effects. She indicated that she observed no evidence of sedation, lethargy, or respiratory depression during those visits.PA #2 further reported that the additional dose of lorazepam, ordered the day prior, was not considered a likely source of the altered mental status because the additional dose was administered at approximately 2:00 PM on 8/25/26, and she indicated that the half-life of the medication was approximately six hours. When the resident was observed to be somnolent, PA #2 assessed the resident and ordered a full infectious disease work-up to rule out other potential causes of encephalopathy and respiratory depression. However,given the resident's lethargy and decreased oxygenation at the time of the assessment, along with the number of opioids administered that morning, PA #2 indicated that she believed it was prudent to administer naloxone, to which the resident responded positively. She subsequently ordered close neurological monitoring and vital signs and reassessed the resident later that day, at which time the resident had returned to baseline.MD #1, interviewed on 8/31/26 at 12:30 PM, indicated that his typical practice was to target the minimum pain medication dose necessary to achieve relief. MD #1 stated that he had not been contacted or consulted regarding Resident #79's dose change and would not have approved such a sharp increase in dosage. MD #1 further indicated that he preferred to addnon-pharmacological interventions before increasing medication doses.The facility failed to ensure Resident #79's medication regimen was adequately monitored and managed to prevent adverse consequences associated with the concurrent use of multiple opioid, benzodiazepine, and other CNS depressant medications. Following an increase in the resident's opioid regimen and the addition of breakthrough lorazepam, Resident #79 received extended-release morphine, oxycodone, and lorazepam concurrently on 8/26/26 and subsequently developed oversedation, altered mental status,obtundation, oxygen desaturation, and respiratory depression requiring the administration of naloxone on two occasions. Following the event, the resident's opioid and benzodiazepine medications were held pending reassessment, the oxycodone 10 mg dose was discontinued, parameters were added to separate oxycodone administration from morphine, and additional monitoring was implemented.

Based on a review of practitioner credentialing information, clinical records, controlled-substance prescribing records, and staff interviews, the facility failed to ensure that 1 of 2 advanced practice registered nurses (APRN #2) maintained the required registration to prescribe controlled substances while providing professional services to facility residents. The findings include: A review of credentialing information for professional staff providing services at the facility, including two (2) advanced practice registered nurses (APRNs), identified that 1 of 2 APRNs did not maintain an active federal Drug Enforcement Administration (DEA) Registration required to prescribe controlled substances. Review identified that APRN #2's DEA Registration expired on [DATE] and was not renewed until [DATE], resulting in a lapse from [DATE] through [DATE]. During this period, APRN #2 maintained an active Connecticut (CT) controlled-substance practitioner registration; however, APRN #2 did not maintain the required active federal DEA Registration and wrote or renewed sixteen (16) controlled-substance prescriptions for twelve (12) facility residents.During an interview on [DATE] at 10:45 AM, APRN #2 acknowledged that her DEA Registration had lapsed and had not been timely renewed. APRN #2 stated that she believed she maintained an active DEA Registration in Massachusetts (MA) during the period of the lapse.During an interview on [DATE] at 10:50 AM, a Connecticut Drug Control Agent confirmed that APRN #2's DEA Registration had lapsed from [DATE] through [DATE]. The Drug Control Agent further confirmed that the MA DEA Registration referenced by APRN #2 had expired in 2008. The matter was referred to the Connecticut Drug Control Division for further review.

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 the resident's side-rail was locked into place prior to directing the resident to turn onto their left side in bed resulting in a fall with injury. The findings include:Based on review of clinical records , facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who required assistance of one (1) staff member with bed mobility, the facility failed to ensure the resident's side-rail was locked into place prior to directing the resident to turn in bed which resulted in the resident falling out of bed and sustaining injuries. The findings include: Resident #1's diagnoses include dementia with agitation, a history of falling and age-related osteoporosis (weak, brittle bones). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe impaired cognition and required substantial assistance for bed mobility and transfers. The Resident Care Plan dated 7/8/25 identified Resident #1 had a deficit in self-care and functional mobility due to dementia. Interventions directed to utilize padded side-rails and partial to moderate assistance of one (1) staff with bed mobility. The resident kardex (care card) dated 7/16/25 identified Resident #1 utilized side-rails for assistance with bed mobility. The nurse's note dated 7/17/25 at 7:50 AM identified during care, NA #1 instructed Resident #1 to roll onto their side and grab the side-rail, the side-rail was not locked, and Resident #1 fell out of bed. The note indicated Resident #1's head hit the corner of the table and sustained a laceration to the head and bruising to the knees, Resident #1 was alert and complained of a headache. The note identified that the Medical Director was in the facility at the time of the incident and an order was obtained to transfer Resident #1 to the Emergency Department (ED) for further evaluation. The Facility Reported Incident form dated 7/17/25 identified at 6:45 AM Resident #1 was receiving care in bed by NA #1, Resident #1 rolled onto his/her left side reaching for the side-rail with his/her right hand and when Resident #1 grabbed onto the side-rail and applied pressure, the side-rail lowered and Resident #1 subsequently rolled off the bed, striking his/her head on the bedside table sustaining a three (3) centimeter (cm) by 0.2 cm laceration (a cut/tear in the skin) and bruising to the right knee and lower leg. The report identified Resident #1 was assessed, the family and provider were notified of the incident, and a new order was obtained to transfer the resident to the Emergency Department (ED) for evaluation. The hospital ED note dated 7/17/25 identified Resident #1 was seen in the ED following a witnessed fall out of bed with a head strike sustaining a laceration to the head and abrasions (superficial injury to the skin caused by scraping or rubbing) to the right knee. The note identified imaging was completed and were negative for any acute fractures, two (2) staples were placed to the laceration to the back of the head and Resident #1 was to follow-up with their Primary Care Physician (PCP) for staple removal in ten (10) to fourteen (14) days. The nurse's note dated 7/17/25 at 3:15 PM identified Resident returned to the facility with two (2) staples to the back of the head and bruising to the right forearm, right knee, and right shin. Interview with NA #1, on 8/7/25 at 9:05 AM identified on 7/17/25 Resident #1 required a bed change with morning care. NA #1 identified she lowered the left side-rail, made the left side of the bed and then raised the left side-rail back up. NA #1 reported she turned Resident #1 onto his/her left side and requested Resident #1 turn a little more, when Resident #1 grabbed onto the left side-rail with his/her right arm, the side-rail lowered down and Resident #1 rolled off the left side of the bed, hitting their head on the nightstand and falling to the floor, landing on his/her right side between the bed and the window. NA #1 reported she yelled for the nurse and the 11PM-7AM Nursing Supervisor came to assess Resident #1. NA #1 identified that although she pulled the left side-rail back up after lowering it to put the fitted sheet on the mattress, she failed to ensure the side-rail clicked and locked back into place. Interview with the Director of Maintenance on 8/6/25 at 12:55 PM identified following Resident #1's fall out of bed on 7/17/25, all the beds within the facility were checked, the side-rails were inspected and found to be in working order without issues. The Director of Maintenance reported the side-rails are inspected annually and as needed and the last inspection was 12/16/24 through 12/24/24. Interview with the Director of Nursing (DON) on 8/6/25 at 1:25 PM identified that for all residents who utilize side-rails for bed-mobility/enablers, staff are expected to ensure the side-rails are locked into place prior to providing any bed-level care to a resident. The DON reported following her investigation of the 7/17/25 fall, if NA #1 had ensured the left side-rail was raised in the locked position, Resident #1 would not have fallen out of bed and sustained the laceration to his/her head that required two (2) staples. Interview with the Staff Development Nurse, RN #3, on 8/6/25 at 1:50 PM identified that for all new employees, bed-mobility education is provided during orientation, which included side-rails and ensuring that they are in a locked position prior to providing bed-level care for residents who utilize them. RN #3 indicated that bed mobility and side-rails are also reviewed in the annual education and competencies, which NA #1 last completed on 10/16/24 along with a review of the Certified Nursing Assistant (CNA) Standards of Care which includes providing overall safety to all residents. RN #3 identified NA #1 should have ensured the side-rails, on Resident #1's bed, were raised and in the locked position prior to turning Resident #1. Although attempted, an interview with RN #1 was not obtained. Review of the Side Rail policy dated 1/2025 directed, in part, that the use of partial side rails will be documented on the resident's plan of care and nursing staff will report any side rail concerns to the maintenance department.The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance as of July 31, 2025.Staff education: To ensure the safety of residents who require assistance with care and the use of side rails, nursing staff must check that the side rails are in locked position before providing care. Staff should immediately report any concerns regarding bed equipmentConducted a facility house audit of all who require the use of side rails are functioning appropriately to ensure resident safetyRandom weekly Care Audits will be conducted weekly times four (4), monthly for three (3) and/or substantial compliance to ensure side rails are locked and good working orderResults of audits will be reviewed during next QAPI meeting.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident # 1) reviewed for medication administration, the facility failed to prevent a medication error when a licensed nurse administered medications to an incorrect resident and failed to notify a Registered Nurse and the provider of the medication error once discovered. The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included fracture of the left tibial spine, heart failure, hypertension and history of breast cancer. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 14) and was independent with eating with set up help. The care plan dated 4/5/25 identified Resident #2 had the potential for untoward effects due to anticoagulant therapy. Interventions included medication considerations and report side effects of anticoagulant therapy to the nurse. Review of Physician orders identified Resident #2 was prescribed the following medications: a. Omeprazole 20 mg one tablet by mouth for GERD at 8:00 AM b. Atorvastatin 40 mg once a day by mouth for hyperlipidemia at 9:00 AM c. Apixaban .5 mg two times a day by mouth for knee arthroplasty at 9:00 AM d. Plaquenil 200 mg once a day by mouth for arthritis at 9:00 AM e. Anastrozole 1 mg once a day by mouth for breast cancer at 9:00 AM f. Metoprolol 50 mg once a day by mouth for hypertension at 9:00 AM g. Furosemide 40 mg once a day for congestive heart failure at 9:00 AM h. Sacubitril Valsartan 24-26 mg once a day by mouth for hypertension at 9:00 AM 2. Resident #1 was admitted to the facility with diagnoses that included fracture of the right femur, atrial fibrillation, epilepsy, hypertension and heart failure. Resident #1's allergies were oxycodone and the pneumococcal vaccine. The care plan dated 4/18/25 identified Resident #1 had the potential for altered cardiac status related to hypertension, congestive heart failure, atrial fibrillation, hyperlipidemia, hypotension and had a pacemaker. Interventions included vital signs per protocol and as needed. A physician's order dated 4/19/25 directed Metoprolol 25 mg tablet half tablet once a day for hypertension. The admission MDS assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating with set up help. A physician's order dated 4/24/25 directed Midodrine 5 mg two times a day for hypotension. A nursing note by RN #1 dated 4/30/25 at 10:30 AM identified Resident #1 received the following wrong medications: Omeprazole 20 mg, Atorvastatin 40 mg, Apixaban .5 mg, Plaquenil 200 mg, Anastrozole 1 mg, Metoprolol 50 mg, Furosemide 40 mg and Sacubitril Valsartan 24-26 mg. Resident #1's blood pressure dropped to 77/46 and Resident #1 was given fluids, Midodrine 5 mg and placed in Trendelenburg position. Resident #1's blood pressure was checked every 15 minutes, and the systolic blood pressure remained in the 80's. Resident #1 denied dizziness, lightheadedness, nausea, vomiting or headache. Resident #1 was able to take fluids without difficulty and remained alert and orientated. The APRN and MD were updated and ordered Resident #1 be transferred to the emergency department (ED) for further evaluation. The ED note dated 4/30/25 identified Resident #1 received a 1-liter bolus of normal saline at 10:57 AM. Poison control was contacted and were not concerned of potential drug interactions. They did not anticipate significant ill effects from the medications other than metoprolol, as the patient was likely prone to hypotension since he/she was prescribed Midodrine. A nursing note dated 4/30/25 at 8:10 PM identified Resident #1 returned to the facility. Resident #1 received 1500 ml of fluid and was stable at the ED. The accident and incident (A & I) form dated 4/30/25 at 8:45 AM identified Resident #1 was administered Resident #2's medications (his/her roommate) in error. Resident #1's blood pressure was monitored every fifteen minutes until transfer to the emergency department (ED). Vital sign monitoring was completed for all other residents on the floor. The medication administration record (MAR) identified on 4/30/25 at 9:00 AM midodrine 5mg was administered. Interview with LPN #1 on 5/14/25 at 11:23 AM identified she prepared medications for Resident #2 on 4/30/25 at the doorway of Resident #1's and Resident #2's room then entered the room and approached Resident #1. She asked Resident #1 if she was Mary and Resident #1 answered yes. She identified she did not check Resident #1's name identification bracelet but checked the picture in the medical record, which she thought looked like Resident #2. She identified she gave Resident #1 the cup of medications and did not tell Resident #1 what the medications were. Resident #1 then asked LPN #1 where her Keppra medication was. LPN #1 went back to the medication cart and found no order for Keppra then realized she administered the medications to the wrong resident. She turned to Resident #1 and he/she already swallowed the medications. She identified she could not find the supervisor to report the medication error so she told LPN #2 that Resident #1 received Resident #2's medications. She then took Resident #1's vital signs, gave Resident #1 fluids and midodrine, placed Resident #1 back into bed into Trendelenburg position. She identified that she continued with her medication pass, including given Resident #2 his/her prescribed medications. Resident #1 did not receive any other medications other than Midodrine. She identified she failed to ensure she had the right resident when administering medications. Interview with RN #1 on 5/14/25 at 12:42 PM identified that around 9:00 AM on 4/30/25 she was notified by LPN #2 that LPN #1 gave Resident #1 50 mg of Metoprolol, not his/her prescribed amount of 12.5 mg. RN #1 identified she assessed Resident #1, his/her systolic blood pressure was 77 (normal systolic blood pressure is 120), and she notified the APRN. Resident #1 was given water, assisted into bed in Trendelenburg position, and blood pressure was monitored every fifteen minutes. She identified she reported the medication error to the DNS at morning report. The DNS asked her to verify the error and RN #1 then discovered Resident #1 received all of Resident #2's morning medications, not just the Metoprolol. The APRN was updated and ordered Resident #1 be sent to the ED. RN #1 identified LPN #1 continued the morning medication pass, as the error was not identified as significant when she was first notified. She identified all the residents LPN #1 administered medications to had their vital signs assessed. RN #1 identified residents should be verified by their name band, picture and date of birth for medication administration and if a resident does not have a name band on, another staff member should verify the resident. Interview with the DNS on 5/14/25 at 1:00 PM identified on 4/30/25 when LPN #1 identified the medication error, she could not find the supervisor so told LPN #2 that Resident #1 received the wrong blood pressure medication and was concerned about Resident #1's blood pressure. The DNS identified LPN #1 did not tell LPN #2 that Resident #1 received all of Resident #2's medications. LPN #2 reported the medication error to RN #1 who then reported the medication error to her (the DNS). It was then discovered that LPN #1 administered all of Resident #2's medications to Resident #1. LPN #1 had competed the medication pass at that time, and the DNS had her leave the building. She identified if she knew LPN #1 administered all of Resident #2's medications to Resident #1, they would have stopped LPN #1 immediately in her medication pass. She identified all other residents LPN #1 administered medications to had their vital signs assessed and were all stable. The DNS identified Resident #1 had a name identification band on for LPN #1 to verify the resident appropriately. She further identified two verifications should be used to identify a resident before medications are administered. Subsequent to the event, medication administration education for all staff was initiated on 4/30/25, LPN #1 was provided medication administration education from her agency and would not be returning to the facility, QAPI improvement plan was initiated on 4/30/25 with a target completion date of 6/1/25 and medication administration audits were initiated on 5/1/25. The facility failed to conduct education or audits related to the failure of notification of a Registered Nurse for a timely assessemnt and timely notification of a provider. Review of the Medication Error Policy directed that a medication error is a discrepancy between what the healthcare provider ordered and what the resident received. Significant med error means one that causes an adverse effect to the resident (discomfort, jeopardized his/her health safety). Review of the Medication Pass policy directed to identify each resident prior to administration (picture, ID bracelet, etc.), know diagnosis and indication for every medication, do not pre-pour medication, administer them as they are prepared. Always observe the resident until they have swallowed all medications that have been administered, do not leave medication in med cup at bedside or tableside. It further directed to remember the six rights: right resident, drug, dose, dosage form, route and time.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident # 1) reviewed for medication administration, the facility failed to prevent a medication error when a licensed nurse administered medications to an incorrect resident. The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included fracture of the left tibial spine, heart failure, hypertension and history of breast cancer. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 14) and was independent with eating with set up help. The care plan dated 4/5/25 identified Resident #2 had the potential for untoward effects due to anticoagulant therapy. Interventions included medication considerations and report side effects of anticoagulant therapy to the nurse. Review of Physician orders identified Resident #2 was prescribed the following medications: a. Omeprazole 20 mg one tablet by mouth for GERD at 8:00 AM b. Atorvastatin 40 mg once a day by mouth for hyperlipidemia at 9:00 AM c. Apixaban .5 mg two times a day by mouth for knee arthroplasty at 9:00 AM d. Plaquenil 200 mg once a day by mouth for arthritis at 9:00 AM e. Anastrozole 1 mg once a day by mouth for breast cancer at 9:00 AM f. Metoprolol 50 mg once a day by mouth for hypertension at 9:00 AM g. Furosemide 40 mg once a day for congestive heart failure at 9:00 AM h. Sacubitril Valsartan 24-26 mg once a day by mouth for hypertension at 9:00 AM 2. Resident #1 was admitted to the facility with diagnoses that included fracture of the right femur, atrial fibrillation, epilepsy, hypertension and heart failure. Resident #1's allergies were oxycodone and the pneumococcal vaccine. The care plan dated 4/18/25 identified Resident #1 had the potential for altered cardiac status related to hypertension, congestive heart failure, atrial fibrillation, hyperlipidemia, hypotension and had a pacemaker. Interventions included vital signs per protocol and as needed. A physician's order dated 4/19/25 directed Metoprolol 25 mg tablet half tablet once a day for hypertension. The admission MDS assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating with set up help. A physician's order dated 4/24/25 directed Midodrine 5 mg two times a day for hypotension. A nursing note by RN #1 dated 4/30/25 at 10:30 AM identified Resident #1 received the following wrong medications: Omeprazole 20 mg, Atorvastatin 40 mg, Apixaban .5 mg, Plaquenil 200 mg, Anastrozole 1 mg, Metoprolol 50 mg, Furosemide 40 mg and Sacubitril Valsartan 24-26 mg. Resident #1's blood pressure dropped to 77/46 and Resident #1 was given fluids, Midodrine 5 mg and placed in Trendelenburg position. Resident #1's blood pressure was checked every 15 minutes, and the systolic blood pressure remained in the 80's. Resident #1 denied dizziness, lightheadedness, nausea, vomiting or headache. Resident #1 was able to take fluids without difficulty and remained alert and orientated. The APRN and MD were updated and ordered Resident #1 be transferred to the emergency department (ED) for further evaluation. The ED note dated 4/30/25 identified Resident #1 received a 1-liter bolus of normal saline at 10:57 AM. Poison control was contacted and were not concerned of potential drug interactions. They did not anticipate significant ill effects from the medications other than metoprolol, as the patient was likely prone to hypotension since he/she was prescribed Midodrine. A nursing note dated 4/30/25 at 8:10 PM identified Resident #1 returned to the facility. Resident #1 received 1500 ml of fluid and was stable at the ED. The accident and incident (A & I) form dated 4/30/25 at 8:45 AM identified Resident #1 was administered Resident #2's medications (his/her roommate) in error. Resident #1's blood pressure was monitored every fifteen minutes until transfer to the emergency department (ED). Vital sign monitoring was completed for all other residents on the floor. The medication administration record (MAR) identified on 4/30/25 at 9:00 AM midodrine 5mg was administered. Interview with LPN #1 on 5/14/25 at 11:23 AM identified she prepared medications for Resident #2 on 4/30/25 at the doorway of Resident #1's and Resident #2's room then entered the room and approached Resident #1. She asked Resident #1 if she was Mary and Resident #1 answered yes. She identified she did not check Resident #1's name identification bracelet but checked the picture in the medical record, which she thought looked like Resident #2. She identified she gave Resident #1 the cup of medications and did not tell Resident #1 what the medications were. Resident #1 then asked LPN #1 where her Keppra medication was. LPN #1 went back to the medication cart and found no order for Keppra then realized she administered the medications to the wrong resident. She turned to Resident #1 and he/she already swallowed the medications. She identified she could not find the supervisor to report the medication error so she told LPN #2 that Resident #1 received Resident #2's medications. She then took Resident #1's vital signs, gave Resident #1 fluids and midodrine, placed Resident #1 back into bed into Trendelenburg position. She identified that she continued with her medication pass, including given Resident #2 his/her prescribed medications. Resident #1 did not receive any other medications other than Midodrine. She identified she failed to ensure she had the right resident when administering medications. Interview with RN #1 on 5/14/25 at 12:42 PM identified that around 9:00 AM on 4/30/25 she was notified by LPN #2 that LPN #1 gave Resident #1 50 mg of Metoprolol, not his/her prescribed amount of 12.5 mg. RN #1 identified she assessed Resident #1, his/her systolic blood pressure was 77 (normal systolic blood pressure is 120), and she notified the APRN. Resident #1 was given water, assisted into bed in Trendelenburg position, and blood pressure was monitored every fifteen minutes. She identified she reported the medication error to the DNS at morning report. The DNS asked her to verify the error and RN #1 then discovered Resident #1 received all of Resident #2's morning medications, not just the Metoprolol. The APRN was updated and ordered Resident #1 be sent to the ED. RN #1 identified LPN #1 continued the morning medication pass, as the error was not identified as significant when she was first notified. She identified all the residents LPN #1 administered medications to had their vital signs assessed. RN #1 identified residents should be verified by their name band, picture and date of birth for medication administration and if a resident does not have a name band on, another staff member should verify the resident. Interview with the DNS on 5/14/25 at 1:00 PM identified on 4/30/25 when LPN #1 identified the medication error, she could not find the supervisor so told LPN #2 that Resident #1 received the wrong blood pressure medication and was concerned about Resident #1's blood pressure. The DNS identified LPN #1 did not tell LPN #2 that Resident #1 received all of Resident #2's medications. LPN #2 reported the medication error to RN #1 who then reported the medication error to her (the DNS). It was then discovered that LPN #1 administered all of Resident #2's medications to Resident #1. LPN #1 had competed the medication pass at that time, and the DNS had her leave the building. She identified if she knew LPN #1 administered all of Resident #2's medications to Resident #1, they would have stopped LPN #1 immediately in her medication pass. She identified all other residents LPN #1 administered medications to had their vital signs assessed and were all stable. The DNS identified Resident #1 had a name identification band on for LPN #1 to verify the resident appropriately. She further identified two verifications should be used to identify a resident before medications are administered. Subsequent to the event, medication administration education for all staff was initiated on 4/30/25, LPN #1 was provided medication administration education from her agency and would not be returning to the facility, QAPI improvement plan was initiated on 4/30/25 with a target completion date of 6/1/25 and medication administration audits were initiated on 5/1/25. Review of the Medication Error Policy directed that a medication error is a discrepancy between what the healthcare provider ordered and what the resident received. Significant med error means one that causes an adverse effect to the resident (discomfort, jeopardized his/her health safety). Review of the Medication Pass policy directed to identify each resident prior to administration (picture, ID bracelet, etc.), know diagnosis and indication for every medication, do not pre-pour medication, administer them as they are prepared. Always observe the resident until they have swallowed all medications that have been administered, do not leave medication in med cup at bedside or tableside. It further directed to remember the six rights: right resident, drug, dose, dosage form, route and time.

Based on review of the infection control program, observations, review of facility policy and staff interviews, the facility failed to ensure all staff members were knowledgeable in identifying residents requiring Enhanced Barrier Precautions (EBP) and proficient in utilizing proper personal protective equipment while providing care for residents requiring EBP. The findings included: a. On 11/19/24 at 12:17 PM during the survey identified no enhanced barrier signs outside resident bedroom doors reported by surveyors. On 11/20/24 at 6:18 AM an observation and interview with the 3rd shift charge nurse (LPN # 12) indicated the orange dots on the resident room plates outside the residents' rooms means that the resident is on enhanced barrier precautions and personal protective equipment (PPE) must be worn for extended periods of time or close contact like direct care and incontinent care. LPN #12 further indicated the PPE is in a bin on the linen cart supplied by the laundry department. On 11/20/24 at 6:20AM an interview with NA#3 located on the second floor of the facility indicated no one on her/his assignment required PPE to be worn during care. NA #3 further indicated s/he would obtain PPE supplies in the supply room if they were not located in a bin outside the resident door. NA #3 further indicated no using any gown while proving care for any residents on her/his unit this past shift and indicated not knowing what the orange dots meant on the resident name plate outside the resident door. NA # 3 further indicates she/h would ask the nurse at the nurse's station the meaning of the dots. LPN #2 and LPN#3 were at the nurse's station and LPN #2 indicated the orange dot meant the resident required Enhanced Barrier Precautions (EBP) and a gown was needed when providing care. LPN #2 further indicated the nurse aides are made aware of what residents require EBP during the beginning of shift report/huddle. LPN #2 further indicated in-servicing would have been completed but working the overnight shift can make it difficult to accomplish. LPN #3, the charge nurse for NA#3 indicated there may have been some talk about EBP directed the use of a gown should be worn for the residents on NA #3's assignment while providing care. The nursing supervisor RN #1 came to the nurse's station and indicated the orange dots meant EBP indicated to wear gown gloves and mask when caring for the residents requiring the precautions and indicated it is difficult for the 3rd shift staff to attend in-servicing and that may be why the staff may not be aware of what to do. An observation and interview on 11/20/2024 at 6:38 AM with charge nurse LPN #4 on the memory care unit indicated a gown, gloves, and mask need to be worn when providing care when there is an orange dot next to the name on the name plate outside the resident door. On 11/20/2024 at 6:40 AM and observation and interview with NA #4 indicated not having any residents on his/her assignment (the low number end of the hall to the double doors and the other NA has all the rooms beyond the double doors) that required the use of a gown and mask in addition to wearing gloves for care. b. An observation and interview with NA #5 on 11/20/2024 at 6:45 AM noted her/him coming out of a room with an orange dot has a mask and gloves no gown), NA # 5 removed gloves and use hand sanitizer after being asked the meaning of the orange dot. NA # 5 indicated the orange dot next to a resident's name was the type of precautions needed. NA #5 indicated Resident # 91 was totally dependent on care requiring incontinent care and indicated neither resident in the room required the use of a gown during care. On 11/20/2024 at 7:05 AM an interview with the Staff Development Coordinator, RN #8 indicated in-servicing of the staff regarding EBP was conducted by and the Infection Preventionist, RN #2 and would locate the information for review. On 11/20/2024 the facility provided a list of 57 residents located throughout the facility that required enhanced barrier precautions. On 11/22/2024 at 11:50 AM and interview and review of facility documents with RN #8 indicated NA #3 had in-service training regarding EBP on 4/12/2024 per the facility EBP in-servicing attendance sheet. However, NA #5 was not found to have attended EPB in-service training. RN #8 indicated the 2 nurse aids were spoken to regarding the occurrences. An interview on 11/22/2024 at 2:00PM with the Infection Preventionist RN # 2 indicated no signage is required outside the resident rooms as visitors are not expected to provide high risk direct care so visitors do not need to know about EBP but, in the event a visitor or family member indicated that they wanted to assist the resident with a high-risk care activity the visitor would be provided 1:1 training by RN # 2 or another staff member. The facility policy labeled Precautions to Prevent Infection, indicated in part enhanced barrier precautions is an approach of targeted gown and glove use during high contact resident care activities designed to reduce transmission of Staphylococcus Aureus and Multidrug Resistant Organisms (MDRO's) when contact precautions do not apply. The policy further indicated residents found at risk for EBP are those infected or colonized with a Center for Disease Control (CDC) novel or targeted MDRO when contact precautions do not apply and those with indwelling medical devices and or wounds even if not known to be infected or colonized with a MDRO. The policy indicated high risk resident care activities included dressing bathing, showering, transferring, proving hygiene, changing linens, briefs or assisting with toileting, device care or use of a device and wound care or dressing changes.

Based on clinical record reviews, facility documentation, review of policy and staff interviews 1 of 2 residents reviewed for limited range of motion (Resident #27), the facility failed to ensure physical therapy was made aware of a resident's change in condition regarding the comfort and fit of a prosthetic device for 1 of 1 resident who utilized a Foley catheter, the facility failed to document the diagnosis for the utilization of urinary catheter and for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to assess the resident's left lower hand bruise area according to facility practice and The findings included: 1. Resident #27's diagnoses Cerebrovascular Accident and amputations. The annual MDS assessment dated [DATE] identified Resident #27 was cognitively intact and used limb prosthetics. A care plan dated 10/9/2024 indicated Resident #27 had a history of amputation. Interventions included applying bilateral lower extremity prosthesis per physician's order and to assist resident as needed with application. Additional interventions included referring to physical therapy or occupational therapy for any changes in wearing tolerance, schedule, or skin integrity. A physical therapy note dated 10/11/2024 recommended continuing bilateral lower extremity prostheses per resident for dignity/appearance. On 11/19/2024 an observation in Resident #27's room identified signs over the head of the bed with instructions on applying prosthetic devices. The resident prosthetic devices were noted behind the entry door. Resident # 27 indicated to surveyor staff did not offer to put on her/his prosthetic devices and she/he did not recall when she/he had the prosthetic devices on last. A review of the NA care card instructed to assist with orthotic devices on with AM care and off when resident requests. A review of the NA flow sheets from 10/24/2024 through 11/19/2024 identified staff had applied the orthotic devices on four occasions: 10/25/2024, 11/3/2024, 11/17/2024, and 11/18/2024. Additionally, the NA Flowsheet indicated Resident #27 had refused his/her orthotic devices 17 times between 10/24/2024 and 11/19/2024. A review of nursing notes from 10/1/2024 to 11/19/2024 failed to identify the resident refusal of orthotic devices. On 11/20/2024 at 12:02 PM, an interview with NA # 9 identified Resident #27 had refused the application of bilateral prosthetic devices because the prostheses they were uncomfortable. NA#9 indicated that on 11/19/2024 she offered to help with the application of the prosthetic devices but that on 11/20/2024 she had overlooked offering to apply the prostheses. Additionally, NA #9 indicated she would document refusals in the electronically medical record but would sometimes also alert the nurse. On 11/20/2024 at 12:10 PM an interview with LPN #8 identified Resident #27 had been offered to wear the bilateral prosthetic devices in the past but the resident had refused to wear them because the prostheses were uncomfortable. LPN #8 indicated that the last time she/he had worn the prostheses was a couple of weeks ago and she/he did not know if the resident had refused or had been offered the prostheses with AM care on 11/20/2024. On 11/20/2024 at 1:15 PM, an interview with Physical Therapist ( PT #2) identified Resident #27's prostheses were not ordered for functionality but rather for appearance and dignity. A review of the medical record with PT #2 failed to identify an order for bilateral prostheses and the last order had been placed on 4/12/2024 and discontinued on 9/20/2024 when the resident was hospitalized . PT#2 further indicated that the physician's order should have been reactivated or reordered when the resident returned from the hospital. PT#2 identified that she was aware that Resident #27 did not want to wear the prostheses but indicated that she was not aware that the prostheses were uncomfortable. PT #2 indicated that if she had been aware Resident # 27's was refusing the prostheses due to discomfort, she would have evaluated the prostheses, and if the issue could not be resolved by the physical therapy department, then the vendor of the prostheses would have been notified for an evaluation. On 11/20/2024 at 2:00 PM, an attempt to reach NA#11 who documented application of Resident #27's prostheses on 11/17/2024 was unsuccessful. On 11/20/2024 at 2:05 PM an interview with NA#10 identified she documented the application of Resident #27's prostheses on 11/18/2024 in error because she do not recall applying Resident #27's prostheses on 11/18/2024. Furthermore, NA#10 indicated the resident sometimes refuses the prostheses because the device caused discomfort. Although requested, the facility did not have a policy for the application of prostheses. 2. Resident #92's diagnosis included Benign Prostatic Hypertrophy ( BPH). A physician's order dated 9/20/2024 indicated an indwelling urinary catheter was removed on 9/20/2024 at 11 :00 AM and if Resident #92 does not urinate in 6 hours to perform a bladder scan or straight catheterize. If the residual urine in the bladder after urinating on own Post Void Residual (PVR) is >350 cc to reinsert a urinary catheter and indicated the order was in effect for 3 days. The admission comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #92 was cognitively intact and used intermittent and indwelling catheterization for urinary elimination. A progress note dated 9/20/2024 at 10:36 PM indicated in part Resident #92 was admitted at 6:30 PM and had an indwelling urinary catheter removed at the hospital at 11:00 AM. The note further indicated physician's orders directed to continue the voiding trial for the next 3 days. The progress notes dated 9/21/2024 at 10:45 PM identified a post void residual of 482 cc urine was noted and straight catheterization was needed. The resident drained 500 cc urine after catherization. The note dated 9/23/24 at 6:48 AM indicated an indwelling catheter was inserted due to 500 cc was obtained and the order indicated to reinsert the indwelling catheter if residual was greater than 350 cc. A physician's order dated 9/23/2024 directed an indwelling urinary catheter size 16 French with 10 cc balloon to. be kept to straight drainage for urinary retention. On 11/22/24 09:56 AM during an interview and record review with the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS) and the Corporate Nurse RN #4 identified they could not find a diagnosis to support the use of an indwelling catheter in the electronic or paper chart or in the Physician's History Examination and physical, APRN notes or in the hospital transfer paperwork. The DNS did indicate a diagnosis to support the use should have been written. 3. Resident # 135 was admitted to the facility on [DATE]. The resident diagnoses included hypothyroidism, hyperlipidemia, hypertension, fall, osteoarthritis left hip and knee and Transient Ischemic Attack (TIA). The hospital discharge summary dated 9/15/24 identified a history of stroke, left side weakness and indicated the patient presented in Emergency Department (ED) for left leg pain. However, studies showed no fracture. Patients ambulate with a walker but have difficulty due to left foot pain. Additionally, noted a need rehabilitation. The patient presents with significant impairment of mobility due to recent fall. The patient will require short term stay rehabilitation secondary to unsafe discharge to home at this time. Patient reported that she/he fell 12 hours prior to ED admission secondary to tripping and falling. Patient noted with bruise on the dorsal aspect of left foot and reports worsening of swelling on lower aspect of leg, denies any injury to head or loss of consciousness, no headaches. X ray of left foot dated 9/13/24 noted bones are well mineralized and identified degenerative changes due to osteoarthritis. The care plan, dated 9/16/24 for Deficit in Self Care Function related to decreased mobility and osteoarthritis. Interventions included: assistance of 1 person for bathing /showers, assistance of 1 person for dressing and toileting. The admission Minimum Data Set ( MDS) assessment dated [DATE] identified the resident as cognitively intact and had no memory problems, upper and lower extremity impairment on one side, utilization of a cane and wheelchair for mobility. The physician's order dated 10/2/24 noted toileting assistance of 1 person. A review of the Reportable Event dated 10/12/24 identified the resident stated a nurse aide grabbed her/his hand and feet to transfer her/him to the wheelchair. The resident stated she/he noticed a bruise on her/his right hand the following day and noted no complaints of pain or discomfort identified. The facility investigation dated 10/12/24 identified the resident rang the call bell for assistance to use the bathroom. The resident stated that the NA helped her/her to a sitting position then the NA grabbed her/his hand and feet to transfer the resident to wheelchair. The resident stated s/he had no pain but noticed a bruise on her/his left lower hand the following day. A body audit conducted, and bruise was noted on the resident's left lower hand. Another small bruise was noted above the same hand. However, the resident stated the second bruise was old. The care plan updated to provide two staff members for care. The facility investigation identified the facility could not substantiate the abuse. The Health Status Note dated 10/15/2024 at 4:58 PM identified the resident stated a Nurse Aide (NA # 9) grabbed her/his hand and feet to transfer the resident to the wheelchair. Resident # 135 stated she/he had no pain but noticed a bruise on her/his left lower hand the following day. A body audit was conducted, and a bruise was noted on the resident's left lower hand and a smaller bruise was noted proximally. The Advanced Practice Registered Nurse (APRN) was updated, family was in house/at bedside and was aware. A review of the Reportable Event (RE) dated 10/15/24 identified the resident indicated a Nurse Aide (NA # 9) had helped her/him to bed around 7:00 PM during the 11-7 AM shift, the resident rang the call bell for assistance to use the bathroom. Resident# 135 stated NA # 9 helped her/him to a sitting position then NA # 9 grabbed her/his hand and feet to transfer the resident to the wheelchair. Resident # 135 denied any pain but was noted with a bruise on her/his left lower hand the following day. A body audit was conducted, and a bruise was noted on the resident's lower hand. Action taken for the incident two staff members for care. The NA #9 was placed on suspension pending further investigation. A review of the electronic clinical record for Resident # 135 from 9/13/24 to 10/12/24 identified no bruise on the resident's body during skin audits until 10/15/24. The clinical record also failed to identify the size of the bruise area on the resident's left lower arm. Interview with the ADNS and the DNS on 11-21-24 at 10:40 AM identified the incident Identified over the weekend of 10/12/24 identified the resident stated on the 3-11 PM the incident occurred. We came on Tuesday 10/15/24 and it was reported to us that the physical therapist had a session with the resident and saw the area. The therapist asked what happened and that is when the resident told therapist what happened. The rehabilitation therapist then reported the incident to the nurse. On 10/12/24 the resident required assistance with care and had to wait 45 minutes. The resident was noted to be helped to bed roughly causing bruising. Interview with RN # 3 ( supervisor ) on 11/21/24 at 2:41 PM identified she was made aware on the 3-11 PM shift on 10/14/24 by the nurse on duty ( LPN # 13) that a family member not part of patient care was upset about the care the Resident # 135 received on the 11- 7 AM shift. RN # 3 indicated the family member had left therefore she did not speak to the family member. RN # 3 further indicated LPN # 13 or NA # 9 did not mention anything about a bruise but she did say maybe NA # 9 should not take care of the resident. RN #3 indicated she reported the concern the ADNS who was the Acting DNS on 10/14/24 who indicated she ( ADNS) would follow up with NA # 9. RN # 3 indicated because she was not made aware of any bruise she did not assess the resident after family member concern after care. The ADNS on 11/21/24 at 3:30 PM identified the facility practice is to assess any bruise on resident for size, color and pain and document in the clinical record. 46046 48880

Based on observations, review of facility policy and staff interviews, the facility failed to ensure staff followed the hot water temperature monitoring requirements by checking and logging the mixing valve daily, testing to be done at different times throughout the month at varied testing locations and weekly calibration of the tester and recording the results to ensure a safe environment. The findings include: An observation on 11/18/24 at 10:40 AM in the memory care unit Resident #46's bathroom faucet hot water temperature was 124.4 degrees Fahrenheit (F.), (Centers for Medicare and Medicaid's acceptable temperature was below 120 degrees F.) An observation on 11/18/2024 at 10:55 AM identified Resident #95's bathroom faucet (at the opposite end of the unit) the hot water temperature was 129.4 degrees F. (10.4 degrees above acceptable hot water temperature). On 11/18/2024 at 11:10 AM Charge Nurse LPN #7 notified of hot water temperatures that were found to be elevated and maintenance was notified to come to the unit. On 11/18/2024 at 11:25 AM an observation and interview with Maintenance Worker #1 who was made aware of the hot water temperature findings and re-temperatures with the facility thermometer were made in Resident #46 and #95's bathroom faucets were 124.1 degrees F. and 127 degrees F which were noted to be (5.1- and 8.0-degrees F. above acceptable hot water temperatures). Maintenance Worker #1 indicated the hot water temperature results were too high and communicated the temperatures to Maintenance Worker #2 who indicated he/she would turn down the mixing valve so the temperature would not climb any higher. An interview with the Director of Maintenance on 11/18/24 at 11:35 AM upon receiving an update of the excessive hot water temperature status by the surveyor, s/he radioed Maintenance Workers #1 and #2 to request the water temperature logs. When asked how the residents on the memory care unit would be kept residents safe from using excessively hot water, s/he indicated the system would be flushed to cool temperatures down and she/he would turn off the hot water to the unit until water temperatures were safe. The Director of Maintenance agreed to supply the water temperature logs, the facility water temperature monitoring policy and by 3:00 PM a written plan of how the facility would monitor the situation over the next 24 hours. An interview on 11/18/24 at 11:40 AM with the Administrator informing him/her of the elevated hot water temperature and a request for a written plan of the process for resolving the issue. A plan on how the facility would be keep residents safe from the hot water was requested along with the facility policy and the temperature logs. The Administrator called the Maintenance Director to obtain the logs. On 11/18/2024 at 2:00 PM and interview and facility document review with the Director of Maintenance indicated the water temperatures were taken daily in 3 resident room locations and found to be within acceptable range including 11/18/2024. The Director of Maintenance further indicated the time temperatures were taken is not documented on the log, but the temp had been taken early AM upon start of the shift. The Director of Maintenance further indicated the time of day the testing was done was not varied as it should have been. The Director of Maintenance indicated the vendor replaced the hot water valve and she/he would provide updated temperature monitoring on 11/19/2024. On 11/18/2024 at 3:00-3:15 PM an interview and facility document review with the Administrator identified the facility policy the Maintenance Director provided to him/her indicated the prior owner did not have a policy for monitoring of hot water temperature logs. Review of the facility policy with the Administrator indicated the Director of Maintenance did not have evidence of checking and logging the mixing valve daily, evidence testing was done at different times throughout the month at varied testing locations (ex. including shower rooms) and no weekly calibration of the tester with documentation of the results. The Administrator further provided the plan for monitoring the hot water temperatures over the next 24 hours along with training of the nursing staff regarding their role in providing resident care with no available hot water and monitoring the hot water temperatures when the maintenance personnel was not in the building overnight. On 11/19/24 at 2:14 PM an interview and facility document review with the Director of Maintenance identified current hourly hot water temperatures were within acceptable limits since the replacement of the hot water valve. The Director of Maintenance further indicated that a final log would be provided on 11/20/2022 once monitoring is completed. The facility policy labeled Engineering Management : Hot Water Temperature Requirements indicated in part; daily hot water temperatures would be taken and recorded in 3 locations throughout the building and recorded, the temperature readings would be taken with a calibrated tester and recorded on the daily water temperature log, the mixing valve gauge would be checked and logged daily, time of the tests were to be at different hours throughout the month, the tester wil be calibrated weekly and recorded as to manufacture's specifications and sample rooms would include shower rooms, utility rooms kitchenettes and other spaces as well as resident's rooms. The policy further indicated any reading over the state's maximum temperature level requires the hot water to be shut off immediately with notification to nursing the administrator and temperature readings taken on an hourly basis for 24 hours through the following day after correction/repairs are completed.

Based on clinical record review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident # 135 was admitted to the facility on [DATE]. The resident diagnoses included hypothyroidism, hyperlipidemia, hypertension, fall, osteoarthritis left hip and knee and Transient Ischemic Attack (TIA). The hospital Discharge summary dated [DATE] identified a history of stroke, left side weakness and indicated the patient presented in Emergency Department (ED) for left leg pain. However, studies showed no fracture. Patients ambulate with a walker but have difficulty due to left foot pain. Additionally, noted a need rehabilitation. The patient presents with significant impairment of mobility due to recent fall. The patient will require short term stay rehabilitation secondary to unsafe discharge to home at this time. Patient reported that she/he fell 12 hours prior to ED admission secondary to tripping and falling. Patient noted with bruise on the dorsal aspect of left foot and reports worsening of swelling on lower aspect of leg, denies any injury to head or loss of consciousness, no headaches. X ray of left foot dated 9/13/24 noted bones are well mineralized and identified degenerative changes due to osteoarthritis. The care plan, dated 9/16/24 for Deficit in Self Care Function related to decreased mobility and osteoarthritis. Interventions included: assistance of 1 person for bathing /showers, assistance of 1 person for dressing and toileting. The admission Minimum Data Set ( MDS) assessment dated [DATE] identified the resident as cognitively intact and had no memory problems, upper and lower extremity impairment on one side, utilization of a cane and wheelchair for mobility. The physician's order dated 10/2/24 noted toileting assistance of 1 person. A review of the Reportable Event dated 10/12/24 identified the resident stated a nurse aide grabbed her/his hand and feet to transfer her/him to the wheelchair. The resident stated she/he noticed a bruise on her/his right hand the following day and noted no complaints of pain or discomfort identified. The facility investigation dated 10/12/24 identified the resident rang the call bell for assistance to use the bathroom. The resident stated that the NA helped her/her to a sitting position then the NA grabbed her/his hand and feet to transfer the resident to wheelchair. The resident stated s/he had no pain but noticed a bruise on her/his left lower hand the following day. A body audit conducted, and bruise was noted on the resident's left lower hand. Another small bruise was noted above the same hand. However, the resident stated the second bruise was old. The care plan updated to provide two staff members for care. The facility investigation identified the facility could not substantiate the abuse. The Health Status Note dated 10/15/2024 at 4:58 PM identified the resident stated a Nurse Aide (NA # 9) grabbed her/his hand and feet to transfer the resident to the wheelchair. Resident # 135 stated she/he had no pain but noticed a bruise on her/his left lower hand the following day. A body audit was conducted, and a bruise was noted on the resident's left lower hand and a smaller bruise was noted proximally. The Advanced Practice Registered Nurse (APRN) was updated, family was in house/at bedside and was aware. A review of the Reportable Event (RE) dated 10/15/24 identified the resident indicated a Nurse Aide (NA # 9) had helped her/him to bed around 7:00 PM during the 11-7 AM shift, the resident rang the call bell for assistance to use the bathroom. Resident# 135 stated NA # 9 helped her/him to a sitting position then NA # 9 grabbed her/his hand and feet to transfer the resident to the wheelchair. Resident # 135 denied any pain but was noted with a bruise on her/his left lower hand the following day. A body audit was conducted, and a bruise was noted on the resident's lower hand. Action taken for the incident two staff members for care. The NA #9 was placed on suspension pending further investigation. A review of the electronic clinical record for Resident # 135 from 9/13/24 to 10/12/24 identified no bruise on the resident's body during skin audits until 10/15/24. Interview with Resident # 135 on 11/20/24 at 10:45 AM identified s/he called the front desk to ask for the nurse aide to come and help her/him. The nurse aide ( NA # 9) came to the room angry and said to me this is my break you have no right calling me on my break for anything. My roommate was asked to give a statement, but she/he stated she/he did not know what happened, I think she did not want to get involved that is ok I understand. The nurse aide ( NA # 9) helped me to get into bed and I noticed black and blue marks on my left arm. After the nurse aide left the next morning, I noticed my left arm was black and blue, but the arm has since healed. I never saw the nurse aide ( NA # 9) after the incident, I believe she/he was an agency nurse aide. Interview with the ADNS and the DNS on 11-21-24 at 10:40 AM identified the incident Identified over the weekend of 10/12/24 identified the resident stated on the 3-11 PM the incident occurred. We came on Tuesday 10/15/24 and it was reported to us that the physical therapist had a session with the resident and saw the area. The therapist asked what happened and that is when the resident told therapist what happened. The rehabilitation therapist then reported the incident to the nurse. On 10/12/24 the resident required assistance with care and had to wait 45 minutes. The resident was noted to be helped to bed roughly causing bruising. The resident did not report the incident on Sunday 10/13/24 but reported the incident following day. The resident stated she/he was fearful of retaliation that is why she/he did not report the incident over the weekend. Interview with the Licensed Practical Nurse (LPN # 13) on 11-21-24 at 11:45 AM identified she was called to the room by the physical therapist who indicated Resident # 135 state on 10/12/24 she/he was in the wheelchair 10:00 AM to 6:00 PM and no one answered her/his call bell, so she/he called the front desk for assistance to get back into bed. Resident # 135 provided evidence of the telephone call on her/his cellular. The resident indicated while being rolled over on 10/12/24 during being put to bed, she/he noticed a pink area on the left forearm but did not call the nurse. Interview on 11-21-24 with NA # 9 in presence of Corporate Nurse Registered Nurse ( RN# 4) at 2:12 PM identified she/he passed out dietary trays and then picked them up. NA # 9 went on her break at 6:30 PM and came back at 7:00 PM because the nurse told her/him Resident # 135 wanted to go to bed. NA # 9 assisted the resident to transfer from the wheelchair to the bed by pulling the resident by the back of pants to assist with transfer because she/he did not have a gait belt on her/him. NA # 9 indicated Resident # 135 was heated because she/he had been in the wheelchair for 10 hours and wanted to go to bed. NA #9 further indicated she told Resident # 135 she has a right to have a break and denied handling the resident roughly. NA # 9 indicated the gait belt was at the nurse's station and she did not want to leave to get the gait belt because the resident was already mad, and she did not want to make her upset again. Interview with the Certified Occupation Therapist Assistant (COTA) on 11-21-24 at 4:30 PM and 4:45 PM identified staff often confuse him with the physical therapist. When he saw Resident # 135 on Monday 10/14/24 the resident had a bruise on the arm. COTA asked Resident # 135 what happened and the resident indicated the bruise happened when the nurse aide put her/him to bed. COTA indicated the residents stated she/he did not have the bruise before and he believed the resident because she/he is truthful. The facility Abuse Policy and Procedure dated 12/2023 notes in part abuse means the wilful infliction of injury , unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect means failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #194) reviewed for abuse, the facility failed to implement policies that ensured allegation(s) of feeling unsafe and being fearful of retaliation were reported. The findings include: Resident #194's diagnoses included acute embolism of the deep veins on the left lower extremity and anxiety disorder. The Nursing Admission assessment dated [DATE] identified Resident #194 was cognitively intact and had no activity of daily living/mobility impairments. The Resident Care Plan dated 11/12/24 identified Resident #194 had a history of depression and with interventions that directed administering medications as ordered and to monitor/report signs of depression, repetitive anxiousness/tearfulness. a. Physician's orders dated 11/13/24 directed Ativan 0.5 MG every 12 hours as needed for anxiety. The Medication Administration Record (MAR) dated 11/16/24 identified that Ativan 0.5 Milligrams (MG) was administered to Resident #194 at 8:28 PM by Licensed Practical Nurse, LPN #5. An interview with Resident #194 on 11/18/24 at 11:40 AM identified on 11/16/24 during the 3:00 PM -11: 00 PM shift, her/his assigned nurse, LPN #5 attempted to administer her/his prescription Ativan earlier than preferred. Instead of removing the medication, the medication was instead left at the bedside. After returning from the bathroom, the medication was no longer at the bedside table where it was last observed. Resident #194 requested the medication a second time and received the medication 45 minutes after the request. LPN #5, according to Resident #194 stated, This will not happen again. The incident left Resident #194 feeling threatened that LPN #5 may poison her/him in retaliation of not believing her/him about the unaccounted medication. Resident #194 further identified she/he reported the incident to Nurse Aide, NA #7 who gave assurances she would not let anything bad happen to her/him. b. Physician's orders dated 11/13/24 directed Eliquis (2) tablets or 10 MG twice daily for deep vein thrombosis (DVT) until 11/16/24. The physician's orders dated 11/17/24 directed Eliquis (1) tablet or 5 Mg twice daily for DVT. The Medication Administration Record (MAR) dated 11/16/24 identified Eliquis 10 Mg was last administered at 8:00 PM. The MAR dated 11/17/24 identified Eliquis 5 MG was started at 8:00 AM. An interview with Resident #194 on 11/18/24 at 11:40 AM identified on 11/17/24 during the 3:00 PM - 11:00 PM shift, LPN #5 administered and a new dose of anticoagulant medication. Resident #194 questioned the dose as s/he was concerned the dose was more than what was prescribed. Resident #194 felt threatened after alleging LPN #5 told her/him that unless Resident #194 wanted a blood clot, s/he would need to take the medication. The second incident left Resident #194 feeling threatened by LPN #5 and fearful of a blood clot, so s/he took the medication. Resident #194 reported the second incident to NA #7 who told him/her the incident should not have happened. An interview with NA #7 on 11/21/24 at 11:36 AM identified she was the assigned Nurse Aide for Resident #194 on 11/16/24 and 11/17/24 during the 3:00 PM to 11:00 PM shift. NA#5 identified Resident #194, was tearful and upset and did report to her that s/he was fearful for her/his own safety, fearful of retaliation and fearful of being poisoned after requesting an additional dose of Ativan when the dose at her/his bedside was unaccounted for and for questioning her/his dose of the blood thinner adding LPN #5 could be harsh. NA #7 did report to LPN #5 that Resident #194 was upset but was unable to recall if she had reported Resident #194 feeling unsafe and fearful of retaliation. NA #7 further identified that anything that was reported was done at the nurse station and in the presence of the Nursing Supervisor, RN #5 who had an office nearby, so therefore did not report directly to her. An interview with the Director of Nursing, DNS on 11/21/24 11:45 AM identified she should be notified of any allegations of mistreatment and confirmed she was not notified at any time over the weekend of any staff to resident allegations of mistreatment pertaining to Resident #194. The DNS identified she would expect staff to follow policies for a resident reported allegation of mistreatment. An interview with Registered Nurse (RN #5) on 11/21/24 at 12:25 PM identified she was the assigned nursing supervisor on 11/16/24 and 11/17/24 during the 3:00 PM to 11:00 PM shift. RN #5 identified that she was made aware of a missing dose of Ativan presumed to have dropped on the floor and cosigned a second dose to be administered to Resident #194. RN #5 further identified she was not notified at any time over the weekend Resident #194 was fearful for her/his safety and fearful of retaliation. A review of the facility policy for Abuse dated 12/2023 directed actions to take when any allegation of abuse, mistreatment, neglect or misappropriation of resident property is observed, reported or suspected by any employee. This would include immediately separating the resident from the alleged abused and notifying the administrative staff or nursing supervisor on duty of the alleged abuse.

Based on review of the clinical record, facility documentation, observations, and interviews for one of three sampled residents (Resident #3) reviewed for accidents, the facility failed to transport a dependent resident in a manner to prevent an accident with injury and/or ensure an exit door alarm was audible when opened to provide and/or electrical equipment was received preventive maintenance to ensure a hazard free environment. The findings include: Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident with moderately impaired cognition and was dependent on staff for activities of daily living including transfers and locomotion on and off the units. The Resident Care Plan dated 10/25/16 identified a self-care deficit, including locomotion, with interventions including to provide the amount of assistance/supervision that is needed. The November 2016 physician orders [REDACTED]. The 30 day custom wheel chair review dated 11/7/16 identified the resident used a CWC with headrest, clasp seat belt, full lap tray and non-elevating foot boxes to prevent sliding and to protect the feet. The Reportable Event dated 11/16/16 identified NA #1 reported that while he/she was pushing Resident #3 in the CWC, Resident #3's left foot was bumped into the side of the door frame. A written statement from NA #1 dated 11/16/16 identified Resident #3 was being brought back to his/her room and NA #1 did not realize the resident had his/her left foot over the side of the foot box leg rest. When NA#1 pushed the CWC through the threshold of the bedroom, he/she heard a cracking noise and the resident was observed to wince in pain. The facility investigation dated 11/17/16 identified NA #1 was aware the resident had the tendency to throw his/her legs over the foot box leg rest. NA #1 indicated he/she could not see the resident's leg when transporting through the doorway. The Mobilex Radiology Report dated 11/16/16 identified an oblique fracture at the distal shaft of the tibia and an oblique fracture at the distal metaphysis of the fibula. The pain evaluation following the incident dated 11/16/16 identified the resident was experiencing moderate pain. The nurse's note dated 11/16/16 identified the resident was transferred to an acute care hospital for an evaluation. Subsequent nurse's note dated 11/17/16 identified the resident returned to the facility with a [DIAGNOSES REDACTED]. The physical therapy note dated 1/30/17 identified the facility met with the customized wheelchair vendor to discuss possible modifications to the custom wheelchair. The physical therapy note dated 2/2/17 identified modifications for leg rests were in process, but will take several weeks. The note indicated positioning in the custom wheelchair was discussed with the nursing assistant and a foam pillow under legs was appropriate until modifications were completed. The note further identified the resident required frequent checks/repositioning to keep his/her legs inside of the foot boxes and comfortably supported. The physical therapy note dated 2/15/17 identified the facility met with the wheelchair vendor to discuss options for lower body positioning in the custom wheelchair. The note indicated the decision was made to elevate the foot boxes for elevation and protection. Interview with the Director of Rehabilitation on 7/11/17 at 11:48 AM identified the resident had foot box leg rests on the CWC at the time of the incident and was occasionally observed to swing his/her legs over the side of the foot box leg rest. Director of Rehab further identified that subsequent to the incident modifications were made to the foot box leg rest to make it deeper. Interview with the Director of Nurses on 7/12/17 at 11:05 AM identified that NA #1 should have slowed down and visualized the resident's feet/legs to ensure they were inside the foot box as he/she was pushing the wheelchair through the doorway. The facility's Wheelchair Policy and Procedure identified that leg rests must always be used when transported by others and feet should be placed on the foot rest. Multiple attempts to contact NA #1 were unsuccessful. 2. Resident #131's [DIAGNOSES REDACTED]. The Resident Care Plan (RCP) dated 6/2/17 identified Resident #131 had an activities of daily living deficit related to surgical repair of a tibia fracture. Interventions directed to provide the assistance of one person for activities of daily living, to assist the resident with gathering and setting up clothing, toiletries and equipment, to encourage self-performance of tasks and to provide assistance as needed. The admission MDS assessment dated [DATE] identified intact cognition and extensive assistance of one person for personal hygiene. Observation on 7/10/17 at 11:30 AM identified a curling iron on the counter alongside the sink in Resident #131's bathroom. Interview with NA #2 on 7/10/17 at 11:40 AM identified that h/she saw the curling iron in Resident #131's bathroom earlier that morning however, h/she did not check to see if the curling iron had a sticker on it indicating it had been inspected by the maintenance department prior use in the facility to ensure a hazard free environment. 3. Initial tour of the 1400 hallway on 7/10/17 at 10:10 AM identified a door (door # 1) at the end of the 1400 hallway without the benefit of an alarm. Door # 1 allowed access to a connector of the 1400 hallway and memory care unit currently under construction. Further observation of the connector between the 1400 corridor and the memory care unit identified a door (door # 2) that leads to a stairwell. When the door was opened on 7/10/17 at 10:11AM an audible alarm was triggered. Direct observation of the stairwell and 1400 hallway, while the alarm was sounding failed to reflect any staff members responded to the door alarm. After three minutes of sounding, the door alarm silenced itself at 10:14 AM. Interview with RN # 2 on 7/10/17 at 10:15 AM identified that the resident areas of the first floor are not locked and that some of the residents from the first floor have dementia and/or psychiatric diagnoses. RN # 2 identified that when door is opened an alarm triggers. RN # 2 did not know if the alarm sounded at the nurse's station, how to silence the alarm and/or if the alarm silenced and reset itself. RN # 2 identified that when the door in the 1400 hallway that leads to the same stairwell is opened, an alarm sounds at the door and at the nurses' station. Observation on 7/10/17 at 3:45 PM identified the door alarm with the RN #1 identified that the alarm silenced and reset itself after three minutes. Additionally, RN #1 identified that when the door alarm was sounding it was not able to be heard at the nurse's station and/or in the middle of the 1400 hallway. Interview on 7/10/17 at 3:50 PM with the Administrator identified he/she was not aware that the door alarm did not alarm at the nurse station of the first floor and/or that the alarm reset itself after three minutes. Interview with the Director of Maintenance on 7/11/17 at 10:30 AM identified that the door alarm has been in place since 2008, has never had the ability to alarm at the nurse's station and has always silenced and reset itself after three minutes. Further interview with the Director of Maintenance identified that subsequent to surveyor inquiry, the facility was in the process of installing an alarm on door with a keypad that will alarm at the door and at the first floor nurses station. Once the alarm is completed all staff will be educated on the new alarm.

Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #164) who required a mechanical lift for transfers out of bed, the facility failed to ensure provide appropriate supervision of the resident during a transfer to prevent an injury. The findings include: Resident #164's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #164 had severe cognitive impairments for daily decision making, exhibited no behavioral symptoms, required total two person assistance with transfers in and/or out the bed and/or chair, was non-ambulatory, and balance during surface to surface transfer, transfer between the bed and chair or wheelchair, the resident was not steady and only able to stabilize with staff assistance. The resident care plan dated 7/14/15 identified a self-care deficit related to the dementia. Interventions directed total assist with all activities of daily living. The nurse's note dated 9/16/15 at 4:30 PM identified Resident #164 was hit in the face above the right eyebrow with the maxi-lift, a mechanical lift, during a transfer and sustained a three (3) centimeter open cut to the area. Subsequent to physician and family notification, Resident #164 was transferred to the Emergency Department (ED) for an evaluation and treatment. The resident care plan dated 9/16/15 identified Resident #164 had sustained a 1.3 centimeter (cm) by 0.3 cm laceration above the right brow that required three (3) sutures. A written statement by NA #1 dated 9/16/15 identified that she and another nurse aide, NA #2 transferred Resident #164 out of bed into the wheelchair via the maxi-lift. NA #1 stated during the lift NA #2 let the weight of the maxi-lift go, Resident #164's head and body fell back and the resident hit his/her head on the lift. A written statement by NA #2 dated 9/16/15 identified that she was having difficulty with the lift and the resident's head accidentally hit the bar ending with a cut on the eyebrow. Interview with the a 3-11 PM nurse aide, NA #2 on 8/24/16 at 2:12 PM identified that while transferring the resident from the bed to the chair with the help of another aide, she turned the resident too fast, resulting in the bar of the lift striking the resident at the right brow line. NA #2 stated that she had utilized the maxi-lift prior to the incident and after the incident was in-serviced regarding the proper use of mechanical lifts. Review of the facility policy for use of the Mechanical Lift directed that once the resident is in the sling, hooked to the lift bar, the lift should be moved away from the bed in such a manner that the resident faces the aide (the resident should not be pulled backwards).

Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Residents #1 and #2) who were identified with a change of condition, the facility failed to notify the physician at the times when the change in condition was first identified. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive two person assistance with toileting, was always continent of bowel had occasional mild pain. The Resident Care Plan dated 12/18/16 identified an alteration in bowel elimination related to a history of ileus. Interventions directed to encourage fluids, monitor for symptoms of dehydration, monitor bowel movements, monitor for signs and symptoms (cramping, abdominal pain, nausea, vomiting, diarrhea, abdominal distention) of ileus and report to the findings to the physician. The 3-11 PM, Licensed Practical Nurse (LPN), nurse's note dated 3/9/16 written at 10:10 PM identified that at 5:00 PM Resident #1 complained of stomach pain. An abdominal assessment was completed and noted the bowel sounds sluggish in all four (4) quadrants, the abdomen was tender to touch, distended and the resident vomited twice thin clear liquid with a foul odor. The note identified an enema was given, the resident had a small watery, loose, brown stool and the Nursing Supervisor was notified immediately. The 11-7 AM LPN nurse's note dated 3/10/16 identified at the start of the shift Resident #1 complained of nausea and the resident's the color was pale. At 1:45 AM the resident vomited a moderate amount of foul smelling yellow liquid, the abdomen was tender to touch, distended and firm on the right side and the bowel sounds were hypoactive in all four (4) quadrants. At 6:00 AM the resident refused medications and fluids stating his/her stomach was too upset to take anything. The Nursing Supervisor was updated. Review of the nurse's notes from 3/9/16 at 5:00 PM through 3/10/16 at 7:10 AM failed to reflect documentation the physician had been notified of Resident #1's change in condition until 7:10 AM on 3/10/16. The nurse's note dated 3/10/16 at 7:10 AM identified Resident #1 complained of abdominal pain, hypoactive bowel sounds were noted, had vomited clear brown liquid, was heard yelling his/her abdomen hurts and requested to go the hospital. The physician was notified, Resident #1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. Interview with the 3-11 PM charge nurse, LPN #1, on 4/12/16 at 1:25 PM identified Resident #1 complained of stomach pain and not feeling well. LPN #1 stated she reviewed the medication kardex, saw the resident was given a suppository earlier, asked the 3-11 PM Supervisor, Registered Nurse (RN) #1, what she should do and was directed to administer an enema. LPN #1 identified RN #1 came into the room with her and assessed the resident at that time. LPN #1 stated that after the enema was given the resident vomited a couple of times. LPN #1 identified that although she updated RN #1, she did not see RN #1 go back to re-assess Resident #1. Interview with the 3-11 PM Supervisor, RN #1, on 4/11/16 at 11:35 AM identified she was doing rounds when LPN #1 reported Resident #1 did not feel well. RN #1 stated she went to assess the resident and noted the bowel sounds were sluggish and the abdomen was tender to touch. RN #1 identified she did not go back and reassess Resident #1 nor did she notify the physician with the change in condition. Interview with the 11-7 AM charge nurse, LPN #2, on 4/12/16 at 12:40 PM identified at approximately 2:00 AM Resident #1 vomited. LPN #2 stated she assessed the resident and noted the bowel sounds were hypoactive, the abdomen was distended the right side more than the left, and the resident complained of not feeling well. LPN #2 identified she reported her findings to the 11-7 AM Supervisor, RN #2, who told her to monitor the resident. LPN #2 stated that when she went to administer medications at 6:00 AM the resident refused. LPN #2 identified she reported this to RN #2. LPN #2 stated that around 7:00 AM a nurse aide reported to her the resident was asking to go to the hospital for stomach pain. LPN #2 stated when she called the other floors to update RN #2, the DON answered who came up to assess the resident. Interview with the 11-7 AM Supervisor, RN #2, on 4/11/16 at 1:45 PM identified LPN #2 notified him of the vomiting and distended abdomen. RN #2 stated that when he went to assess the resident, Resident #1 seemed settled in bed and he could not recall if he assessed the resident. RN #2 stated that he did not notify the physician because he thought RN #1 did on the previous shift. Interview with the Director of Nursing (DON) on 4/11/16 at 11:15 AM identified that she was notified of Resident #1 wanting to go to the hospital and she went and assessed the resident. The DON stated the resident complained of abdominal pain, had hypoactive bowel sounds, vomited clear brown liquid, was yelling that his/her abdomen hurts and wanted to go to the hospital. The DON stated she notified the physician at that time and the resident was transferred to the hospital. The DON identified that RN #1 and RN #2 should have notified the physician when the resident was noted to have a change of condition. Facility Policy and Procedure for Significant Change in Condition identified staff will communicate with the physician when the resident has a change in condition and documented in the clinical record. 2. Resident #2's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had moderate cognitive impairments, adequate vision and utilized corrective lenses, required extensive to total assistance with activities of daily living, had no recent falls and no history of [MEDICAL CONDITIONS] and/or [MEDICATION NAME] degeneration. The 3-11 PM, Licensed Practical Nurse (LPN), nurse's note dated 3/1/16 written at 10:55 PM identified at 8:00 PM a nurse aide reported to the charge nurse Resident #2 was seeing sparkles and spots in the left eye. A neurological assessment completed was noted to be within normal limits and the RN Supervisor was updated. The note identified at approximately 9:30 PM Resident #2 stated seeing lines across his/her left eye. When the resident's right eye was covered, Resident #2 was unable to see the fingers and/or a cup being held up from the left eye. The note indicated that there was no response from the left eye and the left hand grasp was weaker than the right. The Registered Nurse (RN) Supervisor was updated and the resident was sent to the hospital. The hospital history and physical dated 3/1/16 identified the chief complaint was left eye [MEDICAL CONDITION] with slurring speech and left hand weakness. The ophthalmology consultation dated 3/2/16 confirmed left eye retinal artery occlusion. Interview with LPN #3 on 4/12/16 at 11:50 AM identified a nurse aide reported to him that Resident #2 was seeing sparkles and spots. LPN #3 stated he assessed the resident and reported his findings to the 3-11 PM Nursing Supervisor, RN #3. LPN #3 stated he went back later to assess the resident and at that time the resident could see nothing out of the left eye. LPN #3 stated he immediately told the Nursing Supervisor, RN #3, and another nurse, RN #4, went in to assess the resident. Interview with RN #3 on 4/12/16 at 12:05 PM identified LPN #3 did report to her that Resident #2 was seeing spots and sparkles. RN #3 stated she did not assess the resident and/or notify the physician at that time. RN #3 indicated that when LPN #3 came to her later in the shift to report the resident could not see out of his/her left eye she was in the middle of another emergency with another resident and asked the Paramedic and RN #4 to assess Resident #2. Interview with RN #4 on 4/12/16 at 12:10 PM identified that RN #3 asked her to assess Resident #2. RN #4 stated that she completed a neurological assessment and the resident was unable to see out of the left eye. RN #4 stated she reported her findings to RN #3. Interview with the Director of Nursing (DON) on 4/12/16 at 12:55 PM identified that the RN should have assessed the resident and notified the physician when the resident first complained of the spots and sparkles. Facility Policy and Procedure for Significant Change in Condition identified staff will communicate with the physician when the resident has a change in condition and documented in the clinical record.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Residents #1) who were identified with a change of condition, the facility failed to implement interventions in accordance with the plan of care when the change in condition was identified. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive two person assistance with toileting, was always continent of bowel had occasional mild pain. The Resident Care Plan dated 12/18/16 identified an alteration in bowel elimination related to a history of ileus. Interventions directed to encourage fluids, monitor for symptoms of dehydration, monitor bowel movements check for loose stools and/or constipation every shift, monitor for signs and symptoms (cramping, abdominal pain, nausea, vomiting, diarrhea, abdominal distention) of ileus and report to the findings to the physician. The 3-11 PM, Licensed Practical Nurse (LPN), nurse's note dated 3/9/16 written at 10:10 PM identified at 5:00 PM Resident #1 complained of stomach pain. An abdominal assessment was completed and noted the bowel sounds sluggish in all four (4) quadrants, the abdomen was tender to touch, distended and the resident vomited twice thin clear liquid with a foul odor. The note identified an enema was administered prior to the Nursing Supervisor assessing the resident and/or physician notification. The 11-7 AM LPN nurse's note dated 3/10/16 identified at the start of the shift Resident #1 complained of nausea and the color was pale. At 1:45 AM vomited a moderate amount of foul smelling yellow liquid, the abdomen was tender to touch, distended and firm on the right side and the bowel sounds were hypoactive in all four (4) quadrants. At 6:00 AM the resident refused medications and fluids stating his/her stomach was too upset to take anything. The Nursing Supervisor was updated. Review of the nurse's notes from 3/9/16 at 5:00 PM through 3/10/16 at 7:10 AM failed to reflect documentation the physician had been notified of Resident #1's change in condition until 7:10 AM on 3/10/16 at which time Resident #1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. Interview with the 3-11 PM charge nurse, LPN #1, on 4/12/16 at 1:25 PM identified Resident #1 complained of stomach pain and not feeling well. LPN #1 stated she reviewed the medication kardex, saw the resident was given a suppository earlier, asked the 3-11 PM Supervisor, Registered Nurse (RN) #1, what she should do and was directed to administer an enema. LPN #1 identified RN #1 came into the room with her and assessed the resident at that time. LPN #1 stated that after the enema was given the resident vomited a couple of times. LPN #1 identified that although she updated RN #1, she did not see RN #1 go back to re-assess Resident #1. Interview with the 3-11 PM Supervisor, RN #1, on 4/11/16 at 11:35 AM identified she was doing rounds when LPN #1 reported Resident #1 did not feel well. RN #1 stated she went to assess the resident and noted the bowel sounds were sluggish and the abdomen was tender to touch. RN #1 identified she did not go back and reassess Resident #1 nor did she notify the physician with the change in condition. Interview with the 11-7 AM charge nurse, LPN #2, on 4/12/16 at 12:40 PM identified she assessed the resident and noted the bowel sounds were hypoactive, the abdomen was distended the right side more than the left, and she reported her findings to the 11-7 AM Supervisor, RN #2, who told her to monitor the resident. LPN #2 stated that when she went to administer medications at 6:00 AM the resident refused. LPN #2 identified she reported this to RN #2. LPN #2 stated when she called the other floors to update RN #2, the DON answered who came up to assess the resident. Interview with the 11-7 AM Supervisor, RN #2, on 4/11/16 at 1:45 PM identified LPN #2 notified him of the vomiting and distended abdomen. RN #2 stated that when he went to assess the resident, Resident #1 seemed settled in bed and he could not recall if he assessed the resident. RN #2 stated that he did not notify the physician because he thought RN #1 did on the previous shift. Interview with the Director of Nursing (DON) on 4/11/16 at 11:15 AM identified that she was notified of Resident #1 wanting to go to the hospital, she went and assessed the resident. The DON stated the resident complained of abdominal pain, had hypoactive bowel sounds, vomited clear brown liquid, was yelling that his/her abdomen hurts and wanted to go to the hospital. The DON stated she notified the physician at that time, Resident #1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The DON identified that RN #1 and RN #2 should have notified the physician when the resident was noted to have a change of condition.

Based on clinical record review, review of facility documentation, and interviews for one of three sampled residents (Resident #129) who had a decline in oral intake, the facility failed to conduct dehydration assessments and/or notify the physician when the resident's fluid intake failed to meet the estimated fluid needs. The findings include: Resident #129's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #129 had severe cognitive impairments, was totally dependent on staff for eating, and had no history of dehydration. The resident care plan dated 5/14/12 and revised through 7/30/12 identified that the resident had a potential for an alternation in nutrition with a goal no signs or symptoms of dehydration. Interventions directed to assess for sign and symptoms of dehydration including poor skin turgor, dry mouth/mucous membranes, and to encourage additional fluids with medications and when offering nourishments. The dietitian's nutritional assessment dated [DATE] identified the need for 2148 cubic centimeters (cc) of fluid per day. Review of the Intake & Output (I&O) records from 8/8/12 through 8/14/12, a seven day period of time identified that resident #129 consumed less than the estimated intake; 930 cc, 950 cc, 830 cc, 600 cc, 840 cc, 720 cc, 630 cc and the clinical record failed to reflect that dehydration assessments were conducted and/or new interventions were implemented. The nurse's note dated 8/14/12 on the 7:00 AM-3:30 PM shift identified that Resident #129 had very poor oral intake the past week, a fruity breath odor was noticed and the resident would be monitored. The nurse's notes dated 8/15/12 at 9:50 AM identified that Resident #129 had continued with very poor oral intake from 0% to 25% and refused meals as well. Subsequent to physician notification orders directed to obtain blood work. The blood work results dated 8/15/12 identified that the Blood Urea Nitrogen (BUN) level was of 104 (normal range 7-18) and the Creatinine was 2.86 (normal range 0.6-1.0) and the report was faxed to the physician at 11:30 AM. Blood work results dated 5/23/12 indicated a BUN of 13 and Creatinine of 1.11. A physician's orders [REDACTED]. The nurse's note dated 8/15/12 at 12:35 PM identified that Resident #129 had short periods of apnea [MEDICATION NAME] 10-15 seconds, physician was updated and the resident was transferred to the hospital. The Emergency Department Discharge Instructions dated 8/15/12 at 5:09 PM indicated that medications were administered, IV hydration was initiated, and the IV fluids were to remain in place. Additional instructions directed to hold the medication [MEDICATION NAME] until further notice from the physician and IV fluids as per the resident's physician. The discharge [DIAGNOSES REDACTED]. Review of the facility Nutrition and Hydration Policy directed that staff should be aware of each resident's intake, whether or not an official record is being kept, and should be alert to any persistent decrease in intake. Physician notification should occur when intake greater then 2500 cc and less then 1000 cc in two (2) consecutive days, or more than three (3) times in one week, unless resident parameters have already been established by the physician. Interview with the dietician on 8/16/12 at 10:29 AM identified that the resident's ideal fluid intake should be 2148 cc daily and the lowest 1000 cc to 1500 cc daily. The dietician indicated that the last time she evaluated the resident on 7/20/12 and no new interventions were implemented to address resident's poor fluid intake. The dietician identified that she was not notified the resident's fluid intake was decreasing and if she had been she would directed the staff to notify the physician. Interview and review of the nurse's notes and the 24 hour shift report with the Director of Nurses on 8/16/12 at 2:50 PM failed to reflect documentation that the resident was assessed for sign and symptoms of dehydration and/or the physician was notified that the resident's fluid intake was below 1000 cc daily, and/or that new interventions were initiated to prevent dehydration.