Every finding on record at Excelcare at Newark LLC

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, putting 78 residents who received meals from the kitchen (2 residents received nutrition via feeding tubes) out of 80 total residents at potential risk for unsanitary meal services. Findings include:1. During an observation and interview on 03/29/26 from 9:25 AM through 10:28 AM, with the Dietary Manager (DM) revealed two Dietary Aides (DA) 1 and DA2 were observed not wearing beard/hair restraints while engaged in food preparation and dishwashing activities. The DM confirmed the two DAs were not wearing beard/hair restraints.2. During an observation and interview with the DM on 03/31/26 from 8:55 AM through 11:36 AM, during the meal serving line revealed, DA1 and DA3 were not wearing beard/hair restraints. The DM stated beard/hair restraints should be worn at all times. The DM stated the facility was out of beard/hair restraints.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored in a secure manner to prevent unauthorized access when two of five medication carts were left unattended and unlocked. This deficient practice had the potential to affect all residents, staff, and visitors placing them at risk for unauthorized access to medications.Findings include:1. During an observation on 04/01/26 at 4:53 AM revealed the medication cart was unlocked on the [NAME] Hall in front of room W102. Licensed Practical Nurse (LPN)4 was in the room with privacy curtain pulled. The medication cart was not visible from the room. There was one staff member Certified Nursing Assistant (CNA)4 down hall delivering linen to another room. At 4:59 AM LPN4 returned to the medication cart and secured it. She confirmed medication cart was left unlocked and could not be visualized from the resident's room.2. During an observation on 04/01/26 at 5:56 AM revealed the medication cart at the nurses station was unlocked. The Assistant Director of Nursing (ADON) walked past the unlocked medication cart twice. At 6:00 AM the ADON went down the East Hall leaving no one at the nurses' station and the medication cart remained unlocked. At 6:05 AM the ADON returned to the nurses station locked the medication cart.During an interview on 04/01/26 at 6:05 AM with ADON revealed the medication cart at nurses station was shared by both nurses on the [NAME] and East Halls. She revealed it was an expectation that all medication and treatment carts when not in use must be kept locked.Review of the facility's policy titled Storage of Medication revised November 2020 revealed that compartments containing drugs and biologicals are locked when not in use. Unlocked carts should not be left unattended.

Based on record review, interview, and facility policy review, the facility failed to ensure residents received written information regarding advanced directives and the right to accept or refuse medical and surgical treatments for two residents of two residents (Resident (R) 19 and R11) reviewed for advanced directives out of a total sample of 42. This failure places the residents at risk of not understanding their rights and options regarding care. Findings include:1. Review of R19's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R19 admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and , major depressive disorder. Review of R19's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/20/26 and located under the MDS tab of the EMR, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. Review of R19's EMR revealed no evidence to indicate R19 received written information regarding advanced directives. 2. Review of R11's admission Record, located under the Profile tab of the EMR, revealed R11 re-admitted to the facility on [DATE] with diagnoses including heart failure, stage three chronic kidney disease, malignant neoplasm of upper lobe, left bronchus, and pain. Review of R11's quarterly MDS, with an ARD of 01/29/26 and located under the MDS tab of the EMR, revealed R11 had a BIMS score of 12 out of 15, which indicated moderately impaired cognition. Review of R11's EMR revealed no evidence to indicate R11 received written information regarding advanced directives. During an interview on 10/30/26 at 10:35 AM, the Social Service Director (SSD) stated she did not have any written information that she provided to residents regarding the distinct types of advanced directives. There was no signature page to indicate a verbal explanation was provided or to indicate the residents understand they have the right to accept or refuse medical and surgical treatments. During an interview on 04/01/26 1:45 PM, the Admissions Director (AD) stated there was only one page in the admission packet that asked if a resident had an advanced directive or if they would like to formulate one. She stated she did not have any written information defining the types of advanced directives to provide residents with upon admission. During an interview on 04/01/2026 at 1:50 PM, the Administrator stated she was not aware of the regulatory guidance to provide written information regarding advanced directives and the right to accept and or refuse medical and surgical treatment to residents. She was not aware that her policy indicated this would be done. Review of the facility policy titled, Advanced Directives, revised November 2025 revealed, . The resident has the right to formulate and advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.Providing the Resident with Written Information Concerning Advance Directives: . (2) Written information is provided in a manner easily understood by the resident or representative.

Based on interview, record review, and review of facility policy, the facility failed to report an allegation of sexual abuse to the State Survey Agency (SSA) within the required two hour timeframe for one resident (Resident (R)110) out of 11 residents reviewed for abuse out of a total sample of 42 residents. This failure had the potential to delay a timely investigation and the implementation of appropriate protective measures, placing resident safety at risk and increasing the potential for further abuse.Findings include: Review of R110's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnoses of cognitive communication deficit, and mild cognitive impairment. R110 discharged from the facility on 09/25/25. Review of R110's 5-day Entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R110 was cognitively intact. Review of the Grievance/Concern Form dated 09/18/25 and provided by the facility revealed R110's son called to report that sometime this week a male aide come into his mom's room in the middle of the night stating he needed to check if she was wet. Patient refused. A little later aide came back again and she refused. (missing second page). Review of the facilities Investigation Report dated 09/22/25 and provided by the facility indicated R110's assigned Certified Nursing Assistant (CNA)13 made an inappropriate verbal remark directed toward R110. Further review of the investigation report revealed that the CNA stated, you don't know what you are missing.Review of the Incident Tracking Form provided by the facility dated 09/22/25 at 8:21 PM revealed the following A police officer arrived at the facility and informed staff that they had received a complaint from a resident's family alleging that the resident may have been spoken to in a manner that was uncomfortable for her. Per the resident, the male staff who was assigned to her care said You don't know what you are missing when she refused incontinent care.During an interview on 03/30/26 at 4:03 PM, the Admissions Director (AD) stated that she had received a telephone call from R110's son on 09/18/25 who stated a male staff member entered his mother's room to provide incontinent care for R110 who refused and then the male retuned again and the male aide made a comment which made R110 feel uncomfortable with the comment. Further interview with the AD she stated that immediately after concluding the telephone conversation with R110's son she informed the Director of Nursing (DON) of the R110's son's concern. The AD also stated that the facilities protocol is to immediately notify the Administrator and the DON of all grievance and abuse concerns. During an interview on 03/30/26 at 4:26 PM with the DON stated that she did not remember receiving the Grievance/Concern form related to R110's son's concerns. The DON further stated that she learned about the alleged abuse was on 09/22/25 when a Police Officer went to the facility after receiving an allegation of abuse at the facility. The DON further stated that she initiated the investigation on 09/22/25. The DON stated that the SSA should have been notified on 09/18/25 after immediately following the R110's son's grievance concerns.During an interview on 03/30/26 at 4:30 PM with the Administrator/Abuse Coordinator revealed she was not aware of R110's sons grievance concerns as she was out on leave. The Administrator confirmed that alleged violations involving abuse should have been reported to the State SSA within two hours after the allegation was made. During a second interview with the DON on 03/31/26 at 8:52 AM the DON confirmed that the SSA was notified of the abuse allegation on 09/22/25 four days after the R110's grievance allegation. The DON further stated that it is the facility's policy to report alleged violations involving abuse to be reported to the SSA within two hours after the allegation was made. CNA13 was unable to be interviewed as he was on vacation during the survey. Review of the facility's policy titled, Abuse/Neglect-Exploitation Mistreatment and Misappropriation of Property Prevention, dated 06/15/25, revealed it was the policy of the facility that each resident be free from verbal, sexual, physical, and mental abuse, and mistreatment. The policy indicated that alleged violations involving abuse were to be reported to the State Survey Agency within two hours after the allegation was made.

Based on record review, interview, and policy review, the facility failed to conduct a thorough investigation of an abuse allegation for one resident (Resident R110) out of 11 residents reviewed for abuse out of a total sample of 42 residents. This deficient practice placed residents at risk for ongoing abuse and failed to ensure residents' safety.Findings include:Review of R110's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with a diagnosis of cognitive communication deficit and mild cognitive impairment. The resident was discharged from the facility on 09/25/25.Review of R110's 5-day Entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R110 was cognitively intact.Review of the Grievance/Concern Form dated 09/18/25 and provided by the facility revealed R110's son called to report that sometime this week a male aide came into his mom's room in the middle of the night stating he needed to check if she was wet. Patient refused A little later the aide came back again and she refused., (missing second page).Review of the facilities Investigation Report dated 09/22/25 provided by the facility indicated R110's assigned Certified Nursing Assistant (CNA) 13 made an inappropriate verbal remark directed toward R110 after the resident refused an incontinence check/change. Further review of the investigation report revealed that the male CNA had stated, you don't know what you are missing. Although the facility conducted resident interviews receiving care provided by the alleged male CNA, the interview process lacked specifics to the allegation. Interview questions were general in nature (e.g., whether residents had concerns or complaints or if the CNA had been inappropriate), and did not include targeted questions related to potential sexual abuse, such as inappropriate sexual remarks, unwanted touching, or sexual advances. Questions asked to the residents provided care by the alleged CNA were: 1. Have you had any concerns or complaints with your 11-7 CNA. 2. Has . (11-7 CNA ever been inappropriate or spoken to you inappropriately? No other questions were documented.Review of [NAME] 2 State Police Report dated 09/23/25 and provided by the facility revealed the victim reports that she may have been touched inappropriately by a staff member while he was checking her.Review of the typed statement by the Social Services Director (SSD) dated 09/22/25 indicated that the SW had spoken with R110 and indicated that R110 explained that about 4:00 AM the week prior the aide went into her room to check her diaper left the room and then returned and stated, you don't know what you missed. The typed statement indicated R110 was asked if she felt safe in the facility and the resident replied, it was hard to answer. No other questions were documented.Review of the typed statement by the SSD dated 09/23/25 indicated the SSD had spoken with R110 and asked if R110 felt safe in the facility the resident's response was documented as right now talking with you, yes. No further questions were documented on the written statement.Review of a typed interview dated 09/23/25 conducted with the roommate of R110 revealed the roommate was asked the following question: Can you tell me if you heard or know of any problem with A bed and her male CNA on the 11 to 7 shift? No other questions regarding the alleged allegations were asked to R110 or documented.In a typed statement dated 09/25/25 indicated the SSD was following up with R110 to ask how R110 was feeling and doing. The statement indicated R110 stated she was happy as can be. It is also documented that the SSD asked the resident felt safe in the facility and the resident replied, I feel safe now because I am going.(sic) No further questions were documented on the written statement.During an interview on 03/30/26 at 4:03 PM with the Admissions Director (AD) stated she was not aware that the second page of the Grievance/Concern report was missing. The AD further stated that she did not have a copy of the second page of Grievance/Concern Form dated 09/18/25. The AD also stated that she did not keep a copy of the Grievance/Concern report and did not keep any documentation regarding the grievance called in by R110's son. The AD stated that she gave Grievance/Concern to the Director of Nursing (DON) immediately following the call with the resident's son.During an interview on 03/30/26 at 4:26 PM with the DON stated she did not remember receiving the Grievance/Concern report and did not know the second page of the Grievance/Concern dated 9/18/25 was missing. The DON further stated that she learned about the alleged abuse on 09/22/25 when a Police Officer went to the facility after receiving an allegation of abuse at the facility and initiated the investigation.During an interview on 03/30/26 at 4:30 PM with the Administrator/Abuse Coordinator the Administrator revealed she were not aware of R110's sons grievance concerns as she was out on leave. The Administrator also stated she did not know that the second page of the Grievance/Concern Form was missing and stated she would try to locate the missing page.During a follow up interview with the DON on 03/31/26 at 4:46 PM revealed that a skin assessment was completed on R110 on 09/22/25 per her instruction and there were no positive findings of abuse. The DON also stated that the male assigned CNA was re-assigned and was not to enter the resident's room. Additionally, the DON stated that other residents assigned to the male CNA had no complaints reported. The DON stated that the male CNA was interviewed and denied touching the resident inappropriately and denied making the comment you don't know what you're missing after R110 refused the incontinence check. The DON stated that per policy the male CNA was suspended pending the investigation.During a follow-up interview 04/01/26 at 1:30 PM with the Administrator/Abuse Coordinator the Administrator revealed she was unable to find the missing second page of the Grievance/Concern Form.CNA13 was unable to be interviewed as he was on vacation during the survey.Review of the facility's policy titled, Abuse/Neglect -Exploitation Mistreatment and Misappropriation of Property Prevention, dated 06/16/25, revealed .under VII. Reporting/Response: indicates When an allegation or suspicion of one of the activities set out in the definitions herein occurs the facility shall: 2. Have evidence that all alleged violations are thoroughly investigated.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure care plans were revised to accurately reflect the resident's code status for two of two residents (Resident (R) 19 and R11) reviewed for care planning out of a total sample of 42. This failure had the potential to cause residents to not receive appropriate care and treatment. Findings include:1. Review of R19's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R19 admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, major depressive disorder, chronic obstructive pulmonary disease (COPD), and pain in thoracic spine. The admission Record, indicated R19 was a Full Code. Review R19's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/20/26 and located under the MDS tab of the EMR, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating she was cognitively intact. Review R19's Physician Orders, dated March 2026 and located under the Orders tab of the EMR, revealed R19 was a Full Code. Review of the Care Plan, initiated on 06/01/22 and located under the Care Plan, tab of the EMR, revealed . Psychosocial Well-Being: Advance Directive: DNR [do not resuscitate] .2. Review R11's admission Record, located under the Profile tab of the EMR, revealed R11 re-admitted to the facility on [DATE] with diagnoses including heart failure, stage three chronic kidney disease, malignant neoplasm of upper lobe, left bronchus, and pain. Review R11's quarterly MDS, with an ARD of 01/29/26 and located under the MDS tab of the EMR, revealed R11 had a BIMS score of 12 out of 15, which indicated moderately impaired cognition. Review of R11's Physician Orders, dated March 2026 and located under the Orders tab of the EMR revealed R11 was a Full Code.Review of R11's Care Plan, dated 06/07/23 and located under the Care Plan tab of the EMR, revealed . Psychosocial Well-Being: Advance Directive: DNR. During an interview and record review on 03/31/26 at 9:37 AM, Licensed Practical Nurse (LPN) 2 verified the care plan should not indicate R19 and R11 had a DNR status and confirmed the orders indicated the resident were a full code. LPN2 stated the nurses and unit managers usually updated the care plans. During an interview on 03/31/2026 at 11:32 AM, the Assistant Director of Nursing (ADON) confirmed the care plans were not correct for R19 and R11 and did not reflect the current code status. The ADON stated the nurses and unit managers usually updated the care plans. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition changes.

Based on observation, record review, and interview, the facility failed to ensure that one (Resident (R)8) of four residents reviewed for falls was safely transferred using a Hoyer (mechanical lift) out of a total sample of 42 residents. This failure has the potential to cause the resident to sustain an injury.Findings include:Review of R8's admission Record located in the electronic medical records (EMR) under the tab titled Profile revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease with hemiplegia and hemiparesis, abnormalities of gait, and falls.Review of R8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/26 located in the EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out 15 points, which indicated the resident had moderately impaired cognition. The resident was assessed as being totally dependent on staff for activities of living (ADLs) care needs. The resident was assessed to require transfers with a Hoyer lift. Review of R8's Care Plan with a revision date of 10/22/24 located in the EMR under the Care Plan tab revealed the resident required two staff members for bed mobility and Hoyer lift transfers.During an observation 04/01/26 at 10:30 AM revealed Certified Nursing Assistant (CNA)7 used the Hoyer lift by herself to transfer R8 from the bed to a shower stretcher so the resident could be taken to the shower room. CNA7 had to reposition the lift several times to move the lift closer to the stretcher. The resident was swinging the lift sheet holding onto the lift with his good arm. During an interview on 04/01/26 at 1:57 PM with Licensed Practical Nurse (LPN)3 revealed CNA7 had already reported that she had failed to have another staff member present while transferring the resident from the bed to shower stretcher. LPN3 stated the resident was care planned to have two staff members present for bed mobility and transfer. The LPN stated she assumed another staff member was in the room assisting CNA7. During an interview on 04/01/26 at 2:00 PM CNA7 revealed she found it difficult to get someone to help as everyone was busy. CNA7 stated she knew the resident required two persons to assist; she knew what she did was wrong that why she did a self-report.

Based on interview, record review, and other documentation as indicated, it was determined that for one (R1) out of three residents reviewed for change in condition, the facility failed to ensure that the proper assessments, interventions, and timely notifications to the medical provider were done when R1 was observed with changes in her clinical status. R1, a resident who previously did not require oxygen, complained of shortness of breath to nursing staff between 3:00 AM and 4:00 AM on [DATE]. The facility lacked evidence that R1's vital signs or respiratory status were monitored, and that the provider was consulted during this time. R1 was transferred to the hospital approximately two hours later. R1 was unresponsive when she arrived at the emergency room and later expired at the hospital. Due to this failure, an Immediate Jeopardy (IJ) was called on [DATE] at 12:00 PM, with an abatement date of [DATE] at 4:15 PM. Findings include:Cross refer F580A review of R1's clinical record revealed:[DATE] - R1 was admitted to the facility with diagnoses including a right femur fractureXXX[DATE] 2:52 PM - E8 (COTA) documented in R1's clinical record, [R1] presents with labored breathing, oxygen saturation of 89% .session shortened.[R1] unable to participate.XXX[DATE] 9:16 PM - A Daily Skilled Charting note entered by E9 (LPN) documented, .O2 sats [saturation] 93% Date: [DATE] 22:10 [10:10 PM] .R1's documented oxygen saturation level, obtained approximately twenty-four hours earlier, was not a current reading. [DATE] 5:47 AM - A facility document that listed messages that were sent to R1's provider documented E5 (RN) left a message stating, [R1] is having a hard time breathing [sic] wants to go to the hospital.XXX[DATE] 5:51 AM - A review of EMS documentation revealed a 911 call was made requesting emergency assistance for R1 at the facility. [DATE] 6:25 AM - A review of hospital documentation revealed R1 arrived at the emergency roomXXX[DATE] 7:04 AM - An ED (Emergency Department) Physician Record documented, [R1] presents to the emergency department unresponsive. [DATE] 7:10 AM - An EMS Prehospital Care Report narrative documented, .[R1] contact delayed due to no one answering the doorbell.Nursing staff relayed at around 3am [sic] [R1] began complaining of SOB [shortness of breath].they [nursing staff] placed [R1] on 5 lpm (liters per minute) of oxygen via NRB [non-rebreather mask].[R1]'s [oxygen] saturation was in the 60's and had improved to the 80's.EMS placed [R1] on 15 lpm.En route, [R1] began declining and BLS administered [sic].XXX[DATE] 7:30 AM - E5 documented in R1's clinical record, [R1] c/o [complained] of SOB, [R1] put on oxygen, still remained low 65% at 5 liters. Applied non-rebreather and went up to 90%. [R1] insisted on going to the hospital.[R1] sent to ER.sp02 [sic] 90%.[DATE] 8:00 AM - During an interview, E5 stated, I was on break at 4:00 am. E7 [LPN] told me to check on [R1]. [E7] said [R1] can't breathe. [E7] put [R1] on oxygen. [E6, RN Supervisor] and I went in after my break. [R1] was okay, she was on NC (nasal cannula) 2 liters. [R1] said she was hungry. [R1] ate a snack, and I went to start med pass. [R1] again said she couldn't breathe. We titrated [oxygen] up to 3 liters and it [R1's oxygenation level] went up to 92%. The Surveyor asked, What time did this occur? E5 stated, I don't remember the exact time. E5 then stated, [R1] went down to 65% on 3 liters. [E6] put [R1] on a non-rebreather at 6 liters. The Surveyor asked, What time was [R1] put on the non-rebreather? E5 stated, I can't recall the exact time. I called the provider when [R1] went down again. After that I called 911. The Surveyor asked, Did you take [R1]'s vitals or do an assessment? E5 stated, I took her vitals around 4:30 am. I assessed [R1]'s lungs and they sounded diminished. I kept checking her pulse ox [pulse oximeter]. The Surveyor asked, Were the assessment and pulse ox readings documented? E5 stated, I did not document it.[DATE] 10:26 AM - During an interview, E7 stated, I answered the call bell. [R1]'s roommate said that [R1] can't breathe. I saw [R1] and she didn't look well. [R1] said she couldn't breathe. [R1] was at 88%. I put her on O2 [oxygen] at 2 liters. [R1] went up to 92%. I told her nurse [E5]. It was between 3:00 and 4:00 AM. It was before my break. The Surveyor asked, Were any vitals or oxygen saturation readings documented? E7 stated, I did not document them.The facility lacked evidence of documentation of R1's vital signs even though she complained of difficulty breathing and exhibited signs of respiratory distressXXX[DATE] 11:17 AM - During an interview, E8 stated, I remember [R1] did not do therapy that day [[DATE]]. I asked why she couldn't do therapy. [R1] told me she couldn't do therapy because of her breathing. I checked her vitals and put them in my note. I told the nurse whose cart was immediately outside of [R1]'s room. The nurse took [R1]'s pulse ox again.R1's clinical record lacked evidence of nursing documentation of R1's shortness of breath, inability to participate in therapy, any interventions that were implemented or notification to the medical provider on this date. [DATE] 11:00 AM - An undated facility document entitled, Nursing Competencies Identified Through Facility Assessment provided to the Surveyor stated, .the facility has identified the following.to ensure safe and effective care delivery.vital signs monitoring and nursing assessment.recognition and timely reporting of changes in resident condition.oxygen therapy and respiratory treatments.emergency response and clinical escalation.XXX[DATE] 1:50 PM - During an interview, E10 (LPN) stated, We are not trained on oxygen use, if someone is in respiratory distress, I would put them on nasal cannula at 2 liters. If they are under 92%, I will inform the provider.[DATE] 2:25 PM - During an interview, E13 (Staff Development Coordinator) stated, If any vitals are below baseline, the provider should be called. If anyone cannot be maintained at 92% on NC (nasal cannula) 2 liters, I would call 911. If a non-rebreather is being used, 911 should already be in route. The nurses are trained to document the times vitals are taken and when the provider was called in their progress note. The Surveyor asked, When was the last in-service training for nurses held? E13 stated, It was held on [DATE]. The Surveyor asked, Did the training include how to use a non-rebreather mask? E13 stated, Yes, O2 [oxygen] therapy was discussed. A non-rebreather should be used with 10-15 liters of oxygen. The Surveyor the asked, Are the areas of vital signs monitoring, nursing assessment and emergency response addressed in this training? E13 stated, Yes.[DATE] 7:15 AM - During an interview, E6 stated, The nurse [E5] called me, and I went in [R1's] room. [R1] already had oxygen on. [R1] was comfortable. [E5] called me again saying [R1] was having shortness of breath. [E5] put the non-rebreather on [R1]. The Surveyor asked, Do you remember the approximate time this occurred? E6 stated, I don't remember. The Surveyor asked, Do you remember [R1]'s oxygen saturation level at the time or how much oxygen [R1] was given? E6, I cannot remember what oxygen level [R1] was on. We did not have time to document the vitals.[DATE] 12:00 PM - An Immediate Jeopardy (IJ) was called due to the facility's failure to adequately assess R1's change in condition, timely consult the provider, and to promptly request emergency medical assistance when R1 began complaining of not being able to breathe and had low oxygen saturation readings. The facility also failed to maintain oxygen delivery to R1 at an appropriate level until emergency medical assistance arrivedXXX[DATE] 4:15 PM - The facility's abatement plan for the Immediate Jeopardy included:Licensed nursing staff were re-educated on: a) recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation b) initiation and monitoring of oxygen therapy c) timely provider notification All residents were immediately screened by licensed nursing staff for respiratory distress. Residents identified with respiratory distress were assessed and interventions were implemented.The facility failed to ensure that R1 was assessed and appropriate interventions were implemented, including emergency care and services, when she complained of difficulty breathing and was noted with obvious respiratory distressXXX[DATE] 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E4 (VPO).

Based on interview and record review, it was determined that for one (R4) out of three residents reviewed for death, the facility failed to promote and facilitate R4's self determination with respect to signing multiple consents upon his admission to the facility. Findings include:Review of R4's clinical record revealed: [DATE] - R4 was admitted to the facility on Friday evening shift with a diagnosis that included, but was not limited to prostate cancer with metastasized (spread) to the bone and brain. R4's facesheet revealed that he was listed as the Responsible Party. [DATE] (untimed) - A speech therapy evaluation and plan of treatment documented that R4's BIMS was a 14 out of 15, which represented that R4 had a normal cognitive function. [DATE] 1:22 PM - A BIMS evaluation was performed by E16 (former social worker) that documented a score of 10 out of 15, which represented that R4 had a moderate cognitive impairment. [DATE] - The admission MDS assessment documented R4's BIMS score as a 10. Review of the following signed facility consents revealed that R4 did not sign them despite that R4 was evaluated and documented as cognitively intact:-CPR/DNR documentation form was signed on [DATE] by FF1 (friend), E10 (LPN/Charge Nurse) and E11 (NP).-Consent to treatment was signed on [DATE] by FF1;-Care Management Services consent form was signed on [DATE] by FF1;-Consent to treat/assignment of benefits and receipt of notice of privacy practices was signed on [DATE] by FF1; and-Consents to administer influenza vaccination, pneumococcal vaccination, respiratory syncytial virus (RSV) vaccination and Covid-19 vaccination were signed by E10 (LPN/Charge Nurse) on [DATE] with the following handwritten documentation: verbal consent by [FF2, friend] family doesn't want vaccine. [DATE] 11:55 AM - During an interview, E10 (LPN/Charge Nurse) stated that she did not complete R4's admission on Friday evening. E10 stated that the admitting nurse should have obtained the signed consents as part of the admission process. E10 stated that she was told to complete the consents because they were not done. E10 stated that FF1 (friend) was here all the time and was referred to as a brother. E10 stated that she used the BIMS score that was documented 10, revealing that R4 was cognitively impaired. E10 stated that a resident with a BIMS score of 11 or lower cannot sign consents. When asked if she was aware of the BIMS score completed by the Speech Therapist (ST) on [DATE] that documented R4 as a 14/15, E10 stated that nobody shared the speech therapy BIMS score. E10 also stated that she learned later on that FF1 was not R4's real brother. [DATE] 9:25 AM - Finding was reviewed with E4 (VPO). The facility failed to promote and facilitate R4's self determination when obtaining multiple consents upon admission. [DATE] 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4.

Based on record review and interview, it was determined that for one (R1) out of three residents reviewed for change in condition, the facility failed to consult with R1's physician when R1 complained of shortness of breath and when oxygen therapy was initiated. Findings include:Cross refer F68411/13/25 - R1 was admitted to the facility with diagnoses including a right femur fracture.11/23/25 2:52 PM - E8 (COTA) documented in R1's clinical record, [R1] presents with labored breathing, oxygen saturation of 89% .session shortened.[R1] unable to participate.R1's clinical record lacked evidence that the medical provider was consulted of this new onset of respiratory distress.11/25/25 5:51 AM - A review of EMS documentation revealed a 911 call was made requesting emergency assistance for R1 at the facility.11/25/25 7:04 AM - An EMS Prehospital Care Report documented, .Nursing staff relayed at around 3am [sic] [R1] began complaining of SOB [shortness of breath].they [nursing staff] placed [R1] on 5 lpm [liters per minute] of oxygen via NRB [non-rebreather mask].12/19/25 8:00 AM - During an interview, E7 (LPN) stated, I answered the call bell. [R1]'s roommate said that [R1] can't breathe. I saw [R1] and she didn't look well. [R1] said she couldn't breathe. [R1] was at 88%. I put her on O2 [oxygen] at 2 liters.It was between 3:00 and 4:00 AM. It was before my break .The facility lacked evidence of documentation of consultation with R1's medical provider when she complained of shortness of breath, had a low oxygenation saturation level and was started on oxygen therapy.12/19/25 11:17 AM - During an interview (E8) stated, I remember [R1] did not do therapy that day [11/23/25]. I asked why she couldn't do therapy. [R1] told me she couldn't do therapy because of her breathing. I checked her vitals and put them in my note. I told the nurse whose cart was immediately outside of [R1]'s room.The facility lacked evidence that R1's physician was consulted when R1 complained of shortness of breath when it was reported to nursing staff on 11/23/25.12/23/25 11:58 AM - Findings were confirmed with E1, E2, and E3.12/23/25 4:20 PM - Findings were reviewed during the exit conference with E1, E2, E3 and E4.

Based on interview and record review, it was determined that for one (R4) out of three residents reviewed for death, the facility failed to ensure all the required IDT (interdisciplinary team) members contributed to the 11/14/25 care plan conference. Findings include: Review of R4's clinical record revealed: 11/14/25 10:58 AM - The facility's unsigned and incompleted Care Conference Summary documented that Therapy discussed the resident's progress. Discharge planning was discussed. Nursing went over the resident's care. Under Section D. IDT participants who contributed to plan of care lacked evidence of that a specific Physician/Nurse Practitioner/Physician Assistant contributed and how they contributed. 12/22/25 10:30 AM - During an interview, E12 (SSD) stated that the only facility participants that attended R4's care plan conference was E12 from social services, [name of E10, LPN/Charge Nurse] and an unidentified therapy person. E12 stated that E15 (dietician) provided input ahead of the conference as she would not be present. E12 also stated that R4 had two individuals with him (FF1 and FF2). 12/22/25 11:55 AM - During an interview, E10 (LPN/Charge Nurse) stated that the Provider (Physician/NP) did not participate in R4's care plan conference or Provider input. E10 stated that if there are concerns by the resident during the conference, they would be shared with the Provider after the care conference. 12/23/25 9:25 AM - Finding was reviewed with E4 (VPO). The facility failed to ensure all required IDT members contributed to R4's care plan conference. 12/23/25 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4.

Based on interview and record review, it was determined that for one (R4) out of one resident reviewed for death, the facility failed to ensure R4 had a completed and signed resident agreement upon admission to the facility. Findings include: Review of R4's clinical record revealed: 11/7/25 - R4 was admitted to the facility on Friday evening shift with a diagnosis that included, but was not limited to prostate cancer with metastases to the bone and brain. R4's facesheet revealed that he was listed as the Responsible Party. 12/2/25 9:40 PM - A nursing note documented that R4 passed away in the facility. Review of R4's 11/7/25 DE (Delaware) admission Packet revealed that it was unsigned and incomplete. A written statement by E14 (admission Director) revealed, On November 10th patient [R4] was asleep when trying to do the admission agreement; went back in the afternoon and was still sleeping. On November 11th patient refused due to being tired. Facesheet from the hospital had 2 people listed as siblings that we did not find out they were NOT family members until the brother came in the day he [R4] passed away. Agreement. was in progress until the day patient passed away. 12/23/25 9:25 AM - Finding was reviewed with E4 (VPO). The facility failed to ensure R4's medical record included a completed and signed DE admission Packet, a legal document that clearly communicated the resident's rights, facility's policies and described the healthcare services to be provided to the resident. 12/23/25 4:20 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4.

Based on interview and record review, the facility failed to ensure one of one resident (R)72 reviewed for accidents /safety in the sample of 28 revealed that R72 was smoking outside the facility unsupervised, fell and was found on the ground with a bloody nose and swollen, purplish color 5th finger, which was later identified by x-ray as a right hand 5th finger proximal phalanx fracture. Findings include: Review of R72's Face Sheet located in electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary disease (COPD), acute and chronic respiratory with hypoxia, muscle weakness, cognitive communication deficit, and dependence on supplemental oxygen. Review of R72's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/24 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. Review of R72's Care Plan, dated 10/09/24 and located in the residents' EMR under the Care Plan tab revealed, Potential for safety hazard to self or others as evidenced by non-compliance with prescribed safety measures as evidenced by smoking on facility grounds. Review of the facility's Incident Report/5-day follow-up dated 10/22/24 revealed the resident had a fall on 10/18/24, following the fall, the right (R) hand 5th digit was slightly swollen and purplish in color. She was able to move all digits upon command and denied any difficulty in use of hand/extremity, on 10/20/24 to 10/21/24, the swelling and bruising persisted, and an order was received for a Xray of the R hand. Xray result showed a 5th proximal phalanx fracture. Review of R72's Physician Orders dated 08/09/23 and located in the EMR under the Orders tab revealed oxygen at 3 liters per minute (LPM) via nasal cannula. Review of Progress Note dated 10/18/24 at 1:07 PM written by Registered Nurse (RN)1 revealed resident found outside by another resident who notified nursing. The resident was bending and leaning forward to pick up her glasses and fell forward. Resident noted with a bloody nose and a skin tear to right upper eyelid. Nurse Practitioner (NP) notified. Resident safely brought back inside facility and vitals obtained. Review of Radiology Results Report dated 10/21/24 located in the residents EMR under the Misc tab revealed reason acute pain due to trauma. Further review revealed 5th proximal phalanx fracture with mild displacement. During an interview on 02/17/25 at 4:16 PM R72 stated that on 10/18/24 she went out the front door and that nobody told her she could not go outside. She was out there about 30 minutes, but she was not sure if she was supposed to let anyone know. She said she smoked at the time and had a cigarette and lighter with her. She did not know she was not supposed to smoke at the time. She said she took her nasal cannula off and hung it on the back of her wheelchair. She said she took precautions. She fell out of the seat and hit her face on the ground and her arm and hand were sore. She stated she broke one of her fingers. She is not allowed to go outside without staff now, but she was unsure of what the rules were. But she thinks she can still go outside and sit by the bench. During an interview on 02/18/25 at 11:56 AM, RN1 stated that residents who had a BIMS of 12 or higher and were their own responsible person used to be allowed to go outside in front of the facility and hang out on the front porch. But they were not allowed to go to any other area on the facility grounds. They were supposed to make their assigned nurse aware and let the receptionist know. The receptionist was supposed to verify with their nurse if they were allowed to go outside. She said there was no structured process to monitor/supervise residents s while they were outside. She said the facility was a nonsmoking facility. R72 was a smoker prior to being admitted but she was unaware of any time that R72 had attempted to smoke on facility grounds or had smoking materials in her possession. On 10/18/24 another resident (unsure who) was coming back into the facility and notified staff up front (unsure who) that R72 was on the ground. She notified the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and one of the unit managers. She said they all went outside and found the R72 out front by the flagpole near a bench . This was an area that residents were not supposed to be because you were unable to see them from the front door due to bush blocking the front of the bench. She said R72 was sitting up on the grass and her nose was bleeding and she had a skin tear on her eyebrow. She told staff she wanted to come outside and have a moment to herself somewhere quiet. She was unsure if R72 told her nurse she was going outside. She was not sure if there was a change to R72's plan of care. There was an Interdisciplinary Team (IDT) meeting, but she was unsure what was changed. But she assumed R72 would require supervision after that. When asked about the care plan intervention on 10/09/24 that was initiated by her regarding R72 being noncompliant with smoking. she said, I forgot about that. But she was unsure what had occurred to require that change in the resident's care plan. She said she thinks R72 may have had a lighter in her room and that R72 had been caught smoking outside before. But she did not know any specifics. She was unsure what if anything was done to ensure R72 did not have smoking materials or that she was supervised when she went outside. She thinks they took the lighter away from R72 but can't remember. She said she did not remember seeing anything outside on 10/18/24 that suggested R72 was smoking before she was found on the ground. During an interview on 02/18/25 at 12:22 PM, Licensed Practical Nurse ( LPN)1 said in the past residents who had been deemed mentally competent and physically safe to be outside were allowed. But she was unsure how that was decided. She said she would have to ask which residents were allowed to go outside. She was also unsure how or who was responsible for monitoring the residents while they were outside. She is not sure if residents are still allowed outside but she is not aware of any specific residents that can and do go outside without staff supervision. R72 was allowed to go outside without supervision but she is no longer able to without supervision because R72 had a fall outside. She said she was R72's assigned nurse that day on 10/18/24 but she did not see the actual fall, but was told R72 was outside on the ground. She said the R72 did not let her know she was going outside. She said R72 was found behind the bush by the bench next to the flagpole. She said R72 was hiding behind the bush because she was smoking, and she knew she was not supposed to be. She stated that she, along with the DON, ADON, and RN1 went out there. R72 was sitting on her bottom in front of her wheelchair and there was a lit cigarette right by R72 on the ground that was almost a burnt to the butt. She was unsure where the lighter was. She asked the R72 why she was out there and at first she lied but then admitted that she just had a couple of puffs. She was unsure if she was sitting in the wheelchair that had the oxygen tank on the back or on the bench while she was smoking but she did see the nasal cannula hanging over the back of the chair/tank. She said the nasal cannula was not on her face. She said she was unsure if anyone asked R72 about the fact that she was smoking close to her oxygen tank. After that she was not allowed to go outside unassisted without staff anymore. She said staff were not allowed to let any residents outside. During an interview on 02/18/25 at 4:36 PM, the ADON said residents were allowed to go outside who had a BIMS score higher than a 12 or 13 and were not an elopement risk or exit seeking. She said there was no formal process to monitor residents while there was outside but there was an expectation that any staff going by should look for them. The receptionist or another staff at the front desk would have to put in the code for the front door to open. She said the staff at the front desk would usually call the nurses station to see if the resident was allowed to go outside. There was no set time for how long they could be out there, but they did consider things like weather. She said staff had observed R72 smoking when she was not supposed to be, and it was more than once. But she was unsure what was put into place besides educating her and the family member about nonsmoking and with her oxygen near. On 10/18/24 she said R72 was outside, down by the park bench, and had reached to pick up her glasses and fell . She said the staff asked her if she was smoking and she said no and there were no smoking materials around. During an interview on 02/18/25 at 5:01 PM the former receptionist said when residents wanted to go outside she would ask the Activity's Director if they were allowed and would let her know when a resident went outside and that the Activity's Director or the assistant would periodically monitor them. She said residents were not allowed to go to the bench by the flagpole because it was too far for staff to see. R72 had been warned several times about being outside smoking. On 10/18/24 she said she notified the Activity's Director when R72 went outside. She said when she was found R72 she was on the ground, and she was covered by some bushes. She said that was exactly why R72 went out behind the bushes because she was hiding to smoke because she had an oxygen tank, and she knew she wasn't supposed to smoke with it. She said the person who reported seeing the resident on the ground reported that she was out there smoking. She was unable to remember who that person was. But she was unsure how long R72 had been out there before she was observed on the ground. She was unsure if anyone had checked on her before she was found. During an interview on 02/18/25 at 5:20 PM, the Activity's Director said residents that were deemed alert and oriented and were safe to be outside were allowed to be outside without staff supervision. She said staff would keep an eye on them every 15 to 20 minutes. But residents had to remain in the front door area. She said on 10/18/24 she could not remember anyone telling her that R72 went outside and that she did not go outside to check on her during that time. During an interview on 02/19/25 at 4:27 PM the DON stated that on 10/18/24 she was in the office and heard the receptionist yell out. She ran outside along with other staff and observed R72 on the ground. She did not remember seeing any smoking materials. There was history of R72 being non-compliant with smoking after staff had seen her with a cigarette and a vape and that she was on continuous oxygen. She said residents with a BIMS score of 13 and up were allowed to go outside and sit out there during the summer months without staff. She said the Activities Director, or the Activities staff would check them periodically. She said when residents were outside that she expected staff would monitor them and she was unaware that no staff were monitoring R72 on 10/18/24. She also stated that since R72's BIMS prior to 10/18/24 was only a 10 and it was under 13 than R72 should not have been allowed to go outside. She said at that time there was not really a process in place to monitor residents at that time. But that after R72's first noncompliance with smoking in August 2024 and her low BIMS score, she should not have been allowed outside on 10/18/24.

Based on observation, interviews, and facility policy review, the facility failed to ensure containers with rice and pasta were labeled, dated and cleaned; the inside and outside of the oven and microwave were not clean and grease/debris on the handles; the floor under the three-tiered rack had grease and debris; and during meal service the chicken and mixed vegetables were not served at the appropriate temperature on the steam table. This deficient practice had the potential to affect 95 of 95 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness. Findings include: Review of the undated facility policy titled, Equipment Cleaning Policy provided by the facility indicated, The director of Dining Services or designee will ensure that all equipment is maintained, kept clean and in a sanitary condition before and after each use .Conventional/Convection Ovens: Clean after each use, inside and out, using soap and water .Microwave: Clean after each use, inside and out, using soap and water. Review of the undated facility policy titled, Hot Food Policy provided by the facility indicated, Hot food should be at 135 degrees or above at the time food is served to the residents. During the initial kitchen tour on 02/16/25 at 9:20 AM with the [NAME] (CK1), the following observations were made: 1. In the dry goods pantry there were three large plastic containers that had a visible powder substance on the inside and crumbs on the top. The lids were visibly dirty and had a gritty feel to them. One container contained approximately 2 of loose rice and did not have a date. One container has approximately 1/2 loose elbow macaroni and a bag sitting on top of the macaroni dated 2/11. CK1 was uncertain if the date on the bag was the date the bag was opened. The third container had loose spaghetti with a sticker that read 11/02/24. CK1 said they usually keep pasta for thirty days. 2. In the prep area in the kitchen there was a three-tiered rack that held pots and pans. On the floor was a black mat. There was grease on the floor, crumbs, and scraps of paper. 3. The door handles of each side of the oven and the door handle of the microwave was covered in a thick greasy substance and food particles. During the second kitchen tour on 02/17/25 at 4:00 PM with the Dietary Manager (DM), the following observations were made: 1. In the dry goods pantry, there were three large plastic containers that continued to have visible powder substance on the inside and crumbs and the lids were visibly dirty and had a gritty feel to them. The containers held rice, elbow macaroni, and spaghetti. 2. The door handles of each side of the oven and the door handle of the microwave continued to have a thick greasy substance and food particles. On 02/17/25 at 4:15 PM, the dinner meal was observed and CK2 confirmed the food was ready to be served to the residents. CK2 stated the dinner meal was pizza and Dijon chicken as the alternate with peas and carrots. The DM inserted the digital thermometer into a piece of Chicken, the temperature was 112 degrees Fahrenheit (F), while leaving the thermometer in the chicken, the temperature dropped to 110 degrees F then to 108 degrees F. The chicken was placed back into the oven. The chicken was removed at 4:21 PM and the temperature was 128 degrees F. The chicken was placed back into the oven until 4:45 PM when it was removed it was 203 degrees F. During this same time a thermometer was inserted into the mixed vegetables, the temperature was 124 degrees F. The mixed vegetables were placed in the oven and removed at 4:21 PM. The vegetables were 181 degrees F. The DM and CK2 agreed both the chicken and the vegetables were not at the correct temperature when they started the dinner service. On 02/19/25 at 9:45 AM, the Administrator said the temperature for the chicken should have been higher to be served. On 02/19/25 at 3:54 PM, the Registered Dietician (RD) stated she would do a monthly kitchen audit and would look at general labeling and dating. The RD stated she never really looked at the cleanliness of the kitchen. She stated the temperature for the chicken should be 165 degrees F on the steam table.

Based on interview, document review and policy review, the facility failed to act promptly to the concerns and /grievance of the resident council to noise level at shift changes, staff use of phones, earbuds when providing care, and choices offered for breakfast meals for nine of nine (R)60, R4, R21, R37, R14, R39, R5, R73, and R76 sampled residents. This failure could place the residents at risk for decreased quality of life and feelings of hopelessness. Findings include: Review of the facility policy titled Grievance Program dated 05/01/2024, documented grievances could be reported verbally or in writing, and the right to receive prompt efforts by the facility to resolve resident grievances. The actions that should be taken in response to grievances or concerns included, but not limited to, investigation and most practicable resolution, routing the grievance to the appropriate departments for ongoing improvement, identifying trends in care, service delivery, and system organization, and developing long term solutions, implementing changes to improve care/service systems. The policy also stated that a written decision was issued to the person(s) filing the grievance, and to include the collected documentation of grievances in the facility quality improvement program. The policy designated the Social Services Director and/or the Administrator as the key contact responsible to implement the Grievance Procedure, and that the grievances will be logged on the facility grievance log. During an interview on 02/16/25 at 3:15 PM, R76 stated she has had ongoing complaints about the kitchen and had notified staff. The complaints included receiving dirty silverware, cold food, burned food, no yogurt available, burned toast and requesting not to be served cranberry juice but continues to receive it on her tray. During a group meeting on 02/18/25 at 3:30 PM, with nine residents (R)60, R4, R21, R37, R14, R39, R5, R73, and R76, in attendance, they said they had reported excessive noise levels during all shift changes that disrupt their sleep at night and that it is very distracting and intrusive to conversations with family members and other residents. R73 stated, would give anything for a choice at breakfast and also stated that she would like to eat in the dining room for breakfast because it gave her the opportunity to get out of her room and socialize. R76 stated she was not sure why there were no choices for breakfast but quite often does not like what she was given and asks for another option. She said she continues to get cranberry juice even though she has requested not to get it. Review of the electronic medical record (EMR) revealed the following: R60 with a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated R60 was cognitively intact. R4 with a quarterly MDS with an ARD of 11/01/24 revealed a BIMS score of 15 of 15, which indicated R4 was cognitively intact. R21 with a quarterly MDS with an ARD of 11/04/24 revealed a BIMS score of 12 of 15, which indicated R21 had moderately impaired cognition. R37 with a quarterly MDS with an ARD of 01/10/25 revealed a BIMS score of 15 of 15, which indicated R37 was cognitively intact. R14 with an annual MDS with an ARD of 01/02/25 revealed a BIMS score of 15 of 15, which indicated R14 was cognitively intact. R39 with a quarterly MDS with an ARD of 12/13/24 revealed a BIMS score of 15 of 15, which indicated R39 was cognitively intact. R5 with a quarterly MDS with an ARD of 10/05/24 revealed a BIMS score of 12 of 15, which indicated R5 had moderately impaired cognition. R73 with a quarterly MDS with an ARD of 11/19/24 revealed a BIMS score of 15 of 15, which indicated R73 was cognitively intact. R76 with a quarterly MDS with an ARD of 10/10/24 revealed a BIMS score of 15 of 15, which indicated R76 was cognitively intact. Review of Resident Council Meeting Notes for 02/2024 through 01/2025 indicated grievances regarding noise level at shift change were reported March 2024, April 2024, May 2024, August 2024, September 2024, October 2024, and November 2024. The grievance regarding no choices offered for breakfast was reported in September 2024 and the grievance regarding cell phone use was reported in September 2024 and November 2024. During an interview on 02/18/25 at 5:42 PM, the Activities Director (AD) stated the dining room was closed because the facility had an outbreak of COVID last year. She stated the dining room was open 10/2024, 11/2024 and 12/2024 but has been shut down except for lunch since the first of the year. The AD stated the reason it continued to be closed is because the facility does not have enough staff. The AD stated that during resident council meetings they have discussed when it would be open, and residents have stated they would like it open. During an interview with the Administrator, Social Service Worker (SSW), and the Staff Development Coordinator, and the Activity Director (AD) on 02/19/25 at 10:36 AM, the Administrator stated that she has not actually tracked patterns and trends of resident grievances. The AD stated that she tracks the concerns/grievances quarterly, then reports the data to the Quality Improvement committee. The Staff Development Coordinator stated sound levels at shift change had not been audited. The AD stated that she has been communicating with a concern form to the Dietary Manager regarding the grievance requesting a breakfast menu that offered choices. She said she does not follow up with the concern forms and she thought the department managers were supposed to conduct the follow up to the resident council meeting grievances. The AD said she does not follow-up with the grievance or the response to the residents for resolution. The Administrator said she had addressed the grievance voiced by the resident council in June 2024 regarding loud sound levels at shift change. She said she thought the concern had improved and was not aware that the concern was ongoing. She said the resident council grievances had not been addressed since June 2024. .

Based on record review, interviews, and review Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that three residents (Resident (R) 23, R71, and R153) in the sample of 28 were accurately assessed for falls and one resident (R54) was accurately assessed for insulin. Findings include: Review of the RAI Manual dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set [MDS] items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. 1. Review of R23's Admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included history of falls, dementia, and chronic obstructive pulmonary disease. Review of the facility's accident and incident log dated 2024 revealed that R23 sustained falls on the following dates: 04/14/24 witnessed a fall with injury 04/21/24 unwitnessed fall without injury 05/14/24 unwitnessed fall without injury Review of R23's quarterly MDS with an Assessment Reference Date (ARD) 05/15/24 revealed the MDS section N did not capture the falls that occurred on 04/14/24, 04/21/24 and 05/14/24. 2. Review of R71's Admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that include dementia, unsteady gait, and major depressive disorder. Review of the facility's accident and incident log dated 2024 revealed R71 sustained falls on the following dates: 04/09/24 unwitnessed fall 05/25/24 witnessed fall Review of R71's annual MDS with an ARD of 06/12/24 located in the EMR under the MDS tab revealed Section N failed to capture the falls the resident sustained during the assessment period. Review of R71's quarterly MDS with an ARD of 09/12/24 located in the resident's EMR section titled MDS revealed section N failed to capture the falls the resident sustained during this assessment period. 3. Review of R153's Admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis that include cerebral infarction. Review of the facility's accident and incident log dated 2024 revealed the resident sustained falls on the following dates: 08/06/24 witnessed fall 09/16/24 unwitnessed fall Review of R153's quarterly MDS with an ARD of 11/18/24 located in the EMR under the MDS tab revealed section N of the MDS failed to capture the falls that the resident sustained during the assessment period. 4. Review of R54 Admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis that included diabetes mellitus type II. Review of R54's Physicians' Orders dated 05/29/24 located in the EMR under the Orders tab revealed the resident was to receive Semglee Subcutaneous Solution 100 units (Insulin Glargine) 17 units at bedtime. Review of R54's annual MDS with an ARD of 06/27/24 located in the EMR under the MDS tab revealed section N (Medications) of the MDS did not reflect the resident received insulin daily at bedtime. Review of R54's quarterly MDS with an ARD of 12/28/24 located in the EMR under the MDS tab revealed section N (Medications) of the MDS did not reflect the resident received insulin at bedtime. Interview on 02/19/25 at 10:44 AM, the Corporate MDS Coordinator (CMDSC) acknowledged that the MDS assessments for R23, R54, R71, and R153 were inaccurate.

Based on record review, document review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided timely for one of three residents (Residents (R) 303) reviewed for beneficiary notification. This had the potential to affect all residents being discharged from services. Findings include: 1. Review of R303's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy. Review of R303's SNF Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 10/09/24 and the last day covered was 11/04/24. Further review revealed no ABN notification was provided prior to the last date of services. During an interview on 02/19/25 at 2:14 PM the Social Service Worker (SSW) stated that she was under the impression that R303 would discharge home on 11/04/24 since that was the resident's initial projected discharge date . She stated due to some back and forth with the daughter the facility became aware on 11/01/24 that the resident would not be discharged from the facility. At that time, an ABN notice should have been provided to the resident and RP, but it was not. During an interview on 02/19/25 at 7:37 PM the Director of Nursing (DON) stated she expected staff to provide the required documentation to residents and their representatives timely.

Based on record review, interview, and policy review, the facility failed to ensure an incident of resident-to-resident abuse was thoroughly investigated for two of five residents (Resident (R)7 and R12) reviewed for abuse out of 23 sample residents. This had the potential to affect residents in the facility who were at risk for abuse. Findings include: 1. Review of R7's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, anxiety disorder and bipolar disorder. Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/24 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R12's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, dementia, major depressive disorder, and cognitive communication deficit. Review of R12's quarterly MDS with an ARD of 01/11/25 and located in the EMR under the MDS tab revealed a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. Review of R12's Nurse's Note, dated 05/06/24 and located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN) 4 revealed, R12 was in her doorway and staff heard her yell out for R7 to get out of her room, when staff walked to doorway to redirect R7 and R12 said she kicked me Review of the facility's Incident Report/5-day follow-up dated 05/10/24 revealed on 05/06/24 Nurse heard yelling coming from down the hallway, she observed resident [R7]sitting in her wheelchair in the doorway of resident [R12] nurse approached the room to separate the residents .Resident [R12]reported that resident [R7] came into her room and accused her of stealing her sweater and when resident [R12] said she did not have her sweater, resident [R7] kicked resident [R12] in the leg Further review of the investigation revealed no evidence of an investigation. The investigation did not contain staff or resident statements. During an interview on 02/19/25 at 3:43 PM the Assistant Director of Nursing (ADON) she was the one responsible for completing the resident-to-resident investigation in to the incident that occurred on 05/06/24. As part of the investigation, she would make sure to talk to anyone involved and have them write a statement. The supervisor at the time of the incident would also complete a progress note/risk management. She said whatever documentation was in the file was all that was part of the investigation, and she was unsure why there were no statements by staff or residents and there should have been. She did not know why there was no other documentation in the investigation other than a summary. During an interview on 02/19/25 at 7:37 PM the Director of Nursing (DON) stated that the investigation would include staff and witness statements. The DON stated that she expected that all facility investigations to have been completed thoroughly. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation dated 05/01/24 revealed, the facility will investigate different types of incidents and have evidence that all alleged violations are thoroughly investigated.

Based on record review, interview, and review of facility policy, the facility failed to ensure that staff appropriately assessed residents with a change in condition for one Resident (R )153 from a sampled 28 residents. Additionaly staff failed to hold laxatives when the resident was having loose stools. Findings include: Review of facility's policy titled, Medication Administration dated 05/01/24 documents Medications are administered under written orders of the attending physician. lf a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse call the provider pharmacy for clarification before the administration of the medication. lf necessary, the provider pharmacy contacts the physician for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . Review of R153's Admission Record located in the resident's electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility 1/22/24 with diagnoses that included gas gangrene, cerebral infarct, rupture abdominal aortic aneurysm, cognition impairment and unspecified constipation. Review of R153's Medication Administration Record (MAR) for December 2024 located in the resident's EMR revealed the resident was started on Senna tablets (laxative) eight point six milligrams daily for constipation on 05/06/24 Review of R153's Bladder and Bowels Sheets for December 2024 and January 2025 provided by the facility revealed the resident had loose/watery stools on the following days: 12/2/24 12/3/24 (twice) 12/4/24 (twice) 12/5/24 12/6/24 12/7/24 12/8/24 (twice) 12/9/24 12/11/24 12/15/24 12/17/24 12/18/24 (twice) 12/19/24 12/21/24 (twice) 12/23/24 (twice) 12/24/24 12/25/24 (twice) 12/26/24 12/27/24 12/28/24 (twice) 12/30/24 (twice) 12/31/24 01/02/15 (twice) 01/03/25(twice) 01/04/25 (three times 01/05/25 (twice) 01/06/25 01/07/25 01/08/25 01/09/25 Review of R153's MAR for December 2024 and January 2025 located in the EMR revealed the resident received the Senna laxative on the following dates from the assigned nurses: Licensed Practical Nurse (LPN)4 administered the laxative on 12/06/24, 12/14/24 12/15/24, 12/20/24, 12/24/24, 12/28/24, and 12/29/24. In January, LPN4 administered the laxative on 01/02/25 and 1/03/25. LPN5 administered the laxative on 12/01/24 LPN6 administered the laxative on 12/10/24 Registered Nurse (RN)2 administered the laxative on 12/02/24, 12/03/24, 12/04/24, 12/05/24, 12/07/24, 12/08/24, 12/09/24, 12/11/24, 12/12/24, 12/13/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/21/24, 12/22/24, 12/25/24, 12/26/24, 12/27/24, 12/30/24 and 12/31/24. January revealed 01/01/25, 01/04/25, 01/05/25, 01/06/25, 01/08/25, and 01/09/25. RN4 administered the laxative on 12/23/24. Review of R153's Nurses Notes dated 12/01/24 through 01/09/15 located in the resident's EMR section titled Progress Notes revealed no documentation of the resident having loose water/diarrhea stools or notification to the resident's physician or Nurse Practitioner (NP). Review of R153's Nurses Notes located in the resident's EMR section titled Progress Notes dated 01/09/25 at 5:11PM revealed a note written by the NP that indicated the resident had experienced a change in condition, the resident noted with lethargy, slightly increased respirations, and low blood pressure (BP). Upon assessment, resident is grimacing as if in pain but unable to quantify or describe. Lungs were clear with no abdominal distention. Ordered intravenous fluids (IVF), immediate chest x-ray, Complete Blood Count (CBC), basic metabolic panel (BMP), and urinalysis (UA) C&S (culture and sensitivity). Resident was straight catheterized, and urine noted to be milky, thick, and malodorous. The resident was later transferred to the emergency room for treatment on 01/09/25 and was hospitalized until 02/15/25. No further information was available as to what caused the residents change of condition. Interview on 2/18/25 at 1:24PM, LPN2 revealed that on 01/09/25, the assigned certified nursing assistant (CNA)2, notified RN2 that R153 was experiencing diarrhea and a change in mental status. LPN2 stated the RN continued to pass medications and did not assess the resident. LPN2 added that RN2 continued to pass medications. LPN2 further stated CNA2 approached RN2 and expressed concern that R153 had a change in condition. LPN2 stated that she went to assess the resident and determined that he had a change in condition. LPN2 instructed RN2 that she needed to assess R153 immediately and notify the NP. LPN2 stated that she had received calls from the NP asking her to reassess residents that RN2 had called her about. LPN2 stated if the resident was having diarrhea for several days, the nurses should not have administered the Senna medication. Interview on 2/18/25 at 2:15PM, CNA2 revealed that on 01/09/25 she informed RN2 that R153 was having loose stools for the past few days and appeared to have a change in mental status. CNA 2 stated RN2 continued to pass medications and did not come to assess the resident. CNA2 stated that she returned to the resident's room to continue monitoring him. CNA2 stated the resident's condition continued to decline and she again approached RN2 voicing her concerns that the resident's mental status had changed. CNA2 stated RN2 came to the resident's room and looked at him and stated the resident was dehydrated. CNA2 stated RN2 did not perform a physical examination of the resident. CNA2 stated RN2 returned to passing medications. CNA2 stated that she felt the resident needed to be assessed immediately so she notified LPN2 (Charge Nurse) of R153's change in condition. CNA2 stated LPN2 immediately went to assess R153. During an interview with the RN1 on 02/19/25 at 2:20PM, RN1 stated that if the resident had been experiencing loose stools for several days, the Senna medication should not have been given. It was an expectation that RN2 should have immediately assessed R153's condition when the CNA made her aware of the resident's change in condition. Interview on 02/19/25 at 4:20PM, RN2 revealed she remembered the 01/09/25 incident with R153. RN2 stated that CNA2 approached her while she was passing medications about R153 having a change in mental status. RN2 stated CNA2 never informed her the resident had loose stools for several days. RN2 stated she finished passing medications to a resident, then went to assess R153. RN2 stated that she assessed the resident's lung, and bowel sounds, and noticed the resident had low blood pressure. However, RN was unable to explain if she assessed the resident's abdomen for distension or signs of a possible ileus. Interview on 02/19/25 at 4:40PM with the NP revealed that when she arrived on the unit on 01/09/25 to assess R153 she asked that the resident be straight catheterized. However, the NP stated she did not feel comfortable with RN2 performing the catheterization, so she did the procedure herself. NP stated that she has voiced her concerns about RN2's assessment skills to RN1, and the Director of Nursing (DON). The NP also stated that if the resident was having loose stools/diarrhea and continued to receive the laxative, this could have contributed to his dehydration. Interview on 2/19/25 at 06:00PM, the DON and Administrator revealed they were unaware of any problems with RN2's performance. The DON stated that RN2 had employed less than a year for the evening shift. DON stated RN2 was transferred to the LTC unit 2 months and received additional training for that unit. Both DON and the Administrator stated that they had never been approached by the NP regarding RN2's performance.

Based on observation, interview, and review of facility policy, the facility failed to ensure that expired medications and syringes were removed from one of one medication storage room. The failure has the potential for staff to inadvertently use the expired items. Findings include: Review of the facility's policy titled Storage of Medications dated 05/01/24 indicated, .Drug containers that have missing, incomplete, improper, or incorrect, labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biological are returned to the dispensing pharmacy or destroyed . Observation of the facility's main medication storage room next to the nurses' station on 02/17/25 at 1:17 PM revealed the following concerns: Six of six Magellan three-centimeter (cc) syringes with hypodermic need safety needle 23 gauge one inch with an expiration date of 07/31/21 The facility's Intravenous (IV) tray contained the following expired items: one bottle of Imipenem Hydrochloride (synthetic antibiotic) 500 milligrams (undiluted) with an expiration date of 10/24 Six female luer lock caps (used to prevent leakage) with the following expiration dates 03/26/24 (two syringes); 03/27/24 (one syringe); 05/07/24 (two syringes; and 05/08/24 (one syringe) One [NAME] Fluid Dispenser for filling dose syringe from large size syringe with expiration date 12/31/23 Interview on 02/17/25 at 02:10 PM, the Floor Supervisor Licensed Practical Nurse (LPN)2 confirmed the observations and stated that Central Supply was responsible for checking the medication storage for expired items.

Based on observation, interview and record review, it was determined that for two (R248 and R6) out of six residents reviewed for accidents, the facility failed to ensure residents were free from accident hazards and/or were provided adequate supervision to prevent accidents. R248 sustained harm when the facility failed to ensure staff provided supervision and assistance with care resulting in a fall with facial bone fractures. For R6 the facility failed to ensure the resident environment was free of an accident hazard. Findings include: 1. Review of R248's clinical record revealed the following: 5/15/23 - R248 was admitted to the facility with diagnoses including but not limited to history of fall(s) and a broken pelvis (the lower part of the trunk between the abdomen and thighs). 5/15/23 - R248 was care planned for self care deficit related to decrease in functional mobility, strength, balance and endurance and interventions included: - one person assist with bed mobility, one person assist with transfers, toileting, bathing and dressing, Set up assist with eating; - Encourage independence in ADL care, but offer assistance as needed. 5/16/23 - A PT (Physical Therapy) Evaluation documented that R248's functional assessment for bed mobility was SBA (Stand - by Assist). In addition, the PT assessment summary noted, .pt (patient) presents with reduced activity tolerance and strength needed to return to PLOF (previous level of function), Pt c/o (complained of) 7/10 pain (pain scale for severe pain in a scale of 0-10) in B (bilateral) hips and low back which limits ability to return to PLOF Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls and further decline in function. 5/20/23 10:43 AM - A nurse progress note documented, .resident lying on her left side on the floor . c/o (complained of) 'pain all over body' & yelled when left shoulder and left hip palpated .unable to indicate how she got to floor . send to (hospital) as per order via . NP (Nurse Practitioner). 911 notified .Resident left the facility at 10:30 . 5/20/23 12:20 PM - Review of the [hospital ER] physician record documented, .Patient states that she was in her usual state of health .in her bed when she rolled out into the floor while sleeping .She struck her head on the floor sustaining bruising of her face .states that she is having pain over her face .left shoulder right hip pain . 5/20/23 9:55 AM - Facility incident report revealed that, Resident was observed lying on the floor in her room. When asked what happened, she did not respond to the question during assessment, she complained of pain to her L (left) shoulder and L hip. Order was received to send her out to the ER for further evaluation .Resident was transferred to the ER at 10:30 AM . The Facility's 5 day follow up summary documented, .resident complained of generalized body pain including left shoulder and left hip pain which was exacerbated by movement .resident was sent to ER (emergency room ) and returned 5/20/23 2300 (11:00 PM) .CT (computerize tomography scan, an imaging test that takes detailed pictures of the inside of the body) of the facial bone was positive for an acute left tripod fracture (facial bone fracture) .Interview with staff showed that the fall was witnessed. The fall occurred when the assigned aid (CNA)was providing care to the resident who is a 1 person assist with bed mobility. The aid turned the resident to her side, at which time the resident suddenly rolled off the bed before the CNA could break the fall . 5/22/23 - R248's Admission MDS (Minimum Data Set) assessment revealed that R248 had a moderately impaired cognition, required extensive assist of one person for bed mobility and toileting during the review period. An extensive assist of one person staff means that a resident is involved in an activity but the one person staff provides the weight bearing support. Review of R248's May 15, 2023 through May 20, 2023 CNA flowsheet revealed that R248 was an extensive assist of one person staff in 6 out of 14 opportunities, two times on the 3-11 shift and four times during the 11-7 shift. 3/12/24 11:00 AM - Review of the facility's incident report and investigation revealed an undated written statement by E36 (CNA) and documented, I was changing [R248] (sic) I raised the bed to my waist. She crossed her leg over but put her leg over to (sic) far and fell on to the floor. She fell on to the floor and began to complain of her face and left knee hurting. I notified the nurse immediately, her vitals were checked and I waited for the EMT (Emergency Medical Technicians) to come and take her to the hospital. 3/12/24 11: 42 AM - A telephone interview with E36 revealed that she was not familiar with the resident [R248] and it was her first time taking care of her. E36 also stated that she was at the resident's bedside to change her . CNA further stated that she raised the bed with R248 on the bed, turning to be changed. R248 crossed her leg to turn to her side but she crossed her leg way too far that she rolled on to the floor and fell . I did not touch and I did not hold to support her as she was moving on her own. She moved and crossed her legs on her own. Despite the history of a fall at home resulting in an injury and a subsequent hospitalization with a fall risk and high risk of injury designation, the facility failed to ensure R248's safety when E36 turned R248 to her side while providing personal care without touching or holding to support R248, at which time R248 rolled off the bed and had a fall which resulted in facial bone fractures. 47114 2. Review of R6's clinical record revealed: Review of the facility's policy and procedure titled Fall Prevention last updated 4/1/20, documented . 1. Fall prevention is achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce the risk of falls . 2. Potential interventions may include exercise, environmental modification, medication, assistive devices, footwear etc . 3. Develop a plan of care which can include general and specific interventions to reduce fall risks. 4/6/23 - Review of R6's care plan for falls revised 1/30/24 documented .1. At risk for falls related to cognitive deficits, impaired mobility, gait/balance problems, impulsiveness, and poor safety awareness . 2. Fall mats at both sides while in bed . 3. Resident needs a safe environment with even floors free from spills and or clutter . 4. Every one hour checks. 9/17/23 - R6 was readmitted to the facility with diagnoses include dementia, schizoaffective disorder bipolar type, Parkinson disease, osteoarthritis, abnormality of gait and balance and muscle weakness. 12/19/23 - Review of R6's quarterly MDS Assessment documented R6 was severly impaired for daily decision making with a BIMS of 5 and that R6 required partial moderate assist to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Additionally, R6 required partial moderate assist to transfer to and from a bed to chair or wheelchair. 2/11/24 12:12 AM - Review of R6's fall evaluation form documented .1.Balance problem while standing. 2/29/24 11:30 AM - R6 was observed in her room sitting in the wheelchair. R6 had fall mats down on the floor at both sides of the bed, while R6 was not in bed. In addition, R6 was observed self-propelling her wheelchair towards the bed, stopped the wheelchair at the edge of the fall mat on the floor, stood up and walked on the fall mat and leaned over onto the bed to pick up R6's stuffed animal from the center of the bed. 3/1/24 11:02 AM - R6 was observed being assisted back to her room by E40 (CNA). E40 left the room and R6 remained sitting up in her wheelchair with fall mats on the floor at both sides of the bed. 3/1/24 2:26 PM - The third observation in R6's room revealed fall mats at both sides of the bed on the floor while R6 was sitting up in the wheelchair in her room. 3/5/24 10:09 AM - R6 was up and out of bed sitting in the wheelchair in her room. Fall mats at both sides of the bed on the floor. 3/5/24 11:02 AM - During an interview E40 revealed R6 had falls that's why the fall mats are down. 3/5/24 12:43 PM - During an interview E41 (LPN) revealed, [R6] is at risk for falls, and that the fall mats on the floor are a precautionary measure if R6 happens to fall at the bedside. 3/5/24 1:03 PM - During an interview E37 (RN) stated, the fall mats on the floor in [R6's] room provided a cushioned area for [R6] to fall on to if [R6] had a fall. After E37 reviewed R6's care plan for falls E37 confirmed, the fall mats should be on the floor when [R6] is in the bed. The fall mats in R6's room were picked up from the floor as R6 was observed to be sitting in the wheelchair in her room. The facility did not provide R6 a safe environment in her room. R6's care plan was not followed as fall mats were only to be placed on the floor at both sides of the bed when R6 was in bed. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) and E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

Based on observation, record review, interviews and review of facility documentation, it was determined that for one (R1) out of 3 sampled residents, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the plan of care. The facility failed to re-assess R1 after he became non-weight bearing on [DATE]; failed to communicate with PT and implement the [DATE] physician's order for PT; failed to transcribe, communicate and implement the [DATE] physician's order for PT; and failed to provide physical therapy as ordered from [DATE] to [DATE], a total of 25 days. As a result, the [DATE] PT evaluation noted a decline in R1's LE strength, poor standing balance, impaired transfers and pain on L foot upon weight bearing in contrast to his last PT evaluation on [DATE] where he was independent on transfers. In addition, R1's physician orders for wound care on [DATE] were not followed and provided from [DATE] through [DATE], a total of 18 scheduled times. Findings include: The facility's policy entitled Transcription of Orders, last revised on [DATE], stated, Orders from an authorized licensed independent practitioner (doctor) are transcribed by a licensed nurse . Purpose: To communicate all practitioners orders to caregivers regarding patient's care and treatment. 1a. R1 was admitted to the facility on [DATE] for short-term rehabilitation post hospitalization for [MEDICAL CONDITION] on the left lower leg and a wound on the anterior aspect of the left ankle. [DIAGNOSES REDACTED]. [DATE] - The Interagency Nursing Communication Record from the hospital stated that R1 was to weight bear to left foot with surgical shoe for transfers only. [DATE] - R1 was care planned for . exhibits or . at risk for decreasing ability to perform ADL . due to left leg [MEDICAL CONDITION], deconditioning . An intervention included: . Provide extensive assistance . transfers . Review of R1's clinical record revealed this care plan remained in place as of [DATE], approximately 2 ,[DATE] months later. [DATE] - A physician's order stated that Occupational Therapy would evaluate and treat ,[DATE] times a week x 30 days. [DATE] - The Occupational Therapy Initial Evaluation stated, Patient referred to skilled OT due to new onset of impaired ADL performance, impaired balance, impaired functional activity tolerance, impaired functional mobility . impaired strength and impaired transfers indicating the need for OT to increase I w/ADLs, facilitate dynamic standing balance, increase functional activity tolerance, increase safety awareness and facilitate sitting tolerance and postural control. [DATE] - A physician's order stated that Physical Therapy would evaluate and treat 6 times a week for 30 days. [DATE] - The Physical Therapy Initial Evaluation stated that R1's impairments were decreased lower extremity strength, impaired transfers and no ambulation secondary to precautions. The summary of findings stated, . Based on his diagnosis, pt weight-bearing is limited to transfers only. While this will decrease time for wound healing, pt is unable to ambulate at this time. Mild LE weakness was discovered, which will only by (sic) augmented by the increased amount of time pt will be required to spend sedentary secondary to his WBing precautions. [DATE] - The physician's admission history and physical stated that R1 was alert and oriented, had decreased vision, ambulatory dysfunction, decreased lower extremity sensation, left lower leg [MEDICAL CONDITION], severe stasis and a left lower extremity wound. The physician's plan was to continue with administration of two antibiotics for the left foot wound, local wound care treatment in addition to physical therapy and occupational therapy evaluation and treatment for [REDACTED]. [DATE] - The MDS assessment documented that R1 was able to make his own decisions and required limited assist of one staff person for transfers. This assessment was in contrast to the [DATE] care plan which required extensive assistance. [DATE] - E8's (facility's doctor) progress note stated, . L (left) foot ulcer (decreased) swelling & pain L foot [MEDICAL CONDITION] (decreased) . (decreased) LE sensation . L foot [MEDICAL CONDITION] -[MEDICATION NAME]+ [MEDICATION NAME] (antibiotics) . P. (peripheral) [MEDICAL CONDITION] - fairly advanced . amb/ADL dys (dysfunction) - cont. (continue) PT/OT. [DATE] - The Physical Therapy Discharge Summary stated all goals were met and under the summary of progress, Pt currently I (independent) with all transfers and I with HEP for continued strengthening in order to prepare for gait activities once WBing precautions on LLE are lifted. [DATE] - The Occupational Therapy Discharge Summary stated all goals were met. [DATE] and timed 9:09 AM - E7's (NP) progress note stated, . [MEDICAL CONDITION] LLE . left foot wound slowly healing . amb dys wgt bearing for transfers bed to wc, independent with ADL . no c/o pain . [DATE] - R1 was seen by S1 (wound care doctor). The consultation report, mistakenly dated [DATE], stated . Non weight bearing . The consultation report was reviewed and acknowledged by E7's initials and dated ,[DATE]. [DATE] and timed 8:00 PM - A physician's order was transcribed and stated, D/C (discontinue) WB to L foot c surgical shoe transfers. Pt is NWB LLE. It is unclear from the clinical record as to why this order was never signed by the facility's doctor and how the facility responded when R1's status changed to non-weight bearing. The clinical record lacked evidence that R1 was re-assessed when he became non-weight bearing. [DATE] - S1's consultation report stated, . (2) no ambulation . Undated - S2's (foot doctor) consultation report stated, . Ok for PT, WB as tolerated . This consultation report was reviewed and acknowledged by E8 on ,[DATE]. [DATE] and timed 10:35 PM - The undated S2's consultation report was transcribed to a physician's order, however, this order was never received by PT. The facility failed to provide PT despite a consulting physician's order to do so. [DATE] - S2's consultation report stated, Wound looks healed - Start PT to (increase) strength L leg . - C/W (continue with) transfer - Ok for limited WB while in PT setting c supervision . This consultation report was reviewed and acknowledged by E7 on ,[DATE]. It is unclear in the clinical record why the above orders were never transcribed as a physician's order and implemented. S2's second order to start physical therapy was never received by PT. The facility failed to provide PT despite a consulting physician's order to do so. [DATE] - E7's progress note stated, . seen by S2, wound looks healed . [MEDICAL CONDITION] LLE . ok for limited WB . keep LLE elevated . [DATE] - Record review revealed a faxed copy of a prescription addressed to E5 (UM, RN) from S2 which stated, patient is weight baring (sic) as tolerated for PT. The facility failed to provide PT despite a consulting physician's order to do so. [DATE] - Record review revealed a faxed copy of a prescription addressed to E12 (facility's unit clerk) from S3 (foot doctor's staff) which stated, Pt cleared to WB L leg. [DATE] and timed 2:00 PM - E12's typed statement in R1's clinical record stated, Received call back from S3 . S3 stated, 'He (S2) would not write a rx (prescription) for R1 to be discharged . That is our Medical Director's decision. He has already written a rx for full weight bearing.' E12 verbalized understanding of (S2's) decision & reiterated that R1 insisted this rx come directly from (S2) . [DATE] - A physician's order stated that R1 was to bear full weight on LLE. [DATE] - E8's progress note stated, c/o (complaint of) L LE pain - asking staff to Hoyer lift him - called police to complain . L good pedal pulse . no [MEDICAL CONDITION] L foot . skin intact . hoyer lift is inappropriate - D/W patient. L LE wound has healed. He has good pulses. There is no reason why he can't bear full weight on L LE. D/W . podiatry & he agrees c my assessment. Full weight bearing ordered. D/W staff. Pt needs to go home! Medically stable for D/C (discharge). R1 was not discharged . E8 ordered full weight bearing despite the fact that R1 had been non-weight bearing since [DATE] and despite the fact that R1 had not received PT for weight bearing as ordered twice by a consulting physician. [DATE] - Two physician's orders stated that OT and PT were to evaluate and treat R1. [DATE] and timed 2:10 PM - An observation was made of PT and OT assessing R1's range of motion, strength and transfers. R1 demonstrated how he was transferring himself from the bed to the wheelchair and vice versa. E9 (PT Director) stated, This is different (referring to transfers) than when we evaluated you before. E9 and E10 (OT) stated that R1 was a good candidate for using a sliding board when transferring as they both agreed his self-transfer status was not safe. [DATE] and timed 4:16 PM - The Occupational Therapy Initial Evaluation stated, . Patient referred to skilled OT due to impaired ADL performance, impaired functional mobility and impaired transfers . Pt previously on OT caseload from [DATE] to [DATE]. Pt was d/c secondary to all goals met and was issued theraband UE HEP. Pt reports 'probably not as much as I should have' in re: to whether he has been completing HEP . Pt unsafe during transfer. Pt does not WB through LLE . PLOF = independent (at previous OT d/c) . Pt reports pain ,[DATE] when he weight bears on L foot, ,[DATE] at rest . Pt presents with decline in safety during transfers, slight decline in functional transfers, limited standing tolerance requiring skilled OT services to address. Recommend OT 3x/week in conjunction with UE HEP in order to increase I with toileting and functional transfers and to increase safety during transfers. Recommend OT cotreat with physical therapy for safety during transfers. [DATE] and timed 4:41 PM - The Physical Therapy Initial Evaluation stated, R1's impairments were pain on L foot upon wt bearing, poor safety awareness during transfers and poor standing balance. The clinical impressions were Pt is noted with pain and muscle weakness on L foot upon wt bearing resulting to poor standing balance and increasing risk for falls . Pt will benefit from skilled PT services to increase LE strength, improve balance, and complete transfers safely in order to decrease risk for falls, and allow patient to return home at highest functional level. The reason for the referral stated, Patient demonstrates new onset of impaired transfers and pain indicating the need for PT to increase strength, promote safety awareness and reduce risk for falls . Pt was previously on PT/OT caseload and was d/c secondary to meeting all goals. Pt is re-evaluated for PT/OT and services per consult with E1 (NHA) and E2 (DON). This re-evaluation occurred after a meeting with DLTCRP. As noted by OT and PT on [DATE], Pt. was d/c secondary to all goals met . and . all goals were met . Pt currently I with all transfers . On [DATE], however, OT and PT noted, Pt unsafe during transfer. Pt does not WB through LLE . Pt presents with decline in safety during transfers, slight decline in Functional transfers . and . poor safety awareness during transfers and poor standing balance . increasing risk for falls . new onset of impaired transfers and pain . [DATE] at 3:10 PM - In an interview, E9 stated that he was not notified by nursing of the [DATE] and [DATE] physician orders for PT from S2. E9 stated the last time he saw R1 on a clinical basis was [DATE] and he was independent with transfers. [DATE] at 7:53 AM - In an interview, E7 stated that consultation reports are orders from other doctors and they are to be followed and implemented. E7 expected that R1's order was being followed and that R1 was receiving PT. [DATE] at 9:50 AM - In an interview, E13 (LPN) stated that she did not write the [DATE] physician's order for non-weight bearing LLE, however she signed the order at 8:00 PM and transcribed it to the TAR. E13 stated that the Physical Therapy department was closed at that time and she slid it under PT's door. E13 then stated that she placed the original physician's order and S1's consultation report in the facility's doctor folder to be signed. E13 also stated that she passed on R1's non-weight bearing status in report to the next shift. [DATE] at 10:50 AM - In an interview, E14 (RN) stated that she received S2's [DATE] consultation report that stated ok for physical therapy, weight bearing as tolerated and transcribed it to a physician's order and the TAR. E14 stated that she thought R1 was on PT's caseload and admitted that she did not notify PT of the new order. E14 stated that she placed the physician's order and S2's [DATE] consultation report in the facility's physician folder to be signed. E14 stated that she passed on R1's new orders to the next shift. [DATE] at 12:03 PM - In an interview, R1 stated that he gave S2's [DATE] consultation report to E5 as he returned to the facility during day shift. [DATE] at 2:51 PM - In an interview, E11 (PT) stated that she was covering the PT department when E9 (PT Director) was on vacation from [DATE] through [DATE]. When asked if anyone on staff approached you from [DATE] through [DATE] about R1 asking to talk to E9 about transfer status and restarting PT, E11 stated no. [DATE] at 3:04 PM - In a telephone interview, S3 stated that this office received multiple calls from the facility's staff inquiring about scripts for R1's weight bearing status and discharge. S3 stated We were under the impression that he had been there doing the physical therapy. [DATE] at 7:17 AM - In an interview, E5 stated that the consultation reports are not actual orders and they have to call E8 to get her approval before they follow the consultant's recommendations. The facility failed to re-assess R1 when he became non-weight bearing on [DATE]; failed to communicate with PT and implement the [DATE] physician's order for PT; failed to transcribe, communicate and implement the [DATE] physician's order for PT; and failed to provide physical therapy as ordered from [DATE] to [DATE], a total of 25 days. As a result, the [DATE] PT evaluation noted a decline in R1's LE strength, poor standing balance, impaired transfers and pain on L foot upon weight bearing in contrast to his last PT evaluation on [DATE] where he was independent on transfers. Findings were reviewed during the exit conference on [DATE] at 5:30 PM with E1 and E2. 1b. [DATE] - R1 was seen by S1 for a left ankle wound. S1's consultation report stated, . continue . wrap and [MEDICATION NAME] BID (twice a day). [DATE] - S1's consultation report stated, moisturize & wrap BID. Make sure wrap is applied correctly. Rectagles (sic) become square and should be seen all the way down. It is unclear in R1's clinical record as to why S1's order was not transcribed onto a physician's order sheet and the [DATE] TAR updated. [DATE] - A physician's verbal order from E8 stated to discontinue [MEDICATION NAME] as the left ankle wound had healed. Review of R1's [DATE] TAR revealed that R1's treatment for [REDACTED]. The [DATE] TAR revealed that when the [MEDICATION NAME] wound treatment was discontinued on [DATE] so was R1's prescribed wrap twice a day. [DATE] - S1's consultation report stated, . 1) Will need . wrap every day. Off at bedtime . Will need this dressing regimen for lifetime . compression wrap used to treat swelling. Essential to prevent further wounds . [DATE] - In an interview at 6:45 PM, S6 (POA) stated that E5 told her S1's order expired and E5 was not going to wrap R1's left leg. S6 stated that she told E5 that R1 had an order to wrap his left leg twice a day. S6 stated that she had to take R1 to another consult with S1 on [DATE] in order to obtain a lifetime order for a compression wrap. The facility failed to follow S1's physician orders for a compression wrap from [DATE] through [DATE], a total of 18 scheduled times. Findings were reviewed with E1 and E2 on [DATE] at 5:30 PM.