Every finding on record at Geer Nursing and Rehabilitation

Based on observation, record and policy review, and interviews, the facility failed to maintain the resident environment as free of accident hazards and to provide adequate supervision consistent with the resident's assessed needs for 1 of 3 resident reviewed (Resident #58). Despite assessment and care-plan directives indicating supervision/touch assistance with eating and nectar-thick liquids, staff placed very hot coffee (dispensed from resident-accessible machines measured between approximately 178-182 F, with vendor settings later confirmed at 194 F and only reduced to 176 F) in front of Resident #58 without supervision, resulting in Resident #58 spilling coffee on his/her lap and sustaining a second-degree burn to the left thigh (blistering/open areas documented 3/6/26-3/20/26). The facility lacked monitoring controls for hot-beverage dispensers accessible in dining activity areas and did not monitor resident tap water temperatures, which survey measurements found above 120 F in two occupied rooms. These failures to supervise Resident #58 consistent with assessed needs and to ensure accessible hot water dispensers were at safe temperatures resulted in actual harm and placed resident at risk for further burns. These findings resulted in the findings of immediate jeopardy. 1. Resident #58's diagnoses included dysphagia, unspecified lack of coordination and abnormal posture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was moderately cognitively impaired, was dependent with toileting, transfers, and bed mobility. The MDS further noted Resident #58 required supervision and touch assistance with eating and had an upper extremity impairment on one side. The MDS also identified Resident #58 was on a mechanically altered and therapeutic diet. The Resident Care Plan (RCP) dated 12/19/25 identified Resident #58 had a self-care performance deficit related to activity intolerance, musculoskeletal impairment and a need for assistance with personal care. Interventions included aspiration precautions, close supervision with intake by mouth (PO), instructing Resident #58 to eat slowly in an upright position, and alternate small bites of food with sips of liquid. A physician's order dated 2/22/26 directed a heart healthy diet with chopped texture, nectar thick liquid consistency, distant supervision during by mouth (PO) opportunities and to assist Resident #58 with meals as needed for progressive fatigue every shift. A facility Reportable Event (RE) form dated 3/5/26 at 11:30 AM identified the Nursing Supervisor was notified by the Nurse Aide (NA) that Resident #58 had spilled coffee on his/her lap and a reddened area to the left thigh was noted. The RE form indicated Resident #58 was pleasantly confused and required total care before the event, the Advanced Practice Registered Nurse (APRN) and family had been notified and an investigation was initiated. A nursing note dated 3/5/26 at 12:39 PM identified the Nursing Supervisor was notified that while at a recreational activity, Resident #58 spilled coffee on him/herself and the resident's left thigh had reddened intact skin and the APRN was notified. A physician's order dated 3/6/26 directed to check the left thigh blisters (a progression from reddened intact skin on 3/5/26 to blisters) every shift and if the blisters open cover the area with a dry clean dressing. An APRN progress noted dated 3/6/26 at 12:48 PM identified Resident #58 had a hot coffee spill to his/her left thigh, and the burn area had 6 red spots, and 3 intact fluid filled blisters. The diagnosis was a second-degree burn of the left thigh. New orders were to check the burn area every shift and, if the blisters opened, to cover the blisters with a non-stick dry dressing and notify the APRN. A nursing note dated 3/8/26 at 4:11 PM identified Resident #58's small blister to the left upper inner thigh had opened, the area was covered with a dressing, and the Nursing Supervisor was notified. An APRN progress note dated 3/9/26 at 3:06 PM identified Resident #58's blisters sustained last week were now open and the burn presented with erythema (reddened skin due to inflammation) and the redness remained present. The plan was to cover the open blisters with a dry clean dressing, change daily, and continue with wound care management due to the second-degree burn. A nursing note dated 3/15/26 at 5:58 PM identified Resident #58 had an open left inner thigh blister, and a new dressing was applied. A physician's progress note written by the wound care specialist and dated 3/20/26 identified Resident #58 was seen for an initial evaluation for his/her wounds. The wound assessment indicated the left medial thigh had a second degree burn measuring 1.0 centimeter (cm) by 1.5 cm, the left lateral thigh had a second degree burn measuring 1.0 cm by 5.0 cm. Treatment recommendations were to apply skin prep to both of the scabbed blistered areas twice daily. A physician's order dated 3/20/26 and currently in effect directed to apply skin prep twice daily to the left lateral and medial thigh blisters and leave areas open to the air. Interview with Licensed Practical Nurse (LPN) #2 on 4/9/26 at 12:50 PM identified Resident #58 was supervised while eating and had required staff to assist him/her with feeding for a long time. LPN #2 indicated she was working as the charge nurse when Resident #58 spilled coffee on his/her leg, and the staff had not been giving the resident hot beverages since. LPN #2 identified NA #3 made the nectar thick coffee on the unit for Resident #58 with the hot water from the hot beverage machine located in the dining room/lounge. LPN #2 further noted that NA #3 proceeded down the hall to the Recreation Room and provided the coffee to Resident #58 to drink on his/her own. LPN #2 indicated a short time later that the recreation assistant brought Resident #58 back to the unit and indicated the resident had spilled hot coffee on his/her leg. Additionally, LPN #2 stated Resident #58's upper left leg was reddened, and she recalled the reddened area developed into blisters the next day. Interview and review of a facility documented witness statement dated 3/5/26, with NA #2 on 4/9/26 at 12:50 PM identified Resident #58 attended the recreation program and should not have been left alone with hot coffee due to the resident's confusion and weakness. NA #2 indicated she was working when the recreation assistant brought the resident back to the unit and told her Resident #58 had spilled coffee on him/herself, she then notified LPN #2 about the incident. NA #2 identified once Resident #58 was back in bed a large area of skin on his/her upper left leg was red and later developed blisters. Interview and observation with NA #3 on 4/9/26 at 12:59 PM identified he made coffee for Resident #58 on 3/5/26 for the recreation program and he was aware the resident spilled the coffee and sustained a burn on his/her leg. NA #3 indicated he utilized the hot water from the hot beverage machine in the unit lounge/dining room to mix with the nectar thick powdered coffee packet to make the coffee for Resident #58. NA #3 identified after he mixed the coffee packet of nectar consistency with water, he immediately delivered the plastic handled mug filled with nectar thick coffee to Resident #58 (who was down the hall, seated at a table in his/her wheelchair in the recreation room). He indicated although he was unable to recall if the resident was reclined or sitting upright in the wheelchair, he placed the coffee filled mug on the table in front of Resident #58 for him/her to drink alone, alerted the Recreation Aide that he was leaving coffee with Resident #58 and left the room. Additionally, NA #3 stated because he was aware the water came out of the hot beverage machine very hot; before he left the recreation room he informed Resident #58 (who was moderately cognitively impaired) and the recreation staff to be careful because the coffee was very hot.An observation with NA #3 on 4/9/26 at 1:02 PM identified the hot beverage machine he utilized to make the coffee for Resident #58 dispensed hot water into a plastic handled mug at a temperature of 178 F. After 1 minute the hot water temperature was 173 F, after 2 minutes the hot water temperature was 166 F, after 4 minutes the hot water temperature was 161 F, and after 8 minutes the hot water temperature was 150 F. NA #3 further indicated although the residents on the unit utilized and had direct access to the hot beverage machine to make coffee, tea, or hot chocolate, there was no safety mechanism on the machine that he knew of (dispensing by pressing 1 button). NA #3 further stated he thought the water was supposed to come out of the machine too hot. Interview and review of a facility obtained witness statement dated 3/5/26 with the Recreation Aide on 4/9/26 at 1:06 PM identified she observed NA #3 bring the coffee to Resident #58 and put it on the table in front of the resident. The Recreation Aide did not recall what kind of cup the coffee was in, if the resident was sitting up or reclined in the wheelchair, or if NA #3 said anything out loud before leaving the room. Although she was in the general area of Resident #58, she was not supervising the resident and did not witness the coffee spill on his/her leg. The Recreation Aide was unable to indicate how much coffee the resident spilled and stated the Recreation Assistant brought the spill to her attention and then returned Resident #58 back to the unit/charge nurse. Interview with the Maintenance Director and the Director of Nursing Services (DNS) on 4/9/26 at 2:23 PM identified other than giving the resident a lidded cup for hot beverages, no further interventions were implemented to ensure another resident would not be injured following Resident #58's burns on 3/5/26. The DNS indicated she did not go back to the source or do an investigation of the incident on 3/5/26 and in retrospect, although the facility should have determined if there was an issue with the temperature of the liquids coming out of the hot beverage machines, they did not. Additionally, the DNS identified Resident #58 required assistance to eat and drink and if NA #3 thought the coffee was too hot should not have put it down in front of Resident #58 and should not have left Resident #58 alone with hot coffee. Interview with the Recreation Assistant on 4/10/26 at 3:20 PM identified she recalled the incident when Resident #58 spilled hot coffee in his/her lap on 3/5/26. She indicated that shortly after NA #3 served Resident #58 the plastic handled mug with coffee inside, and while she was serving other residents' coffee, she did not witness Resident #58 spill the coffee but was alerted by another resident. The Recreation Assistant was unable to recall if NA #3 said anything out loud to Resident #58 after he placed the mug of coffee on the table in front of Resident #58 or before he left the room. She identified the resident spilled the coffee right away as it was before the recreation activity had even started. Although she was unsure of the amount of coffee the resident spilled, she put cold water on a towel for the resident's leg and brought the resident back to the unit/charge nurse. Additionally, the Recreation Assistant identified she did not know Resident #58 well because the resident had rarely attended coffee programs before. 2. An observation with the Maintenance Director on 4/9/26 at 1:59 PM identified the hot beverage dispenser machine (used to make hot water, coffee, tea and hot chocolate) in the first-floor dining/activity room was located on a counter and accessible to residents. The hot water dispensed into a plastic handled mug at that time measured a temperature of 182 F. The hot beverage dispenser machine located in the third-floor locked closet dispensed hot water into a plastic handled mug at a temperature of 180 F. An observation with NA #3 on 4/9/26 at 1:02 PM identified the hot beverage machine located on the counter in the dining room and accessible to residents dispensed hot water at a temperature of 178 F. After 1 minute the hot water temperature was 173 F, after 2 minutes the hot water temperature was 166 F, after 4 minutes the hot water temperature was 161 F.Additionally, the Maintenance Director identified the hot beverage liquid dispensing machines were the property of an outsourced kitchen company and there were 3 of them located in the facility, (1 in the first floor activity/dining room accessible to residents, 1 in the second floor lounge/dining area accessible to residents and 1 inside of a locked closet next to the third floor lounge/dining area). The Maintenance Director indicated he did not deal with the kitchen company, never monitored the dispensed liquid temperatures of the machines to ensure they were at an appropriate temperature to prevent burns, and was unsure when or what maintenance had been performed on the dispensers. Both the Maintenance Director and the DNS stated that the hot beverage dispenser machines on the first and second floor did not have a safety mechanism to prevent the dispensing of hot liquids (1 button was pushed to dispense liquids). Residents utilized and had direct access to those 2 machines, and the machines had been in the facility for over a year. The Maintenance Director further stated he was unsure if the machines had temperature regulators on them and was not aware of what temperatures the machines were set at. Interview with the Dietary Director on 4/9/26 at 2:40 PM identified that although there were limits that water temperatures should be for hot beverages served to the residents, he was unsure what they were. The Dietary Director indicated an outsourced kitchen company supplied the facility with the hot beverage machines, and he never took or monitored temperatures of the liquids and didn't know if he should have. The Dietary Director identified he was aware the hot beverage machines on the first and second floor were utilized by and offered direct access to the residents of the facility. Subsequent to surveyor inquiry on 4/9/26 at 3:05 PM the Maintenance Director and Administrator indicated that all 3 of the hot beverage machines had been disconnected and disabled and the outsourced kitchen company would be at the facility to service the machines as soon as possible. Re-interview and review of facility documents with the Dietary Director on 4/9/26 at 3:13 PM identified the kitchen company was scheduled to be at the facility on 4/10/26 to lower the temperature on the hot beverage machines. Review of the facility Food Holding Temperature Log indicated liquids, which the Dietary Director stated included coffee, should be served to residents at a temperature no higher than 165 F. He further indicated the kitchen only made and sent coffee to the units for breakfast service, so residents who requested coffee or another hot beverage for lunch or dinner, needed to utilize the hot beverage machines. A third interview with the Dietary Director on 4/10/26 at 9:35 AM identified the kitchen company representative was at the facility to lower the water temperatures on the hot beverage machines. The Dietary Director indicated all 3 machines in the facility were found to been set at 194 F for the water temperature, which was a high setting. The Dietary Director stated the 3 machine temperatures were being lowered to 176 F (which was still above the temperature to potentially cause burns). Interview with the outsourced kitchen company representative (vendor service person) on 4/10/26 at 9:45 AM identified on 4/9/26 he was called to the facility to service the hot beverage machines and found all of the machines were set at 194 F, which was considered a high setting for the machines. The kitchen company representative indicated there was no safety mechanism on the machines for dispensing the hot liquids and although the machine temperatures were all being lowered to 176 F (the lowest temperature the machine could go without compromising the machine's operation) he indicated residents should still be supervised or assisted if using the machine. The kitchen company representative further indicated that although he had installed the same machines at other facilities, he was unsure if the machines were safe in areas where a cognitively impaired resident would have direct access. Review of the work performed summary provided by the kitchen company representative (vendor service person) dated 4/10/26 indicated water temperature for all 3 machines were set for 194 F and needed to be lowered to 176 F. Subsequent to surveyor inquiry, observations on 4/13/26 at 10:13 AM and 4/13/26 at 10:22 AM identified although the hot beverage dispensers on the first and second floor remained in the same locations and had large CAUTION Hot Liquids signs posted on them. Review of the hot beverage machines operator manual, provided by the Dietary Director, identified the dispenser was not intended for use by persons with limited physical, sensory, and mental faculties or persons with insufficient experience and/or knowledge of the dispenser. The manual also indicated the liquids delivered by the dispenser were hot! and to keep hands and other body parts away from the dispenser. Although requested a policy on hot beverages was not provided by the facility. 3. Observation on 4/7/26 at 11:00 AM and 3:00 PM with Maintenance Worker #1 identified water temperatures in room [ROOM NUMBER] were 128.3 degrees ( ) Fahrenheit (F) at 11:00 AM and 128.8 F at 3:00 PM. Additionally, water temperatures in room [ROOM NUMBER] were 127.2 F at 11:07 AM and 121.7 at 3:00 PM. Both rooms were occupied with 2 residents and one resident in each room was able to use the sink independently.Interview with the Administrator on 4/7/26 at 2:15 PM identified that Nursing Supervisors on all 3 shifts were responsible for monitoring water temperatures (not maintenance) and notifying maintenance if there were any issues.Interview with Registered Nurse (RN) #1 on 4/8/26 at 9:20 AM (who was the 7:00 AM to 3:00 PM nursing supervisor) and RN #2 (who was the 11:00 PM to 7:00 AM shift nursing supervisor) identified that they were not monitoring water temperatures and have never been instructed to do so. Additionally, RN #1 and RN #2 noted they were not aware of any water temperature logs. RN #1 indicated that she had been employed at the facility for 3 years as a nursing supervisor and that she was never informed that monitoring water temperatures was part of the nursing supervisor job duties. Interview with the Administrator on 4/8/26 at 9:35 AM identified that he was not aware nursing was not monitoring or documenting water temperatures.Interview with the Director of Facilities Maintenance (DM) on 4/8/26 at 10:00 AM identified that maintenance had never monitored or documented water temperatures and had never been instructed to do so, The DM was informed that nursing was monitoring water temperatures although he had never seen a water temperature log, had he ever provided any education to nursing on how to take water temperatures or provide them with the appropriate water temperature ranges. The DM identified the facility did not have a policy for monitoring water temperatures that he was aware of, and that he was not aware of a regulation which directed to monitor water temperatures in resident bathrooms/rooms. Furthermore, subsequent to surveyor's elevated temperature readings, he indicated the vendor replaced the mixing valve in the evening on 4/7/26 as it had a buildup of sediment that would affect temperature stability.Subsequent to surveyor inquiry, the Administrator and DNS were in the process of developing a policy for water temperature monitoring for the facility. In addition, nursing supervisors were continuing to conduct random water temperature monitoring on the first and second floor for all 3 shifts with immediate notification to the DM for any water temperatures that were out of normal range. After observations made on 4/7/26, the three coffee machines were shut down until the manufacturer could assess the hot beverage dispensing machines and lower the temperatures. Staff were instructed not to serve coffee directly to residents and coordinate with the kitchen for distribution. The manufacturer subsequently lowered the temperature to 179 F as that was the lowest temperature the machine could be set at to prevent bacterial growth. Once determined that the temperature could not be further lowered, all machines were equipped with warning signage to ensure awareness of the temperature. The above deficiency resulted in the findings of Immediate Jeopardy (IJ). The facility Administrator was provided with the IJ template on 4/30/26 at 9:17 AM and submitted a removal plan which was approved by the Stage Agency on 4/30/26. On 4/30/26 at 9:52 AM, tour of the facility identified the hot beverage dispensing machine on the 1st floor dining/recreation room remained accessible to resident and was being dismantled by the Director of Maintenance. Interview with the Director of Maintenance on 4/30/26 at 12: 41 PM noted that the hot beverage dispensing machine on the 1st floor had been in operation until surveyor inquiry on 4/30/26 and that he was instructed by the Administrator to dismantle and remove the hot beverage dispensing machines from the 1st and 3rd floors. The hot beverage dispensing machine had previously been removed from the 2nd floor dining room.The removal plan noted in part, that the hot beverage dispensing machines were removed and the kitchen would now prepare and distribute coffee in carafes to each unit.Observations on 4/30/26 identified the facility implemented the removal plan and the IJ was removed.

Based on observation, interviews, facility policy review and clinical record review, the facility failed to implement pressure-ulcer prevention consistent with professional standards of practice for 1 of 3 residents reviewed for pressure ulcers (Resident #58), who was repeatedly identified as high risk on Braden assessments (5/22/24, 2/29/25, 3/12//26, 4/6/26) but had no care-plan problem or prevention interventions addressing pressure-injury risk until after developing a facility-acquired Stage 2 coccyx ulcer on 4/6/26 (2.0 cm by 2.0 cm). Despite physician orders for topical treatment on 4/6/26, surveyor observation on 4/13/26 found the resident positioned supine after incontinent care without offloading of the coccyx, evidencing ongoing failure to implement preventions/treatment measures. This deficient practice resulted in actual harm (a Stage 2 pressure ulcer) and placed the resident at continued risk for worsening skin breakdown. The findings include: Resident #58 was admitted to the facility in February 2024 with diagnoses that included fracture of the left humerus, need for assistance with personal care and limitation of activities due to disability. An annual Braden Scale assessment dated [DATE] identified Resident #58 remained a high risk for the development of pressure ulcers/injuries. A quarterly Braden Scale assessment (a tool used for predicting pressure ulcer risk) dated 5/22/24 identified Resident #58 was at high risk for the development of pressure ulcers/injuries. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS also indicated Resident #58 had an upper extremity impairment on one side and was at risk of developing pressure ulcers/injuries based on formal and clinical assessments. A quarterly Braden Scale assessment dated [DATE] identified Resident #58 remained a high risk for the development of pressure ulcers/injuries. The Resident Care Plan (RCP) dated 3/17/26 identified Resident #58 had a self-care performance deficit and required assistance of two staff to turn and reposition in bed related to an activity intolerance and musculoskeletal impairment. Interventions included to provide assistance of 2 staff for incontinent care, to observe the resident's skin for redness or open areas and report changes to the nurse. The RCP failed to identify Resident #58's risk for developing pressure ulcers or identify interventions to prevent the development of pressure ulcers. A significant change Braden Scale assessment dated [DATE] identified Resident #58 remained a high risk for the development of pressure ulcers/injuries. A facility Reportable Event (RE) form dated 4/6/26 at 10:00 AM identified Resident #58 had developed an open area on his/her coccyx which measured 2.0 centimeters (cm) by 2.0 cm. The RE form indicated the Advanced Practice Registered Nurse (APRN) and family were notified and the resident had remained total care for activities of daily living (ADLs) and toileting. A Facility Acquired Pressure Ulcer (PU) investigation report dated 4/6/26 indicated Resident #58 had developed a Stage 2 pressure ulcer to the coccyx and the resident's care plan was updated. A physician's order dated 4/6/26 directed to apply Triad paste to the coccyx topically every shift and as needed for open area. A nursing note dated 4/6/26 at 1:44 PM identified the nursing supervisor was made aware that Resident #58 had a 2.0 cm by 2.0 cm open area to the coccyx area, the APRN was updated and a new order for Triad to the area every shift and as needed was obtained. Interview and review of the clinical record with the MDS nurse (RN #4) on 4/10/26 at 1:20 PM identified although Resident #58 was high risk for developing pressure ulcers/injuries according to the MDS and the Braden Scale assessment, a care plan was not developed for the prevention of the development of a pressure ulcer with no interventions in place to prevent a pressure ulcer from developing. RN #4 indicated Resident #58 should have had a care plan with interventions for pressure ulcer prevention in place and it would have been the unit manager, nursing supervisor or her responsibility to ensure the care plan was initiated and updated. RN #4 was unable to indicate the reason a care plan with interventions for pressure ulcer prevention was not in place and indicated when the quarterly MDS assessments were completed she should have realized pressure ulcer preventions were not included in the care plan, corrected and updated the care plan. Interview and review of the clinical record with the unit manager (RN # 5) on 4/10/26 at 2:15 PM identified it would have been her responsibility to complete the Braden scale assessment, assess the resident's skin on admission and implement a care plan for pressure ulcer prevention and she was unsure why that was not done. Review of the resident's care plan with RN #5 failed to identify Resident #58 was at risk for pressure ulcers and failed to provide interventions for the prevention of pressure ulcer development. RN #5 stated Resident #58 only utilized a standard pressure relieving mattress on the bed and she would have expected to see other interventions for pressure ulcer prevention in place. Interview and review of the clinical record with the Medical Director (MD #1) on 4/10/26 at 2:25 PM identified he was aware Resident #58 had developed a pressure ulcer on his/her coccyx on 4/6/26 and the resident was prone to developing pressure ulcers. MD #1 stated Resident #58 spent a lot of time in bed and he did not see him/her out of bed all that much. MD #1 indicated Resident #58 should have had a risk for pressure ulcer development identified in the care plan and interventions to prevent the development of pressure ulcers should have been put in place. MD #1 identified it would have been the responsibility of the nursing staff to develop the care plan and to put interventions in place to prevent the development of a pressure ulcer. Interview and review of the clinical record with the Director of Nurses (DNS) on 4/10/26 at 2:40 PM identified for a resident with a high-risk Braden Scale there should be a care plan in place for the prevention of pressure ulcers. Review of Resident #58's care plan with the DNS failed to identify a care plan with interventions in place to prevent the development of pressure ulcers/injuries. The DNS indicated other than the standard pressure relieving mattress (which all residents have), Resident #58 did not have other interventions in place which would have prevented the development of his/her pressure ulcer on 4/6/26. The DNS further identified it would have been the responsibility of RN #4 and RN #5 to ensure Resident #58 had a pressure ulcer prevention care plan in place because the resident was largely incontinent. Additionally, the DNS indicated it was an oversight by RN #4 and RN #5 because upon review at Resident #58's quarterly care plan meetings, it should have been identified, and pressure ulcer prevention should have been included in the care plan. Observation on 4/13/26 at 10:05 AM of Resident #58's Stage 2 coccyx pressure ulcer identified there were multiple open areas with red/pink wound beds and surrounding redness noted. The physician ordered barrier cream was applied by NA #5, the resident was positioned in a supine position (on his/her back) and was not offloaded from the coccyx after incontinent care was provided. Interview with the Nursing Supervisor (RN #6) on 4/13/26 at 12:10 PM identified Resident #58 was in bed in a supine position and was not positioned off his/her coccyx. Review of the facility policy, Pressure Sores, dated 4/24, directed a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure. A pressure sore risk assessment (Braden Scale for Predicting Pressure Sore Risk) will be done for all residents on admission and quarterly and based on individual risk factors, a preventative plan will be written and implemented. A Stage 2 pressure sore is a partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. Upon development of a pressure sore the care plan will be reviewed and revised based on individual risk factors.

Based on the facility policy, record review, and interviews for 1 of 4 sampled residents (Resident #34) reviewed for accidents, the facility failed to ensure the Resident Care Plan (RCP) was reviewed and revised after a fall to include added interventions to prevent further falls. Resident #34's diagnosis included dementia, hypertension, and atrial fibrillation.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was cognitively intact and independent for eating. The MDS also identified Resident #34 required substantial/maximal assistance for bathing, dressing, and partial moderate assistance for transfers. The MDS further identified Resident #34 had a history of falls with minor injuries.The RCP dated 1/24/26 identified Resident #34 was at risk for falls with interventions that included to place Resident #34 in an observable area such as the lounge to prevent the resident from attempting to ambulate unassisted, offer the restroom every 2 hours while awake, and provide/keep the resident in an observable area when awake.A nursing note dated 1/26/26 at 1:14PM identified Resident #34 was found on the floor in the unit shower core. Resident #34 denied pain and had full range of motion to all extremities. Resident #34 was provided with incontinent care.A Reportable Event (RE) form dated 1/26/26 identified Resident #34 had an unwitnessed fall and was attempting to go to the bathroom while using his/her walker. The Disposition/comment section on the RE form identified staff was to make sure the shower core door was closed and locked.A Fall Risk assessment dated [DATE] identified Resident #34 had a history of falls in the past 3 months of 3 or more. Also, identified Resident #34 used a walker, was incontinent and ambulatory.An interview and review of the RCP on 4/10/26 at 1:28 PM with the MDS Registered Nurse (RN) #4 identified the RCP was not updated on 1/26/26 after Resident #34 fell to include the interventions to ensure the shower core door was closed and locked. Also, identifying RN #5 was responsible to update the RCP after the fall because she had filled out the Reportable Event form. Further, identifying the RCP per the facility policy was to be updated with interventions and the fall should be identified on the RCP with the date.Interview on 4/10/26 at 1:48 PM with the Director of Nursing Services (DNS) identified that the RCP failed to indicate a fall on 1/26/26 nor was it updated with the new intervention to ensure staff close and lock the shower core door. Also, identifying the staff member who completed the Reportable Event form was responsible for updating the RCP after the fall and this was the facility policy.An interview on 4/10/26 at 2:11 PM with RN #5 identified she did not update the RCP after Resident #34 fell on 1/26/26 per the facility policy. Also, identifying she was responsible for updating the RCP with the date of the fall and providing a new intervention to the RCP. Further, identifying it was an oversight on her part.Review of the Reportable Event policy dated 10/2016 directed in part to ensure that all accidents and incidents involving resident are documented and investigated with remedial measure developed and implemented to prevent further reoccurrence when possible. An accident/incident was defined as any happening not consistent with the routine operations of the facility involving residents, which may or may not have resulted in an injury and or property damage. Also, a reportable event form was to be completed by the charge nurse or supervisor who evaluated the circumstances of the event. The form should give as complete a description as possible of the reportable event. The nursing supervisor or the charge nurse will be responsible for checking the accuracy, completeness, appropriate interventions have been implemented and documented. Care plan changes should be documented.

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #58) reviewed for pressure ulcer/injuries, the facility failed to ensure appropriate personal protective equipment (PPE) was donned (placed on) prior to incontinent care for a resident on enhanced barrier precautions (EBP) and failed to ensure staff handled soiled items and linens appropriately and for Resident #82, the facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy and in a manner to maintain a clean environment. The findings included: 1. Resident #58's diagnoses included fracture of the left humerus, need for assistance with personal care and limitation of activities due to disability. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was significantly cognitively impaired and was dependent with bed mobility, toileting, and transfers.The Resident Care Plan (RCP) dated 3/17/26 identified Resident #58 had history of Clostridium Difficile (C. Diff) (a bacterium that causes severe diarrhea which is highly contagious) and a need for assistance with personal care. Interventions included to maintain Enhanced Barrier Precautions and assistance of 2 staff for incontinent care.A physician's order dated 3/24/26 and currently in effect directed to maintain Enhanced Barrier Precautions every shift for a history of C. Diff.Observation of Resident #58's room on 4/7/26 at 11:00 AM identified EBP signage was posted on the door frame which directed staff must wear gloves and a gown for dressing, bathing, providing hygiene and changing briefs. A cart containing disposable isolation gowns and other PPE was located outside of Resident #58's room.Observation and interview with Nurse Aide (NA) #5 and NA #6 on 4/13/26 at 10:05 AM identified they were providing incontinent care to Resident #58 without the benefit of wearing an isolation gown. NA #5 indicated she was aware Resident #58 was on EBP but was too busy to put on an isolation gown but should have. NA #6 stated she came to the room to help NA #5 and did not have time to put on an isolation gown but should have. Both NA #5 and NA #6 identified they were aware there was EBP signage and a PPE cart (containing isolation gowns) available outside of Resident #58's room, had received training on EBP and were aware of the reasons for it. Additionally, a soiled incontinent brief and soiled linens (nightgown, towels and washcloths) with a brown substance on them were located on the floor next to NA #5. NA #5 indicated she just provided incontinent care because Resident #58 had a bowel movement and threw the items on the floor. NA #5 further stated she should not have thrown the soiled incontinent brief and soiled linens on the floor and should have bagged them instead.Interview and observation with RN #6 on 4/13/26 at 10:10 AM identified NA #5 and NA #6 should have worn isolation gowns while providing incontinent care to Resident #58. RN #6 indicated it was the responsibility of the NA's to don PPE (gloves and isolation gown) when they provided direct care to a resident on EBP. RN #6 identified NA #5 should not have put the soiled incontinent brief and soiled linens on the floor and should have bagged the items for proper handling and disposal after she provided care. Further, RN #6 observed the EBP signage and PPE cart outside of Resident #58's room.Interview with the Director of Nurses (DNS) on 4/13/26 at 10:15 AM identified NA #5 and NA #6 should have worn isolation gowns while providing incontinent care to Resident #58. The DNS indicated it was the responsibility of the NA's to don PPE (gloves and isolation gown) when they provided direct care to a resident on EBP. The DNS identified NA #5 should not have put the soiled incontinent brief/soiled linens on the floor, should have bagged the items for proper handling and disposal after she provided care. The DNS indicated she needed to provide further education to the NA's regarding EBP and PPE. Review of the facility policy, Enhanced Barrier Precautions, dated 3/20, directed EBP referred to the use of gowns and gloves during high-contact care activities that provide opportunities for transfer of MDRO's (multi-drug resistant organisms) to staff hands and clothing. PPE required for EBP are gloves and gown) prior to high contact care activities such as dressing, bathing, providing hygiene, and changing briefs.Review of the facility policy, Linen Handling, undated, directed soiled linen should be deposited immediately into the soiled linen hamper and if soiled linen must be carried into the hall it must be placed into a plastic bag. Soiled linen is not to be placed on the floor, it should be placed into a plastic bag on a surface (foot of the bed, bedside chair) until ready to be disposed of.2.Resident #82's diagnosis included fracture of the right femur, right shoulder fracture, and emphysema.The Resident Care Plan (RCP) dated 3/27/26 identified an activities of daily living self-care performance deficit related to a right femur fracture, right shoulder fracture with assistance needed with personal care. Interventions included providing assistance of 2 for toileting while the resident remains supine(lying) in bed, setup of meal tray, assist of 1 with personal hygiene and oral care.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #82 was cognitively intact and independent for eating. Also, identified Resident #82 was dependent for toileting, bathing, dressing personal hygiene and transfers.An observation/interview on 4/13/2026 at 10:00 AM of Resident 82's bathroom identified a urinal hanging on side rail behind toilet not labeled not covered. Also, Resident #82 identified that he/she was unable to go into the bathroom because of his/her having fractures.On 4/13/26 at 10:18 AM interview/observation with Registered Nurse (RN) #1 identified the urinal belonged to Resident #82's because his/her roommate (Resident #7) cannot urinate on his/her own. Also, identifying the urinal should be dated, labeled with the resident's name and stored in Resident #82's bottom drawer of the bedside stand.An interview on 4/13/26 at10:29 AM with the Director of Nurses (DNS) identified urinals were to be stored in the resident's bottom drawer of the bedside stand in a paper covering. The DNS further identified the urinal should be labeled, dated with identifying information with the resident's name and room number.Review of the policy for General Infection Prevention and Control Policies directed in part to ensure all nursing activities will be performed in a manner to minimize the potential for infection in residents, staff, and visitors. Some of the specific guidelines include: All items used for resident care will be cleaned and disinfected, will be designated for residents to use only. All resident's personal items will be appropriately labeled with the Resident's name and stored in the bedside stand or other designated resident storage area.

Based on interviews, record review and facility policy for 1 of 3 residents (Resident #56) reviewed for urinary tract infections (UTI), the facility failed to complete an assessment by a Registered Nurse (RN) for a resident with increased lethargy and a physician order for a urine culture to rule out a UTI. Additionally, the facility failed to initiate a 3-day bladder pattern as indicated on the Treatment Administration Record. The findings include: Resident #56 diagnoses included congestive heart failure, urinary retention, neuromuscular dysfunction of the bladder, stroke, history of urinary tract infection (UTI).A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified although a Brief Interview for Mental Status (a tool used to assess cognitive patterns) was not completed, Resident #56 had no problem with short/long term memory. Additionally, the MDS identified Resident #56 had an indwelling catheter (suprapubic catheter), had a feeding tube, used a wheelchair, and was dependent with personal hygiene, bed mobility, and bed/chair transfers.The Resident Care Plan (RCP) dated 1/14/26 identified Resident #56 had a suprapubic catheter (SP tube) related to a neurogenic bladder. Interventions included to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, change the catheter every 30 days, and check the tubing for kinks every shift. Additionally, the RCP dated 1/14/26 identified Resident #56 had a history of a urinary tract infection (UTI). Interventions included to give antibiotic therapy as ordered, obtain and monitor lab/diagnostic work as ordered, and report results to the physician and follow-up as indicated.A Bowel and Bladder Evaluation dated 3/31/26 at 11:27 PM identified Resident #56 never voided appropriately without incontinence, was immobile or required assistance of 2 staff members, was alert and oriented, was never aware of needing to toilet, and had no predisposing factors (diabetes, multiple sclerosis, stroke, bladder or prostate disease, frequent UTIs, spinal cord injury, or cerebral palsy). The evaluation also failed to identify Resident #56 had 3 predisposing factors (stroke, bladder disease, and frequent UTIs) that were also an option to choose.A nursing note dated 4/1/26 at 6:24 AM identified Resident #56's SP tube was replaced at the Urologist office on 3/31/26 and the urine was blood tinged.A physician order written by the Medical Director (MD) #1 and dated 4/7/26 directed to obtain a urine for urinalysis with culture and sensitivity (UA/C&S) related to Resident #56's altered mental status.Physician progress notes for 4/1/26 through 4/13/26 failed to identify a physician progress note written by MD #1 related to Resident #56's altered mental status and new order for a UA/C&S on 4/7/26.A nursing note dated 4/7/26 at 5:58 PM identified Resident #56's SP tube was intact, patent, and draining yellow urine. The nursing note further identified Resident #56 seemed more sleepy per his/her family member, however there was no documentation of an assessment of Resident #56.The Medication Administration Record (MAR) dated 4/8/26 identified a one time order that directed to obtain a UA/C&S for urinary symptoms and bladder monitoring for 3 days. Interview and clinical record review with RN #7 on 4/10/26 at 1:25 PM failed to identify a 3 day bladder monitoring record was initiated following the written order by MD #1 on 4/7/26 for a UA/C&S. RN #7 identified all residents with urine samples sent should have bladder monitoring for 3 days. RN #7 further identified urine test results would be received by the nursing Supervisor, but it was too early yet for a urine collected on 4/8/26 to have results.Interview with the Director of Nursing Services (DNS) on 4/10/26 at 1:58 PM identified that 3 day bladder monitoring should be done when a urine was sent on a resident, but that it typically was done prior to sending a urine for testing and would be initiated by the 11:00 PM to 7:00 AM shift and the nurses would document urine/bladder status every shift for 3 days. The DNS was unable to identify why the 3 day bladder monitoring had not been initiated.Interview with MD #1 on 4/10/26 at 2:35 PM identified he had written an order to collect and send a urine for a UA/C&S because Resident #56 was more lethargic that day than in previous visits, and he knew Resident #56 was getting blood work that week so he added the urine test to rule out an infection. MD #1 identified he had not observed, nor did Resident #56 express, signs or symptoms of a UTI.Interview with RN #1 on 4/13/26 at 10:35 AM identified there were no results for the urine signed/sent out by LPN #1 on 4/8/26 because that urine was not sent to the laboratory. RN #1 identified the SP tube for Resident #56 had been changed too many days prior to the UA/C&S order on 4/7/26 so any urine collected from the SP tube would be contaminated, and Resident #56's SP tube needed to be changed by interventional radiology which wouldn't be until May. RN #1 identified she had notified MD #1 that the urine could not be collected and had requested that he discontinue the order. RN #1 identified she had not written a note related to the inability to complete the UA/C&S as ordered and her conversation with MD #1. RN #1 further identified she had not completed an RN assessment for Resident #56 because she had not known the urine test was ordered for the reason of altered mental status. She indicated she should have done an RN assessment, and additionally if the urine had been ordered due to signs/symptoms of a UTI a 3 day bladder monitoring should have been completed.Interview with the DNS on 4/13/26 at 1:15 PM identified RN #1 should have written a nursing note that MD #1 had been notified a urine could not be sent for Resident #56 because the SP tube could not be changed to collect the urine.Review of the Urinary Catheters-Indwelling policy directed, in part, for residents with medical justification for indwelling catheter use, ongoing evaluation should address actual or potential problems such as infection or bacteruria.

Based on interviews, review of the clinical record, facility documentation and facility policy for 1 of 5 residents (Resident #1) reviewed for unnecessary medications, the facility failed to notify the provider of missed doses of an anticoagulant and after administering the medication outside of physician ordered blood pressure parameters resulting in a medication error. Additionally, for the only resident (Resident #11) reviewed for general change in condition, the facility failed to ensure the physician and responsible party were notified timely when there was a change in condition and the responsible party was not notified when a new medication was initiated. The findings include: 1. Resident #1's diagnoses included sepsis (a serious body wide infection) likely related to a urinary tract infection with an indwelling catheter device, an irregular heartbeat, and dementia. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required substantial assistance for toilet transfers, and was dependent for toileting hygiene.a. The Resident Care Plan (RCP) dated 2/17/26 identified that Resident #1 was receiving Eliquis (a blood thinner to reduce the risk of stroke) to reduce the risk of stroke and blood clots associated with his/her irregular heart rhythm and noted a history of a blood clot in the lungs. Interventions included to monitor for signs and symptoms of excessive or unusual bleeding and to check with the primary care provider when Eliquis was to be held for certain medical procedures or diagnostics.A physician's order dated 2/24/26 directed 5 milligrams (mg) of Eliquis twice a day for blood thinning related to Resident #1's diagnoses of an irregular heart rhythm.The Medication Administration Record (MAR) dated 3/1/26 through 4/13/26 identified Eliquis 5 mg was to be administered at 9:30 AM and 9:30 PM. Additionally, the MAR identified doses of Eliquis were omitted on 3/29/26 at 9:30 AM, 3/29/26 at 9:30 PM, 3/30/26 at 9:30 AM, 3/30/26 at 9:30 PM, 3/31/26 at 9:30 AM, 4/1/26 at 9:30 AM, 4/2/26 at 9:30 AM. A nursing note dated 4/1/26 at 9:45 PM and written by RN #1 indicated that the nursing supervisor was notified that Resident #1 did not receive a dose of Eliquis on 4/1/26 for the 9:30 AM dose because the medication was not available. The note further identified that the pharmacy was contacted and reported they would work on sending Resident #1's Eliquis prescription.Clinical record reviewed for the period of 3/1/26 through 4/13/26 failed to reflect documentation that Eliquis was reordered for Resident #1 prior to 4/1/26, nor did it reflect that the physician was notified that the resident had missed multiple doses of Eliquis.An interview with the Director of Nurses (DNS) on 4/13/26 at 11:30 AM indicated that name brand medications such as Eliquis were often on backorder; however, the physician should be notified when a resident missed at least three doses. The DNS further explained that when a medication needed to be ordered, the nursing supervisor should be contacted, and appropriate documentation should be completed to reflect any communication with the provider. An interview with MD #1 indicated that although no new orders or interventions would have been required for Resident #1 after missing multiple doses of Eliquis, he was unsure whether the facility had notified him that the resident had missed those doses. Review of the facility's policy, Medication Orders, dated 7/2023, indicated that the prescriber must be contacted for direction when delivery of a medication will be delayed or when the medication is not, or will not be, available. The policy further directed that for non emergency medication orders, the first dose should be scheduled to be given after the next regularly scheduled pharmacy delivery to the facility. b. The Resident Care Plan dated 2/24/26 identified Resident #1 was at risk for dehydration and recurrent urinary tract infections. Interventions included encouraging fluids, monitoring of vital signs and watching for signs of dehydration such as an increased heart rate, dizziness when sitting or standing, and fatigue or weakness, and notifying the physician of any significant changes. A physician's order dated 3/10/26 directed staff to administer 2.5 milligrams (mg) of Midodrine (a medication used to raise low blood pressure) three times a day only if the resident's blood pressure dropped below 90 millimeters of mercury (mm HG) for the top number (systolic) and below 50 mm HG for the bottom number (diastolic). The Medication Administration Record (MAR) from for the period of 3/1/26 through 4/13/26 identified Resident #1 received 2.5 mg of Midodrine on numerous occasions during this period for low blood pressure, however, on 3/14/26 at 9:30 AM; 3/15/26 at 9:30 PM; 3/16/26 at 9:30 PM; 3/21/26 at 2:30 PM; 3/29/26 at 9:30 PM and 4/5/26 at 9:30 PM, the medication was administered despite the resident's blood pressure exceeding the ordered parameters (greater than 90 systolic and 50 diastolic). The highest documented blood pressure at a time when Midodrine was still administered was 146/86 on 3/29/26 at 2:30 PM. Nursing notes from 3/1/26 through 4/13/26 failed to reflect any documentation regarding notification to the provider regarding Midrodrine being administered outside of physician ordered blood pressure parameters. Interview with the Director of Nursing (DNS) on 4/13/26 at 11:30 AM indicated that when medications were ordered with parameters such as vital signs, the electronic MAR prompts the nurse to administer the medication and does not display the parameter requirements until the nurse opens the order to enter the vital signs. As a result, the DNS stated the medication was most likely administered inadvertently. The DNS further explained that when a medication was given inadvertently or outside the ordered parameters, the expectation was that the nurse notifies the provider, receives and implements any new orders, and closely monitors the resident for potential adverse effects. Interview with MD #1 on 4/13/26 at 3:11 PM identified that he could not recall if he was notified that Resident #1 received Midodrine outside the ordered blood pressure parameters but would have instructed nursing staff to monitor Resident #1's blood pressure. 2. Resident #11 was admitted to the facility in January 2025 with diagnoses that included dementia with severe agitation, epilepsy, and abnormal posture.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was severely cognitively impaired and was totally dependent on staff for activities of daily living. The Resident Care Plan (RCP) dated 3/18/26 identified Resident #11 required assistance with activities of daily living related to limited mobility and dementia. Interventions included providing gentle passive range of motion (ROM) to all extremities two times a day during care following Resident #11's restorative nursing care program. Resident #11's private duty caregivers may complete ROM, apply bilateral resting hand splints on in the morning (am) and off with meals and nighttime care, out of bed daily with the assist of 2 using pivot transfer, out of bed to tilt and space wheelchair with footrest, and assist of 1 staff member for washing, dressing and bed mobility. A physician progress note written by MD #1 and dated 3/27/26 identified Resident #11 had left side weakness for approximately one week. Additionally, MD #1 indicated that he was not made aware from staff that Resident #11 had been experiencing weakness to the left side. MD #1 subsequently prescribed ASA 81mg once a day for Resident #11 for diagnosis of cerebral vascular accident (CVA) on 3/27/26 after MD #1's assessment of Resident #11.Physician's orders dated 3/27/26 directed to administer aspirin (ASA) 81milligrams (mg) for cerebral vascular accident (CVA/stroke) daily and give one dose on 3/27/26 now. Advanced Practice Registered Nurse (APRN) #1 identified in late entry progress note dated 4/6/26 that Resident #11 had been experiencing left side weakness in the left arm 2 weeks ago and left arm was flaccid (weak). APRN #1's progress indicated that licensed nursing staff at the facility did not notify APRN #1 until 4 days after the occurrence and that MD #1 had seen Resident #11 on 3/27/26 with possible diagnosis of CVA.Nursing notes from 3/1/26 through 4/8/26 failed to reflect documentation that the practitioners and Person #1 were not notified of Resident #11's change in condition. Furthermore, there was no documentation that Person #1 was made aware that MD #1 had ordered ASA 81 mg once a day for a CVA.Interview and review of Resident #11's nursing notes on 4/9/26 at 9:20 AM with the Director of Nursing (DNS) identified there was a lack of documentation in the electronic medical record indicating that a physician/APRN and Person #1 was made aware of Resident #11's change in condition. The DNS indicated that it was facility policy that when a resident experiences a change in condition and new orders were obtained it should be documented in nursing notes including notifications to a practitioner and responsible party. Furthermore, the DNS indicated that although Resident #11 had private duty nurse aides (NA) it was still the responsibility of facility nursing staff to document notifications to the practitioner and responsible party when there was a change in condition and new medication ordered.Interview with Person #1 on 4/9/26 at 11:18AM identified that the facility had not notified him/her of Resident #11's left side weakness nor was he/she ever made aware that Resident #11 was started on ASA 81mg. Person #1 indicated that he/she was made aware of left side weakness by Resident #11's private duty caregiver, that the facility does not communicate changes timely and most of the time it was the private duty caregivers that update Person #1 when there was a change in Resident #11.Interview with Person #2 on 4/9/26 at 11:54 AM indicated that she had identified 3/21/26 (on a Saturday) that Resident #11's left side was weaker than normal. She indicated that the nursing supervisor was made aware immediately of Person #2's noted change in Resident #11. Person #2 stated that she believed the nursing supervisor came into assess Resident #11 a short time after she had made licensed nursing staff aware of Resident #11's change in condition. Person #2 indicated that she was unsure what was done for Resident #11 after she had reported the change in condition.Interview with APRN #1 on 4/9/26 at 3:51PM indicated that she had assessed Resident #11 after the MD had seen Resident #11 for a possible CVA and left side weakness on 3/27/26. APRN #1 indicated that she was not notified by facility staff that Resident #11 had experienced left side weakness for several days. She indicated that she was available on Saturday for changes in condition and indicated that her expectation was that licensed nursing staff would have assessed Resident #11, documented their assessment and notified her that day of the possible change in condition at the time of occurrence. She indicated that there was no documentation that the on-call APRN was notified of any changes for Resident #11 on Saturday 3/21/26. Interview and review of the clinical record with RN #3 on 4/10/26 indicated that she did not note any major changes in Resident #11's condition; therefore, she did not update the practitioner or responsible party. In addition, RN #3 stated she may have documented her assessment on the supervisor report sheet. RN #3 indicated that she should have updated the practitioner of her assessment even though she believed that Resident #11 was at his/her baseline medical status. She indicated that it was an oversight and facility policy was to document in nursing notes, notify practitioner and responsible party. A review of facility documentation on 4/10/26 identified that there were no notations for Resident #11 in the MD #1's communication book or APRN #1's communication book on Resident #11's new left sided weakness from 3/2/26 through 4/10/26. There was an RN assessment documented on the nursing supervisor report sheet for 3/21/26 by RN #3 indicating that RN #3 assessed Resident #11 indicating Resident #11 left side had increased flaccid (lacking normal firmness) in the AM and much better in the afternoon and that muscle tone was almost normal now. However, there was no documentation in the supervisor report sheet that Resident #11's practitioners and/or responsible party had been notified.Interview with MD #1 on 4/10/26 at 2:30 PM identified that he was not notified by facility nursing staff regarding Resident #11's change in condition. He indicated that he was notified of Resident #11 change in condition by Person #2 when he came into the facility on 3/27/26 (6 days after left side weakness was noted). He indicated that his expectation was that he should have been notified timely of Resident #11's change and it should have been nursing staff from the facility providing the notification.A review of the Change in Condition policy dated 1/20 directed, in part, residents with a clinical change in condition will be assessed by an RN. The physician will be notified of clinically significant findings in a timely manner. The RN supervisor will utilize the Interact Change in Condition Cares and Pathways. Contact the physician or APRN for issues that require immediate notification. For issues that can wait until the next office day, put a note in the Park Avenue book for the APRN or prepare a fax or call sheet to be sent to or called to the physician during regular business hours. Document finding and action taken.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #23) reviewed for pressure ulcers, the facility failed to complete a thorough Registered Nurse (RN) assessment for a newly identified pressure ulcer and for 1 of 3 residents (Resident #56) reviewed for urinary tract infections (UTIs), the facility failed to document the inability to obtain a physician ordered urine culture. The findings include: 1.Resident #23's diagnoses included a left femur fracture with repair, peripheral vascular disease, chronic obstructive pulmonary disease (COPD).The Resident Care Plan (RCP) dated 12/29/25 identified Resident #23 had potential for pressure ulcer development related to fragile skin. Interventions included following facility policy for prevention/treatment of skin breakdown and perform a weekly body audit.A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired, used a walker and wheelchair, was independent with eating, and was dependent with bed mobility and bed/chair transfers. The MDS assessment further identified Resident #23 had a surgical wound, was at risk for developing pressure ulcers, and had pressure reducing devices for bed and chair.A Weekly Skin Check dated 2/8/26 at 10:17 PM identified bruising to the left hip, bilateral upper arms, and a surgical incision to the left hip with staples in place. The skin check indicated no other areas of concern.The Treatment Administration Record (TAR) dated 2/1/26 through 2/28/26 noted weekly skin checks every Wednesday on the evening shift was signed off on 2/11/26 with a documentation code of 9 indicating a nursing note was written.A nursing note dated 2/11/26 at 9:21 PM identified the skin check for 2/11/26 was not completed because a skin check was completed on 2/8/26.A physician's order dated 2/13/26 directed for placement of heel booties while in bed and for application of skin prep to bilateral heels twice a day related to heel pain. A nursing note dated 2/18/26 at 6:19 AM identified boots were placed onto bilateral heels and there were no complaints or concerns for that shift.A Weekly Skin Check completed by RN #1 on 2/18/26 at 9:32 PM identified a new open area to the left heel. The skin check failed to include measurements of the wound size, a description of the wound, or classification of the type of wound.A Wound-Weekly and New Observation Tool dated 2/19/26 at 11:45 AM identified the APRN, family, and dietician had been notified of a suspected deep tissue injury (sDTI) with a pinpoint opening to the left heel acquired 2/18/26 which measured 4.0 centimeters (cm) long by 4.0 cm wide.Interview with the DNS on 4/13/26 at 1:10 PM identified when a new order was written for treatment with skin prep and heel booties for the reason of heel pain, there should be an RN assessment of the area to ensure there is not any skin breakdown at that time. Additionally, the DNS identified when nurses were applying the skin prep to Resident #23's heels, they should have been visualizing the skin to ensure timely identification of any signs of skin breakdown. Review of the Pressure Injuries policy directed, in part, all residents will have a weekly skin check by a licensed nurse with results documented. The policy directed when a pressure area develops, the physician, responsible party, dietician and therapy department will be notified, and a new treatment order obtained. The policy directed all wound assessments and treatments will be documented by the licensed nurses.Review of the Skin Checks policy directed, in part, all residents will have a skin check completed by the licensed nurse weekly and results documented. The policy directed when a new or worsened alteration in skin integrity is identified, the nursing supervisor, physician, and responsible party are notified. The policy directed to update the care plan and notify the dietician and therapy department. The policy further directed a narrative nursing note should be written to indicate what was found and the actions taken.2. Resident #56's diagnoses included congestive heart failure, urinary retention, neuromuscular dysfunction of the bladder, stroke, history of urinary tract infection (UTI).A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified although a Brief Interview for Mental Status (a tool used to assess cognitive patterns) was not completed, Resident #56 had no problem with short/long term memory. Additionally, the MDS identified Resident #56 had an indwelling catheter (suprapubic catheter), had a feeding tube, used a wheelchair, and was dependent with personal hygiene, bed mobility, and bed/chair transfers.The Resident Care Plan (RCP) dated 1/14/26 identified Resident #56 had a suprapubic catheter (SP tube) related to a neurogenic bladder. Interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, change the catheter every 30 days, and check the tubing for kinks every shift. Additionally, the RCP dated 1/14/26 identified Resident #56 had a history of a urinary tract infection (UTI). Interventions included to give antibiotic therapy as ordered, obtain and monitor lab/diagnostic work as ordered, and report results to the physician and follow-up as indicated.A Bowel and Bladder Evaluation dated 3/31/26 at 11:27 PM identified Resident #56 never voided appropriately without incontinence, was immobile or required assistance of 2 staff members, was alert and oriented, was never aware of needing to toilet, and had no predisposing factors (diabetes, multiple sclerosis, stroke, bladder or prostate disease, frequent UTIs, spinal cord injury, or cerebral palsy). The evaluation failed to identify Resident #56 had 3 predisposing factors that were listed as options on the evaluation (stroke, bladder disease, and frequent UTIs)A nursing note dated 4/1/26 at 6:24 AM identified Resident #56's SP tube was replaced at the Urologist office on 3/31/26 and the urine was blood tinged.A physician order written by the Medical Director (MD) #1 and dated 4/7/26 directed to obtain a urine for urinalysis with culture and sensitivity (UA/C&S) related to Resident #56's altered mental status.A nursing note dated 4/7/26 at 5:58 PM identified Resident #56's SP tube was intact, patent, and draining yellow urine. The nursing note further identified Resident #56 seemed more sleepy per his/her family member.A nursing note written by Registered Nurse (RN) #1 on 4/9/26 at 10:22 AM identified she was disconnecting Resident #56's tube feeding when he/she requested to be sent to the hospital. The nursing note identified Resident #56 had stable vital signs, was unable to specify a reason for going to the hospital, denied pain, and denied feeling anxious. The note identified Resident #56 had a worried facial expression. Physician progress notes dated 4/1/26 through 4/13/26 failed to identify a physician progress note written by MD #1 related to Resident #56's altered mental status and new order for a UA/C&S on 4/7/26.The Medication Administration Record (MAR) dated 4/8/26 identified a one time order that directed to obtain a UA/C&S for urinary symptoms and bladder monitoring for 3 days. Interview and clinical record review with RN #7 on 4/10/26 at 1:25 PM identified urine test results would be received by the nursing Supervisor, but it was too early for a urine collected on 4/8/26 to have results.Interview with MD #1 on 4/10/26 at 2:35 PM identified he had written an order to collect and send a urine for a UA/C&S because Resident #56 was more lethargic that day than in previous visits, and he knew Resident #56 was getting blood work that week so he added the urine test to rule out an infection. MD #1 identified he had not observed, nor did Resident #56 express, signs or symptoms of a UTI.Interview with RN #1 on 4/13/26 at 10:35 AM identified there were no results for the urine signed out by LPN #1 on 4/8/26 because that urine was not sent to the laboratory. RN #1 identified Resident #56's SP tube had been changed too many days prior to the UA/C&S order on 4/7/26 so any urine collected from the SP tube would be contaminated, and Resident #56's SP tube needed to be changed by interventional radiology which wouldn't be until May. RN #1 identified she had notified MD #1 that the urine could not be collected, and had requested that he discontinue the order. RN #1 identified she had not written a note related to the inability to complete the UA/C&S as ordered and her conversation with MD #1.Interview with the DNS on 4/13/26 at 1:15 PM identified RN #1 should have written a nursing note that MD #1 had been notified a urine could not be sent for Resident #56 because the sp tube could not be changed to collect the urine.Review of the Change of Condition-Protocols for Physician Notification policy directed, in part, residents with a clinical change in condition will be assessed by an RN, and the physician will be notified in a timely manner of clinically significant findings. The policy directed when a resident has a change in condition the charge nurse should take a full set of vital signs, assess the resident's condition, notify the RN supervisor, and document findings and actions taken. The policy further directed the RN supervisor will discuss the physical findings with the charge nurse, and do additional physical assessments as indicated, contact the physician with issues that require immediate notification, and document findings and actions taken.

Based on review of the clinical record and facility policy for 1 of 4 residents (Resident #2) reviewed for falls, the facility failed to ensure completion of neurological checks (vital signs, level of consciousness, pupil reactions, motor strength, and sensory function) according to physician orders for a resident readmitted to the facility following hospitalization for a fall with an acute intraparenchymal hemorrhage of the brain. The findings include: Resident #2 had diagnoses that included intracerebral hemorrhage, dementia, hypertension, and atrial fibrillation.An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired, had not fallen since the previous assessment, used a walker, and was independent with putting on/taking off footwear, bed mobility, and walking 10 to 150 feet.The Resident Care Plan (RCP) dated 2/24/26 identified Resident #2 was at risk for falls related to dementia and use of a rolling walker. Interventions included to ensure Resident #2 was wearing appropriate footwear when ambulating, educate Resident #2/family/caregivers on safety reminders and what to do if a fall occurred.A nursing note dated 2/28/26 at 11:10 AM identified Resident #2 was sent to the hospital for evaluation of left hip pain following a witnessed fall.A nursing note dated 2/28/26 at 5:00 PM identified the hospital called with an update that Resident #2 did not have a hip fracture, but he/she was being transferred to a different hospital related to a diagnosis of an intraparenchymal hemorrhage of the brain.A nursing note dated 3/3/26 at 1:22 PM identified Resident #2 arrived by ambulance and was re-admitted to the facility from the hospital.A physician order dated 3/3/26 directed to complete a neurological evaluation every shift for 7 days and document on the neurological assessment sheet. The directions indicated for the evaluation to include level of consciousness, mentation, pupil reactions, extremity evaluation, and vital signs for the indication of post intraparenchymal hemorrhage of the brain.The Medication Administration Record dated 3/3/26 through 3/10/26 identified neurological assessments were signed off (initialed) every shift from 3/3/26 on the 11:00 PM to 7:00 AM shift through 3/10/26 on the 3:00 PM to 11:00 PM shift.A Neurological Assessment form dated 3/3/26 to 3/11/26 identified directions to document neurological checks every shift (11:00 PM to 7:00 AM, 7:00 AM to 3:00 PM, and 3:00 PM to 11:00 PM) for 7 days (as directed by physician orders). The Neurological Assessment form identified the documentation started on 3/3/26 on the 3:00 PM to 11:00 PM shift and ended on 3/11/26 on the 3:00 PM to 11:00 PM shift but failed to identify documentation of neurological checks on 3/6/26 on the 7:00 AM to 3:00 PM shift except for vital signs, and additionally failed to identify documentation of neurological checks on 3/6/26 on the 3:00 PM to 11:00 PM shift (this indicated at least 16 hours in a row without assessment of neurological status).Nursing notes for the dates that neurological assessments were not completed (3/6/26 on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift) did not indicate neurological assessments were documented there instead of on the Neurological Assessment form.Review of the Neurological-Vital Signs policy directed, in part, neurological vital signs will be conducted on all residents with known or suspected head injury. The policy directed to obtain vital signs (temperature, pulse, respirations, blood pressure) and record in the comments section of the Neurological Assessments form, assess the residents level of consciousness and record on the Neurological Assessments form, assess the pupils and eye movements and record on the Neurological Assessments form, evaluate motor response and record the best response on the Neurological Assessments form. The policy further directed a narrative nurses note should be completed to indicate that Neurological Vital Signs were monitored and refer to the Neurological Assessments form for details.

Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for 1 of 3 residents (Resident #28) reviewed for respiratory care, the facility failed to obtain a physician's order for oxygen administration. The findings include: Resident #28's diagnosis included dementia with agitation, atherosclerotic heart disease and paroxysmal atrial fibrillation.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was severely cognitively compared and required substantial/maximal assistance with toileting and transfers and was independent with bed mobility. The MDS did not reflect Resident #28 utilized oxygen at the time of the assessment.A Resident Care Plan (RCP) dated 3/11/26 identified Resident #28 had altered cardiovascular status elated to heart disease and atrial fibrillation. Interventions included to monitor any changes in lung sounds and monitor/document/report shortness of breath.A nursing note dated 3/30/26 at 2:51 PM identified Resident #12 had Oxygen (O2) applied via nasal cannula at 2 liters per minute (L/M) and lung sounds were unchanged.A nursing note dated 4/1/26 at 1:58 PM identified Resident #12 was started on antibiotics for a congested cough, had the head of the bed elevated and O2 at 2 liters (L) via nasal cannula was on. A nursing note dated 4/5/26 at 7:24 PM identified Resident #12 was on O2 at 2L via nasal cannula and continued an antibiotic for presumed pneumonia. A nursing note dated 4/8/26 at 6:42 AM identified Resident #12 was on O2 at 2L via nasal cannula and continued antibiotics.Observations on 4/7/26 at 11:46 AM, 4/8/26 at 10:40 AM and 4/9/26 at 11:54 AM noted Resident #12 seated in a wheelchair in his/her room and lounge areas with O2 at 2L via nasal cannula on.Observation, interview and review of the clinical record with Licensed Practical Nurse (LPN) # 2 on 4/9/26 at 12:50 PM identified Resident #12 was seated in a wheelchair with oxygen on at 2L via nasal cannula. Review of the physician's orders with LPN #2 at that time failed to identify a physician's order for oxygen use despite oxygen being administered to Resident #28 since 3/30/26. LPN #2 indicated the resident had pneumonia last week and he/she should not have been administered oxygen without a physician's order. LPN #2 was unsure why an order was not obtained and stated it would have been the charge nurses' responsibility to obtain an order for oxygen administration from the physician once the oxygen was needed (on 3/30/26).Interview with the DNS on 4/9/26 at 2:42 PM identified Resident #28 should have had a physician's order in place for the administration of supplemental oxygen. The DNS indicated it would have been the responsibility of the charge nurse or nursing supervisor who at the time of the residents change in condition, should have obtained a physician's order when oxygen was applied (on 3/30/26). The DNS was unsure why Resident #28 continued to receive oxygen without a physician's order and stated it must have been an oversight. Subsequent to surveyor inquiry, on 4/9/26 a physician's order was obtained which directed may apply supplemental O2 at 0.5 to 2L via nasal cannula to maintain an oxygen saturation of 90% or greater.Facility policy titled, Initial Set-Up of Oxygen, undated, directed initially to obtain a physicians order and information required for the set-up of oxygen was a prescription.Facility policy titled, Oxygen Administration, undated, directed a physician's order is necessary for the administration of oxygen.

Based on review of the clinical record, facility documentation, facility policy and interviews the only sampled resident (Resident #10 ) reviewed for activities of daily living (ADLs), the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. The findings include: Resident #10 had diagnoses that included legal blindness, vascular dementia, and diabetes.A quarterly MDS assessment dated [DATE] identified Resident #10 was cognitively intact, used a wheelchair, was independent with eating, required partial/moderate assistance with bed mobility, lying to sitting, sit to stand, and transfers, and received physical therapy (PT) services that started 7/4/25. Additionally, the assessment indicated Resident #10 was not assessed for walking due to a medical condition or safety concerns which did not accurately reflect the mobility orders in the resident care plan (RCP) and staff documentation. The assessment failed to identify Resident #10 used a walker.The Resident Care Plan (RCP) dated 7/21/25 identified Resident #10 had an ADLs self-care performance deficit related to blindness, difficulty walking, and the need for assistance with personal care. Interventions included Resident #10 required the assistance of 1 staff member for bed mobility, required the assistance of 2 staff members with a gait belt and rolling walker for toileting in the bathroom, and assistance of 1 staff member with a rolling walker and gait belt for transfers. The RCP dated 7/21/25 further identified Resident #10 had limited physical mobility related to a decline in function, impaired vision, and difficulty walking. Interventions included Resident #10's family member was cleared to ambulate with Resident #10, and to offer a walking program of 25 feet twice a day in the room or hallway using a rolling walker, gait belt, and with a wheelchair following. The RCP reflected a discrepancy from the MDS assessment in toileting assistance and walking.a. A quarterly MDS assessment dated [DATE] identified Resident #10 was moderately cognitively impaired, used a wheelchair, was independent with eating, required substantial/maximal assistance with bed mobility, sit to lying, lying to sitting, sit to stand, and transfers (chair, bed, toilet, shower) (a decline from the previous MDS dated [DATE]). Additionally, the assessment indicated Resident #10 was not assessed for walking due to a medical condition or safety concerns which did not accurately reflect the mobility orders in the resident care plan (RCP) and staff documentation. The assessment failed to identify Resident #10 used a walker.A nursing note dated 10/26/25 at 4:25 PM identified Resident #10 required assistance of 1 staff member for care (ADLs) and transfers.Review of the Documentation Survey Report for October 2025 identified a nurse aide task for an ambulation program for assistance of 2 staff members to ambulate with the rolling walker and gait belt 25 feet 2 times a day with a wheelchair follow. The report identified the nurse aides (NA) documented Resident #10 met his/her ambulation goal 11 out of 62 opportunities. The report further identified 2 out of the 11 times Resident #10 met his/her ambulation goals during the look back period for completion of the 10/15/25 quarterly MDS assessment. This reflected a discrepancy for walking in Section GG of the 10/15/25 MDS assessment which indicated Resident #10 was not assessed for walking due to a medical condition.Additionally, the Documentation Survey Report for October 2025 identified a nurse aide task for transferring Resident #10 from 10/9/25 to 10/15/25 identified 10 out of 14 opportunities (while Resident #10 was awake on the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts) of transfers indicated Resident #10 transferred with limited assistance of 1 person, 4 out of 14 opportunities of documentation for Resident #10's transfers indicated he/she transferred with extensive assistance of 1 person. Additionally, the report indicated for the 11:00 PM to 7:00 AM shift 10/9/25 to 10/15/25 transfers were not applicable (Resident #10 did not get transferred during that shift). This reflected a discrepancy for transfers in Section GG from the 10/15/25 MDS assessment which indicated Resident #10 required substantial/maximal assistance with transfers.A nursing note dated 12/29/25 at 9:29 PM identified Resident #10 required assistance of 1 staff member for care (ADLs) and transfers.b. A quarterly MDS assessment dated [DATE] identified Resident #10 was cognitively intact, used a wheelchair, was independent with eating, required substantial/maximal assistance with lower body dressing, and was dependent with putting on/taking off footwear, sitting to standing, and transfers (chair, bed, toilet, shower). Additionally, the assessment indicated Resident #10 was not assessed for walking due to a medical condition or safety concerns which did not accurately reflect the mobility orders in the resident care plan (RCP) and staff documentation. The assessment failed to identify Resident #10 used a walker.Review of the Documentation Survey Report for December 2025 identified a nurse aide task for walking in the room and from 12/25/25 to 12/31/25 identified 5 out of 14 opportunities (while Resident #10 was awake on the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts) for Resident #10's walking in room indicated he/she walked in the room with limited assistance of 1 person, and 2 out of 14 opportunities indicated he/she walked in the room with extensive assistance of 1 person. This reflected a discrepancy for transfers in Section GG of the 12/31/25 MDS assessment which indicated Resident #10 required substantial/maximal assistance with walking.Additionally, the Documentation Survey Report for December 2025 identified a nurse aide task for transferring which identified 12/25/25 to 12/31/25 10 out of 14 opportunities (while Resident #10 was awake on the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts) of documentation for Resident #10's transfers indicated he/she transferred with limited assistance of 1 person, 4 out of 14 opportunities of documentation for Resident #10's transfers indicated he/she transferred with extensive assistance of 1 person. Additionally, the report indicated for the 11:00 PM to 7:00 AM shift from 12/25/25 to 12/31/25 transfers were not applicable (Resident #10 did not get transfer during that shift). This reflected a discrepancy for transfers in Section GG of the 12/31/25 MDS assessment which indicated Resident #10 required substantial/maximal assistance with transfers.Interview with Nurse Aide (NA) #7 on 4/13/26 at 12:30 PM identified Resident #10's usual performance of activities of daily living required the assistance of 1 staff member and included transfers and walking with a rolling walker. NA #7 identified that occasionally later in the evening Resident #10 might require assistance of 2 staff members for transfers if he/she was tired from the day, but usually he/she required the assistance of 1 staff member.Interview and clinical record review with Registered Nurse (RN) #4 on 4/13/26 at 12:30 PM identified when she completed the MDS assessments she obtained the information for completion of the GG section (Functional Abilities) of the MDS from the GG form completed by the nurses, nurse aide documentation, Rehab therapy notes, and the RCP. RN #4 identified she typically would ask for clarification when the Rehab therapy notes, RCP, and nurse aide documentation did not show consistency, but she could not identify why she did not question the discrepancies.Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual which contained instructions the facility must follow when submitting MDS assessments directed, in part a resident's functional status can be impacted by the environment or situations encountered at the facility. Observing the resident's interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident's functional status. If the resident's functional status varies, record the resident's usual ability to perform each activity. Do not record the resident's best performance and do not record the resident's worst performance, but rather record the resident's usual performance. The manual directed when coding the resident's usual performance, use the six-point scale (Code 06-independent, Code 05-setup or clean-up assistance, Code 04-supervision or touching assistance, Code 03-partial/moderate assistance, Code 02-substantial/maximal assistance, and Code 01-dependent). The manual directed to use Code 02-substantial/maximal assistance if the helper does more than half the effort to complete the activity. The manual further directed to use Code 01-dependent if the helper does all of the effort and the resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity.

Based on interviews, review of the clinical record, facility documentation and facility policy for the only resident (Resident #11) reviewed for general change in condition, the facility failed to ensure a change in condition nursing assessment was documented in the clinical record and for 1 of 3 residents (Resident #23) reviewed for pressure ulcers, the facility failed to ensure the clinical record contained documentation of the completion of a treatment for a pressure ulcer per physician order. The findings include: 1.Resident #11 was admitted to the facility in January 2025 with diagnoses that included dementia with severe agitation, epilepsy, and abnormal posture. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #11 was severely cognitively impaired and was totally dependent on staff for activities of daily living. The Resident Care Plan (RCP) dated 3/18/26 identified that Resident #11 required assistance with activities of daily living related to limited mobility and dementia. Interventions included to provide gentle passive range of motion (ROM) to all extremities two times a day during care following Resident #11's restorative nursing care program. Resident #11's private duty caregivers may complete ROM, apply bilateral resting hand splints on in the am and off with meals and nighttime care, out of bed daily with the assistance of 2 using pivot transfer out of bed to tilt and space wheelchair with footrest, and assistance of 1 staff member for washing, dressing and bed mobility. Physician's orders dated 3/27/26 directed to administer Aspirin 81milligrams (mg) for cerebral vascular accident (CVA/stroke) daily and administer one 81 mg dose now. A physician progress note dated 3/27/26 and written by MD #1's identified that Resident #11 had left side weakness for approximately one week. MD #1 indicated he was not made aware from staff that Resident #11 had been experiencing weakness to the left side. MD #1 subsequently prescribed ASA 81mg once a day for Resident #11 for diagnosis of CVA on 3/27/26 after MD #1's assessment of Resident #11. Advanced Practice Registered Nurse (APRN) #1 identified in a late entry progress note dated 4/6/26 that Resident #11 had been experiencing left side weakness in the left arm 2 weeks ago and left arm was flaccid (weak). APRN #1's progress indicated that licensed nursing staff at the facility did not notify APRN #1 until 4 days after the occurrence. Nursing notes from 3/1/26 through 4/8/26 failed to reflect documentation of a Registered Nurse (RN) assessment of left side weakness. Interview and review of Resident #11's nursing notes on 4/9/26 at 9:20 AM with the Director of Nursing (DNS) identified there was a lack of documentation in Resident #11 electronic medical record indicating that Resident #11 was assessed by a RN for left sided weakness. The DNS indicated that it was facility policy that when a resident experiences a change in condition it was documented in nursing and indicated that although Resident #11 had private duty nurse aides (NA) it was still the responsibility of facility nursing staff to document an assessment. Interview with Person #2 on 4/9/26 at 11:54 AM indicated that she had identified on 3/21/26 on a Saturday that Resident #11's left side was weaker than normal. She indicated that the nursing supervisor was made aware immediately of Person #2's noted change in Resident #11. Person #2 stated that she believed the nursing supervisor came into assess Resident #11 a short time after she had made licensed nursing staff aware of Resident #11's change in condition Interview and review of the clinical record with RN #3 on 4/10/26 identified that there was no documentation in Resident #11's nursing notes that Resident #11 was assessed for left side weakness. RN #3 indicated that she remembered that she had assessed Resident #11 when she was notified on that Saturday and performed a neurological assessment of Resident #11 and thought she had documented the assessment in Resident #11 nursing notes. RN #3 indicated that she did not note any major changes in Resident #11's condition. In addition, RN #3 stated she may have documented the assessment on the supervisor report sheet but should have documented Resident 11's assessment in the nursing notes. A review of the Change in Condition policy dated 1/20 directed, in part, residents with a clinical change in condition will be assessed by an RN. The physician will be notified of clinically significant findings in a timely manner. The RN supervisor will utilize the Interact Change in Condition Cares and Pathways. Contact the physician or APRN for issues that require immediate notification. For issues that can wait until the next office day, put a note in the Park Avenue book for the APRN or prepare a fax or call sheet to be sent to or called to the physician during regular business hours. Document finding and action taken. Although requested, the facility did not have a policy on documentation by licensed nursing staff. 2. Resident #23 had diagnoses that included a left femur fracture with repair, peripheral vascular disease, stage 2 pressure ulcer of the left heel. The Resident Care Plan (RCP) dated 12/29/25 identified Resident #23 had the potential for pressure ulcer development related to fragile skin. Interventions included to follow facility policy for prevention/treatment of skin breakdown and perform a weekly body audit. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired, used a walker and wheelchair, was independent with eating, and was dependent with bed mobility and bed/chair transfers. The MDS further identified Resident #23 had a surgical wound, was at risk for developing pressure ulcers, and had pressure reducing devices for bed and chair. A physician order dated 2/13/26 directed that heel booties were to be worn when Resident #23 was in bed every shift for reason of heel pain. A physician order dated 2/20/26 directed for the left heel Stage 2 pressure ulcer: cleanse the wound with Normal Saline and pat dry, then apply Calcium Alginate (topical absorbent wound dressing) and cover with a dry clean dressing daily on the evening shift (3:00 PM to 11:00 PM) and as needed. Review of the Treatment Administration Record (TAR) dated 4/1/26 through 4/30/26 identified for the left heel treatment ordered for the evening shift: on 4/2/26 the nurse documented the chart code 9 which indicated other/see progress note; on 4/3/26 the nurse documented the chart code 5 which indicated hold/see progress note; and on 4/5/26 and 4/10/26 the TAR failed to identify documentation the treatment was completed. Additionally, the TAR identified no initials that the treatment was completed to the left heel pressure ulcer 4 out of 12 opportunities (33.3%). Interview with the Director of Nurses (DNS) on 4/13/26 at 2:30 PM identified there should be documentation in the TAR for completion of all treatments for Resident #23's pressure ulcer. The DNS identified there should not be any missing entries within the TAR for completion of the pressure ulcer treatment as this indicated the treatment was not performed. The DNS further identified if the resident refused the treatment it should be documented as such on the TAR. Review of the Dressing-Clean Technique policy directed, in part, to check the physician order for the current treatment, gather supplies, and inform the resident what will be done. The policy directed to remove the old dressing, perform the treatment, and observe the wound appearance. The policy directed after completion of the treatment initial it in the TAR, and document in the nursing notes weekly and as needed if warranted.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from verbal abuse. The findings include: Resident #1's diagnoses included vascular dementia, Parkinson's disease, depression, psychotic disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen (08/15), indicative of moderately impaired cognition and was independent for mobility with a wheelchair. The Resident Care Plan (RCP) dated 10/02/2024 identified Resident #1 had Parkinson's and dementia, and had the potential for physical aggressive behaviors. Interventions directed to administer medications per physician orders, psychiatric follow up as needed, if agitated, intervene before escalates and guide away from the source of distress. A facility reportable event form and investigation dated 10/17/2024 at 8:45 PM identified NA #1 reported she witnessed LPN #1 swear at Resident #1 on 10/16/2024 at 8:00 PM. Resident #1 alleged LPN #1 was rude and stated that LPN #1 told him/her to get lost when he/she requested eye drop medication. Resident #1 said he/she would come back, and when Resident #1 reapproached, LPN #1 told Resident #1 to f*** off. Review of NA #1's written statement dated 10/17/2024 identified on 10/16/2024 NA #1 observed Resident #1 ask LPN #1 for eye drops and LPN #1 responded stop asking me and get the f*** away from me. Review of LPN #1's written statement dated 10/18/2024, identified on 10/16/2024 at about 4:38 PM Resident #1 asked for eye drops, and she administered the eye drops. Resident #1 then accused LPN #1 of taking his/her shampoo, face cream, body cream and body soap out of his/her room during the 7 AM to 3 PM shift. LPN #1 explained she did not work that shift and Resident #1 then accused LPN #1 of lying and swore at LPN #1 and said f*** off. The statement further indicated that when LPN #1 received report from the day shift nurse, she was told that someone removed shampoo, face cream, body cream and body soap from his/her room, and that Resident #1 had a history of accusatory behavior. Facility summary dated 10/21/2024 identified NA #1 overheard LPN #1 be rude to and swear at Resident #1. The allegation of verbal abuse was substantiated and LPN #1's employment was terminated. Interview with RN #1 on 11/7/2024 at 11:50 AM identified she was the supervisor on 10/17/2024 and was notified NA #1 heard LPN #1 tell Resident #1 to f*** off during the 3 to 11 PM shift on 10/16/2024. NA #1 reported when Resident #1 initially approached LPN #1 and asked for eye drops, LPN #1 told Resident #1 to get lost. When Resident #1 reapproached, LPN #1 responded f*** off. RN #1 stated both Resident #1 and NA #1's statements matched, and the allegation was substantiated. Interview with LPN #1 on 11/7/2024 at 1:20 PM identified on 10/16/2024 at 3:00 to 3:30 PM, Resident #1 requested his/her eye drops. LPN #1 told Resident #1 that she had just got the order in, and he/she will need to wait once she finished administering medications. Later, Resident #1 became angry because items were removed from his/her room, and he/she accused LPN #1 of removing them. LPN #1 denied all allegations and indicated she would never say any of those things to a resident. Interview with DON on 11/7/2024 at 12:55 PM identified she was notified on 10/17/2024 at 8:00 PM that NA #1 reported an allegation of abuse against Resident #1 by LPN #1 occurred on 10/16/2024. The DON stated NA #1 reported LPN #1 swore at Resident #1 when he/she asked for eyedrops. The investigation identified the allegation was substantiated, and the facility subsequently terminated LPN #1's employment. Although attempted, interview with NA #1 was unable to be obtained during the survey. Review of facility Resident Rights and Responsibilities Policy dated 4/2021 identified residents have the right to exercise their rights without fear of discrimination, restraint, interference, or punishment. Residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality. Review of the facility Abuse Prevention Policy dated 8/2020, directed in part, the facility will not condone any form of resident abuse. The policy further directed, verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but not limited to: threats of harm; saying things to frighten a resident.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for quality of care, the facility failed to ensure orders were accurately entered into the electronic medical record, resulting in staples not being removed timely in accordance with physician orders. The findings include: Resident #2's diagnoses included a displaced fracture of right femur, dementia, Alzheimer's Disease, venous insufficiency, and a pilonidal sinus abscess with open wound. The hospital Discharge summary dated [DATE] directed to remove staples from Resident #2's incision in 14 days. Physician orders dated 7/2/2019 directed to nursing to remove Resident #2's staples on 7/13/2019. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of cognitively intact and limited assistance with ADL's (activities of daily living). The Resident Care Plan (RCP) dated 7/12/2019 identified Resident #2 had a right hip fracture due to a fall. Interventions directed to monitor the incision site and right lower extremity for signs of infection, thrombus, or contracture. Record review failed to identify Resident #2's staples were removed on 7/13/2019. Interview and record review with the DON on 11/7/2024 at 12:55 PM identified Resident #2's discharge instructions directed to remove the staples in 14 days, and a physician order was written to direct the staples to be removed on 7/13/2019. The DON identified that although there was a physician order for the removal of staples, there was an error in the way the order was entered into the electronic charting system. The DON stated the error would prevent the staple removal from showing up on the Medication/Treatment Administration Record on 7/13/2019. The DON stated the entry error is why the staple removal order may have been missed and not performed, and stated the staples should have been removed on 7/13/2019. Review of the facility Medication Order Policy dated 7/2023 directed in part, to enter the new order on the MAR/TAR.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely. The findings include: Resident #1's diagnoses included vascular dementia, Parkinson's disease, depression, psychotic disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen (08/15), indicative of moderately impaired cognition and was independent for mobility with a wheelchair. The Resident Care Plan (RCP) dated 10/02/2024 identified Resident #1 had Parkinson's and dementia and had the potential for physical aggressive behaviors. Interventions directed to administer medications per physician orders, psychiatric follow up as needed, if agitated, intervene before escalates and guide away from the source of distress. A facility reportable event form and investigation dated 10/17/2024 at 8:45 PM identified NA #1 reported she witnessed LPN #1 swear at Resident #1 on 10/16/2024 at 8:00 PM. Resident #1 alleged LPN #1 was rude and stated that LPN #1 told him/her to get lost when he/she requested eye drop medication. Resident #1 said he/she would come back, and when Resident #1 reapproached, LPN #1 told Resident #1 to f*** off. Facility summary dated 10/21/2024 identified NA #1 overheard LPN #1 be rude to and swear at Resident #1. The summary further identified NA #1 heard the incident on 10/16 but did not report the allegation until 10/17/2024, and NA #1 was provided re-education regarding timely reporting. Review of NA #1's written statement dated 10/17/2024 identified on 10/16/2024 NA #1 observed Resident #1 ask LPN #1 for eye drops and LPN #1 responded stop asking me and get the f*** away from me. The statement further indicated NA #1 reported the allegation the following day to RN #2 due to fear of retaliation from LPN #1. Although attempted, interview with NA #1 was unable to be obtained during the survey. Interview with DON on 11/7/2024 at 12:55 PM identified although NA #1 heard the incident on 10/16, NA #1 did not report the allegation until 10/17/2024 (one day after it occurred). The DON stated NA #1 should have reported the incident event immediately, and NA #1 was provided with educated regarding reporting allegations of abuse. Review of the facility Abuse Prevention Policy dated 8/2020 directed in part, all staff are required to report an observation or verbal allegation of abuse to their supervisor immediately.

Based on clinical record reviews, facility documentation, facility policy and interviews for 3 of 5 sampled residents (Residents #4, #14 and #71) reviewed for immunizations, the facility failed to ensure pneumococcal vaccines were administered after obtaining consent. The findings included: A clinical record review of the pneumococcal immunization record identified the following: 1.For Resident #4, a Pneumococcal Vaccine Informed Consent/Declination Form dated 5/29/24 identified consent was obtained from Resident #4 to receive the Pneumovax vaccine with no documented history of administration following consent. An interview with the Director of Nursing Services (DNS) on 8/27/24 at 9:44 AM identified availability for the vaccine was inconsistent. An alternate vaccination could have been offered to Resident #4 but was not. Additionally, there was a community pharmacy that offered pneumococcal vaccinations that could have been utilized but were not. Resident #4 was scheduled to receive the Pneumovax vaccine after surveyor inquiry. 2. For Resident #14, a Pneumococcal Vaccine Informed Consent/Declination Form dated 2/17/23 identified consent was obtained from the responsible party to receive the Pneumovax vaccine with no documented history of administration following consent. An interview with the DNS on 8/27/24 at 9:44 AM identified availability for the vaccine was inconsistent. An alternate vaccination could have been offered to Resident #14 but was not. Additionally, the was a community pharmacy that offered pneumococcal vaccinations that could have been utilized but were not. Resident #14 received Prevnar 20 on 7/23/24. 3. For Resident #71, a Pneumococcal Vaccine Informed Consent/Declination Form dated 7/17/24 identified consent was obtained from the responsible party to receive the Prevnar 20 vaccine with no documented history of administration following consent. An interview with the DNS on 8/27/24 at 9:44 AM identified availability for the vaccine was inconsistent. An alternate vaccination could have been offered to Resident #71 but was not. Additionally, there was a community pharmacy that offered pneumococcal vaccinations that could have been utilized but were not. Resident #71 was scheduled to receive the Prevnar 20 vaccine after surveyor inquiry. Review of the facility policy for Pneumonia Vaccine Administration Guidelines dated 2/2023 directed pneumococcal vaccines will be administered in accordance with best practice immunization guidelines.Vaccine information Sheets (VIS) will be reviewed and informed consent must be obtained.

Based on observations, interviews, and review of the facility policies, the facility failed to keep refrigerators at the appropriate temperatures for maintaining medications and for 2 of 2 medication rooms, the facility failed to dispose of expired medications. The Findings included: 1. Observation of the Harmany Lane medication room with LPN #3 on 8/24/24 around 10:00 AM identified the Medication Room refrigerator Temperature Log was found to be below 36 degrees on 9 days out of 27 days logged, the dates included 8/1/24, 8/2/24, 8/3/24, 8/19/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, and 8/24/24. The refrigerator contained the following: A package of Humalog containing 100 per milliliters 3 Flex pens of insulin 1 package of Lantus insulin 3 packages of Lorazepam (Anti-Anxiety) containing 30cc each LPN #2 identified that none of the medications were being used and the medications were for emergency only and that 3-11 PM shift was responsible for logging the refrigerator temperatures. Observation of the Cardinal Court medication room with LPN #2 on 8/24/24 at 10:30 AM identified the Medication Room refrigerator Temperature Log was found to be below 36 degrees on 27 days of the month of July which include 7/2/24, 7/3/24, 7/5/24, 7/6/24, 7/7/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/16/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/24/24,7/25/24, 7/26/24, 7/27/24, 7/28/24, 7/29/24 and 7/30/24 and missing temperatures from 4 of the days for July 2024 which include 7/1/24, 7/4/24, 7/17/24, and 7/31/24. Review of the August 2024 Refrigerator Temperature Log identified 7 days were logged below 36 degrees which included 8/1/24,8/2/24, 8/3/24, 8/5/24, and 8/22/24. Further observations also identified missing temperature logged for 8/15/24, and 8/16/24. The refrigerator contained the following: 2.2 packages of influenza vaccine 5 milliliter dose with an expiration date of 6/24. 2 packages of lorazepam 30cc. A box of 8 influenza high dose which contained 7 vials of 0.7 milliliters with an expiration date of 6/24, and it was noted 1 dose was missing. 1 Package of Levemir insulin flex pen. On 8/24/24 at 10:50 AM interview with LPN #2 identified s/he was unsure of when the last time the influenza vaccine was given, and s/he would find out. LPN #2 also identified s/he had planned to give the supervisor the expired medication but just had not had the time. LPN #2 also identified that s/he will give the refrigerated medications to the supervisor and order replacements. On 08/27/24 at 11:09 AM an interview with RN#3 identified if the medication refrigerator temperatures are below 36 degrees the supervisor and maintenance should have been notified. RN#3 provided evidence that no one was given expired influenza, and the last time an influenza vaccine was given was 2/24. On 08/27/24 at 11:18 AM an interview with the DNS identified that the 11:00 -7:00 AM shift was responsible to monitor the Medication Refrigerator Temperature Logs and to report any issues to maintenance. The DNS also identified the facility policy for Medication Refrigerator Temperatures noted not between 36-46 degrees directs that the supervisor and maintenance be notified. The DNS also indicated monthly audits are performed for the Medication Refrigerator Temperature Logs. The DNS Identified that the policy for expired medication was for the unit nurse to notify the supervisor who then collects the medication, and a double signed destruction sheet was to be filled out. After that a company comes to the facility to pick up the expired medications. On 8/2/4/24 at 12:00 PM an interview with the Director of Maintenance identified s/he was unaware the refrigerators had issues with the temperatures, and no one had placed a ticket. The Director of Maintenance further identified that a ticket should have been placed and staff should have notified her/ him of the policy. Review of the facility policy dated 7/23 for Refrigerator in Kitchenettes, Unit Lounges and Medication Rooms, temperature was to be between 36-46 degrees, that the temperatures will be checked and logged in daily by the 11:00 PM-7:00 AM by shift Nursing Aide staff. If temperatures were outside of the acceptable ranges a maintenance work ticket needs to be entered and the Nursing Supervisor needs to be notified. If the temperature is more than 5 degrees off, the medication needs to be replaced by the pharmacy. Review of the facility policy for Medication Storage in the Facility identified that outdated medications were to be immediately removed from the stock, disposed of according to procedures for supplies and reordered from the pharmacy. Medications are to be stored in a clean, well-lit, free from clutter, and extreme temperatures. Medications storage containers are monitored monthly and corrective action was to be taken if any problems were identified.

Based on review of facility documentation, facility policy and interview, the facility failed to ensure staff education was completed and competencies up to date for the provision of Intravenous Therapy (IV) services. The findings include: An interview and review of staff education for the initiation of intravenous therapy and competencies for intravenous services with the Director of Nursing Services on 8/27/24 at 9:44 AM failed to identify licensed staff were certified in the implementation of IV therapy and when staff competencies were last evaluated. The DNS further identified s/he was responsible for ensuring the completion of the education and competencies which were to be completed on an annual basis. A review of the Facility Assessment Tool identified the facility assessment is to be updated at least annually or as needed and includes staff training, education and competencies.

Based on clinical record reviews, facility policy review and interviews for 1 of 3 sampled residents (Resident #21) reviewed for dementia care, the facility failed develop a care plan that identified a resident with dementia and individualized care needs and for (Resident #4) reviewed for nutrition, the facility failed to ensure daily weights were implemented according to the plan of care for a resident at risk for fluid overload and for 2 of 2 residents, (Resident #47 and # 278)) reviewed for medication administration, the facility failed to ensure medications were administered in accordance to the plan of care and for for 1 of 5 residents, (Resident #7) reviewed for unnecessary medications, the facility failed to report a significant change in blood pressure per plan of care and for 1 of 1 resident ( Resident # 60 reviewed for Hospice/ End of Life Services, the facility failed to ensure staff transcribed special diet instructions for a resident with dysphagia upon admission to the facility per plan of care The findings included: 1.Resident #21's diagnoses included Parkinson's disease and dementia without behavioral disturbance. The Minimum Data Set (MDS)assessment dated [DATE] identified Resident #21 as cognitively intact, independent/required set up assist with activities of daily living and noted a diagnosis that included dementia. The Resident Care Plan dated 6/26/24 identified Resident #21 had Parkinson's disease. Interventions included to monitor/document and report signs of Parkinson's disease complications such as tremors, mood changes and decline in cognitive function. The Resident Care Plan failed to identify Resident #21 had a diagnosis of dementia or any interventions that would support h/her individualized care needs. An interview with the Director of Nursing Services (DNS) on 8/27/24 at 12:10 PM identified the care plan should have been individualized to reflect Resident #21's diagnosis of dementia and h/her care needs. A review of the facility policy for Care Plans dated 3/2024 notes a resident care plan is a communication tool that guides all members of the healthcare team on how to meet each resident's needs. Developed and implemented within the first 48 hours of admission, the care plan should focus on preventing avoidable decline, managing risks factors, preserving resident strengths, evaluating progress towards goals and respecting a resident right to decline treatment. 2.Resident #4 's diagnoses included chronic atrial fibrillation and chronic diastolic congestive heart failure (CHF). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 as cognitively intact and required extensive two-person assist with activities of daily living, supervision with eating. The physician orders 5/23/24 directed daily weights. The Resident Care Plan 5/29/24 identified Resident #4 had altered cardiac status, was at risk for fluid overload related to CHF and had a potential for a nutritional problem related to heart disease. Interventions directed to monitor/document/report any signs and symptoms of coronary artery disease and to obtain weight according to facility guidelines. A review of the weight log dated 7/2/24 through 8/26/24 identified Resident #4's weight was recorded 11 out of 30 days in July 2024 and 19 out of 26 days in August. An interview with the Director of Nursing Services ( DNS) on 8/27/24 at 1:22 PM identified that weights should have been obtained in accordance with physician orders. An interview with Nurse Practitioner, NP #1 on 8/27/24 at 1:41 PM identified monitoring weights assisted in evaluating how a resident with CHF was doing clinically as there were risks for fluid overload and abnormal laboratory. NP #1 identified the weights should be done in accordance with physician orders. Although requested, a facility policy for monitoring weights for a resident with CHF was not provided. 3. Resident #47's diagnoses that included asthma and hyperlipidemia (elevated cholesterol). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 as cognitively intact and independent with activities of daily living (ADL). The Resident Care Plan dated 7/18/24 identified Resident #47 had a communication deficit related to hearing loss and an ADL deficit related to gait imbalance and history of seizures. Interventions directed to provide a white board for communication and maintain a clutter free environment. The physician's orders dated 7/22/24 directed Atorvastatin 40 Milligrams (MG) one time a day for hyperlipidemia and Cetirizine hydrochloride (HCL) 10mg one time a day for dry skin. An observation on 8/26/24 at 10:02 AM identified Licensed Practical Nurse, LPN #1 retrieved a blister pack from the medication cart. Instructions directed Atorvastatin 40mg one time a day at bedtime. The medication administration record (MAR) directed to administer the medication at 8:30 AM LPN #1 retrieved a second blister pack with instructions that directed Cetirizine hydrochloride (HCL) 10mg one time a day at bedtime. The MAR directed the medication at 8:30 AM. LPN #1 placed both medication blister packs aside and contacted the pharmacy to address the discrepancy and received clarification that both medications were ordered to be given at bedtime. The medications were subsequently held, and Resident #47 received the remainder of h/her prescribed medications. A review of the physician orders dated 6/1/24 through 8/22/24 identified that physician prescription renewal orders dated 6/10/24 directed Atorvastatin 40mg one time a day at bedtime for hyperlipidemia. Additionally, physician prescription renewal orders dated 6/12/24 directed Cetirizine hydrochloride (HCL) 10mg one time a day at bedtime for dry skin. A review of the Medication Administration Record (MAR) dated 6/11/24 through 7/22/24 identified the Atorvastatin was administered at 8:30 AM instead of bedtime as prescribed. A review of the Medication Administration Record (MAR) dated 6/13/24 through 7/22/24 identified the Cetirizine HCL was administered at 8:30 AM instead of bedtime as prescribed. An interview and facility documentation review with the facility Pharmacist on 8/22/24 at 1:15 PM identified he reached out to the provider directly for any medication renewals. The prescriptions for renewals were stored in a separate system used by the pharmacy and were not integrated with the facility MAR. The Pharmacist obtained a medication renewal for Atorvastatin on 6/10/24 once daily at bedtime and Cetirizine HCL10 mg at bedtime on 6/12/24. The Pharmacist filled the prescriptions and sent the medication with instructions to the unit. The Pharmacist further identified Resident #47 was readmitted to the facility on [DATE]. However, no orders were sent following that readmission with any medication changes. An interview and clinical record review with the Director of Nursing Services (DNS) on 8/26/24 at 9:49 AM identified the Pharmacist reaches out to the provider independently for medication renewals. The system utilized by the Pharmacist was not integrated into the electronic medical record. However, any discrepancies between the administration instructions on the blister packs and the MAR should have been clarified by nursing staff and changed according to the most accurate order. A review of the facility policy for Medication Orders dated 7/2023 directed that Medications are administered only upon clear, complete, and signed orders of a person lawfully authorized to prescribe. Elements of the medication order and specify the name of the medication, strength, dose, time and frequency of administration and route, duration and indication for use. 4. Resident #278 was admitted to the facility on [DATE]. The resident diagnosis includes Parkinson's disease. The admission MDS assessment dated [DATE] identified Resident #278 as cognitively intact and required extensive assistance with bed mobility, toileting, and personal hygiene. The hospital discharge instructions dated 7/25/2023 directed Resident #278 to continue taking carbidopa-levodopa (a medication to treat Parkinson's disease) 25-100 milligrams (mg) three times a day but did not indicate the number of tablets to be taken. The hospital discharge instructions also indicated Resident #278 would continue taking one tablet of carbidopa-levodopa 25-100mg extended release (a version designed to release medication gradually in the body) twice daily at 1:00 PM and noon. A nursing note dated 7/25/2023 indicated the nursing supervisor Registered Nurse (RN#5) had spoken to Resident #278's family member regarding the resident's medications, including the preferred schedule. The preferred schedule was observed to be handwritten over the hospital discharge instructions and indicated the resident was to have one and a half tablets of carbidopa-levodopa 25-100mg at 6;00 AM, 9:00 AM, 3:00 PM, 6:00 PM, and 9:00 PM. The handwritten note also indicated the resident was to have one tablet of carbidopa-levodopa 25-100mg extended release at noon and at bedtime. A physician's order dated 7/26/2023 directed to administer one and a half tablets of carbidopa-levodopa 25-100mg five times a day. Additionally, a physician's order dated 7/27/2023 directed to administer one tablet of carbidopa-levodopa 25-100mg extended release once in the day and once before bed. A nursing note dated 8/4/2023 written by RN #3 identified Resident #278's family member had indicated Resident #278 should have been receiving one tablet of carbidopa-levodopa 25-100mg at noon along with one tablet of carbidopa-levodopa 25-100mg extended-release. A physician's note dated 8/4/2023 identified the physician clarified with the resident's family member the medication and ordered carbidopa-levodopa 25-100mg to be administered at noon. A physician's order dated 8/5/2023 directed to administer one tablet of carbidopa-levodopa 25-100mg with the noon dose of carbidopa-levodopa 25-100mg extended release. A review of the medication administration record (MAR) from 7/25/23 through 8/15/23 failed to provide evidence that one and a half tablets of carbidopa-levodopa 25-100mg were administered as ordered for the following dates and times: 7/26/2023 at 2:30 PM, 7/28/2023 at 2:30 PM, 7/31/2023 at 2:30 PM, 8/3/2023 at 2:30 PM, 8/6/2023 at 2:30 PM, 8/13/2023 at 6:00 AM and 8/14/2023 at 2:30 PM. A review of nursing progress notes from 7/25/23 through 8/15/23 did not identify any reason for the not administering carbidopa-levodopa 25-100mg. In an interview on 8/26/2024 at 1:57 PM, RN #3 indicated s/he could not recall how the conversation with Resident #278 family member came about but identified the family member had requested that carbidopa-levodopa 25-100mg be administered as per the resident's home schedule including the doses for noon. RN#3 indicated s/he notified the physician and had the noon dose ordered. Additionally, RN#3 indicated on admission to the facility, the hospital Intra-Agency Report (W10), discharge instructions, and discussion with the resident or family are used to determine what medications a resident should be ordered. RN #3 indicated s/he was not aware of any complaints prior to or after her/his conversation with Resident #278's family member. In an interview on 8/27/2024 at 11:15 AM, APRN #2 indicated s/he could not recall specifics regarding the conversation with the resident's spouse. APRN #2 also indicated s/he placed an order for carbidopa-levodopa but could not recall the dose or the scheduled time and referred to her/his note and physician's orders. On 8/27/2024 at 11:45 AM, a record review and interview with the DNS identified the discharge paperwork from the hospital was not always accurate regarding specific regimens, especially with Parkinson's medications. The DNS indicated that verifying a resident's particular medication regimen with the family was important. Additionally, the DNS was unable to identify why there were blanks in the MAR for carbidopa-levodopa 25-100mg for the scheduled times of 7/26/2023 at 2:30 PM, 7/28/2023 at 2:30 PM, 7/31/2023 at 2:30 PM, 8/3/2023 at 2:30 PM, 8/6/2023 at 2:30 PM, 8/13/2023 at 6:00 AM and 8/14/2023 at 2:30 PM. The DNS further indicated that if a dose of medication was not given or was held, s/he would expect a nursing note. On 8/27/2024 at 12:13PM an interview with RN#5 identified s/he had spoken to Resident #278's family member and verified the schedule of the residents Parkinson medications. In an interview and record review on 8/27/2024 at 1:57 PM, LPN #3 indicated that based on his/her documentation in the MAR, the resident did not receive the 2:30 PM dose of carbidopa-levodopa on 7/26/2023 because the medication was not available. LPN #3 could not recall why the medication was not available at the time. Additionally, LPN #3 could not identify a reason why the MAR had blanks on 7/31/2023 at 2:30 PM, 8/3/2023 at 2:30 PM, and 8/14/2023 at 2:30 PM (times on which s/he was on duty). LPN #3 indicated that s/he most likely gave the medications but was not sure since s/he could not recall the resident. A review of the facility policy for medication administration identified the individual who administers the medication records the administration on the resident's MAR directly after it is given. Additionally, the facility policy indicated an individual who administered medications should not report off-duty without first recording the administration of any medications. 5. Resident #7's diagnoses included Alzheimer's disease, insomnia, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 as severely cognitively impaired and required extensive assistance for transfers, toileting, and supervision for eating. The Resident Care Plan dated 7/1/24 identified Resident #7 has a diagnosis of anxiety. Interventions included mood assessment and provision of supportive care through one-on-one visits. A physician's order dated 7/18/24 directed to obtain orthostatic blood pressures monthly for postural hypotension. Report a decrease in systolic blood pressure of 20mmHg or more and decrease in diastolic blood pressure of 10 mmHg or more with change in position. A nursing note written by LPN #5 dated 7/2724 at 3:00 PM identified Resident # 7's orthostatic blood pressures as 146/69 ( 120/80 Normal Range ) lying, 177/68 sitting, and 95/71 standing. The pharmacy reports dated 6/14/24, and 8/18/24 recommend monitoring orthostatic blood pressures at least monthly to monitor for postural hypotension. The report also directed to report a decrease in systolic blood pressure of 20mmHg or more and decrease in diastolic blood pressure of 10 mmHg or more with change in position. In an interview and clinical record review with the DNS on 8/28/24 at 11:00 AM identified the clinical record failed to reflect documentation that the decrease in blood pressure on 7/27/24 was reported to the Medical Doctor (MD)/APRN. The parameters state to report a decrease in BP greater than 20 mmHg systolic or 10 mmHg diastolic with position change to the MD/APRN. Resident # 7's BP on 7/27/24 indicated a pressure of 146/69 Lying, 177/68 sitting, and 95/71 standing. The systolic pressure decreased by 82 mmHg from sitting to standing. When asked, the DNS identified the decrease from sitting to standing should have been reported to the MD/APRN. The DNS also stated staff should be documenting in the nursing notes any notification to the MD/APRN. The DNS indicated s/he could not provide evidence of the notification to the MD/APRN on 7/27/24 per physician's parameters for blood pressure monitoring. Review of the Orthostatic Blood Pressure Monitoring policy 3/07 directed, in part, to report newly or unexpectedly abnormal orthostatic changes as follows: systolic BP is decreased by 20 or more, with or without change in diastolic BP. 6. Resident #60's diagnoses included pneumonitis, dysphagia (difficulty swallowing), a progressive neurogenerative disorder and palliative care. The hospital discharge summary dated 7/17/2024 at 11:34 AM directed to provide an easy to chew diet cut into bite sized pieces with discharge special instruction to provide Strict Aspiration Precautions with upright posture while eating. A physician's order dated 7/17/2024 directed to provide a puree texture diet with nectar thick liquids. A physician's order dated 7/18/2024 directed to provide a regular chopped texture diet with nectar thick liquids due to Resident #60 and family preferring a more palatable texture. The RCP dated 7/19/2024 indicated Resident #60 had a swallowing problem related to couching, choking during meals or swallowing medications and difficulty with thin liquids. Interventions included in part for all staff to be informed of Resident #60's special dietary and safety needs, instruct resident to eat in an upright position, eat slowly and chew each bite thoroughly and to provide food for comfort. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 as cognitively intact and noted coughing or choking during meals and or with medications and indicated the resident was on a mechanically altered diet. A facility Reported Incident dated 8/23/2024 at 8:30 AM identified Resident #60 required the successful application of the Heimlich Maneuver after choking on a piece of fruit provided at breakfast. The physician's orders obtained post episode of choking dated 8/23/2024 at 3:00 PM directed to provide supervision with eating with aspiration precautions every shift and provide a regular diet, puree consistency. The RCP was updated on 8/23/2024 indicated Resident #60 was to eat only with supervision with aspiration precautions (37 days after admission) and to mash banana. An interview and record review on 8/26/2024 at 1:20 PM with RN #3 indicated on part The admission discharge summary from the hospital indicated strict aspiration precautions which was not transcribed onto the admission orders and did not mention in the plan of care but indicated supervision while eating and cleanse mouth before and after eating and to have head of bed elevated. An interview on 8/26/2034 at 1:40PM with the DNS indicated if strict aspiration precautions was on the discharge summary it should have been transcribed as an order. The facility policy labeled Aspiration Precautions indicated in part the facility was to provide guidelines in the policy when ordered by a physician to reduce the risk of aspiration: clear oral cavity of residual food and fluid following all oral intake including medications and to position to approximately 90 degrees for all oral intakes including fluids. However, the facility policy makes no indication if staff must remain present when a resident is taking food and or fluids.

Based on clinical record reviews, facility policy review and interviews for 1 of 3 sampled residents reviewed for care planning for( Resident # 71), the facility failed to conduct a Resident Care Conference (RCC) within the appropriate timeframe and invite the resident's responsible party/ family and for 1 of 1 resident ( Resident # 60), reviewed for End of Life Services, the facility failed to revise the care plan to address the resident's wishes to received non prescribe foods for comfort. The findings included: 1. Resident #71 's diagnoses included unspecified dementia, cognitive communication deficit and aphasia. A review of the admission record identified Resident #71 was admitted on [DATE] The admission Minimum Data Set assessment dated [DATE] identified Resident #71 was cognitively impaired and required one person assistance in bed mobility and transfers and requires set up for food. The RCP dated 7/18/24 identified the need for long-term care. Interventions included collaborating with residents, family and Interdisciplinary Team (IDT) to determine emotional needs and to maintain quality of care. A review of progress notes dated 7/17/24 through 8/26/24 failed to indicate that RCC was held for Resident # 71. Interview with Person #1 on 8/22/24 at 11:54 AM indicated s/he has not been invited to a care plan meeting for Resident # 71. Person #1 also indicated it has been over 4 weeks since Resident # 71 was admitted . On 8/28/24 at 10: 37 AM a review of the RCC sign off sheet was requested; however, the facility was unable to provide the requested document. Interview Social Worker (SW #1) on 8/28/24 at 10:43 AM indicated residents on long term units care plan completed quarterly. For new residents the care plan is completed with in 2.5 months of admission. SW#1 further indicated Resident #71 has an upcoming MDS assessment and care plan review in October 2024. SW #1 further indicated care conference is done after the MDS assessment. When asked about MDS completed on 7/22/24, SW #1 indicated s/he was not aware the RCC could have been completed based on the MDS assessment completed on 7/22/24. 2. Resident #60's diagnoses included pneumonitis, dysphagia (difficulty swallowing), a progressive neurogenerative disorder and palliative care. Resident #60 elected Hospice services on 7/19/2024. The Resident Care Plan (RCP) dated 7/24/2024 indicated Resident #60 was receiving End of Life Services. Interventions included collaboration between End-of-Life Services and the Skilled Nursing Facility and directed the social worker to provide support to the resident and family. An interview on 8/26/2024 at 1:24 PM with Hospice Agency Nurse (RN #6) identified eating food for comfort in the consistency Resident # 60 preferred though not recommended by physician due to progressive dysphagia diagnosis, was one of the most important needs expressed by the resident and family while on Hospice/ End of Life Services. An interview and record review with the Director of Nursing Services (DNS) on 8/28/2024 indicated Resident #60's care plan would need to be updated/ revised to reflect Resident # 60's choice to eat food in a consistency not recommended by physician. Interventions to assist the resident by providing the safest eating experience while providing food for comfort and to prevent further choking episodes.

Based on clinical record review, observations and staff interviews for 1 of 5 Residents (#60) reviewed for accidents, the facility failed to ensure the resident's discharge summary physician's orders for aspiration precautions were transcribed to meet professional standards of practice. The findings include. Resident #60's diagnoses included pneumonitis, dysphagia (difficulty swallowing), a progressive neurogenerative disorder and palliative care. The hospital discharge summary dated 7/17/2024 at 11:34 AM directed to provide an easy to chew diet cut into bite sized pieces with discharge special instruction to provide Strict Aspiration Precautions with upright posture while eating. A physician's order dated 7/17/2024 directed to provide a puree texture diet with nectar thick liquids. A physician's order dated 7/18/2024 directed to provide a regular chopped texture diet with nectar thick liquids due to Resident #60 and family preferring a more palatable texture. Resident #60 elected Hospice services on 7/19/2024. The admitting note indicated Resident #60 and family were made aware of risks of recurring aspiration due to disease progression by choosing not to follow a recommended diet consistency of puree and opting for a chopped consistency diet. The RCP dated 7/19/2024 indicated Resident #60 had a swallowing problem related to couching, choking during meals or swallowing medications and difficulty with thin liquids. Interventions included in part for all staff to be informed of Resident #60's special dietary and safety needs, instruct resident to eat in an upright position, eat slowly and chew each bite thoroughly and to provide food for comfort. Additionally, the care further indicated Resident #60 had a self-care deficit related to activity intolerance related to aspiration pneumonia and a progressive neurodegenerative disorder. Interventions included in part for staff to provide supervision for eating, to cleanse mouth with wet swabs prior to and post eating and to position plate or bowl in lap, use an inner lip plate at all meals and to keep drinks on right hand side of the table. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 as cognitively intact and noted coughing or choking during meals and or with medications and indicated the resident was on a mechanically altered diet. A facility Reported Incident dated 8/23/2024 at 8:30 AM identified Resident #60 required the successful application of the Heimlich Maneuver after choking on a piece of fruit provided at breakfast. The physician's orders obtained post episode of choking dated 8/23/2024 at 3:00 PM directed to provide supervision with eating with aspiration precautions every shift and provide a regular diet, puree consistency. The RCP was updated on 8/23/2024 indicated Resident #60 was to eat only with supervision with aspiration precautions (37 days after admission) and to mash banana. A physician's order dated 8/24/2024 at 6:48 PM directed to provide a regular diet, ground texture, with nectar thick liquids and mashed bananas aspiration precautions. Resident #60 had declined the puree consistency as it did not meet his/her comfort needs while on hospice. An observation on 8/25/2024 at 12:38 PM found Resident #60 sitting upright in bed alone and without supervision, the tray table was noted in front of the resident with two full beverages within reach. On 8/25/2024 at 12:40 PM an interview with NA #1 who was sitting at the nurse's station at the end of hallway 2 rooms down from Resident #60's indicated s/he supervises Resident #60 while eating by walking up and down the hall, looking in and checking on the resident, s/he sometimes sits with the resident, but Resident # 60 does not always like someone sitting with him/her. NA #1 further indicated Resident#60's diet required food to be cut into small pieces, was not on duty the day Resident #60 choked and further indicated Resident # 60 had not received a banana for breakfast this am. NA #1 indicated s/he thought the kitchen would mash the banana before sending the tray up from the kitchen. On 8/25/2024 at 12:45 PM and interview with the unit charge nurse LPN #3 indicated s/he supervises Resident #60 while eating by walking up and down the hallway looking in the room, sometimes staying with the resident and sometimes observing from the doorway. LPN #3 indicated Resident #60 did not like to be watched. LPN #3 further indicated staff is not required to stay with Resident #60 while eating or drinking, just to supervise and check in on the resident and instructed the surveyor to talk with the unit manager RN #3. On 8/25/2024 at 12:48 PM an interview with the Unit Manager, RN#3 indicated a staff member is expected to stay with Resident #60 while eating and drinking. However, hospice election notes Resident #60 chooses to eat for comfort despite the consistency recommended. RN #3 acknowledged a difference in interpretation of what supervision requires staff members caring for Resident #60 to do and indicated s/he would find a copy of the facility policy. On 8/25/2024 12:48 PM during interview, record review with RN #3 at nurses' station and direct observation with charge nurse LPN #3, LPN #3 indicated aspiration precautions was put in place and updated on the care card. Observation of Resident #60 with charge nurse LPN #3 found Resident # 60 alone in room in bed without supervision with the tray table pulled up to the chest and two beverage cups upright and empty and the contents of one spilled on the tray table. LPN #3 checked on Resident #60 and cleaned the spill. LPN #3 provided the NA care card updated on 8/23/24 which indicated supervision with meals, aspiration precautions and to provide mashed bananas. An interview and record review on 8/26/2024 at 1:20 PM with RN #3 indicated in part the admission discharge summary from the hospital indicated strict aspiration precautions which were not transcribed onto the admission orders but was not noted in the plan of care. However, the plan of care indicated supervision while eating and cleanse mouth before and after eating and to have head of bed elevated. An interview on 8/26/2034 at 1:40PM with the DNS indicated if strict aspiration precautions were noted on the discharge summary the strict aspiration precautions should have been transcribed as an physician's order.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident # 1) reviewed for accidents, the facility failed to ensure the resident received an assessment when the resident refused to ambulate and complained of pain to identify a potential serious injury timely. The findings include: Resident #1 was admitted on [DATE] with diagnoses that included syncope, glaucoma hypertension and dementia with behavioral disturbances. The Nursing Admission assessment dated [DATE] identified Resident #1 had no mobility issues, no balance issues and indicated the resident was able to ambulate with minimal assist. The assessment also noted no pain. The RCP dated 12/21/21 identified Resident #1 was at high risk for falls. Interventions included: to remind resident/ caregivers about safety reminders and what to do if a fall occur, 30-minute safety checks and to provide a Physical Therapy (PT) evaluation and treat as indicated. The physician's orders dated 12/21/22 directed to administer Tylenol 325 Milligrams (MG) two tablets by mouth every 4 hours for pain and not to exceed 3000 mg/24 hours. The physician's orders dated 12/21/22 directed to administer Ativan 0.5 MG by mouth every 12 hours for agitation / anxiety. The Fall Risk assessment dated [DATE] identified a score of 9 indicating Resident #1 was at high risk for falls. The Physical Therapy Evaluation dated 12/23/21 identified Resident #1 was unable to adequately participate in a skilled program. A rolling walker and wheelchair were trialed, however, Resident # 1 refused to participate. Recommendations were made for one-person physical assist with ambulation for safety. The admission MDS assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, had behavioral symptoms directed at others that included: hitting, kicking, scratching, grabbing 1-3 days; verbal behaviors that included screaming and cursing at others 4-6 days and indicated the resident required extensive two person assist with bed mobility, transfers, extensive one person assist with ambulation in the room and corridor with the use of a walker. The nursing progress note dated 1/1/22 at 3:16 AM (completed by LPN #3) identified Resident #1's gait was observed to be weaker since admission, the resident received Tylenol 324 MG for complaint of bilateral knee discomfort. Assist of one was offered to the bathroom where Resident #1 was observed favoring the right lower extremity with no visible injury. The nursing progress note dated 1/1/22 at 3:53AM (completed by LPN #3) identified Resident #1 was still complaining of right hip pain with no visible injury. Full passive range of motion was noted. Resident #1 stated My right leg hurts. I can lift it unless I do it with my arms and indicated my left leg is good. I guess I won 't do that again .bumping into the bed. Review of the ADL flow sheets for ambulation program dated 12/23/21 through 12/31/21 identified Resident #1 was ambulating between 25 feet and 300 feet daily. Beginning 1/1/21 the clinical record identified no further documented ambulation. The Medication Administration Record (MAR) dated 12/23/21 through 1/3/22 noted Tylenol 325 MG was administered on 12/23/21 and 12/24/21 for mild discomfort with effect. On 1/1/22 Tylenol 325 MG two tablets was administered at 3:16AM and 2:53 PM for a pain level 4-6 with good effect. On 1/2/22 Tylenol 325 MG two tablets was administered at 1:27AM for a pain level of 6 with good effect. On 1/3/22 Tylenol 325 MG two tablets was administered at 3:45AM for a pain level of 6 with good effect. The 24-hour nursing reports dated 12/31/21 through 1/3/22 identified 12/31/21 on the 3-11 PM shift, Resident #1 was medicated with Ativan 0.5 MG at 5:00 PM for increased anxiety. Beginning 1/1/22 11-7 AM shift, Resident #1 was medicated with Tylenol 325 two tablets MG for right lower extremity pain with repeated doses at 3:00 PM and 8:30 PM. On 1/2/22 Resident #1 was medicated with Tylenol 325 MG two tablets for right hip pain at 1:20AM with no further documentation of dose administrations. On 1/3/22 11-7 A M shift, Resident #1 complained of right hip pain with no documented intervention. Resident #1 was transferred to an acute care facility on the 3-11PM shift for an evaluation. The RN Nursing Progress notes dated 1/3/22 at 2:07 PM noted Resident #1 stated s/he had right hip pain and was unable to walk since Friday (12/31/21) without having pain. Resident #1 stated s/he had a fall week ago but not recently. A yellow bruise was noted as well as a yellow faded bruise to the right leg. Resident #1 was unable to lift his/her right leg up without severe pain. Tylenol 650 MG two tablets was administered at 9:30AM. A physician's order was obtained on 1/3/22 for a stat (immediate) x-ray and Tramadol 50 MG for pain. The x-ray showed Resident #1 had an obvious fracture of the right femoral head. A subsequent nursing progress note dated 1/3/22 at 11:51 PM noted Resident #1 was admitted to an acute care facility for surgery on the right hip. A Reportable Event dated 1/3/22 identified Resident #1 complained of right hip pain starting on 1/1/2022 approximately 3:30 AM. Resident #1 was unable to lift his/her right leg without using his/her arms to assist. Resident # 1 had been ambulating with assist of one with a rolling walker on the shift. Resident #1 made a comment to nurse about bumping his/her leg on the bed. When needed (PRN) Tylenol was administered for pain with effect. On 1/3/2022, x-ray was ordered by APRN secondary to the RN report of internal rotation of the right leg and continued right hip pain. X-ray was completed at 2:30 PM on 1/3/2022 (2 days later) that showed an acute fracture of the right femoral neck with lateral displacement. Resident #1 was sent to an acute care facility for an evaluation on 1/3/22. A partial hip replacement was planned for 1/4/2022 per acute care facility. An interview on 1/20/22 at 2:00PM identified Person #1 and (Person #2) who visited alternately daily except on January 1, 2022. The facility received a report that Resident #1 was complaining of hip pain, the resident was noted with confusion, but nothing appeared to be wrong. Person #1 indicated she/he had visited the day before and she/he and Resident #1 walked the hallways together, Resident #1 was in a good mood and there were no concerns. According to Person #1, (Person #2) visited the following day (January 2, 2022) and Resident #1 was confused and yelling and had a pillow under his/her legs. Staff at that time reported to (Person #2) that Resident #1 woke up screaming and refused to get out of bed. (Person #2) suspected another UTI and requested a urinalysis. Person #1 indicated she/he went to visit the following day, Resident #1 complained of pain in the right leg. When Person #1 went to sit on the bed the resident stated s/he felt as if s/he was dying. Person #1 removed the covers to observe that Resident #1's right leg did not look right and had a large hematoma (bruise) on the right hip. Person #1 reported to the nurse something was wrong with Resident # 1. The nurse came in and stated she thought the hip was broken and nothing had previously been reported. The RN tried to attempt range of motion, but Resident #1 was in extreme pain. An x-ray confirmed the right hip was broken and Resident #1 was transferred to the hospital for hip replacement. An interview on 1/21/22 at 10:50AM with RN #1 identified she worked as a Nursing Supervisor on 1/3/22 when the injury was first observed. RN #1 indicated (Person #1) reported Resident #1 was having pain. On examination, the right hip was externally rotated, and the resident was in pain. (Person #1) indicated Resident #1 was not right since the fall at home where there were also reports of pain. An x-ray was obtained which confirmed a fracture and the resident was sent out for an evaluation. RN #1 indicated she had done some research and learned Resident #1 had not been out of bed since the Friday (12/31/21) and the resident was noted with pain and appeared groggy. The nurse aides also reported they were having trouble getting Resident #1 out of bed the previous Friday 12/24/21 or Saturday 12/25/21. An interview on 1/21/22 at 11:27 AM with NA #1 indicated although she could not recall if she was assigned to Resident #1 on Saturday 1/1/2 dayshift, she did recall observing Resident #1 in a wheelchair in the dining area. Resident #1 stated s/he wanted to go to bed and NA #1 assisted Resident #1 back to bed without difficulty. An interview on 1/21/22 at 11:37AM with LPN #1 identified Resident would wake up screaming on occasion. LPN #1 told a family member Resident #1 may not have been familiar with the surroundings. There was an occasion where Resident #1 complained of right hip pain, perhaps on day shift 1/1/22. LPN #1 indicated she medicated Resident #1 with Tylenol 325 MG but that when she later asked how the pain was Resident #1 indicated the pain had been in her/his foot. LPN #1 stated Resident #1 had refused to get up that shift but did not find it unusual as residents may refuse to get out of bed at times. An interview on 1/21/22 at 11:53AM with NA#3 identified on 1/1/22 or 1/2/22 day shift, Resident #1 did not want to get out of bed or eat. Resident #1 did not indicate why s/he did not want to get out of bed. NA #3 further indicated she was not concerned because a resident may choose not to get out of bed. NA #3 assisted Resident #1 in a sitting position in bed where there were no complaints of pain. NA #3 also later returned to provide personal care and there were no complaints or signs of bruising when moving side to side. NA #3 recalled a family member came into visit Resident #1 during the same shift. After NA #3 returned from lunch, she observed Resident #1 was up in his/her chair with the family member stating she got Resident #1 out of bed. There were no complaints offered at that time either. An interview on 1/21/22 at 12:33PM with the DNS identified Resident #1 required assist of one with a rolling walker. Resident #1 had poor safety awareness, often observed walking up and down the hall without assists or the rolling walker. Resident #1 had reported right lower extremity pain on 1/1/22 during the day and received Tylenol 325 MG during the shift and twice in the evening. The DNS indicated the injury occurred at the facility, but she was not able to determine how or exactly when it occurred given that Resident #1 had been on 15-minute checks. Resident #1 could have fallen and then gotten up without pain because of the effects of adrenalin. An interview on 1/21/22 at 1:18 PM with NA #2 indicated although he was never assigned to Resident #1, he did provide assist with getting the resident out of bed. NA #3 recalled having worked on 1/2/22 day shift and was assisting the assigned aide (NA #3). Resident #1 did not want the aides (NA #3 and NA #2) to do anything with him/her. There were no complaints. However, NA #2 and NA #3 determined they would leave Resident #1 alone and return later. NA #2 did return later and observed Resident #1 was with a family member, out of bed, and in a chair. NA #2 recalled saying Oh! You got her/him out of bed! Thank you. Resident #1 was fully dressed but she/he did not know if Resident #1 had ambulated with the family member. The family member also put Resident #1 back to bed before she/he left. An interview on 1/21/22 at 12:28 PM with PT #1 identified she completed an initial evaluation for Resident #1 who would not participate, becoming extremely agitated, confused, pushing the walker away. Resident #1 had poor safety awareness, poor vision and would not use a walker which the family which was also the case at home. PT #1 made recommendations for hand holding with ambulation and made several observations where Resident #1 was non-complaint with ambulation with assist. Nursing also reported Resident #1 was observed roaming without assist. PT #1 indicated if Resident #1 fell , s/he would likely be able to get up without assist. An interview on 1/21/22 at 2:50PM with RN #2 indicated she was the assigned Nursing Supervisor on the evening shift on 1/1/22. RN #2 indicated she could not recall if a change of condition was reported to her on the evening of 1/1/22. An interview on 1/28/22 at 2:30PM with the Medical Director identified he felt that although unwitnessed, the fracture occurred in the facility as Resident #1 was previously ambulating and had no other documented change of condition. If Resident #1 fell , s/he would not likely be able to get up on her/his own given the nature of the injury. An interview on 1/31/22 at 12:49 AM with NA #4 indicated she observed on the evening of 1/1/22 before supper, Resident #1 had gone to the bathroom unassisted. Resident #1 was turned to the side of bed and could not stand. NA #4 attempted to assist to a standing position but was unable so instead, assisted Resident #1 back into the bed thinking s/he was just tired as s/he offered no complaints. NA #4 returned after dinner to wash Resident # 1 for evening care. NA #4 observed Resident #1 ' s right leg was externally rotated. NA #4 attempted to lift the right leg slightly when Resident #1 screamed and stated it hurt. NA #4 immediately reported the concern to the nurse (LPN #2) who also reported Residents #1's difficulty standing earlier in the shift. An interview on 2/15/21 at 12:44 PM with RN#3 identified on 1/1/22 during the day shift, a family member was visiting with Resident #1 who expressed a concern of increased confusion. The family member also reported she walked Resident #1 to the bathroom and back and the resident seemed weaker, suspecting a UTI. An order was obtained for a straight catheterization procedure. RN #3 indicated Resident #1 tolerated the procedure well without complaints of pain and slept. Attempts to reach Person #2 were unsuccessful. Attempts to reach LPN #2 were unsuccessful. Attempts to reach LPN #3 were unsuccessful. The facility failed to assess and follow up on the resident's continued right hip pain to rule out a potential fracture. The facility policy for Reportable Events directs all incidents resulting in injury must be investigated with submission of findings within 72 hours.

Based on clinical record review, review of facility documentation, and interviews, for one of eight residents (R #1) reviewed for wandering, the facility failed to adequately supervise one resident (Resident #1) with a known history of inappropriate sexual touching, and as a result, the resident inappropriately touched four residents (Resident #2, #3, #4, and #5) resulting in immediate jeopardy. On 4/2/19 at 1:00 PM, immediate jeopardy was removed when the facility placed Resident #1 on one to one monitoring until the resident was discharged to the hospital on [DATE]. The finding includes: Resident #1's [DIAGNOSES REDACTED]. Review of the preadmission referral from Nursing Home#1 dated 2/21/19 identified R #1 required 1:1 monitoring twice during the month of (MONTH) for inappropriate touching of another person, has significant dementia, the behavior was constantly monitored, and to continue every fifteen (15) minute checks. R#1 was admitted to the facility from Nursing Home #1 on 2/27/19 and placed on a locked Dementia Unit. Review of the transfer/discharge report dated 2/27/19 identified R #1 had multiple episodes of sexually inappropriate behavior that had not been corrected despite multiple medication changes along with redirection. The admission nursing assessment dated [DATE] identified that R #1 was alert, oriented to person only, and was ambulatory. The Resident Care Plan (RCP) dated 2/28/19 identified a potential to be sexually inappropriate related to poor impulse control with interventions to modify the environment when in the common area or recreation activities, to sit R #1 next to male residents to help lessen the temptation of inappropriate touch, monitor and document observed behaviors and attempted interventions, and a psychiatry consult as needed. a. Resident #2's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified R #2 had severely impaired cognition, and was unable to ambulate. Review of facility documentation dated 2/28/19 at 12:35 PM identified R #1 was observed in the lounge area to lift R #2's shirt up and was observed touching R #2's left breast. The residents were immediately separated. R #1's plan of care was updated to include not to sit next to female residents. Review of R #2's nurse's note dated 2/28/19 at 9:42 PM identified R #2 had no negative effect from the incident, was unable to state what had happened or how he/she felt about it. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #2. b. Resident #3's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #3 had severely impaired cognition, and ambulated with limited assist of one staff. Review of facility documentation dated 3/4/19 at 7:26 PM identified R #1 was observed in the lounge area to place his/her hand down R #3's blouse and grab his/her breast. The residents were immediately separated. R #1's plan of care was updated to include sitting R #1 in a corner chair to help keep female residents away from R #1. Review of R #3's nurse's note dated 3/5/19 at 2:05 PM identified R #3 had no recollection of the incident. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #3. Review of the psychiatry note dated 3/5/19 identified that Resident #1 had a change in behaviors due to changes in his/her location and was started on a as needed medication without any recommendations for additional monitoring. c. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #4 had severely impaired cognition and ambulated independently with supervision. Review of facility documentation dated 3/6/19 at 4:10 PM identified R #1 was observed by staff touching another resident's buttocks. The residents were immediately separated. R #1's plan of care was updated to include to offer R #1 activities to keep his/her hands busy and distract from female residents. Review of R #4's nurse's note dated 3/6/19 at 7:09 PM identified R #4 did not appear to realize what had happened and was not upset. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #4. d. Resident #5's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified R #5 had severely impaired cognition, and ambulated independently. Review of facility documentation dated 3/11/19 identified that R #5 reported that R #1 had grabbed his/her breast when they were seated next to each other. Review of R #5's nurse's note dated 3/11/19 at 2:06 PM identified on 3/11/19, R #5 notified staff that R #1 had touched his/her left breast while sitting in the common area on 3/9/19. R #5 stated that he/she got up and moved away from R #1, and told R #1 not to touch him/her again. Review of R #5's nurse's note dated 3/12/19 at 2:03 PM identified R #5 was able to recall the incident but stated he/she was okay. R #1's plan of care was updated to include give R #1 a plush pillow/tactile soft hand held items to hold to keep his/her mind occupied, and seen by psychiatry with medication changes made. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #5. e. Review of facility documentation dated 3/21/19 at 3 PM identified R #1 was observed by staff to massage R #2's breast. Review of R #2's nurse's note dated 3/21/19 at 10:43 PM identified R #2 was unable to vocalize what occurred or if he/she remembered the incident, and did not appear anxious. R #1's plan of care was updated to include to continue close monitoring and to utilize a busy box for distraction. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #2 for a second time (first time was on 2/28/19). Review of the clinical record, facility documentation and interview with RN #2 (charge nurse) on 4/2/19 at 9:30 AM and 11:28 AM stated she was aware of R #1's history of inappropriate touching prior to R #1's admission to the facility and educated staff about R #1's history of inappropriate touching and directed them to watch him/her for any abnormal behaviors. RN #2 indicated that R #1 was fast; staff could be feeding a resident in the area, and R #1 could move quickly before any staff noticed. RN #2 identified that although all residents on the locked unit are monitored every thirty minutes, the facility does not provide one to one (1:1) monitoring for residents. Further interview with RN #2 stated R #1 also inappropriately touched staff. Interview with the Administrator and the Admissions Coordinator on 4/2/19 at 11:28 AM identified that they were aware R #1 had behaviors of inappropriate touching prior to R #1's admission to the facility, and R #1 was independent with ambulation, however, they failed to implement any monitoring of Resident #1 since s/he was admitted to a locked dementia unit. Further interview with the Administrator on 4/2/19 identified that the facility had no policy and/or procedure to monitor a resident who required close monitoring. Interview with RN #1 on 4/2/19 at 11:28 AM identified that R#1 was not on every 15 minute checks or 1:1 monitoring, but indirect caregiver staff would visually supervise R #1 while they were performing their other job duties, and if they observed any behaviors they would alert nursing staff to intervene. Although staff were aware of R #1's prior behaviors upon admission, the Administrator and RN #1 stated on 4/2/19 at 11:28 AM that they were unable to identify why R #1 was not put on closer monitoring and/or how other residents on the unit were to be kept from enduring inappropriate touching from R #1. Interview and record review on 4/3/19 at 9:31 AM with APRN #1 identified she evaluated R #1 on 3/5/19, was aware of R #1's behaviors prior to admission, and aware of the incidents on 2/28 and 3/4/19. APRN #1 indicated that although R #1 was on the dementia unit, was independent with ambulation, and residents on the unit are closely monitored, she was unable to say or have recommendation on how R #1 should have been monitored. Interview and record review with MD #1 on 4/3/19 at 11:17 AM identified although he was aware of R #1's behaviors before admission, and the incidents that occurred on 2/28, 3/4, 3/6, 3/9, and 3/21/19, R #1 was monitored by staff on the dementia locked unit while they performed their job duties, MD #1 was unable to identify how staff supervised R #1 to prevent reoccurrence of behaviors. Subsequent to surveyor inquiry, R #1 was placed on 1:1 monitoring on 4/2/19 at 1 PM this was verified during the onsite visit on 4/2/19 and 4/3/19. Review of the immediate action plan dated 4/2/19 identified the resident was placed on one to one monitoring at 1:00 PM, the facility will develop a policy regarding residents who display sexually inappropriate behaviors, educate staff on the policy, and develop audits to monitor compliance.

Based on clinical record review, review of facility documentation, review of facility policies and procedures, and interviews, the facility failed to protect four residents (Resident #2, #3, #4, and #5) from inappropriate sexual advances from one resident (Resident #1) with a known history of inappropriate touch resulting in immediate jeopardy. On 4/2/19 at 1:00 PM, immediate jeopardy was removed when the facility placed Resident #1 on one to one monitoring until the resident was discharged to the hospital on [DATE]. The findings include: R #1's [DIAGNOSES REDACTED]. Review of the preadmission referral from Nursing Home #1 dated 2/21/19 identified R #1 required one to one (1:1) monitoring twice during the month of (MONTH) of 2019 for inappropriate touching of another resident, had significant dementia, the behavior was constantly monitored, and to continue every fifteen (15) minute checks. Resident #1 was admitted to the facility on [DATE] from Nursing Home #1 and was placed on the locked Dementia Unit. Review of the transfer/discharge report dated 2/27/19 identified R #1 had multiple episodes of sexually inappropriate behavior that had not been corrected despite multiple medication changes along with redirection. The admission nursing assessment dated [DATE] identified that R #1 was alert, oriented to person only, and was ambulatory. The Resident Care Plan (RCP) dated 2/28/19 identified a potential to be sexually inappropriate related to poor impulse control with interventions that directed to modify the environment, when in the common area or recreation activities, to sit R #1 next to male residents to help lessen the temptation of inappropriate touch, monitor and document observed behaviors and attempted interventions, and psychiatry consult as needed. a. Resident #2's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified R #2 had severely impaired cognition, and was unable to ambulate. Review of facility documentation dated 2/28/19 at 12:35 PM identified R #1 was observed in the lounge area to lift R #2's shirt up and was observed touching R #2's left breast. The residents were immediately separated. R #1's plan of care was updated to include not to sit next to female residents. Review of R #2's nurse's note dated 2/28/19 at 9:42 PM identified R #2 had no negative effect from the incident and was unable to state what had happened or how he/she felt about it. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #2. b. Resident #3's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #3 had severely impaired cognition, and ambulated with limited assist of one staff. Review of facility documentation dated 3/4/19 at 7:26 PM identified that R #1 was observed in the lounge area to place his/her hand down R #3's blouse and grab his/her breast. The residents were immediately separated. R #1's plan of care was updated to include sitting R #1 in a corner chair to help keep female residents away from R #1. Review of R #3's nurse's note dated 3/5/19 at 2:05 PM identified R #3 had no recollection of the incident. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #3. Review of the psychiatry note dated 3/5/19 identified that Resident #1 had a change in behaviors due to changes in his/her location and was started on a as needed medication without any recommendations for additional monitoring. c. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R #4 had severely impaired cognition and ambulated independently with supervision. Review of facility documentation dated 3/6/19 at 4:10 PM identified R #1 was observed by staff in the sunroom touching another resident's buttocks. The residents were immediately separated. R #1's plan of care was updated to include to offer R #1 activities to keep his/her hands busy and distract from female residents. Review of R #4's nurse's note dated 3/6/19 at 7:09 PM identified R #4 did not appear to realize what had happened and was not upset. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #4. d. Resident #5's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified R #5 had severely impaired cognition, and ambulated independently. Review of facility documentation dated 3/11/19 identified that R #5 reported that R #1 had grabbed his/her breast when they were seated next to each other in the lounge area. Review of R #5's nurse's note dated 3/11/19 at 2:06 PM identified on 3/11/19, R #5 notified staff that R #1 had touched his/her left breast while sitting in the common area on 3/9/19. R #5 stated that he/she got up and moved away from R #1, and told R #1 not to touch him/her again. Review of R #5's nurse's note dated 3/12/19 at 2:03 PM identified R #5 was able to recall the incident but stated he/she was okay. R #1's plan of care was updated to include giving R #1 a plush pillow/tactile soft hand held items to hold to keep his/her mind occupied, and seen by psychiatry with medication changes made. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #5. e. Review of facility documentation dated 3/21/19 at 3 PM identified R #1 was observed by staff in a common area to massage R #2's breast. Review of R #2's nurse's note dated 3/21/19 at 10:43 PM identified R #2 was unable to vocalize what occurred or if he/she remembered the incident, and did not appear anxious. R #1's plan of care was updated to include to continue close monitoring and utilize a busy box for distraction. The facility failed to ensure that R#1 was supervised appropriately to prevent inappropriate touching of Resident #2 for a second time (first incident was on 2/28/19). Review of the clinical record, facility documentation and interview with RN #2 (charge nurse) on 4/2/19 at 9:30 AM and 11:28 AM stated she was aware of R #1's history of inappropriate touching prior to R #1's admission to the facility and educated staff about R #1's history of inappropriate touching and directed them to watch him/her for any abnormal behaviors. RN #2 indicated that R #1 was fast; staff could be feeding a resident in the area, and R #1 could move quickly before any staff noticed. RN #2 identified that although all residents on the locked unit are monitored every thirty minutes, the facility does not provide one to one (1:1) monitoring for residents. Further interview with RN #2 stated R #1 also inappropriately touched staff. Interview with the Administrator and the Admissions Coordinator on 4/2/19 at 11:28 AM identified that they were aware R #1 had behaviors of inappropriate touching prior to R #1's admission to the facility, and R #1 was independent with ambulation, however, they failed to implement any monitoring of Resident #1 since s/he was admitted to a locked dementia unit. Further interview with the Administrator on 4/2/19 identified that the facility had no policy and/or procedure to monitor a resident who required close monitoring. Interview with RN #1 on 4/2/19 at 11:28 AM identified that R#1 was not on every 15 minute checks or 1:1 monitoring, but indirect caregiver staff would visually supervise R #1 while they were performing their other job duties, and if they observed any behaviors they would alert nursing staff to intervene. Although staff were aware of R #1's prior behaviors upon admission, the Administrator and RN #1 stated on 4/2/19 at 11:28 AM that they were unable to identify why R #1 was not put on closer monitoring and/or how other residents on the unit were to be kept from enduring inappropriate touching from R #1. Interview and record review on 4/3/19 at 9:31 AM with APRN #1 identified she evaluated R #1 on 3/5/19, was aware of R #1's behaviors prior to admission, and aware of the incidents on 2/28 and 3/4/19. APRN #1 indicated that although R #1 was on the dementia unit, was independent with ambulation, and residents on the unit are closely monitored, she was unable to say or have recommendation on how R #1 should have been monitored. Interview and record review with MD #1 on 4/3/19 at 11:17 AM identified although he was aware of R #1's behaviors before admission, and the incidents that occurred on 2/28, 3/4, 3/6, 3/9, and 3/21/19, R #1 was monitored by staff on the dementia locked unit while they performed their job duties, MD #1 was unable to identify how staff supervised R #1 to prevent reoccurrence of behaviors. Subsequent to surveyor inquiry, R #1 was placed on 1:1 monitoring on 4/2/19 at 1 PM this was verified during the onsite visit on 4/2/19 and 4/3/19. Review of facility Abuse Prevention Policy directed in part, preventing resident abuse was a primary concern, assessing, care planning and monitoring of residents with needs and behaviors that may lead to conflict or neglect and developing and implementing care plans to address the needs. The Policy further directed to maintain adequate staffing to ensure resident needs are met, and sexual abuse included any unwanted or inappropriate touching. Review of facility Resident Rights Policy, directed in part, the resident has the right to be free from sexual abuse. Review of the immediate action plan dated 4/2/19 identified the resident was placed on one to one monitoring at 1:00 PM, the facility will develop a policy regarding residents who display sexually inappropriate behaviors, educate staff on the policy, and develop audits to monitor compliance.

Based on clinical record review, facility documentation review, interviews, and policy review, for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure that the Marisa (mechanical Hoyer) lift pad was properly placed beneath the resident and when staff attempted to remove the lift pad, the resident slid out of the wheelchair resulting in bilateral leg fractures. The finding includes: Resident #1's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that Resident #1 was alert and oriented, required total assistance of two or more staff for transfers, and had no falls in the last 90 days. The Resident Care Plan (RCP) dated 1/4/18 identified an ADL deficit related to MS. Interventions directed to transfer with mechanical lift with two staff and remove Marisa lift sling once positioned in wheelchair. The nurse's note dated 1/16/18 at 11:30 AM identified that two Nurse Aides transferred R #1 into his/her wheelchair with a Hoyer lift, and proceeded to remove the lift pad, R #1 leaned forward and slid out of the chair, and staff were unable to stop the fall. Review of the facility incident report dated 1/16/18 at 10:30 AM identified NA #1 and NA #2 transferred R #1 into the wheelchair, leaned the resident forward to allow staff to remove the lift pad, his/her legs slipped and staff were unable to stop the fall. The facility investigation dated 1/25/18 noted that the resident had poor trunk control with a plan to continue with the use of the Marissa lift for transfers with the lift pad to remain beneath the resident while seated in the w/c. The APRN note dated 1/16/18 at 6:14 PM identified she was called to assess R #1 at 10:50 AM, who had slid out of the wheelchair during care. The resident's left leg was bent up backwards under his/her body, and the right leg was at approximately a 45 degree angle out to the right side. The resident had strong femoral and popliteal pulses present but no pedal pulse. The resident's right knee appeared dislocated and the top of his/her tibia/fibula had a large hematoma with swelling. R #1 stated that his/her right knee hurts a lot. EMS arrived, and straightened the right leg, tolerated movement well with a faint right pedal pulse present. The resident was transferred to the stretcher then to the hospital for evaluation. Review of the hospital radiology reports dated 1/16/18 identified R #1 had a left knee multiplanar oblique fracture; left proximal tibial and fibular fractures without significant displacement; right distal femoral fracture/oblique fracture through the distal femur involving the distal diaphysis and metaphysis. Treatment was conservative with a long leg cast applied to the left leg and a long leg knee immobilizer was applied to the right. Interview, clinical record review, and facility documentation review with NA #1 on 6/19/18 at 12:40 PM identified that she was the resident's assigned NA 5 times a week on the 7AM-3PM shift. On 1/16/18, NA #1 stated that RN #1 brought NA #2 into the room to assist with the transfer and although he was on orientation, RN #1 said it was ok for him to assist. In preparation to get the resident out of bed, she searched for a mesh Hoyer lift pad in the linen closet, that was usually used to transfer the resident out of bed but was unable to locate one. For the time being, NA #1 stated they used a regular type of pad, for the transfer. NA #1 stated she informed NA #2 that when the mesh pad is utilized, it remains beneath the resident, whereas the regular Hoyer lift pad would need to be removed once seated in the w/c. NA #1 stated that she and NA #2 utilized the Hoyer lift to move the resident to the w/c, disconnected the Hoyer lift from the pad, hooked their arms under R #1's arms, pulled the resident forward a little in an attempt to remove the pad, however, realized the pad was too far beneath his/her bottom. In the process of pulling the resident forward, they noticed R #1 was too close to the edge of the seat, R #1 started to slide forward off the seat, NA #1 and #2 were unable to stop the fall, and lowered R #1 to the floor into a kneeling position with his/her buttocks on his/her legs/feet. NA #1 stated that she should have looked for a mesh lift pad that would have remained under the resident. Interview, clinical record review, and facility documentation review with NA #2 on 6/19/18 at 2:27 PM identified he was a new nurse aide being oriented to the facility, and was directed by RN #1 to assist with transferring R #1 into the wheelchair using the mechanical lift. NA #2 stated after R #1 was transferred into the wheelchair, NA #1 and #2 each put one arm under one of R #1's arms and lifted him/her up to remove the lift pad. NA #2 stated they did not have a good grip on R #1, and R #1 started to slide out of the wheelchair. When R #1 landed on the floor his/her legs were bent, and NA #2 heard a cracking sound. Interview, clinical record review, and facility documentation review with RN #1 on 6/19/18 at 3:20 PM identified NA #2 was a new employee, had not been educated and/or observed for mechanical lift transfers, and she should have been in the room to supervise NA #2 during the mechanical lift transfer. Interview, clinical record review, and facility documentation review with the DON on 6/20/18 at 8:53 AM identified that the resident was at risk for skin breakdown so the regular Hoyer lift pad would need to be removed, however, this pad can only be used with a resident who has enough truck control and can safely lean forward to remove the pad. The DON further stated that it was NA #2's first experience on the nursing unit on 1/16/18 and RN #1 should have been in the room guiding NA #2 during the transfer. Interview with the DON identified there was no orientation facility policy for surveyor review, however the expectation was that the new NA should be supervised by the RN. Review of facility Marisa Lift Policy directed in part, to place sling around resident and pull each leg piece under the thigh so it emerges on the inside of the thigh. After lowering resident into the chair, and resident in a good sitting position, unclip the sling from the spreader bar and remove the sling.

Based on review of the clinical record, staff interview, and review of facility documentation for one sampled resident reviewed for medication error (Resident # 155), the facility failed to follow physician orders [REDACTED]. The findings included: Resident #155's [DIAGNOSES REDACTED]. A care plan dated 8/6/13 identified a problem with nutrition related to a [DIAGNOSES REDACTED]. A revised care plan dated 7/27/13 identified R #155 had experienced a [MEDICAL CONDITION] with a documented blood sugar of 40. physician's orders [REDACTED]. The physician orders [REDACTED]. Nursing notes dated 7/27/13 at 12:35 am identified R #155 was exhibiting [MEDICAL CONDITION] activity [MEDICATION NAME] approximately seven minutes. A FSBS by glucometer at that time was noted to display "LOW". [MEDICATION NAME] 1 mg intramuscularly was administered into the left thigh per hypoglycemic protocol. FSBS at 12:50 am identified a blood glucose level of '42'. The physician was notified and directed to continue to monitor. FSBS at 3:15 am identified a blood glucose level of 168 with resident now alert and talking with no recollection of incident. A facility investigation dated 7/27/13 identified R #155 received 9 units of Humalog regular insulin coverage at 8:00 pm in error, and subsequently experienced a hypoglycemic reaction resulting in a [MEDICAL CONDITION]. Interview and review of the documentation with the DNS on 8/29/13 at 10:00 am identified R#155 had physician's orders [REDACTED].

Based on clinical record review and interviews for one sampled resident reviewed for pressure ulcers (Resident #146), the facility failed to provide appropriate treatment and/or pressure relief to prevent pressure sores and/or aide in healing a wound. The finding include: Resident #146's [DIAGNOSES REDACTED]. The admission minimum (MDS) data set [DATE] identified the resident had no cognitive impairments, required extensive assistance with ADL's, and had no pressure sores. The pressure sore risk assessment dated [DATE] identified a score of 15 indicating a high risk for pressure ulcer development. A care plan dated 8/1/13 identified a potential for pressure sores. Interventions included to assist with repositioning every 2 hours in bed/chair, head of bed not elevated greater than 30 degrees, pressure reducing mattress or overlay on bed, pressure relieving cushion in chair and report any changes in skin integrity to charge nurse. Nurse's notes dated 8/8/13 at 7:30 pm identified that a small open area was found on the left buttock. Physician orders [REDACTED]. Weekly wound assessments dated 8/8/13 identified a stage 2 pressure wound noted to the left buttock, measuring 2.5 cm by 0.25 cm, superficial depth. On 8/13/13 the wound measured 2 cm x 2 cm, superficial depth. On 8/15/13, the wound measured 3 cm x 3 cm with <0.1 cm depth. On 8/21/13, the wound had declined to to 3.5 cm x 3 cm with <0.1 cm depth. Nurse's notes from 8/17/13 through 8/24/13 identified the resident was uncomfortable in bed as noted by restlessness. Additionally R # 146 was noted to be sliding up and down while in the bed, requiring the need to re-apply the Allevyn dressing multiple times. Review of treatment kardex identified the Allevyn dressing was changed 15 times between 8/8/13 and 8/27/13. A revised care plan dated 8/21/13 identified a stage 2 pressure area to the left buttock. Interventions included daily skin inspections with care, assist with pressure relief and repositioning every 2-3 hours if resident is unable and perform wound care as ordered. Observation of the resident on 8/27/13 at 8:45 am, 9:40 am and 10:20 am, identified the resident positioned flat on his/her back on a regular mattress. Interview with Person #1 on 8/27/13 at 8:45 am identified R#146's wound dressing needed to be frequently changed due to the resident squirming around and sliding up and down in bed. Additionally the area on the buttocks appeared to be causing the resident discomfort. At 2:55 pm, Person #1 identified that R#146 had been on a low air loss mattress, but they had requested it be removed because it was "bottoming out." Interview with the Director of Nursing Services (DNS) on 8/27/13 at 3:05 pm identified that the resident had been on the low air loss mattress, however due to his/her desire to sit upright in bed, the mattress was "bottoming out." According to the DNS, the low air loss mattress was removed from the bed on the evening of 8/16/13 and no other alternative low air loss mattress had been tried. The DNS also indicated that it would be the Infection Control Nurse's responsibility to obtain an alternate dressing if the current dressing/treatment was not effective, however it would be the Unit Manager's responsibility to communicate if the treatment was ineffective. Subsequent to surveyor inquiry on 8/27/13 the resident was placed on a low air loss mattress in bed and DNS contacted the Advanced Practioner Registered Nurse (APRN) for a change in treatment order. Interview with Infection Control Nurse (ICN) on 8/29/13 at 9:45 identified the Charge Nurse or the Unit Manager would be responsible for reporting any issues with a dressing/treatment order to the Physician or APRN. ICN also indicated that a dressing that does not stay on deserved to be looked at and re-evaluated. ICN indicated that she was not made aware that there were issues with dressing/treatment in place for Resident #146. Interview with Unit Manager on 8/29/13 at 10:00 am identified that although she was not fully aware of the frequency in which the dressing was required to be replaced, she was aware that it was not staying on as long as it was supposed to. Unit Manger also indicated that she was aware that the wound had increased in size. Review of the medical record with Unit Manager at that time failed to provide any documentation that the dressing/treatment alternative(s) were discussed with the Physician and/or APRN, and/or that alternate pressure relieving/reducing devices were attempted, and/or that the care plan reflected specific interventions address the resident's discomfort and/or restlessness, and/or inability to keep the wound dressed.