Every finding on record at Gladeview Health Care Center

Based on clinical record review, observation, review of facility policy and staff interviews for the 1 resident reviewed for choices (Resident #110), the facility failed to ensure a resident's family member (Person #1) was allowed to accompany the resident during dining or provide an alternative when the dining room was full. The findings include: Resident #110's diagnoses included Parkinsons's disease, Alzheimer's disease, and dementia.The annual Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #110 had severe cognitive impairment (BIMS 3), was dependent for eating, and utilized the wheelchair for mobility. The MDS further indicated the resident had not exhibited signs and symptoms of a possible swallowing disorder during the 7-day look-back period. The MDS also identified Resident #110 had indicated that family or a close friend involved in the discussion about their care was very important to them.A speech therapy note dated 12/31/2025 identified Resident #110 was evaluated for increased pocketing of food, weight loss, and a regular diet order from the hospital. The note recommended continuing an NDD3 diet (dysphagia advanced) and thin liquids with 1:1 feeding support and to utilize tactile/verbal cues to encourage the resident to swallow/eliminate pocketed food.A speech therapy note dated 1/29/2026 indicated Resident #110 was evaluated for swallowing during breakfast. Only the speech therapist was present during this evaluation. The resident was observed to pocket food and required removal with a toothette. The resident was also evaluated the same day during lunch with Person #1 present. At lunch, the resident was distracted and again needed food removed with a toothette.A physician's order dated 1/29/2026 directed a NDD2 (mechanically altered) diet with 1:1 feeding by staff in a supervised dining room for meals.A speech therapy note dated 2/2/2026 identified Resident #110 was evaluated for swallowing with Person #1 present. The note indicated that Resident #110 tolerated meals with less pocketing and increased ability to masticate food without external distractions. Person #1 was educated on distractions such as television, loud conversations, and encouraging comments. The note further indicated Resident #110 appeared to tolerate all trials of mashed potatoes, stuffing, and cranberry sauce without pocketing.A safety plan dated 2/10/2026, signed by facility staff and Resident #110's family Person #1 identified that outside food would not be brought into the facility for the resident, Person #1 would allow staff to implement the appropriate protocol when Resident #110 pockets food, and Person #1 would avoid distracting or interrupting the resident during feeding.A speech therapy note dated 2/19/2026 identified Resident #110 was evaluated for swallowing in the dining room with Person #1 present. The note indicated that Resident #110 had improved attention and ability to follow simple commands throughout the meal, did not pocket, and successfully cleared all oral residue with the use of liquid wash.A speech therapy note dated 2/25/2026 identified Resident #110 was being discharged from speech therapy due to the demonstrated ability to safely eat an NDD2 diet with less pocketing. The note added Resident #110's ability was variable, likely due to dementia and mental status changes, and that may impact the resident's ability to follow simple directions and maintain arousal.A social services note dated 3/18/2026 indicated Person #1 had a durable power of attorney for the resident since 2003 and that during the probate hearing, the judge did not find sufficient evidence to appoint a new conservator of person.A review of probate hearing documentation dated 3/30/2026 identified the petition for involuntary appointment of a conservator of person was denied and Person #1 was the durable power of attorney with authority over Resident #110's health care decisions.A care plan last reviewed on 6/28/2026 indicated Resident #110 was at risk for choking related to Person #1 continuing to feed the resident while the resident was pocketing food. Interventions included providing 1:1 feeding in the dining room, being fed by staff only, and re-educating Person #1.The care plan stated Resident #110 preferred to eat what Person #1 provided. Person #1 had a history of providing foods not consistent with the therapeutic diet. Interventions included that when Resident #110 and Person #1 dined together, they should eat in a location visible to staff.On 6/28/2026 at 12:20 PM in the third-floor dining room, Registered Nurse (RN #6) was observed telling Person #1 that, as a reminder, family was not allowed in the dining room, and the Director of Nursing Services ( DNS) enforced it.On 6/28/2026 at 12:30 PM, an interview with Person #1 indicated that about 3 days ago, they were informed that family was no longer allowed in the dining room. Person #1 indicated that they were told that they were not allowed in the dining room due to space constraints. Person #1 also indicated Person #1 was no longer allowed to feed Resident #110 or bring food from home a few months ago.On 6/29/2026 at 12:07 PM, an interview with RN #6 indicated she was informed by the DNS family was no longer allowed in the third-floor dining due to not having enough space. RN#6 indicated that she was not aware of a maximum capacity for the dining room and the floor also had lounges at the end of the hallways, where alert and oriented residents could eat. RN#6 indicated that not allowing family to be in the dining room started one to two weeks ago, and she/he was not aware of any information that might have been provided to families prior to the start of the new rule.On 6/29/2026 at 12:44 PM, an interview with Nurse Aide ( NA#2) indicated that the dining room was usually full. If the census on the unit were higher, the facility would sometimes use the lounges for residents who could feed themselves independently. NA#2 also indicated the DNS did not want any family in the dining room because it would become too crowded, and families did not always follow dietary restrictions.On 6/29/2026 at 12:50 PM, observation of both resident lounges on the third floor identified the presence of clean tables and chairs, but no residents or staff were present.On 6/29/2026 at 2:17 PM, an interview with the Speech Language Pathologist (SLP#1) indicated that on an NDD2 diet, Resident #110 was successful in 80% of opportunities during feeding without pocketing. SLP#1 indicated Resident #110 required cuing and minimizing distractions. SLP#1 also indicated Resident #110 can, at times, be tired or have mental status fluctuations related to their dementia, and so their ability to safely eat can vary from day to day. SLP#1 indicated that having only staff feed 1:1 versus family was a nursing order and not a recommendation made by SLP#1. SLP#1 indicated that not allowing family in the dining room was also a nursing decision and not a speech therapy recommendation.On 6/30/2026 at 9:39 PM, an interview with Social Worker #1 and the DNS identified the facility had extensive conversations and meetings with Person #1 related to Person #1's impulsive behavior and feeding Resident #110 food not consistent with Resident #110's diet. The DNS and Social Worker #1 indicated for a time, Person #1 was under supervised visits due to bringing outside food to Resident #110. Additionally, the facility had unsuccessfully petitioned for a court-appointed conservator for Resident #110, and Person #1 continued to be Resident #110's power of attorney and made healthcare decisions for Resident #110. Social Worker #1 indicated the family was not encouraged to sit in the 3rd-floor dining room because when the family visits, they might be taking another resident's spot, and the residents might feel like another resident's family took their seat. Social Worker #1 further indicated families were allowed to go into the dining room. The DNS indicated that the family that wants to visit during dining is the family of residents who require 1:1 feeding by staff, and that having the family would be a distraction for the residents. The DNS indicated Person #1 would distract Resident #110 when she/he was being fed by talking to the resident or showing videos. The DNS indicated that family members were allowed to be in the dining room. The DNS indicated that she was not aware of why RN#6 told Person #1 that there was no family allowed in the dining room since there was no directive from the DNS. The DNS also indicated that situations are taken on a case-by-case basis.Although requested, the facility did not have a policy for 1:1 feeding, dining

Based on clinical record review, observation, review of facility policy and staff interviews for the 1 resident (Resident # 113) reviewed for Accidents/Hazards, the facility failed to provide adequate supervision by following the implementation of the plan of care for a resident at high risk for falls. The findings include: Resident #113's diagnosis includes Parkinson's disease. A Fall risk assessment completed on the following dates identified Resident #113 at high risk for falls: 12/20/2025, 12/23/2025 and 1/3/2026. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #113 was cognitively intact and had one fall since the prior assessment. The care plan dated 4/9/2026 indicated Resident #113 was at risk for falls and injury due to fall history gait and balance problems and orthostatic blood pressure( blood pressure that drops upon changes in position from lying to sitting to standing) and indicated to provide toileting at 11:30 PM- 12:30 AM, 6:00 AM-7:00AM before and after meals and at bedtime and as needed. Additional interventions included to cue Resident #113 for safety, keeping frequently used items within reach, encourage use of non-slip footwear and to encourage to change positions slowly. A facility Incident Report dated 6/11/2026 indicated Resident #113 was found on the floor in his/her room at 8:30 PM and although no injuries were noted the resident was sent to the emergency room (ER) due to the use of blood thinners that increase the risk of bleeding (internally). The investigation further indicated recommendations to prevent further falls due to dementia secondary to no safety awareness and directed resident to always be in eyesight of staff. A care plan intervention was added to the care plan on 6/11/2026 which indicated to ensure Resident #113 is always within eyesight of staff at all times related to poor safety awareness and frequents falls. A fall risk assessment completed on 6/11/2026 indicated Resident #113 continued to be at high risk for falls. A facility Incident Report and investigation statement dated 6/12/2026 at 8:30 PM indicated Resident #113 received toileting and care at 7:15 PM and then went to bed. It also indicated Resident #113 had been restless and/or agitated during the shift with attempts to calm him/herself and indicated staff initiated a call to a family member to talk to Resident #113. The Investigation statement indicated at 8:30 PM while being checked on by a Nurse Aide (NA #4), Resident #113 was found kneeling on the floor, proceeded to lay him/herself down on the floor at which time NA #4 immediately called for the charge nurse for assistance. The charge nurse Licensed Practical Nurse (LPN #4) indicated when s/he entered the room, Resident #113 was lying on the floor next to his/her bed. An Incident Report dated 6/13/2026 identified Resident #113 was witnessed by NA#1 ambulating with a rollator walker in the hallway then grabbed the linen cart and fell to the floor. The investigation found Resident #113 had last been toileted at 4:30 PM by NA #1 and at 6:30 PM was offered toileting but refused care. The resident was seen walking in the hall and falling. The recommended intervention added to the fall care plan on 6/14/2026 directed to keep Resident #113's wheelchair in a locked position while in bed.An Incident Report dated 6/15/2026 at 5:00 PM identified Resident #113 with an abrasion and hematoma(blood filled elevation under the skin)on the right side of his/her forehead after returning from a Leave of Absence ( LOA) with a responsible party. Resident #113 was sent to the emergency room for an evaluation. The Incident Report indicated the recommendation for intervention to prevent further falls was to always keep Resident #113 in view of staff when not in bed. An Incident Report dated 6/22/2026 at 4:30 PM indicated Resident #113 was found on his/her left knee on the floor at the bedside and lifting him/herself up to get into the wheelchair. The suggested intervention to prevent further falls was to have resident within eyesight of staff (on the unit and common area) when not in bed. No other new intervention was added to the care plan. The care plan and visual bedside/kardex report ( NA care card) dated 6/25/2026 directed also to keep Resident #113 within eyesight of staff at all times related to poor safety awareness and frequent falls. A fall risk assessment dated [DATE] identified Resident #113 as continued high risk for falls. An observation on 6/28/2026 at 10:40 AM noted Resident #113 sitting at edge of the bed leaning slightly forward, drooling no staff members were noted in the room or outside the doorway. An interview with the Director of Nursing Services (DNS) on 6/29/2026 at 2:07 PM identified most falls occurred while Resident # 113 was in bed or in his/her room and occurred between the hours of 8:15-8:30 PM. The DNS was also unable to explain how staff conducted the intervention from 6/11/2026 to always keep Resident #113 within eyesight of staff due to his/her fall risk and frequent falls. The DNS indicated she/he would need to talk to the nursing supervisor on that shift and look further for any documentation (no additional information was provided). An interview with NA #4 who regularly provided care for Resident #113 indicated it was difficult to keep Resident #113 within eyesight while in the common area as s/he can move about in the wheelchair independently and will get up and walk without assistance. NA#4 indicated staff was unable to keep Resident #113 within eyesight while in his/her room because other residents require care and Resident #113 liked to stay in his/her room.An interview with RN #5 (evening Supervisor on 6/30/2026 at 10:25 AM) identified staff added an intervention on 6/11/2026 to always keep Resident #113 within eyesight of staff secondary to frequent falls. RN# 4 also indicated it was difficult to keep Resident #113 within eyesight of staff as s/he is always moving about. RN#4 denied the use of 1:1 staff for observation or the use of frequent checks to observe Resident #113 due to staff members having other residents needing assistance and care. RN #4 further indicated she/he thought she/he had updated the care plan after the last fall to keep Resident #113 in staff view while out of bed. RN #4 did not indicate how this intervention would have helped prevent falls while Resident #113 was alone in his/her room or in bed at which time many of the falls occurred. The facility fall policy revised 7/28/2025 and reviewed on 6/28/2026 indicated in part when a resident falls the nurse/supervisor will evaluate the fall details to determine probable causative factors and the investigation and appropriate interventions will be initiated at the time. The resident's plan of care will be reviewed by the interdisciplinary team. Residents who sustain a fall will have the care plan revised at the time the incident occurs, with the intervention implemented and placed on the NA care kardex.

Based on observations, review of the facility shift to shift controlled count, review of facility policy and staff interviews, the facility failed to ensure that required shift-to-shift controlled-substance count documentation was complete for 1 of 5 medication carts reviewed (Third Floor Cart 3 AH/SP). Specifically, 16 of 28 (57.14%) required narcotic count handoffs between the 7:00 AM to 3:00 PM licensed nurse and the 3:00 PM to 11:00 PM licensed nurse were documented only by the incoming 3:00 PM to 11:00 PM licensed nurse. The shift-to-shift controlled substance count also lacked the required signature of the outgoing 7:00 AM to 3:00 PM licensed nurse. This failure has the potential to compromise accountability for controlled substances and increase the risk that discrepancies in controlled substance inventory would not be promptly identified. Findings included: Observation conducted on 6/29/26 at approximately 8:45 AM of the controlled substance count records for Medication Cart #3 AH/SP identified the shift-to-shift narcotic count log containing multiple incomplete entries. Review of the controlled substance count documentation identified that 16 of 28 required handoffs between the 7:00 AM to 3:00 PM shift and the 3:00 PM to 11:00 PM shift lacked the required licensed nurse signatures documenting completion of the controlled substance count, representing 57.14% of the required shift handoffs reviewed.During an interview conducted with the Director of Nursing Services (DNS) on 6/29/26 at 11:03 AM, the DNS identified the controlled substance count records for Medication Cart #3 AH/SP were incomplete, and that upon review with LPN #2 indicated he was unaware that the shift-to-shift controlled substance count log required completion and had only been signing the individual controlled substance administration records. The DNS further indicated licensed staff are expected to sign the controlled substance count logs when counts are completed by two licensed staff, and that counts are expected to be completed by two licensed staff between shifts. The DNS identified LPN #2 worked the 7:00 AM to 3:00 PM shift five days per week and offered to obtain a written statement from LPN #2 regarding the missing documentation.The DNS further indicated the Staff Development Nurse identified that completion of the shift-to-shift controlled substance count log had not been included in new staff orientation and acknowledged newly hired staff without previous long-term care experience may not have been aware of the requirement to complete this handoff in addition to documenting individual resident administration record counts. The DNS stated this process would be incorporated into new staff orientation after surveyor observation.Additional review of staffing schedules and controlled substance count documentation provided by the DNS indicated LPN #2 had worked the 7:00 AM to 3:00 PM shift on 14 of the 16 dates when the required shift handoff documentation was absent. Staffing agency licensed nurses had worked the remaining two shifts associated with the missing documentation.When asked why other licensed nurses had not prompted completion of the required documentation, the DNS indicated agency staff may have been unaware of the requirement or that licensed staff may have inadvertently forgotten to complete the documentation.After surveyor inquiry, the DNS provided a written statement from LPN #2 indicating that he had been unaware of the requirement to sign the shift-to-shift controlled substance count log following joint narcotic counts, that education regarding the process had subsequently been provided, and he understood the requirement as of 6/29/26.Review of the facility's Medication Storage in the Facility: ID2 - Controlled Substance Storage policy, dated 4/2/2026, directed that at each shift change, or whenever medication cart keys were transferred, a physical inventory of all controlled substances, including refrigerated controlled substances, will be conducted by two licensed nurses and documented.The facility failed to ensure that required shift-to-shift controlled substance count documentation was consistently completed in accordance with facility policy and accepted medication-accountability practices.

Based on clinical record reviews, review of policy and staff interviews for 2 residents ( Residents #8 and #17) reviewed for Hospice, and 1 resident ( Resident # 113 ) reviewed for accidents, the facility failed to document the date of determination for each Significant Change in Status Assessment (SCSA) in the clinical record, thereby ensuring the Significant Change Minimum Data Set (MDS) assessments were completed within fourteen (14 ) day required time frame. The findings included: 2.A clinical record review identified Resident #17 elected the Medicare hospice benefit on 4/21/26. A social worker progress note dated 4/21/26 at 2:38 PM documented that a referral was made to the facility hospice vendor and the resident was enrolled in routine hospice level of care on 4/21/26. A nursing progress note dated 4/21/26 at 2:59 PM documented the resident was admitted to the facility hospice vendor for services and that the Advanced Practice Registered Nurse (APRN #1) was notified. The resident's Minimum Data Set (MDS) assessment history identified the facility established an Assessment Reference Date (ARD) of 4/28/26 for a Significant Change in Status Assessment related to the resident's transition to hospice services. Documentation further identified the assessment was not completed until 5/18/26. According to the Resident Assessment Instrument (RAI) User's Manual, Version 1.20.1, Chapter 2, page 2-25, the Assessment Reference Date (ARD) for a Significant Change in Status Assessment related to hospice election must be established within 14 days of the effective date of the hospice election to ensure a coordinated plan of care between the hospice provider and the nursing home. Based on the established ARD of 4/28/26, the assessment should have been completed by 5/4/26. Completion on 5/18/26 exceeded the required timeframe by 14 days. During an interview with Registered Nurse (RN #4), the MDS Coordinator, on 6/30/26 at 2:20 PM, concurrent clinical record review confirmed Resident #17 elected hospice services on 4/21/26, an ARD of 4/28/26 had been established, and the Significant Change in Status Assessment was not completed until 5/18/26. When asked whether the assessment had been completed within the required timeframe, RN #4 noted the electronic medical record did not contain an indicator or alert highlighting due dates for Significant Change in Status Assessments related to hospice elections, requiring staff to use an alternative method to monitor assessment due dates. After surveyor's inquiry, RN #4 stated that staff education would be implemented and an alternate process would be established to monitor Significant Change in Status Assessments to promote timely completion. The facility failed to complete the Significant Change in Status Assessment within the required timeframe following the election of hospice services by Residents #8. 1.Resident #8's diagnoses included coronary artery disease, Congestive Heart Failure (CHF), and dementia. A physician's order dated 4/8/2026 directed Resident #8 hospice services. A social services note dated 4/8/2026 identified Resident #8 had signed up for hospice services. A Significant Change MDS assessment dated [DATE], section Z0500 (the section which verifies completion of the MDS assessment), identified the MDS was completed on 4/24/2026. On 6/30/26 at 2:22 PM, an interview with the MDS Coordinator indicated that Resident #8's Significant Change MDS assessment should have been completed within 14 days by 4/21/2026. A review of the RAI Manual with the MDS Coordinator identified a significant change assessment should be completed within 14 days from the effective date of the hospice election. 3. Resident #113's diagnosis includes Parkinson's Disease. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #113 as severely cognitively impaired, required maximum/substantial assistance for turning in bed, transferring from sit to standing position, used a wheelchair, required touching or supervision or toilet transfer. The assessment also noted the resident was frequently incontinent of bowel and bladder therefore requiring substantial/maximum assistance of staff for toileting hygiene. The care plan dated 6/25/2026 indicated Resident #113 had a continued decline in mobility and physical and occupational therapy was in progress. Interventions included: providing assistance of 2 staff members including transferring with a 2 wheeled walker, and ambulation only with therapy staff. The care plan also directed providing assistance with feeding. An interview of review of the clinical record and Chapter 2 of the Resident Assessment Instrument (RAI)Manual (instructions for completing the significant change MDS assessment) on 6/30/2026 at 10:45 AM with RN #4, the MDS Coordinator indicated the Significant Change Minimum Data Set assessment was completed by the prior MDS Coordinator (who recently retired from the position) and who attended the at-risk meetings with the interdisciplinary team. Although a review of the clinical record was completed, RN #4 was unable to provide the date the interdisciplinary team determined Resident #113's overall condition met the criteria for the need to conduct a significant change in condition MDS assessment. Review of the directions in chapter 2 of the RAI manual indicated when a significant change MDS assessment is planned the date of determination should be documented in the clinical record and the MDS assessment will be completed in its entirety within 14 days of the date of determination. Not having the date of determination established did not ensure the MDS assessment was completed within the 14-day time required. On 7/1/2026 at 9:14 AM RN #4 provided staff education completed on this day regarding the need to document the date of determination of a Significant Change MDS assessment within the clinical record and completion of the Significant Change assessment within 14 days.

Based on observations, review of facility staffing and staff interview, the facility failed to ensure that daily nurse staffing information, including the facility census and the total number of hours worked by licensed nurses and nurse aides responsible for resident care, was posted on a daily basis for resident and public review as required to promote transparency regarding daily staffing levels. This deficient practice has the potential to prevent residents, families, and visitors from accessing current staffing information as required. Findings included: Upon entering the facility on 6/28/26 at approximately 9:00 AM, the surveyor observed the nurse staffing information posted in the facility lobby was dated 6/26/26. The posting included the facility census and staffing hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) and noted the daily staffing had not been updated to reflect the staffing and census information for either 6/27/26 or 6/28/26. A subsequent observation on 6/28/26 at approximately 2:00 PM identified the same posting observed at 9:00 AM remained displayed in the lobby and still had not been updated.An additional observation conducted on 6/29/26 at approximately 11:00 AM identified NA #4 revising the staffing information on the 6/29/26 posting to reflect that day's staffing changes. This observation identified the facility routinely modified the daily posting as staffing changed on weekdays.During an interview with the Administrator on 6/29/26 at 2:30 PM identified NA #4 was responsible for preparing the daily census and staffing postings. The Administrator further stated that NA #4 prepared the weekend postings in advance because she did not work weekends, and either the secretary or the nursing supervisor was responsible for posting the information on weekends. When asked whether responsibility for posting the weekend staffing information had been clearly assigned, the Administrator stated that it had not been and acknowledged this responsibility would be designated following surveyor inquiry to prevent future lapses in weekend posting.The facility failed to ensure that current nurse staffing information was posted daily, as required.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for misappropriation of medication, the facility failed to ensure narcotic medications were removed from the medication cart following the resident's discharge which led to the medication going missing from the medication cart. The findings include:Resident #1's diagnoses included aftercare following joint replacement surgery and right knee joint prothesis. The admission Evaluation dated 8/7/25 identified that Resident #1 was oriented to person, place, time and situation and reported no pain on admission. The Resident Care Plan dated 9/12/25 identified that Resident #1 had an alteration in comfort due to post operative surgery and chronic right knee pain. A physician's order dated 9/12/25 directed to administer oxycodone 5 milligram (mg) tablet by mouth every four (4) hours as needed for severe pain. The Facility Reported Incident form dated 9/26/25 identified at 11:00 AM during the Director of Nursing's (DON) bi-monthly narcotic count, two (2) blister pack cards of oxycodone were prescribed for Resident #1 were unaccounted for as well as the white disposition sheets associated with the two (2) cards of oxycodone that get signed off by nursing when the medication is administered. The Facility Reported Incident form identified that all facility medication carts were searched, nurses assigned to that medication cart were interviewed and the Advanced Practice Registered Nurse (APRN) was contacted and reported the oxycodone had been discontinued prior to discharge. The report identified that an agency Licensed Practical Nurse (LPN) #1, who was working the day shift on 9/26/25, was alleged to have taken the two (2) cards of oxycodone and the police and Connecticut Drug Control Division were notified. Review of the clinical record identified Resident #1 was discharged from the facility on 9/25/25 on the 7AM-3PM shift. The investigation identified in a review of the Controlled Substance Disposition Records identified thirty (30) oxycodone 5 mg tablets were received by the facility on 8/7/25 and thirty (30) oxycodone 5 mg tablets were received by the facility on 9/13/25 for a total of sixty (60) oxycodone 5 mg tablets. Review of the August and September 2025 Medication Administration Records (MAR's) identified that only eight (8) oxycodone 5 mg tablets were administered to Resident #1 between 8/7/25 and 9/25/25, leaving fifty-two (52) tablets unaccounted for. Review of the schedule identified LPN #1 was assigned to Resident #1's unit on 9/26/25 on the 7AM-3PM shift. Review of the Connecticut Drug Control report dated 10/28/25 identified in a written statement LPN #2 stated that during the 9/25/25 11PM-7AM shift, the controlled substance count was correct, and she questioned why the oxycodone for Resident #1 was in the narcotic box inn the medication cart if Resident #1 had been discharged earlier in the day. The report indicated LPN #1 worked the 7AM-3PM shift on 9/26/25 and the Director of Nursing conducted her bi-monthly audit of the narcotics on 9/26/25 between 10-11AM. Review of camera surveillance screenshots and interview with the Director of Nursing (DON) on 11/20/25 at 10:57 AM identified LPN #1 arrived for his shift on 9/26/25 at 7:06 AM. LPN #1 can be seen exiting the building to the back parking lot at 9:43 AM and then returning at 10:01 AM. Although LPN #1 cannot be seen holding any blister packs of medication, the DON reported that at the time he was seen exiting the building, most nurses are still passing medications and do not have time to take a break. The DON identified LPN #2 (11-7 shift) reported counting the two (2) cards of Resident #1's oxycodone 5 mg tablets with LPN #1 on 9/26/25 just after 7:00 AM. The DON reported to have arrived on Resident #1's unit and start to complete her bi-monthly narcotic audits around 10:30 AM and then at around 11:00 AM, when she attempted to match the yellow disposition sheets for the oxycodone 5 mg tablets to the white disposition sheets on the cart, she identified that neither the white disposition sheets or the two (2) blister packs of oxycodone 5 mg were on the cart or able to be located so she initiated an investigation. Interviews on 11/20/25 with LPN #2 (11PM-7AM shift 9/25/25 into 9/26/25), LPN #3 (3PM-11PM shift on 9/25/25) and LPN #4 (7AM-3PM shift on 9/25/25) identified they did not remove Resident #1's oxycodone 5 mg tablets from the cart and recalled counting the oxycodone 5 mg tablets during their shift change narcotic count for the three (3) shifts prior to the medication going missing on 9/26/25 and both the oxycodone and disposition sheets were present in the medication cart. LPN #4 identified Resident #1 was discharged towards the end of her 7AM-3PM shift on 9/25/25 and although she would usually request the DON take the narcotics of any discharged residents or discontinued medications, she did not see the DON that shift, so the oxycodone cards remained locked in the medication cart. LPN #2 identified she recalled questioning LPN #3 when she (LPN #2) arrived for her shift at 11:00 PM on 9/25/25 as to why the oxycodone cards were still in the medication cart despite Resident #1 being discharged during the day on 9/25/25. LPN #3 confirmed that LPN #2 questioned her as to why Resident #1's oxycodone 5 mg tablets were still in the narcotic box at 11:00 PM on 9/25/25. LPN #3 explained that narcotic medications were not being removed regularly from the medication carts when a narcotic was either discontinued or a resident was discharged , stating the two (2) cards of oxycodone and the two (2) disposition sheets belonging to Resident #1's oxycodone 5 mg tablets remained in the cart when she counted with LPN #1 just after 7:00 AM on 9/26/25. Interview with LPN #1 on 11/20/25 at 12:13 PM identified he could not recall counting Resident #1's two (2) cards of oxycodone 5 mg tablets on 9/26/25 around 7:00 AM, he did not have anyone else hold his narcotic keys on 9/26/25 and denied removing the two (2) cards of oxycodone 5 mg tablets and the associated disposition sheets from the medication cart. LPN #1 was unable to explain why the two (2) cards of oxycodone 5 mg tablets and the associated disposition sheets were unable to be located at 11:00 AM when the DON was auditing the narcotic medication. Interview with the DON on 11/20/25 at 1:06 PM identified that although the police and drug enforcement agency did not report to her any criminal findings regarding LPN #1, the staffing agency communicated to her that LPN #1 was terminated. The DON identified staff do not always notify her of discontinued narcotics in real time and if she knows someone was being discharged from the facility, she will go to the unit to collect the narcotics by the next day. The DON indicated LPN #3 and LPN #4 did not notify her on 9/25/25 Resident #1 had been discharged , and the facility has no policy speaking to the timeframe that the narcotics are to be taken out of the cart and given to her. Review of the Resident Abuse policy (undated) directed, in part, that misappropriation of property includes the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Abuse by staff will not be tolerated by the facility.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #3) reviewed for transfers, the facility failed to transfer the resident with equipment appropriate for the resident's standing ability. The findings include: Resident # 3's diagnoses included absence of right leg above the knee, history of falling, primary osteoarthritis of the right hand and anxiety disorder. The Resident Care Plan (RCP) dated 9/30/24 identified that Resident #3 had an alteration in physical mobility and independence with daily activities with interventions that included Physical Therapy (PT) and Occupational Therapy (OT) treatment per order and to transfer the resident with assist per orders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required moderate assistance with bed mobility and transfers. A physician's order dated 10/1/24 directed staff assistance of two (2) for bed to wheelchair and wheelchair to bed transfers and identified that Resident #3 was non-ambulatory. Although a facility incident report was unavailable statements regarding a concern about a transfer from NA #3, NA #5 and RN #1 were provided regarding an incident while trying to transfer with Resident #3 on 10/10/25. Statement from NA #3 dated 10/10/24 at 6:41 PM identified that on 10/10/24 at 5:50 PM, she was in the dining room and was asked to help transfer Resident #3. The statement reported that when she went into Resident #3's room with the other staff member, and because the resident had fallen earlier in the shift she requested that the other NA (NA #5) go get another staff to assist them, but NA #5 instead returned with sit-to-stand lift (Sara lift). She reported that while standing the resident up in the lift, the resident's foot moved away from the lift and his/her knee moved, stating they then sat the resident back into the chair and the Nursing Supervisor (RN #1) was called. She identified that when RN #1 arrived, Resident #3's family was yelling that the NA's were killing the resident and another NA (NA #7) was sent in to assist and the resident was then placed in bed. Statement from NA #5 dated 10/10/24 identified that Resident #3's family requested that she transfer him/her from the wheelchair to the bed. She reported that she asked another staff member (NA #3) to assist her in lifting the resident from the wheelchair to the bed, stating they were unsuccessful, so she left to get another NA to assist them. She identified that she was unable to find assistance so she brought in the Sara lift, thinking it would be helpful, and they hooked the resident up to the lift and asked him/her to stand as it was lifting, to which the resident agreed. NA #5 reported that as they were lifting the resident, his/her foot slipped to the side and the resident stated that he/she was losing strength, and he/she started sliding down. She identified that they then lowered the lift into the wheelchair, but that he/she wasn't completely sitting in the wheelchair. Interview with NA #7 on 2/26/25 at 12:42 PM identified that on 10/10/24 the Nursing Supervisor (RN #1) had approached him and requested that he assist the other staff with a transfer of Resident #3. He reported that when he entered the room, Resident #3's family member was in distress about the transfer, and although he could not remember all the details, he remembered Resident #3 sitting partly in the wheelchair, still attached to the Sara lift (sit-to-stand mechanical lift) with his/her upper body slouching forwards between the handlebars of the lift. Interview with PT #1 (Director of Rehab) and OT #1 on 2/26/25 at 12:59 PM identified that Resident #3's functional abilities fluctuated day to day, as well as his/her motor planning and cognition. They identified that if the resident had already been exhibiting signs of weakness and was unable to stand with an assist of two (2) staff, the staff should not have used the Sara lift because the resident requiresfour limbs (resident is a right leg amputee) and the ability to stand to safely be transferred with the Sara lift. Interview with RN #1 on 2/26/25 at 4:03 PM and review of statement dated 10/15/24 identified that she was in the dining room assisting another resident when Person #1 ran in and started yelling about a resident falling, stating she followed him/her into Resident #3's room and Person #1 yelled, They're killing him/her. RN #1 reported that when she entered the room, two (2) NA's were standing beside Resident #3, who was attached to the Sara lift and it appeared as if his/her left leg gave out, stating he/she was in a sitting position but was on the edge of the wheelchair. She identified that the resident did not fall but the staff was unable to get him/her further onto or off the wheelchair and the NA's were unable to explain what had happened, so she reported she left the room to get another NA (NA #7) to assist them, stating all three (3) NA's (NA #3, NA #5 and NA #7) were then able to place the Hoyer sling onto the wheelchair and transfer Resident #3 safely back to bed. RN #1 identified that she then left a message for the therapy department requesting an evaluation on Resident #3's transfer status, as it appeared the resident was too weak to use the sit-to-stand (Sara lift), notified the APRN and obtained a new order for laboratory testing, notified the family and printed safety reminder signs for the resident's bathroom and bedroom. Interview with the DNS on 2/26/25 at 1:28 PM identified that agency NA's are expected to be educated and have the skills to use mechanical lifts prior to working in the facility, stating that she expects for them to follow the plan of care and be able to transfer the residents with the mechanical lifts (Hoyer and Sara lift) and should ask the facility staff if they have any questions or need assistance with the equipment. She was unsure if the staff should have used the Sara lift with Resident #3, but identified that staff can always downgrade the resident's transfer status if needed, but cannot upgrade their status. A physician's order dated 10/11/24 directed that Resident #3 was a Hoyer lift and staff assistance of two (2) for bed to wheelchair and wheelchair to bed transfers and identified that Resident #3 was non-ambulatory. Although attempted, interviews with NA #3 and NA #5 were not obtained. Although requested, a facility policy for the Sara lift was not provided.

Based on observation, staff interview, and facility policy for medication storage and labeling, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include: a. An observation on 11/20/24 at 5:04 AM identified that the third floor rolling medication cart was located outside of the third-floor dining room in the lobby, was unlocked. There was one resident, unsupervised in a wheelchair, approximately 15 feet from the unlocked rolling medication cart. An interview with Licensed Practical Nurse (LPN) #10 on 11/20/24 at 5:08 AM identified that she was aware the medication cart was unlocked and she left it unlocked and unattended to attend to a resident's care down one of the hallways. The narcotics within the rolling cart were only secured with a single lock, as the main lock to the rolling cart was unlocked. An observation on 11/20/24 at 5:45 AM identified that 2 second floor rolling medication carts, located on the outside right-hand side of the nursing station, were unlocked. LPN #12 was sitting behind the nursing station, on the left-hand side of the nursing station, with his back to the medication carts. There were two residents seated in a wheelchair within 10-15 feet from the medication carts. An interview with Licensed Practical Nurse (LPN) #12 on 11/20/24 at 5:45 AM identified that he was aware the medication cart was unlocked and he left it unlocked and unattended to finish typing his nursing notes from his last medication pass. The narcotics within the rolling cart were only secured with a single lock, as the main lock to the rolling cart was unlocked. An observation on 11/22/24 at 8:00 AM of the second floor rolling medication cart with the Assistant Director of Nursing (ADN) identified that the medication cart was unlocked. There were 6 residents in the lobby within 10-15 feet of the unlocked cart. The ADN noted it was the nurse's responsibility to keep the cart locked while not in use. The narcotics within the rolling cart were only secured with a single lock, as the main lock to the rolling cart was unlocked. An observation on 11/22/24 at 8:04 AM identified that the third floor rolling medication cart, located outside of the third-floor dining room in the lobby, was unlocked. There were 5 residents, unsupervised in a wheelchair, approximately 10 feet from the rolling medication cart. No staff members were located within eyesight of the cart. An interview with Licensed Practical Nurse (LPN) #14 on 11/22/24 at 8:08 AM identified that she was aware the medication cart was unlocked and she left it unlocked because the cart was being shared between two LPNs and there was only one key. The narcotics within the rolling cart were only secured with a single lock, as the main lock to the rolling cart was unlocked. b. An observation on 11/21/24 with LPN #9 and the Assistant Director of Nurses (ADNS) on 11/21/24 at 12:35 PM identified that 2 of 2 narcotic medication boxes located within the third-floor medication refrigerator (the refrigerator was not locked or didn't have the capability to be locked) had a dangling chain attached to the back of the boxes, but the chains were not affixed to the refrigerator. Each of the two boxes contained one 30 milliliter bottle of Lorazepam (a schedule IV controlled substance). The ADNS noted that maintenance was responsible for ensuring the boxes were chained to the refrigerator. Subsequent to surveyor inquiry, the chains were affixed to the inside of the refrigerator with a screw by maintenance. Review of the facility's Medication storage policy identified that medications should only be accessible to licensed nursing personnel or other staff members lawfully authorized to administer medications, and those medications subject to abuse or diversion are to be stored in a double locked compartment. Controlled substances stored in the refrigerator must be in a locked box that is permanently affixed to the refrigerator.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure foods were dated when opened and expired food was disposed of timely. The findings include: On [DATE] at 10:52 AM, a tour of the Dietary Department with the Food Service Director (FSD) identified the following: a. In the dry storage area there was an opened and undated ,d+[DATE] bag of granola and 3 open bags of hamburger rolls. Attached to the ceiling to the right of the hamburger rolls was an approximate 12 inch section of fly paper with a dead fly attached. b. In the main freezer there was an opened and undated package of pancakes, 1 bag of imitation crabmeat, 1 bag of frozen shrimp, ,d+[DATE] package of cookies, ,d+[DATE] package of blueberries, 1 gallon of leftover soup dated [DATE], and 1 bag of pizza dough. c. In the walk-in refrigerator there was a gallon container that was ,d+[DATE] full of Feta cheese that was dated [DATE], containing a greenish mold like substance. Interview with the FSD on [DATE] at 11:15 AM indicated that he or the chef were responsible for dating items when the packaging was opened. He was unable to explain the reason the identified items were opened and undated, but if staff did not know the expiration dates, they could be accessed via the US Foods website. Additionally, he indicated that he hung fly paper in the bread storage area in [DATE] because of a problem with having flies in the Dietary Department but did not contact the pest control vendor. Interview with the Administrator on [DATE] at 12:30 PM identified that he was not made aware of the issue of flies in the Dietary Department and had he been made aware, he would have contacted the pest control vendor for treatment. Review of the facility food storage policy directed that dry storage foods would be dated as appropriate and cold foods would be labeled and dated.

Based on observations, clinical record review, review of facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #7) reviewed for nebulizer equipment the facility failed to ensure the equipment was not on the floor, the mask was covered and tubing was dated when changed. Additionally, for 1 of 5 residents (Resident #85) observed for medication administration, the facility failed to ensure appropriate hand hygiene was performed during medication administration and for 2 of 4 sampled residents (Resident #7 and Resident #101) reviewed for pressure ulcers, the facility failed to ensure appropriate personal protective equipment (PPE) was donned for a resident on precautions and failed to ensure hand hygiene was performed in accordance with infection control standards (Resident #101). Also, the facility failed to ensure personal care equipment was stored to maintain infection control. The findings include: 1. Resident #7 was admitted to the facility in July 2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and chronic pressure ulcer on coccyx. a. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #7 was severely cognitively impaired and was dependent on staff for activities of daily living. A Resident Care Plan dated 4/19/24 identified that Resident #7 was on Enhanced Barrier Precautions for a history of a multidrug resistant organism (MDRO) infection and for a suprapubic urinary tube. Interventions included wearing a gown and gloves for any high contact activities. Physician's orders dated 10/22/24 directed to use Enhanced Barrier Precautions (PPE) for MDRO colonization of bacteria for Extended-spectrum beta-lactamases (ESBL) in urine, a chronic wound on the coccyx and having a urinary catheter. Physician's orders dated 11/14/24 direct to cleanse the stage 2 wound on the coccyx, apply Triad paste to peri wound area, Silvadene to the base of the wound, secure with a dry, clean dressing daily. The physician order further directed to change the dressing as needed for soiling, saturation, or accidental removal. Observation on 11/19/24 at 11:15 AM identified signage was posted on Resident #7's door that Resident #7 was on Enhanced Barrier Precautions and directed staff to wear gloves and a gown for high-contact resident care activities including dressing, bathing and wound care. Additionally, LPN #6 was observed performing wound care to Resident #7's coccyx without the benefit of wearing a gown. Interview with LPN # 6 on 11/19/24 at 12:10 PM identified that she did not see the Enhanced Barrier Precaution sign outside the door and that she should have worn a gown when completing Resident #7's treatment. LPN # 6 indicated that she had provided care for Resident # 7 on several different occasions. Interview with LPN # 7 on 11/19/24 at 12:30 PM indicated that any direct care needed for Resident #7 such as treatment, the nurse would need to wear PPE which consist of a gown and gloves. A review of the Enhanced Barrier Policy dated August 2022 directed in part, EBPs employ target gown and glove use for high contact resident care activities when contact precautions do not otherwise apply such as wound care (any skin opening requiring a dressing) and for residents infected or colonized with ESBL. b. A quarterly Minimum Data Assessment (MDS) assessment dated [DATE] identified Resident #7 was moderately cognitively impaired and required assistance of 1 for medication administration and bed mobility. The Resident Care Plan dated 8/31/24 identified an exacerbation of COPD with interventions that included oxygen as needed, monitor respiratory status and administer medications as ordered. Physician's orders dated 9/17/24 directed to administer Ipratroplum-Albuterol Solution 0.5-2.5 (3) mg/3 ml 1 vial inhale orally 2 times a day (use of nebulizer machine) related to COPD. Observations on 11/18/24 at 11:00 AM, 12:30 PM, and 2:30 PM identified a nebulizer machine on top of Resident #7's floor mat beside his/her bed with the mask and tubing hanging off the wall without the benefit of being bagged or labeled. Observation on 11/19/24 at 8:30 AM, 12:00 PM and 2:00 PM noted the nebulizer machine remained on top of the floor mat with the mask and tubing hanging off wall without the benefit of being bagged or labeled. Interview with LPN # 7 on 11/20/24 at 12:00 PM indicated that nebulizer equipment should be on the bedside table and the tubing should be dated with mask in a bag. Interview with LPN #5 (the Infection Preventionist) on 11/22/24 at 11:30 AM identified that nebulizer equipment should not be on the floor, the mask in a bag and the tubing should be dated when changed. Although requested, a policy for nebulizer and/or oxygen tubing was not provided as the facility did not have a policy. 2. Resident #85's diagnoses included diabetes, depression, and heart disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #85 had no cognitive impairment, required extensive assistance with bed mobility, and was dependent for transfers. The Resident Care Plan dated 11/13/24 identified Resident #85 had a diagnosis of diabetes with interventions to obtain finger sticks (blood sugar test) as ordered. Observation and interview with LPN #1 on 11/19/24 at 9:45 AM, identified she was preparing Resident #85's medications for administration. LPN #1 was observed to drop a medication package onto the floor, picked the container up, placed it on top of the cart, and resumed medication preparations. Although LPN #1 had picked up the container from what was considered a dirty surface (floor), she failed to sanitize or wash her hands prior to proceeding. LPN #1 was then observed to place on gloves, drew up insulin into a syringe, removed her gloves and placed a clean pair of gloves on without the benefit of sanitizing or washing her hands. At the bedside, just prior to medication administration, the surveyor stopped LPN #1 and brought her out of the room. Interview with LPN #1 identified that the facility policy directed staff to perform hand hygiene in between glove changes and after contact with the environment and that she was nervous during the time of Resident #85's medication preparation. Subsequent to surveyor inquiry, LPN #1 washed her hands and placed on clean gloves. Review of the Medication Administration-General Guidelines policy, dated 2017, directed hand hygiene performance before beginning a medication pass; before handling medications; and after contact with patient. Additionally, the policy directed staff to perform hand hygiene before putting on examination gloves and after gloves are removed. 3. Resident #101's diagnoses included congestive heart failure, chronic kidney disease and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #101's cognition was intact, was independent for eating and dependent for toileting and transfers. The Resident Care Plan dated 11/5/24 identified Resident #101 was at risk for infection requiring enhanced barrier precautions (EBP) related to an indwelling urinary catheter. Interventions included enhanced barrier precautions: use a gown and gloves during high-contact activities: dressing, hygiene, toileting, transferring, bathing/showering, changing linens, device care and wound care, as well as to perform hand hygiene prior to and after providing care to residents. A physician's order dated 11/12/24 directed that every shift follow enhanced barrier precautions. Observation on 11/20/24 at 12:27 PM identified an enhanced barrier precaution sign posted next to Resident #101's door, and a precaution cart with personal protective equipment (PPE) supplies consisting of gown and gloves was noted to be in the hallway, a couple rooms away. The sign identified that staff must wear gloves and a gown for high-contact activities including dressing, changing linens and wound care. Observation on 11/20/24 at 12:28 PM identified Licensed Practical Nurse (LPN) #2 and LPN #3 enter Resident #101's room and don gloves without the benefit of hand hygiene, and without the benefit of PPE (a gown) as indicated. LPN #2 was on Resident #101's right side, while LPN #3 was on the left side preparing wound care supplies on a sterile field on top of the treatment cart, alcohol based hand rub (ABHR) was noted to be attached to the left side of the treatment cart. LPN #3 removed the dressing dated 11/19 located on Resident #101's coccyx, and discarded the gloves and dressing, she then applied a clean pair of gloves without the benefit of performing hand hygiene, and cleaned the coccyx with the wound cleanser, removed her gloves and applied a clean pair of gloves without the benefit of performing hand hygiene. LPN #3 then applied Silver Alginate to the wound and covered it with a dry clean dressing that was dated 11/20, then she removed and discarded her gloves without the benefit of hand hygiene. Interview with LPN #2 on 11/20/24 at 12:40 PM identified she was unaware of the policy on hand hygiene between glove changes, but she had received education on EBP and that she should have worn a gown but did not because she was just there to help. Interview with LPN #3 on 11/20/24 at 12:40 PM identified she was unaware of the policy on hand hygiene between glove changes but added that it made sense to perform hand hygiene after removing soiled gloves so that the clean pair would not be contaminated. LPN #3 identified she had received education on EBP but did not don a gown because she was stressed. Interview with the LPN #5 (the Infection Preventionist) on 11/20/24 at 1:30 PM identified it was facility policy to perform hand hygiene between glove changes, and the facility policy for residents on EBP precautions was that staff had to don PPE that consisted of gloves and gowns when performing any high contact activities such as wound care. In addition, she identified that staff is educated on the above policies. Review of the Hand Hygiene Policy directed in part that ABHS is most effective in reducing the number of germs on the hands of health care providers and should be performed immediately upon removal of gloves or PPE. Review of the Glove Technique (non-sterile) directed in part that hand hygiene be performed after the removal of gloves. Review of the Enhanced Barrier Precautions Policy directed in part that enhanced barrier precautions are used as an infection control prevention and control intervention to reduce the spread of multi drug resistant organisms to residents and that gowns and gloves should be applied prior to performing high contact activities, such as wound care. 4. Observations made on 11/18/24 during initial tour 11:00 AM identified the following: a. room [ROOM NUMBER] had a urinal not bagged b. room [ROOM NUMBER] had 3 basins on the floor along with a urinal bed pan and emesis basin that was also uncovered. c. room [ROOM NUMBER] had a basin on the floor, unbagged. d. room [ROOM NUMBER] had a basin on the floor. e. room [ROOM NUMBER] had a basin on the floor. f. room [ROOM NUMBER] had a basin on the floor. g. room [ROOM NUMBER] had a basin on the floor. h. room [ROOM NUMBER] had a basin on the floor. i. room [ROOM NUMBER] had a urinal and urinary cylinder that were not bagged and 6 basins on the floor. j. room [ROOM NUMBER] had 2 urinals unbagged, and a basin on the floor. k. room [ROOM NUMBER] had a urinal, bed pan, and basin unbagged and on the floor. l. room [ROOM NUMBER] had a basin on the floor. m. room [ROOM NUMBER] had a basin on the floor. n. room [ROOM NUMBER] had a basin on the floor. o. room [ROOM NUMBER] had a basin on the floor. p. room [ROOM NUMBER] had a basin on the floor. q: room [ROOM NUMBER] had a basin on the floor. r: room [ROOM NUMBER] had a urinal and a basin unbagged and on the floor. A second tour of the facility's second and third floor rooms on 11/20/24 at 10:00 AM identified that personal care equipment continued to be on the floor not bagged or labeled. In an interview with LPN #5 (the Infection Preventionist) on 11/20/24 at 11:15 AM identified that personal care equipment (basins, urinary cylinders, bed pans, emesis basin, and urinary collection devices) should be labeled, and bagged, stored hung up or in the resident's bedside table. She also identified that the Nurses Aids (NA) were responsible for this, education had been provided and that this was the facility policy. In an interview with NA #1 on 11/20/24 at 1:45 PM identified that all personal care equipment should be labeled and bagged, that was the facility policy. Further identifying that it was an oversight. In an interview with NA #2 on 11/20/24 at 2:00 PM identified that all personal care equipment should be labeled, bagged and placed in the resident's bedside table drawer. NA #2 further identified that she was unsure of the reason this was not done. Review of the facility policy for Giving and Removing the Bedpan and Urinal date 6/97 directed that the personal care equipment be cleansed, protective cover placed followed by placing into the bedside table. 51102 51756 51867

Based on observations, clinical record review, review of facility policy,and interviews for 2 of 4 residents, (Resident #8 and Resident #20) reviewed for dignity, and for 1 of 3 residents, (Resident #105), reviewed for abuse, the facility failed to ensure Residents #8 and #105 were treated in a dignified manner when spoken to and for Resident #20, failed to provide a dignified experience for a resident who could not eat. The findings include. 1. Resident #8's diagnoses include multiple sclerosis, coronary artery disease and hypertension. The annual Minimum Data Set assessment dated [DATE] identified Resident #8 had no cognitive impairment and was totally dependent on staff for transfers, bathing, and dressing. Additionally, Resident #8 had functional limitation to range of motion on both sides to the upper and lower extremities. Interview with Resident #8 on 11/19/24 at 12:15 PM indicated that LPN #11 was not nice and had poor communication skills. Resident #8 stated he/she had seen LPN #11 treat other residents in an undignified manner, including hearing this LPN say to another unidentified resident, what do you want abruptly. Additionally, Resident #8 indicated that LPN #11 had come into the room, when his/her roommate was not present, and turned up the television volume to a loud tone intentionally to annoy him/her. Resident #8 further indicated that when he/she requested the volume be lowered, LPN #11 responded abruptly and using a strong tone, that his/her roommate had the right to watch television too. Resident #8 indicated this was reported to a staff member but was unable to recall their name, and that LPN #11's actions feel retaliatory. Resident #8 thought that he/she had shared reporting these incidents to the DNS in the past. 2. Resident #20's diagnoses include Cerebral Palsy, vascular dementia, and a developmental disorder of speech and language. The physician's order dated 9/6/24 directed for Resident #20 to be NPO (nothing by mouth), totally dependent, and assist of one with enteral/tube feeding related to dysphagia due to cerebral palsy. The Resident Care Plan dated 9/10/24 identified Resident #20's only source of nutrition and hydration was via feeding tube, and she/he does not take anything by mouth. Interventions included for the feeding tube to be flushed and free water given as ordered, and to report any signs of aspiration or difficulty with feeding tolerance to the doctor. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired and was dependent for eating, toileting and transfers. The MDS further identified Resident #20 had a feeding tube while a resident at the facility. Observation on 11/18/24 at 12:15 PM identified Resident #20 sitting in her/his wheelchair in the hallway across from the dining room during lunch time, with a clear view of residents eating lunch. No other residents were noted to be in the hallway at the time. Observation on 11/19/24 at 12:14 PM identified Resident #20 sitting in her/his wheelchair in the hallway outside of the dining room, next to the steam table, while facility staff was placing lunch orders and plating the meals. Resident #20 was noted to have her/his right index finger in her mouth, and no other residents were in the hallway at the time. Observation on 11/20/24 at 12:18 PM identified Resident #20 sitting in her/his wheelchair in the hallway across from the dining room during lunch time, with a clear view of residents eating lunch. No other residents were noted to be in the hallway at the time. An interview with Licensed Practical Nurse (LPN) #4 on 11/20/24 at 12:18 PM identified Resident #20 always sits outside of the dining room during lunch time for socialization, otherwise she/he was in her/his room listening to music, additionally putting her/his fingers in her/his mouth was a behavior and not an indication of hunger. Additionally, LPN #4 stated she felt it was alright for Resident #20, who cannot eat by mouth, to be watching others eat because Resident #20 does not recognize what she/he can and cannot do. Subsequent to surveyor interview, LPN #4 stated she was moving Resident #20 into the resident's room to administer medication and have her/him listen to music. An interview with the DNS on 11/20/24 at 1:25 PM identified it was appropriate for Resident #20 to be sitting outside of the dining room watching others eat, even though Resident #20 cannot eat because it was something Resident #20 had always done, otherwise she/he was in her/his room listening to music. When questioned about the reasonable person concept relating to the dignity of placing an individual in view of others eating when she/he cannot eat, the DNS responded that this was what Resident #20 had always done. Although requested, a facility policy for a Dining Experience was not provided. 3. Resident #105's diagnoses include congestive heart failure, cirrhosis of liver, adjustment disorder with anxiety, and type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #105 had no cognitive impairment, required assist of 2 to transfer, and was fully dependent on staff assistance to mobilize his/her wheelchair. Interview with Resident #105 on 11/18/24 at 12:20 PM identified that a couple of months ago LPN #11 had been standing at the end of his/her bed and stated, I don't like you to him/her, to which Resident #105 replied I don't like you very much. Resident #105 indicated that this was reported to the RN Supervisor and his/her family member. Additionally, Resident #105 reported an incident which occurred the evening of 11/17/24 at unknown time with LPN #11 when he/she wanted to know who his/her NA was as he/she was ready for bed. LPN #11 responded what do you want, in a harsh, stern tone and added that everyone was busy and didn't have time for him/her. Resident #105 indicated that this incident had not been reported to facility staff. The DNS was immediately notified by the surveyors, of Resident #105's statements. The APRN psychiatric evaluation and consultation note dated 11/18/24 documented that Resident #105 reported a nurse came in, was terse in her speech and does not talk with him/her like other nurses. Interview with LPN #11 and the DNS on 11/18/24 at 3:45 PM identified that she did have an interaction with Resident #105 the evening prior when Resident #105 asked who his/her NA was because he/she wanted to go to bed. LPN #11 indicated her response was the NA's were passing trays, when they were done, they would come in to put him/her to bed. Further, LPN #11 stated that a few months ago as she was walking out of the resident's room, he/she heard Resident #8 state I don't like her, but there was no one else in the room, LPN #11 did not respond and did not report the incident to any supervisory or managerial staff. Review of a social work note dated 11/18/24 indicated she was asked to see Resident #105 secondary to a complaint made against a nurse. Resident #105 stated that last night he/she was ringing his/her call bell to find out who the NA was for the night. Resident #105 indicated that LPN #11 came in and yelled at him/her stating you better not give my aides a hard time, that he/she wanted LPN #11 to stay away from him/her, and that all the other staff were wonderful. Interview with NA #4 on 11/22/24 at 8:30 AM identified that Resident #105 had discussed feeling threatened and disrespected by LPN #11. NA #4 indicated that she had reported this to the nurse on the shift weeks ago but could not recall their name due to the frequency of changes to nurses working on that unit. The facility Abuse policy indicated that should a resident make a complaint of abuse, an investigation will take place, staff in question would be suspended pending the outcome of the investigation. 51867

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #38 and Resident #95) reviewed for nutrition, the facility failed to notify the provider in a timely manner when there was a change in condition and a significant weight loss. The findings included: 1. Resident #38's diagnoses included interstitial pulmonary disease, dysphagia with gastrostomy status and traumatic brain injury (TBI). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was cognitively intact but without speech, was dependent with toileting and transfers and required moderate assistance with bed mobility. The MDS assessment indicated Resident #38 had a feeding tube and received tube feedings for 51% or more of calories. The Resident Care Plan dated 10/7/24 identified dysphagia with gastrostomy tube (G-tube) and a history of respiratory arrest and aspiration pneumonia. Interventions included to report any signs and symptoms of aspiration, increased shortness of breath or dyspnea (difficulty breathing) to the medical doctor (M.D). A nurse's note dated 11/15/24 at 10:33 PM identified Resident #38 had a congested cough, complaints of shortness of breath (SOB) and was requesting to go to the hospital. The nurse's note indicated that Resident #38 had diminished lung sounds (LS) throughout and shallow respirations. Additionally, the nurse's note identified that the supervisor (RN #2) was made aware. A nurse's note dated 11/16/24 at 1:08 AM identified Resident #38 was alert and non-verbal, had an occasional cough with no complaints of respiratory distress and a slightly distended abdomen. A nurse's note dated 11/17/24 at 2:06 AM identified Resident #38 was alert and non-verbal with no respiratory distress and a slightly distended abdomen. An observation on 11/18/24 at 11:30 AM, identified Resident #38 was in bed with a cough and audible congestion. LPN #4 was made aware, entered the room, and utilized a communication board to further evaluate the resident. A nurse's note written by LPN #4 on 11/18/24 at 2:55 PM identified Resident #38 had a deep congested cough, was suctioned for a minimum amount of phlegm, and had an expiratory wheeze with a nebulizer treatment given with some effect. LPN #4's nurses note indicated the supervisor (RN #1) was made aware. An Advanced Practice Registered Nurse (APRN #1) progress note dated 11/19/24 at 8:40 AM identified Resident #38 had a cough and shortness of breath, was ill appearing with an irregular heart rhythm, tachypnea (increased respiratory rate) and respiratory distress. APRN #1's progress note indicated Resident #38 appeared uncomfortable and had decreased breath sounds in the right and left lower lung fields. APRN #1's assessment further reflected Resident #38 was not communicating with his/her board, had an altered mental status, his/her skin was flushed and warm to the touch with pneumonia suspected. The APRN's progress note identified Resident #38 was transferred to the ED (emergency department) with respiratory distress. A physician's order dated 11/19/24 directed to transfer to ED with respiratory distress, resident to be evaluated in ER (emergency room ). An interview and clinical record review with the 7:00 AM to 3:00 PM Registered Nurse supervisor (RN #1) on 11/21/24 at 1:30 PM, identified that Resident #38 had respiratory distress and was evaluated by the APRN on the morning of 11/19/24. Subsequently, Resident #38 was transferred to the hospital and was admitted to the hospital with pneumonia. RN #1 indicated that Resident #38 had a history of respiratory distress and aspiration and had recently returned from a hospitalization for aspiration. RN #1 further identified that Resident #38 was a fragile individual whose status could change on the drop of a dime. Review of the clinical record with RN #1 identified that, although the nursing supervisor (RN #2) had been notified of Resident #38's change in condition on 11/15/24, RN #2 failed to notify the provider. RN #1 indicated that although she was notified of Resident #38's change in condition on 11/18/24, she had failed to notify the provider. RN #1 indicated that when notified of a resident's change in condition, the nursing supervisor should inform the provider of the change in condition. RN #1 was unable to identify a reason RN #2 did not notify the provider of Resident #38's change in condition on 11/15/24. Additionally, RN #1 was unable to identify the reason she failed to notify the provider of Resident #38's change in condition on 11/18/24. Interview and record review with the 3:00 PM to 11:00 PM Registered Nurse Supervisor (RN #2) on 11/21/24 at 3:10 PM identified although Resident #38 had complaints of shortness of breath and asked to go to the hospital on 11/15/24, she did not notify the provider because Resident #38 was not in distress when she saw him/her and there was no reason to transfer the resident out. Interview and record review with the DNS on 11/22/24 at 9:41 AM identified that when the Registered Nurse supervisors (RN #1 and RN #2) were notified of Resident #38's change in condition, on 11/15/24 and 11/18/24 respectively, they should have notified the APRN. Review of the clinical record with the DNS at that time indicated that, although Resident #38 should have been evaluated by a provider after his/her change in condition on 11/15/24, the resident was not evaluated by the APRN until the morning of 11/19/24, when Resident #38 was found in respiratory distress and subsequently transferred to the hospital. Interview and record review with APRN #1 on 11/22/24 at 10:00 AM identified that she was not notified of Resident #38's change in condition on 11/15/24 or 11/18/24. APRN #1 indicated that if she had been notified on 11/15/24 and 11/18/24, she would have asked for further RN assessment and, based on the assessments, she would have given additional orders and/or sent Resident #38 to the hospital. APRN #1 identified that the Registered Nurse supervisors (RN #1 and RN #2) should have notified her of the residents change in condition on 11/15/24 and 11/18/24. APRN #1 indicated that Resident #38 should have had close monitoring and lung assessments in the days after his/her change in condition on 11/15/24 and that, she evaluated Resident #38 on the morning of 11/19/24, he/she was found in respiratory distress and required transfer to the hospital. Review of the facility's, Observation & Recording Change of Resident's Condition policy, undated, directed to ensure that when a resident has a change in condition that timely notification of physician, APRN and responsible party occur. 2. Resident #95 was admitted to the facility in April 2022 with diagnoses that included vascular dementia with psychotic disturbances, Down syndrome, depression, and hypothyroidism. A Resident Care Plan dated 2/19/24 identified a problem with Resident #95 having a significant weight loss in 6 months (weight of 195.4 pounds/lbs). Interventions included to start on nutritional supplements, encourage food/fluids, and obtain weights as ordered. Physician orders dated 3/14/24 directed weekly weights to be obtained every Friday. The annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident # 95 was severely cognitively impaired and required total dependence from staff for eating. A review of Resident #95's weight identified a weight of 190.1 pounds (lbs) on 6/23/24 and a weight of 177.6 lbs on 7/20/24 (a 12.6 lb/6.5 % loss in less than a month). APRN #1's progress notes dated 7/30/24 identified a weight of 177 lbs. but did not identify Resident #95 had a significant weight loss. Physician's orders dated 8/15/24 directed to administer house supplements 3 times a day (26 days after Resident #95 had a significant weight loss). Observations of Resident #95 on 11/18/24 at 12:25 PM and 11/20/24 at 8:15 AM and 12:30 PM, identified he/she received a regular diet and needed to be fed by nursing staff. Interview with APRN #1 on 11/21/24 at 11:30 AM noted she could not recall if she was made aware of Resident #95's weight loss from 7/20/24 by staff as she was new to the facility and had just started in July of 2024. A review of the APRN communication book from 7/20/24 through 11/21/24 indicated that there were no entries to update the APRN regarding Resident #95's significant weight loss. An APRN #1 progress note dated 9/10/24 identified Resident #95 was seen for weight loss with no new orders and to continue with supplement orders from 8/15/24 as Resident # 95 was starting to trend up in weights with a weight of 179 lbs (APRN #1 did not address weight loss in the progress notes until 53 days after the initial weight loss was documented on 7/20/24). A review of the facility's Weight Policy dated 12/20/23 directed in part, MD or APRN will be notified of any significant weight loss or gain of 5% in one month or 10% in 6 months unless expected. Consult with Dietitian if loses or gains more than normal range. The Dietitian is available in building 2-3 times weekly. A review of the facility's Change of Condition Policy revised 6/2017 directed in part, to clearly document date and time the physician/APRN was notified of change and notifications are done in a timely manner after a change in condition. 51756

Based on observation, staff interview, review of the clinical record, and facility policy for 1 of 3 residents (Resident #91) reviewed for accidents, the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include a known behavioral issue. The findings include: Resident #91's diagnoses included cerebral palsy, neuromuscular dysfunction of the bladder, and anxiety. The annual Minimum Data Set assessment dated [DATE] identified Resident #91 was cognitively intact, was dependent on chair/bed to chair transfers, and used a motorized wheelchair. The RCP dated 10/9/24 identified Resident #91 had a history of crying with a goal of initiating a conversation with staff when tearful, and a history of impaired physical mobility with an intervention of transferring him/her to and from the wheelchair using a mechanical lift. An observation and interview with Resident #91 on 11/18/24 at 11:14 AM identified he/she was wheelchair bound and his/her legs were positioned in a tucked-up position, not outward facing from the body. Resident #91 stated that a prior injury to his/her left foot and knee occurred from a mechanical transfer that occurred approximately 2 to 3 months ago, x-rays were performed that showed no broken bones, and now he/she received daily pain patches for the injury which was not needed before the mechanical lift accident. Resident #91 could not identify the exact date or time of the alleged accident nor who was transferring him/her in the mechanical lift. A nursing note dated 8/9/24 at 11:05 AM identified that Resident #91 approached an LPN and reported he/she had been experiencing left leg pain over a period of several days. The note further indicated the Advanced Practice Registered Nurse evaluated him/her on 8/9/24 and ordered an x-ray of Resident #91's left leg. A review of APRN and MD progress notes failed to identify documentation of an evaluation by a provider on 8/9/24 for Resident #91. Radiology results on 8/10/24 at 12:51 PM, of an X-ray of the left leg and left knee for complaint of severe pain to Resident #91's left lower leg, identified no new fractures. An interview with the Director of Nursing Service (DNS) on 11/21/24 at 2:55 PM identified that she did not fill out an accident and incident form for Resident #91's complaint of being injured from a mechanical lift transfer because she was not made aware of an incident. The DNS further identified that Resident #91 had a history of confabulating complaints for attention and the Social Worker (SW) would be responsible to include those behaviors in the RCP. SW notes dated 12/22/23 through 11/14/24 failed to identify documentation of Resident #91's alleged history of confabulation or false reporting. An interview with SW #2 identified that she was aware of a history of manipulation of staff and confabulation by Resident #91. SW #2 failed to identify that these behavioral issues were included in the RCP and indicated they should be, stating she would incorporate them into the RCP moving forward. She was unable to identify the reason the behaviors were not previously included within the RCP. Request for the facility's policy on Care Plans identified the facility has no policy on Care Plans.

Based on interviews, review of facility documentation and facility policy for 1 of 1 sampled resident (Resident #38) reviewed for a change of condition, the facility failed to ensure the Registered Nurse (RN) completed and documented an assessment and during a review of the Intravenous program, the facility failed to ensure that an RN and not a Licensed Practical Nurse (LPN) assessed and evaluated RNs as being competent to administer IV medications and fluids using IV infusion pumps. The findings included: 1. Resident #38's diagnoses included interstitial pulmonary disease, dysphagia with gastrostomy status and traumatic brain injury (TBI). The annual Minimum Data Set assessment dated [DATE] identified Resident #38 was cognitively intact but without speech, was dependent with toileting and transfers and required moderate assistance with bed mobility. The MDS assessment indicated Resident #38 had a feeding tube and received tube feedings for 51% or more of calories. The Resident Care Plan dated 10/7/24 identified dysphagia with gastrostomy tube (G-tube) and a history of respiratory arrest and aspiration pneumonia. Interventions included to report any signs and symptoms of aspiration, increased shortness of breath or dyspnea (difficulty breathing) to the medical doctor (M.D). A nurse's note dated 11/15/24 at 10:33 PM identified Resident #38 had a congested cough, complaints of shortness of breath (SOB) and was requesting to go to the hospital. The nurse's note indicated that Resident #38 had diminished lung sounds (LS) throughout and shallow respirations. Additionally, the nurse's note identified that the supervisor (RN #2) was made aware. A nurse's note dated 11/16/24 at 1:08 AM identified Resident #38 was alert and non-verbal, had an occasional cough with no complaints of respiratory distress and a slightly distended abdomen. A nurse's note dated 11/17/24 at 2:06 AM identified Resident #38 was alert and non-verbal with no respiratory distress and a slightly distended abdomen. An observation on 11/18/24 at 11:30 AM, identified Resident #38 was in bed with a cough and audible congestion. LPN #4 was made aware, entered the room, and utilized a communication board to further evaluate the resident. A nurse's note (LPN #4) on 11/18/24 at 2:55 PM identified Resident #38 had a deep congested cough, was suctioned for a minimum amount of phlegm, and had an expiratory wheeze with a nebulizer treatment given with some effect. LPN #4's nurses note indicated the supervisor (RN #1) was made aware. An Advanced Practice Registered Nurse (APRN #1) progress note dated 11/19/24 at 8:40 AM identified Resident #38 had a cough and shortness of breath, was ill appearing with an irregular heart rhythm, tachypnea (increased respiratory rate) and respiratory distress. APRN 1's progress note indicated Resident #38 appeared uncomfortable and had decreased breath sounds in the right and left lower lung fields. APRN #1's assessment further reflected Resident #38 was not communicating with his board, had an altered mental status, his/her skin was flushed and warm to the touch with pneumonia suspected. The APRN's progress note identified Resident #38 was transferred to the ED (emergency department) with respiratory distress. A physician's order dated 11/19/24 directed to transfer to ED with respiratory distress, resident to be evaluated in ER (emergency room ). An interview and clinical record review with the 7:00 AM to 3:00 PM Registered Nurse supervisor (RN #1) on 11/21/24 at 1:30 PM, identified that Resident #38 had respiratory distress and was evaluated by the APRN on the morning of 11/19/24. Subsequently, Resident #38 was transferred to the hospital and was admitted to the hospital with pneumonia. RN #1 indicated that Resident #38 had a history of respiratory distress and aspiration and had recently returned from a hospitalization for aspiration. RN #1 further identified that Resident #38 was a fragile individual whose status could change on the drop of a dime. Review of the clinical record with RN #1 identified that, although the nursing supervisor (RN #2) had been notified of Resident #38's change in condition on 11/15/24, RN #2 had failed to complete and document an assessment of Resident #38. RN #1 further identified that although she was notified of Resident #38's change in condition on 11/18/24 she failed to complete and document an assessment of Resident #38. RN #1 indicated that when notified of a resident's change in condition, the nursing supervisor should complete and document an assessment of the resident. RN #1 was unable to identify a reason why RN #2 failed to complete and document an assessment of Resident #38's change in condition on 11/15/24. Additionally, RN #1 was unable to identify a reason why she failed to complete and document an assessment of Resident #38's change in condition on 11/18/24. Interview and record review with the 3:00 PM to 11:00 PM Registered Nurse supervisor (RN #2) on 11/21/24 at 3:10 PM identified that although she was notified and saw Resident #38 on 11/15/24 for a change in condition, she did not listen to the resident's lungs, take his/her vital signs or write a progress note in Resident #38's clinical record. RN #2 indicated that she should have completed and documented an assessment of Resident #38 on 11/15/24 but had made a mistake. RN #2 identified that although Resident #38 had complained of shortness of breath and asked to go to the hospital on the evening of 11/15/24, she thought there was no reason to transfer the resident out because he/she frequently asked to go to the hospital. Interview and record review with the DNS on 11/22/24 at 9:41 AM identified that when the RN supervisors (RN #1 and RN #2) were notified of Resident #38's change in condition, on 11/15/24 and 11/18/24 respectively, they should have assessed the resident and documented their assessments in the clinical record. Review of the clinical record with the DNS at that time failed to reflect documentation that lung assessments were completed on Resident #38 on 11/16/24, 11/17/24 and 11/18/24 and failed to reflect that vital signs were completed on Resident #38 on 11/15/24 and 11/18/24. Interview and record review with APRN #1 on 11/22/24 at 10:00 AM identified the RN supervisors (RN #1 and RN #2) should have completed a comprehensive assessment of Resident #38 and written a nursing note on 11/15/24 and 11/18/24. APRN #1 further indicated that Resident #38 should have had close monitoring and lung assessments in the days after his/her change in condition on 11/15/24 and that, although she evaluated Resident #38 on the morning of 11/19/24, he/she was found in respiratory distress and required transfer to the hospital. Review of the facility's, Observation & Recording Change of Resident's Condition policy, undated, directed to ensure that when a resident has a change in condition that appropriate assessments are performed and documented. The policy further directed that when a change of condition occurs the licensed nurse will perform an assessment and vital signs will be included as part of all change in condition assessments and documentation should be in the narrative nurse's notes. 2. On 11/22/24 at 11:30 AM, a review of annual IV competencies for IV infusion pump use for licensed nursing staff with LPN #5 (who is the Infection Control Preventionist and Staff Development Nurse) indicated that she completed IV competencies for the RNs and was not aware that it was beyond the LPN's scope of practice to deem an RN competed for IV skills. Interview with the DNS on 11/22/24 at 11:45 AM indicated she was unaware that LPN #5 was not able to complete competencies for RN staff and that she oversees LPN #5 in her role but was not present when LPN #5 was completing competencies for RNs. A review of the IV Long Term Care manual effective January 2022 on 11/22/24 at 12:00 PM provides a form to complete IV skills for Infusion Pump administration for IV medications and fluids for licensed nursing staff. The form has a signature and date line for the nurse evaluator and for the nurse being evaluated for his/her IV skills. 51756

Based on observations, review of the clinical record, facility policy, and interviews for 3 of 5 residents (Resident #21, Resident #73, and Resident #77) reviewed for Activities of Daily Living (ADL's), the facility failed to provide timely assistance with fingernail care to dependent residents. The findings include: 1. Resident #21's diagnoses included vascular dementia, metabolic encephalopathy and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and was dependent with toileting, bed mobility and transfers. The Resident Care Plan dated 9/24/24 identified that Resident #21 was dependent with ADL's and had longstanding upper extremity contractures with interventions that included a rehabilitation screen and evaluation as needed and to allow resident choices. Review of the Nurse Aide Care Card for Resident #21 identified that shower and weights were to be completed on Wednesdays on the 3:00 PM to 11:00 PM shift. Observation and interview with Resident #21 on 11/19/24 at 11:53 AM, identified had very lengthy, untrimmed, and jagged fingernails with a dark colored substance beneath them. Resident #21 indicated that he/she preferred his/her fingernails kept short and clean but when he/she received a shower or bath staff did not clean or trim them. Resident #21 was observed with 4 fingers of his/her bilateral hands contracted when at rest with the ability to straighten them upon request. Observation and interview with Nurse Aide (NA) #4 on 11/20/24 at 1:40 PM identified that she was familiar with Resident #21 and had frequently provided him/her care. NA #4 indicated that Resident #21 had dirty and long fingernails on both hands and that they should not have appeared that way. NA #4 further identified that under Resident #21's contracted right hand 4th finger was a dark substance on the skin. NA #4 indicated that although she or another NA were responsible for fingernail cleaning and trimming for residents on bath day or when needed, she had too many tasks to complete and there was not enough time in the day to get it done. Observation and interview with LPN #4 on 11/20/24 at 1:45 PM identified Resident #21's fingernails on both hands were very filthy and long and should absolutely not look that way. LPN #4 indicated there was a dark substance under Resident #21's right 4th finger and the skin on the palm of his/her right hand was also very dirty. LPN #4 identified that although fingernails should be cleaned and trimmed on a resident's scheduled shower day or if they are long, the NA's responsible did not complete the task. LPN #4 further indicated that if Resident #21 did not get out of bed for a shower due to his/her condition, his/her fingernails should have still been cleaned and trimmed. Subsequent to surveyor inquiry, an observation on 11/20/24 at 2:30 PM identified Resident #21 was having his/her hands cleaned and his/her fingernails cleaned and trimmed by NA #4. Interview with the 7:00 AM to 3:00 PM nursing supervisor (RN #1) on 11/20/24 at 2:00 PM identified Resident #21's shower day was on Wednesday on the 3:00 PM to 11:00 PM shift and on Wednesday 11/13/24 the NA assigned to Resident #21 was NA #5. Interview with NA #5 on 11/20/24 at 3:15 PM identified that she took care of Resident #21 on Wednesday 11/13/24 from 3:00 PM to 11:00 PM, which was Resident #21's scheduled shower day. NA #5 indicated Resident #21 preferred a bed bath, which she gave him/her, but that she did not clean or trim Resident #21's fingernails last week because she was never told to do that on scheduled shower days. NA #5 further identified that she thought Resident #21's fingernails were cleaned and trimmed during the day or by recreation and that she did not usually work this shift so needed to check with the nursing supervisor. Subsequent to surveyor inquiry, on 11/21/24 at 10:15 AM, RN #1 identified that she had conducted an in-service with the NA staff on her unit regarding required fingernail cleaning and trimming on a resident's scheduled shower day. 2. Resident #73's diagnoses included Parkinson's disease, congestive heart failure, and gastro-esophageal reflux disease. The quarterly MDS assessment dated [DATE] identified Resident #73 was moderately cognitively impaired, required moderate/total assist of 1 for bathing, dressing, personal care, and was totally dependent on staff for personal hygiene. The Resident Care Plan dated 9/25/24 identified Resident #73 was dependent with bathing, dressing, hygiene, and incontinent care. Interventions included to set up for hygiene, dressing, and assist as needed for completion. Observations on 11/18/24 at 11:55 AM and 2:10 PM and 11/19/24 at 10:00 AM identified Resident #73's fingernails (3) on the left hand were noted to have a brown material under the fingernails, were long, and in need of trimming. Interview and observation with LPN #1 on 11/21/24 at 12:35 PM identified Resident #73's nails were long and noted to have brown material under his/her fingernails. LPN #1 identified that the facility policy was to provide nail care on the resident's shower day and as needed. LPN #1 identified that although Resident #73 had received a shower on 11/19/24, the resident's fingernails had not been cleaned and trimmed according to the facility policy. Interview with NA #4 on 11/21/24 at 12:41 PM identified she did not have time to provide Resident #73 with fingernail care since first the first observation on 11/18/24. NA #4 reported that although nailcare should be provided during the Resident's shower, however, she did not have enough time to provide Resident #73 with nail care. NA #4 indicated she reported this to the unit nurse but could not recall which nurse due the frequency of changes to nurses working on that unit and added she felt like a 1-man show. Additionally, NA #4 indicated there were other staff on the unit and throughout the 3 shifts who could have provided nail care. Subsequent to surveyor inquiry, Resident #73's fingernails were cleaned and trimmed. 3. Resident #77's diagnoses included multiple sclerosis, dementia and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #77 was cognitively intact and was dependent with toileting, bed mobility and transfers. The Resident Care Plan dated 10/2/24 identified that Resident #77 had an alteration in mobility and independence. Interventions included to assist resident with ADL's and to offer the resident a choice between a shower, bed bath or comfort bath. Review of the Nurse Aide Care Card for Resident #77 identified that showers/bathing were to be completed on Tuesdays on the 7:00 AM to 3:00 PM shift. Observation and interview on 11/18/24 at 11:40 AM identified Resident #77 had lengthy and jagged fingernails with a brown substance underneath the fingernails on his/her bilateral hands. Resident #77 indicated that he/she preferred to have his/her fingernails kept short but that he/she was unable to clean or trim them. Resident #77 identified that although he/she had asked staff to clean and trim his/her fingernails when he/she was bathed, it was not done. Observation and Interview with NA #3 on 11/20/24 at 2:10 PM identified that she frequently took care of Resident #77 and his/her fingernails on both hands appeared long, jagged, and had a brown substance underneath them. NA #3 indicated Resident #77's shower/bath day was on Tuesday on the 7:00 AM to 3:00 PM shift and that she worked with him/her every other Tuesday and would clean and trim his/her nails then. NA #3 identified that Resident #77's nails should have been cleaned and trimmed on his/her last scheduled shower/bath day on 11/19/24, but that she was not working that day. Additionally, NA #3 was unable to recall if she cleaned and trimmed Resident #77's fingernails on the resident's last scheduled shower/bath day when she was assigned. Observation and Interview with the 7:00 AM to 3:00 PM nursing supervisor (RN#1) on 11/21/24 at 11:00 AM identified Resident #77's fingernails on both hands were long and jagged and needed to be cleaned and trimmed. RN #1 indicated that Resident #77's fingernails should have been cleaned and trimmed by the assigned NA on his/her shower/bath day. Although RN #1 was unable to identify why Resident 77's fingernails were not cleaned and trimmed on his/her scheduled shower/bath day on 11/19/24, she indicated she would have a NA complete the task for Resident #77 now. Review of the facility policy, Personal Care Routine, dated 05/03, directed that a bath was to cleanse, refresh and soothe the resident and care of the fingernails was part of the bath and to be certain nails are clean. 51867

Based on observations, interviews and record review for 2 of 2 residents (Resident #6 and Resident #81), reviewed for positioning, the facility failed to ensure hand rolls were in place for Resident #6 and a lap tray was applied consistently for Resident #81 in accordance with the physician's order. The findings include: 1. Resident #6 's diagnoses included a contracture of unspecified joint, peripheral vascular disease, diabetes, and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired and was totally dependent on facility staff for dressing, eating and personal hygiene. The Resident Care Plan dated 9/9/24 identified that Resident #6 was at risk for skin breakdown related to impaired mobility. Interventions included to apply bilateral palm guards and check skin integrity per the physician orders. A physician's order dated 10/8/24 directed to place rolled up washcloths in the palms of Resident #6's hands every shift. An Occupational Therapist (OT) #2's note dated 10/8/24 identified that Resident #6 had bilateral hand contractures upon admission in May of 2024. Bilateral hand splints were trialed at admission with the subsequent development of a wound on 10/8/24. Resident #6 was noted to be resistant to the hand splints increasing the risk for skin breakdown and rolled washcloths were ordered by the physician. Observation on 11/19/24 at 9:57 AM, identified Resident #6 sitting in a chair without the benefit of washcloths in his/her hands. Observation on 11/20/24 at 5:58 AM identified Resident #6 in bed, his/her left hand above the covers, without the benefit of a rolled washcloth in place. A second observation on 11/20/24 at 7:45 AM identified Resident #6 lying on his/her back with both hands above the covers, without the benefit of a rolled washcloth in either hand. Observations of Resident #6 on 11/21/24 at 11:42 AM and 1:30 PM identified the resident lying in bed, both hands above the blankets, without the benefit of a washcloth in either hand. Interview with LPN #7 on 11/21/24 at 1:30 PM identified that the order for rolled washcloths was entered in Resident #6's chart and added to the Treatment Administration Record. The RN or LPN assigned to Resident #6 each day was responsible to ensure the rolled washcloth placement. Interview on 11/21/24 at 1:34 PM with LPN #13 identified that she was aware of the order and would place the rolled washcloths after she had completed her noon medication rounds. Although requested, a facility policy for hand splints or rolled washcloth splinting was not provided. 2. Resident #81's diagnoses included spastic hemiplegia (paralysis) affecting the left nondominant side, unspecified osteoarthritis, and unspecified cataracts. The quarterly Minimum Date Set (MDS) assessment dated [DATE] identified Resident #81 was severely cognitively impaired, requiring partial/moderate assistance for eating and dependent for toileting and transfers. The Resident Care Plan dated 9/4/24 identified Resident #81 as having an alteration in physical mobility and independence with daily activities relating to impaired mobility, hemiplegia and apraxia (a neurologic disorder that makes it difficult to make certain movements), in addition Resident #81 transferred with an assist of 2, does not ambulate, had left upper extremity contractures and a lap tray was to be in the wheelchair to improve left upper extremity positioning. Interventions included to don a left resting hand splint with AM care and the lap tray to be in the wheelchair as ordered, out of bed to modified custom wheelchair as tolerated/desired with 1/2 lap tray to be in place at all times. A physician's order dated 11/1/24 directed Resident #81 to be out of bed to a modified custom wheelchair as desired/tolerated with the lap tray in place at all times. The Resident Care card located in Resident #81's room directed for the lap tray to be in the wheelchair as ordered and 1/2 lap tray to be in place at all times. Observations of Resident #81 identified her/him sitting in a modified custom wheelchair in the hallway on 11/18/24 at 12:15 PM, 11/19/24 at 9:30 AM, and 11/21/24 at 9:17 AM without the benefit of the lap tray being in place. Observation of Resident #81 on 11/19/24 at 10:13 AM identified the DNS approached the resident who was in the hallway at the time without the benefit of a lap tray being in place and stated let me fix your arm while repositioning Resident #81's arm that kept slipping down the side of the chair. An interview with the DNS on 11/20/24 at 11:14 AM identified it was facility policy for the therapy department to write custom/adaptive wheelchair orders, with the therapy and nursing departments responsible for applying positioning devices such as lap trays. She could not identify the reason Resident #81 was not provided with the lap tray. An interview and record review with Occupational Therapist (OT) #1 on 11/21/24 at 10:02 AM identified the physician's order was put in place by therapy, with the nursing department responsible for ensuring the lap tray was on. The expectation of the order in place was that Resident #81 should have a lap tray on at all times for pelvic positioning and to prevent her/his left arm from sliding down and potentially getting caught or injured. Furthermore, without the benefit of the lap tray, Resident #81 would have to be repositioned throughout the day and due to her/his hemiparesis the left arm could come in contact with something that could potentially cause skin breakdown. An interview and care card review with Nurse Aid (NA) #4 on 11/21/24 at 10:18 AM identified the therapy department writes orders relating to positioning and wheelchairs, and the instructions were on the care card located in the resident's closets. The care card for Resident #81 identified the lap tray to be on at all times. NA #4 identified that although nursing was responsible for putting on the lap tray it was not on because third shift gets Resident #81 up and out of bed. Although requested, a facility policy for customized wheelchairs and positioning was not provided. 51313

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #95) reviewed for nutrition, the facility failed to identify when a significant weight loss occured and implement nutritional supplements in a timely manner. The findings included: Resident #95 was admitted to the facility in April 2022 with diagnoses that included vascular dementia with psychotic disturbances, Down syndrome, depression, and hypothyroidism. A Resident Care Plan dated 2/19/24 identified a problem with Resident #95 having a significant weight loss in 6 months (weight of 195.4 pounds/lbs). Interventions included to start on nutritional supplements, encourage food/fluids, and obtain weights as ordered. Physician orders dated 3/14/24 directed weekly weights to be obtained every Friday. The annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident # 95 was severely cognitively impaired and required total dependance from staff for eating. Physician's orders dated 8/15/24 directed to administer house supplements 3 times a day. A review of Resident #95's weight identified a weight of 190.1pounds (lbs) on 6/23/24 and a weight of 177.6 lbs on 7/20/24 (a 12.6 lb/6.5 % loss in less than a month). APRN #1's progress notes dated 7/30/24 identified a weight of 177 lbs. but did not identify Resident #95's significant weight loss. A review and interview with the Dietitian on 11/21/24 at 10:00 AM identified a progress note dated 8/15/24 that identified Resident #95's weights continued to slowly decrease. The Dietitian obtained a new order on 8/15/24 to increase house supplements to 3 times a day (27 days after the initial significant weight loss was identified). The Dietitian stated that the intervention to increase supplements was not implemented timely and should have been in place when weight loss was initially identified. Physician's orders dated 8/15/24 directed to administer house supplements 3 times a day. An APRN #1 progress note dated 9/10/24 identified Resident #95 was seen for weight loss with no new orders and to continue with supplement orders from 8/15/24 as Resident # 95 was starting to trend up in weights with a weight of 179 lbs. A review of the facility's Supplement Nutritional Program Policy dated 6/30/06 directed in part, that nursing and the Dietitian will identify residents who would benefit from supplements to provide calorically dense oral supplements for residents at risk for weight loss. Nursing and Dietary will evaluate the effectiveness of the program at weekly standards of care meetings.

Based on observation, interviews, record and policy review for 1 of 3 residents, (Resident #52), reviewed for respiratory care, the facility failed to follow physician's order for oxygen administration. The findings include: Resident #52's diagnoses included congestive heart failure, chronic kidney disease and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #52 was severely cognitively impaired, independent for eating, and required partial/moderate assistance for toileting and transfers. The Resident Care Plan dated 9/3/24 identified Resident #52 had a potential for alteration in respiratory status related to a diagnosis of asthma. Interventions included to administer oxygen per orders and monitor oxygen saturations per orders and as needed. The physician's order dated 11/1/24 directed to administer oxygen at 2 liters per nasal cannula at bedtime for shortness of breath. Observations on 11/18/24 at 2:23 PM, 11/19/24 at 10:17 AM, and 11/19/24 at 12:27 PM identified Resident #52 was receiving 4 liters of oxygen per minute (Lpm) via nasal cannula and on 11/21/24 at 2:54 PM receiving 3.5 Lpm via nasal cannula. An interview and record review with Licensed Practical Nurse (LPN) #1 on 11/21/24 at 2:55 PM identified Resident #52 should receive oxygen therapy continuously at 2 liters per minute, at which point LPN #1 turned the oxygen down from 3.5 Lpm to 2 Lpm. Physician's order review with LPN #1 failed to identify an order for oxygen to be received continuously and failed to identify oxygen saturation levels consistent with a need for oxygen (although not documented LPN #1 stated Resident #52's oxygen saturation earlier that day was 95%). LPN #1 could not identify the reason Resident #52 was receiving oxygen therapy other than at bedtime. An interview and record review with Registered Nurse (RN) #1 on 11/21/24 at 3:00 PM identified the facility policy was that residents who had oxygen saturations below 92% would be assessed and receive oxygen per physician's orders, with the floor nurse responsible for putting the oxygen in place. Physicians order review failed to identify an order for Resident #52 to receive oxygen during the day, or to titrate oxygen per oxygen saturation levels. Additionally, RN #1 stated she did not know the reason Resident #52 was currently receiving oxygen because Resident #52 had no indication for it. An interview and record review with APRN #1 on 11/22/24 at 9:56 AM identified Resident #52 should have a physician's order to be on oxygen therapy during the day, and an as needed (prn) oxygen order to maintain oxygen saturation above 92%, but did not . Review of oxygen saturation levels for the last 3 month with APRN #1 failed to identify levels below 92%. Subsequent to surveyor inquiry, APRN #1 stated she would assess Resident #52 for oxygen therapy needs. The Oxygen Therapy Policy directed in part that oxygen therapy is provided upon written order of the physician, and administered then monitored by the licensed nurse.

Based on observations, review of clinical record, facility documentation, facility policy and interviews for medication administration, the facility to ensure that medication error rate of less than 5%. The findings include: 1. Resident #84 was admitted to the facility in February 2022 with diagnoses that included dementia with other behavioral disturbances and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #84 was severely cognitively impaired. Physician orders dated 11/12/24 directed to administer Trazodone 50 mg (milligrams) 2 times a day, Namenda 5 mg 2 times a day, Depakote 125 mg sprinkles 1 capsule in AM and 2 capsules at bedtime. The times of administration for the morning medications were to be given at 8:00 AM. Observation of medication administration with Licensed Practical Nurse (LPN) #8 on 11/20/24 at 10:30 AM identified Trazodone, Namenda and Depakote were due to be administered at 8:00 AM and medications were administered at 10:30 AM, an hour and a half after the allowed timeframe. Interview with LPN #8 at that time identified he would make APRN #1 aware of the late medication pass and that he was an agency nurse and this was his first time working in the facility. Interview with the DNS on 11/20/24 at 10:45 AM identified that no one had made her aware that LPN #8 was late with the medication pass otherwise she would have assigned someone to assist him. The DNS indicated that she would have LPN #7 assist LPN #8 with finishing the medication pass and would notify APRN # 1. Interview with LPN #7 on 11/20/24 at 11:00 AM indicated that she assisted LPN #8 to finish the medication pass and if LPN #8 made her aware earlier she would have provided him with assistance to finish the medication pass timely. 2. Resident #102 was admitted to the facility in February 2023 with diagnoses that included anemia and delusional disorder. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 was moderately cognitively impaired. Physician's orders dated 11/7/24 directed to administer Magnesium Oxide 400 mg (milligrams) 2 times a day, Hiprex 1 gm (gram) 2 times a day and Bactrim DS q 12 hours 2 times a day for 7 days with a start date of 11/17/24. Observation on 11/21/24 at 9:45 AM of medication administration with LPN #9 identified Resident #102's 8:00 AM medications were administered at 9:45 AM, 45 minutes after the allowed timeframe. An interview with the DNS on 11/21/24 at 10:00 AM indicated that LPN #9 was very busy and a resident on the unit had vomited which caused a delay in her medication pass. DNS indicated that APRN #1 would be made aware of the medication pass time. An interview with APRN #1 on 11/21/24 at 11:30 AM indicated that she was notified of the medications being administered late and that she had no new orders. APRN #1 indicated that she did not think they were significant medication errors causing any ill effects. The observed medication pass error rate was 17.6 %. A review of the Medication Administration Policy dated 2017 directed in part, medications are administered within 60 minutes of scheduled time, except before, with or after meals ordered which are administered according to the established medication administration time for the facility.

Based on staff interview, review of the clinical record, and facility policy for 3 of 3 Nurse Aides reviewed for sufficient staffing (NA #4, NA #9 and NA #10), the facility failed to complete a yearly performance evaluation. The findings include: 1. NA #4's employee file identified a date of hire as 8/1/23. There had been no yearly performance evaluation completed during the length of NA #4's employment with the facility. 2. NA #9's employee file identified a date of hire as 11/13/17. There had been no performance evaluation completed during the length of NA #9's employment. 3. NA #10's employee file identified a date of hire as 5/7/02. The last performance evaluation was completed on 6/29/15 (over 9 years ago). Interview with the Administrator on 11/21/24 at 3:14 PM identified that in the past, supervisors were responsible for performance evaluations, but now department heads were responsible for conducting performance evaluations. The Administrator further identified that performance evaluations had not been completed for NAs since 2015 because the facility had been overwhelmed with other things, for example Covid and Legionnaires Disease. In lieu of performance evaluations, the Administrator indicated that 30 day action plans for problems were being completed. Request for the Facility's policy on Performance Evaluations identified there was no policy for performance evaluations.

Based on clinical record reviews, facility policy review and interviews for 1 sample resident (Resident #67) reviewed for limited range of motion and contractures and history of resistance to care, the facility failed to ensure that licensed and non-licensed staff consistently monitored the resident for potential skin breakdown after ADL care and within accordance to facility practice to ensue the resident did not develop an open wound to the left antecubital elbow with tendon exposure and for 1 of 3 sampled residents (Resident #217) reviewed for hospitalization s, the facility failed to administer medications in accordance with the physician's written order. The findings included: 1. Resident #67's diagnoses rheumatoid arthritis, dementia, osteoporosis, and anxiety. A Braden Scale dated 2/1/22 noted a score of 12 (Total score of 12 or less represents the resident was high risk for pressure ulcer development. The physician's order dated 9/20/22 directed to apply Geri-sleeves to bilateral upper and lower arm every shift for skin tear prevention. The physician's order dated 9/26/22 directed to conduct weekly skin observation. A review of Treatment Administration Record (TAR) for 9/26/2022 directed weekly skin observation and noted a zero for no skin impairment. The Resident Care Plan (RCP) dated 9/29/22 identified Resident #67 required assist with bathing, dressing and hygiene. Interventions directed staff to assist with bathing, mouth care, dressing and hygiene. The RCP dated 9/29/22 for at risk for skin injury related to fragile skin and the aging process. Interventions included: the application of Geri sleeve only to right arm /do not apply to left upper extremity, Geri legs per physician's orders, encourage protective clothing, moisturize skin with care and to report signs of any injury to the physician or Advanced Practice Registered Nurse (APRN). The RCP dated 9/30/22 for at risk for skin breakdown related to bowel and bladder incontinence and impaired mobility, decreased Range of Motion (ROM) of left upper extremity. Interventions included: to apply a pressure reducing mattress, encourage proper nutrition and hydration, apply protective barrier to peri area after incontinence care, discontinue splint to left upper extremity per physician's orders, check skin integrity and to notify the Medical Doctor (MD) of any sign of skin breakdown. The 9/2022 TAR identified the application of Geri sleeves to bilateral upper and lower extremities every shift for skin tear prevention from 9/20/22 to 9/30/22 except on one occasion on 9/21/22 the evening shift. The quarterly MDS assessment dated [DATE] identified Resident #67 had severe impaired cognition and required total assistance with transfer, mobility, toileting, hygiene and eating. Additionally, the assessment identified no pressure ulcer wounds but noted at risk for pressure ulcer development and the need for a pressure reducing devices for the chair and bed, turning and repositioning and the application of ointments/medications other than feet. The October 2022 TAR directed the application of Geri sleeves to bilateral upper and extremity every shift for skin tear prevention. The October 2022 TAR for weekly skin observations on 10/3/22, 10/10/22, 10/17/22 noted a 1 indicating previously identified area and on 10/24/22 and 10/31/22 zero no areas. The November 2022 TAR identified from 11/1/22 through 11/7/22 identified the application of Geri sleeve to bilateral upper and lower extremities every shift for skin tear prevention. The November 2022 TAR identified RN #1 signed off on the weekly skin check on 11/7/22 and identified no areas. The nurse's notes dated 10/3/22 through 11/7/22 did not identify any skin impairment. However, the nurse's note dated 11/8/22 identified Resident #67 had an open area with tendon exposure to the left antecubital area. The physician's order dated 11/8/22 directed Geri sleeve to right upper and lower bilateral extremities every shift and do not apply to (left upper) every shift for skin tear prevention. The physician's progress notes dated 11/8/22 directed to administered Cephalexin (antibiotic) 500 MG by mouth three times per day for 7 for left upper arm wound infection. The physician's progress notes dated 11/9/22 identified Resident #67 with an open wound to left antecubital area. The measurement noted 3 Centimeter (CM) x 2.5 CM x 1 CM depth with tendon exposure and mild odor and clear drainage. The wound progress note dated 11/10/22 identified Resident #67 with acute wound on left antecubital fossa and measurement of 2.5 CM (length) x 1.8 CM (width) x 0.5 CM (depth). The note further indicated tendon was exposed. There was a moderate amount of sero-sanguineous drainage which has no odor. Wound bed identified to be 51-75% granulation. The physician's order dated 11/11/22 directed to cleanse wound to left antecubital followed by triad to peri-wound and hydrafera blue (moistened) to wound bed followed by dry clean dressing. The Rehabilitation Screening Request form dated 12/19/22 of observation of the resident's left elbow measurement by Occupational Therapy noted left elbow extension resting 106 degree and passive ROM 94 degree. Recommendations noted no evaluation indicated at this time. Interview with Nurse Aide (NA) #9 on 12/15/22 at 11:00 AM identified that she was responsible for providing personal hygiene to the resident. She also indicated she was aware of the Resident #67 left elbow contracture. She further indicated she tried to provide hygiene to the left elbow area, but it was very difficult because the resident's left elbow was very stiff. Interview with Physical Therapist (PT #1) on 12/19/22 at 9:30 AM identified Resident #67 had limited range of motion to the shoulder and elbow at time of admission. She also indicated Resident #67 had received moist heat, diathermy treatment, pain medication and had received Botox injection from neurology to manage the left elbow contracture. She indicated skin breakdown and pain were usually the common complication related to the left elbow contracture. PT #1 further indicated that the nursing department was responsible for providing an intervention to protect the resident from skin breakdown secondary to left elbow contracture. Interview and clinical record review with Registered Nurse (RN #1) on 12/19/22 at 2:55 PM identified the license nurse is responsible for conducting a skin assessment for any new skin issue. She also indicated the license nurse would perform a comprehensive skin check weekly on the resident's shower day. Clinical record review with RN#1 identified she did sign off in the TAR that Resident #67 had no skin issue on 11/7/22. She also did not remove the Geri sleeves on the left elbow to check the skin under the protective clothing because the nurse aides would inform her of any concerns. She further indicated that she was made aware the next day that Resident #67 had an open wound to the left antecubital area. Interview and clinical record review with Advance Practice Registered Nurse (APRN #1) on 12/20/22 at 11:00 AM identified Resident #67 had left elbow contracture. She also indicated common complications from left elbow contracture are skin break down and pain. She further indicated the nursing staff would be responsible for monitoring Resident #67 skin integrity related to the left elbow contracture. Clinical record reviewed with APRN #1 indicated that she was called to assess a new wound that had developed on the left antecubital area on 11/8/22 on the resident. Although she could not remember who reported the new skin condition, she noted an open wound with tendon showing on the antecubital area with mild odor and drainage. Although she could not provide the exact amount of time before the wound could develop to that extent, she indicated that usually the skin would show redness, maceration, or moisture then a break into the skin to become a wound. She identified moisture and poor hygiene could potentially lead to development of the wound that was the reason why she discontinued the use of Geri-sleeve to the left elbow. She further indicated that the severity of wound would not happen overnight if RN #1 indicated that there was no skin issue the day before the new onset of wound on 11/8/22. Interview with Assistant Director of Nursing Services (ADNS) on 12/20/22 at 12:30 PM identified that nursing would develop an intervention to prevent skin breakdown if any resident had been high risk for skin breakdown. He also indicated that the intervention should be in place immediately. He also identified nursing staff conducts weekly skin check. The ADNS further indicated s/he would expect the nursing staff to remove any protective clothing and check the resident's skin thoroughly. Interview with NA #2 on 12/30/22 at 9:40 AM identified she only provided care to Resident #67 once when the facility was short of nurse aides. She identified that NA # 9 was his/her permanent nurse aide. She further indicated she removed Resident # 67's Geri-sleeve and cleanse around the left elbow. NA #2 indicated that she did not attempt to clean the inner elbow because Resident #67 was resistive and combative when you open his/her arm. Follow-up interview with NA #9 on 12/30/22 at 10:15 AM identified that she threw out the Geri-sleeve when it was dirty and got a new one. She indicated she cleanses the resident's left elbow once a day during the morning care. She further indicated that she only cleanses the surrounding area of the left elbow because Resident #67 left elbow was very stiff and difficult to move. When she tried to move the left elbow, Resident #67 would yell. She did not notice a foul smell on the resident's left elbow. She also identified that she would help the license nurse to provide the wound care on the left elbow to open Resident # 67's left elbow. NA #9 indicated she did not ask for a second person during morning care to provide care to the left elbow because Resident # 67 was an assist of 1 with her/his hygiene. Interview with RN #3 on 12/30/22 at 11:15 AM identified that she was called in to the resident room to assess the wound on the left elbow. She identified APRN #1 was also present and treated the area with an oral antibiotic to the left elbow and discontinued the Geri-sleeve on the left elbow. She further indicated that APRN #1 thought Resident # 67's Geri-sleeve could be causing moisture and rubbing the resident skin. She also indicated APRN #1 could have said that there was a history of the wound on the left elbow antecubital area, but she was not sure. She indicated that if there was a history of wound to the left antecubital area there should be an intervention to prevent the wound from re-occurrence. Interview with RN #6 on 12/30/22 at 12:00 PM identified she reported the new onset of the wound to the left antecubital elbow. She indicated that she could smell a foul odor in the Resident # 67 room which lead her to remove Resident #67 Geri-sleeve and at which time, she saw redness to the upper arm and tried to pull down his/her elbow and saw the wound in the left elbow antecubital area. She also identified the Geri-sleeve was an intervention to prevent a skin tear. Interview with NA #12 on 12/30/22 at 2:30 PM identified that she was permanently assigned to Resident #67 when she was working. She identified that she washed the surrounding area of the left elbow of Resident #67. She did not wash the left elbow antecubital area because she did not want to hurt Resident #67. The facility failed to ensure that licensed and non-licensed staff consistently monitored the resident's left elbow contracture arm and monitored the area in accordance with facility practice for potential skin breakdown to prevent the development of an open area on the resident's left antecubital area with tendon exposure. The facility was unable to identify why the left antecubital tendon exposure wound was not identified until 11/8/22. A review of facility nursing policy Skin Care System identified that the facility was dedicated to preventing pressure ulcer and develop a system so that each resident would retain or regain their optimal skin integrity and health. Residents will receive the care and services needed according to the established practice guidelines. An ongoing monitoring and evaluation will be provided to ensure optimal resident outcomes. 2. Resident #217 was admitted on [DATE] with diagnoses that included heart failure, chronic kidney disease, stage 3, retention of urine, and acute kidney failure. An admission physician's order dated 12/06/2022 directed that Resident #217 receive Torsemide 20 milligrams (mg), give one table in the morning for congestive heart failure as follows: Take 60 mg if Resident #217's weight was greater than 220 pounds (lbs.); take 40 mg if the resident's weight was 215-220 lbs.; take 20 mg if the resident's weight was 210-215 lbs., and if Resident #217 weighed less than 210 lbs., do not administer any of the Torsemide medication. Review of Resident #217's baseline Admission Nursing Care Plan dated 12/06/2022 identified that s/he utilized a diuretic. Interventions included to be weighed according to physician orders. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #217 was mildly cognitively impaired, was independent with eating after set-up, and required extensive assistance with personal hygiene. Interview with Resident #217 on 12/13/2022 at 11:15 AM indicated that Torsemide (a diuretic medication to treat fluid overload in heart failure and chronic kidney disease) was incorrectly administered. Although Resident #217 indicated that s/he had spoken to staff related the error, s/he was unable to identify which staff or the staff's response. Additionally, Resident #217 explained that s/he had just returned from the hospital today due to the medication error. Review of the December 2022 Medication Administration Record, (MAR) identified that on 12/7/22 Resident #217's weight was not documented and that Torsemide was not administered. On 12/8/22 the MAR identified Resident #217's weight was 209.6 lbs. (less than the 210 lb. parameter) but that s/he had been administered Torsemide 20 mg. On 12/9/22 Resident #217's weight was 206.6 lbs. (less than the 210 lb. parameter), s/he received both a 40 mg dose of Torsemide as well as a 60 mg dose of Torsemide, and a notation to see the nursing progress note was indicated. On 12/10/22 the MAR lacked Resident #217's weight, but indicated Torsemide, 20mg, 40mg, as well as a 60mg dose was administered. On 12/11/22 the MAR indicated a notation that Resident #217's weight was 206.6 lbs., (less than the 210 lb. parameter), but s/he was administered Torsemide 20mg. On 12/12/22 Resident #217's weight was documented as 207 lbs. (less than the 210 lb. parameter) and s/he received Torsemide 40 mg. A notation on 12/12/22 indicated that the Torsemide was held and to refer to the nursing progress notes. The MAR dated 12/13/22 failed to indicate Resident #217's weight, no Torsemide was administered, and the administration notation directed to refer to the nursing progress note. Review of the physician and nursing progress notes dated 12/6/22 through 12/19/22 for Resident #217 failed to include documentation that corresponded to the MAR notations to view progress notes dated 12/9/22, 12/12/22, and 12/13/22. Interview, review of the MAR, nursing progress notes, and physician's orders with the Assistant Director of Nursing Services (ADNS) on 12/19/2022 at 11:45 AM failed to identify that he could explain why there were irregularities between the physician's orders and the actual administration of the Torsemide medication. The ADNS indicated that Resident #217's Torsemide was not administered in accordance with the prescribed physician's order. Review of the medication administration policy indicated that Medications are administered in accordance with written orders of the prescriber. Additionally, the medication administration policy indicated that if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, an explanatory note is entered. 47489

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred without injury. The findings include: Resident #1's diagnoses included type 2 diabetes mellitus, thrombocytopenia, hypothyroidism, hypertension, and dementia with behavioral disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment with no behavioral issues and required extensive assistance with bed mobility and transfers. A review of the Resident Care Plan dated 8/16/2022 identified Resident #1 required extensive to total assist with ADLs and transferred using a Hoyer with an assist of two persons. Care plan also identified Resident #1 was at risk for falls related to cognitive deficits and poor insight to safety awareness. Interventions included observe body position, body alignment in chair and transfer with assistance as per orders. A physician order dated 9/19/2022 directed Hoyer lift transfers with an assist of 2 persons. A Facility incident report dated 9/28/2022 at 2:30 AM identified that Resident #1 was being transferred back to bed from his/her wheelchair via Hoyer lift and Resident #1 slid backwards and landed on the floor. Resident #1 was transferred to the hospital for evaluation and was diagnosed with an acute/subacute T3 endplate fracture with orders to follow up with orthopedics. A nurse's note dated 9/28/2022 at 4:07 AM identified that a NA notified the nurse that Resident #1 fell out of Hoyer lift during a transfer. The nurse notified supervisor and went to Resident #1's room and observed Resident #1 lying on the floor on left side with knees positioned towards chest, bleeding from top left side of head. EMS was notified and Resident #1 was transported to the hospital. Review of hospital record dated 9/28/2022 identified that Resident #1 sustained a three (3) centimeter (cm) contusion and laceration to the posterior (back) scalp with no sutures required. A Computed Tomography (CT) scan results identified an acute compression fracture of the superior endplate and body of T3, possibly acute/subacute with noted osteopenia of bones. CT scan of the head identified a small hematoma (a collection of blood in tissue space) in left parietal scalp noted. The report further directed for orthopedic follow-up. An interview with NA #1 on 10/20/2022 at 11:00 AM identified that on 9/28/2022 she and NA #2 attempted to transfer Resident #1 from the wheelchair to bed utilizing a crisscrossed Hoyer pad. Once the Hoyer lift was connected to the Hoyer pad, NA #1 operated the Hoyer while standing in front of Resident #1. NA #2 was standing behind Resident #1's wheelchair next to the Resident's bed. NA #1 identified that as she operated the Hoyer to lift Resident #1 out of wheelchair and moved the Hoyer towards the bed, Resident #1 flipped backwards out of the Hoyer pad and fell on to the floor. NA #1 refused to identify where NA #2 was positioned when she was directing/operating the Hoyer lift (stating she preferred NA #2 gave her own account of her position) at the time. An interview with Director of Physical Therapy on 10/20/2022 at 11:30 AM identified the interdisciplinary team reviewed the crisscrossed Hoyer pad used for Resident #1 at the time of incident and identified no issue with the size or type of pad used. Interview with NA #2 on 10/20/2022 at 2:00 PM, identified that she assisted NA #1 during the attempt to transfer Resident #1 from the wheelchair to the bed on 9/28/2022. NA #2 indicated that she stood on the right side of Resident #1 with one hand on the Hoyer pad near Resident #1's waist and the other hand supporting the back of the Hoyer pad (where the Resident's back rested). She identified that as NA #2 directed the Hoyer lift towards the bed Resident #1 flipped out and fell on to the floor. NA #1 identified that her hand never let go of the Hoyer pad and she was unable to identify how the fall occurred. Interview with ADON on 10/20/2022 at 2:55 PM identified that a reenactment identified Resident #1 could have fallen due to improper positioning of the Hoyer pad. The ADON indicated if the correct Hoyer pad was used but not positioned correctly and the Hoyer lift is lowered too much it could cause the Resident to flip backwards and fall out of Hoyer. Interview with DON on 11/03/2022 at 11:30 AM identified that the NAs used the correct Hoyer pad, and the Hoyer lift was checked by maintenance and there were no issues identified with lift. The DON indicated that based on that information, she concluded that it was human error, and the NAs must have done something incorrectly during transfer. A review of facility's documentation identified licensed staff and nurse aides were re-educated after Resident #1's fall, regarding mechanical lift transfers, and safe positioning of Residents during Hoyer lift transfers.

Based on clinical record review and interview for one of four residents reviewed for pressure ulcers (R#109) the facility failed to revise the plan of care to prevent development of a second open wound in the same area and/or failed to ensure the area of the wound was protected from pressure. Findings included: Resident #109's [DIAGNOSES REDACTED]. A Wound Nurse's note dated 2/14/14 identified that a deep tissue injury (DTI) was suspected which was located on the resident's right lateral foot (status [REDACTED]. An assessment dated [DATE] identified that the area had changed from a DTI to an unstageable pressure ulcer. Subsequent assessments identified improvement and healing of the area on 3/14/14. A quarterly MDS assessment dated [DATE] identified Resident #109 was without cognitive impairment, was totally dependent on staff for transfers and locomotion, required extensive assistance with all other ADL's and was at risk for pressure ulcer development. A pressure sore risk assessment dated [DATE] identified that the resident was at high risk. The resident care plan dated 8/11/14 identified R #109 with a risk for skin break down. Interventions included to encourage proper nutrition and hydration, notify MD of skin changes, provide incontinent care, provide vitamin and mineral supplements, reposition every two hours and have the wound nurse follow as needed. An assessment dated [DATE] at 10 PM of R#109's right foot lateral amputation site identified a 1.0 cm x 1.0 cm purple discoloration that was non-blanchable. Allevyn was applied. The RCP revised on 9/12/14 identified a DTI on the right lateral foot with an intervention to apply dimethicone. A nurse's note dated 9/15/14 identified that the DTI area located on the right lateral side of R#109's foot was slightly open. A Wound Nurse's note dated 9/15/14 identified a 1.0 cm x 1.0 cm area, DTI with purple discoloration with recommendations to apply Allevyn foam to protect the area. Observations on 9/16/14 at 11:45 AM noted R#109 was out of bed, sitting in a wheel chair, in socks, with both feet resting directly on foot rests without the benefit of any pressure relief. Review of the nurse aide care card lacked any directions related to preventing pressure on R#109's right foot and /or need for daily diabetic foot inspections. Observation of R#109 on 9/17/14 at 10:45 AM with RN#2 and LPN#2 present noted that the right lateral foot dressing was falling off. The area visible appeared to glisten with a darkened area around the outside with an open area in the center that measured approximately 1.0 CM in diameter. Further observation at that time noted the presence of a pressure reducing boot device located on the bedside table, but not on the resident's foot. Interview and review of R#109's clinical record, including care plans with LPN#2 on 9/17/14 at 11:15 PM, failed to identify documentation that the plan of care was revised with interventions to prevent the reoccurrence of R#109's right lateral foot wound prior to the area breaking down the second time. He/she indicated that the care plan was revised that day (9/17/14) to include the provision of an off-loading foam boot when R#109 was out of bed and in the wheelchair subsequent to surveyor inquiry.

Based on review of clinical records, review of facility documentation/investigations and interviews for three of six sampled residents reviewed for accidents (R#17, 20, 165), the facility failed to transfer a resident according to the plan of care resulting in an injury, and/or failed to ensure fall prevention interventions were carried out, and/or failed to respond to elopement (wanderguard) alarms appropriately to prevent an elopement. The findings include: 1. Resident 20's [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] identified the resident had severe cognitive impairment, and was totally dependent on staff for ADL's including the assistance of two for transfers. The RCP dated 8/20/13 and the NA Care Card identified Resident #20 was non-ambulatory and required the assistance of two for transfers. physician's orders [REDACTED].#20 with the assistance of two staff and a rolling walker. Nurse's Notes dated 9/28/13 at 9:30 AM identified R#20 complained of right knee discomfort after a transfer back to bed. The physician was notified and directed the staff to obtain an x-ray of the right knee and femur. A Radiology Report dated 9/28/13 identified an acute displaced fracture of the distal femur. The physician was notified and Resident #20 was transferred to the ED for evaluation. The ED report identified a mildly displaced and comminuted fracture of the distal right femoral metadiaphysis. Resident #20 was admitted to the hospital with [REDACTED]. Interview and review of facility documentation on 9/18/14 at 9:45 AM with NA #3, who witnessed the event, identified that while he/she left the room to obtain a gloves to assist with transferring Resident #20 back to bed, NA #2 had provided the transfer without his/her assistance. Resident #20 and NA#2 were observed lying across the bed. NA#2 was lying on top of R#20 and the resident was calling out as if in pain. Further interview identified that a rolling walker and a gait belt had not been used during the transfer. Interview, review of the clinical record and facility documentation on 9/18/14 a at 12:15 PM with the DNS identified that the resident required the assistance of two for transfers and the NA #2 was terminated for not following the resident's plan of care. 2. Resident #17's [DIAGNOSES REDACTED]. A quarterly minimum data assessment dated [DATE] indicated that R#17 had short and long-term memory problems, required total care, and did not walk. The care plan dated 8/7/14 identified a risk for falls related to cognitive deficits, impaired safety awareness and a history of falls. Interventions included to keep items in reach, and use a low bed with mats. Resident #17's nurse aide care card directed facility staff to use padded side rails. A nurse's note dated 8/7/14 at 7:00 AM indicated R #17 was found lying on the floor next to the bed and the left side rail was noted in the low position. The resident was assessed and sustained no injury. The facility investigation dated 8/7/14 indicated NA #6 thought he/she had put the siderail up, but with the pads on, the siderail may not have latched. At that time NA #6 was educated on ensuring the siderails are up and latched as indicated. An interview on 9/18/14 at 10:15 AM with the Director of Nursing indicated the padded siderail was a safety intervention for R #17 to prevent falls and should have been in the up position and latched when the resident was in bed. 3. Resident #165's [DIAGNOSES REDACTED]. An Admission MDS assessment dated [DATE] identified Resident #165 was severely cognitively impaired, required limited assistance with ADL's, had verbal behavioral symptoms toward others, was resistive to care and with wandering behaviors. Physician orders [REDACTED]. A Wandering/Elopement Risk assessment dated [DATE] identified that R#165 expressed a desire to leave the facility, attempted to leave the unit to get coffee requiring redirection and was observed pacing and/or wandering aimlessly. Based on the risk assessment, Resident #165 was determined to be at risk for wandering and/or elopement. The RCP dated 2/18/14 identified the risk for elopement. Interventions included a wander guard be placed on the resident's right ankle and to report verbalizations to leave the facility. Nurse ' s notes dated 3/3/14 identified that at 5:45 PM, Person #1 reported that the resident left the building, got into a gray car and left. The facility grounds were searched and emergency services were notified. At 7:00 PM, the resident was located at a local club and was transferred to the ED for evaluation and then to a hospital Crisis Unit. Further review of the nurse's notes identified Resident #165 returned to the facility on [DATE] and was put on 1:1 constant observation. Review of the facility investigation identified that on 3/3/14 at approximately 5:30 PM, Person #1 opened the door for Resident #165, which activated the wander guard alarm. NA#5 responded to the alarm and deactivated the alarm on the keypad near the door. He/she then looked through the glass window on the door, didn't see anyone and went back to the dining room. At approximately 5:30 PM, a wander guard alarm sounded in the lobby of the facility's main entrance. RN#3 heard the alarm sounding from his/her office, went to the lobby, turned off the alarm, observed Person #1 by the coffee machine, and returned to his/her office. Additionally, the receptionist also heard the alarm and accompanied RN#3 down the hall to the lobby. Interview and review of facility documentation on 9/18/14 at 9:45 AM with NA#5 identified that although he/she responded to the wander guard alarm, he/she failed to thoroughly check to determine who set the alarm off and/or failed to notify the charge nurse that the alarm had sounded. Interview and review of facility documentation on 9/18/14 at 9:25 AM with RN#3 identified that although he/she responded to the alarm and deactivated it, he/she assumed that Person #1 had set it off and failed to check outside the facility for Resident #165. Interview with the receptionist on 9/18/14 at 10:30 AM identified he/she did not leave the facility to look for the resident. Interview, review of the clinical record and facility documentation on 9/18/14 at 12:15 PM with the DNS identified that the NA should have reported to the charge nurse that the alarm had sounded and both the NA and the RN should have conducted a more thorough search when the alarms sounded.

Based on clinical record reviews and interviews for two of six sampled residents reviewed for pressure ulcers (R#38, 83), the facility failed to accurately identify, assess, monitor, treat, and/or prevent pressure sores, and/or failed to develop and/or revise the plan of care with specific interventions to prevent development, worsening and/or promote healing of pressure ulcers The findings include. 1. Resident #38's [DIAGNOSES REDACTED]. The admission MDS (5 day) dated 4/11/13 identified the resident was cognitively intact, at risk for pressure ulcers and had no pressure ulcers. The initial care plan dated 4/4/13 identified altered skin integrity related to multiple scabbed areas with interventions that included to assess skin on admission and weekly and preventative measures as indicated. Further review noted that no preventative measures were identified. Physician orders [REDACTED]. A nursing note dated 4/14/13 on the night shift identified the resident complained of pain behind the left ear. The resident was noted with a 1 cm x 1 cm pressure area from the oxygen tubing behind the left ear. The area was cleansed with wound cleaner and [MEDICATION NAME] ointment was applied with additional 2 x 2 gauze (padding). A physician order [REDACTED]. The clinical record lacked documentation of a thorough assessment of the identified area at that time. Review of the nursing narratives from 4/15/13 until 4/23/13 failed to identify any assessments, monitoring and/or treatments to the pressure area behind the left ear noted on 4/14/13, until it was documented as a stage 3 pressure ulcer on 4/24/13. A Wound Nurse's note dated 4/24/13, identified a Stage III pressure ulcer which measured 0.3 cm x 0.2 cm x 0.2 cm. The wound bed was documented as pink with scant amount yellow tissue and no exudate. A physician order [REDACTED]. Interview and review of the clinical record on 9/22/13 at 8:50 AM with RN #5 who initially identified the pressure area on the night shift identified that the O2 tubing comes with thin padding that was present at the time. After the application [MEDICATION NAME] she wrapped the tubing with gauze to provide additional padding to the area. Although she did not obtain an physician's orders [REDACTED]. Review of nursing notes and the Treatment Administration Records for April and May 2013 failed to identify that the resident's oxygen cannula was padded and /or that the additional padding was utilized after the area was identified. Interview and review of the clinical record on 8/22/13 at 11:20 AM with LPN #3 who provided care for the resident daily identified that he/she would not monitor the area behind the resident's ears unless the resident complained of discomfort. Additionally, he/she did not recall if extra padding was applied to the tubing. LPN#3 was unable to provide documentation that the physician was notified of the pressure sore when it was identified on 4/14/13, that treatment orders were obtained and/or any treatments carried out from 4/14-4/23/13, and/or that the area was assessed from 4/14/-4/24/13. 2. Resident #83 was admitted to facility on 4/11/13 with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified the presence of an indwelling Foley catheter and that the resident had no skin problems. Physician's admission orders [REDACTED]. An interim care plan dated 4/11/13 identified a potential for altered skin related to decreased mobility. Interventions included assess skin on admission and weekly, complete a Braden assessment on admission, dietician to evaluate and preventative measures as indicated. Further review noted that there were no specific preventive measures identified. Physician orders [REDACTED]. An initial MDS dated [DATE] identified that R#83 had no cognitive problems, required total assistance from staff with ADL's including bed mobility and was not admitted with and/or had a history of [REDACTED]. Nurse's notes dated 4/18/13 at 7:35 PM identified the presence of a stage I (pressure) area that was red and non-blanchable located on the resident's right buttock. Wound tracking identified that the right buttock stage I pressure area measured 4.6 CM x 5.4 CM. physician's orders [REDACTED]. Nurse's notes dated 4/22/13 at 11:40 PM identified that the stage I to the right buttock was now open and to continue Triacl paste. Although the pressure ulcer was noted as open, the assessment lacked any measurements and/or any other wound characteristics. Review of nurse's notes and/or physician's orders [REDACTED]. Nurse's note dated 4/23/13 at 9:30 AM identified a sheared area to right buttock that was pink. A subsequent note at 12:40 PM identified that the treatment to the right buttock was changed to application of a [MEDICATION NAME] dressing. Wound nurse (RN #1) notes dated 4/23/13 identified that the coccyx right side clinically presented as a stage II pressure ulcer that measured 3.0 CM x 2.0 CM x <0.2 CM. Although wound nurse's notes and wound tracking dated 4/29/13 identified that "coccyx right site" was healed, skilled daily nurse's notes dated 4/30/13, 5/1/13 and 5/2/13 identified the continued presence of a pressure ulcer. Resident #83 was re-admitted on [DATE] from the hospital after treatment for [REDACTED]. treated with [MEDICATION NAME] dressing. Inter-Agency patient referral report dated 5/8/13 identified the resident required a special mattress for pressure ulcers, like air mattress. Nursing admission assessment dated [DATE] identified the presence of a .2 cm pressure ulcer and under comments identified as "old pressure area". Physician's admission orders [REDACTED]. No pressure sore treatment orders were noted. An interim care plan dated 5/08/13 identified altered skin related to stage II and potential for altered skin related to decreased mobility. Interventions included assess skin on admission and weekly, complete a Braden assessment on admission, treat skin condition, wounds etc as ordered, labs as ordered, dietician to evaluate and "preventative measures as indicated". Further review noted that there were no specific measures identified. Although skilled daily nurse's notes dated 5/8/13, 5/09/13 and 5/10/13 identified skin color as "pallor", they lacked any reference to the presence of a pressure ulcer. Nurse's notes dated 5/11/13 during the night shift identified that the skin was intact with a [MEDICATION NAME] (dressing) in place. LPN#2's nurse's note dated 5/12/13 7 AM-3 PM identified "dressing from hospital removed from coccyx, 1.2 cm x 1.0 open area to coccyx, left message with wound nurse for new treatment". physician progress notes [REDACTED]. Skilled daily nurse's notes dated 5/13/13, 5/14/13 and 5/15/13 identified normal skin and lacked any reference to the presence of a pressure ulcer. Nurse's note dated 5/16/13 at 3:00 AM identified patient has redness to coccyx and buttocks. Physicians orders dated 5/16/13 directed to apply [MEDICATION NAME] ointment every shift to coccyx for 14 days and then re-evaluate. Nurse's notes dated 5/16/13, 5/17/13 and 5/18/13 failed to indicate the presence of a pressure ulcer. Nurse's note dated 5/20/13 at 7 AM identified pressure ulcer to coccyx cleaned and [MEDICATION NAME] applied. Wound nurse notes dated 5/21/13 identified the coccyx wound had become an unstageable pressure ulcer, measuring 0.5 cm x 0.5 cm x unknown with the wound bed covered with firmly adherent slough. The note further indicated the presence of a second open area described as a stage II pressure ulcer located on the right side of coccyx that measured 1.2 cm x 1.0 cm x 0.2 cm. Subsequent wound nurse (wound tracking) dated 5/28/13 identified that the coccyx unstageable pressure ulcer changed to stage III, that measured 1.0 cm x 1.0 cm x<.02 cm. Interview with LPN #2 on 8/22/13 at 11:12 AM indicated that when he/she removed the dressing on 5/12/13, he/she found a pressure area and had notified the wound nurse by leaving a voice message. He/she further indicated that subsequent contact with R#83 noted that the pressure area continued to be present. During an interview and review of R#83"s clinical record with (RN #1) on 8/22/13 at 11:39 AM, he/she indicated that although resident concerns are discussed during morning report, he/she was not aware of the presence of the pressure areas upon R#83's re-admission to the facility. He/she indicated that if he/she was aware, the dressing would have been removed and the area assessed and documented with proper treatment orders obtained from the physician. Further review failed to provide documentation that treatment orders were obtained and/or proper treatments provided to the pressure sore from 5/8/13 through 5/21/13. During interview and review of R#83's 5/8/13 admission assessment on 8/22/13 at 1:00 PM with RN #2, he/she could not explain exactly what the admission assessment identified related to the pressure sore nor could he/she recall if a dressing was present and/or if it had been removed. Interview and review of R#83's RCP on 8/26/13 at 12:30 PM with the Director of Nursing and LPN#3 (care plan coordinator) failed to provide documentation that the care plan reflected specific preventive interventions customized to the resident's needs.