Every finding on record at Greentree Manor Nursing and Rehabilitation Center

Based on review of the clinical record, facility documentation, facility policy, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for change in condition, the facility failed to ensure the provider was notified of changes in the resident's status following an unwitnessed fall with a head injury. This included failure to notify the provider timely of increasing confusion, continued pain, uncompleted diagnostic imaging, and worsening symptoms. These failures resulted in delayed evaluation and delayed care. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, repeated falls, muscle weakness, and unsteadiness on feet.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 2), was dependent on staff for bed mobility, required substantial assistance for transfers, and was independent with mobility using a manual wheelchair. It also identified Resident #1 had more than two (2) falls since admission, one (1) with injury.The Resident Care Plan (RCP) dated 1/26/26 identified Resident #1 was at risk for falls related to three (3) prior falls, deconditioning, generalized weakness, and dementia, and required assistance with Activities of Daily Living (ADLs). Interventions included providing an assist of one (1) with transfers, reminding the resident to call for assistance, maintaining a clutter free environment, and providing frequent checks while in the room.A Post Fall Evaluation note by RN #1 dated 3/18/26 at 8:08 PM identified that at 7:20 PM Resident #1 had an unwitnessed fall after climbing out of bed independently and blood was noted coming from the nose. Vital signs were within normal limits, Resident #1 complained of 6/10 left lower leg pain, and the APRN and responsible party were notified. A nurse's note at 9:00 PM identified that Resident #1 was assessed, assisted back to bed, and monitored per protocol.A nurse's note by the former DON dated 3/18/26 at 9:17 PM identified Resident #1 complained of left shoulder pain when the arm was raised. The on call provider was notified, a left shoulder x ray was ordered, and the diagnostic provider confirmed receipt. A physician's order dated 3/18/26 directed a two (2) view x ray of the left shoulder.A nurse's note by LPN #5 dated 3/19/26 at 11:58 AM identified Resident #1 was alert and confused, received tramadol for left shoulder pain, and was self propelling into walls and objects. LPN #5 notified the nursing supervisor (RN #2) and documented that safety was maintained.A social services note dated 3/19/26 at 3:35 PM identified increased confusion, inability to determine spatial orientation, continued bumping into walls and objects, and leaning in the wheelchair, and noted the resident was being monitored by nursing.Review of the clinical record failed to identify documentation from RN #2 dated 3/19/26 or documentation that a provider was notified of the change in condition, despite changes identified beginning at 11:58 AM (nearly four hours earlier). The record also failed to identify that the left shoulder x ray ordered on 3/18/26 was obtained or resulted.A nurse's note by RN #1 dated 3/19/26 at 6:18 PM identified Resident #1 was sent to the ED around 4:00 PM due to increased confusion and red spots under both eyes following the unwitnessed fall the previous day and identified the APRN requested transfer for evaluation.Ambulance documentation identified a call from the facility on 3/19/26 at 3:55 PM reporting altered mental status following the fall the previous day. Upon arrival at 4:13 PM, Resident #1 was seated near the nurse's station with facial bruising around the eyes and guarding of the left arm and shoulder. Staff reported lower than usual responsiveness and that Emergency Services had not been called at the time of the fall. Resident #1 left the facility at 4:28 PM.Hospital documentation dated 3/19/26 identified imaging results showed a closed fracture of the proximal end of the left humerus and a closed fracture of the nasal bone. Resident #1 was discharged back to the facility with a left arm sling.Interview with APRN #1 on 5/8/26 at 11:43 AM identified she was notified on 3/18/26 at 7:13 PM of an unwitnessed fall, active bleeding, and uncertainty regarding the source. She ordered immediate ED transfer. At 9:00 PM, the facility reported the resident was not transferred because bleeding was believed to be nasal, and staff requested a left shoulder x ray instead. On 3/19/26 at 3:00 PM, LPN #5 notified the APRN of increased confusion, raccoon eyes, and difficulty moving the shoulder. The APRN identified the resident should have been transferred immediately following the 7:13 PM order and staff should not have waited nearly two hours to report they chose not to follow it. She indicated the facility should have notified the provider when the x ray could not be obtained, should have followed up on diagnostic timing, and should not have waited until 3:00 PM to report continued confusion and pain.Interview with Person #2 (diagnostic representative) on 5/8/26 at 11:58 AM identified the x ray was called in on 3/18/26 at 9:17 PM as ASAP (within 6-8 hours) but not STAT. Person #2 indicated they notified the facility at 9:30 PM that no technician was available until the next day. On 3/19/26 at 4:30 PM, a technician arrived but Resident #1 had already been sent to the ED and the x ray was never obtained.Interview with RN #1 on 5/8/26 at 1:40 PM identified Resident #1 frequently got out of bed without calling for assistance and was found on the floor with blood on the face and floor. She called the on call provider, received the order to send the resident to the ED, and assessed the resident. She indicated the DON and RN #3 reassessed Resident #1 later and determined the resident did not need ED evaluation, but she was unsure why the provider was not contacted immediately regarding that decision. RN #1 identified that when she returned the next day, the resident was already being transferred to the ED and she documented a summary note.Interview with LPN #5 on 5/8/26 at 12:54 PM identified she observed Resident #1 self propelling into walls around 11:00 AM on 3/19/26, which was not baseline. She medicated the resident and notified RN #2 regarding the change in cognition, pain, and the absence of the x ray technician. LPN #5 eventually called the on call provider at 3:00 PM but indicated she could not recall why notification was delayed.Interview with RN #2 on 5/8/26 at 2:26 PM identified she could not recall being notified of changes on 3/19/26 and indicated that if she did not document an assessment or provider notification, she could not confirm she was informed.Interview with the Regional Nurse/Interim DON and RN #3 on 5/8/26 at 3:05 PM identified the resident should have been transferred immediately after the initial ED order at 7:13 PM. They identified the provider should have been notified when staff chose not to send the resident, when the diagnostic provider reported the x ray delay, and when changes in cognition continued. They indicated an RN assessment should have occurred and been documented with the change in condition and identified a delay in notifying the provider and a delay in care following the 3/18/26 fall.Although attempted, an interview with the former DON was not obtained.Review of the Change in Condition, Change in Treatment/Services policy (undated) directed that the provider must be immediately informed following an accident with injury, significant physical, mental, or psychosocial change, or when treatment needs to be altered. The policy required the Charge Nurse to notify the RN Supervisor, who completes an assessment and notifies the physician and responsible party; and required documentation of all notification attempts. Examples of change in condition included behavioral changes, neurological changes, and falls.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure adequate supervision and assistive measures to prevent accidents. Specifically, the facility failed to address the resident's repeated behaviors of getting out of bed independently despite requiring assistance, resulting in an unwitnessed fall with injuries, and failed to ensure the resident was transferred to and evaluated timely in the Emergency Department (ED) following an identified head injury, limited range of motion, and complaints of pain. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, repeated falls, muscle weakness, and unsteadiness on feet.A Fall Evaluation dated 1/12/26 identified Resident #1 was a medium risk for falls.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 2), was dependent on staff for bed mobility, required substantial assistance for transfers, and was independent with mobility in a manual wheelchair. The MDS identified Resident #1 had experienced more than two (2) falls since admission, including one (1) with injury.The Resident Care Plan (RCP) dated 1/26/26 identified Resident #1 was at risk for falls related to three (3) previous falls, deconditioning, generalized weakness, and dementia and required assistance with Activities of Daily Living (ADLs). Interventions included providing an assist of one (1) with transfers, identifying the resident was non ambulatory, reminding the resident to call for assistance, maintaining a clutter free environment, and providing frequent checks while in the room.A Post Fall Evaluation note by RN #1 dated 3/18/26 at 8:08 PM identified that at 7:20 PM Resident #1 had an unwitnessed fall after climbing out of bed. Blood was noted coming from the nose, vital signs were within normal limits, and the resident complained of six (6) out of ten (10) left lower leg pain. The APRN and responsible party were notified.A nurse's note by RN #1 dated 3/18/26 at 9:00 PM identified Resident #1 was assessed, assisted back into bed, and monitored per facility protocol.Review of the March 2026 Medication Administration Record (MAR) identified an order dated 6/19/25 for tramadol 25 milligrams (mg) by mouth every six (6) hours as needed for moderate to severe pain. The MAR identified Resident #1 was administered tramadol 25 mg on 3/18/26 at 9:03 PM, one hour and forty three minutes after the documented pain of 6/10, and the medication was noted as effective.A nurse's note by the former DON dated 3/18/26 at 9:17 PM identified Resident #1 complained of left shoulder pain when the arm was flexed above the head. The on call provider was notified, a left shoulder x ray ordered, and a confirmation number obtained from the diagnostic provider.A physician's order dated 3/18/26 directed a two (2) view x ray of the left shoulder.A nurse's note by LPN #5 dated 3/19/26 at 11:58 AM identified Resident #1 was alert and confused, was administered tramadol for left shoulder pain, and was self propelling in a wheelchair and bumping into walls and objects. LPN #5 identified she notified the nursing supervisor (RN #2).A social services note dated 3/19/26 at 3:35 PM identified Resident #1 had increased confusion, was unable to determine positioning relative to objects and walls, continued bumping into objects, and was leaning in the wheelchair.Review of the clinical record failed to identify documentation from RN #2 dated 3/19/26 or documentation that a provider was notified of the change in condition, despite the change being identified around 11:58 AM. Review also failed to identify that the left shoulder x ray had been obtained.A nurse's note by RN #1 dated 3/19/26 at 6:18 PM identified Resident #1 was sent to the ED around 4:00 PM due to increased confusion and red spots under both eyes following the unwitnessed fall the prior day. The APRN was notified and directed the transfer.The ambulance run sheet identified a call received on 3/19/26 at 3:55 PM, reporting Resident #1 had an unwitnessed fall the previous day and was now displaying altered mental status. Upon arrival at 4:13 PM, Resident #1 was seated near the nurse's station with facial bruising and guarding of the left arm/shoulder. Staff reported lower responsiveness than usual and confirmed Emergency Services had not been contacted after the fall.Hospital documentation dated 3/19/26 identified a closed fracture of the proximal end of the left humerus and a closed fracture of the nasal bone. Resident #1 was discharged back to the facility with a left arm sling.Interview with APRN #1 on 5/8/26 at 11:43 AM identified she was notified on 3/18/26 at 7:13 PM of an unwitnessed fall with active bleeding on the right side of the head and ordered immediate ED transfer. At 9:00 PM, staff reported the resident was not transferred because bleeding was believed to be nasal and requested a left shoulder x ray instead. On 3/19/26 at 3:00 PM, LPN #5 notified the APRN of increased confusion, raccoon eyes, and difficulty moving the shoulder, and an ED transfer order was given.Interview with Person #2 (diagnostic representative) on 5/8/26 at 11:58 AM identified the x ray was called in as ASAP, requiring completion within six (6) to eight (8) hours. Person #2 reported they notified the facility at 9:30 PM that no technician was available until the next day and no timeframe was provided.Interview with RN #1 on 5/8/26 at 1:40 PM identified Resident #1 frequently got out of bed without calling for assistance and was found lying on the left side with blood noted on the face and floor. She called the on call provider and received the order to send the resident to the ED. She identified the DON and RN #3 reassessed Resident #1 later and determined transfer was unnecessary, but the APRN was not notified of this decision.Interview with LPN #3 on 5/8/26 at 2:16 PM identified Resident #1 often got out of bed without calling and had never been on documented frequent checks. She reported she administered tramadol at approximately 9:00 PM after RN #1 reported pain.Interview with NA #1 on 5/8/26 at 2:55 PM identified she assisted Resident #1 to bed forty (40) minutes before the fall but had not checked again due to caring for other residents.Interview with LPN #5 on 5/8/26 at 12:54 PM identified she observed Resident #1 bumping into walls around 11:00 AM on 3/19/26 and complaining of left shoulder pain. She medicated the resident and notified RN #2, who she believed was responsible for provider notification. She eventually contacted the APRN at 3:00 PM.Interview with RN #2 on 5/8/26 at 2:26 PM identified she did not recall being notified of changes and stated that without documentation she could not verify being informed.Interview with the Director of Rehab on 5/8/26 at 12:45 PM identified Resident #1 was an assist of one (1) for transfers, non ambulatory, and independent with wheelchair mobility. She identified therapy was not re consulted despite reports of unsafe self transferring.Interview with the Regional Nurse/Interim DON and RN #3 on 5/8/26 at 3:05 PM identified Resident #1 should have been transferred immediately following the ED order at 7:13 PM, and the APRN should have been notified when staff chose not to transfer the resident and when imaging could not be obtained. They stated an RN assessment should have been completed and documented when cognition changed and identified a delay in care following the fall.Although attempted, an interview with the former DON was not obtained.Review of the Fall Risk Assessment policy (undated) directed staff to identify and document fall risk factors and develop a resident centered fall prevention plan based on assessment information, including evaluation of functional, psychosocial, and environmental contributors.Review of the Change in Condition, Change in Treatment/Services policy (undated) directed that the provider must be immediately informed when an accident results in injury, there is a significant change in status, or treatment must be altered. The policy required RN assessment, documentation, and timely physician notification.A facility policy for x rays and diagnostic imaging orders was requested but not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure the resident's pain was treated timely following a fall with head trauma and identified pain. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, repeated falls, muscle weakness, and unsteadiness on feet.Physician's orders dated 6/19/25 directed tramadol 25 milligrams (mg), one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain. A physician's order dated 7/8/25 directed acetaminophen 325 mg, two (2) tablets by mouth every six (6) hours as needed for pain or fever.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2), dependent on staff for bed mobility, required substantial assistance for transfers, and was independent with mobility in a manual wheelchair.The Resident Care Plan (RCP) dated 1/26/26 identified Resident #1 was at risk for pain related to deconditioning and immobility and at risk for falls due to three (3) previous falls, deconditioning, generalized weakness, and dementia. Interventions included assessing characteristics of pain, administering pain medications as ordered, providing an assist of one (1) with transfers, reminding the resident to call for assistance, maintaining a clutter free environment, and providing frequent checks while in the room.A Post Fall Evaluation by RN #1 dated 3/18/26 at 8:08 PM identified that at 7:20 PM Resident #1 had an unwitnessed fall after climbing out of bed. Blood was noted coming from the nose, vital signs were within normal limits, and Resident #1 complained of 6/10 pain to the left lower leg. The APRN and responsible party were notified. A nurse's note dated 3/18/26 at 9:00 PM identified that an assessment was completed, Resident #1 was helped back into bed, and monitoring continued per protocol.Review of the March 2026 Medication Administration Record (MAR) identified Resident #1 was administered tramadol 25 mg on 3/18/26 at 9:03 PM-one hour and forty three minutes after the fall-for 6/10 pain, which was effective.A nurse's note by the former DON dated 3/18/26 at 9:17 PM identified Resident #1 complained of left shoulder pain when the arm was flexed above the head. The on call provider was notified, a left shoulder x ray was ordered and called into the diagnostic provider, and a confirmation number obtained. The responsible party was notified.A nurse's note by LPN #5 dated 3/19/26 at 11:58 AM identified Resident #1 was alert and confused, tramadol was administered for left shoulder pain, and Resident #1 was self propelling into walls and objects. RN #2, the nursing supervisor, was notified. The note identified no new injuries, that Resident #1 was reoriented as needed, and was seated at the nurse's station.Review of the clinical record failed to identify documentation from RN #2 dated 3/19/26 or documentation that a provider was notified of the change in cognition or pain, despite the change being identified at 11:58 AM (nearly four hours earlier). The record also failed to identify that an RN assessed Resident #1's pain. Review additionally failed to identify the resident was offered or administered pain medication prior to transfer to the ED.A nurse's note by RN #1 dated 3/19/26 at 6:18 PM identified Resident #1 was sent to the ED around 4:00 PM due to increased confusion and red spots under both eyes following the unwitnessed fall the previous day and that the APRN requested evaluation.Hospital documentation dated 3/19/26 identified imaging showed a closed fracture of the proximal end of the left humerus and a closed fracture of the nasal bone. Resident #1 was discharged back to the facility with a left arm sling.Interview with RN #1 on 5/8/26 at 1:40 PM identified that on 3/18/26 Resident #1 was found on the floor lying on the left side with a moderate amount of blood on the face and floor. She contacted the on call provider, received instructions to send Resident #1 to the ED, and then assessed the resident. She reported Resident #1 complained of moderate leg pain but did not recall if she notified the charge nurse. She identified the DON and RN #3 reassessed the resident and, despite complaints of left shoulder pain, determined Resident #1 did not need to be transferred and the on call provider was notified for a shoulder x ray instead. RN #1 reported that when she arrived the next day, Resident #1 was already being transferred to the ED, and she completed a summary note. She identified she could not recall whether Resident #1 complained of or displayed signs of pain prior to transfer but stated staff should have assessed, documented, and administered pain relief as needed before transfer.Interview with LPN #5 on 5/8/26 at 12:54 PM identified she observed Resident #1 self propelling into walls around 11:00 AM on 3/19/26 and complaining of left shoulder pain. She medicated the resident and notified RN #2. She stated she did not recall the last time she saw Resident #1 prior to the end of her shift and indicated that had the resident been sent to the ED during her shift, she would have offered pain medication.Interview with RN #2 on 5/8/26 at 2:26 PM identified she could not recall sending Resident #1 to the ED on 3/19/26, but if the resident was transferred due to cognition changes and left shoulder pain, pain medication should have been offered prior to transfer.Interview with the Regional Nurse/Interim DON and RN #3 on 5/8/26 at 3:05 PM identified staff should document all care provided prior to the end of their shift. RN #3 reported she was present on 3/18/26 after the fall and Resident #1 complained of left shoulder pain and should have been medicated for pain relief and should not have waited until after 9:00 PM. They further identified Resident #1 was transferred to the ED for a change in cognition and left shoulder pain and should have been offered pain relief medication prior to transfer.Although attempted, an interview with the former DON was not obtained.Review of the Pain Assessment and Management policy (undated) directed that pain management is based on the resident's condition and treatment goals and requires a comprehensive pain assessment upon admission, quarterly, with significant changes, and with new or worsening pain. Staff are to observe for signs of pain, ask the resident about pain, review medication administration patterns, and ensure interventions reflect the type and severity of pain and underlying causes.Review of the Change in Condition, Change in Treatment/Services policy (undated) directed that the physician must be immediately informed when there is an accident with injury, significant physical, mental, or psychosocial change, or when treatment must be altered. The policy required the Charge Nurse to notify the RN Supervisor, who completes an assessment, documents findings, and notifies the physician and responsible party.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls, the facility failed to ensure a full RN assessment was documented following a fall with injury, including documentation of the time the provider was notified, and failed to ensure pain medication was signed out under the correct licensed nurse's name in the Medication Administration Record (MAR). The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, repeated falls, muscle weakness, and unsteadiness on feet.A physician's order dated 6/19/25 directed tramadol 25 milligrams (mg), one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2), dependent on staff for bed mobility, required substantial assistance for transfers, and was independent with mobility in a manual wheelchair.The Resident Care Plan (RCP) dated 1/26/26 identified Resident #1 was at risk for pain related to deconditioning and immobility and at risk for falls due to three (3) prior falls, deconditioning, generalized weakness, and dementia, and required assistance with Activities of Daily Living (ADLs). Interventions included assessing pain characteristics, administering pain medications as ordered, providing an assist of one (1) with transfers, reminding the resident to call for assistance, maintaining a clutter free environment, and providing frequent checks while in the room.A Post Fall Evaluation note by RN #1 dated 3/18/26 at 8:08 PM identified that at 7:20 PM Resident #1 had an unwitnessed fall after climbing out of bed independently. Blood was noted coming from the nose, vital signs were within normal limits, and Resident #1 complained of 6/10 left lower leg pain. The APRN and responsible party were notified. The note failed to identify a full assessment, including range of motion to all extremities, neurological signs, or the time the provider was notified.A nurse's note by RN #1 dated 3/18/26 at 9:00 PM identified that an assessment was completed and Resident #1 was assisted back into bed and monitored per protocol. The note failed to identify a full assessment, including range of motion and neurological signs following a fall with a head injury.Interview with RN #1 on 5/8/26 at 1:40 PM identified she completed a full assessment, including range of motion and neurological checks, but failed to document it. She identified she could not recall the time she called the on call provider because she did not document the notification time and reported that she should have.Review of the March 2026 MAR identified Resident #1 was administered tramadol 25 mg on 3/18/26 at 9:03 PM for 6/10 pain. The MAR listed LPN #5 as administering the medication.Review of the facility's staffing schedule for 3/18/26 identified LPN #5 did not work the 3:00 PM to 11:00 PM shift that day; LPN #3 was scheduled.Review of the Controlled Substance Disposition Record for tramadol, dated as received on 6/19/25, identified LPN #3 administered the tramadol 25 mg tablet to Resident #1 on 3/18/26 at 9:03 PM.Interview with LPN #5 on 5/8/26 at 1:27 PM identified she did not work the 3:00 PM to 11:00 PM shift on 3/18/26 and left at 3:00 PM. She was unsure why the MAR identified she administered tramadol at 9:03 PM and indicated she should always log out of the computer before leaving her shift to ensure accurate documentation.Interview with LPN #3 on 5/8/26 at 2:16 PM identified she administered the tramadol 25 mg tablet at 9:03 PM per the Controlled Substance Disposition Record and was unaware the administration was documented under LPN #5's name. She identified she should ensure she is logged into the computer under her own credentials before documenting.Interview with the Regional Nurse/Interim DON and RN #3 (Staff Development nurse) on 5/8/26 at 3:05 PM identified licensed nurses should document a full assessment, including range of motion and neurological signs, following a fall with injury and should document the time of provider notification. They identified they were unaware that the tramadol administered on 3/18/26 was documented under the wrong nurse's name and stated licensed nurses should ensure they log out of the computer before leaving the shift and that oncoming nurses log in with their own credentials to ensure complete and accurate documentation.Review of the Change in Condition, Change in Treatment/Services policy (undated) directed that the physician must be immediately informed when an accident results in injury, when there is a significant change in physical, mental, or psychosocial status, or when treatment must be altered. The policy required the Charge Nurse to notify the RN Supervisor, who completes an SBAR assessment, documents findings in the clinical record, and documents the resident's response to symptoms such as pain, anxiety, or discomfort.Review of the Charting and Documentation policy dated 3/2023 directed that all services provided to the resident, progress toward care plan goals, and any changes in medical, physical, functional, or psychosocial condition must be documented. Documentation must include date and time, name and title of the staff member, assessment data, unusual findings, how the resident tolerated treatment, and notification of family, physician, or other staff.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who was at risk for elopement and wore a wanderguard, the facility failed to ensure staff responded appropriately to a door alarm when the resident exited the facility unattended and was found by an off-duty staff member on the sidewalk located near the front driveway. The findings include:Resident #1's diagnoses included dementia, depression, and anxiety disorder. The quarterly Minimum Data Seta assessment dated [DATE] identified Resident #1 had poor memory recall difficulty focusing, required substantial/maximal assistance with most Activities of Daily Living, was non-ambulatory, used a wheelchair for mobility, was able to self-propel independently once in the wheelchair, and used a wander/elopement alarm daily. The Resident Care Plan dated 10/31/25 indicated Resident #1 was at risk for wandering and elopement as evidenced by pacing, roaming or wandering in and out of peers' rooms. The care plan indicated Resident #1 had not attempted to leave the facility without an escort. Interventions directed to check function of the wanderguard every evening shift, ensure resident's picture was in the elopement risk binder at receptionist's desk, check placement of the wanderguard every shift, introduce resident to all staff as a wanderer, apply a code alert bracelet if indicated and make sure the bracelet was functioning appropriately, check using code alert transmitters as per facility policy, and assist to find own room or unit as needed. The Facility Reported Incident form dated 11/26/25 identified on 11/26/25 at 1:15 PM Resident #1 was observed outside of the building, sitting in his/her wheelchair, unsupervised. The report indicated Resident #1 was observed five (5) to eight (8) feet outside the building and was brought back through the main entrance by a witness. The investigation identified Resident #1 pushed on the emergency exit door until the door opened and although staff heard and responded to the alarm, the staff did not witness Resident #1 leave the building or proceed to go outside to check the surrounding area. Interview and review of the 11/26/25 incident with the Director of Nursing (DON) on 12/22/25 at 12:57 PM identified she was the person responsible for the investigation. The DON indicated it was determined Resident #1 exited the building through the South pod exit door located at the end of the unit on the South wing. The DON explained although Resident #1 was wearing a wanderguard at the time of the incident, the South pod exit door was not equipped with a wanderguard alarm because it was an emergency exit door. The DON identified Resident #1 was last seen by a nurse aide, Nurse Aide (NA) #2, ten (10) minutes prior to being found outside. The DON indicated Resident #1 had pushed the South pod exit door long enough for the door to open, then self-propelled in the wheelchair to the sidewalk located near the main entrance, where Resident #1 was observed minutes later, about five (5) feet from the main entrance by an off-duty nurse aide (NA #1) who had returned to the facility to pick up a personal item NA #1 left behind. The DON identified statements were obtained from staff during the investigation, which determined no staff on duty observed Resident #1 leave through the South pod exit door, although the staff had heard the emergency door alarm going off. The DON identified a statement provided by the Food Service Director identified on 11/26/25 at 1:15 PM, he observed a nurse aide (NA #1) bring Resident #1 through the front door, heard the front door alarm go off because of Resident #1's wanderguard and turned off the front door alarm and then the Food Service Director checked all the doors. The DON stated the Food Service Director saw the South pod exit door had a green light, which indicated Resident #1 had exited out that door, and the Food Service Director then pushed on the door, opened it, and reset the door because the alarm was going off. The DON identified staff did not exit out the South pod door immediately following the alarm being set off, which staff were expected to do, and indicated staff did not know the code to reset the exit door alarm. Interview with RN #1 on 12/22/25 at 1:17 PM identified she was notified on 11/26/25 that an off-duty nurse aide (NA #1) brought Resident #1 into the building through the front doors after Resident #1 was found unattended in his/her wheelchair outside the building. RN #1 indicated the temperature was in the mid-sixties and Resident #1 was wearing long pants, a sweater, and sneakers. RN #1 indicated following the incident Resident #1 was assessed, no injuries were noted, Resident #1's doctor and responsible party were notified, and education was initiated the same day for all staff. RN #1 identified facility policy indicated staff were responsible for checking the alarm, checking the area, and making sure no one was outside the area. Although requested, facility policies for Missing Resident/Elopement and for Wanderguard/Secured Exit were not provided.

Based on clinical record reviews, facility documentation, facility policies and interviews for five (5) of eight (8) sampled residents (Residents #1, #2, #3, #4, and #5) who were reviewed for allegations of misappropriation of personal property, the facility failed to ensure the residents' medications were not removed from the facility by staff. The findings include:Resident #1's diagnoses included osteomyelitis of the right ankle, diabetes mellitus with polyneuropathy, and left foot amputation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily living. A physician's order dated 7/8/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. Review of the July and August 2025 Medication Administration Records identified Resident #1 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with the contracted pharmacist, Person #2, on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility for Resident #1 were on 7/9/25 a total of thirty (30) tablets and on 8/7/25 a total of twenty (20) tablets. The facility failed to provide documentation of the Control Disposition Records for the Oxycodone that were delivered on 7/9/25 and 8/7/25 and the blister packs of medication. 2. Resident #2's diagnoses included stage four (4) pressure ulcer to the sacrum, congestive heart failure, and spinal stenosis. A physician's order dated 9/11/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily living. Review of the September 2025 Medication Administration Record identified Resident #2 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Resident #2 on 11/6/25 at 1:10 PM identified he/she was discharged home on 9/30/25 with medications and recalled the Oxycodone was not one (1) of them. Resident #2 indicated the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, told him/her that the facility could not release the pain medication for him/her to take home. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility for Resident #2 were on 9/6/25 a total of twenty-eight (28) tablets and on 9/23/25 a total of thirty (30) tablets. The facility failed to provide documentation of the Control Disposition Records for the Oxycodone that was delivered on 9/23/25 and the blister pack of medication. 3. Resident #3's diagnoses included metabolic encephalopathy, congestive heart failure, and rheumatoid arthritis. A physician's order dated 8/20/25 directed to administer the pain medication Hydromorphone 2 milligrams (mg) every four (4) hours as needed for pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 was unable to make reasonable and consistent decisions regarding tasks of daily living. The nurse's note dated 8/23/25 at 2:47 PM identified Resident #3's family member requested Resident #3 be transferred to the hospital for evaluation (due to increased pain), the Advacnced Practice Registered Nurse (APRN) was notified, Resident #3 was transferred to the hospital, and did not return to the facility. Review of the August 2025 Medication Administration Record for identified Resident #3 received the Hydromorphone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Hydromorphone 2 mg delivered to the facility on 8/20/25 was a total of eighteen (18) tablets. The facility failed to provide documentation of the Control Disposition Record for the Hydromorphone delivered on 8/20/25 and the blister pack of medication. 4. Resident #4's diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, and neuropathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was able to make reasonable and consistent decisions regarding tasks of daily living. A physician's order dated 8/14/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every twelve (12) hours as needed for pain. A physician's order dated 9/19/25 discontinued Oxycodone. Review of the August and September 2025 Medication Administration Records identified Resident #4 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility were on 6/2/25 a total of thirty (30) tablets; 6/20/25 a total of thirty (30) tablets, 8/18/25 a total of thirty (30) tablets and 9/16/25 a total of thirty (30) tablets. The facility failed to provide documentation of the Control Disposition Record for the destruction of the Oxycodone delivered on 9/16/25 and the blister pack of medication. 5. Resident #5's diagnoses included rectal cancer, chronic obstructive pulmonary disease, and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was able to make reasonable and consistent decisions regarding tasks of daily living. A physician's order dated 8/30/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. A physician's order dated 8/30/25 directed to administer the pain medication Oxycodone 10 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. Review of the August and September 2025 Medication Administration Records identified Resident #5 received the Oxycodone as ordered. The Facility Reported incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility were on: 6/8/25 a total of thirty (30) tablets; 7/22/25 a total of thirty (30) tablets, 8/26/25 a total of thirty (30) tablets and 9/3/25 a total of thirty (30) tablets. The facility failed to provide documentation of the Control Disposition Record for the destruction of the Oxycodone delivered on 9/16/25 and the blister pack of medication. Interview and review of the Facility Reported Incident report dated 10/27/25 with the Regional Director on 11/7/25 at 12:15 PM identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed regarding missing narcotics. The Regional Director stated theDEA concluded their investigation on 10/27/25 and informed her although they were unable to determine the cause of missing narcotics, they discovered that a total of six (6) blister packs for five (5) residents were not accounted for. The Regional Director identified the six (6) missing Control Disposition Records along with the six (6) blister packs that were delivered to the facility were missing. Review of the facility Abuse Policy directed abuse or mistreatment of any kind toward a resident is strictly prohibited and would be thoroughly investigated. The policy further identified misappropriation of resident property as a form of abuse. Although attempted, interviews with Resident #1, RN #1, and Person #3 were not obtained.

Based on clinical record reviews, facility documentation, facility policies and interviews for five (5) of eight (8) sampled residents (Residents #1, #2, #3, #4, and #5) who were reviewed for allegations of misappropriation of residents' personal property, the facility failed to establish a system of records of receipt and disposition to account for the administration and destruction of controlled medications. The findings include: Resident #1's diagnoses included osteomyelitis of the right ankle, diabetes mellitus with polyneuropathy, and left foot amputation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily living. A physician's order dated 7/8/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. Review of the July and August 2025 Medication Administration Records identified Resident #1 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with the contracted pharmacist, Person #2, on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility for Resident #1 were on 7/9/25 a total of thirty (30) tablets and on 8/7/25 a total of twenty (20) tablets. The facility failed to provide documentation of the Control Disposition Records for the Oxycodone that were delivered on 7/9/25 and 8/7/25 and the blister packs of medication. 2. Resident #2's diagnoses included stage four (4) pressure ulcer to the sacrum, congestive heart failure, and spinal stenosis. A physician's order dated 9/11/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily living. Review of the September 2025 Medication Administration Record identified Resident #2 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Resident #2 on 11/6/25 at 1:10 PM identified he/she was discharged home on 9/30/25 with medications and recalled the Oxycodone was not one (1) of them. Resident #2 indicated the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, told him/her that the facility could not release the pain medication for him/her to take home. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility for Resident #2 were on 9/6/25 a total of twenty-eight (28) tablets and on 9/23/25 a total of thirty (30) tablets. The facility failed to provide documentation of the Control Disposition Records for the Oxycodone that was delivered on 9/23/25 and the blister pack of medication. 3. Resident #3's diagnoses included metabolic encephalopathy, congestive heart failure, and rheumatoid arthritis. A physician's order dated 8/20/25 directed to administer the pain medication Hydromorphone 2 milligrams (mg) every four (4) hours as needed for pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 was unable to make reasonable and consistent decisions regarding tasks of daily living. The nurse's note dated 8/23/25 at 2:47 PM identified Resident #3's family member requested Resident #3 be transferred to the hospital for evaluation (due to increased pain), the Advacnced Practice Registered Nurse (APRN) was notified, Resident #3 was transferred to the hospital, and did not return to the facility. Review of the August 2025 Medication Administration Record for identified Resident #3 received the Hydromorphone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Hydromorphone 2 mg delivered to the facility on 8/20/25 was a total of eighteen (18) tablets. The facility failed to provide documentation of the Control Disposition Record for the Hydromorphone delivered on 8/20/25 and the blister pack of medication. 4. Resident #4's diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, and neuropathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was able to make reasonable and consistent decisions regarding tasks of daily living. A physician's order dated 8/14/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every twelve (12) hours as needed for pain. A physician's order dated 9/19/25 discontinued Oxycodone. Review of the August and September 2025 Medication Administration Records identified Resident #4 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility were on 6/2/25 a total of thirty (30) tablets; 6/20/25 a total of thirty (30) tablets, 8/18/25 a total of thirty (30) tablets and 9/16/25 a total of thirty (30) tablets. The facility failed to provide documentation of the Control Disposition Record for the destruction of the Oxycodone delivered on 9/16/25 and the blister pack of medication. 5. Resident #5's diagnoses included rectal cancer, chronic obstructive pulmonary disease, and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was able to make reasonable and consistent decisions regarding tasks of daily living. A physician's order dated 8/30/25 directed to administer the pain medication Oxycodone 5 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. A physician's order dated 8/30/25 directed to administer the pain medication Oxycodone 10 milligrams (mg) one (1) tablet every six (6) hours as needed for pain. Review of the August and September 2025 Medication Administration Records identified Resident #5 received the Oxycodone as ordered. The Facility Reported Incident form dated 10/27/25 identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The DEA concluded their investigation on 10/27/25 and discovered that a total of six (6) blister packs for five (5) residents were not accounted for along with the Control Disposition Records. An interview with Person #2 on 11/7/25 at 12:50 PM and review of the pharmacy shipment summaries identified the dates and quantities of the Oxycodone 5 mg delivered to the facility were on: 6/8/25 a total of thirty (30) tablets; 7/22/25 a total of thirty (30) tablets, 8/26/25 a total of thirty (30) tablets and 9/3/25 a total of thirty (30) tablets. The facility failed to provide documentation of the Control Disposition Record for the destruction of the Oxycodone delivered on 9/16/25 and the blister pack of medication. Interview and review of the Facility Reported Incident report dated 10/27/25 with the Regional Director on 11/7/25 at 12:15 PM identified the Drug Enforcement Agency (DEA) had entered the facility on 10/7/25 to investigate a complaint filed with them regarding missing narcotics. The Regional Director stated the DEA concluded their investigation on 10/27/25 and informed her although they were unable to determine the cause of missing narcotics, they discovered that a total of six (6) blister packs for five (5) residents were not accounted for. The Regional Director identified the six (6) missing Control Disposition Records along with the six (6) blister packs that were delivered to the facility were missing. The Regional Director identified the six (6) missing Control Disposition Records along with the six (6) blister packs had been delivered to the facility and explained the facility failed to keep an accurate accounting of discontinued controlled substances after they left the unit to be disposed of by the Director of Nursing or were sent home with residents upon discharge. The report indicated the facility failed to remove discontinued drugs from the individual units and dispose of the discontinued drugs in a timely manner. Interview with the Medical Director on 11/7/25 at 12:46 PM identified she had received a call from DEA as a professional courtesy because they had received a complaint that a staff member had removed controlled medication from the facility. The Medical Director explained she asked the Director of Nursing (DON) to clear the medication carts because she had overheard some licensed nurses saying the carts were overfilled with medications. The Medical Director identified there were discrepancies in documentation on the Medication Administration Records, Controlled Substance Disposition sheets and some medications were not found. Although requested, the facility failed to provide a policy that was in place prior to the allegation regarding the Receipt and Disposition of Controlled Substances.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure that documented grievance resolutions were implemented. The findings include:Resident #1's diagnoses included dementia with agitation, history of falling and anxiety disorder.The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0) and required moderate assistance for transfers and ambulation.The Resident Care Plan (RCP) dated 4/24/25 identified that on 4/24/25 Resident #1 had a fall that resulted in a laceration to the back of his/her head (scalp). Interventions included assessing for injuries and notification to the nursing supervisor, provider and family. A nurse's note dated 4/24/25 at 3:34 PM identified Resident #1 had an unwitnessed fall at approximately 3:15 PM, the family and the provider were notified of the incident, and Resident #1 was transferred to the Emergency Department (ED) per physician's orders. Hospital ED notes dated 4/24/25 identified Resident #1 had a laceration to the posterior (backside) aspect of the head, measuring 2.5 centimeters (cm) by 2.5 cm which was cleansed and repaired with five (5) staples, followed by antibiotic ointment and an adhesive bandage. No further directions were documented.A nurse's note dated 4/24/25 at 9:27 PM identified Resident #1 returned to the facility from the ED with 5 staples to the scalp, a new order for Cephalexin (antibiotic) and noted that the staples were to be removed at the facility in seven (7) days.A physician's order dated 4/25/25 directed to monitor 5 staples to the back of the head and report bleeding or signs and symptoms of infection every shift, but failed to direct staple removal until 5/7/25 (13-days after the placement of the staples).A facility grievance dated 5/7/25 identified that per Resident #1's family member, the staples were not removed from the scalp laceration timely. The facility investigation identified that the physician's order for staple monitoring and removal did not include a stop date, a new physician's order was obtained, the 5 staples were removed, and RN #3 received education on ensuring physician's orders included stop dates.Interview with Social Worker #1 (Director of Social Services) on 7/8/25 at 11:55 AM identified she filled out the grievance form and communicated the resolution to the complainant but she was not involved in the investigation. She identified RN #4 (previous DNS) directed her in what to write in the investigation section of the grievance form. She identified that she never saw a documented education for RN #3 but that if it was done, the Administrator would have it.Interview with the Administrator on 7/8/25 at 12:12 PM identified that if a grievance form reported that the corrective action was to include education to the nurse involved, the education should have been documented and available.Interview with RN #3 (Infection Control nurse) on 7/8/25 at 3:25 PM identified she entered the physician's order dated 4/25/25 directing to monitor the staples to Resident #1's scalp laceration, and further identified she should have included staple removal in the order. She identified she was unaware she had not entered a stop date and the facility never educated her on the incident.Interview with the DNS on 7/8/25 at 3:47 PM identified that the facility was unable to locate education or disciplinary action for RN #3 related to the 4/25/25 physician's order or related to the 5/7/25 grievance. She further indicated that if education was completed, it should have been available. The DNS identified that all grievance forms should be complete and accurate.Although attempted, an interview with RN #4 was not obtained.Review of the Concerns, Complaints and/or Grievances policy dated 11/25/16 directed, in part, that concerns, complaints/grievances brought to the Administration's attention will be actively addressed for resolution and inform the resident/interested party of that outcome. The Director of Social Services, Grievance Official, oversees the process, tracks grievances, leads investigations, maintains confidentiality, issues decisions and coordinates with government agencies. All concerns/complaints are investigated and findings reviewed with the Administrator and a Department Head.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to review and revise the plan of care to include a new intervention following a fall in the facility. The findings include:Resident #1's diagnoses included dementia with agitation, history of falling and anxiety disorder.The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0) and required moderate assistance for transfers and ambulation.The Resident Care Plan (RCP) dated 4/24/25 identified that on 4/24/25 Resident #1 had a fall that resulted in a laceration to the back of his/her head (scalp). Interventions included assessing for injuries and notification to the nursing supervisor, provider and family.A Fall Risk Evaluation dated 4/24/25 identified Resident #1 had three (3) or more falls in the past 3 months, was disoriented at all times, was incontinent, had a balance problem, decreased muscular coordination, and was at high risk for falls.A nurse's note dated 5/9/25 at 6:12 PM by LPN #2 identified Resident #1 had an unwitnessed fall and was found on the floor by a NA. Upon assessment Resident #1 denied pain, headache or blurred vision, vital signs were stable and the family and the provider were notified of the fall with no new orders.Review of the facility Accident and Investigation (A & I) dated 5/9/25 identified Resident #1 was assisted to bed after visiting with family at 6:00 PM and when NA #2 went to check on Resident #1, he/she was on the floor next to the bed. The A & I failed to identify that an intervention was initiated following the fall. Review of the RCP dated 5/21/25 identified a fall with head laceration on 4/24/25 and a fall with no injuries on 5/21/25. The RCP failed to identify the 5/9/25 fall or that new fall interventions were added following the 5/9/25 fall. Interview with the DNS on 7/8/25 at 1:45 PM identified that following a fall, an appropriate intervention should be added to the RCP to prevent future falls. She identified that no interventions were added to the 5/9/25 fall A & I and no new intervention was added to the RCP. She identified that the RN supervisor was responsible for ensuring the A & I was fully completed following a fall and that A & I's are further reviewed in morning report. Interview with LPN #2 on 7/8/25 at 2:08 PM identified she did not add an intervention for Resident #1 following the 5/9/25 fall and was unaware that an intervention needed to be added to the RCP for falls with no injuries.Although attempted, interviews with RN #2 (Nursing Supervisor at the time of the incident) and RN #4 (previous DNS) were not obtained.Review of the Managing Falls and Fall Risk policy (undated) directed, in part, that if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try and minimize serious consequences of falling.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure a physician's order was obtained timely for the removal of staples from a facility acquired scalp laceration which was sustained from a mechanical fall in the facility. The findings include:Resident #1's diagnoses included dementia with agitation, history of falling and anxiety disorder.The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0) and required moderate assistance for transfers and ambulation.The Resident Care Plan (RCP) dated 4/24/25 identified that on 4/24/25 Resident #1 had a fall that resulted in a laceration to the back of his/her head (scalp). Interventions included assessing for injuries and notification to the nursing supervisor, provider and family. A nurse's note dated 4/24/25 at 3:34 PM identified Resident #1 had an unwitnessed fall at approximately 3:15 PM, the family and the provider were notified of the incident, and Resident #1 was transferred to the Emergency Department (ED) per physician's orders. Hospital ED notes dated 4/24/25 identified Resident #1 had a laceration to the posterior (backside) aspect of the head, measuring 2.5 centimeters (cm) by 2.5 cm which was cleansed and repaired with five (5) staples, followed by antibiotic ointment and an adhesive bandage. No further directions were documented.A nurse's note dated 4/24/25 at 9:27 PM identified Resident #1 returned to the facility from the ED with 5 staples to the scalp, a new order for Cephalexin (antibiotic) and noted that the staples were to be removed at the facility in seven (7) days.A physician's order dated 4/25/25 directed to monitor 5 staples to the back of the head and report bleeding or signs and symptoms of infection every shift, but failed to direct staple removal until 5/7/25 (13-days after the placement of the staples).A facility grievance dated 5/7/25 identified that per Resident #1's family member, the staples were not removed from the scalp laceration timely. The facility investigation identified that the physician's order for staple monitoring and removal did not include a stop date, a new physician's order was obtained, the 5 staples were removed, and RN #3 received education on ensuring physician's orders included stop dates.Interview with RN #3 (Infection Control nurse) on 7/8/25 at 3:25 PM identified she entered the physician's order dated 4/25/25 directing to monitor the staples to Resident #1's scalp laceration, and further identified she should have included staple removal in the order. She identified she was unaware she had not entered a stop date and the facility never educated her on the incident.Interview with the DNS on 7/8/25 at 3:47 PM identified the 11:00 PM to 7:00 AM shift nurses are responsible for chart checks and reviewing all new orders each day. She identified that the missing order stop date and missing staple removal date should have been identified during a chart check. Additionally, she identified that the facility was unable to locate education for RN #3 related to the 4/25/25 physician's order or any disciplinary action related to the incident.Review of the Medication and Treatment Orders policy (undated) directed, in part, that orders must include the start and stop date and/or specific duration of therapy and any interim follow-up requirements.Review of the admission of a Resident policy (undated) directed, in part, that the nurse shall reconcile medications with the discharging facility's discharge summary/W10. The nurse will notify the attending physician of the resident's arrival and verify orders as ordered and reconciled on the discharge summary/W10.Although requested, a facility policy for physician's orders reconciliation process was not provided.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of two residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings include: A. Resident #1's diagnoses included depression and anxiety. The Resident Care Plan (RCP) dated 4/24/2025 identified Resident #1 was incontinent of bladder. Interventions directed to provide incontinent care every two hours and as needed, and update the nurse for any areas of skin breakdown. The quarterly Minimum Data (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and required substantial assistance to dependent with ADLs (activities of daily living). B. Resident #2's diagnoses included congestive heart failure and mental disorder due to known physiological condition. The admission MDS assessment dated [DATE] identified Resident #2 had a BIMS score of fifteen out of fifteen (15/15), indicative of being cognitively intact and was partial to substantial assistance with ADLs (activities of daily living). The RCP dated 4/2/2025 identified Resident #2 has a pressure ulcer and requires wound management. Interventions directed to provide wound care per treatment order. Record review and observations identified Resident #1 and Resident #2 were roommates. A facility reportable event form and investigation dated 5/1/2025 at 1:00 PM identified Resident #1 contacted the Administrator by phone and requested an in-person conversation. At that time, Resident #1 reported that NA #1 on the evening shift had yelled at him/her using profanity, when asked Resident #1 requested help with a bedpan. Resident #2 was also interviewed and corroborated the complaint, and NA #1 was suspended pending investigation results. The investigation included staff statements, and identified NA #2 was also involved in the incident and was suspended as well. The facility investigation substantiated the allegation of verbal abuse, Resident #1 and Resident #2 were provided with social service support visits, and the residents were informed the NAs involved would not return to the facility. Interview with Resident #1 on 5/15/2025 at 11:00 AM identified on 4/30/2025 at approximately 7:30 PM, Resident #1 rang his/her call bell to use the bedpan. Resident #1 indicated the curtain was closed and he/she was not able to see anything beyond his/her area. Resident #1 indicated when the staff member arrived in the room, she immediately began yelling/screaming at Resident #2, stating what are you calling for and you're ringing every two f****** seconds. Resident #2 responded by saying I wasn't calling and Resident #1 intervened and said, it was me calling. The staff member did not respond and left the room. Resident #1 indicated the staff member did not provide any care and later LPN #1 came into the room and placed Resident #1 on the bedpan. Resident #1 further indicated he/she did not report the incident until the next day when he/she reported it to the Administrator. Resident #1 stated he/she believed the staff person's voice that responded to the room was NA #1. Interview with Resident #2 on 5/16/2025 at 3:20 PM identified on 4/30/2025 during the 3:00 PM to 11:00 PM shift, Resident #1 had called for assistance and when NA #1 came into the doorway, NA #1 began yelling/screaming/swearing. Resident #2 indicated NA #1 had said you're ringing the bell every f*****g two seconds and made other statements that included swearing and then left the room. Resident #2 indicated NA #1 never assisted Resident #1 with his/her request. Interview with NA #1 on 5/15/2025 at 12:00 PM identified she worked on 4/30/2025 during the 3:00 PM to 11:00 PM shift, and her assignment was heavy with many incontinent residents and residents who utilize the call bell frequently. NA #1 identified she was overwhelmed during the shift and had no assistance from other staff and when she answered a resident's call light, she would initially tell them that she needed to get help first and would come back. NA #1 denied the allegation and indicated she did not swear and would never say those types of statements to the residents. Interview with LPN #1 on 5/15/2025 at 2:05 PM identified on 4/30/2025 during the 3:00 PM to 11:00 PM shift, NA #1 and NA #2 worked on the same unit. LPN #1 indicated that during the shift she heard NA #2 say loudly, why you ringing, and what you want but indicated she's unable to verify when and where she heard the comments. LPN #1 identified NA #2 normally talks like that in general, but not in a negative way. LPN #1 indicated she did not hear either NA #1 or NA #2 make the alleged comments to Resident #1 or Resident #2. Interview with the DON on 5/15/2025 at 2:45 PM identified on 5/1/2025, Resident #1 reported the allegation to the Administrator. The DON indicated that both Resident #1 and Resident #2 were interviewed, and the facility investigation substantiated that the residents were verbally abused by NA #1. Further, NA #1 was an agency NA, and they would not schedule her in the future, and NA #2 resigned prior to the completion of the investigation. Review of the undated facility Abuse Policy directed in part, the facility will ensure each resident is treated with kindness, compassion, and in a dignified manner, and abuse or mistreatment toward a resident was strictly prohibited. Verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their ability to comprehend. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident/patient, such as telling a resident/patient that he/she will never see their family again.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to utilize a gait belt for transfers, failed to conduct a Registered Nurse (RN) assessment following a fall and prior to further movement, once transferred failed to conduct a thorough assessment, and failed to contact the physician representing a failure to maintain professional standards of practice. The findings include: Resident #23's diagnoses included dementia, malignant neoplasm of the anal canal, morbid obesity, and was actively receiving chemotherapy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #23 required a wheelchair and a walker for mobility and was dependent on staff for bed mobility, toileting, bathing, transfers. The Resident Care Plan dated 1/28/2025 identified Resident #23 was a fall risk related to a history of falling. Interventions included, keeping the bed in lowest position, remind Resident #23 of self-limitations, and encourage the resident to ask for assistance with personal care. Review of the Physical Therapy Evaluation and Plan of Treatment report dated 3/27/2025 directed staff to use a mechanical lift for all transfers due to medical and safety needs. Review of the Facility Reported Incident (FRI) event form dated 3/31/2025 identified that on 3/31/2025 at 10:30 AM Resident #23 was being transferred from the bed to a wheelchair when his/her legs became weak. Three staff members assisted the resident to the floor, during which the resident's legs bent behind him/her. Resident #23 was then mechanically lifted from the floor to the wheelchair. Resident #23 was assessed and had no complaints and was transferred to his/her scheduled appointment. The FRI report indicated RN #7 notified MD #1 at 2:30 PM on 3/31/2025. Upon arrival to the physician's office, Resident #23 complained of chest pain and left lower extremity pain. The resident was transferred to the Emergency Department and was subsequently diagnosed with a tibia/fibula fracture. An interview with Resident #23 on 4/28/2025 at 11:42 AM identified he/she experienced a fall on 3/31/2025. Resident #23 stated that multiple nursing assistants were helping him/her get out of bed when his/her legs felt weak, were giving out, and he/she informed the staff. Resident #23 was then lowered to the floor and reported to staff he/she was unable to bear weight on the left leg. Staff transferred Resident #23 to the chair and proceeded to send the resident to his/her scheduled colorectal office visit. Resident #23 reported that the APRN at the doctor's office noticed that he/she appeared as pale as a ghost and transferred him/her to the Emergency Department for evaluation. Resident #23 indicated that when he/she was transferred to the stretcher he/she screamed in pain when they moved the left leg. Interview with NA #5 on 5/5/2025 at 11:54 AM identified that after providing morning care to Resident #23, NA #5 positioned him/her seated at the edge of the bed and placed a walker in front of him/her in preparation for transfer. NA #5 indicated that she and NA #1 failed to use a gait belt when transferring Resident #23. Instead, both NAs attempted to transfer Resident #23 by positioning their arms under the resident's armpits in a hook like manner in order to lift Resident #23 from the bed. When the resident attempted to stand, he/she complained of pain, so they stopped the transfer. NA #5 observed that Resident #23's left leg was slightly twisted, and the resident was unable to straighten the leg, NA #5 notified LPN #5, who then assisted with a second attempt to stand Resident #23 before notifying the RN to assess the pain or the slightly twisted leg. While both NAs were positioned on either side of Resident #23, LPN #5 was on the bed pushing the resident up from behind. Resident #23 again expressed pain and an inability to stand. A third attempt was made, the resident was asked by staff to pivot, stated Put me down, and indicated he/she was unable to continue. NA #5 reported that Resident #23's legs just gave out, so they assisted to lower him/her to the floor. Once on the floor, Resident #23 began screaming, My leg, my leg, my leg. NA #5 stated they realized the resident's left leg had been twisted underneath him/her. LPN #8 then lifted the resident's lower body while NA #1 repositioned Resident #23's left leg, and the resident was transferred via a mechanical lift, all prior to RN notification and assessment. NA #5 stated that when RN #7 arrived, she assessed the resident's bandage on her leg (a skin tear that was sustained during a fall on 3/18/2025) and changed the dressing (bandage), but no further assessment of the resident was conducted by RN #7. Staff put a blanket over Resident #23's lap; NA #5 accompanied the resident to the front of the facility and then accompanied Resident #23 to his/her scheduled doctor's appointment. NA #5 indicated that when she and Resident #23 arrived at the doctor's appointment, the resident was noted to be sweating, reported feeling dizzy, his/her blood pressure was elevated, and he/she complained of chest pain. Resident #23 was evaluated by the physician's staff at the appointment and subsequently was transferred to the Emergency Department. NA #5 reiterated that staff had not used a gait belt to transfer Resident #23 during any of the 3 attempts to stand the resident, nor was a mechanical lift considered until after the fall. NA #5 indicated that she knew a gait belt should be used when standing a resident, but she did not have one at the time. NA #5 indicated that a gait belt could have offered support, but she did not request one, despite knowing the facility would have provided one. Interview with the Director of Nursing (DNS) on 5/5/2025 at 12:35 PM identified that if a resident expressed difficulty standing and stated he/she could not stand, staff should have stopped, and a mechanical lift should have been used. The DNS stated that lifting a resident under the axilla was not an appropriate transfer method and a gait belt should have been used. Furthermore, staff should have stopped immediately when the resident stated he/she could not continue. The situation should have been escalated to a Registered Nurse Supervisor to assess the resident's condition prior to proceeding with any transfer or manipulation of Resident #23's leg. Re-interview with the DNS on 5/5/25 at 2:53 identified that although it was indicated on the Reportable Event following Resident #23's fall that the provider (MD or APRN) was notified, through the investigation process, she was unable to substantiate provider notification had occurred. The DNS stated that the facility's policy directed the nurse supervisor to notify the DNS, the administrator, and the physician when there is a change in a resident's condition. The DNS indicated that the facility used an off-hour encrypted provider notification system to report changes in a resident's condition. The DNS indicated that the facility MD never found out that Resident #23 had fallen until the following day when the hospital called the facility. Interview with the Director of Rehabilitation Services on 5/5/2025 at 3:13 PM indicated that using a gait belt to transfer any resident was the standard practice for all resident transfers. Interview with the Chief Clinical and Safety Officer on 5/5/2025 at 3:15 PM identified that staff should have used a gait belt when transferring residents. Interview with MD #1 on 5/6/2025 at 1:36 PM identified that any change in a resident's condition must be reported immediately. MD #1 reported she was not informed of Resident #23's fall and only became aware Resident #23 sustained a fracture when she was contacted by the Emergency Department. MD #1 stated that had she been notified she would not have allowed the resident to leave for her scheduled appointment, instead she would have evaluated the resident herself. If she had not been on-site, she would have evaluated the situation and sent the resident to the Emergency Department. Although requested, the facility did not have a transfer policy. Review of the Notification Change in Condition, Change in Treatment/Services Policy that was in effect directed, in part, that the facility must immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or any interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. According to the American Nurses Association Safe Patient Handling and Mobility, manual patient handling is hazardous for both health care workers and patients. The most common patient related tasks that lead to injury are lifting repositions and transferring. According to American Nurse, if you're walking with a patient who becomes dizzy or experiences a syncopal event, you may not be able to prevent a fall. But you can help to prevent injury by holding on to the gait belt and guiding the patient to the floor, supporting him or her on your thigh and with your large quadricep muscle as you slow descent to the floor.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to ensure a resident was transferred appropriately, failed to end the transfer and call for the Registered Nurse to assess the resident when he/she complained of pain, failed to ensure a Registered Nurse conducted a thorough assessment that included a range of motion prior to transferring the resident off the floor, and failed to notify the physician of the fall which resulted in a major injury. The findings include: Resident #23's diagnoses included dementia, malignant neoplasm of the anal canal, morbid obesity, and was actively receiving chemotherapy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #23 required a wheelchair and a walker for mobility and was dependent on staff for bed mobility, toileting, bathing, transfers. The Resident Care Plan dated 1/28/2025 identified Resident #23 was a fall risk related to a history of falling. Interventions included, keeping the bed in lowest position, remind Resident #23 of self-limitations, and encourage the resident to ask for assistance with personal care. Review of a Fall Risk Evaluation dated 3/18/2025 directed the facility to observe the resident status using 11 clinical condition parameters, then assign the corresponding risk score, and if the total score was 10 or greater, the resident should be at HIGH RISK for potential falls. Although the evaluation was completed, the facility failed to assign a total score to indicate the level of Resident #23's fall risk. Review of the Physical Therapy Evaluation and Plan of Treatment report dated 3/27/2025 indicated that Resident #23 was seen after hospitalization and was to be mechanically lifted to the wheelchair as the air mattress and bed frame/environmental situation was unsafe at this time for transfers until the patient gains strength. Review of the physician orders, nursing notes, and Resident Care Plan from 3/27/25 through 3/31/2025 failed to identify that the Physical Therapy Evaluation recommendation for a mechanical lift had been implemented. Review of the Facility Reported Incident (FRI) event form dated 3/31/2025 identified that on 3/31/2025 at 10:30 AM Resident #23 was being transferred from the bed to a wheelchair when his/her legs became weak. Three staff members assisted the resident to the floor, during which the resident's legs bent behind him/her. Resident #23 was then mechanically lifted from the floor to the wheelchair. Resident #23 was assessed and had no complaints and was transferred to his/her scheduled appointment. The FRI report indicated RN #7 notified MD #1 at 2:30 PM on 3/31/2025. Upon arrival to the physician's office, Resident #23 complained of chest pain and left lower extremity pain. The resident was transferred to the Emergency Department and was subsequently diagnosed with a tibia/fibula fracture. The physical status before the event was noted to include assisting the resident with 2 staff and a rolling walker for transfers to the wheelchair. After the event, the physical status reflected that Resident #23 required a mechanical lift. Review of the Hospital Discharge summary dated [DATE] identified x-rays taken on 3/31/2025 indicated Resident #23 had a spiral, mildly displaced fracture of the distal fibular metadiaphysis, a transverse mildly displaced fracture of the medial malleolus (distal tibia and fibula fracture), and a hemorrhagic blister on the left shin, which required debridement at the hospital. Observation and interview with Resident #23 on 4/28/2025 at 11:42 AM identified he/she experienced a fall on 3/31/2025. Resident #23 stated that multiple nursing assistants were helping him/her get out of bed when his/her legs felt weak, were giving out, and he/she informed the staff. Resident #23 was then lowered to the floor and reported to staff he/she was unable to bear weight on the left leg. Staff transferred Resident #23 to the chair and proceeded to send the resident to his/her scheduled colorectal office visit. Resident #23 reported that the APRN at the doctor's office noticed that he/she appeared as pale as a ghost and transferred him/her to the Emergency Department for evaluation. Resident #23 indicated that when he/she was transferred to the stretcher he/she screamed in pain when they moved the left leg. Resident #23 was then transferred to the Emergency Department. Interview with NA #5 on 5/5/2025 at 11:54 AM identified that around noon on 3/31/2025, she assisted Resident #23 with morning care in preparation for a 2:30 PM scheduled doctor's appointment. Once Resident #23 was ready, NA #5 positioned him/her seated at the edge of the bed and placed a walker in front of him/her in preparation for the transfer. She indicated that she and NA #1 assisted Resident #23 without the benefit of a gait belt. The transfer was completed by the NAs positioning their arms under the resident's armpits in a hook like manner in order to lift Resident #23 from the bed. When the resident attempted to stand, he/she complained of pain, so they stopped the transfer. NA #5 observed that Resident #23's left leg was slightly twisted, and the resident was unable to straighten the leg. NA #5 notified the LPN. NA #5 stated that when LPN #5 entered the room, a second attempt was made to stand Resident #23. Both NAs were positioned on either side of Resident #23 and LPN #5 was on the bed pushing the resident up from behind. Resident #23 again expressed pain and an inability to stand. A third attempt was then made when LPN #8 entered the room. LPN #8 stood on one side, while both NA #5 and NA#1 stood on Resident #23's opposite side. Resident #23 was brought to a standing position, and they told the resident to pivot. NA#5 stated the resident said, Put me down, and indicated that he/she was unable to continue. NA #5 reported that Resident #23's legs just gave out, so they assisted to lower the resident to the floor. Once on the floor, Resident #23 began screaming, My leg, my leg, my leg. NA #5 stated they realized the resident's left leg had been twisted underneath him/her. LPN #8 then lifted the resident's lower body while NA #1 repositioned Resident #23's left leg. NA #5 reported that a mechanical lift pad was placed under the resident, and LPN #8 used a mechanical lift to transfer Resident #23 to the wheelchair. After Resident #23 was seated in the wheelchair, LPN #5 assessed Resident #23's leg and left to get RN #7. NA #5 stated that when RN #7 arrived, she assessed the resident's bandage on her leg (a skin tear that was sustained during a fall on 3/18/2025) and changed the dressing (bandage), but no further assessment of the resident was conducted. Staff put a blanket over Resident #23's lap, NA #5 accompanied the resident to the front of the facility and then accompanied Resident #23 to his/her scheduled doctor's appointment. When NA #5 and Resident #23 arrived at the doctor's appointment the resident was noted to be sweating, reported feeling dizzy, his/her blood pressure was elevated, and he/she complained of chest pain. NA #5 indicated Resident #23 stated he/she felt as though he/she was spinning. Resident #23 was evaluated by the physician's staff at the appointment and subsequently was transferred to the Emergency Department. NA #5 reiterated that staff had not used a gait belt to transfer Resident #23 during any of the 3 attempts to stand the resident, nor was a mechanical lift considered until after the fall. NA #5 indicated that she knew a gait belt should be used when standing a resident, but she did not have one at the time. NA #5 indicated that a gait belt could have offered support, but she did not request one, despite knowing the facility would have provided one. Additionally, she stated a staff member told her that that the resident now required transfers with a mechanical lift, but that no one had communicated the information to use the mechanical lift for Resident #23 prior to the fall. Interview with the Director of Nursing (DNS) on 5/5/2025 at 12:35 PM identified that if a resident expressed difficulty standing and stated he/she could not stand, staff should have stopped, and a mechanical lift should have been used. The DNS stated that lifting a resident under the axilla was not an appropriate transfer method and a gait belt should have been used. Furthermore, staff should have stopped immediately when the resident stated he/she could not continue. The situation should have been escalated to a Registered Nurse Supervisor to assess the resident's condition prior to proceeding with any transfer or manipulation Resident #23's leg. Re-interview with the DNS on 5/5/25 at 2:53 identified that although it was indicated on the Reportable Event following Resident #23's fall, through the investigation process, the DNS was able to substantiate that RN #7 never notified a provider, MD or APRN, that Resident #23 had fallen. The DNS indicated that the facility MD was not notified until the following day when the hospital called the facility. Interview with the Director of Rehabilitation Services on 5/5/2025 at 3:13 PM indicated that using a gait belt to transfer any resident was the standard practice for all resident transfers. Interview with the Chief Clinical and Safety Officer on 5/5/2025 at 3:15 PM identified that staff should have used a gait belt when transferring residents. Interview with MD #1 on 5/6/2025 at 1:36 PM identified that any change in a resident's condition must be reported immediately. MD #1 reported she was not informed of Resident #23's fall and only became aware Resident #23 sustained a fracture when she was contacted by the Emergency Department. MD #1 stated that had she been notified she would not have allowed the resident to leave for her scheduled appointment, instead she would have evaluated the resident herself. If she had not been on-site, she would have evaluated the situation and sent the resident to the Emergency Department. She further noted that while an orthopedic specialist would be the best suited to speak to the exact cause of the injury, a fall with a twisting mechanism could reasonably result in the type of spiral fracture Resident #23 had sustained. Although requested, the facility did not have a transfer policy. Review of the Notification Change in Condition, Change in Treatment/Services Policy directed, in part, that the supervisor/ RN Manager conduct a complete physical/mental assessment and document the findings. The facility will inform the resident, resident's physician, and the resident's family/legal representative when there is a change in condition.

Based on review of clinical records, facility policy, and interviews for 1 of 3 sampled residents (Resident #22) reviewed for choices, the facility failed to make a reasonable accommodation for an individual with mobility needs. The findings include: Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent for transfers, required maximal assistance with personal hygiene and bed mobility, and utilized a motorized wheelchair. The Resident Care Plan (RCP) dated 3/5/2025 identified Resident #22 required assistance with Activities of Daily Living (ADLs). Interventions included assisting with ADLs, mechanical lift for transfers, and reposition Resident #22 in his/her power wheelchair every 2 hours. An interview with Resident #22 on 4/29/2025 at 9:54 AM identified he/she was unable to leave his/her room independently because there was insufficient room for the power wheelchair to exit between his/her roommate's dresser and the end of the bed. Resident #22 further indicated he felt locked up when he/she could not exit the room. An interview with Social Worker #1 on 5/1/2025 at 11:05 AM identified that she was aware Resident #22 could not exit his/her room independently due to space issues between the roommate's bed and dresser and stated to get Resident #22 out of his/her room in the power wheelchair, the roommate's bed needed to be scooted over by staff. Further, she indicated Resident #22 was in a private room on 8/1/2022 with no wheelchair mobility concerns but was moved into a shared room on 6/14/2023. She indicated moving Resident #22 into the shared room, where staff were required to move a bed and dresser each time Resident #22's wheelchair was to exit the room, was not accommodating the resident's need to leave his/her room at will. An observation with the Director of Nursing Services (DNS) on 5/1/2025 at 11:36 AM identified that the width of Resident #22's wheelchair and the distance from his/her roommates dresser and bed were both 90 inches. The DNS moved the dresser in a left direction towards the corner of the wall and measured a new distance from the dresser to the end of the bed of 92 inches. The DNS failed to identify if the new setup of the room, with an additional 2 inch clearance, would accommodate the resident's needs to independently go in and out of his/her room as the distance was measured at an angle. She stated the facility would need to test it to gauge if Resident #22 could exit the room. Although requested, the facility did not provide a policy on Accommodation of Needs for residents.

Based on review of the clinical record, facility policy and interviews for 1 of 4 sampled residents (Resident #22) reviewed for abuse, for the only sampled resident (Resident # 27) reviewed for hospitalization, and for 1 of 3 residents, (Resident #36) reviewed for smoking, the facility failed to develop and implement comprehensive Resident Care Plans. The findings include: 1. Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent for transfers, required maximal assistance with bed mobility, and utilized a motorized wheelchair. The Resident Care Plan (RCP) dated 3/5/2025 identified Resident #22 had communication difficulties as a result of a stroke. Interventions included speaking directly to the resident while facing him/her, ask simple yes/no questions, and provide speech therapy as needed. An interview with Resident #22 on 4/29/2025 at 9:38 AM identified he/she had notified the facility of potential abuse/misappropriation of funds which had not yet been resolved. Resident #22 verbalized being upset that the facility had not provided an update on where the money was and that the police were not returning his/her phone calls. Review of the Reportable Event dated 2/28/25 identified that Resident #22 had reported that $2,000 was missing from his/her bedside table. Review of the summary of events dated 3/6/25 indicated that the facility was unable to substantiate Resident had any money missing. Review of the RCP in effect following the facility summary dated 3/6/2025 and through 5/1/2025 failed to identify Resident #22's had a RCP developed and implemented following an allegation of misappropriation. An interview with the Director of Nursing Services (DNS) on 5/1/2025 at 10:21 AM identified she was aware of the allegation of misappropriation of funds, an investigation had been conducted, and a report was filed with the State Agency on 2/28/2025. The DNS indicated the facility had offered Resident #22 a lock box, which was refused, but she failed to document the offering of the lock box or add the allegation of misappropriation of funds or any new interventions to Resident #22's RCP but indicated the RCP should have been updated. Subsequent to surveyor inquiry, on 5/1/2025 the DNS updated Resident #22's care plan to include his/her needs after an allegation of misappropriation of funds. 2. Resident #27 's diagnoses included respiratory failure, deep vein thrombosis, pulmonary emboli, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #27 required a walker for ambulation, was independent with eating, required supervision with transfers, and partial assistance with dressing and tub/shower transfers. Review of the Resident Care Plan (RCP) dated 12/20/2025 identified that although Resident #27 had listed diagnoses of congestive heart failure (CHF), asthma, and pulmonary embolism, there were no problems, interventions, goals, or monitoring parameters related to CHF or respiratory distress noted in Resident #27's RCP. Interview and review of clinical record with the Chief Clinical and Safety Officer (CCSO) on 5/6/2025 at 11:33 AM identified that Resident #27 had a significant medical history including a recent hospitalization for shortness of breath, acute asthma exacerbation, pulmonary embolism, and a history of congestive heart failure. Although this information was documented on the facility's History and Physical Form, the resident's medical history was not reflected in the RCP. The CCSO confirmed these conditions should have been included and stated he would have expected them to be part of Resident #27's RCP. 3. Resident #36's diagnoses included anxiety, right sided hemiplegia (complete loss of strength on 1 side), and hemiparesis (partial weakness on 1 side) secondary to cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 36 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Resident #36 used a wheelchair for mobility but could independently walk 10 feet. Resident #36 was independent with eating, personal hygiene, dressing, bed mobility and transfers. Review of the Resident Care Plan (RCP) from 4/4/2025 through 4/29/25 did not identify Resident #36 as a smoker, nor did the RCP include interventions related to smoking i.e. supervision level, staff assistance, safety measures, or behavioral concerns. Observation on 4/29/25 at 10:08 AM identified Resident #36 was seated in a wheelchair at the facility's designated outdoor smoking area located in the back of the facility's main building. Resident #36 wore a smoking apron; there were no identified issues with the observation. Interview with the Director of Nursing Services (DNS) on 5/5/25 at 3:28 P.M. identified that Resident #36 should have had a smoking care plan in place. The DNS indicated that Resident #36 had opted for a nicotine patch in lieu of smoking, but that when the resident decided to return to smoking the plan should have been updated. The DNS acknowledged the plan was incomplete and did not reflect current staff practices or the resident's preference for smoking. Subsequent to surveyor interview, the RCP was updated on 5/5/2025. The RCP reflected that the resident smokes three times per day. Interventions included completing a smoking assessment every 90 days and ensuring smoking materials are stored by nursing staff in a secured cart. Review of the Care Planning Policy, in part, directed that a comprehensive and individualized plan of care would be developed for each resident. The care plan would be used to guide caregivers to assist residents to achieve or maintain their highest practical level of well-being.

Based on review of clinical records, facility policy, and interviews for 1 of 3 sampled residents, (Resident #7), reviewed for choices, the only sampled resident (Resident #13) reviewed for rehabilitation, the only sampled resident, (Resident #22), reviewed for abuse, the only sampled resident (Resident # 27) reviewed for hospitalization, the only sampled resident (Resident #52) reviewed for care planning, and the only sampled resident (Resident #56) reviewed for hemolytic treatments, the facility failed to review and revise care plans per the requirement and failed to hold quarterly Resident Care Plan (RCP) meetings as required. The findings include: 1.Resident #7's was admitted [DATE] with diagnoses that included seizure disorder, chronic obstructive pulmonary disease, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition and was independent with transfers and walking 150 feet. The Resident Care Plan (RCP) dated 2/13/2025 identified Resident #7's quality of life should be maintained through providing activities of interest. Interventions included assess and discuss the resident's needs, interests, and communicate resident's preferences with staff via the care plan and verbal communication. a. Review of Resident #7's RCP meeting attendance sheets from 7/8/2024 through 5/1/2025 identified a RCP meeting was held on 10/16/2024. The facility failed to hold any subsequent RCP meetings for Resident #7. b. Review of the resident's clinical record identified quarterly Minimum Data Set (MDS) assessments were completed on 10/11/2024, and 11/9/2024. The facility failed to review and revise Resident #7's care plan within 7 days of the MDS. 2. Resident #13's admission date was 10/22/2024 for diagnoses that included epilepsy, dysphagia, and depression. The Resident Care Plan (RCP) dated 1/22/2025 identified Resident #13 was at risk for issues related to psychosocial wellbeing. Interventions included allow/encourage the resident to express feelings, and to participate in daily care and decision/goal making. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, and was independent with personal hygiene, transfers, and walking 150 feet. The facility failed to provide Resident #13's RCP meeting attendance sheets from 10/22/2024 through 5/1/2025 or any documentation that a RCP meetings for Resident #13 had taken place. 3. Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent on chair/bed-to-chair transfers, required maximal assistance with personal hygiene and rolling left and right, and utilized a motorized wheelchair. The Resident Care Plan (RCP) dated 3/5/2025 identified Resident #22 required assistance with ADLs. Interventions included assist with ADLs, mechanical lift for transfers, and reposition the resident in his/her power wheelchair every 2 hours. a. The facility failed to provide Resident #22's RCP meeting attendance sheets for Resident #22 for the calendar years 2024 and 2025. b. Review of the clinical record identified that although quarterly MDS assessments were completed on 8/3/2023, 1/16/2024, 4/11/2024, and 11/30/2024, the facility failed to review and revise Resident #22's care plan within 7 days of the MDS. An interview with Social Worker (SW) #1 on 5/1/25 at 11:05 AM identified that for Resident #7 RCP meetings were no longer held due to the conservator's unattendance, for Resident #13, there were no RCP meetings due to the residents' lack of a conservator for a long period of time, and for Resident #22, the last RCP meeting was held on 12/5/24 and she was unable to explain why there was no RCP meeting held in 2025. SW #1 indicated that she was aware of the requirement and timing to hold RCP meetings, but meetings had not been held. Additionally, SW #1 indicated that for Resident #'s 7 and 22, she was aware that RCP's were to be updated within 7 days after the completion of the MDS assessment but was unable to explain the lack of RCP review and revision. 4. Resident #27's diagnoses included congestive heart failure, pulmonary emboli, and opioid dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #27 required a walker for ambulation, was independent with eating, bed mobility, and transfers. The Resident Care Plan (RCP) dated 3/26/2025 identified Resident #27 experienced chronic pain related to multiple conditions along with behavior problems with occasional medication refusal. Interventions included administering mediations as ordered, monitoring for potential side effects, and staff were to notify the physician of any changes. Physician's notes reviewed from 3/17/2025 to 3/27/2025 identified that during a routine check of the Connecticut's Prescription Monitoring Program, MD #1 identified Resident #27 had filled several prescriptions for narcotics at an outside pharmacy not the facility pharmacy. MD #1 indicated the facility was also filling and administering the same medication that had been allegedly filled by Resident #27. The facility implemented 1:1 constant observation to ensure the resident's safety. Observation and interview with Resident #27 on 4/30/2025 at 9:45 AM identified that Resident #27 was on 1:1 constant observation. Resident #27 reported that he/she made an error by filling prescribed narcotic medications from an outside pharmacy. Resident #27 denied self-administration of these medications. Resident #27 indicated the facility implemented constant observation to watch him/her. Review of the RCP in effect from 3/26/2025 through 4/30/2025 failed to identify that the RCP had been reviewed or revised to include the acquisition of medications from an outside pharmacy or the need for 1:1 constant observation. Interview with the Director of Nursing (DNS) on 5/1/2025 at 5:02 PM identified that the RCP had not been updated to include concerns related to the alleged drug diversion or the implementation of constant observation. The DNS stated that any of the nurses could have updated the RCP and that it was the facility's expectation that this should have been done. 5. Resident #52 's diagnoses included morbid obesity, lymphedema, and osteoarthritis of the knee and hip. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #52 required a wheelchair for mobility, was dependent on dressing, and transfers, and required some assistance with bed mobility. The Resident Care Plan (RCP) dated 4/4/2025 identified Resident #52's wished to be discharged home. Interventions directed staff to evaluate and document the resident's abilities and strengths in collaboration with family, caregivers, and the Interdisciplinary Team (IDT). Review of the Routine Quarterly Care Conference Attendance form dated 4/10/2025, identified in addition to Resident #52, and 2 family members, the IDT consisted of Social Worker (SW) #1 and the Administrator. During an interview with Resident #52 on 4/28/25 at 12:27 PM he/she indicated that he/she felt the interdisciplinary care team does not exist and stated that a representative was not present from the Nursing or Dietary Departments during the last few RCP meetings. Resident #52 expressed he/she felt unsupported due to the absence and lack of input from several clinical disciplines. Interview with SW #1 on 5/1/25 at 3:48 PM identified that she was aware Resident #52's care plan focused on discharge planning and reported that while the resident's 2 family members usually attended the meetings, other departments typically did not, nor did they provide input for the meeting. She stated that the absence of IDT participation had been escalated to the Director of Nursing Services (DNS), who advised her to do her best. SW #1 acknowledged that the lack of input from other IDT members had been a barrier to developing an effective personalized discharge RCP prioritized to meet Resident #52's goals. Interview with the DNS on 5/1/25 at 4:33 P.M. identified the facility had been without an MDS coordinator for approximately 9 months. The DNS stated that the facility policy required attendance and input from social work, nursing, the MDS coordinator, dietary, and recreation staff. The DNS acknowledged that the lack of IDT participation was a known issue and stated, We are just doing the best we can. 6. Resident #56's diagnoses included end stage renal disease, dependence on hemolytic treatment, anemia, and amputation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, independent for eating and bed mobility, dependence on staff for transfers, and was receiving hemolytic treatments. The Resident Care Plan (RCP) in effect for the month of April of 2025 identified Resident #56 was on hemolytic treatment. Interventions included encouraging Resident #56 to go for the scheduled hemolytic appointments, monitor lab work, and monitor for peripheral edema, infection to the access site, and obtain vital signs and weight per protocol. Report any significant changes to the physician. A physician order in effect for the month of April of 2025, directed to send Resident #56 to hemolytic treatments 3 times per week. Upon Resident #56's return, staff were to record the hemolytic center weight from the communication book. Review of the Routine Quarterly Care Conference attendance sheets from 6/6/2024 to 4/7/2025 identified that only the Social Worker (SW#1) and Resident #56 were present for 7 of 8 scheduled RCP meetings. Interview and record review with SW#1 on 5/5/2025 at 11:00 AM, identified that she was the only staff member who attended Resident #56's RCP meetings. SW#1 identified the Interdisciplinary Team (IDT) comprised of the dietician, charge nurse, rehabilitation, activities, social worker, and MDS care coordinator were responsible for attending RCP meetings. SW#1was unable to explain why the other IDT members did not attend Resident #56's RCP meetings. SW#1 indicated that she gave notices for Resident #56's scheduled IDT meetings on time, but only the Resident #56 ever showed up. SW#1 indicated that she was aware that Resident #56 was having issues with her rides for his/her hemolytic treatments and indicated that such issues would be discussed in RCP meetings. SW #1 indicated that it had been difficult for her to individually address any resident issues that require a multidisciplinary approach. Interview with the DNS on 5/5/2025 at 11:30 AM, identified that residents care conferences should be attended by all responsible members (IDT members) and could not explain why only SW #1 was attending. The DNS indicated that she will be looking into the issue. Review of the Care Planning - Interdisciplinary Team (IDT) Policy directed, in part, a resident's comprehensive care plan was to be developed by a care planning/interdisciplinary team which includes, the attending physician, the registered nurse, dietary, social services, activity director, physical, occupational, speech therapy, the DNS, charge nurse, nursing assistant, resident, and the resident's family or representative. Additionally, a comprehensive and individualized plan of care would be developed for each resident will be developed within 7 days of the completion of the Resident's MDS. The RCP would be reviewed and updated at least quarterly and as necessary to reflect changes in a resident's status.

Based on observations, review of clinical records, facility documentation, facility policy, and interviews on 1 of 4 units reviewed for medication to residents, (Resident #1, Resident #4, Resident #8, Resident #16, Resident #17, Resident #36, Resident #37, Resident #38, Resident #39, Resident #45, Resident #46, Resident #49, Resident #50, Resident #55, Resident #56, Resident #66, Resident #68, Resident #75, Resident #77, Resident #233 and Resident #282), the facility failed to ensure meds given greater than once daily were administered at the correct time per the physicians orders. The findings include: Based on observations, review of clinical records, facility documentation, facility policy, and interviews for Residents #1, #4, #8, #16, #17, #37, #38, #39, #46, #49, #50, #55, #56, #68, #75, #77, #233, #282, the facility failed to ensure medications were administered at the correct time per the physician's orders. The findings include: 1. Resident 1's diagnosis included chronic obstructive pulmonary disease, heart failure, old myocardial infarction and chronic respiratory failure with hypoxia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Physician's orders for the month of April 2025, directed to administer Apixaban 5mg, give 1 tablet by mouth every 12 hours for anticoagulation, Budesonide suspension 0.25 milligrams (mg)/2 milliliters (ml) give 2 ml inhalation orally via nebulizer every 12 hours for COPD exacerbation for 14 days, natural balance tears solution 0.1-0.3% (Dextran 70-Hypromellose) instill 2 drop in both eyes 2 times a day, and Formoterol Fumarate inhalation nebulization solution 20 (mcg) micrograms/2ml (Formoterol Fumarate) give 2ml inhalation orally via nebulizer every 12 hours for COPD exacerbation for 14 days. Record review identified that Resident #1's scheduled medications for 4/28/2025 at 9:00 AM were administered at 11:21 AM, an hour and 21 minutes after the acceptable timeframe. 2. Resident #4's diagnoses included diabetes, schizophrenia and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #4 a BIMS score of 5 indicating severe cognitive impairment Physician's orders for the month of April 2025 directed to administer Haloperidol Lactate Concentrate 2mg/ml, give 5 ml by mouth in the morning and 7.5 ml by mouth at bedtime for schizophrenia, Trazodone HCl oral tablet 50 mg (Trazodone HCl). Give 0.5 tablet by mouth 2 times a day for anxiety, and Valproate Sodium oral solution 250mg/5ml (Valproate Sodium), give 2.5 ml by mouth 2 times a day related to schizophrenia. Record review identified that Resident #4's scheduled medications for 4/28/2025 at 9:00 AM were administered at 11:00 AM, an hour and after the allowed timeframe. 3. Resident 8's diagnoses included hypertensive heart disease with heart failure, other specified disorders of urinary system. The quarterly MDS assessment dated [DATE] identified Resident #8 had a BIMS score of 3 indicating severe cognitive impairment. Physician's orders for the month of April 2025 directed to administer Metoprolol tartrate tablet 50 mg by mouth 2 times a day related to hypertension and Potassium Chloride powder 40 mEq by mouth 2 times a day for hypokalemia. Record review identified that Resident #8's scheduled medications for 4/28/2025 at 9:00 AM were administered at 2:10 PM, 4 hours and 10 minutes after the allowed timeframe. 4. Resident 16's diagnoses included diabetes, dysphagia and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #16 had BIMS score of 14 indicative no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Insulin Lispro injection solution 100 unit/ml (Insulin Lispro). Inject 6 units subcutaneously before meals related to type 2 diabetes mellitus 3 times a day with meals. Record review identified that Resident #16's scheduled medications for 4/28/2025 at 9:00 AM were administered at 1:24 PM, 1 hour and 24 minutes after the allowed timeframe. 5. Resident 17's diagnoses included dementia, chronic kidney disease, and generalized muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #17 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment Physician's orders for the month of April 2025 directed to administer Potassium Chloride Extended Release (ER) Capsule 10 MEQ (Potassium Chloride ER), give 10 mEq by mouth 2 times a day for vitamin/mineral deficiency and hypokalemia and Promod liquid protein 2 times a day for wound healing 30cc orally twice a day for wound healing. Record review identified that Resident #17's scheduled medications for 4/28/2025 at 9:00 AM were administered at 6:30 AM, 1 hour and 30 minutes before the allowed timeframe. 6. Resident 37's diagnoses included glaucoma, hallucinations, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #37 had a BIMS score of 7 indicating severe cognitive impairment Physician's orders for the month of April 2025 directed to administer levetiracetam oral tablet 500mg (Levetiracetam), give 1 tablet by mouth 2 times a day for seizure disorder, Timolol Maleate ophthalmic solution 0.5 % (Timolol Maleate (Ophthalmic), instill 1 drop in both eyes 2 times a day for glaucoma, and Brimonidine Tartrate ophthalmic Solution 0.2 % (Brimonidine Tartrate), instill 1 drop in both eyes 2 times a day for glaucoma. Record review identified that Resident #37's scheduled medications for 4/28/2025 at 9:00 AM were administered at 6:35 AM, 1 hour and 35 minutes before the allowed timeframe. 7. Resident 38's diagnoses included hypertension, acute embolism and thrombosis and atrial fibrillation. The quarterly MDS assessment dated [DATE] identified Resident #38 BIMS score was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Apixaban Oral Tablet 2.5 mg give 1 tablet by mouth 2 times a day related to acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity, Combigan ophthalmic solution 0.2-0.5%, Brimonidine Tartrate-Timolol maleate). Instill 1 drop in both eyes every 12 hours for glaucoma, and Gabapentin capsule100mg, give 200mg by mouth 2 times a day for neuropathic pain. Record review identified that Resident #38's scheduled medications for 4/28/2025 at 9:00 AM were administered at 12:00 PM, 2 hours after the allowed timeframe. 8. Resident 39's diagnoses included cardiomyopathy, anemia, epilepsy and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #39 BIMS score was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Acyclovir Oral tablet 400 mg give 1 tablet by mouth every 12 hours related to personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues, Carvedilol oral tablet 6.25 mg give 1 tablet by mouth every 12 hours for hypertension, Keppra oral tablet 500 mg (Levetiracetam), 1 tablet by mouth 2 times a day for seizure disorder, Midodrine HCl oral tablet 5 mg (Midodrine give1 tablet by mouth 3 times a day related to cardiomyopathy and Magnesium oxide 400 mg oral tablet (magnesium oxide supplement) give 2 tablet by mouth 3 times a day related to personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues. Record review identified that Resident #39's scheduled medications for 4/28/2025 at 9:00 AM were administered at 1:00 PM, 3 hours after the allowed timeframe. 9. Resident 46's diagnoses included anemia, diabetes and heart failure. The quarterly MDS assessment dated [DATE] identified Resident # 46 BIMS 6 indicating severe cognitive impairment. Physician's orders for the month of April 2025 directed to administer Ferrous Sulfate tablet 325 (65 Fe) mg. Give 1 tablet by mouth 2 times a day for supplement and ProSource Oral liquid (Nutritional Supplements), give 30 ml by mouth 2 times a day for low albumin. Record review identified that Resident #46 's scheduled medications for 4/28/2025 at 9:00 AM were administered at 1:00 PM, 3 hours after the allowed timeframe. 10. Resident 49's diagnoses included dementia, anxiety and depression. The quarterly MDS assessment dated [DATE] identified Resident #49 BIMS 7 indicating severe cognitive impairment. Physician's orders for the month of April 2025 directed to administer Calcium 600+D tablet 600-200 mg-unit(Calcium Carbonate-Vitamin D). Give 1 tablet by mouth 2 times a day for Vitamin/ Mineral deficiency. Record review identified that Resident #49's scheduled medications for 4/28/2025 at 9:00 AM were administered at 11:37 PM, 1 hour and 37 minutes after the allowed timeframe. 11. Resident 50's diagnoses included chronic kidney disease, diabetes and heart failure. The admission MDS assessment dated [DATE] identified Resident #50 BIMS was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Probiotic oral capsule (Saccharomyces boulardii), give 1 capsule by mouth 2 times a day for antibiotic use, and Saccharomyces boulardii oral packet 250 mg (Saccharomyces boulardii), give 250 mg by mouth 2 times a day related to osteomyelitis. Record review identified that Resident #50 's scheduled medication for 4/28/2025 at 9:00 AM were administered at 1:53 PM, 3 hours 53 minutes after the allowed timeframe. 12. Resident 55's diagnoses included diabetes, hypertension and depression. The quarterly MDS assessment dated [DATE] identified Resident #55 BIMS was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025, directed to administer Eliquis tablet 5 mg (Apixaban) 5 mg by mouth 2 times a day for anticoagulant, Gabapentin tablet 400 mg by mouth 3 times a day for neuropathy, and Tylenol extra strength tablet 500 mg (Acetaminophen) 2 tablets by mouth 2 times a day for pain. Record review identified that Resident #55 's scheduled medications for 4/28/2025 at 9:00 AM were administered at 1:30 PM, 3 hours 30 minutes after the allowed timeframe. 13. Resident 56's diagnoses included end stage renal disease, diabetes and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #56 BIMS was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Novolog Flex pen subcutaneous solution Pen-injector 100unit/ml (insulin Aspartate) inject 15 unit subcutaneously before meals for diabetes. Record review identified that Resident # 56's scheduled medications for 4/28/2025 at 8:00 AM were administered at 10:08 AM, 1 hours 8 minutes after the allowed timeframe. 14. Resident 68's diagnoses included coronary artery disease, retention of urine depression, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #68 BIMS was 14 indicating no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Acetaminophen Oral Tablet, give 325 mg by mouth 4 times a day for pain related to atherosclerotic heart disease of native coronary artery without angina pectoris. Record review identified that Resident #68's scheduled medications for 4/28/2025 at 9:00 AM were administered at 11:30 PM, 1 hour and 30 minutes after the allowed timeframe. 15. Resident 75's diagnoses included dementia, hemiplegia and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #75 BIMS was 13 indicating no cognitive impairment. Physician's orders for the month of April 2025, directed to administer Diclofenac Sodium external gel 1 % (topical), apply to the back of the neck topically 4 times a day for pain/inflammation 2 g. Record review identified that Resident #75 's scheduled medications for 4/28/2025 at 9:00 AM medications were administered at 12:21 PM, 2 hours and 21 minutes after the allowed timeframe. 16. Resident 77's diagnoses included diabetes, hypertension and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #77 BIMS was 99 indicating severe cognitive impairment. Physician's orders for the month of April 2025 directed to administer Lovenox injection solution prefilled syringe 60 mg/0.6ml (Enoxaparin Sodium). Inject 60 mg subcutaneously every 12 hours for right lower extremity deep venous thrombosis and Humalog injection solution 100 unit/ml (Insulin Lispro), inject as per sliding scale: subcutaneously before meals and at bedtime for diabetes. Record review identified that Resident #77 's scheduled medications for 4/28/2025 at 9:00 AM were administered at 12:44 PM, 2 hours, 44 minutes after the allowed timeframe. 17. Resident 233's diagnoses included hypertension, anxiety and arthritis. The quarterly MDS assessment dated [DATE] identified Resident #233 BIMS was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025, directed to administer Apixaban oral tablet 2.5 mg give 1 tablet by mouth 2 times a day for anticoagulant, buspirone HCl oral tablet 5 mg give 1 tablet by mouth every 12 hours for mood, Loperamide HCl oral capsule 2 mg, give 1 capsule by mouth 2 times a day for antidiarrheal, and clonidine HCl oral tablet 0.1 mg give 1 tablet by mouth 3 times a day for blood pressure. Record review identified that Resident #233 's scheduled medications for 4/28/2025 at 9:00 AM medications were administered at 1:41 PM, 3 hours and 41 minutes after the allowed timeframe. 18. Resident 282's diagnoses included diabetes, hypokalemia (low potassium) and iron deficiency anemia. The admission MDS assessment dated 2/25 /2025 identified Resident #282 BIMS was 15 indicating no cognitive impairment. Physician's orders for the month of April 2025 directed to administer Tums oral tablet 10mg (Calcium carbonate (antiacid)). Give 1 tablet 2 times a day for hypocalcemia. Record review identified that Resident #282's scheduled medications for 4/28/2025 at 9:00 AM were administered at 1:25 PM, 3 hours and 25 minutes after the allowed timeframe. Observation and interview with RN #2 on 4/28/25 at 12:30 PM identified that she was in the hallway still passing 9:00 AM meds. RN #2 identified that facility had experienced 3 nurse call outs for the 7:00 AM to 3:00 PM shift and efforts for replacements had failed. RN #2 identified that she was fairly new to the facility and had been hired as an Infection Prevention nurse. RN #2 further identified that she had been scheduled to attend her infection control training/orientation in a different facility but while on her way, she was told to come back to the facility and work as a floor RN due to multiple call outs. RN #2 identified that she had arrived back to the facility about 9:00 AM, received report and assumed her role as a floor nurse. Additionally, RN #2 identified that several residents were still awaiting their 9:00 AM meds and indicated that she was slow in passing meds because she started the medication pass late and she had never worked or received orientation on the unit. RN #2 indicated that she had reached out to the DNS about 10:00 AM and expressed concern about the delay in medication pass, but the DNS indicated that she was aware of the situation and had encouraged her to do the best she could. Interview with the Chief Clinical and Safety Officer (CCSO) on 4/28/2025 at 1:00 PM, identified that he had learned of the delay in resident medication administration not long ago and had reallocated staff to help with the medication pass. The CCSO indicated they had experienced multiple call outs and were unable to find replacements. The CCSO indicated that he was not aware that RN #2 had reached out to the DNS and had expressed her concern of the delay in medication administration. Re-interview with the CCSO on 4/28/2025 at 2:00PM identified that he had reached out to the facility's Medical Director, who was physically in the building conducting residents' assessments, to identify any harm or potential harm due to the delay in medication administration. Review of residents' medical records identified that there was no actual harm that resulted due to the delay in medication administration. A review of the Administration of Medications Policies and Procedures policy directed, in part, that medications should be administered within 60 minutes of the scheduled administration time except before, with or after meal orders, which are administered based on mealtimes. The five rights of medication administration, right resident, right drug, right dose, right route and right time are applied for each medication being administered.

Based on clinical record review, facility policy, and interviews for 1 of 2 residents, (Resident #22), reviewed for food, the facility failed to accommodate a resident's preferences for meal items. The findings include: Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent on transfers, required maximal assistance with bed mobility, and utilized a motorized wheelchair. A Nutrition assessment dated [DATE] identified Resident #22 was on a LCS diet, had food preferences that should be honored, was to receive large portions, and was to receive a bedtime snack daily. The Resident Care Plan (RCP) dated 3/5/2025 through 4/29/2025 identified Resident #22 was on a regular LCS diet. Interventions included ethnic foods, encourage to eat healthier options, and provide bedtime snacks every evening shift. Physician orders in effect from 11/1/2019 though 4/29/2025 identified Resident #22 was on a low calorie sweetener (LCS) diet of regular texture with liquids at a thin consistency. An interview with Resident #22 on 4/29/2025 at 9:49 AM identified he/she is given boneless pieces of chicken, instead of chicken legs and boned chicken thighs, and provided with bland tasting meals despite making the facility aware of his/her food preferences. Resident #22 further stated he purchased his/her own food outside of the facility and kept peanut butter and jelly, fruit, and other food items in his room because the facility did not accommodate his food requests. Review of the clinical record identified a Social Services note dated 6/27/2023 and written by Social Worker #1 identifying that the Director of Food Services was made aware of Resident #22's preferences, at that time, and indicated he had ordered meat pies, jerk seasoning, and bone-in chicken wings and thighs to meet Resident #22's preference for cultural meals. An interview with the Director of Food Services on 5/5/2025 at 8:14 AM identified he was aware of Resident #22's cultural requests for food and had purchased Jamaican meat pies and fresh fruit. The Director of Food Service stated he would not buy bone in meat because he believed it was a choking hazard and should never be in a long term care facility. He identified Resident #22's needs were being met with the Jamaican meat pies. The Director of Food Service failed to provide evidence that any Jamaican meat pies were currently in the facility's freezer or refrigerator and stated he must have used them all up. An interview with the Director of Nursing Services (DNS) on 5/5/2025 at 9:58 AM identified she was aware of Resident #22's food preferences and indicated the Director of Food Services was responsible for accommodating food requests. She further identified that she was not aware that Resident #22's food preferences were not being accommodated according to his/her request and RCP. Although requested the facility failed to provide a policy for accommodating a resident's food preferences.

Based on observations, facility documentation, facility policy, and interviews the facility failed to ensure the steam table was washed and sanitized after every use, failed to ensure open food items were appropriately dated, and failed to ensure expired foods were removed from storage. The findings include: During a tour of the kitchen with the Director of Food Services on 4/28/2025 at 9:50 AM the following was identified: a. 2 half gallons of milk, each with an expiration date of 4/23/2025, were on a drink cart and were not set in ice. 1 half gallon was 1/2 full and 1 half gallon was full. An interview with the Director of Food Services identified that he was not aware the milk was expired and indicated the milk was intended to be used to serve the residents. b. The walk-in fridge had a soup bowl containing tuna salad dated 4/10/2025. c. 1 tray of cranberry jelly/sauce was dated 2/9/2025. d. 1 tray of cranberry jelly/sauce was dated 4/9/2025. e. 1 open plastic container of cranberry jelly was dated 4/6/2025. f. 2-12 ounce open bags of non-dairy topping, both 1/8 full, was noted to be undated. g. The walk-in freezer was found to have 1 bag of approximately 4 dozen frozen egg patties. The bag was open to air and undated. h. The milk refrigerator was found to have an open and undated 5 pound bag of shredded white cheese that still contained approximately 1 ½ pounds. Tour of the resident dining room with the Director of Food Services on 4/28/2025 at 10:45 AM identified the following: i. The steam table was found to have crusted red food on the sneeze guard. j. One ant was crawling in and out of a chafing dish. k. Crumbs of food were located on the table of the steam table and around 4 chafing dishes. l. Water in 3 of the chafing dishes was discolored and had floating food particles. m. There were stuck on food particles on the outside of the steam table cart. n. Three dirty plates were in chafing dish #2. An interview with the Director of Food Services identified the water in the chafing dishes had not been changed in a few days. A second observation of the steam table with the Director of Food Services on 4/29/25 at 9:15 AM identified the chafing dish lids had food debris on the edges and the side tabletop and bottom shelf had not been cleaned. Further, he indicated that the steam table and side table were not cleaned with sanitizing spray as he uses a scouring powder instead. An interview with the Director of Food Services on 5/1/2025 at 12:25 PM identified the water in the chafing dishes should be emptied after every meal and the steam table should also be cleaned at that time. A third observation of the steam table with the Director of Food Services on 5/5/2025 at 8:06 AM identified the water in the chafing dishes had floating food particles. The Director of Food Services identified that the chafing dishes were not scrubbed and should have been run through the dishwasher. The facility's food policy identified, in part, that all items stored in the refrigerator will be covered, labeled with the contents and date, and prepared foods must be discarded within 3 calendar days of preparation. Further the policy stated that the steam table will be maintained in a safe and sanitary condition.

F814 [NAME] final Scope and Severity: E Based on observation and interview, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner and refuse was appropriately contained. The findings include: Observation of the facility's dumpster area with the Director of Food Service on 4/28/2025 at 10:24 AM identified the following items littered on the ground in front of 2 dumpsters: a. One, 3 cushion sized couch, flipped upside down, with visible water stains and dirt. b. One wood table with padding, upside down with wood in various stages of decomposition/rot. c. One tabletop with cover and foam. Foam was disintegrating and pieces of foam had been chewed away. d. Five cardboard boxes. e. One pedestal table with a metal base. f. One snow shovel. g. One used incontinence disposable under pad (Chux pad). h. Multiple used face masks, used bandages, paper scraps, plastic bags, and Styrofoam cups. An interview with the Director of Food Service on 4/28/2025 at 10:24 AM identified that he had just swept the area around the dumpster and indicated the wind often blew trash against the fence. He further indicated he was aware of a rodent problem near the dumpster and the pest control contractor had placed multiple traps outside of the dumpster area to catch the rats before they entered the facility. The Director of Food Services stated the couch, and tables had been on the ground for about a year and the Director of Maintenance was responsible for removal. An interview on 4/28/2025 at 10:28 AM with the Director of Maintenance identified he was aware of the garbage and used furniture in front of the dumpsters. He stated his request for a dumpster from corporate was denied and calls to local trash haul-away companies were too expensive. An interview with the facility's Chief Clinical Officer on 4/29/2025 at 8:56 AM identified he was made aware of the trash problem near the dumpster on 4/28/2025 by the Director of Maintenance but he had not personally seen the trash issue. An interview and observation with the facility's Chief Clinical Officer on 4/29/2025 at 9:02 AM of the facility's dumpster area identified that the items observed with the Director of Food Service remained as previously observed. The Chief Clinical Officer stated the amount of garbage was greater than what he understood it to be, and he would need to order a dumpster to remove all of the items. The Chief Clinical Officer identified that he was uncertain of the specifics of the facility's policy, but the facility should ensure garbage bags are tied, and all medical/procedure gloves must be bagged and tied. Although requested a facility policy on refuse and garbage storage and disposal was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #55) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from neglect. The findings include: Resident #55's diagnosis included anxiety, morbid obesity, osteoarthritis, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively intact (no cognitive deficit), and required the extensive assistance of 2 staff with bed mobility, the assistance of 1 staff with toilet use, and was occasionally incontinent of urine and frequently incontinent of bowel. The care plan dated 4/12/23 identified an allegation of abuse, neglect, related to lengthy call bell response times. Interventions included to provide requests for help with elimination in a timely manner. Interview with Resident #55 on 5/18/23 at 10:54 AM identified that on Sunday night (5/14/23) s/he sat in feces for about 3 hours on the 3:00 PM to 11:00 PM shift. Resident #55 indicated that there were no nurse aides for his/her unit after 7:30 PM leaving two licensed nurses to provide care. Resident #55 indicated that s/he had notified Social Worker #1 of the lack of incontinence care provided to him/her. Resident #55 stated that s/he had a dietary reaction causing him to have diarrhea and be incontinent of stool. Further, Resident #55 indicated that he felt embarrassed and was uncomfortable from sitting in stool for too long. Review of the facility grievance form dated 5/16/23 identified that Resident #55's agency Nurse Aide, NA #4, gave a terrible wash-up/bed bath, there were long call bell wait times, NA #4 left him/her in a soiled brief for too long after a loose bowel movement making him/her feel very uncomfortable, and the situation was embarrassing. The grievance form indicated that all the these problems occurred with NA #4 over the same weekend. Further, the grievance form identified that Social Worker #1 had interviewed Resident #55, had notified nursing and the Administrator, and that the corrective action, to educate the NA on proper bed baths and call bell response times, had been provided, thereby resolving Resident #55's concern. Review of the licensed nurse and social worker progress notes dated 5/12/23 through 5/22/23 failed to identify Resident #55 had any complaints of the weekend of 5/13/23 to 5/14/23. Review of the facility staffing dated 5/13/23 and 5/14/23 identified NA #4 had left the facility at 7:30 PM without a scheduled replacement NA. Interview with Social Worker #1 on 5/22/23 at 9:27 AM identified that Resident #55 was a great advocate for him/herself. Social Worker #1 indicated that Resident #55 had specified that s/he, on 5/14/23, had remained in a feces, (diarrhea), in a soiled brief for 1 hour. Social Worker #1 stated that Resident #55 reported waiting a couple of hours for a response to the call bell and that s/he was told by LPN #10 on 5/14/23, that the facility was short-staffed. Social Worker #1 identified that she had informed the Administrator and the Staff Development Nurse of the allegation of neglect but was unaware if there was a current DNS at the time. Social Worker #1 stated that Resident #55's allegation, according to the facility abuse policy, was an allegation of neglect and should have been reported to the Department of Public Health. Social Worker #1 indicated that Resident #55 had experienced undignified treatment and that Resident #55's allegation of mistreatment was an act of neglect. Interview with the Administrator on 5/22/23 at 1:20 PM indicated that she had talked to Social Worker #1 and felt that there was not enough information to report the allegation to the Department of Public Health. The Administrator indicated that, in review, Resident #55's allegation of neglect should have been reported. Additionally, the Administrator identified that Social Worker #1 had gone to speak with Resident #55 and that there should have been a note in the clinical record. Interview with the DNS on 5/22/23 at 3:15 PM identified that she had not been made aware of the allegation of neglect. Interview with Supervising Registered Nurse #1, on 5/25/23 at 1:35 PM identified that she had worked on 5/14/23 from 7:00 PM to 7:00 AM but had not been notified that Resident #55 had a complaint about NA #4. Interview and review of the facility grievance log with Corporate RN #2 on 5/25/23 at 1:35 PM identified that the incident has now been reported to the Department of Public Health as an allegation of neglect. Although RN #2 indicated that he had conversed with the charge nurse who was caring for Resident #55 at the time of the incontinence incident and was told that the LPN offerred Resident #55 the bed pan, he did not indicate why Resident #55 had been left in soiled incontinent product for from approximately 1 to 3 hours. Attempts to interview NA #4, NA #14, LPN #10, and RN #8 (who worked on 5/14/23 from 7:00 AM to 7:00 PM), were unsuccessful. Review of the facility Grievance Policy dated 12/5/16, identified, in part, that allegations of abuse, would be addressed in accordance with state law and the facility's policies regarding abuse. Review of the Abuse policy identified, in part, that Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident, that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Investigation/Protection of a resident includes completing a Reportable Event form, documentation of the description of the incident in each resident's nursing notes, notification of the Department of Public Health, completion of an investigation, interviews of witnesses including the accused, and interviews with any party having knowledge useful to the investigation. All alleged violation involving abuse will be reported to DPH immediately, but not later than 2 hours after the allegation is made.

Based on observations, review of facility documentation, review of sampling quality reports, and interviews, the facility failed to conduct an assessment prior to the implementation of carpet and floor removal including but not limited to asbestos testing. The facility initiated the scope of work by allowing vendors to rip up carpeting and underlying flooring (which was later determined to contain asbestos) on 2 nursing units during the hours of 8:00 AM and 5:00 PM, resulting in gaps in flooring and uneven surfaces, floors laden with loose tile fragments, and an inability to effectively clean these surfaces. Residents were observed in the hallways seated in wheelchairs and ambulating through the debris. This posed an immediate risk to the health and safety of residents residing in these units. Sixty-nine (69) residents were evacuated from the facility on 3/9 and 3/10/23 resulting in a finding of Immediate Jeopardy. Facility capacity: 90 Facility census: 81 The following was observed on 3/9/2023 at approximately 10:45 AM along with the facility Maintenance Director: a. The carpeting for South Wing had been completely removed in the corridors and the floor had residual black mastic/floor glue (raised surfaces) apparent throughout the South Wing corridors. b. The flooring contractor was observed on the North wing pulling back carpet with nine (9) by nine (9) inch flooring tiles underneath the carpet that were lifting and identified as Possibly Asbestos Vinyl Tiles. Tile fragments and loose tiles were observed in the area where the carpeting had already been removed. c. The North and South wing door thresholds to resident rooms throughout both hallways and floor surfaces were uneven, posing potential accident hazards. Further, the North wing floor contained tile debris, also posing potential accident hazards as residents of the facility. Residents were observed to be sitting in the hallway in wheelchairs (Resident #1, 2, 3, 4, 5, and 6) and Resident #7 was noted to be ambulating from the South wing and into the North wing unaccompanied where there were loose broken tiles on the floor. d. Observation of the construction dumpster behind the building on 3/9/23 at 11:30 AM identified that the carpeting that had been removed from the South and North Wings along with tile fragments and full tiles were inside the dumpster. The project was stopped after observations of unsafe practices of carpet and flooring removal putting residents at risk resulting in Immediate Jeopardy. The facility failed to mitigate risks to ensure the safety of all residents. e. The survey team observed at approximately 6:30 PM, the facility's negative air machines arrived from a contracted vendor and the company placed 4 negative air machines within the facility; two (2) on the north center wing that had the suspected asbestos disturbed tiles and one (1) on each of the south wings (south center, south shore). At approximately 7:00 PM after the contractor exited the facility it was identified that the machines were not properly installed to maintain negative air and was not ventilated to the exterior of the facility. The machines were exhausting directly into the north center wing hallway. The machines were turned off, unplugged and secured until proper ventilation could be established. The facility requested the company return to the building to establish proper negative air for the facility corridors. At approximately 10:30 PM, the company returned to the facility and properly established negative air for the facility corridors to the exterior of the facility. Interview with the Staff Development Nurse on 3/9/23 at 11:30 AM stated she was informed by corporate staff on 3/6/23 that a carpeting vendor would be coming to the facility to remove and replace the flooring throughout the North and South wings with hardwood vinyl plank flooring. On 3/7/23, work was started by the vendor at 8:00 AM, they worked throughout the day and removed the carpeting out of the south center and south shore wing. The work was loud and disruptive to the unit and ended at 5:00 PM. Interview with Licensed Practical Nurse (LPN) #1 (the charge nurse on North wing) on 3/9/23 at 11:00 AM identified the census on that unit was 30 residents, six (6) residents of which had respiratory diagnoses and required oxygen therapy. Interview with LPN #2 (the charge nurse on South wing) on 3/9/23 at 11:15 AM identified that the census was thirty-nine (39) residents, six (6) of which had respiratory diagnoses, five (5) were dependent on oxygen, and Resident #8 had a tracheostomy (a surgical opening in the neck where a tube is inserted to assist in breathing). Interview with the Chief Operating Officer (COO) on 3/9/23 at 12:30 PM identified that the facility had started the carpet removal on 3/7/23 and had failed to notify the State agency of the flooring project, and neither the facility and/or contractor had the areas tested for asbestos containing materials prior to the flooring project being initiated. Further interview with the COO identified that an environmental consultant was contracted by the facility to test and analyze tile, carpeting, mastic ( floor glue), and air samples for asbestos. The facility had also arranged for negative air machines delivered for a total of 4 negative air machines within the facility two (2) on the North center wing that had the suspected asbestos disturbed tiles and two (2) on the South wings. Review of the Air Quality report dated 3/10/23 identified that a contracted company conducted asbestos ambient air and bulk samples in response to a carpet removal project in hallways North and South where black adhesive was discovered along with a section of 9x9 floor tile (approximately 720 square feet). The samples obtained from the North wing contained 1 percent or greater of total asbestos and should only be handled by a licensed asbestos contractor if disturbed. Asbestos was classified by the Federal Government as a carcinogenic (cancer producing) material. During the period of 3/9/23 at 5:00 PM until 3/10/23 at 5:15 AM, sixty-nine (69) residents were transferred to other skilled nursing facilities for continued care as a result of the unsafe environment that resulted in Immediate Jeopardy. The Immediate Jeopardy was removed on 3/10/23 when the evacuation of residents who resided on the South and North units was completed.

Based on clinical record review, review of facility documentation , review of facility policies and procedures and interviews for two of seven residents (R #2 and #3) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings include: R #1's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified R #1 was confused, unable to state the correct day, month or year, unable to recall words, had no behaviors in the last seven days, and required supervision of one staff for walking in the room or hall. The Resident Care Plan (RCP) dated 1/2/19 identified R #1 exhibited sexual inappropriate behaviors, and touched other residents/visitors inappropriately in the past with interventions that directed to provide diversional activity as needed, every 15 minute checks as ordered, monitor resident's emotional status, and a referral to psychiatry services. A physician's orders [REDACTED].#1 was in his/her room, and 1:1 supervision while R #1 was out of his/her room. Review of the progress note dated 1/23/19 identified that the R#1's status was changed to every 15 minute checks. Review of the physician order [REDACTED]. Further review identified that even though R#1 was on every 15 minute checks, the resident was still able to touch other residents inappropriately. a. R #2's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified that R #2 was alert/oriented, used a wheelchair, and required supervision for locomotion on the unit. Review of the nurse's note dated 2/6/18 at 4:41 PM identified R #2 stated R #1 came up behind him/her and grabbed his/her breast. Review of facility documentation dated 2/6/18 at 4:30 PM identified the incident occurred in a common area of the building, no staff witnessed the incident. R#1 was subsequently placed on 1:1 supervision until seen by psychiatry. Review of the psychiatry note dated 2/7/19 indicated that the recommendation was to downgrade the 1:1 supervision to every 15 minute checks. Interview and review of the clinical record with the DON on 3/5/19 at1:21 PM identified R #1 was independent with use of a walker, staff were aware of R #1's prior history of sexually inappropriate behavior, and that staff should redirect R #1 away from female residents. The DON stated that R #2 was in his/her wheelchair, and R #1 put his/her hand down R #2's shirt. Further interview with the DON identified that R #1 was not on 1:1 supervision at that time, but staff should have monitored R #1 when out of his/her room, and staff should have redirected R#1 away from R # 2. b. R #3's [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] identified R #3 was confused, unable to recall words, the correct day, month or year, and walked independently. Review of facility documentation dated 2/17/19, reported at 2:30 PM, identified another resident reported witnessing R #1 grab R #3's groin while sitting on the couch outside the DON's office. The documentation further identified the cause of the incident was that R#1 had disinhibiting behaviors but was allowed to sit in close proximity of a female residents. R#1 was then placed on 1:1 supervision. Interview and review of the clinical record with the DON on 3/5/19 at1:21 PM identified R #1 was independent with use of a walker, staff were aware of R #1's prior history of sexually inappropriate behavior, and staff should redirect R #1 away from female residents. The DON indicated that the incident occurred when R #1 and R # 3 were located in the common area outside the DON's office, and staff should have been in the area at the time of the allegation. In addition, staff should have separated the residents when they were both on the couch before the incident occurred. Further interview with the DON indicated that R #1 was not on 1:1 supervision at that time, staff should have monitored R #1 when out of his/her room, and staff should have redirected R#1 away from R #3. Review of facility Reporting Abuse To Facility Management Policy directed in part, the facility will not condone resident abuse by anyone, including staff members, or other residents.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of seven residents (R #1, R#2), reviewed for abuse, the facility failed to provide adequate supervision to prevent an incident of inappropriate touching for a resident with a history of inappropriately touching other residents and/or visitors. The findings include: R #1's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified R #1 was confused, unable to state the correct day, month or year, unable to recall words, had no behaviors in the last seven days, and required supervision of one staff for walking in the room or hall. The Resident Care Plan (RCP) dated 1/2/19 identified R #1 exhibited sexual inappropriate behaviors, and touched other residents/visitors inappropriately in the past with interventions that directed to provide diversional activity as needed, every 15 minute checks as ordered, monitor resident's emotional status, and a referral to psychiatry services. A physician's orders [REDACTED].#1 was in his/her room, and 1:1 supervision while R #1 was out of his/her room. Review of the progress note dated 1/23/19 indicated that the resident was to continue every 15 minute checks and redirection as needed and had usual behaviors/wandering to the lobby to sleep on couches. Although the progress note on 1/23/19 identified the resident was on every 15 minute checks, the clinical record failed to reflect the rationale for discontinuing the 1:1. A physician order [REDACTED]. a. R #2's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified that R #2 was alert and oriented, used a wheelchair, and required supervision for locomotion on the unit. Review of the nurse's note dated 2/6/19 at 4:41 PM identified R #2 stated R #1 came up behind him/her and grabbed his/her breast. Review of facility documentation dated 2/6/19 at 4:30 PM identified the incident occurred in a common area of the building, no staff witnessed the incident, and R #1 was subsequently placed on 1:1 supervision until seen by psychiatry. Review of the clinical record, facility documentation and interview with DON on 3/5/19 at1:21 PM identified that R #1 was independent with use of a walker, staff were aware of R #1's prior history of sexually inappropriate behavior, and staff should redirect R #1 away from female residents. The DON stated R #2 was in his/her wheelchair, and R #1 put his/her hand down R #2's shirt. Further interview indicated that R #1 should have been redirected away from R #2. Review of the psychiatry note dated 2/7/19 indicated that the recommendation was to downgrade the 1:1 supervision to every 15 minute checks. b. R #3's [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] identified R #3 was confused, unable to recall words, the correct day, month or year, and walked independently. Review of facility documentation dated 2/17/19, reported at 2:30 PM, identified another resident reported witnessing R #1 grab R #3's groin while sitting on the couch outside the DON's office. Further review identified that the cause of the incident was that R#1 had disinhibiting behaviors but was allowed to sit in close proximity of a female resident. Interview with R #5 (alert/oriented) on 3/5/19 at 12:35 PM identified on 2/17/19 he/she witnessed R #1 touch R 3's groin, and R #3 responded by standing up, yelling at R #1, and then walked away from R #1. Review of the clinical record, facility documentation and interview with the DON on 3/5/19 at 1:21 PM identified that R #1 was independent with use of a walker, staff were aware of R #1's prior history of sexually inappropriate behavior, and staff should of redirected R #1 away from female residents. The DON stated the incident occurred when R #1 and #3 were located in the common area outside the DON's office, staff should have been in the area at the time of the allegation. In addition, the DON stated that staff should have separated the residents when they were both on the couch before the incident occurred. c. Review of facility documentation dated 2/17/19 at 2:40 PM identified LPN #2 witnessed R #1 in the hall near the nurse's station, reach his/her arm around a four (4) year old visitor and grab his/her buttocks. The visitor was observed to move away from R #1, and say that was not appropriate, why did you grab my butt? R #1 was subsequently placed on 1:1 supervision. Review of the clinical record, review of facility documentation and interview with RN #3 on 3/5/19 at 12:02 PM identified on 2/17/19, she heard the minor visitor say that's naughty, you don't touch a little girl's private parts. RN #3 indicated that LPN #2 told her that R #1 had grabbed the minor visitor's buttocks. Interview with R #5 (alert and oriented resident) on 3/5/19 at 12:35 PM identified on 2/17/19 after the incident occurred indicated that he/she asked the minor visitor to demonstrate what had happened, and the visitor put his/her hands inside the back of his/her mother's pants against the skin and said that is what he did. Review of clinical record, facility documentation and interview with the DON on 3/5/19 at1:21 PM identified that R #1 was independent with use of a walker, staff were aware of R #1's prior history of sexually inappropriate behavior with other residents/visitors, and that staff should of redirected R #1 away from female residents and/or visitors. Further interview with the DON stated that the incidents on 2/6/19 and 2/17/19 occurred in public areas of the facility where staff should have been monitoring R #1. The DON further stated R #1 staff should have monitored R #1 when out of his/her room, and staff should have redirected R #1 away from the situations before they occurred.

Based on observations, clinical record review and staff interview for 1 of 1 sampled resident who verbalized suicidal ideation, (Resident # 10) the facility failed to immediately assess and/or monitor and/or initiate interventions to ensure the safety of a resident who expressed a wish to die on multiple occasions resulting in a finding of immediate jeopardy. The findings include: Resident # 10 was admitted to the facility on [DATE] for respite care. [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified moderately impaired cognition, and limited assistance with ADL's. The RCP dated 7/5/18 identified [MEDICAL CONDITION] medication use for depression. Interventions included administer medications as ordered, monitor for decline in mood, and behaviors. Additionally the care plan identified the resident was at the facility for respite care and interventions included to work with family to set up home care services and evaluate discharge potential. a. Nurse's notes dated 7/9/18 at 1:47PM identified Resident #10 asked the NA can I request to die? The note identified that this was immediately reported to the DON for proper notifications and actions to be taken. The note further identified the nurse spoke to Resident # 10 who stated he/she had no plans related to dying and stated whatever God's plan is for me. The note further identified that the statement was reported to the physician, the residents name was placed in the psychiatry (psych) book to be seen, and the DON was to follow through. Interview with MD # 1 on 7/12/18 at 1:50PM stated that she was made aware on 7/9/18 that during the day shift Resident #10 requested to die (but did not assess the resident). MD # 1 stated that she directed to place the resident on every fifteen minute checks and that the resident be seen by psych. MD # 1 stated that she did not feel that Resident #10 needed to be on a one to one. Review of the clinical record and interview with the DON on 7/12/18 at 2:00PM failed to identify that psych was notified of the resident's verbalizations of wanting to die and/or kill self. The DON stated that every fifteen minute checks were to be completed on the resident (per MD direction). Review of the clinical record identified that every 15 minute checks were not started on the resident until 7/11/18 (2 days after the MD directed staff to implement them) and could not explain why they were not done. Additionally, review of Resident #10's care plan identified that it was not updated regarding the resident's wish to die to include safety interventions/precautions. b. LPN #1's nurse's note dated 7/9/18 at 11:30PM identified Resident # 10 verbalizes despair over wife leaving (being discharged ). The note identified the resident stated my wife left me and she hates my guts, all I need to do is die now. The note further identified that one to one was provided. Review of the clinical record with the DON on 7/12/18 at 2:30PM failed to identify the resident was assessed for suicidal ideation, and/or the physician was made aware of the resident's wish to die. Interview with LPN # 1 on 7/16/18 at 11:40AM (from messages left on 7/12/18) stated that when she was assisting the resident into bed around 7:30PM the resident stated my wife left me and she hates my guts, all I need to do is die now. LPN # 1 stated that when she documented provided one to one, she meant she provided reassurance to the resident at that time. LPN # 1 stated that she did not assess the resident for a plan to harm self or a means to do so. LPN # 1 further stated that she did not notify the physician or pass it on to the next shifts because it was a busy night. c. Nurse's notes dated 7/12/18 at 12:15PM identified NA reported that Resident # 10 stated I want to kill myself, what is the point of living. The note further identified the nurse immediately reported it to the DON for her to proceed with proper actions and notifications. The note stated that the nurse spoke to the resident and he/she had made no plans to kill him/herself and denied the means to do so. Additionally the note identified the DON was to follow through and the resident was kept in a common area for safety. Interview with the DON on 7/12/18 at 12:20PM stated that Resident # 10 again verbalized wanting to kill him/herself and that she needed to put the resident on a one to one supervision. Review of the facility policy for suicide threat identified if suicide actions/ideations are suspected, the licensed nurse will immediately intervene, conduct an assessment and initiate safety measures for the resident's protection. The policy further identified that the nurse will attempt to interview the resident to assess the severity of the suicidality. Additionally, the policy identified one to one direct observation of the resident until the resident can be transferred to psychiatric/acute care facility or psychiatrist deems the resident not a threat to self or others. Observation at 12:27PM noted that Resident # 10 was sitting in a wheelchair at a dining room table with 3 other residents present. Observations at that time noted that the resident did not have a staff member with him/her providing one to one supervision, and that a knife was in front of the resident on the table. Upon surveyor inquiry of the knife, the DON was observed to remove the knife from the table. The DON stated it was going to be NA # 5 to provide one to one supervision for Resident # 10. Observations identified although NA #5 was then seated next to the resident, NA # 5 was noted to be talking to the other residents at the table, turning around to talk with other staff members, and was not observing Resident #10 at all times. Subsequently, the DON was observed to speak to NA # 5 and explain that she needed to watch and be with the resident at all times. Interview with LPN # 2 on 7/12/18 at 12:45PM stated that while she was doing the medication pass around on 7/12/18 at 9:00AM, NA # 6 reported to her that Resident # 10 verbalized that he/she wanted to kill him/herself. LPN # 2 stated that she placed the resident in the hallway while she continued on with her med pass because the resident was already on every fifteen minute check (not in constant observation of the resident). LPN # 2 further stated that when she finished her med pass around 10:30AM (1 and 1/2 hours later) she reported to the RN supervisor that the resident stated he/she wanted to kill him/herself. Interview with RN # 1 (RN Supervisor) on 7/12/18 at 12:52PM stated that after LPN # 2 completed the medication pass (approximately 10:30AM) she reported that the resident wanted to kill him/herself. The DON was paged but she didn't get a hold of her. RN # 1 stated that she found the DON around 12:15PM (approximately 3.5 hours after resident stated he/she wanted to kill self) and reported to the DNS that Resident # 10 verbalized he/she wanted to kill him/herself. RN # 1 stated that although she did ask the resident if he/she had a plan she did not assess the resident further or check to see if the resident had any sharp objects, or notify the MD. RN # 1 further stated that she wrote in her nurse's note that she notified the DON immediately, but did not notify her until 1.75 hours later because she had to find her and she was busy doing other things. Interview with the DON on 7/12/18 at 1:10PM stated that she was not made aware that Resident # 10 verbalized wanting to kill him/herself at 9:00 AM until notified by the supervisor at 12:15PM. The DON stated that when NA # 6 reported the resident verbalized wanting to kill him/herself to the LPN at 9:00AM, the LPN should have immediately placed the resident on one to one supervision, notified the RN Supervisor, ensured the resident was safe in the surroundings and notify the MD and psych services. Interview with NA # 6 on 7/12/18 at 1:35PM stated that while she was providing care to Resident # 10 on 7/12/18 at 9:00 AM the resident stated several times he/she wants to die and I want to kill myself. NA # 6 stated she immediately brought the resident to LPN # 1 and reported what the resident said. Interview with MD # 1 on 7/12/18 at 1:50PM stated that she and/or her service were not made aware that Resident #10 again stated on 7/9/18 during the 3-11 shift that he/she wanted to die. The MD stated that had she been notified she would have placed resident on a one to one until seen by herself or psych. Additionally, the MD stated that the DON came to her today (7/12/18) regarding the resident wanting to kill him/herself and she order the resident be placed on one to one until assessed by psych. Subsequently, the facility provided an action plan that identified all residents would be assessed for suicidality, residents with suicidal thoughts would be placed on one to one supervision, the resident would be assessed, physician and family notified, a psychiatric evaluation would be completed, and staff on duty were re-educated on the facilities suicide policy.

Based on review of the clinical record, facility documentation and interviews for the only sampled resident reviewed for wandering and behaviors (Resident #111), the facility failed to provide adequate supervision to a resident with a history of eating non-edible items which resulted in a choking incident, hospitalization and Myocardial Infarction due to hypoxemia and/or failed to ensure appropriate supervision was implemented when the resident returned from hospitalization resulting in a finding of immediate jeopardy. The findings include: Resident #111's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] and 4/30/14 identified the resident had severe cognitive impairment, required extensive assistance with ADL's, supervision while ambulating, and had no signs of coughing or choking during meals. The 4/30/14 quarterly MDS assessment further identified the resident wandered daily. The Choking Risk assessment dated [DATE] identified the resident was a high risk for choking and the Choking Risk assessment dated [DATE] identified a medium risk for choking. Review of nurse's notes and the care plans from 1/10/14 to 7/31/14 identified the following incidents: 2/8/14: The resident ate oasis (floral Styrofoam) from artificial floral centerpieces in the dining room and the care plan directed the staff to remove the centerpieces. 4/7/14: The resident was observed eating sugar packets on a regular basis and was unaware that it was not food. No new interventions were identified in the care plan. The Psychiatry progress note dated 4/9/14 identified recent episodes of eating inedible items (paper) or whole sugar packets. "Likely these behaviors caused by a combination of cognitive impairment and anxiety, and possibly used by the resident for relief of tension". The recommendation was to increase Zoloft to 125mg every day. 4/10/14: The resident was found with a rock in his/her mouth. 4/12/14: The resident was observed eating artificial flowers and sugar packets. 4/13/14: The resident ate a paper chux (incontinent bed protector). 4/16/14: The resident ate a breakfast dietary slip. 4/19/14: The resident ate the base of a medication cup and aluminum foil. The Psychiatry progress note dated 4/23/14 indicated the resident had "no recall of reported behaviors. Attempts to eat inedible items likely caused by underlying anxiety in the setting of cognitive impairment". Recommendations included to increase Xanax to twice a day. 5/8/14: The resident was observed eating pepper out of the shaker. Review of the care plan failed to reflect the above incidents and/or failed to identify that the care plan was reviewed and/or revised after each incident to ensure appropriate supervision of the resident was provided. On 7/1/14 at 9:50 AM, the resident was noted making a gurgling noise in the day room on the unit. There was a half-eaten donut on the floor. LPN #1 offered the resident sips of water and medication and although the resident swallowed without difficulty, she/he continued with gurgling and began coughing. The resident stood up and his/her color became dusky and blue. The Heimlich maneuver was attempted numerous times, oxygen was administered and suctioning was attempted and the resident continued to cough and gag. The O2 saturation was 59% (normal range above 95%), Emergency 911 was called and the resident was transferred to the hospital at 10:13 AM. The Ambulance Run Sheet dated 7/1/14 identified that upon arrival the resident was unresponsive although attempts to clear the airway were conducted by facility staff. An object was removed from the throat; however, the resident remained unresponsive and was transferred to the hospital. The cardiology consultation dated 7/2/14 and the Hospital Discharge Summary dated 7/3/14 identified the resident "choked and aspirated on a yogurt cap". The discharge [DIAGNOSES REDACTED]. The nurse's note dated 7/3/14 identified the resident returned to the facility. The nurse's note indicated the resident was placed on one to one observation during "waking hours when the family was not here" and mouth checks were to be conducted every 15 minutes while awake. The physician's orders [REDACTED]. The Attending physician progress notes [REDACTED]. The Psychiatry Inpatient Discharge Summary dated 7/15/14 identified the resident was maintained on a one to one throughout the hospitalization in an effort to prevent him/her from eating either inanimate objects or food when not appropriate. The Discharge Summary indicated the resident appeared to have a very primitive reflex reaction and "had a history of [REDACTED]. The Discharge Summary further noted that the "behavior was not amenable to any psychotropic medication adjustments, other than inducing severe sedation, which is not clinically indicated". The psychiatric facility recommendations included that the nursing home facility was to keep a close eye on the resident and behaviorally prevent from ingesting any objects that he/she should not be ingesting. Review of the current NA assignment (reviewed on 7/31/14) noted as follows: one to one supervision when out of bed. Monitor the resident for picking up small objects and putting in the mouth. Check hands, pockets, bedside table, nightstand, and under the pillow for small objects before bedtime. Conduct room checks every shift. The NA care plan/card also identified that the resident was independent with transfers and ambulation. Interview and review of the clinical record and facility documentation on 7/31/14 at 10:00 AM with RN #4, the Unit Supervisor, identified the facility investigation of the incident that occurred on 7/1/14 concluded the resident may have wandered into another resident's room who always had yogurt and ingested the yogurt cap. RN #4 indicated that although the resident was checked frequently at night, one to one observation and/or every fifteen minute checks were not provided at night when the resident returned from the hospital after the choking incident. Interview, review of the clinical record, and review of facility documentation on 7/31/14 at 10:30 AM with the DNS, ADNS and the Corporate Nurse identified that although the resident was able to get out of bed and ambulate without assistance, the resident wasn't known to get out of bed at night and therefore the facility did not provide one to one supervision of the resident when in bed. Interview with the Medical Director on 8/1/14 at 1:10 PM indicated the facility did not notify him "that the resident had a history of [REDACTED]. The behavior "is a manifestation of degenerative dementia and oral facial stimulation can come to the surface". The Medical Director indicated there are "no drugs to help" the behavior of eating non-edible objects. He/she further noted that the environment needs to be modified and all staff need to be aware of the behavior to ensure the resident's safety. Each time the resident "moves to a new space the space needs to be set up so appropriate" for the resident "to diminish risk". From 2/8/14 through 7/11/14, the facility repeatedly failed to provide adequate supervision to the resident with a history of eating non-edible items which resulted in a choking incident, hospitalization and Myocardial Infarction. In addition, the facility failed to ensure appropriate supervision was provided when the resident returned from hospitalization resulting in a finding of immediate jeopardy. Subsequent to request for an immediate action plan, the resident was placed on one to one observation at all times and the care plan was revised.

Based on clinical record reviews, observations, interviews and review of facility policies for two of three sampled residents reviewed with wounds (R#37, 113), the facility failed to ensure wounds were assessed thoroughly upon admission, change of condition and at least weekly, and/or failed to ensure that interventions were initiated to prevent breakdown and assess for problems in a diabetic resident's feet and for the only sampled resident reviewed for hospice (R#17), the facility failed to ensure on-going coordination of care between the facility and the hospice. The findings include: 1. Resident #37 was admitted to the facility on [DATE] after surgery to repair a left [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Hospital documentation dated 3/14/14 indicated that the resident was assessed by the podiatrist and was noted with bilateral heel blisters and a bruise of the left great toe. No other areas of concern were noted. The nursing admission assessment noted that the resident had a left heel blister/bruising and the the right heel had a blister. No further descriptions of the heels were noted and no other areas of feet were noted to have skin issues. The care plan dated 3/16/14 indicated a risk for alteration in skin integrity due to decreased mobility. Interventions included weekly skin assessments, float heels, heel boots as ordered and daily skin inspection during morning and evening care; report changes to nurse. Nurse's notes from 3/15/14 through 4/2/14 did not indicate any foot assessments had been completed. On 4/2/14, "black spots" were noted to the left foot in between the toes from 3rd to last toe. No further description was noted, no treatment initiated and/or no physician notification was documented. On 4/3/14 at 12:30 AM, nurse's notes indicated that the resident received [MEDICATION NAME] for complaint of pain rated at a 10 out of 10 in the left foot. No assessment was documented. At 7:50 AM, notes indicated that the resident was anxious and concerned about left foot toes and stating, "no one cares if I lose my foot". No assessment was documented or physician notification. At 3:27 PM, documentation indicated that there was a bruise between the "pinky and the 4th toe" on the left foot. No further assessment, treatment and/or physician notification was noted. On 4/4/14, nurse's notes indicated that the resident went to the podiatrist and returned with new order for dressing to the foot and order for Keflex. The facility communication on the podiatry consult form on 4/4/14 noted "please note bruising between left 3rd and 4th toes". The podiatrist reported that the "bruising" was actually a full thickness pressure sore of the lateral left 3rd toe and medial left 4th toe with serous drainage. The podiatrist directed dressing changes and antibiotics. A follow up on 4/11/14 with the podiatrist noted that the resident had been scheduled for vascular studies, a wound consult at the wound center, and a vascular surgeon consult. On 4/21/14, the resident was transferred to the hospital with a change in condition and increased confusion. The hospital admission information dated 4/21/14 indicated that the resident was admitted with [MEDICAL CONDITION], acute kidney injury and worsening gangrene and pain of left lower extremity. Pain 10/10. The resident subsequently underwent angioplasty to the left leg to restore circulation. Hospital documentation indicated that the resident had left firth toe ulceration, left fourth toe ulceration, left distal first toe ulceration of the tip, and right lateral fourth toe pressure or diabetic ulcer. Interview and clinical record review with the ADNS on 8/1/14 at 11:15 AM failed to provide documentation that the resident's feet were assessed daily, that interventions were intimated to prevent foot breakdown, that complete assessments of the area were done and documented including color, size, depth, surrounding tissue, etc., and/or that interventions were initiated to prevent breakdown and assess for problems in a diabetic resident's feet. Facility policy for diabetic foot care directs that the licensed nurse will document diabetic foot care on the medication administration record. Review of the March administration records and treatment kardexes failed to provide documentation that the residents feet were being checked daily. 2. Resident #113's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] documented that R#113 did not have any open areas to the skin. The MDS assessment dated [DATE] identified that the resident was without cognitive impairment. The MDS dated [DATE] documented that R#113 demonstrated modified independence with cognition for daily decision making. Both the 3/4/14 and 6/9/14 assessments identified that the resident required extensive physical assistance with ADL's. The care plan dated 3/9/14 identified that R#113 was at risk for hyper/[DIAGNOSES REDACTED] related to diabetes and at risk for skin breakdown complicated by [MEDICAL CONDITION]. Interventions included diabetic foot care as needed, arrange podiatry consult as ordered, report any signs of skin changes, discolorations, irritation or breakdown and address promptly. Nursing notes dated 5/5/14 noted a new wound on the left second toe that measured 1 cm by 1 cm with depth not measurable. On 5/27/14, a wound to the right great toe was noted. An assessment by MD#2 (the wound consultant) documented that the wound had a light purulent exudate. A culture was obtained on 5/27/14 and [MEDICATION NAME] ordered by mouth to treat the infection. On 5/30/14, the wound culture identified an infection due [MEDICAL CONDITION]. Review of the MAR indicated [REDACTED]. Further review of the laboratory results indicated that the report on 5/30/14 indicated that [MEDICAL CONDITION] infection in the wound was not sensitive to treatment with [MEDICATION NAME]. Review of the clinical record and interview with RN#4 on 7/29/14 at 2:30 PM indicated that R#113 continued on [MEDICATION NAME] until 6/3/14 (5 days after it was determined in-effective). RN#4 indicated that the unit manager is responsible for reviewing the labs results and communicating the reports to the MD. RN#4 indicated that the labs are usually reported in 24 hours and he/she could not determine why the labs were not reported sooner. Interview with the Assistant Director of Nurses on 7/31/14 at 11:12 AM indicated that the unit manager should have reviewed and communicated the laboratory report to the physician the day the results were available. Interview with MD#4 on 7/31/14 at 12:25 PM indicated that he/she recalls being informed on 6/3/14 of the sensitivity report and directed the staff to change the antibiotic. MD indicated that if he/she was informed sooner the therapy could have been initiated sooner. 3. Resident #17's [DIAGNOSES REDACTED]. A change of condition MDS assessment dated [DATE] identified Resident #17 was alert and oriented and required extensive assistance with bed mobility, and was totally dependent on staff for transfers. Additionally that Resident #17 had a chronic condition that may result in a life expectancy of less than 6 months. Interview and review of facility documentation with RN#1 on 7/30/14 at 8 AM failed to identify documentation that a record of scheduled hospice visits (according to the hospice provided schedule) was kept at the facility other than an RN visit on 7/28/14. According to the hospice schedule, the Social Worker and Chaplain were scheduled to visit on 7/9/14, the RN on 7/11/14, 7/14/14, 7/21/14, the RN and Chaplin on 7/25/14, and the RN on 7/29/14. RN#1 identified that the hospice visit documentation should be kept in the hospice section of the clinical record and he/she would expect to find the information there. Additionally, RN#1 was unable to identify that the hospice certification was in the record and/or that the physician certified a prognosis was less than 6 months, and/or that an MD order for a Hospice evaluation was obtained. Interview and review of the clinical record and hospice documentation with the DNS on 7/30/13 at 10 AM identified that the hospice provider had faxed over a record of visits including the initial evaluation on 7/7/14, and follow up visits on 7/9/14, 7/11/14, 7/14/14, 7/25/14 and 7/29/14. The DNS was unable to explain why the information had not been forwarded from the hospice provider to the facility and/or how the facility coordinated the resident's care with the hospice provider. Further review failed to provide documentation of a care plan to identify the resident's end of life needs.