Every finding on record at Greenwich Woods Rehabilitation

Based on observations, review of facility documentation, and interviews, the facility failed to follow the manufacturers' recommendations for replacing the Nephros water filters which were in place since [DATE], following a presumptive positive case of Legionella in a resident at the facility, and the facility failed to ensure that a positive Legionella water sample was reported to the State Agency in a timely manner. These failures resulted in the finding of Immediate Jeopardy. The findings include: The daily census report dated [DATE] identified a resident census of 83. The facility's total capacity is 217. The facility's layout consists of two floors with resident units on both floors. There are three nursing units on the first floor and four nursing units on the second floor with three of the units closed (no residents residing on the units) and one resident unit (Redwood) with twenty-three residents residing on the unit. On [DATE] at 9:00 AM the Administrator was asked to provide documentation of all Legionella water sample testing from [DATE] to February 2025 along with all documentation related to the facility's water management maintenance records such as flushes. Review of the water management plan and facility documentation identified the facility contracted with two outside water management companies. The first water contractor (WC #1) is responsible for recommendations, collecting water samples, and providing the water sample test results. The second water contractor (WC #2) is responsible for the chlorination system (a water treatment method that uses chlorine to disinfect water by killing harmful bacteria, viruses, and other pathogens). Review of facility documentation and Department of Public Health documentation identified that in July of 2024, the facility transferred a resident to the hospital who subsequently tested positive for Legionella which was considered a presumptive healthcare associated case because the resident had resided in the facility during the incubation period. Subsequently, the facility received recommendations from Epidemiologist #1 (Department of Public Health), as a result, the following recommendations were implemented: The facility placed Nephros water filters on all faucets and shower heads in July of 2024, held weekly water management meetings, started biweekly water sampling testing and started flushing the potable water sources 2 to 3 times per week. The water management plan identified that when Legionella species is found in the water, the following interpretive testing guidance should be considered: When the positive Legionella test sites detect less than (<) 1 CFU/ml, the facility will maintain their environmental assessment and Legionella monitoring. When the positive Legionella test sites detect greater than (>) or equal to 1 CFU/ml, the facility will review the water sample collection, handling, and testing for potential areas. The facility will confirm the water system (chlorination) is currently operating. Review the record of its water management plan. Review the water characteristics and any incoming water changes. Immediately institute a short-term control measure in accordance with the direction of the qualified professional (contracted water management providers) and notify the local health department, and the state Department of Public Health (DPH). The guidance further identified that the water system should be re-tested no sooner than 48 hours and no later than 7 days after a disinfection to determine the efficacy of the treatment. If the re-tested water indicates a greater than or equal to 1, the facility will repeat the short-term measures, and additional measures should be reviewed. When the positive legionella test sites detect greater than or equal to 10 CFU/ml, the facility will immediately institute a short-term control measure in accordance with the direction of a qualified professional and will immediately notify the local health department and the state Department of Health (DPH). Additionally, the water system should not be used for potable water until the facility is cleared by the local health department and DPH. The water management documentation identified laboratory water testing results in various sites throughout the facility (resident occupied areas and none resident occupied areas) for Legionella species that noted the following: Five test samples (5 different locations of potable water sources) in [DATE] resulted in positive results ranging from 1.2 to 31.9 Colony Forming Units per milliliters (CFU/ml). Five test samples in [DATE] resulted in positive results ranging from 1.2 to 6.9 CFU/ml. Six test samples in [DATE] resulted in positive results ranging from 1.4 to 10.6 CFU/ml. Eight testing sites in [DATE] resulted in no positive results. Three test samples in [DATE] resulted in positive results ranging from 5.9 to 7.2 CFU/ml. Four test samples in [DATE] resulted in positive results ranging from 1.3 to 14.5 CFU/ml. Five test samples in February 2025 resulted in positive results ranging from 4.2 to 13.6 CFU/ml. The March testing results were pending and unavailable during the course of the survey. The facility's water management plan identified that when a positive Legionella water sample is identified, the following short-term control measures would be taken: 1. The use of potable water will be restricted and bottled water will be utilized. 2. The faucet aerators removed (a device to prevent unnecessary water splashes that could result in the spread of the bacteria), soaked in a bleach solution for 30 minutes and left off until otherwise directed. 3. The removal and replacement of shower heads and lines throughout the facility that are in use and assess the need for point of use filters that are in accordance with the Environmental Protection Agency (EPA). 4. Flush each affected area faucet immediately for 5 to 10 minutes (hot and cold tap water). 5. Notify the Medical Director and state Department of Health (DPH). 6. Perform clinical surveillance on residents for any respiratory signs and symptoms. 7. Consider the need to notify the residents, families, and staff. Review of facility documentation failed to reflect documentation that the state Department of Public Health was notified of the positive water sample test results when the tests indicated the Legionella species was greater than 1CFU/ml. The Legionella committee's documented agenda identified the committee consists of the Administrator, DNS, Maintenance Director, Infection Preventionist, Staff Development, and any other facility staff deemed appropriate. The documentation identified that each section of the water management plan would be reviewed with an open discussion on areas that may need improvement or other concerns. Tasks are assigned to members to oversee based on the recommendation of the mitigation plan. The agenda further noted that there was a recommendation that the water committee members meet annually to review the plan and document meeting minutes. It also identified that Legionella results are reviewed with the water contractor and in the event of a positive result, confirmed case, or outbreak, the water contractor would be contacted immediately for guidance to protect resident safety. Review of the Legionella committee members meeting minutes identified the committee met on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. One of purposes of the water management committee meetings was to discuss the water sample positive results and continue to follow state guidelines and water contractor recommendations, but the minutes failed to identify in detail how the positive Legionella testing results were addressed. Observation on [DATE] at 10:48 AM on the Redwood unit identified rooms 256, 261, 268, 272, 273 and the Soiled utility room lacked Nephros water filters on the faucets. Tour with the Maintenance Director on [DATE] at 11:25 AM on the Redwood unit identified 5 of the 17 resident bathroom faucets without the Nephros water filters. Two of the 5 resident rooms were occupied (rooms [ROOM NUMBERS]). Interview with the Maintenance Director on [DATE] at 11:30 AM identified he was unaware that the identified rooms did not have water filters in place. The Maintenance Director indicated the Nephros water filters were installed last year in [DATE] when the facility had the Legionella issue and the manufacturer's expiration dates on the installed Nephros water filters are [DATE]. The Maintenance Director indicated he would immediately install the Nephros water filters to the rooms that do not have them in place. Interview with the Administrator on [DATE] at 12:55 PM identified he was unaware of the missing filters. The Administrator indicated the Nephros water filters only get replaced when the water filter falls off the faucet or breaks. Interview with WC #1 on [DATE] at 12:58 PM identified he last provided the facility with recommendations on [DATE]. WC #1 indicated the facility does not have an additional contract for further recommendations. WC #1 indicated the facility installed 90-day water filters in ,d+[DATE] and noted the facility should be flushing the systems. WC #1 indicated he did not convey to the facility that the water filters should be replaced every 90 days. He further identified the facility should change the water filters based on the water test results and indicated that he only collects the water samples for testing bi-weekly and then e-mails the Administrator the testing results. Interview with the Administrator on [DATE] at 1:20 PM identified the facility installed a chlorination system in [DATE] and identified that the water filters installed on all faucets in the building have not been changed and identified that it was never conveyed to him that the filters needed to be changed after 90 days of use. Interview with the Maintenance Director on [DATE] at 1:50 PM identified he flushes the water system 2 to 3 times a week. The Maintenance Director indicated that when the filters are broken in the resident bathroom sinks the nurse aides notify the maintenance department, and the maintenance staff replaces the water filters. The Maintenance Director indicated he did not keep a record of the rooms where the water filters have been replaced but moving forward he will keep a record of the rooms. Interview on [DATE] at 6:28 PM with the Northeast Regional Manager of the water filter company that supplied the Nephros filters identified the water filters are certified by the FDA to be used in place for 90 days and when the 90 days are exceeded the efficacy of the filters decrease. The Northeast Regional Manager further indicated that the filters are the first line of defense in removing Legionella from the potable water supply. Interview with the Maintenance Director on [DATE] at 7:14 AM identified he flushes the system 2 - 3 times a week and randomly selects resident rooms that are occupied, but he flushes every room on the [NAME] and Oakwood units (closed nursing units). The Maintenance Director identified he has not flushed or changed the water filters in the areas that have tested positive for Legionella species. The Maintenance Director indicated that on [DATE], the Administrator directed him to change the water filters in all the areas where the testing results have exceeded 1cfu/ml. The Maintenance Director indicated WC #2 will be coming to raise the chlorine in the chlorination system. Interview with RN #1 (Infection Preventionist) on [DATE] at 9:28 AM identified that she started working at the facility in [DATE]. RN #1 indicated she was aware of the Legionella issue at the facility since [DATE] and indicated she does not review the water sample test results. RN #1 identified the Administrator notifies her of the positive results. RN #1 indicated she does not maintain a line list specific for Legionella monitoring; she indicated she monitors residents for cold symptoms. RN #1 further noted she was not monitoring the residents in the rooms with positive water sample results. Additionally, RN #1 indicated that when a resident has pneumonia and there is a known etiology, and a history of respiratory diagnosis the facility does not test for Legionella. Interview with MD #1 (Medical Director) on [DATE] at 12:54 PM identified he was unaware of the water test results identifying positive Legionella species. MD #1 indicated that if he was aware of the positive test results, he would have ordered the Legionella antigen test for residents with respiratory symptoms. Facility documentation identified that Nephros filters were installed on all faucets and shower heads in [DATE], and they have not been replaced. According to Manufacturer's recommendations the filters should have been replaced in [DATE] and [DATE]. The facility failed to follow the manufacturers' recommendations for replacing the Nephros water filters which were in place since [DATE], following a presumptive positive case of Legionella, and placed all residents at risk for Legionnaire disease. Which resulted in the finding of Immediately Jeopardy. The Immediate Jeopardy template was provided to the DNS on [DATE] at 3:05 PM. The facility provided an Immediate Jeopardy removal plan that was accepted on [DATE] at 5:44 PM. The plan included the following measures: replace the water filters on all shower heads and previous resident care areas that tested positive. 35 water filters based on number of shower and positive areas, were shipped overnight and replaced by 10:00 AM on [DATE]. WC #2 adjusted chlorine levels per WC #1's guidance on [DATE]. The previous level was 1.0mg, the updated level is 2.2mg. Additions to the plan of correction requested by DPH on [DATE] identified that 115 additional water filters were ordered and should be delivered and installed on [DATE]. All water filters in the kitchen were replaced on [DATE]. The provision of bottled water for drinking and oral care until the water filters are replaced/changed. Staff education to be provided on the use of bottled water for drinking and providing oral care. The plan further identified the facility will continue to perform bi-weekly water sampling testing to be conducted by WC #1. Hand sanitizer was provided for hand hygiene and disposable wipes have been provided for use in resident rooms. The sinks have been marked for non-use until water filters are replaced. The plan further identified residents and families will be notified of the concern with the water and residents will continue to be monitored, and physician orders will be obtained to conduct further testing if indicated. Review of the Immediate Jeopardy removal plan with the DNS on [DATE] at 9:20 AM identified water filters were due to be delivered on [DATE], but she received an email from United Parcel Services (UPS) on [DATE] indicating delivery was delayed due to the weather conditions and delivered on [DATE]. The DNS indicated the water filters were delivered and the Maintenance Director was in the process of changing out all the existing expired filters. She further noted that over the weekend all resident rooms that did not have a new water filter, the faucets were bagged with signs posted identifying not to use. Wipes and hand sanitizers were placed in every room. Signs were placed to not use the water on the front door and on the units. Every resident was educated regarding the wipes and hand sanitizer in the affected rooms. The staff were able to use the shower room, staff bathroom, and the soiled utility room sinks for hand washing. Additionally, water bottles were delivered to all units. The survey team validated the implementation of the removal plan through observations, staff and resident interviews, and facility verification that all water filters in the facility had been replaced including in the kitchen. The Immediate Jeopardy was removed on [DATE] at 10:30 AM The water management plan policy identified that the facility complies with all federal requirements for the purpose of reducing the risk of growth and the spread of Legionella and other opportunistic pathogens in the water system.

Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure the second-floor windows contained mechanisms to prevent them from fully opening, presenting a safety hazard to residents residing on the unit (dementia unit). The findings include: Observation on 3/10/25 at 10:05 AM identified in room [ROOM NUMBER](a resident room), the window was fully opened, and did not contain a screen. The degree to which the window was opened presented a safety hazard to residents who were able to access the window. Interview with NA #2 on 3/10/25 at 10:10 AM indicated that she was providing care to a resident in that room with NA#1 and NA #1 opened the window because it was very hot in the room. Interview with NA #1 on 3/10/25 at 10:15 AM identified she had opened the window in room [ROOM NUMBER] because while providing care to the resident she had gotten hot. NA #1 indicated that she was aware that windows are only supposed to open a little but that for at least a month the window could be opened fully. NA #1 indicated that she opens the windows because it is hot on the second floor, and she needs the cool air. She further identified that some residents ask for their windows to be opened and indicated that she had not put it in the maintenance book for repair nor had she informed anyone. Interview with the Director of Maintenance (DOM) on 3/10/25 at 10:27 AM indicated that it was maintenance's responsibility to make sure the windows have a safety device on them to prevent the windows from opening more than 6 inches. The DOM indicated that he does not make rounds to check that the windows have the safety device he relies on the nursing staff to report it in the maintenance book. The DOM measured the open window in room [ROOM NUMBER] and it measured 17 inches high by 33 inches wide and the windowsill from the floor to the base of the window was 30.5 inches. The DOM indicated that he was not aware that this window did not have the safety device, and no one had put it in the maintenance book. The DOM indicated that the window never should be able to open that much especially on the second floor. The DOM indicated that he would have it fixed right away. The DOM indicated that most windows do not have screens, and he does not think they need them. Tour with the Director of Maintenance on 3/10/25 at 10:50 AM on the secured dementia unit on the second floor identified 8 (room [ROOM NUMBER], 253, 257, 258, 259, 260, 263, and 269) out of 17 rooms had windows that did not have the safety device to prevent the windows from fully opening. The DOM measurements of the open windows were from 17 to 22 inches high by 33 inches wide. Below the windows on the outside of the buildings contained grass or a concrete walkway. The DOM indicated that the windows had air conditioners in them that had been removed. Interview with the Administrator, DOM, DNS, and the [NAME] President of Clinical Services on 3/10/25 indicated that the second floor contained 23 residents. The Administrator identified the windows were not to open more than a maximum of 6 inches and the maintenance director was responsible for periodically checking the windows to make sure there was a safety device on them. The Administrator indicated that there was no documentation of the periodical checks. The VP of Clinical Services indicated that maintenance will immediately go around and repair the 8 windows that were identified on the second floor and then audit all the rest of the windows in the facility on first and second floor. The VP of Clinical Services indicated that nursing will immediately start education with staff regarding the windows must have a safety device to prevent windows from opening more than 6 inches and if a safety device was missing to remove the residents from the room for safety and call maintenance immediately to repair it. The VP of Clinical Services indicated that if maintenance was not in the facility residents would be removed and someone would stay in that room until maintenance came in and repaired the window. The VP of Clinical Services indicated that since the beginning of October when the air conditioners were removed there have not been any residents that have attempted to exit the windows that she was aware of. The VP of Clinical Services identified that she was aware that all residents on the second floor were at risk of an accident or incident occurring. Interview with LPN #1 on 3/10/25 at 12:10 PM indicated there were 23 residents on the secured unit and there were 7 residents that ambulate independently on the secure dementia unit and there were 3 residents that ambulate independently with supervision but do get up unassisted at times. Interview with the Director of Maintenance on 3/10/25 at 1:30 PM identified when the air conditioners were removed by his maintenance guys in the first 2 weeks of October, they did not install the safety devices to the windows. The DOM indicated that he should have informed them to do that and then checked the windows after removal to make sure there was a safety device installed but he was his fault he did not do that. Interview with the Administrator on 3/10/25 at 1:40 PM identified that all windows in resident areas cannot open more than a maximum of 6 inches. The Administrator indicated that he was not aware of the issue regarding the windows being able to open fully on the second floor. The Administrator identified there was not a system in place for routine checking and monitoring of the windows for the safety devices in the facility unless it was reported by nursing to maintenance. Interview with VP of Clinical Services on 3/10/25 at 1:50 PM identified that the 8 windows that were identified as not secured was repaired and the education has started. Review of the Window Opening Policy identified windows within the residents' accessible areas shall not be allowed to open more than 6 inches at any time. This limitation is in place to ensure safety, prevent unauthorized access, and maintain proper building conditions. When air conditioning units are removal from windows, appropriate stopping devices (window stoppers or locks) must be installed security and prevent the window from being inadvertently opened beyond the safe limit. Prior to the winter season, it is required that when air conditioning units are removed, the stopper or screw used to secure the window should be replaced if it has been removed during the unit's installation or removal. The stopper or screw must be inspected for wear or damage, and if needed, replaced to ensure propre window security. A training and awareness program will be provided to educate all relevant personnel on the importance of this procedure and the proper installation of the stopper or screw to maintain window security during colder months. This will be monitored and checked monthly and as needed by maintenance.

Based on observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #33 and Resident #336) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice and the facility failed to ensure that medication was not left at the resident's bedside for a resident who is without an order or assessment for self-administration. The findings include: 1. Resident #33's diagnoses included chronic diastolic congestive heart failure, hypoxemia, and acute cough. The quarterly MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment, required moderate assistance with toileting hygiene, and supervision or touch assistance with dressing and personal hygiene. The assessment further identified the resident uses a walker with supervision for ambulation. The care plan dated 3/13/25 identified Resident #33 had a memory/recall problem related to low BIMS (brief Interview for Mental Status) score with interventions that included ensure resident's areas are free of hazards and encourage assistive devices available and in good condition. The physician's order dated 2/13/25 directed medications may not be self-administered. The physician's order dated 3/6/25 directed Guaifenesin liquid 100 milligram/5mililiter (mg/ml) to give 10 ml by mouth four times daily at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. Observation on 3/10/25 at 10:53 AM identified Resident #33 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was a medicine cup containing approximately 15ml of a reddish liquid and other personal items in which resident indicated the nurse left the medicine cup for him/her to take. Observation on 3/10/25 at 11:12 AM with the Charge Nurse (RN #5) identified Resident #33 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was a medicine cup containing 15ml of a reddish liquid and other personal items. RN #5 identified the liquid in the medication cup as the resident's cough medicine. RN #5 then removed the medicine cup and brought it to the medication cart to discard. Interview with RN #5 on 3/10/25 at 11:12 AM identified she brought the resident's medication in the room when the resident had to use the bathroom and was to return to check if the resident had taken the medication, but she did not return. RN #5 identified Resident #33 did not have a medication self-administration order and she should not have left the medication for the resident to take without being present. RN #5 signed off in the Medication Administration Record indicating that she had administered the medication to Resident #33 but should have only signed when the resident had taken the medication. She added that she then changed the MAR subsequent to the surveyor's inquiry. Interview with the Nursing Supervisor (RN #3) on 3/12/25 at 11:37 AM identified the nurse should stay with the resident when administering medication for safety and to ensure they took the medication. Interview with the DNS on 3/14/25 at 12:50 PM identified the nurse should watch the resident take the medication and staff was provided education. Review of the General Guidelines for Medication Administration policy identified the resident is always observed after administration to ensure that the dose was completely ingested. The policy further identifies that residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medication. 2. Resident #336's diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, atrial fibrillation, and heart failure. The Nursing Admission assessment/observation dated 3/7/25 identified Resident #336 was alert and oriented to person, place and time, had no impairment to upper and lower extremities and utilized a walker for mobility. The care plan dated 3/11/25 identified Resident #336 had altered respiratory status related to pneumonia complicated by COPD with interventions that included to administer mediation/antibiotic as ordered and to observe alterations in respiratory status and report abnormalities to MD. The physician's order dated 3/7/25 directed Albuterol Sulfate HFA aerosol inhaler 90 microgram (mcg)/actuation to inhale 2 puffs into lungs every four hours as needed (PRN) for COPD. The physician's order dated 3/7/25 directed medications may not be self-administered. Observation on 3/10/25 at 10:13 AM identified Resident #336 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was an opened medication box containing albuterol sulfate HFA aerosol inhaler 90 microgram (mcg)/actuation, television remote, water pitcher, and other personal items. Resident #336 identified the nurse left the medication. Review of the Medication Administration Record from 3/7/25 to 3/11/25 failed to identify that the medication was administered. Observation on 3/10/25 at 11:51 AM with the Charge Nurse (RN #6) identified Resident #336 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was an opened medication box containing albuterol sulfate HFA aerosol inhaler 90 microgram (mcg)/actuation, water pitcher, and other personal items as resident identified that he/she had taken the medication. Interview with RN #6 on 3/10/25 at 11:52 AM identified the resident did have a PRN physician's order for the medication but the medication should not have been left in the resident's room. She also identified that the medication was dispensed from the facility's pharmacy. RN #6 further identified that Resident #336 did not have an order for medication self-administration, and she had not administered this medication to the resident. Interview with the Nursing Supervisor (RN #3) on 3/12/24 at 11:37 AM identified that if a resident wanted to administer their medication a self-administration assessment would need to be completed, and the medication would be stored in the medication cart. Review of the General Guidelines for Medication Administration policy identified the resident is always observed after administration to ensure that the dose was completely ingested. The policy further identifies that residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medication. Review of the Medication, Self-Administration and Discharge Program policy identified that an individual may self-administer medications only after the interdisciplinary team has determined that this practice is safe.

Based on review of facility documentation, facility policy, and interviews, the facility failed to complete license nurses and nurse aides education and competencies related to intravenous therapy (IV) therapy and the facility failed to ensure licensed nurses had intravenous therapy (IV) certificate. The findings included: 1. Review of the State Agency documentation identified the facility has a licensed bed capacity of 217 and an IV therapy program. Review of the census daily report dated 3/10/25 identified the facility census was 83 residents in the facility. A request was made on 3/17/25 for documentation of the annual licensed nurses and nurse aides IV competencies for 2023. The facility failed to provide any documentation regarding the completion of 2023 annual competencies. Review of the nursing IV competencies provided for 2024 identified only 15 of 29 licensed nurses received competency training in intravenous therapy (IV), and 17 of 43 nurse aides received competency training in intravenous therapy (IV). Although requested, RN #1 (Infection Preventionist) and LPN #9 failed to provide documentation that IV therapy education/training/in-service and competencies was provided to the license nurse and nurse aides in 2023 and 2024. Interview with RN #1 on 3/17/25 at 11:34 AM identified she has been employed by the facility since 3/2024 as the Infection Preventionist (IP), staff development, and the wound nurse. RN #1 indicated she could not locate IV competencies completed in 2023. RN #1 indicated she was unable to find any more documentation related to IV competencies for 2024. RN #1 indicated she was responsible for the education, in-service and competencies of the IV therapy to the nursing staff for the year 2024. Interview with the DNS on 3/18/25 at 8:00 AM identified she was not aware that all the licensed nurses and nurse aides did not have yearly education, in-service, and competencies of IV therapy for the year 2024. The DNS indicated it was the responsibility of RN #1 to provide the nursing staff with education, in-service and competency of IV therapy. Although requested, a facility policy was not provided. Review of the facility assessment dated [DATE] identified staff competencies that are necessary to provide the level and types of care needed for the resident population. Establishing a peripheral venous route, central line dressing changes, and intermittent infusion via peripherally inserted catheter. Annual competencies/training, and in-service. Clinical departments are encouraged to utilize continuing education. 2. Review of the licensed nurses IV certificate log failed to reflect documentation (IV certificate) for 11 of 29 licensed nurses had IV certificates. Review of the State Agency documentation identified the facility has a licensed bed capacity of 217 and an IV therapy program. Review of the census daily report dated 3/10/25 identified the facility census was 83 residents in the facility. A request was made on 3/17/25 for documentation of IV certificate for licensed nurses. The facility failed to provide 11 of 29 IV certificates. Interview and facility documentation review with RN #1 on 3/17/25 at 11:34 AM identified she was not aware of the issue. RN #1 indicated she was not aware that 11 of 29 licensed nurses do not have an IV certificate. RN #1 indicated she will contact the pharmacy IV department and schedule an IV education and certificate class. Interview with the DNS on 3/18/25 at 8:10 AM identified she was not aware of the issue and that RN #1 was responsible to oversee the staff development position and review the licensed nurse's IV certificates. The DNS indicated the facility will address the issue. Although requested, a facility policy was not provided. Review of the facility assessment dated [DATE] identified staff competencies that are necessary to provide the level and types of care needed for the resident population. Establishing a peripheral venous route, central line dressing changes, and intermittent infusion via peripherally inserted catheter. Annual competencies/training, and in-service. Clinical departments are encouraged to utilize continuing education.

Based on observations, review of facility documentation, review of facility policy, and interviews for four of four medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include: Based on observations, review of facility documentation, facility policy, and interviews for 4 of 4 medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include: Observations on 3/18/25 between 1:44 PM - 2:00 PM of the medication carts with LPN #9 (IP from another facility) identified the February 2025 and March 2025 narcotic drug change of shift audit sheet (the narcotic count that the on-coming and off-going nurses complete to ensure the narcotic medications are counted) were missing signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the following units: The [NAME] 1 unit was missing 21 signatures for the month of February 2025, and 9 signatures for the month of March 1, 2025 - March 18, 2025. The Aspen unit was missing 10 signatures for the month of March 1, 2025 - March 18, 2025. The [NAME] 2 unit was missing 21 signatures for the month of February 2025, and 11 signatures for the month of March 1, 2025 - March 18, 2025. The Redwood unit was missing 6 signatures for the month of March 1, 2025 - March 18, 2025. Interview with LPN #2 on 3/18/25 at 1:50 PM identified she is an agency nurse. LPN #2 indicated would you like for me to sign the narcotic drug change of shift audit sheet now. Interview with RN #3 on 3/18/25 at 1:53 PM identified all nurses are responsible to sign the narcotic drug change of shift audit sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with LPN #4 on 3/18/25 at 1:55 PM identified it was the responsibility of all the nurses to sign the narcotic count sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with LPN #1 on 3/18/25 at 2:00 PM identified all nurses are responsible to sign the narcotic count sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with the DNS on 3/19/25 at 8:30 AM identified she was aware of the issue, and she has been educating the licenses nurses regarding signing the narcotic count sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. The DNS indicated the expectation of the facility is that the on-coming and out-going nurse count the controlled substances during each shift change and sign the narcotic count sheet after completing the count. The DNS indicated that the facility would continue to educate the licensed nurses. Review of the pharmacy storage of controlled substance form identified the medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for 5 of 5 sampled residents (Resident #14, 16, 24, 56, and 73) reviewed for immunizations, the facility failed to offer and provide influenza vaccine as required and for 4 of 5 residents (Resident #12, 26, 37, and 61) reviewed for immunizations, the facility failed to offer and provide pneumococcal vaccine as required. The findings include: Interview and review of facility immunization documentation with RN #1 (Infection Preventionist) on 3/17/2023 at 12:37 PM identified the following: a) Resident #14 was admitted to the facility on [DATE] with diagnosis that included diabetes mellitus, hypertension, and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #14 had severe cognitive impairment. The assessment further identified that Resident #14 influenza vaccination was not up to date. Review of Resident #14 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. b) Resident #16 was admitted to the facility on [DATE] with diagnosis that included vascular dementia, psychotic disturbance, and mood disturbance. The quarterly MDS assessment dated [DATE] identified Resident #16 had severe cognitive impairment. The assessment further identified that Resident #16 influenza vaccination was not up to date. Review of Resident #16 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. c) Resident #24 was admitted to the facility on [DATE] with diagnosis that included multiple sclerosis, hypertension, and hydrocephalus. The quarterly MDS assessment dated [DATE] identified Resident #24 had severe cognitive impairment. The assessment further identified that Resident #24 influenza vaccination was not up to date. Review of Resident #24 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. d) Resident #56 was admitted to the facility on [DATE] with diagnosis that included schizophrenia, and pulmonary fibrosis. The quarterly MDS assessment dated [DATE] identified Resident #56 had moderate cognitive impairment. The assessment further identified that Resident #56 influenza vaccination was not up to date. Review of Resident #56 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. e) Resident #73 was admitted to the facility on [DATE] with diagnosis that included dementia with psychotic disturbance, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #73 had intact cognition. The assessment further identified that Resident #73 influenza vaccination was not up to date. Review of Resident #73 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. f) Resident #12 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, and hyperlipidemia. The annual MDS assessment dated [DATE] identified Resident #12 had moderate cognitive impairment. The assessment further identified that Resident #12 pneumococcal vaccination was not up to date. Review of Resident #12 clinical record on 3/17/25 at 12:37 PM failed to identified that the pneumococcal vaccine was offered and/or administered to the resident. g) Resident #26 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis, and cerebrovascular disease affecting the right dominant side. The annual MDS assessment dated [DATE] identified Resident #26 had intact cognition. The assessment further identified that Resident #26 pneumococcal vaccination was not up to date. Review of Resident #26 clinical record on 3/17/25 at 12:37 PM failed to identified that the pneumococcal vaccine was offered and/or administered to the resident. h) Resident #37 was admitted to the facility on [DATE] with diagnosis that included cerebral palsy, and hydronephrosis. The quarterly MDS assessment dated [DATE] identified Resident #37 had severe cognitive impairment. The assessment further identified that Resident #37 pneumococcal vaccination was not up to date. i) Resident #61 was admitted to the facility on [DATE] with diagnosis that included subarachnoid hemorrhage, and diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #61 had severe cognitive impairment. The assessment further identified that Resident #61 pneumococcal vaccination was not up to date. Review of Resident #61 clinical record on 3/17/25 at 12:37 PM failed to identified that the pneumococcal vaccine was offered and/or administered to the resident. Interview with RN #1 on 3/17/25 at 1:00 PM identified that she did not receive some of the influenza vaccine consent forms from the resident representatives, so the facility was unable to administer the influenza vaccine. RN #1 was unable to verify if the facility had followed up with the resident representatives. RN #1 indicated the facility had obtained some consents for the influenza and pneumococcal vaccination on 3/13/25. RN #1 indicated she was unable to find any previous pneumococcal vaccination records from 2023 and 2024. RN #1 indicated she did not administer any pneumococcal vaccine in 2024 and 2025. Interview with RN #1 on 3/19/25 at 9:50 AM identified influenza and pneumococcal vaccine were offered on 3/14/25 but the pharmacy did not deliver the vaccines. RN #1 indicated she will reach out to the pharmacy regarding the delay of the influenza and pneumococcal vaccines. Interview with RN #1 on 3/19/25 at 11:10 AM identified that the pharmacy received the vaccines but some where the profile for payment purpose and insurance coverage was not communicated. RN #1 indicated the communication from the pharmacy to the facility to explain why there was a delay and/or a reason why there was not a delivery done. RN #1 indicated that she asked the pharmacy to escalate to quality insurance and she was told that it would take approximately 48 hours for a response. Interview with the DNS on 3/19/25 at 11:30 AM identified she was not aware of the issue. The DNS indicated RN #1 is responsible to oversee that all resident in the facility receives their influenza and pneumococcal vaccines in a timely manner. Review of the facility immunization of residents policy identified all eligible residents will be offered the influenza and pneumococcal vaccines unless medically contraindicated. The resident or the resident's legal representative will be provided a copy of the current vaccine information statement prior to administration. The resident or resident's legal representative has the right to refuse the vaccine.

Based on clinical record reviews, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #2, 12, 19, 59, and 61) reviewed for immunizations, the facility failed to offer and provide Covid-19 immunizations as required. The findings include: Interview and review of facility immunization documentation with RN #1 (Infection Preventionist) on 3/17/2023 at 12:37 PM identified the following: 1) Resident #2 was admitted to the facility on [DATE] with diagnosis that included fracture of shaft of left femur, difficulty walking, and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #2 had intact cognition. The assessment further identified that Resident #2 Covid-19 Booster vaccination was not up to date. Review of Resident #2 clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. Review of the Covid-19 immunization record identified Resident #2 had a consent for the vaccine. 2) Resident #12 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, and hydrocephalus. The annual MDS assessment dated [DATE] identified Resident #12 had intact cognition. The assessment further identified that Resident #12 Covid-19 Booster vaccination was not up to date. Review of Resident #12's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/18/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. 3) Resident #19 was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder, and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #19 had intact cognition. The assessment further identified that Resident #19 Covid-19 Booster vaccination was not up to date. Review of Resident #19's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/18/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. 4) Resident #59 was admitted to the facility on [DATE] with diagnosis that included malignant neoplasm of right female breast, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #59 had severe cognitive impairment. The assessment further identified that Resident #59 Covid-19 Booster vaccination was not up to date. Review of Resident #59's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/19/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. 5) Resident #61 was admitted to the facility on [DATE] with diagnosis that included subarachnoid hemorrhage, and diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #61 had severe cognitive impairment. The assessment further identified that Resident #61 Covid-19 Booster vaccination was not up to date. Review of Resident #69's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/19/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. Review of the Covid-19 vaccine documentation form identified Resident #2, 12, 19, 59, and 61 had a sign consent dated 3/13/25 by the residents and/or the resident representative. Interview with RN #1 on 3/17/25 at 1:00 PM identified that she did not receive some of the Covid-19 vaccine consent forms from the resident representatives, so the facility was unable to administer the Covid-19 booster vaccine. RN #1 was unable to verify if the facility had followed up with the resident representatives. RN #1 indicated the facility had obtained some consents for the Covid-19 vaccination on 3/13/25. RN #1 indicated she did not administer any Covid-19 Booster vaccine in 2024 and 2025. Interview with RN #1 on 3/19/25 at 9:50 AM identified Covid-19 vaccine were offered on 3/14/25 but the pharmacy did not deliver the vaccines. RN #1 indicated she will reach out to the pharmacy regarding the delay of the influenza, pneumococcal, and Covid-19 Booster vaccines. Interview with RN #1 on 3/19/25 at 11:10 AM identified that the pharmacy received the vaccines but some where the profile for payment purpose and insurance coverage was not communicated. RN #1 indicated the communication from the pharmacy to the facility to explain why there was a delay and/or why there was no delivery was not done. RN #1 indicated that she asked the pharmacy to escalate to quality insurance and she was told that it would take approximately 48 hours for a response. Interview with the DNS on 3/19/25 at 11:30 AM identified she was not aware of the issue. The DNS indicated RN #1 is responsible to oversee that all resident in the facility receives their Covid-19 Booster vaccines in a timely manner. Review of the facility resident Covid-19 vaccine documentation form identified the vaccine will be offered to all eligible residents as recommended by the Center for Disease Control (CDC), and the resident or legal guardian is provided with education regarding the pros and cons of the vaccine. The resident or resident's legal representative has the right to refuse the vaccine.

Based on review of the clinical records, review of facility policy, and interviews for two of three sampled residents (Resident #15 and #68) reviewed for pain management, the facility failed to ensure accurate administration documentation of pain medication. The findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included lower back pain, pain in the left upper arm, and dementia. The care plan dated 2/7/25 identified Resident #15 had activities of daily living (ADL) function compromised related to dementia, weakness, and advanced age. Interventions included referring to Resident #15's 24-hour positioning plan and to encourage him/her to do as much as possible before offering assistance. The quarterly MDS dated [DATE] identified Resident #15 had moderately impaired cognition, had pain with occasional frequency with a numeric rating scale of 3/10, and was not on a scheduled pain medication regimen. A physician's order dated 1/20/25 directed to administer Acetaminophen 325mg, administer 2 tablets by mouth, every 6 hours, as needed (PRN) for pain/fever. A physician's order dated 3/4/25 directed to administer Acetaminophen 325mg, administer 2 tablets by mouth, twice daily at 9:00 AM and 5:00 PM. The 24-Hour Shift Report dated 3/1/25 identified that Resident #15 was given PRN APAP (Acetaminophen) with positive effects, on the 7:00 AM-3:00 PM shift. The 24-Hour Shift Report dated 3/13/25 identified that Resident #15 was given Tylenol (Acetaminophen) at 12:30 AM, crushed with applesauce and tolerated well. The 24-Hour Shift Report dated 3/17/25 identified that Resident #15 was given PRN Tylenol 650mg. The March 2025 Medication Administration Record (MAR) failed to identify documentation that PRN Acetaminophen was administered on 3/1/25, 3/13/25, and 3/17/25. Interview and clinical record review with LPN #8 on 3/17/25 at 11:20 AM identified that the nurse aide had notified her that Resident #15 had requested Tylenol for arm pain, but she was unable to administer Tylenol because he/she had just received her scheduled Tylenol dose, and that, during morning report, LPN #10 had told her that she had given Resident #15 a PRN dose not too long ago around 5:00 AM or 6:00 AM. Review of the MAR failed to identify that the PRN dose was administered. LPN #8 indicated that she would expect medication administration times to be documented in the MAR to ensure resident safety and appropriate administration times. LPN #8 further indicated that she would follow up with Resident #15 to assess his/her pain. Interview with LPN #10 on 3/18/25 at 9:29 AM identified that she had worked at the facility on 3/17/25 from 11:00 PM-7:00 AM, and that she had medicated Resident #15 with Tylenol around 6:00 AM and thought that she had signed the medication as given in the MAR. LPN #10 indicated that she was aware that the expectation was to sign a medication as given right away but she must have forgotten. LPN #10 further indicated that she usually always signs out PRN medications on the MAR and also documents on the 24-hour report. Interview and clinical record review with the DNS on 3/19/25 at 11:37 AM failed to identify documentation in Resident #15's MAR that corresponded with the documentation on the 24-Hour Report that Acetaminophen was given on 3/1, 3/13, and 3/17/25. The DNS indicated that she would expect that any order completed, and medication given to a resident would be signed off in the MAR and only documenting in the 24-hour report was not the expectation; documentation needed to be completed in the resident's clinical record. The facility's General Guidelines for Medication Administration policy directs the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. When PRN medications are administered, the following documentation is provided: date and time of the administration, dose, complaints or symptoms for which the medication was given, results achieved from giving the dose, and the time the results were noted. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, malignant neoplasm of pancreas, and Myelodysplastic syndrome. The nurse's note dated 3/6/25 at 7:20 PM identified that Resident #68 was readmitted to the facility at 2:00 PM. Resident was alert and oriented to person, place, and time. A physician's order dated 3/6/25 directed to administer Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days. The care plan dated 3/7/25 identified Resident #68 required an opioid medication to help with pain management. Interventions included providing opioid medication to manage pain and evaluate its efficacy. Interview with Resident #68 on 3/12/25 at 8:29 AM identified that he/she has an order for Tramadol to take as needed for pain, and that he/she requests it every night around 9:00 PM or just before going to bed. Resident #68 indicated that he/she was told that Tramadol was unavailable last night because the order needed to be renewed and that he/she had been in pain throughout the night. The Control Substance Disposition Record (accountability record) identified that one Tramadol 50mg tablet was dispensed on the following dates in March of 2025: 3/6 at 9:00 PM, 3/7 at 9:00 PM, 3/8 at 9:00 PM, 3/9 at 9:00 PM, 3/10 at 9:00 PM, 3/12 at 9:15 AM and 9:45 PM, 3/13 10:00 PM, 3/14 at 9:00 PM, 3/15 at 9:00 PM, 3/16 at 9:30 PM, and 3/17 at 11:15 PM. The March 2025 Medication Administration Record (MAR) failed to identify that Tramadol was administered to Resident #68 on 3/6, 3/7, 3/10, 3/15, and 3/17/25. The Progress Notes dated 3/6/25 through 3/17/25 failed to identify documentation that Tramadol was administered to Resident #68 on 3/6, 3/7, 3/10, 3/15, and 3/17/25. Interview and clinical record review with RN #5 on 3/19/25 at 11:14 AM identified that it was her initials on Resident #68's Control Substance Disposition Record for the removal of Tramadol on 3/6, 3/7, and 3/17/25 but failed to document that the medication was administered on the MAR. RN #5 indicated that she was aware of the importance to document on both the disposition record and MAR, and she also tries to write a progress note identifying the reason the medication was given. RN #5 further indicated that sometimes she works double shifts or works on multiple units, and may get pulled away to assist another resident before she has the time to circle back and sign the medication off in the MAR. Interview and clinical record review on 3/17/25 at 12:26 PM with the DNS failed to identify that the Tramadol that was signed off on the Control Substance Disposition Record on 3/6, 3/7, 3/10, 3/15, and 3/17/25 was also signed off as administered in Resident #68's MAR. The DNS identified that it was her expectation that when a controlled substance is removed and signed off on the Control Substance Disposition Record it must also be signed off, as administered, in the resident's MAR. The DNS indicated that the nurse administering the medication would be responsible for both signoffs, and re-education would be provided to licensed nursing staff. The facility's Controlled Substances policy directs the provider pharmacy shall identify medications as controlled medications either as a part of the label, or by sending a controlled medication countdown sheet with the medication, or both. Accurate inventory of all controlled medications is maintained at all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the MAR: date and time of administration (MAR and Accountability Record), amount administered (Accountability Record), remaining quantity (Accountability Record), signature of the nursing personnel administering the dose (Accountability Record), and the initials of the nurse administering the dose, completed after the medication has been administered (MAR).

Based on review of the clinical record, review of facility policy, and interviews for one of five sampled residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure target behavior monitoring was completed, per the physician's order. The findings include: Resident #65 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety disorder, dementia in other diseases classified elsewhere, with other behavioral disturbances, and repeated falls. A physician's order dated 11/28/23 directed to administer Quetiapine (an antipsychotic medication) 50mg by mouth, at bedtime. A physician's order dated 9/13/24 directed to monitor target behaviors: hallucinations/aggression, every day, evening, and night shift. The annual MDS dated [DATE] identified Resident #65 had severely impaired cognition, had no changes in behavior status, care rejection, or wandering compared to the prior assessment, was receiving an antipsychotic on a routine basis, and a gradual dose reduction (GDR) had been documented by a physician as clinically contraindicated. The care plan dated 12/18/24 identified Resident #65 was prescribed an antipsychotic medication. Interventions included observing resident's interactions with others for appropriateness and observing the resident's mood and behavior. January 2025 through March 2025 Medication Administration Records (MAR) failed to identify documentation for target behavior monitoring. January 2025 through March 2025 Treatment Administration Records (TAR) failed to identify documentation for target behavior monitoring. Nurse's notes dated January 2025 through March 2025 failed to identify documentation for target behavior monitoring, every day, evening, and night shift. The Psychiatric APRN note dated 11/28/25 identified upon regular follow-up that staff denied behavioral disturbances, for Resident #65, since medication management and current medications. Resident was eating and sleeping well, with no signs and symptoms of delusions and hallucinations; will continue to monitor closely. Interview and clinical record review with the RN Supervisor, also working as the floor nurse (RN #3) on 3/19/25 at 10:12 AM identified that while there was an order to monitor Resident #65's target behaviors, the field to document the behaviors was not showing up on the TAR, due to the way the order was entered. RN #3 indicated that she did not see documentation for behavior monitoring in Resident #65's clinical record, but she would expect to see documentation for target behavior monitoring, per the physician's order, and any new behaviors exhibited by the resident would be documented under the progress notes and a notification would be made to the psychiatric provider. RN #3 identified target behavior monitoring was the responsibility of the floor nurse, and while she was not aware that there had not been target behavior monitoring documentation, she would have been expected to have been notified if the nurse was having an issue documenting his or her observations. RN #3 further indicated that she would modify the order to ensure target behavior monitoring documentation could be completed in the TAR. Interview with the Psychiatric APRN (APRN #3) on 3/19/25 at10:59 AM identified that Resident #65 takes an antipsychotic medication for agitation, delusions, and hallucinations, and that he/she has been stable at baseline for these behaviors, for some time. APRN #3 indicated that when she comes in to speak with Resident #65, she will also speak to the nurse aides and nurses on the floor to assess if any increased behaviors have been reported, but she would also expect target behavior monitoring to be completed per the physician's order, to ensure the resident's on-going treatment remains effective. Interview and clinical record review with the DNS on 3/19/25 at 11:37 AM identified that she would expect target behavior monitoring to be completed every shift, by the floor nurse, per the physician's order. The DNS indicated that the original physician's order for target behavior monitoring was placed on 9/13/24, but she did not see documentation of the behavior monitoring in accordance with the order. The DNS further indicated that any of the licensed nurses could have modified the order to create a documentation field for target behavior monitoring, or they could have documented in the progress notes. The Medication Management policy directs that when a resident receives a new medication the dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. When a resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved and/or non-pharmacological interventions have been effective in reducing the symptoms, the resident is evaluated for the appropriateness of a taper or GDR. For antipsychotics, if a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility should attempt a GDR in two separate quarters within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. GDR is considered clinically contraindicated if target symptoms returned or worsened after the most recent attempt at a GDR and the physician documents the clinical rationale for why any additional attempted dose reductions would likely impair the resident's function or the continued use is in accordance with relevant current standards of practice.

Based on review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #68) reviewed for pain management, the facility failed to ensure pain medication was administered in accordance with the physician's order. The findings include: Resident #68 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, malignant neoplasm of pancreas, and Myelodysplastic syndrome. The nurse's note dated [DATE] at 7:20 PM identified that Resident #68 was readmitted to the facility at 2:00 PM. Resident was alert and oriented to person, place, and time. The care plan dated [DATE] identified Resident #68 required an opioid medication to help with pain management. Interventions included providing opioid medication to manage pain and evaluate its efficacy. A physician's order dated [DATE] directed to administer Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days. Interview with Resident #68 on [DATE] at 8:29 AM identified that he/she had an order for Tramadol to take as needed for pain, and that he/she requests it every night usually around 9:00 PM or just before going to bed. Resident #68 indicated that he/she had requested Tramadol before bed on [DATE], and a male staff member told him/her that the nurse would return with the medication, but nobody returned. Resident #68 further indicated that he/she had difficulty falling asleep and was finally given Tylenol around 3:30 AM, because he/she was done requesting the Tramadol. Resident #68 identified that he/she had ,d+[DATE] pain in the head, mouth, and ribs, which was not relieved by the Tylenol. Resident #68 indicated that the nurse did not assess his/her pain. Resident #68 further indicated that around 6:00 AM somebody communicated to him/her that the Tramadol order needed to be renewed and that was why the medication had not been available. Interview and clinical record review with RN #5 on [DATE] at 9:01 AM identified that during morning report LPN #3 identified that on [DATE], Resident #68 had requested Tramadol, but the PRN order had been completed and the order needed to be renewed, and he administered Tylenol for pain. RN #5 indicated that LPN #3 told her that he added a request to renew the Tramadol order to the APRN notification book, at the desk, and asked RN #5 to follow up on the order. Review of the clinical record identified that the Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days order was active and had an end date of [DATE]. RN #5 identified that since the Tramadol order remained active, she would assess Resident #68's pain and offer him/her Tylenol or Tramadol, if needed. Subsequent to surveyor inquiry Tramadol 50mg was administered on [DATE] at 9:50 AM. Interview with LPN #3 on [DATE] at 9:16 AM identified that Resident #68 has chronic pain that he/she had asked for Tramadol by name but could not recall the exact time of the request because he was working on both units. LPN #3 indicated that while he did not assess his/her pain using a pain rating scale, he/she appeared to be a ,d+[DATE] based on non-verbal indicators, so he had repositioned Resident #68 and gave him/her water. LPN #3 further indicated that he saw that the PRN order for Tramadol had expired and could not be given without a provider's order. LPN #3 identified that he returned to Resident #68's room, but he/she had fallen asleep, and when he returned to check on Resident #68, he/she had identified that he/she was in more pain. LPN #3 indicated that he informed Resident #68 that the PRN Tramadol order had expired and needed to be renewed, and he administered Tylenol for pain. LPN #3 identified that he did not contact a medical provider overnight to renew the order, but he notified the RN supervisor, wrote a notification of the expired Tramadol in the APRN book, and reported off to the on-coming nurse to ensure the order got renewed. Interview with the Nursing Supervisor (RN #2) on [DATE] at 9:48 AM identified that LPN #3 notified her that Resident 68's Tramadol order had expired, and that LPN #3 had medicated Resident #68 with Tylenol. RN #2 indicated that LPN #3 had put the renewal request in the APRN book, which she felt was appropriate because usually Tylenol is offered first for pain, and she was not notified that Resident #68 had unrelieved pain after the Tylenol. Interview with APRN #1 on [DATE] at 10:43 AM identified that Resident #68 has chronic pain, and she would have expected a pain assessment to have been completed when Resident #68 requested the Tramadol, and if he/she reported ,d+[DATE] pain, she would have expected the on-call physician to have been notified to reinstate the Tramadol order, if it had expired. Interview and clinical record review with the DNS on [DATE] at 12:26 PM failed to identify that the Tramadol order had expired. The DNS indicated that, had the Tramadol been expired, she would have expected Resident #68's pain to be assessed and if he/she reported ,d+[DATE] pain the doctor should have been contacted to renew the order so the Tramadol could have been given that night. The facility's Pain Management policy directs general treatment principles to include: ask about pain regularly, believe the resident's and family's reports of pain and what relieves it, choose appropriate pain control options, deliver interventions in a timely, logical, and coordinated fashion, and empower patients and their families.

documentation, review of facility policy/procedures and interviews for two of two sampled residents (Residents #9 and #336) reviewed for choices, the facility failed to ensure the resident's choices were accommodated when the resident requested to go to bed, and staff did not assist the resident for four hours and failed to ensure menu choices were provided at mealtime. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty walking, abnormal posture, pain, and peripheral neuropathy. The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition, required partial to moderate assistance with personal hygiene, required total dependent with transfers (chair to bed/bed to chair), bed mobility, toileting, dressing, and utilized a wheelchair for mobility. The care plan dated 1/27/25 identified Resident #9 had an ADL (activities of daily living) function compromise and required substantial and maximal assist with transfers. Interventions directed extensive assist of 2 with bed transfers, extensive assist of 1 with dressing, personal hygiene, bed mobility, and toileting. The physician orders dated 3/1/25 - 3/12/25 directed to transfer with extensive assist of 2. The nurse's note dated 3/1/25 - 3/12/25 failed to reflect documentation for 3/4/25 on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. Review of the nurse aide's late loss ADL report dated 3/1/20 - 3/12/25 failed to reflect documentation for 3/4/25 on the 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. Review of the nurse aide's point of care ADL category report dated 3/1/25 - 3/12/25 failed to reflect documentation for 3/4/25 on the 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. Review of the concern/complaint form dated 3/5/25 identified Resident #9's representative had concerns regarding Resident #9 being put to bed late and no one answering his/her call light. The investigation identified NA #7 was coached because she did not put Resident #9 to bed in a timely manner. NA #7 was in-service on putting residents to bed and answering call lights in a timely manner. A discussion with the 3:00 PM - 11:00 PM shift nursing staff regarding putting residents to bed in a timely manner. The resident representative was satisfied with the resolution. An e-mail statement by the resident representative dated 3/5/25 at 2:26 PM identified Resident #9 told him/her that he/she had the worst night. Apparently, nobody put Resident #9 to bed until midnight and fully clothed. The night nurse had finally answered Resident #9 call light and explained that there was nobody to help him/her for another half an hour. Resident #9 indicated he/she did not get much sleep. Resident #9 indicated he/she hates going to bed at night because he/she never knows who's going to be assigned to him/her and what type of care they will provide. The resident representative indicated it all goes back to the shortage of staffing and resident not getting care. The resident representative indicated it is a travesty. During the Resident Council meeting on 3/10/25 at 12:30 PM Resident #9 identified the night (3/4/25) the president gave his speech he/she was put back to bed at midnight. Interview with the DNS on 3/10/25 at 1:15 PM identified was aware of the issue. The DNS indicated she was notified via an e-mail on 3/5/25 at 2:26 PM from the resident representative. The DNS indicated a concern/complaint form was initiated and an investigation was conducted. The DNS indicated the investigation concluded that the nurse aide that was assigned to Resident #9 failed to provide care to the resident on 3/4/25 on the 3:00 PM - 11:00 PM shift. The DNS identified NA #7 indicated she was not aware that Resident #9 was on her assignment, and she did not provide care to the resident. Interview with Resident #9 on 3/10/25 at 1:40 PM identified the night (3/4/25 on the 3:00 PM - 11:00 PM shift) the president gave his speech was the night the nurse aide did not put him/her to bed. Resident #9 indicated he/she rang the call light, and no one answered. Resident #9 indicated he/she was put to bed at midnight, and he/she was very upset. Resident #9 indicated he/she notified his/her representative of the issue. Resident #9 indicated he/she likes to go to bed after supper around 7:00 PM and no later than 8:00 PM. (Resident #9 was put to bed 4 hours later). Interview with the DNS on 3/18/25 at 9:10 AM identified the expectation of the facility is that all nurse aides read their assignment thoroughly and provide resident care in a timely manner. The DNS indicated NA #7 should have put Resident #9 to bed in a timely manner. The DNS indicated all nursing staff on the 3:00 PM - 11:00 PM shift were in-service. Interview with NA #7 on 3/19/25 at 1:25 PM identified she has been employed by the facility since 9/2024. NA #7 indicated she works on the 3:00 PM - 11:00 PM shift and she is a float. NA #7 indicated she does not remember if Resident #9 was on her assignment. NA #7 indicated if she did not put Resident #9 to bed it was a mistake. NA #7 indicated she did not provide any care to Resident #9. Although attempted, an interview with NA #1, NA #8, NA #10, LPN #6, and RN #10 was not obtained. Review of the facility Activities of Daily Living (ADL) policy identified residents will receive services to optimize their level of independence with activities of daily living and the assistance they need to complete activities of daily living. The resident will receive assistance daily with hygiene, dressing, bathing, feeding, transfer, ambulation, and elimination as necessary. Resident are encouraged to make choices regarding their care including the timing of care and choice of clothing and activities. Review of the facility Resident's [NAME] of Rights identified you have the right to be treated equally with other residents in receiving care and services, and regarding transfer and discharge, regardless of the source of payment for your care. 2. Resident #336's diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, atrial fibrillation, and heart failure. The Nursing Admission assessment/observation dated 3/7/25 identified Resident #336 was alert and oriented to person, place and time, had no impairment to upper and lower extremities and utilized a walker for mobility. The care plan dated 3/7/25 identified Resident #336 had potential for ADL function compromise with interventions that included resident was independent with meal set-up. The physician's order dated 3/7/25 directed regular diet with thin liquids. Observation on 3/10/25 at 12:56 PM identified Resident #336 was seated in his/her wheelchair with the overbed table positioned in front of him/her. On top of the overbed table was the lunch tray which contained a plate with a sandwich made with lettuce and bacon on tossed bread, a cup of hot water, a small carton of milk, small container with yellow-orange colored fruit, unopened tea bag, sugar packets, glass with yellow liquid, utensils, and napkins. On the resident's meal ticket, it indicated coffee, milk, no cheese, no onion, ginger ale zero, and BLT (bacon, lettuce and tomato) with mayo. Resident #336 indicated that he/she was unable to eat the sandwich provided as it did not have the tomato nor the mayo which he/she had specifically requested. Resident #336 continued to identify that his/her meal trays have been wrong since being admitted to the facility and has made them aware. She further noted that they conveyed they were going to ensure he/she would receive what she had ordered moving forward. Interview with the Director of Dietary Services and the Dietician on 3/10/25 at 1:07 PM identified that there were no tomatoes on the sandwich as they did not receive any tomatoes on Friday's delivery. The Dietician identified she had spoken to the resident in the morning to discuss the menu as there was no chef salad and he/she then selected a BLT sandwich and coffee as he/she reported not wanting to have tea. She identified that this was communicated on the meal ticket and to the kitchen. The Director of the Dietary services identified that it was the kitchen staff who were responsible for placing the coffee, tea and beverages on the trays and to ensure that resident have the items they select on their meal tray. Interview with [NAME] #1 on 3/14/25 at 9:25 AM identified she had prepared the sandwich for the resident on that day and there were no tomatoes and that she had placed the mayo on the sandwich but moving forward the mayo will be placed on the side. Interview with the Director of Dietary Services on 3/18/25 at 9:15 AM identified he was not aware that there were no tomatoes and if he did, he would have gone to the store or informed the residents they had no tomatoes. He further identified that the BLT was an alternative menu and was not on the regular menu for the day. He identified that everyone on the tray line is responsible for checking and ensuring that the items selected by the residents are on their tray prior to leaving the kitchen. The Director of Dietary Services identified he did not see the mayo on the sandwich but moving forward that the mayonnaise will be placed on the side for the resident to add. He also identified that residents should get the menu items they select on their meal ticket and staff will be in-service as such. Review of the Menus policy identified that menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Review of the Dietary Notice policy identified when resident food/fluid preferences are identified by the staff, a dietary notice should be completed allowing communication to the kitchen of the resident's choice. 47900

Based on clinical record review, observations, review of facility policy/procedures and interviews for one sampled resident (Resident #24) reviewed for pressure ulcer/injury, the facility failed to ensure the bilateral hand rolls/rolled wash cloths were in place as ordered. The findings include: Resident #24's diagnoses included multiple sclerosis, deformity of the wrist, deformity of the hand and right sided weakness. The quarterly MDS assessment dated [DATE] identified Resident #24 was severely cognitively impaired, was dependent with bed mobility, transfers, bathing and personal hygiene. The care plan dated 2/1/25 identified Resident #24 was at risk for skin breakdown/redness related to bilateral hand deformities (contractures), with interventions that included the application of bilateral hand rolls or rolled wash cloths at all times. The nursing assistant (NA) care card identified left and right-hand rolls (can utilize wash cloths) to be worn at all times. Physician's orders for March 2024 directed that bilateral hand rolls and or rolled wash cloths be placed in the resident's hands, to be worn at all times. Remove for skin checks and hygiene, and check every shift, per facility policy. Observation on 3/10/25 at 10:43 AM identified Resident #24's air mattress was set at 200, and the resident had no hand rolls or rolled washcloths in place. Observation on 3/12/25 at 11:28 AM identified, Resident #24 did not have hand rolls nor rolled washcloths in place. Bilateral heel lift boots were on. Left foot observed with thick scaley like areas covering the top and side of the left foot and slightly on the lower ankle area of the left foot. Scaley skin appeared brown to dark brown in color. Observation on 3/14/25 at 9:54 AM of Resident #24 identified, there were no hand rolls or wash cloths placed for the resident as ordered by the physician. Interview on 3/14/25 at 9:58 AM with LPN #4, indicated, NA #3, had just been getting supplies ready to provide care for Resident #24, that's why the heel lift boots were off and possibly why the hand rolls were not in place. The hand rolls/splints should be worn at all times, except when providing skin care or changing them when they are soiled. The heel lift boots would be put on after care is provided as ordered by the physician. Interview on 3/14/25 at 10:03 AM with RN #3 (7-3 supervisor), indicated the supervisor was not sure why the hand rolls or splints for the resident's hands were not in place. RN #3 was unable to find or locate any hand rolls or splints for the resident in the resident's room, closet or dressers. Subsequent to surveyor inquiry, a soft pillowcase was placed by RN #3 to Resident #24's left hand. RN #3 was unable to place a rolled washcloth or rolled soft pillowcase to Resident #24's right hand, due to right hand and finger deformity and stiffness. RN #3 explained, due to the contracture, it could cause pain to the resident. RN #3 spoke to one of the Occupational Therapists, OT #1 to update him/her regarding the inability to place a rolled wash cloth to the right hand. Occupational therapy to evaluate due to inability to place the hand roll to the right hand. Interview on 3/14/25 at 10:08 AM with NA #3, indicated there were hand rolls in each hand, that were removed by NA #3 as they were soiled. NA #3 along with RN #3 attempted to place a rolled washcloth and or soft rolled pillowcase in the right hand and were unsuccessful at placing it, due to right hand contractures. NA #3 then indicated bilateral clean hand rolls would have been placed once care was provided/completed. Interview on 3/14/25 at 11:55 AM with OT #1, indicated OT had been working with Resident #24 and is very familiar with the resident. OT #1 also indicated the resident had been followed by all 3 OT's ongoing, due to bilateral hand contractures and wheelchair positioning needs. Initially, splints were utilized then carrots (carrot shaped splints) due to the ongoing bilateral hand contractures. Resident #24 occasionally resists the placement of the washcloths subsequently; the staff may have found it difficult to place the washcloths at times. This has been an ongoing issue with the staff, education has been provided to staff on how to place the washcloths. Wash cloths are utilized now, as the splints and carrots are no longer appropriate due to the worsening of the hand contractures. OT #1 placed wash cloths to both hands prior to the interview. OT #1 also indicated that he/she informed the resident prior to placing the washcloths and had no issues placing the washcloths today. Review of the Splint/Orthotics/Prosthetics policy identified the nursing staff will apply/remove the designated splint/orthotic/prosthetic device during the scheduled wear times. Also, the nursing staff should notify the rehabilitation department of any ill-fitting and or misplaced splint/device. Including, if the resident refused to wear any device, to notify the rehab department, physician and responsible party.

Based on observations, clinical record reviews, facility policy review, and interviews for one sampled residents (Resident #51) for enteral feeding, the facility failed to ensure enteral feeding were properly labeled with date and time and discarded when appropriate in accordance to the facility policy. The findings include: Resident #51's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant hand, dysphagia, and gastrostomy. The significant change MDS assessment dated [DATE] identified Resident #51 with intact cognition, required extensive assistance with eating and had an enteral feeding tube. The physician's orders dated 2/13/25 directed to administer Jevity 1.5 calories via enteral feeding at 30 centimeters (cc) per hours in which the enteral feeding will be stop every day at 6:00 AM and resume at 10:00 AM every day. The care plan dated 2/20/25 identified Resident #51 had an enteral feeding tube to supplement food intake. Care plan interventions directed to check the placement of the enteral feeding, kept the head of bed at least 45 degree to prevent aspirations, and to provide the enteral feeding and fluid per physician orders. Observation on 3/17/25 at 9:00 AM identified Resident #51 lying in bed, with Jevity 1.5 calories with approximately 700 milliliters (ml) left in the plastic container hung in the pole with no label and tubing was hung in the pole with no cap (means tubing was exposed and not covered with cap) and not connected to the resident. Observation on 3/17/25 at 11:15 AM identified Resident #51 was sitting in the wheel chair, with Jevity 1.5 calories (same bottle) was connected to Resident #51 and the Jevity 1.5 calories bottle had a date label on 3/16/25 and with time at 8:00 PM. Interview with LPN #4 on 3/17/25 at 11:30 AM identified that she stopped and disconnected Resident #51's enteral feeding at 6:00 AM and re-started the enteral feeding at 10:00 AM per physician's order. She identified that the enteral feeding must be labeled with date, time, rate and the tubing should be re-capped when not in use to ensure the safe administration of the enteral feeding. She identified that she noted that the enteral feeding was not labeled this morning. She further identified that she labeled the enteral feeding bottle dated for 3/16/25 at 8:00 PM because she knew that it was changed the previous shift. She further identified that she should discarded the undated enteral feeding bottle and replaced with the new one when she noticed that it was not labeled. Subsequent to surveyor inquiry, LPN #4 discarded the old container of Jevity and replace with a new container. Interview with the DNS on 3/17/25 at 11:45 AM identified that the facility policy for enteral feeding was to properly label the enteral feeding with date, time, and rate for each administration. She further identified that the enteral feeding can be re-connected to the resident as long as enteral tubing was capped when not in use; otherwise, the enteral feeding should be replace when the enteral feeding was not properly label and/or when the enteral feeding cap was missing. The Enteral Feeding policy identified to check the physician's order for formula, rate, and water flushes. The policy also identified to label the formula and administration set with date, time, resident's name and discard the supplies and equipment when appropriate.

Based on review of the clinical record, review of facility policy, and interviews for two of four sampled residents (Resident #36 and #286) reviewed for pressure ulcer/injury, the facility failed to ensure weekly skin audits were completed per the physician's order. The findings include: 1. Resident #36's diagnoses included dementia, and pressure ulcers on the right and left buttock. The quarterly MDS assessment dated [DATE] identified Resident #36 had severely impaired cognition, was always incontinent of bowel and bladder and required total assistance with eating, bed mobility, toileting, dressing, and personal hygiene. Additionally, Resident #36 had one stage 4 pressure ulcer. The care plan dated 12/10/24 identified Resident #36 had a coccyx pressure ulcer. Interventions included pressure reducing mattress and cushions and provide incontinent care with barrier cream as needed. Physician's orders dated 12/19/24 directed to perform weekly body audits on shower days Tuesday 3:00 PM to 11:00 PM shift and document under skin observation section in the EMR. Review of the weekly body audits dated 12/17/24 to 3/4/25 did not reflect the body audits were completed on 12/31/24, 1/14, 2/4, 2/11, 2/18, and 2/25/25. There were 6 missing out of 12 weeks. Interview with the DNS on 3/19/25 at 11:58 AM indicated that the charge nurses are responsible for performing the weekly body audits on the resident's shower day and document in the EMR. The DNS indicated that Resident #36 was to have a weekly body audit completed and documented on Tuesdays 3:00 PM to 11:00 PM shift. Interview and clinical record review with the DNS on 3/19/25 at 12:20 PM was unable to provide documentation to reflect that the weekly body audits had been completed during that time frame. Review of the facility Body Audits identified residents will have a body audit performed weekly to ensure that skin is intact and without impairment. Body audits are scheduled to coincide with shower days. Body audits are completed by the licensed nurse assigned to that unit. Body audits are signed as done on the body audit form. Any area of skin that is not intact or is impaired will be followed up per the facility protocol. 2. Resident #286 was admitted to the facility on [DATE] with diagnoses that included zoster without complications, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, benign hyperplasia with lower urinary tract symptoms, and atopic dermatitis. A physician's order dated 12/2/24 directed to complete a body audit weekly, on Tuesday; 7:00 AM-3:00 PM. The admission MDS dated [DATE] identified Resident #286 had moderately impaired cognition, was dependent for personal and toilet hygiene, required substantial/maximal assistance rolling left to right and lying to sitting on the side of the bed, had an indwelling catheter, was frequently incontinent of bowel, and had no pressure ulcers/injuries. The APRN note dated 12/23/34 at 8:00 AM identified Resident #286 was seen for pain management status post shingles treatment and pain management was reviewed. The patient was admitted to the facility for short term rehabilitation following a recent hospitalization for fever and abdominal shingles. The review of systems identified a left buttock blister with treatment recommendations directing to cleanse the wound, apply Calcium Alginate, secure dry/clean dressing, and change daily and as needed. The care plan dated 12/30/25 identified Resident #286 had fragile skin. Interventions included handling skin with extra care, inspecting skin tears, and providing dressing and skin tear treatments as ordered. Review of the December 2024 through February 2025 weekly body audits documentation failed to identify weekly body audits were completed during the week of: 12/31/24, 1/4/25, 2/4/25, and 2/11/25. Review of the nurse's notes on 12/31/24, 1/4/25, 2/4/25, and 2/11/25 failed to identify that a body audit was completed or that Resident #286 had refused a shower or body audit. Interview and clinical record review with the RN Supervisor (RN #3) on 3/19/25 at 12:13 PM identified Resident #286 does not ambulate and is incontinent of bowel, which places him/her at risk for skin issues and has current skin conditions with treatments in place. RN #3 indicated that she was not aware that Resident #286's weekly body audits were not completed on 12/31/24, 1/4/25, 2/4/25, and 2/11/25, and she was not notified of any refusals. RN #3 identified that weekly body audits are to be completed by the charge nurse on the resident's first shower day, and she would expect to be notified if the skin audit was not completed, for any reason. Interview and clinical record review with the DNS on 3/19/25 at 12:02 PM identified that she was not aware that Resident #286 did not have documented body audits completed on 12/31/24, 1/4/25, 2/4/25, and 2/11/25. The DNS indicated that she would expect weekly skin audits to be completed on the resident's shower day, by the floor nurse, per the facility policy. Interview and clinical record review with the charge nurse (RN#5) on 3/19/25 at 12:41 PM identified that she could not recall if she was the nurse assigned to Resident #286 on 12/31/24, 1/4/25, 2/4/25, or 2/11/25, but the expectation is that body audits are completed weekly on the resident's shower day and documentation would be completed on the body audit form. RN #5 indicated that she could not recall if Resident #286 had refused any body audits, but if he/she had refused a shower or bed bath she would have documented the refusal in the chart, notified the RN Supervisor, educated the resident, and reapproached at a later time. Although attempted, an interview with the wound nurse was not obtained. The facility's Body Audit policy directs that residents will have a body audit performed weekly to ensure the skin is intact and without impairment. Body audits are scheduled to coincide with shower days by the licensed nurse assigned to that unit and body audits are signed as done on the Body/Oral Check form. 47457 r

Based on observation, review of clinical records, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #62) reviewed for unnecessary medication the facility failed to ensure that physician's orders were implemented and completed as prescribed by the physician and one of seven residents (Resident #335) reviewed for accidents the facility failed to ensure that medications were administered as prescribed by the physician. The findings include: 1. Resident #62's diagnoses included anxiety disorder, type 2 diabetes mellitus, and squamous cell carcinoma. The admission MDS assessment dated [DATE] identified Resident #62 was cognitively intact, independent with personal hygiene, and was dependent on care with toileting hygiene, lower body dressing, and transfers. The assessment further identified the resident utilized antipsychotic (used for managing mental health disorders) medication which the assessment noted to be of the high-risk drug classes. Review of physician orders from January/2025 through March 12, 2025, directed to administer Risperidone 1 milligrams (mg) two tablets by mouth twice daily at 9:00 AM and 9:00 PM (used to treat bipolar disorder). Review of the Medication Administration Records (MAR) from January/2025 through March/2025 identified anti-psychotic drug use and to observe closely for significant side effects: sedation, drowsiness, dry mouth, extra pyramidal reactions, postural hypotension, loss of appetite, edema and urinary retention. The physician order dated 2/2/25 directed orthostatic blood pressure (BP) monitoring once weekly on Monday on the day shift for four weeks, lying and standing or lying and sitting, if unable to stand, and to notify the provider for systolic change greater than 20 millimeters of mercury (mm Hg) and/or diastolic change greater than 10 mm Hg and to document BP readings in progress note. The Pharmacy Medication Regimen Review by the Consultant Pharmacist dated 1/20/25 identified a recommendation to consider adding an order for orthostatic blood pressure (BP) monitoring once weekly for four weeks, lying and standing or lying and sitting if unable to stand and notify MD for systolic change greater than 20 millimeters of mercury (mm Hg) and/or diastolic change greater than 10 mm Hg, which APRN #1 signed and agreed on 2/2/25. Review of the MAR from February/2025 through March 12, 2025, identified nurses initial on the date the orthostatic BP was ordered to be completed, which indicated that the order was completed. However, a review of Resident #62's clinical records failed to identify the orthostatic blood pressure that was taken as ordered by the APRN #1. Interview and record review with the Nursing Supervisor (RN #3) on 3/18/25 at 12:15 PM failed to identify the orthostatic BP readings after reviewing resident #62's nursing progress notes, vitals and MAR. RN #3 identified when the order was transcribed, the task option should have been trigger for the nurse to document the reading. She further identified the order did indicate to document the BP readings in the progress note, therefore the charge nurse should have documented the readings in his/her note as the physician's order had indicated. Interview with the Charge Nurse (RN #5) who worked on some of the Mondays when the Orthostatic BP was to be completed on 3/18/25 at 1:50 PM identified when she signs the MAR it indicates that the order was completed, or the medication was administered, or she would write a note if it was not completed. RN #5 was asked where she would document the orthostatic BP and her response was there was no place on the MAR to document the readings and if the order was inputted correctly, they would have been written there. She was then asked if orthostatic BP was taken, and she did not respond. She further identified she could not recall if she had written them in her nurse's note or in the vital section of the electronic record and kept indicating that the order was inputted incorrectly. Interview with APRN #1 on 3/18/25 at 1:20 PM identified that normally she puts in her orders into the electronic health record system and added that she did enter the orders for Resident #62 on 2/2/25. The APRN #1 identified she does not know how to place the drop down for the nurses to input the BP, hence why she added to the order that the BP reading be placed in the progress note. She added that orthostatic blood pressure monitoring was ordered as the resident was on an antipsychotic medication which could cause orthostatic changes to resident's BP. Further, she indicated that there wasn't a need to follow-up whether the orthostatic blood pressure was completed because if there was a concern with the reading the facility would have notified her as stated in the order. Interview with the DNS on 3/18/25 at 2:10 PM identified that 11-7AM shift nurse completes a 24-order check to ensure orders are inputted correctly. The DNS further identified if the charge nurse was responsible for reviewing and completing a physician's order as directed and if he/she signs it means that the order was completed so the BP should have been documented as directed. Review of the Doctor's Order policy identified that the facility would meet all current standards of nursing practice in accepting, transcribing and executing doctor's orders to ensure compliance with current standards of nursing practice a ensure the resident's needs are met. 2. Resident #335's diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] identified Resident #335 was moderately impaired cognition, required maximal assistance with dressing, toileting hygiene and bed mobility. The care plan dated 3/10/25 identified Resident #335 had COPD related to recent acute respiratory failure and it may be hard for the resident to breathe at times with interventions that included offer to provide resident with nebulizer treatments, and if increased coughing, respiratory rate, decreased oxygen levels, trouble breathing, increased mucus production could indicate an exacerbation of the resident COPD. The physician's order dated 3/5/25 directed Trelegy Ellipta (Fluticasone-umeclidin-vilanter) 200-62-5-25 micrograms (mcg) to inhale one puff once daily at 9:00 AM (used to treat COPD). Review of the electronic Medication Administration Record (MAR) identified the following: On 3/6/25 and 3/7/25 the medication was not administered with a note that indicated the resident was a new admission and awaiting pharmacy delivery. On 3/8/25, 3/9/25, 3/10/25, and 3/11/25 the medication was administered On 3/12/25 and 3/13/25 the medication was not administered with a note that indicated drug/item unavailable. Review of Resident #335 clinical records failed to identify the provider was updated regarding Trelegy medication was unavailable until 3/13/25. Interview and observation of the Medication Cart on unit with the day shift Nursing Supervisor (RN #3) and the Charge Nurse (LPN #12) on 3/12/25 at 11:30 AM failed to identify the Trelegy medication within the cart. LPN #12 identified that the medication was not there as she was unable to administer the medication in the morning. LPN #12 added she looked in the medication storage room and was unable to locate the medication. RN #3 indicated that she had spoken to the pharmacy regarding the medication to clarify the duplicate order and that the pharmacy would deliver the medication. Interview with the Pharmacist #1 on 3/14/25 at 9:28 AM identified Trelegy was not dispensed to the facility due to a duplicate warning which was clarified on 3/7/25 and due to a billing issue. However, she added that the pharmacy sent an email to the facility (usually to the DON and ADON) on 3/7/25, 3/9/25, 3/10/25, 3/11/25, and 3/12/25 for authorization to bill the facility for the medication, which the pharmacy received no response from the facility. Pharmacist #1 identified if the resident was not receiving the medication he/she could have an exacerbation of symptoms, and it would not be immediate as the medication was a long-acting inhaler. Interview with the DNS on 3/14/25 at 12:50 PM identified she had received the notification from the pharmacy regarding Resident #335 inhaler. She added that the email sent by the pharmacy was also sent to the nursing supervisor's, however, she usually prints the email and gives it to the nursing supervisor to follow-up. The DNS was unable to locate the copy of the pharmacy notification she had provided to the nursing supervisor after searching through a folder in her office where she kept her records. Interview with RN #3 on 3/14/25 at 12:19 PM identified she was unable to recall receiving any information from the pharmacy from the DNS as if she did, she would have followed up as she was looking for the medication. RN #3 added that she had called the pharmacy on 3/12/25 and discovered that the medication was not sent as it was not covered by the resident's insurance, and this would need approval from the DNS. She further added that the resident's family was notified, and they picked up the medication from the local pharmacy and brought it to the facility. RN #3 was asked if the provider was notified throughout the time-period the resident was not getting the medication, which she responded that the charge nurse was responsible for notifying the provider if the medication was unavailable. She further indicated that she then notified the provider on 3/13/25 regarding the resident not receiving the medication. Interview with the Charge Nurse (RN #6) on 3/17/25 at 10:20 AM identified she did not notify the provider as she thought the medication would have been delivered by the pharmacy to administer the medication. However, she added that the provider should have been notified as the medication was not available to administer. Interview with the Nursing Supervisor (RN #7) on 3/17/25 at 11:05 AM identified she had worked on 3/9/25 and had signed the MAR, indicating Trelegy was administered. She further identified she was unable to recall if the medication was there and had not notified the provider regarding the resident not receiving the inhaler but should have if the medication was unavailable. Review of the General Guidelines for Medication Administration policy identified if 3 consecutive doses of vital medication are withheld or not available, the physician is notified and nursing documents the notification and physician's response. The policy further identifies the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

Based on review of clinical records, review of facility documentation, review of facility policy/procedure and interviews for one of two sampled residents (Resident #62) reviewed for Pre-Admission Screening and Record Review (PASRR), the facility failed to ensure that a Level 2 determination was completed when the 30-day approval stay expired. The findings include: Resident #62 was admitted to the facility in January/2025 and had diagnoses that included anxiety disorder, type 2 diabetes mellitus, and squamous cell carcinoma The admission MDS assessment dated [DATE] identified Resident #62 was cognitively intact, independent with personal hygiene, and was dependent on care with toileting hygiene, lower body dressing, and transfers. Review of the PASRR screen level 1 dated [DATE] identified Resident #62 was approved for 30 days. The Psychiatric APRN note dated [DATE] identified Resident #62 has a history of bipolar disorder. Interview with the Social Worker (SW) on [DATE] at 12:20 PM identified she is responsible for submitting the request for PASRR screens to the PASRR agency. She further identified Resident #62 was approved for a 30 day stay which ended on [DATE] but she had not requested for a PASRR screen Level 2 (rescreen) because the approved time expired on [DATE]. The SW identified that she submitted the request for the screen on [DATE], after the request was made by the surveyor for the information. She added that the resident stayed beyond the 30 days (discharged [DATE]) and had a diagnosis of bipolar so a level 2 PASRR request should have been submitted prior to the expiration date. She identified she was the only Social Worker in the building and had expressed to both the DNS and Administrator that she was behind and needed some assistance. Interview with the DNS and the Administrator on [DATE] at 1:18 PM identified the social worker was responsible for submitting request for PASRR. They both identified, they were only aware that she was behind with MDS assessment and needed assistance, which they provided. However, they were unaware that she needed any other assistance or was behind in any other areas of her work. Review of the Pre-admission Screening and Resident Review (PASRR) policy and procedure identifies a level of Care are also required to determine the medical necessity for individuals continued stay at a Skilled Nursing facility. In addition, if a resident is admitted with a short-term level 1 or level of care add them to facility PASRR/Ascend Smart sheet tracker and ensure to place a due date for 10 days prior to expiration date. The policy and procedure further identified that a level of care request for continued approval must be submitted no later than 10 days prior to current approval expiration, and up to 15 days prior to current level of care approval expiration.

Based on review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews for one of two sampled residents (Resident #335) reviewed for advanced directives, the facility failed to ensure consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status from the resident/responsible party. The findings include: Resident #335 was admitted to the facility in March/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] identified Resident #335 was moderately impaired cognition, required maximal assistance with dressing, toileting hygiene and bed mobility. The physician's order dated [DATE] directed full code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The care plan dated [DATE] identified Resident #335 had chosen to be a full code with interventions that included the resident or responsible party will notify social service if choses to change code status. Review of Resident #335's physical chart and the electronic clinical record system both failed to identify a signed Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form signed by the resident/resident representative indicating the code status of Full Code was completed. Interview with the Charge Nurse (RN #5) on [DATE] at 11:20 AM identified that if Resident #335 had a life-threatening emergency where it would be necessary to provide CPR or withhold CPR, she would look in the physical chart under the advance directive tab as this is the most accurate place than the physician's order to determine the resident's code status. RN #5 reviewed the physical chart and noted Resident #335 did not have a completed Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form signed by the resident/resident representative. RN #5 identified the Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form should be completed on admission and based on what the resident/resident representative selected the physician's order would then be written. Subsequent to surveyor's inquiry, an Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form for Resident #335 was completed and signed by the resident on [DATE] indicating a code status of do not resuscitate (DNR) and do not intubate. Interview with the Nursing Supervisor (RN #8) who was the admitting nurse on [DATE] at 9:32 AM identified the advance directive form was not completed at the time of admission. RN #8 identified that Resident #335 was capable of completing the advance directive paperwork but when she went to the resident to sign the form, he/she was asleep. She added that she then utilized the code status written on the hospital discharge paperwork to determine what the code status was until the resident/responsible party signed the form. RN #8 identified the hospital discharge code status is often used when the resident is unable to complete the form, and the facility is unable to reach the responsible party. RN #8 identified on that evening she had received a total of three admissions and had passed on in report that Resident #335 advance directive form was not completed and for the next shift to follow-up. Review of the Advance Directives policy and procedures identified Advance Directive are discussed with the resident and/or primary decision maker by a licensed nurse at the time of admission. The policy further identified that the resident and/or primary decision maker will be asked to sign the appropriate form according to his/her wishes which will be maintained in the clinical record and the physician will then sign the Advance Directive form.

Based on review of facility documentation, review of facility policy and interviews, the facility failed to ensure the Office of the Sate Long-Term Care Ombudsman was notified of resident transfers and discharges on a monthly basis. The findings include: Review of the facility's discharge report for the months of October 2024 - January 2025 identified the following: 1. For the month of October 2024, there were thirty-six residents discharged and/or transferred from the facility. 2. For the month of November 2024, there were forty-one residents discharged and/or transferred from the facility. 3. For the month of December 2024, there were twenty-six residents discharged and/or transferred from the facility. 4. For the month of January 2025, there were thirty-six residents discharged and/or transferred from the facility. A request for the monthly Ombudsman's report for transfers and discharges for the months of October 2024, November 2024, December 2024, and January 2025 identified that the monthly reports for October, November and December were sent to the Ombudsmen's office on February 4, 2025, and the January 2025 report was sent to the Office of the Sate Long-Term Care Ombudsman on 3/11/25. Interview with the Office Manager on 3/17/25 at 10:21 AM identified she has been employed by the facility for 12 years. The Office Manager indicated she is responsible for sending the monthly report of transfers and discharges to the Office of the Sate Long-Term Care Ombudsman. The Office Manager identified that she did not have a reason for not sending the reports monthly but is aware that she should be sending the report on a monthly basis. Interview with the Administrator on 3/18/25 at 8:02 AM identified he was not aware of the discharge reports not being sent to the Office of the State Long-Term Care Ombudsman timely. Interview with the DNS on 3/18/25 at 9:24 AM identified she was unaware of the discharge and transfer reports not being sent to the Office of the Sate Long-Term Care Ombudsman within acceptable parameters, which is monthly. Review of the facility transfer or discharge, facility-initiated identified once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of four sampled residents (Resident #66) reviewed for hospitalization and had multiple hospitalizations, the facility failed to ensure the resident and/or resident representative were provided with written information regarding the bed hold policy. The findings include: Resident #66 was admitted to the facility in December 2023 with diagnoses that included heart failure and dementia. The admission MDS assessment dated [DATE] identified Resident #66 had severely impaired cognition and required supervision/contact guard assistance with personal hygiene and maximum assistance with toileting and dressing. The physician's note dated 1/18/24 identified Resident #66 was admitted on [DATE] status post hospitalization for leg pain after a fall. The ombudsman's notification book for the month of January 2024 identified Resident #66 was transferred to the hospital on 1/31/24 and readmitted to the facility on [DATE]. A reportable event dated 1/31/24 at 7:30 PM identified Resident #66 was observed on the floor in the resident's room with no witnesses. Resident #66 had a bump on the left side of the forehead. Resident #66 was on Xarelto (a blood thinner), and the physician ordered Resident #66 be sent to the emergency room. The nurses note dated 2/6/24 at 2:19 PM identified Resident #66 was readmitted at approximately 12:15 PM via stretcher from the hospital with a diagnosis of subarachnoid hemorrhage. The ombudsman's notification book for the month of February 2024 identified Resident #66 was transferred to the hospital on 2/7/24 and readmitted to the facility on [DATE]. The nurses note dated 2/7/24 at 7:42 PM identified Resident #66 showed signs of weakness while sitting in the dining room. Resident #66 was taken to his/her room for an assessment. Resident #66 appeared weak and lethargic. Resident #66's blood pressure was 90/47 (low, respirations were 11, and oxygen level was 79-84% on room air. Resident #66 was placed on a nonrebreather oxygen mask via concentrator and oxygen saturation increased to 90-93%. The physician was notified, and Resident #66 was sent to the emergency room via 911 at 5:35 PM. The nurse's note dated 2/16/24 at 6:24 PM identified Resident #66 was readmitted to the facility at 3:10 PM from the hospital with a diagnosis of Clostridium Difficile and is on antibiotics. The ombudsman's notification book for the month of April 2024 identified Resident #66 was transferred to the hospital on 4/17/24 and readmitted to the facility on [DATE]. The reportable event dated 4/17/24 at 8:30 PM identified Resident #66 was noted on the floor in the dining room. Resident #66 had a bump to his/her forehead. Resident #66 was on Lovenox (a blood thinner) every 12 hours. Resident #66 was sent to the emergency room for hematoma to the forehead. The nurse's note dated 4/18/24 at 3:58 AM identified Resident #66 returned on 4/17/24 at 11:35 PM from the hospital. The ombudsman's notification book for the month of April 2024 identified Resident #66 was transferred to the hospital on 4/18/24 and readmitted to the facility on [DATE]. The nurses note dated 4/18/24 at 10:50 AM identified noted with mental status changes. The resident was placed on oxygen at 2 liters per minute for low oxygen saturation. Resident #66 was lethargic but responded by tactile stimuli by opening his/her eyes. Placed call to 911 and the resident left the facility at 10: 45 AM. The nurse's note dated 4/24/24 at 11:47 PM identified Resident#66 was readmitted to the facility from the hospital. Resident #66 had facial bruises. The ombudsman's notification book for the months of July and August 2024 identified Resident #66 was transferred to the hospital on 7/26/24 and readmitted to the facility on [DATE]. The nurse's note dated 7/26/24 at 6:38 PM Resident #66 had poor fluid intake, was seen by the physician who ordered intravenous hydration and immediate labs to be done. Resident #66's responsible party was updated, and he/she requested Resident #66 be transferred to the hospital. The physician's order directed the resident be sent to the emergency room. Resident #66 was transferred at 6:55 PM. The nurse's note dated 8/8/24 at 12:48 PM identified Resident #66 was readmitted at 11:30 AM from the hospital with a diagnosis of a urinary tract infection. Interview with the DNS on 3/17/25 at 12:45 PM indicated that she is not aware of the bed hold policy and unable to identify who is responsible for providing the bed hold policy to residents/responsible party. Interview with RN #3 (7:00 AM to 3:00 PM supervisor) on 3/17/25 at 12:54 PM indicated when she or another supervisor sends a resident to the hospital the resident is sent with a inter agency referral report (W-10 which is a continuity of care document) that consists of medication list, allergy list, current vital signs, diagnosis list, insurance provider, immunizations, resent test/lab results, level of care needs, and the signed advanced directive for a resident that is a full code and the hand print for a resident that is a DNR. RN #3 indicated that the supervisors only keep the yellow copy of the w-10 and send the white copy with the resident to the hospital. RN #3 indicated that she nor the other supervisors provide the bed hold policy. RN #3 indicated that she knows what a bed hold is but she nor any other supervisors have any part of that. RN #3 indicates that the bed hold has to do with money so she thinks the finance office would be responsible for that. Interview with SW#1 on 3/17/25 at 1:04 PM indicated that she does not hand out the bed hold form to resident's and does not call resident's or resident representative to discuss the bed hold policy when a resident is sent to the hospital. Interview with the Business Office Manager on 3/18/25 at 10:55 AM indicated the nursing supervisor is responsible to give the resident the bed hold policy when they are being sent out to the hospital and only if a resident is private pay, will she contact the resident or resident representative to see if they want to hold the bed and pay for it. Additionally, Business Office Manager #1 indicated that she does not call the resident or resident representative if the resident is on a Medicare A stay and was sent to the hospital even though then the resident would be private pay to offer for them to pay to hold the bed privately. Interview and clinical record review with DNS on 3/17/25 at 2:00 PM, failed to provide documentation that the bed hold policy/notice was given to Resident #66's responsible party with any of the 5 hospitalizations the resident had in 2024. Review of the facility Bed-Hold and Returns Policy identified prior to transfers and therapeutic leaves, residents or resident's representatives will be informed in writing of the bed hold and return policy. Residents Prior to a transfer, written information will be given to the residents and the residents representative that explain in detail the rights and limitations of the resident regarding bed-holds, the reserve bed payment policy as indicated by the state plan (Medicaid residents), the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period(Medicaid residents), and the details of the transfer (per the Notice of Transfer).

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound care, the facility failed to ensure wound treatment recommendations were implemented. The findings include: Resident #1 had diagnoses that included metastatic malignant neoplasm of breast, fungating mass (tumor has broken through the skin) of right breast, secondary malignant neoplasm of bone, severe protein-calorie malnutrition, and adult failure to thrive. The nursing admission body audit dated 11/14/24 at 4:37 P.M. completed by RN #3 (wound nurse) identified Resident #1 has alterations in skin integrity with a cancerous wound to h/her right breast that is erythematous (red)with sanguineous drainage (clear fluid mixed with blood). A physician's order dated 11/14/24 directed to cleanse the right breast cancer wound with Dakins 0.125 % (an antimicrobial cleanser) , pat dry, apply Xeroform 4x4 gauze (a non adhesive dressing), cover with dry gauze, and abdominal pad secure with large stockinette like tube top change daily while awake on the 11:00 P.M.- 7:00 A.M. shift. The care plan dated 11/15/2024 identified Resident #1 has impaired skin integrity with interventions that directed to provide treatment as ordered, weekly skin assessment per facility protocol, monitor for healing process and notify MD and responsible party if no improvement, and change treatment as indicated. Review of APRN #2's (wound APRN) note dated 11/19/24 at 9:48 A.M. identified Resident #1 was seen today for evaluation and management of wounds. APRN #2 identified Resident #1 has a full thickness wound to h/her right breast from carcinoma that measures 14.0 centimeters (cm) in length by 12.0 cm in width, with a depth of 0.2 cm, and a moderate amount of sanguineous drainage. APRN #2 identified on 11/19/24 for Resident #1's right breast the wound treatment recommendation directed to cleanse with 0.125 % Dakins, apply xeroform, calcium alginate with silver to base of the wound (absorbs excess moisture), secure with an abdominal pad, change daily and as needed. Review of the physician's orders dated 11/19/24 to 11/24/24 failed to reflect that APRN #2's wound treatment recommendation for Resident #1's right breast were implemented. Review of Resident #1's Treatment Administration Record (TAR) from 11/19/24 to 11/24/24 identified the wound treatments for Resident #1's right breast cancer directed to cleanse the right breast cancer wound with Dakins 0.125 %, pat dry, apply Xeroform 4x4 gauze, cover with dry gauze, and abdominal pad secure with large stockinette like tube top change daily while awake not before 5:00 A.M. and did not include APRN #2's wound treatment recommendations dated 11/19/24 that directed to apply calcium alginate with silver to base of wound. An interview with APRN #2 (wound APRN) on 12/19/24 at 3:25 P.M. identified on 11/19/24 she was consulted to evaluate Resident #1's wounds. APRN #2 identified Resident #1's right breast carcinoma wound had a moderate amount of sanguineous drainage. APRN #2 identified based on the amount of drainage from Resident #1's right breast she changed the wound treatment and added calcium alginate with silver to be applied to the base of the wound. APRN #2 identified on 11/19/24 her wound treatment recommendation for Resident #1's right breast wound directed to cleanse the right breast with 0.125 % Dakin's solution, apply xeroform, apply calcium alginate with silver to base of the wound, secure with an abdominal pad, change daily and as needed. APRN #2 identified on 11/19/24 Resident #1's wound treatment recommendations for the right breast should of been implemented. Interview with the DNS on 12/19/24 at 3:45 P.M. identified on 11/19/24 RN #3 (wound nurse) was on vacation and on the charge nurses of each unit conducted wound rounds with APRN #2. The DNS identified the charge nurses are responsible for implementing APRN #2's wound treatment recommendations. The DNS was unable to provide documentation to reflect that on 11/19/24 APRN #2's wound treatment recommendations for Resident #1's right breast was implemented. The DNS identified her expectation is the charge nurses implement APRN #2's wound treatment recommendations. The DNS further identified on 11/19/24 APRN #2's wound treatment recommendation for Resident #1's right breast should have been implemented. Review of facility undated wound treatment and wound care policy identified that there are scheduled wound observation rounds (same day each week) with observation of resident's skin (head to toe) and documentation of meetings will be kept to include recommendations as appropriate, new treatments, and progress of wounds.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, (Resident #2), the facility failed to ensure a resident who is completely dependent on staff for transfers, wheelchair mobility, bed mobility and Activities of Daily Living (ADLs) remained free from significant injuries of unknown origin including bilateral (both sides) femur (bone in upper thigh) fractures. The findings include: Resident #2 had diagnoses that included vascular dementia, anxiety, depression, bipolar, and atrial fibrillation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had short-term and long-term memory impairment (not capable of completing a brief interview for mental status exam), severely impaired cognitive skills for daily decision making, was always incontinent of bowel and bladder, dependent on staff for all ADLs, including bed mobility, and transfers, was non ambulatory and dependent on staff for mobility in the wheelchair. The care plan dated 9/4/24 identified Resident #2's ADL function is compromised with interventions that directed to provide total assist of two staff for bed mobility and a Hoyer lift with assist of two. A nurse's note dated 11/5/24 at 6:26 A.M., written by Licensed Practical Nurse (LPN) #4 (11:00 PM- 7 :00 AM shift charge nurse), identified she was called to Resident #2's room by Nurse Aide (NA) #1 who observed a discoloration to the resident's right thigh area. RN #3 was notified and assessed the area and notified the Advanced Practice Registered Nurse (APRN). A nurse's note dated 11/5/24 at 6:22 A.M., written by Registered Nurse (RN) #3 (11:00 PM -7:00 AM supervisor), identified staff reported that Resident #2's right knee was red and swollen, the APRN was notified and would be in to assess the resident. Review of APRN #1's note dated 11/5/24 at 12:15 P.M. identified Resident #2 was seen for right knee redness, swelling, tenderness, and warmth to touch. Resident #2 appeared comfortable and was sitting in wheelchair upon assessment with no facial grimacing. Resident #2 is a poor historian in the setting of dementia, history obtained from nursing there had been no recent falls or injuries. Resident #2 had erythema (redness) and swelling noted to right knee, heat in the right knee joint, and tenderness only upon palpation, clinical presentation is suspect of a joint infection/effusion of right knee. New orders were written for intravenous (IV) Unasyn 1.5 grams (antibiotic to treat infection), start Mobic 7.5 milligrams (mg) (used to treat inflammation and reduce pain), obtain blood work, and an X-ray of right knee to rule out fracture, although no recent fall/injury reported. Review of Resident #2's right knee X-ray report dated 11/5/24 at 11:29 P.M. identified an acute comminuted fracture of the right distal femur with displacement. A nurse's note dated 11/6/24 at 1:44 A.M. written by Registered Nurse (RN) #3 identified on 11/5/24 at 11:20 P.M. the X-ray company reported that Resident #2's right knee X-ray identified an acute comminuted fracture of the distal femur with displacement. Resident #2 was awake, verbally responsive. The physician was notified of the result at 12:25 A.M. an order obtained from MD #1 to transfer Resident #2 to the hospital. Review of the facility's accident and incident report dated 11/6/24 identified the date of the event as 11/5/24 at 11:30 P.M. for injury of unknown origin. The facility's summary dated 11/12/24 identified Resident #2 is a total care assist with ADLs, assist with meals, non-ambulatory, and a Hoyer lift. On November 5, 2024, there was redness and swelling noted to Resident #2's right knee, the area was red, warm, and tender to touch, however, no bruising was identified. APRN #1 assessed the area and ordered an X-ray determined Resident #2 had a distal femur fracture and the resident was sent to the hospital. On November 6, 2024, the facility received a call from the hospital that identified that Resident #2 had a fracture of both the left and right femur and a diagnosis of severe osteoporosis. All staff that cared for the resident seventy-two hours prior to the discovery of the injury were interviewed and identified that there were no falls, any issues Hoyer lift transfers, with confirmation that the Hoyer lifts were completed with the assist of two (2) staff. Resident #2 returned with bilateral knee immobilizers and will follow up an orthopedic physician. The facility was unable to determine the exact cause of Resident #2's bilateral femur fractures other than severe osteoporosis as the investigation did not determine any falls, improper transfers, or abuse. The hospital Discharge summary dated [DATE] identified Resident #2 presented to the hospital from the facility after Resident #2 was found to have a right distal femur fracture. A trauma work-up further identified that the resident had a fading bruise to the left forehead, and right and left distal femur fractures. Interview with Nurse Aide (NA) #1 on 11/15/24 at 6:40 A.M. identified on 11/5/24 she noted Resident #2's right knee was red and swollen and immediately reported the findings to LPN #4 and RN #3. NA #1 identified Resident #2 is totally dependent with ADLs, requires the assistance of two (2) with bed mobility, transfers with use of a Hoyer lift and assistance of two (2). NA #1 indicated she was not aware of Resident #2 having any falls or accidents. Interviews on 11/15/24 with NA #5, NA #6, LPN #3, LPN #5, RN #2, RN #5 at various times, who cared for the resident 24 hours prior to the injury being discovered, failed to identify any abnormalities to the lower extremities, bruising, falls, accidents, behaviors, or incidents with the Hoyer lift prior to 11/5/24. Interview with the Director of Nursing Services (DNS) on 11/15/24 at 9:30 A.M. identified on 11/6/24 the facility received the results of Resident #2's right knee X-ray results which indicated a right femur fracture and Resident #2 was transferred to the hospital, where a second femur fracture was identified on the left side, as well as a diagnosis of severe osteoporosis. The DNS identified that she was not aware of the bruise to left forehead and could not identify the cause. Resident #2 was totally dependent on staff for care, does not ambulate, requires the assistance of two (2) staff with bed mobility and transfers using a Hoyer lift, and has no behaviors such as agitation or restlessness. The DNS indicated based on the investigation Resident #2's transfers were properly conducted with two (2) staff assisting with the use of the Hoyer lift. The DNS indicated Resident #2 had a customized wheelchair and there were no concerns with positioning. The DNS identified staff interviews indicated Resident #2 had no recent falls and Resident #2's last fall occurred on 10/10/22. The DNS identified although a complete and thorough investigation was completed the DNS could not determine what caused Resident #2's bilateral femur fractures. Interview with APRN #1 on 11/15/24 at 12:30 P.M, identified on 11/5/24 APRN #1 was asked to see Resident #2 due to right knee swelling, redness, warmth, and tenderness only with touch. APRN #1 indicated Resident #2 had no falls, trauma or injury and based on Resident #2's clinical presentation she suspected Resident #2 had septic arthritis ordered IV antibiotics and an X-ray of Resident #2's right knee to rule out a fracture. APRN #1 identified the X-ray results indicated Resident #2 had a distal right femur fracture and Resident #2 was sent to the hospital. Interview with the Orthopedic Surgeon (OS) that treated Resident #2 in the hospital on [DATE] at 6:00 P.M. identified on 11/6/24 Resident #2 presented in the hospital from the facility for evaluation of a right femur fracture, and subsequently a left femur fracture. The OS identified per the facility report Resident #2 was non-ambulatory, required use of a Hoyer lift, and had no falls, and even with severe osteoporosis routine movements and positioning would not attribute to bilateral fractures of the femur. MD #2 identified he attributes Resident #2's bilateral femur fractures to some type of trauma, such as a fall. Although attempted interviews with RN #3 and LPN #4 were not obtained.

Based on observation, review of the clinical record, facility documentation, and manufacturer's recommendations for 1 of 3 residents (Resident #197) reviewed for accidents, the facility failed to provide adequate supervision to a resident who could not be educated regarding safe positioning while in a transport wheelchair and/or the facility failed to perform thorough and ongoing inspections of the transport wheelchair, in accordance with the Owner's manual which resulted in a the resident tipping backward while in the chair and sustaining a neck fracture. The findings include: Resident #197's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #197 had moderately impaired cognition, required limited assistance for transfers, and was independent for walking in the corridors with the use of a walker. The care plan dated 3/6/18 identified Resident #197 had a self-care deficit with interventions that included to allow the resident to perform tasks at his/her own rate, give choices while providing care, adjust level of care accordingly to individual needs, and report persistent change. The care plan also identified Resident #197 self-propelled in the wheelchair for long distances and declines the use of leg rests while being transported by another person. Facility documentation dated 5/22/18 identified Resident #197 was 5 foot 8 inches and weighed 160 lbs. A nurse's note dated 5/22/18 identified that at approximately 12:50 PM, he/she was called to the beauty parlor and observed Resident #197 lying on the floor on his/her back. Subsequently, the RN Supervisor was immediately notified. A nurse's note written by RN #5 on 5/22/18 at 3:38 PM identified Resident #197 was pushing him/herself backwards in the transport wheelchair while at the hairdresser's when the wheelchair flipped backwards. An assessment after the fall indicated Resident #197 had no visible injuries, or rotation or shortening of the extremities, but complained of neck pain. The APRN was notified and directed to transfer Resident #197 to the emergency room for an evaluation. Review of facility documentation dated 5/25/18 identified Resident #197 sustained a [MEDICATION NAME] fracture across the C3 - C4 disc which required surgical intervention. Facility documentation dated 5/29/18 identified Resident #197 had a discectomy and fusion at the hospital on [DATE], and was slowly improving, when a change in condition occurred which resulted in the resident's death from cardiopulmonary arrest on 5/25/18. Interview with the Director of Maintenance on 9/18/18 at 11:30AM identified the transport wheelchair was washed weekly and inspected at that time, however documentation on routine preventative maintenance as directed by the manufacturer was not completed. Interview with RN #5 on 9/19/18 at 11:05 AM identified that he/she observed Resident #197 in the wheelchair on the floor with his/her legs in the air. Neurological assessment at that time was normal, the resident had his/her usual mentation, no pain, visible injuries or deformities. When staff asked Resident #197 what happened, the resident, while back in the transport wheelchair, began to demonstrate how he/she pushed the transport wheelchair backward, and the transport wheelchair began to tip backwards again. RN #5 directed Resident #197 to stop, and then wheeled the resident back to his/her room. Resident #197 complained of neck pain, and subsequent to APRN notification and consultation with the family, the resident was sent to the hospital. Interview with the Hairdressing Assistant on 9/20/18 at 9:40 AM indicated Resident #197 was assisted into the transport wheelchair when he/she arrived at the beauty parlor after having walked there after lunch on 5/22/18. Once Resident #197 was seated, the Hairdressing Assistant moved the resident's walker towards the wall, and then turned to get the hairdresser's cape when he/she heard a fall and observed Resident #197 on the floor. The Hairdressing Assistant further indicated Resident #197 did not propel nor move the wheelchair, it just tipped over. Further interview identified that the beauty parlor uses two kinds of wheelchairs for beauty and barber services, whichever is free at the time of need. One of the wheelchairs was a regular wheelchair and one was a transport wheelchair as the beauty parlor was not equipped with permanently affixed chairs. Interview and review of the clinical record with the Rehabilitation Manager on 9/20/18 at 11:00 AM identified Resident #197 was assessed for the use of a standard wheelchair on 2/15/18, but there was not assessment for the safe use of the transport wheelchair during hair trimming at the beauty parlor. Interview and demonstration with the Occupational Therapist on 9/18/18 at 11:55 AM identified the transport wheelchair easily tipped over backwards with the slightest movement with the wheel locks engaged. Observation and demonstration with 3 surveyors on 9/20/18 at 12:35 PM identified while seated in the transport wheelchair, once feet were lightly placed on the floor, the chair immediately tipped backward. Review of the Owner's operator's maintenance manual safety and handling of the transport chair requires the close attention of the transport chair user as well as the assistant. The Owner's operator's maintenance manual also identified to assure stability and proper operation of the transport chair, you must at all times maintain proper balance. Your transport chair has been designed to remain upright and stable during normal daily activities as long as you do not move beyond the center of gravity. Virtually all activities which involve movements in the transport chair have an effect on the center of gravity. Use seat/chest positioning straps for additional safety while involved in activities that shift your weight. Do not lean forward out of the transport chair any further than the length of the armrest. Make sure the casters are pointing in the forward position whenever you lean forward. This can be achieved by advancing the transport chair and then reversing in a straight line. Many activities require the transport chair owner to reach, bend and transfer in and out of the transport chair. These movements will cause a change to the normal balance, the center of gravity, and the weigh distribution of the transport chair. To determine and establish your particular safety limits, practice bending, reaching and transferring activities in several combinations in the presence of a qualified health care professional before attempting active use of the transport chair. Proper positioning is essential for your safety. When reaching, leaning, or bending forward, it is important to use the front casters as a tool to maintain stability and balance. Warning; do not lean over the top of the back upholstery. This will change your center of gravity and may cause you to tip over. Reach back only as far as your arm will extend without changing your sitting position. Every 6 months take your transport chair to a qualified technician for a thorough inspection and servicing. Periodically check the wheels and tires for cracks and wear. Have a qualified technician replace if damaged. Periodically adjust the wheel locks in correlation to tire wear. Operating information; do not shift your weight or sitting position toward the direction you are reaching as the transport chair may tip over. The facility failed to ensure adequate supervision of Resident #197, (who had moderately impaired cognition and could not be educated on the details of safe positioning and movement while in the transport wheelchair to prevent the chair from tipping, such as do not lean over the top of the back upholstery, this will change your center of gravity and may cause you to tip over, reach back only as far as your arm will extend without changing your sitting position), which resulted in Resident #197 tipping backward onto the floor while in the transport wheelchair and sustaining a [MEDICATION NAME] fracture across the C3 - C4 disc which required discectomy and fusion. Additionally, the facility failed to ensure the transport wheelchair had thorough inspections according to the Owner's operators maintenance manual.

Based on review of the clinical record, review of facility documentation and interview for one of four sampled residents reviewed for accidents(R#255), the facility failed to ensure support to a LE afflicted with hemiparesis during wheelchair transport resulting in a fall with an injury. The findings include: Resident # 255's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident had moderately impaired cognition, was totally dependent on 2 staff for transfers, unable to ambulate, had an unsteady balance and limited range of motion on one side. The Resident Care Plan dated 10/19/15 identified a potential for falls/injuries related to unsteady gait and impaired balance and a need for assist with ADL's. Interventions directed the staff to maintain proper body alignment while in the chair and bed and transfer with the assist of 2 staff. The care plan failed to reflect [DIAGNOSES REDACTED]. Nurse's notes dated 11/17/15 at 10:20 PM identified while NA # 2 wheeled the resident from the bathroom, the resident's foot got stuck under the wheelchair causing her/him to fall forward out of the wheelchair. The resident sustained [REDACTED]. The area was cleansed with normal saline and steri strips were applied. The physician was notified and the resident was transferred to the ED for an evaluation at 11:30 PM. The resident returned to the facility on [DATE] at 3:07 AM with three sutures to the right eyebrow. The physician's orders [REDACTED]. The Resident's Care Plan was revised to include that the staff were re-educated to ensure leg rests were on the resident's wheelchair at all times due to to the resident's tendency to lean forward and due to hemiparesis. Interview review of the clinical record and facility documentation on 3/22/16 at 8:30 AM with the Director of Rehab identified that the resident should have had the leg rests on the wheelchair at the time of the incident to prevent the resident from dragging her/his foot and/or from falling forward out of the wheelchair. He/she noted that it is a standard of practice that residents with hemiparesis should always utilize leg rests while in a wheelchair.

Based on clinical record reviews and staff interviews for three of six residents in the survey sample reviewed for pressure ulcers (R# 2, 27 and 91), the facility failed to ensure a resident with a pressure ulcer was assessed weekly, and/or monitored after an area was identified and/or when the area developed into a pressure ulcer conduct a complete initial assessment, and/or ensure appropriate functioning of a specialty mattress, and/or failed to initially appropriately identify and treat wounds as pressure ulcers. The finding included: 1. Resident #2's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified R#2 was severely cognitively impaired, totally dependent on staff for all ADL's, and was at risk for developing pressure ulcers. The resident care plan (RCP) dated 8/26/13 identified a problem with skin breakdown. Interventions included to report redness, open areas and excoriation and to apply pressure relieving device as indicated. A nurse's note dated 10/31/13 at 11:50 AM identified redness in the left popliteal (back of knee) area. It further identified that "the area is an irritation from the leg of the wheelchair". The RCP dated 10/31/13 identified potential pressure ulcers to the bilateral heels. An interim identified irritation to left popliteal (back of knee) area seen by the wound nurse. Intervention included treatment in place. physician's orders [REDACTED]. A wound nurse note dated 12/4/13 at 10:30 AM identified an open area to left popliteal area previously reddened from rubbing. The note continues that although the wheelchair was padded, staff reports R#2 continued to rub his/her leg on chair. Nurse's note dated 12/17/13 at 11:00 AM identified that the irritation to left popliteal "scab" had deteriorated leaving an open wound that measures 4.0 cm x 1.3 cm x 0.1 cm. with periwound [DIAGNOSES REDACTED], 50% granulation and 50% necrotic tissue in the wound bed and moderate serous drainage. Review of R#2's weekly body audits dated 11/6/13 and 11/13/13 identified "open area to left popliteal ". Review of R#2's weekly wound documentation dated 12/23/13 identified that the open area located on R#2's back of knee area had 50% exposed tendon , 20% gray and 30% granular tissue that measured 4.3 cm x 1.5 cm x 0.2 cm. Review of the facility weekly wound round documentation identified that the first documentation of R#2's open area was dated for week of 12/28/13-1/03/14. Interview and review of facility documentation with the Occupational therapists (OT#1) and (OT#2) on 6/18/14 at 9:58 AM indicated that although it was not documented, they had evaluated R#2's wheelchair on 12/4/13 and could not identify any problems with the wheelchair and/or padding. Interview and review of R#2's clinical record and facility documentation with the ADNS on 6/18/14 and on 6/19/14 at 9:35 AM failed to provide documentation that thorough, accurate, and/or consistent at least weekly assessments and/or monitoring had been conducted of the "irritated" area from when it was first identified on 10/31/13 until after it was found to have exposed tendon on 12/28/13. 2. Resident # 27's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive dysfunction, required extensive assist with bed mobility, did not transfer, did not walk, and was at risk for pressure ulcers. A care plan dated 3/8/14 indicated the resident was at risk for pressure ulcers. Interventions included pressure reducing mattress and to turn and position every 2 hours. A nurse's note dated 6/2/14 indicated the resident had a "tape injury" to the left upper inner buttock that measured 1.5 cm x 1 cm x 0.1 cm and was irregularly shaped with slough in the center. A subsequent nurse's note and pressure ulcer documentation form dated 6/12/14 (10 days later) indicated the left buttock was an unstageable 2 cm x 4 cm pressure sore with 100% slough. An interview on 6/19/14 at 10:45 AM with RN # 3 indicated per facility policy, wounds are to be assessed weekly and although the wound nurse was currently on vacation, he/she did not know why the wound on the left buttock was not assessed for 10 days after being identified. 3. Resident #91 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified one "denuded" area located on the left buttock measuring 1.0 cm x 0.7 cm with two small scabs on each side, and one "denuded" area over the natal cleft measuring 0.5 cm x 0.3 cm. Buttocks were reddened and appeared to be moisture associated skin [MEDICAL CONDITION] (MASD). Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Physician orders [REDACTED]. Pressure ulcer assessment records first noted the area on 4/30/14. Weekly assessments were not documented until 6/4/14 when the coccyx pressure ulcer was noted as a stage three measuring 1.0 cm x 0.5 cm x 0.1 cm with 50% slough and light serous drainage. No further assessments were noted until 6/17/14 (14 days later) when the area was identified as an unstageable pressure ulcer measuring 1.2 cm x 1.0 cm x < .1 with 70 % slough and 30% granulation. Interview and review of the clinical record with RN # 3 on 6/19/14 at 7:30 AM identified when a resident is noted with a pressure ulcer an assessment is completed and documented weekly on the wound tracking sheet. RN #3 identified the regular wound nurse has been on vacation for two weeks and she/he was recently directed to complete wound rounds. Additionally the facility does not have a policy related to monitoring of the function of an alternating air mattress. Facility skin and wound management policy procedure identified, in part, residents with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. It further indicated that on going monitoring and evaluation are provided to ensure optimal resident outcomes.

Based on review of the clinical records, observations, reviews of facility documentation and interviews for three of five resident's sampled for accident's (R#9, 137 and 242), the facility failed to provide appropriate supervision, and/or ensure interventions developed to prevent falls were initiated/followed through and/or that a resident was safe during a shower resulting in falls. The findings include: 1. Resident #242's [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] identified the resident was at risk for falls related to a balance problem while walking, had jerky or unstable movements when making turns, and the required an assistive device. A Quarterly Minimum Data Set assessment dated [DATE] identified the resident with severe cognitive impairment, required extensive assistance with ADL's including transfers, ambulation and toilet use and required staff assistance due to unsteadiness when moving from seated to standing, walking, moving on and off the toilet and surface to surface transfers. The Resident Care Plan dated 3/11/14 identified a potential for falls. Interventions directed the use of fall-deterrent equipment/devices. Nurse's notes dated 3/16/14 identified the resident was observed on the floor. NA #1 assisted the resident to the bathroom and "looked away" while the resident was seated on the toilet. The resident stood up from the toilet and fell to the floor. An open area was observed on the resident's right ear. The physician was notified and directed a transfer to the ED for evaluation. The resident returned to the facility at 5:00 PM with sutures in the left ear lobe. Interview and review of facility documentation on 6/17/14 at 10:30 AM with NA#1 identified that the NA responded to a sounding bed alarm and found the resident attempting to get out of bed. The NA assisted the resident to the toilet. Then NA#1 left the resident seated on the toilet while he/she left the bathroom to retrieve the resident's clothing. The NA heard the resident fall and immediately notified the nurse. Interview, review of the clinical record and facility documentation on 6/18/2014 at 10 AM with the DNS identified that cognitively impaired residents who are at risk for falls should not be left unattended in the bathroom. NA#1 was instructed that the NA must keep eyes on the resident at all times while in the bathroom and stay within arm's length. 2. Resident #9's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, required extensive assistance from two staff for transfers, was unable to ambulate, and had experienced two falls in the previous three months without injuries. The care plan dated 3/17/14 (with updates through 5/28/14) identified the risk for falls. Interventions included a scoop mattress placed on the floor with floor mats, educate staff, a Velcro alarm self-release seat belt, closely monitor, and put in common areas e.g. nurse's station for monitoring. Review of facility investigations from 1/5/14 through 5/18/14 noted the resident experienced 15 falls; 8 falls were from his/her wheelchair, and 4 falls on 4/29/14, 5/3/14, 5/9/14 and 5/11/14 were in the dining room not during meal times. The documentation identified that the staff were re-educated on following the plan of care and ensuring alarms were on and functioning after the 4/29 and 5/9/14 falls. Observations on 6/16/14 at 8:05 AM noted the resident with a large area of bruising on the face, red, blue and green in color. A facility investigation dated 6/13/14 at 12:45 PM noted that the resident was found on the floor in the dining room by recreation staff and sustained a hematoma to the forehead. The alarm was not sounding at the time. Interview and review of a facility investigation with RN#1 and the ADNS on 6/19/14 at 9:30 AM noted that the nurse aides were in the process of receiving written counseling for failure to supervise the resident (leaving resident without staff in the dining room) and failure to ensure the alarm was functioning. 3. Resident # 137's [DIAGNOSES REDACTED]. A quarterly minimum data set assessment dated [DATE] indicated the resident had severe cognitive impairment and required extensive assist transfer, walking, locomotion, and physical help with bathing. A fall risk assessment dated [DATE] indicated the resident was a high risk for falls. A resident care plan dated 6/4/14 indicated the resident was at risk for falls. Interventions included to maintain proper body alignment in the chair and apply fall deterrent equipment. A nurse's note dated 6/12/14 at 7:40 PM indicated R #137 slipped in the shower room. No injury was identified. A reportable event dated 6/12/14 indicated R #137 slipped in the shower room and was found sitting on the floor. The investigation indicated the resident attempted to stand during the shower and slipped and fell . An interview on 6/19/14 at 9:10 AM with LPN #1 indicated he/she did not know how R #137 slipped in the shower room. When he/she went into the shower room the resident was on the floor. He/she did notice the shower chair in the room, but did not know if the seat belt had been used during the shower. Attempts to contact NA#3 were unsuccessful. An interview with the ADNS and DNS on 6/19/14 at 9:30 AM indicated R #137 fell from the shower chair after the chair hit the pad located on the floor. The ADNS and DNS did not know if the shower chairs were equipped with seat belts. Subsequent to surveyor inquiry, observations noted some shower chairs had seat belts and other shower chairs in the facility did not have seat belts. The ADNS and DNS were unable to provide a system of assessing and identifying which residents required a seat belt and which residents were safe without a seat belt in a shower chair.

Based on clinical record reviews, interviews and facility documentation for three of six residents reviewed for accidents(Resident#58, Resident#64, Resident#234) the facility failed to secure smoking materials to prevent potential accident and/or provide adequate supervision to prevent an accident. The findings include: 1. Resident #58 ' s [DIAGNOSES REDACTED]. A quarterly minimum data set assessment dated [DATE] identified intact cognition and required supervision for transfers, dressing and hygiene. The care plan dated 7/3/13 identified a potential for safety hazard, injury related to smoking with interventions that included a safe smoking assessment quarterly and smoking allowed outdoors only. Interview and observation on 7/18/13 at 10:00AM with Resident #58 identified he/she kept smoking materials including cigars and lighters in a locked humidor in his/her room and that he/she retains the key. Interview and observation on 7/18/13 at 10:05 AM with LPN# 4 identified Resident #58 ' s humidor was unlocked and contained cigars but no lighters. LPN#4 identified five working lighters stored in a green bag on Resident #58 ' s bedside chair in his/her shared room. Interview and review of facility policy on 7/18/13 at 10:15 AM with RN#2 identified Resident #58 could retain smoking materials if the assessment determined he/she was a safe smoker however the smoking assessment was not comprehensive to include Resident #58 ' s ability to manage and/or compliance with managing smoking materials. Interview and review of facility policy on 7/18/13 at 2:00 PM with the DNS identified it was the expectation that the lighters would be stored in the locked humidor. 2. Resident # 64 ' s [DIAGNOSES REDACTED]. The care plan dated 3/4/13 identified a potential problem with falls/injuries related to impaired ADL function and cognition with interventions which directed the assistance of two staff for mechanical lift transfers and repositioning. The nurse ' s notes dated 3/4/13 identified at 7:00 PM Resident #64's right arm was bruised and swollen. A nurse aide noticed the injury during a transfer to bed after dinner. The physician was notified and directed to obtain an X-ray of the right shoulder and arm which identified a fracture of the right humerous. The physician was notified of the results and directed to send Resident #64 to the emergency room for evaluation and treatment. The Emergency Department imaging of the right humerous on 3/5/13 identified a displaced fracture, oblique distal radial diaphysis with fragments at the fracture site. The report also identified that there was no underlying pathological component seen on the images. An investigation of the injury of the unknown origin was initiated and determined the injury was the result of an un witnessed event. Interview, review of the clinical record and facility documentation on 7/16/13 at 11:45 with the DNS identified that although statements from staff failed to identify a traumatic event, there were no statements from the 11:00PM to 7:00 AM shift staff, which provided care to the resident the night before the injury was identified. Further interview with the DNS identified that the injury may have occurred during repositioning in the bed or during the Hoyer transfer. Interview and review of the X-ray results dated 3/5/13 with Radiologist #1 on 7/22/13 at 12:20PM identified the fracture was caused by a traumatic event and was not pathological in nature. 3. Resident#234 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] at 2:30PM identified a fall risk. Fall Risk assessment dated [DATE] identified the resident was a score of 9 with 10 being a high risk for fall on admission. The physician orders [REDACTED]. The care plan dated 6/28/13 identified the need for assistance with activities of daily living (ADL'S) with interventions which included assistance of one person with ADL'S. The care plan further identified the potential problem for falls related to impaired ADL function with interventions which included providing assistance with repositioning and maintaining proper body alignment while in bed and chair. The nurse's notes dated 6/28/13 during the day and evening shift identified Resident #234 exhibited an unsteady gait and required limited assistance with locomotion and assistance of one person. A review of facility documentation and investigation dated 6/28/13 at 8:15AM identified Resident #234 was standing at the bathroom sink combing her/his hair in front of the mirror with the rolling walker and lost his/her balance and fell on the floor. The investigation further identified the NA was making the resident bed at the time of the fall. Interview and review of the facility investigation and care plan with the ADON on 7/17/13 at 12:00PM identified NA#5 left the resident alone in the bathroom and failed to follow the plan of care to assist with ADL's which resulted in the resident falling and sustaining an injury. A review of the facility documentation identified on 6/30/13 Resident #234 complained of increasing right sided chest pain and was transferred to the hospital for an evaluation. The X-ray report dated 6/30/13 at 11:36AM identified multiple angulated rib fractures of the lower right ribs involving the 6th thru 10th ribs. Interview with NA #5 on 7/18/13 at 9:05AM identified that although the nurse aide assignment was reviewed prior to caring for Resident #234, he/she left the resident unattended in the bathroom during morning care.

Based on review of the clinical records, facility documentation and staff interviews for 3 of 5 residents reviewed for accidents (R #s 63, 180 and 312), the facility failed to ensure there was appropriate supervision and/or assistance and/or revision of the care plan to prevent accidents with injury. The findings include: 1. Resident #63 ' s [DIAGNOSES REDACTED]. The care plan dated 12/13/11 and physician orders [REDACTED]. Review of facility investigation dated 1/25/12 at 7:20 PM noted that the resident sustained [REDACTED]. NA #5 written statement indicated that she had put the resident into bed, went to the next resident, heard the bed alarm, and found R#63 getting out of bed. She saw drops of blood on the floor and proceeded to transfer the resident into the wheelchair so that she could " attend to her wound and try and stop the bleeding " . A written statement by LPN #4 noted that the resident sustained [REDACTED]. LPN #4 ' s statement noted that there was blood on the floor, on the left side of the wheelchair and under the leg rest. The resident was assessed by the physician and transferred to the hospital for sutures to the laceration. There were no sharp edges noted on the bed and no blood was noted in the bed or on the bed. NA #5 received a written warning for transferring the resident without assistance. Interview and review of the investigation with the Administrator and DNS on 6/27/12 at 11 AM noted that although they classified the laceration as " unwitnessed " , they inspected the bed and rails and there were no sharp edges that would cause the laceration. Blood was noted on the floor and under the foot pedal of the wheelchair and none in the bed or on the rails that would indicate that the resident caused the laceration trying to get out of bed. 2. Resident #180's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident was severely cognitively impaired, had daily wandering behaviors, ambulated with set up assistance and supervision, and utilized a chair that prevents rising. The care plan dated 2/14/12 identified the risk for falls/injuries. Interventions included a bed alarm, use of a merry walker on the unit, keep in area of high visibility, and to get out of bed first thing in morning to the Merry Walker (MW). The nurse's note dated 3/8/12 at 2:15 PM identified the resident was found in room 258 on the floor. The resident had climbed out of the merry walker and sustained an abrasion to back of the right shoulder. The nurse's note dated 3/14/12 noted the resident was attempting to climb out of merry walker after lunch and sustained a small skin tear left upper arm. A subsequent nurse's note dated 3/16/12 identified the resident was trying to climb out of the merry walker several times. The nurse's note dated 3/17/12 at 6:20 PM identified the resident was found in room 267 on the floor. Thee resident climbed out of the merry walker falling to the floor and sustained a laceration to the temporal area of the head. The resident was transferred to the hospital for an evaluation and required 3 staples to approximate the wound. Interview with the RN #3 and LPN #1 on 6/27/12 at 10:10 AM indicated new care plan interventions were not implemented and/or supervision provided for the resident's safety when the resident exhibited behaviors of climbing out of the Merry Walker. 3. Resident #312 had [DIAGNOSES REDACTED]. The assessment dated [DATE] identified that the resident was severely cognitively impaired, dependent for transfers and had impaired balance. The resident care plan (RCP) dated 8/29/11 indicated that the resident had restless behavior, fell on [DATE] and interventions included the use of a chair alarm. Nursing narratives dated 9/28/11, on the day shift, noted that the resident required constant monitoring to keep him/her safe. Nursing narratives dated 9/28/11 on the evening shift identified that the resident was "coming out of the chair, was redirected many times" and received Risperdal, Trazadone and Ativan by 5:30 PM with minimal effect. The narrative further noted that the resident was found in the dining room at 6 PM, was bleeding from the lip and was sent to the ED. The resident's acute care discharge paperwork dated 9/29/12 indicated that the resident required sutures to the right upper lip laceration and sustained a left frontal subdural hematoma. Facility documentation for 9/29/12 indicated that the NA heard the resident's chair alarm sound and saw the resident on the floor in the dining room during the evening meal. Interview with the evening shift Charge Nurse on 6/27/12 at 12:30 PM identified that the resident was very restless and the evening Supervisor took the resident next to the supervisor's office prior to dinner so that the Charge Nurse could pass the 5 PM medications. Although the resident received minimal effect from the psychoactive medications administered on the evening shift and was assessed to require constant monitoring on 9/28/11, the resident was left unattended in the chair in the dining room and sustained a fall with injury. The supervisor job description identified that a responsibility of the supervisor included checking staffing pattern with nursing coverage to meet the facility's needs.

Based on review of clinical records, facility policies and procedures, and interviews for three of three sampled residents reviewed for significant changes in condition (R# 285, 297, 298), the facility failed to ensure a significant medication was transcribed and administered for a new admission, and/or the facility failed to provide necessary services to maintain the highest practicable physical well-being in accordance with a comprehensive assessment and/or plan of care. The findings include: 1. Resident # 285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary and Interagency Referral Form dated 4/13/2011 directed the staff, in part, to administer [MEDICATION NAME] 4 mg two times a day at 9:00 am and 9:00 PM. Review of a nurse's note dated 4/13/11 at 6:00 PM noted R # 285 was alert and verbal. A nurse's note dated 4/15/11 at 2:30 AM noted R#285 was found to be lethargic and unable to talk. The physician was notified and the resident was transferred to the hospital for evaluation. Review of the readmission hospital discharge summary/Interagency Referral Form dated 4/26/2011 indicated R #285 was admitted secondary to worsening mental status with significant cerebral [MEDICAL CONDITION]. The note indicated the resident had not received his/her steroids for at least 1 and possibly 2 days, now admitted with obtundation and treated with IV steroids. Further review of the clinical record noted that although the physician was notified of the resident's admission and verified admission medications, the [MEDICATION NAME] 4 mg two times a day was not transcribed and not administered, resulting in the omission of three doses of [MEDICATION NAME]. An interview and review of the clinical record on 5/16/11 at 10:00 AM with RN #2 indicated the nurse supervisor is responsible to review the hospital discharge summary/Interagency Referral Form with the physician to verify the medications, transcribe the medications to the physician's orders [REDACTED]. She was unable to explain why the [MEDICATION NAME] was not transcribed and/or administered resulting in the omission of three doses of [MEDICATION NAME]. Review of the facility's admission procedure directs the staff, in part, to verify receipt of the W-10 and discharge summary. Formulate orders and transcribe from W-10 to house order sheets, and notify the attending physician of residents arrival and need for verification. 2. Resident #297's (R #297) [DIAGNOSES REDACTED]. A quarterly minimum data set (MDS) assessment dated [DATE] identified impaired cognition with severely impaired decision-making, impaired communication, total assistance for all activities of daily living and mobility activities, full loss of voluntary movement on one side including arm, hand, leg and foot, incontinent of bowel and bladder, and medically stable. Review of a Nursing progress note dated 06/22/10 documented at 1:30 PM by LPN #3 identified that nursing reported that, during morning care, R #297 was alert but aphasic with a right sided facial paralysis. Physician #1 and the family member were notified and the resident was sent to Acute Care Hospital #1 for further evaluation. A progress note documented by Advanced Practice Registered Nurse (APRN) #2 on 06/22/10 identified that the Nursing Supervisor asked him/her to evaluate R #297's facial droop as soon as possible. Nursing reported a facial droop and an inability to swallow. The family member was updated and wished for transfer to Acute Care Hospital #1. Physical examination identified, in part, that the resident was observed leaning to the right in the wheelchair. The resident was afebrile with a pulse rate of 76 (normal range 58-70 beats per minute and regular) and respiratory rate of 20 breaths per minute (normal range 16-20) unlabored and auscultation of lungs with bilateral crackles heard. Abnormal exam details included eyes drifting to the left. Assessment and plan included a question of a [MEDICAL CONDITIONS] as evidenced by a right facial droop, lack of response to verbal stimuli, and increased right sided weakness. R #297 was observed leaning to the right in wheelchair. Interview with the Assistant Director of Nursing on 05/18/11 at 7:45 AM identified that the Emergency Medical Service (EMS) was notified of the need to transport R #297 to the hospital at 12:17 PM. Interview with Nurse Aide (NA) #3 on 05/17/11 at 11:00 AM and 05/18/11 he/she was assigned to care for R # 297 on 06/22/10. He /she performed safety rounds when she came on duty and, between 8:30 AM and 9:30 AM went to R #297's room to prepare the resident for breakfast and feed him/her. NA #3 immediately observed a change in the resident's condition. The resident's mouth was abnormally twisted and he/she did not respond to the NA's touch. A spoonful of juice placed in the corner of the resident's mouth resulted in no effort to open the mouth, and no attempt to swallow the juice and the juice ran out of the mouth. NA #3 reported the observation to LPN #3 immediately and then observed LPN #3 and Nursing Supervisor #3 examining the resident. NA #3 then provided AM care and went on to care for the other residents on his/her assignment. NA #3 was unable to recall observing the resident being transported out to the hospital. Interview with LPN #3 on 05/23/11 at 10:00 AM identified that he/she recalled being notified of a change in R #297's condition by NA #3 about 9:00 AM on 06/22/10. LPN #3 and Nursing Supervisor #3 assessed the resident who was leaning to the right and drooling. The APRN assessed the resident while seated in a wheelchair in the dining room but was unable to recall the specific time, although he/she recalled that R #297 was transported out of the facility sometime between 11:30 AM and 12:00 PM. LPN #3 did not notify the family or physician. Interview with the former DNS on 05/23/112 at 11:00 AM identified that he/she was on the unit at the time that NA #3 reported the change in condition. The Assistant Director of Nursing (ADNS), formerly the Unit Manager, was conducting wound rounds on the unit. The former DNS observed R #297 and identified that the resident had clearly had a stroke and left the resident in the care of the experienced staff on the unit that included the ADNS, Nursing Supervisor #3, and LPN #3 and preceded to Morning Report. During the Morning Report, the former DNS wondered why he/she had not observed the arrival and/or departure of an ambulance and returned to the unit to check on the issue. The ambulance had not yet been called by the staff. The former DNS would have expected that the resident would have been assessed, the physician or APRN notified and the resident immediately transported to the hospital. Interview with APRN #2 on 05/17/11 at 9:30 AM identified that at approximately lunch time, he/she was notified by Nursing Supervisor #3 that R #297 did not look well and he/she went into the dining room to assess the resident who was seated in a wheelchair. The resident had clearly experienced a significant change in condition and APRN #2 immediately initiated a transport to the hospital. The supervisor usually followed up with a call to the physician. APRN #2 would expect to be notified immediately of a significant change in condition. Interview with Physician #1 on 05/18/11 at 2:00 PM identified that he/she was not able to recall when or if he/she had been notified of the resident's change in condition and answering service records were not available for that time frame. He/she was the attending physician for R #297 during the acute care hospitalization . R #297 was treated for [REDACTED]. Physician #1 identified that the delay in assessment and transport to the hospital would not have necessarily made a difference in treatment or outcome. Review of the clinical record failed to identify documentation of a comprehensive nursing assessment conducted at the time that the facial droop and change in responsiveness was reported to LPN #3, Nursing Supervisor #3, former Unit Manager and/or former DNS. 3. Resident #298's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a facility Blood Sugar Record dated 05/29/10 identified blood sugars of 230 mg/dL (normal range 60-99 mg/dL) before lunch, 280 mg/dL before dinner, and 238 mg/dL at bedtime. Blood Sugar Record dated 05/30/10 identified blood sugars of 250 mg/dL before breakfast, 254 mg/dL before lunch, 210 mg/dL before dinner, and 292 mg/dL at bedtime. Blood Sugar Record dated 05/31/10 identified blood sugars of 546 mg/dL before breakfast, 345 mg/dL before dinner, and 398 at bedtime. Blood Sugar Record dated 06/01/10 identified blood sugars of 302 mg/dL before lunch, 334 mg/dL before dinner, and 347 mg/dL at bedtime. Review of nursing progress notes dated 05/29/10 through 05/30/10, a physician's progress note dated 05/29/10, and an APRN progress note dated 05/29/10 failed to identify that the physician was notified of blood sugars greater then 200 mg/dL. A nursing progress note dated 05/31/10 at 6:30 AM identified a blood sugar of 546 mg/dL and noted that the Nursing Supervisor was instructed to notify the Physician by facsimile (fax), awaiting response. A facility fax dated 05/31/10 and time stamped 6:05 AM identified that Physician #2 was notified of the 6:30 AM blood sugar of 546 mg/dL via fax. Review of the facility schedule identified that 05/31/10 was a Monday, and the Memorial Day Holiday. A fax forwarded to Physician #2 dated 06/01/10 and time stamped 5:02 AM identified, in part, that R #297's family had requested that the resident be placed back on [MEDICATION NAME] and that the fingersticks had been elevated. Both faxes were returned to the facility on [DATE] during the 7:00 AM through 3:00 PM shift with signed physician's orders [REDACTED]. The orders included ac and hs blood sugars, a sliding scale of insulin coverage, and [MEDICATION NAME] 5 mg by mouth daily. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no blood sugar documented for 06/01/10 before breakfast. Interview with Physician #2 on 05/23/11 at 10:30 AM identified that he/she was not aware of being notified for elevated blood sugars 05/29/10 through 05/31/10, but he would expect to be called for a blood sugar greater then 500 mg/dL. The facility failed to notify Physician #2 of significantly elevated blood sugars on 05/29, 05/30, and 05/31 in accordance with physician's orders [REDACTED].