Every finding on record at Harbor Village North Health and Rehabilitation Cen

Based on review of the clinical record, facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for elopement risk, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed an identified elopement risk. Resident #1 resided on the secured memory care unit, demonstrated ongoing wandering and exit-seeking behaviors, and repeatedly verbalized wanting to leave the facility. Despite documented behaviors and an evaluation identifying Resident #1 as at risk for elopement, the facility did not develop an elopement care plan with individualized interventions prior to Resident #1's elopement on 7/14/26. Further, following the elopement, although the facility developed an RCP addressing Resident #1's trauma response to fire alarms, the facility failed to effectively communicate and implement the resident-specific interventions, leaving direct care staff unaware of the required interventions during future fire alarms or drills. The findings include:Resident #1's diagnoses included schizoaffective disorder, anxiety disorder, and cognitive communication deficits.An Elopement Evaluation by RN #2 dated 4/29/26 identified Resident #1 wandered and had a history of elopement or attempted elopement, resulting in a score of 2. The evaluation identified a score value of 1 or higher indicated a Risk of Elopement.The 5-day significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), and required partial assistance with bed mobility, transfers, and ambulation.The Resident Care Plan (RCP) dated 5/18/26 identified Resident #1 had impaired cognitive function or impaired thought processes related to cognitive impairments and resided on the secured memory unit. Interventions included cueing, reorienting, supervising as needed, and maintaining placement on the secured memory unit to ensure quality of life.A BIMS Evaluation dated 6/15/26 identified Resident #1 had moderately impaired cognition (score of 12).A. A Medication Administration Note dated 6/18/26 at 11:01 AM identified Resident #1 stated he/she was leaving at 12:00 PM. Staff attempted to redirect Resident #1 with food and distraction as Resident #1 was pacing and discussing discharge.A nurse's note dated 6/23/26 at 12:08 AM identified Resident #1 was unruly throughout the shift and left the floor without proper supervision.A nurse's note dated 6/23/26 at 10:15 PM identified Resident #1 complained of pins in his/her feet and was given Tylenol for pain/discomfort with good effect. Resident #1 requested to be transferred to the hospital and, when asked why, stated, I don't want to be here anymore.A nurse's note dated 6/25/26 at 2:15 PM identified Resident #1 participated in a morning smoking session in the secured courtyard due to an elopement risk. Resident #1 was alert and confused, stated he/she was leaving, but did not attempt to exit.A nurse's note dated 6/30/26 at 3:03 PM identified, in part, Resident #1 was alert and confused at baseline and stated he/she was going home the following day (7/1/26).A nurse's note dated 7/4/26 at 10:03 PM identified Resident #1 was very quiet but stated he/she was getting discharged on Monday.A nurse's note dated 7/7/26 at 3:06 PM identified, in part, Resident #1 reported, I have an apartment in town, and my sister is coming to pick me up.A nurse's note dated 7/8/26 at 6:44 AM identified Resident #1 was up pacing most of the night. Trazodone, for anxiety/restlessness, was offered but Resident #1 refused and was redirected by staff.A nurse's note dated 7/9/26 at 7:24 AM identified Resident #1 was pacing in the hallway but refused trazodone.A nurse's note dated 7/11/26 at 6:44 AM identified Resident #1 was pacing in the hallway and was redirected by staff.A nurse's note dated 7/12/26 at 7:05 AM identified, in part, Resident #1 was alert with increased confusion. Increased anxiety, restlessness, sleeplessness, and delusions were noted. Beginning on the 3:00 PM to 11:00 PM shift, Resident #1 had most of his/her belongings packed in a corner in the hallway and continued bringing additional belongings out but was not easily redirected. PRN Ativan was administered for anxiety with no effect. The nursing supervisor was made aware. Resident #1 remained awake throughout the night shift and was ambulating in the hallway.A nurse's note dated 7/12/26 at 10:41 PM identified, in part, Resident #1 demonstrated increased psychotic behaviors throughout the shift, packing his/her personal belongings in sheets and placing them in the middle of the common area, then demanding staff move them to the corner. Resident #1 verbalized the belief he/she was being discharged despite having no discharge orders. Resident #1 continuously refused medication and accused the nurse of trying to overdose him/her. The nursing supervisor was notified of the behaviors throughout the shift, and all safety measures were in place.A nurse's note dated 7/13/26 at 2:31 PM identified, in part, Resident #1 was having increased behaviors and delusions of leaving and was unable to be redirected. Resident #1 was arguing with staff and other residents and had packed all of his/her belongings, including briefs and pillows, because he/she believed they were leaving. Resident #1 spoke with the conservator's office and was informed that he/she needed to stay.A nurse's note dated 7/14/26 at 9:53 AM identified, in part, Resident #1 had been experiencing increased hallucinations, delusions, and behavioral disturbances over the preceding several days. Resident #1 was evaluated by the MD and psychiatric APRN, with multiple medication adjustments and PRN interventions implemented to address the symptoms. The note identified that earlier that morning, the facility's fire alarm was activated. Residents were relocated to designated safe areas in accordance with facility emergency procedures, including remaining in resident rooms on the secured unit. Once the fire alarm was resolved, staff conducted safety checks of all residents. During these checks, staff observed that the window in Resident #1's room had been broken and Resident #1 had exited through the window. Resident #1 was located shortly thereafter and returned safely to the facility. Resident #1 had a documented history of elopement attempts, although prior attempts to leave the facility had been unsuccessful.A nurse's note by RN #1 dated 7/14/26 at 10:35 AM identified the facility fire alarm sounded. Resident #1 was in his/her room with two (2) other roommates, and the door was closed in accordance with fire protocol. RN #1 was accounting for staff when a roommate stated, Emergency, Resident #1 went out the window. RN #1 observed the window was broken and Resident #1 was not in sight. A Code Pink (missing person) was activated, and Resident #1 was found approximately ten (10) feet into a wooded area near the facility, sitting in a ditch and unable to stand without assistance. Resident #1 was assessed and denied pain; no deformities were noted, and Resident #1 had active and full range of motion. A fire department member and RN #1 assisted Resident #1 to his/her feet and out of the woods. Resident #1 stated that he/she heard there was a fire and had to get out of there. Resident #1 had been experiencing increased impulsive behaviors and was placed on one-to-one observation due to exit-seeking behaviors.Although Resident #1 had been identified as an elopement risk and had demonstrated wandering and exit-seeking behaviors prior to the 7/14/26 elopement, an RCP addressing the identified elopement risk and individualized interventions had not been initiated prior to the event.Interview with RN #1 on 8/18/26 at 11:16 AM identified he was assigned to Resident #1 full-time on the 7:00 AM to 3:00 PM shift. He reported Resident #1 was at risk for elopement prior to the 7/14/26 incident and frequently paced, wandered the hallways, and stated he/she was leaving. RN #1 identified that a few months prior, Resident #1 stood by the doors and attempted to follow people out. RN #1 was unaware that an at-risk-for-elopement RCP had not been in place prior to the 7/14/26 elopement and stated one should have been.Interview with RN #2 on 8/18/26 at 2:42 PM identified Resident #1 had a history of wandering behaviors and frequently stated he/she was going home. RN #2 completed the 4/29/26 Elopement evaluation and assumed an at-risk-for-elopement RCP was already in place because the behavior was not new, but acknowledged he did not verify this and should have.B. An RCP dated 7/16/26 identified Resident #1 had Post-Traumatic Stress Disorder (PTSD) due to a history of being involved in a fire. Interventions included monitoring Resident #1 during fire drills, providing one-on-one visits by staff whom Resident #1 felt comfortable with, and encouraging Resident #1 to discuss his/her feelings and concerns.Interview with Person #2 on 8/18/26 at 12:00 PM identified Resident #1 had a fear of fires. Person #2 reported he/she had not been notified by the facility about how future elopement incidents would be prevented during fire alarms or drills or how the facility planned to keep Resident #1 safe during those events.Interview with NA #1 on 8/18/26 at 12:39 PM identified Resident #1 was a known wanderer who ambulated the halls independently and verbalized wanting to leave the facility all the time prior to the 7/14/26 incident. NA #1 reported she was unaware of what would be done for Resident #1 during future fire alarms/drills.Interview with LPN #1 on 8/18/26 at 12:45 PM identified Resident #1 was at risk for elopement prior to the 7/14/26 incident. Resident #1 frequently wandered and displayed exit-seeking behaviors. LPN #1 identified she was unsure what would be done for Resident #1 during future fire alarms/drills.Interview with NA #2 on 8/18/26 at 12:53 PM identified that, prior to the 7/14/26 elopement, Resident #1 had been increasingly anxious, agitated, wandering, and voicing that he/she wanted to leave the facility. Following the incident, Resident #1 reported to NA #2 that when he/she heard the word fire on the intercom, he/she feared for his/her life and had to leave. NA #2 identified she was unsure what would be done for Resident #1 during future fire alarms/drills.Review of the Kardex dated 8/18/26 failed to identify interventions related to fire alarms or monitoring during emergency events. The PTSD/fire-response RCP interventions had not transferred to the Kardex, leaving staff unaware of the required actions.Interview with the DON on 8/18/26 at 2:04 PM identified Resident #1 was at risk for elopement prior to the 7/14/26 incident. The DON reported she was unaware of Resident #1's fear of fire before the incident and did not believe the event could have been prevented; however, she identified that an at-risk-for-elopement care plan should have been developed once wandering and exit-seeking patterns were observed. The DON reported that when the 4/29/26 Elopement Evaluation identified Resident #1 was at risk for elopement, RN #2 should also have reviewed the RCP to ensure the risk was identified and interventions were implemented. The DON identified that immediately following the incident, a plan addressing fire alarms/drills to prevent future elopement and ensure Resident #1's safety should have been implemented, and all direct care staff should have been educated regarding the resident-specific care. Although the DON initiated the RCP dated 7/16/26, she did not ensure the intervention to monitor Resident #1 during fire alarms/drills transferred to the Kardex, resulting in staff being unaware of the required intervention. The DON identified she intended to provide education to direct care staff regarding Resident #1's fear of fire and the plan to monitor and keep him/her safe during fire alarms/drills but went on vacation and did not delegate the education to another staff member.Review of the Wandering, Unsafe Resident policy (undated) directed, in part, that the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents at risk for elopement. Staff are responsible for identifying residents who may be at risk for harm due to unsafe wandering, including elopement, and assessing these individuals for any potentially correctable risk factors. The resident's care plan must clearly indicate if the resident is at risk for elopement or other safety concerns and must include interventions designed to maintain safety, such as detailed monitoring plans.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure a licensed nurse remained with Resident #1 following an unresponsive episode of unknown origin and failed to ensure Resident #1 was kept in place and not moved until directed by the Nursing Supervisor following an unresponsive episode in the outside smoking area. The findings include:Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), myoclonus (sudden, brief, involuntary twitching or jerking of a muscle or a group of muscles), seizures, bradycardia (low heart rate less than 60 beats per minute), macular degeneration (an eye disease that affects central vision), weakness and cognitive communication deficit.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13), and required setup assistance for bed mobility, substantial assistance for transfers, did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The Resident Care Plan (RCP) dated 3/4/26 identified Resident #1 was a current smoker, had an Activities of Daily Living (ADL) self-care, mobility and performance deficit due to failure to initiate, weakness and impaired vision, a history of chest pain and altered respiratory status/difficulty breathing due to COPD. Interventions included supervision for smoking at all times, observing for smoking safety through observation and interview, assist of two (2) transfer to bed/chair/bathroom, wheelchair use for locomotion and monitoring, documenting and reporting abnormal breathing patterns to the physician. A nurse's note by RN #4 dated 3/8/26 at 12:14 PM identified Resident #1 went to the smoking activity by rolling walker with an assist at 8:45 AM, as Resident #1 wanted to walk rather than utilize the wheelchair. The note identified the nursing supervisor (RN #3) went to RN #4 and reported Resident #1 was slumped over on a bench in the smoking area, so she went to check on Resident #1, who was unresponsive, with abnormal skin color and a sternal rub was initiated. The note reported she went back into the building to obtain oxygen, and when she returned Resident #1 was responsive and was in the wheelchair being brought towards his/her room by another nurse. She applied oxygen to Resident #1 in the hallway prior to Resident #1 being brought into his/her room and reported Resident #1 had one episode of vomiting as Emergency Medical Services (EMS) came to transport Resident #1.A nurse's note by RN #3 dated 3/8/26 at 2:06 PM identified she was at the nurse's station when NA #1 reported Resident #1 was outside and may not be breathing. She immediately went outside and observed Resident #1 hunched over on a bench breathing but nonverbal, not communicating, not moving and his/her skin color appeared pale/abnormal. She immediately called EMS, initiated a code and reported she witnessed Resident #1 being assisted back to his/her room by nursing staff. Resident #1 remained on observation until EMS arrived and upon EMS arrival, Resident #1 was awake in his/her room and had one episode of vomiting. Review of the Patient Care Record (ambulance run sheet) dated 3/8/26 identified, in part, they were notified at 9:32 AM that Resident #1 sustained a fall and was subsequently unconscious, not breathing and with a possible cardiac arrest. When crews arrived on scene, Resident #1 was found lying in bed, conscious and alert but at an altered state and crews attempted to get an accurate history of the incident, but staff were unable to give an accurate description of the event, could not agree on what transpired, were unsure if a head strike occurred and reported they were not actually present for the majority of the incident. EMS treated Resident #1 according to his/her symptoms and transported Resident #1 to the hospital.The hospital discharge summary identified Resident #1 was admitted from 3/8/26 through 3/19/26 for acute hypoxemic respiratory failure (not enough oxygen in the blood) likely due to bacterial pneumonia and COVID-19 and Resident #1 was treated with intravenous (IV) fluids and antibiotics.Interview with RN #3 on 4/6/26 at 11:39 AM identified that just prior to 9:30 AM, NA #1 came running down the hallway, visibly distraught, and notified her that Resident #1 was unresponsive and possibly not breathing in the outside smoking area and that NA #1 and herself both ran out to the outside smoking area immediately. She identified she assessed Resident #1, checked vital signs and neurological signs, which were normal, but identified Resident #1 had his/her eyes closed and was not responding to verbal cues. RN #3 identified she requested NA #1 and NA #2 stay with Resident #1 and directed them not to move Resident #1 while she ran back inside to call a code blue, notify the charge nurse (RN #4) and call EMS with the computer in front of her. RN #3 reported she observed staff running in the direction of the outside smoking area to respond but when she got off the phone with EMS, LPN #1 was pushing Resident #1 down the hallway to his/her room. She identified she should have stayed with Resident #1 until another licensed nurse responded to assist and ensure Resident #1 was stable and kept in place until she identified what happened. She left Resident #1 with the two (2) NA's and Resident #1 was subsequently transferred to a wheelchair and transported inside before she could finish her assessment. RN #3 identified NA #1 and NA #2 reported afterwards that Resident #1 leaned forward and fell back into a seated position on the bench and became unconscious. RN #3 identified she did not document those reports in her nurse's note and did not obtain statements regarding the incident.Interview with LPN #1 on 4/6/26 at 2:22 PM identified when she responded to the code blue in the outside smoking area on 3/8/26, Resident #1 was on a bench leaning forward, breathing and answering questions appropriately and she sat him/her up. She identified no RN's were present at the time and could not recall anyone directing her to move Resident #1 or to transfer him/her to a wheelchair. She located a wheelchair and transferred Resident #1 with the help of NA #1 and NA #2 to the wheelchair and transported Resident #1 into the building to his/her room.Interview with the DON on 4/6/26 at 3:18 PM identified RN #3 should not have left Resident #1, who was identified to be unresponsive, without first requesting assistance from another licensed nurse. Additionally, she reported staff should have never moved Resident #1 following the 3/8/26 incident without first being directed by RN #3 to ensure a full assessment had been completed and to prevent any injuries.Although attempted, an interview with NA #2 was not obtained.Review of the Resident Change in Condition and Notification of Change policy dated 6/13/25 directed, in part, the licensed nurse will assess the resident for signs and symptoms of physical or mental change in condition and will complete the assessment for change in condition. Documentation of the change in condition will be completed by the licensed nurse who completed the assessment in a progress note.Review of the Accident and Incidents policy dated 6/16/2017 directed, in part, the center provides an environment that is free from accident hazards over which the center has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Staff are involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident and they help to identify solutions to ensure a safe resident environment.Although requested, a facility policy for unresponsive episodes was not provided.

Based on review of the clinical record, facility documentation/policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision and the use of appropriate assistive devices to prevent accidents when staff did not follow the resident's mobility plan, did not have a wheelchair readily available, and did not follow established procedures during an emergency at a supervised smoking activity. The findings include: Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), myoclonus (sudden, brief, involuntary twitching or jerking of a muscle or a group of muscles), seizures, bradycardia (low heart rate less than 60 beats per minute), macular degeneration (an eye disease that affects central vision), weakness and cognitive communication deficit.A physician's order dated 1/7/26 directed an assist of one (1) for all transfers with a rollator and Resident #1 was to ambulate with therapy only.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13), and required setup assistance for bed mobility, substantial assistance for transfers, did not ambulate, utilized a wheelchair and was dependent on staff for mobility.A Smoking Evaluation dated 2/28/26 identified Resident #1 could safely smoke with supervision and a cigarette holder, and a smoking apron would be utilized for safety interventions.The Resident Care Plan (RCP) dated 3/4/26 identified Resident #1 was a current smoker, had an Activities of Daily Living (ADL) self-care, mobility and performance deficit due to failure to initiate, weakness and impaired vision, a history of chest pain and altered respiratory status/difficulty breathing due to COPD. Interventions included supervision for smoking at all times, observing for smoking safety through observation and interview, assist of two (2) transfer to bed/chair/bathroom, wheelchair use for locomotion and monitoring, documenting and reporting abnormal breathing patterns to the physician.A nurse's note by RN #4 dated 3/8/26 at 12:14 PM identified Resident #1 went to the smoking activity by rolling walker with an assist at 8:45 AM, as Resident #1 wanted to walk rather than utilize the wheelchair. The note identified the nursing supervisor (RN #3) went to RN #4 and reported Resident #1 was slumped over on a bench in the smoking area, so she went to check on Resident #1, who was unresponsive, with abnormal skin color and a sternal rub was initiated. The note reported she went back into the building to obtain oxygen, and when she returned Resident #1 was responsive and was in the wheelchair being brought towards his/her room by another nurse. She applied oxygen to Resident #1 in the hallway prior to Resident #1 being brought into his/her room and reported Resident #1 had one episode of vomiting as Emergency Medical Services (EMS) came to transport Resident #1.A nurse's note by RN #3 dated 3/8/26 at 2:06 PM identified she was at the nurse's station when NA #1 reported Resident #1 was outside and may not be breathing. She immediately went outside and observed Resident #1 hunched over on a bench breathing but nonverbal, not communicating, not moving and his/her skin color appeared pale/abnormal. She immediately called EMS, initiated a code and reported she witnessed Resident #1 being assisted back to his/her room by nursing staff. Resident #1 remained on observation until EMS arrived and upon EMS arrival, Resident #1 was awake in his/her room and had one episode of vomiting.The hospital discharge summary identified Resident #1 was admitted from 3/8/26 through 3/19/26 for acute hypoxemic respiratory failure (not enough oxygen in the blood) likely due to bacterial pneumonia and COVID-19.Interview with RN #3 on 4/6/26 at 11:39 AM identified neither NA #1 nor NA #2 contacted her by phone to notify her of the incident at the outside smoking area on 3/8/26 and that NA #1 ran inside the building and notified her in person.Interview with the Director of Rehab (DOR) on 4/6/26 at 12:11 PM identified Resident #1 was receiving Occupational Therapy (OT) and Physical Therapy (PT) services at the time of the 3/8/26 incident and Resident #1 was unsafe to ambulate with nursing staff. Resident #1 was legally blind and had inconsistent weakness, balance and activity tolerance. The DOR identified NA #6 should have checked the resident care card (RCC) and transported Resident #1 to the smoking activity via wheelchair, as Resident #1 required the wheelchair to be within reach at all times due to being unpredictable.Interview with NA #1 on 4/6/26 at 1:42 PM identified on 3/8/26 during the morning smoking activity, Resident #1 walked outside independently with a rolling walker and sat on a bench. She identified NA #2 and herself were responsible for supervising around twelve (12) residents at the time, including Resident #1 and about fifteen (15) minutes into the smoking activity, she observed Resident #1 slumped forward and to the right side while sitting on the bench. Resident #1 appeared faint and unresponsive to verbal cues. She identified she panicked and ran inside to locate RN #3, leaving NA #2 outside with Resident #1 and the other residents at the smoking activity. NA #1 reported she knew it was required that two (2) staff were to remain outside during the smoking activity at all times but she needed to contact RN #3. She identified the facility did not utilize walkie-talkies and she did not think to call the facility main line. She reported that another staff member had to go back inside once a code was called to locate a wheelchair since there were none nearby.Interview with NA #6 on 4/6/26 at 2:30 PM identified on 3/8/26 she dressed and assisted Resident #1 into the wheelchair for the morning smoking activity and Resident #1 requested to walk with a rolling walker. She identified she did not know Resident #1 to walk, and instead of referencing the RCC, she asked RN #4 if she could walk Resident #1 to the smoking activity and RN #4 indicated that was fine and Resident #1 could use the exercise. NA #6 reported she walked alongside Resident #1, without a wheelchair following behind the resident, as Resident #1 pushed the rolling walker the length of the hallway to the Center dining room and assisted him/her into a chair in the dining room, which was a holding room until the outside doors were opened for the smoking activity. She left Resident #1 and went back to the unit to care for other residents. NA #6 identified she was unaware Resident #1 was not supposed to walk and should have instead been pushed in the wheelchair to the smoking activity.Interview with RN #4 on 4/6/26 at 2:47 PM identified on 3/8/26, NA #6 reported Resident #1 wanted to walk to the morning smoking activity, and she told NA #6 that was fine. She identified that she did not check physician's orders or the RCP to ensure Resident #1 was cleared and safe to walk. RN #4 identified she was unaware there was a physician's order directing Resident #1 walk with therapy only, and she should have verified orders prior to communicating that Resident #1 could walk to the activity which could have prevented the search for a wheelchair when Resident #1 became unresponsive outside at the smoking activity.Interview with the DON on 4/6/26 at 3:18 PM identified NA #6 should have verified Resident #1's activity orders on the RCC prior to walking Resident #1 to the activity and returning back to the unit. The DON reported RN #4 should have verified Resident #1's ambulation orders prior to communicating with NA #6 that she could walk Resident #1 to the smoking activity, as she put Resident #1's safety at risk by not ensuring Resident #1 was transported by wheelchair. She identified staff do not utilize walkie-talkies during the smoking activity because they are unreliable but the staff supervising the residents during the smoking activity are responsible for having a cell phone and contacting the phone that the nursing supervisor kept on hand during weekends and the afternoon smoking activity. The DON reported NA #1 should have ensured NA #2 or herself contacted RN #3 from the outside activity immediately and should not have left Resident #1 and the other residents with only one (1) staff member, which was against facility policy.Although attempted, an interview with NA #2 was not obtained.Review of the Smoking policy dated 10/11/23 directed, in part, the supervision will include a maximum of twelve (12) residents to two (2) observers. Any unusual occurrences regarding smoking or smoking materials should be reported to the charge nurse/supervisor immediately. Walkie-talkies/electronic devices must be brought out with the smoking cart. One of the walkie-talkies are to be kept with the cart and the other is to be given to the Supervisor or North wing nurse in case of need/emergency while supervising smoking session.Review of the Accident and Incidents policy dated 6/16/2017 directed, in part, the center provides an environment that is free from accident hazards over which the center has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Staff are involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident and they help to identify solutions to ensure a safe resident environment. The center assesses residents to determine the resident's degree of mobility and physical impairment and the proper transfer method. The center provides appropriate assistive devices to reduce the risk and/or prevent accidents. Ways to reduce risk and/or prevent risk are: education of the staff in using assistive devices properly. Although requested, a facility policy for following physician's orders was not provided.

Based on observations, interviews, review of the clinical records, and facility policies, the facility failed to prevent, identify, assess, and treat pressure ulcers/injuries in accordance with resident's needs and facility policy for 2 of 3 sampled residents (Resident #3 and Resident #11). Specifically, the facility did not complete timely risk assessments or comprehensive skin assessments; failed to implement and ensure staff adherence to required offloading/turning interventions; did not measure and monitor wounds after onset; and did not follow physician orders (including heel offloading and catheter anchoring). These failures resulted in actual harm: Resident #3 developed an in-house deep tissue pressure injury to the right heel and a stage 2 sacral/coccyx ulcer that worsened, and Resident #11 developed a device associated stage 3 pressure ulcer of the penis and lacked heel offloading despite an existing stage 4 heel ulcer. The facility's systemic failures to implement, monitor, and revise interventions to prevent deterioration constitute noncompliance, which resulted in actual harm. The findings include: 1. Resident #3's diagnoses included chronic kidney disease, muscle weakness, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment, was dependent on staff for toileting and transfers, and required substantial/maximal assistance with changing positions in bed (rolling, lying and sitting). Additionally, the MDS identified Resident #3 was at risk for developing pressure ulcers, did not have any current unhealed pressure ulcers/injuries, and skin ulcer/injury treatments included a pressure reducing device for the bed, and application of ointments/medications. The Resident Care Plan in effect from 1/18/26 through 1/25/26 identified Resident #3 was at risk for developing a wound. Interventions directed to provide a pressure reducing device to the bed and chair and apply [NAME] lotion to the skin twice daily. The Resident Care Plan failed to include interventions for turning and positioning or to offload Resident #3's heels. Although physicians order dated 1/18/26 and in effect through 1/25/26 directed to apply a protective foam dressing to the resident's coccyx every shift and as needed, the orders failed to direct interventions for turning and positioning or to offload Resident #3's heels. a. A physician's order in effect from 1/18/26 through 1/25/26 directed to apply skin prep twice a day to Resident #3's heels. Review of the nurses note dated 1/25/26 at 10:14 PM identified a Nurse Aid (NA) noted redness on both of Resident #3's heels. On evaluation the shift nurse identified a possible pressure wound to the resident's bilateral heels. The skin appeared dark and dry with some scaling on the right heel. Review of the nurse's note dated 1/26/26 at 12:00 PM identified Resident #3's heels were assessed by the Assistant Director of Nursing Services (ADNS), who was also the wound nurse. Resident #3's bilateral heels were red and blanchable with calloused skin forming, skin was intact, pedal pulses were positive, and no pressure ulcer was identified. The APRN was updated and new orders were obtained to apply skin prep every shift (increased from twice daily) and apply bilateral foam boots when in bed. The Resident Care Plan was updated on 1/26/26 to include the intervention to provide bilateral offloading foam boots in bed, treatment as ordered and encourage the resident to reposition every 2 to 3 hours. A physician's order dated 1/26/26 directed foam boots when in bed every shift. The physician's order failed to include the new APRN order for skin prep every shift (increased from twice daily) as directed in the nurse's note dated 1/26/26 resulting in no change to the previous order. Review of the facility weekly wound rounds and clinical record from 1/26/26/26/26 through 2/16/26 failed to indicate that Resident #3's reddened heels had been assessed, monitored or measured for improvement or deterioration since initially identified in the nurse's note as blanchable on 1/26/26. Review of weekly skin assessments dated 2/1/26, 2/8/26, 2/22/26, and 3/1/26 failed to indicate Resident #3 had or did not have a skin alteration of the right heel. Review of the facility weekly wound evaluation and initial wound physician's visit note dated 2/17/26 identified Resident #3 had a new in-house acquired deep tissue pressure injury to the right heel with an onset date of 2/17/26 measuring 1.8 cm x 2.4 cm x 0 cm, intact skin, and with purple/maroon discoloration. The wound physician Plan of Care recommendations included floating heels in bed, elevating legs, offloading the wound, turning side to side in bed, repositioning per the facility protocol and obtain a Dietitian consultation. b. Review of a weekly skin check assessment dated [DATE] at 10:55 AM identified a new skin issue, purple discoloration to the sacrum/coccyx, wound acquired in house. Subsequent skin checks on 2/8/26, 2/22/26, and 3/1/26 described the sacrum/coccyx area as other, purple discoloration acquired in house. (The skin checks failed to identify measurements or any further wound assessment). Review of the nurses note dated 2/7/26 at 2:49 PM identified the sacrum/coccyx wound was nonblanchable. (The note failed to identify measurements or any further wound assessment). Review of the APRN progress note dated 2/9/26 at 12:00 PM identified Resident #3 was evaluated for a decline and was bedbound for the majority of the day. Additionally, he/she experienced a progressive functional decline over recent weeks with decreased mobility and increased time spent in bed. The APRN note failed to indicate that Resident #3 had any skin issues of the heels or sacrum/coccyx. Review of the clinical record and facility provided ADNS/wound nurse weekly wound evaluation rounds dated 2/12/26 at 1:32 PM identified Resident #3 had a new in-house acquired open area to the sacrum/coccyx with an initial onset date of 2/7/26. Although documentation in a nurse's note on 1/31/26 indicated discoloration remained present, on 2/1/26 a skin check assessment identified a new skin issue with purple discoloration to the sacrum/coccyx was acquired in house, and on 2/7/26 at 2:49 PM a nurse's note identified a non-blanchable sacrum/coccyx wound, the facility lacked documentation of a completed assessment or any measurements of the wound until the weekly wound evaluation rounds dated 2/12/26. On 2/12/26 (5 days after the recorded initial onset date) the wound was identified as a stage 2 pressure ulcer/injury and measured 1 centimeter (cm) x 0.5 cm x 0.1 cm with exposed dermis, light serous drainage, and blanchable redness to the peri (surrounding) skin. Review of nurse's notes and physician's orders failed to identify the implementation of any new interventions to aide in prevention of deterioration or to promote healing following the development of the sacral/coccyx wound on 2/7/26, until 2/12/26 (5 days later) when a treatment order was obtained. Although the Resident Care Plan included to encourage Resident #3, to turn and reposition every 2-3 hours the resident required substantial/maximal assistance with changing positions in bed (rolling, lying and sitting). A physician's order dated 2/12/26 directed to clean the sacral/coccyx wound with cleanser followed by calcium alginate with Ag (silver) to the wound bed followed by a dry clean dressing, to be changed daily and as needed. Review of the facility weekly wound evaluation and initial wound physician's visit note dated 2/17/26 identified Resident #3 had a sacral/coccyx stage 2 in house acquired pressure injury measuring 1.4 cm x 1 cm x 0.1 cm (an increase from 2/12/26, 5 days prior) with an onset date of 2/7/26. c. Review of the clinical record identified a Braden Scale evaluation (skin risk assessment) dated 2/12/26 indicated a very high risk for pressure ulcer development. The clinical record failed to identify any further Braden Scale or skin risk assessments had been completed upon or since Resident #3's admission date in February 2025. An observation on 2/25/26 at 10:17 AM identified Resident #3, alone, in the room, in bed without the benefit of heel boots. Observation and interview on 2/27/26 at 9:41 AM with Nurse Aid (NA) #1 identified Resident #3 in bed with heel boots applied. Upon removal of the heel boots by NA #1 noted that Resident #3 had a quarter sized dried brown area on the outside of his/her right sock as well as on the linen by the foot board. NA #1 identified the areas as dried blood, stating that Resident #3 regularly kicked off the heel boots. Observation and interview with Registered Nurse (RN) #4 on 2/27/26 at 9:43 AM identified he was the regular nurse for Resident #3, and he/she was noncompliant with the off-loading foam heel boots and removed the heel boots all the time by kicking them off. RN #4 proceeded to perform the treatment to the wounds per the physician's orders. RN #4 indicated that the ADNS/Wound nurse was previously made aware that Resident #3 often self-removed his/her heel boots. Interview and record review with the ADNS/Wound Nurse on 2/27/26 at 1:15 PM identified the facility policy directed residents as at risk for skin breakdown were to be turned and repositioned every 2-3 hours, provided with supplements and vitamins per registered Dietitian evaluation and recommendations, as well as other interventions like skin prep, lotions, heel boots and a low air loss mattress. She stated Resident #3's sacrum was initially identified on 1/31/26 as Moisture Associated Skin Damage (MASD) and was noted to progress to a stage 2 pressure injury on 2/7/26. The ADNS did not indicate during the interview why there was a lack of assessment or measurements on 2/7/26 for the sacral/coccyx stage 2 sacral pressure ulcer until 2/12/26. The ADNS identified that although the Resident Care Plan had been updated to encourage Resident #3 to turn and reposition on 1/26/26, the facility failed to obtain a physician order to alert the staff of the need to assist the resident until 2/12/26 (5 days after the sacral/coccyx pressure injury onset) but an order should have been obtained. Further, she was unable to identify documentation that Resident #3 had been turned and repositioned every 2-3 hours since the onset of the pressure ulcer on 2/7/26. The ADNS identified the area on Resident #3's heel was first identified on 1/26/26 as red, but blanchable, at which point skin prep and heel boot orders were initiated. Following the discovery of the red heels, monitoring occurred weekly during skin rounds performed by the unit nurses (previous review of the weekly skin check records dated 2/1/26, 2/8/26, 2/22/26, and 3/1/26 failed to identify Resident #3 had a skin alteration of the right heel). On 2/17/26 Resident #3's right heel was assessed by the wound MD and noted to be a deep tissue injury. Although the ADNS indicated she had been made aware that the resident kicked off the heel boots on 2/17/26 (10 days prior) she had not implemented any new measures to prevent further deterioration. Resident #3 had been followed by the Registered Dietitian who ordered Boost glucose control (supplemental drink for diabetics) but Resident #3 should have had additional nutritional supplements and vitamins to promote wound healing, adding that she thought about obtaining a pressure-reducing mattress for Resident #3 but that the wound doctor did not agree, however she was unable to provide documentation requesting or being denied an alternating pressure mattress by the wound MD. Interview and record review with the Regional Clinical Registered Nurse (RN) #3 on 2/27/26 at 1:30 PM identified in addition to the interventions already discussed by the ADNS that could have been implemented, residents, such as Resident #3, who were clinically compromised due to wounds, weight loss, and at risk for pressure ulcer development over bony prominences, should have an alternating pressure mattress/low air loss mattress put in place as a nursing measure, as well as being referred to Occupational Therapy for evaluation of positioning. RN #3 added once it was identified that Resident #3's was not compliant with the heel boots, new interventions such as placing the residents heels up on a wedge could have been implemented, adding that all interventions listed should have been instituted. RN #3 was unable to identify why no further measures had been put in place once it was known Resident #3 was kicked off the offloading foam heel boots. Additionally, RN #3 indicated that it was facility policy to perform Braden scale assessments upon admission/ readmission, quarterly, annually and with a change of condition. Review of Resident #3's clinical record with RN #3 failed to identify that Resident #3 had any Braden scale assessments conducted except for the assessment conducted on 2/12/26 which was completed upon determination that Resident #3 had a sacrum/coccyx pressure ulcer that had developed on 2/7/26 Interview and record review with the Registered Dietitian (RD) on 3/2/26 at 10:25 AM identified the facility policy to promote wound healing included adding extra protein, first assessing food then supplements and vitamins as well as calculating the resident's nutritional needs. The RD identified she was aware Resident #3 had wounds by attending the weekly at risk meetings, and he/she was discussed weekly. A review of Resident #3's clinical record with the RD identified a weight of 107 lbs. on 11/26/25 and a weight of 96 lbs. on 3/1/26, an 11 lbs. 10.28 % weight loss in 3 months which indicated a severe weight loss. Her intervention was put in place on 2/13/26 increasing the Boost glucose from 2 to 3 times daily and as needed if meals were refused, however, review of the clinical record failed to identify an order or documentation to alert staff to give Boost glucose if Resident #3 refused his/her meal. The RD identified that for a compromised resident who had severe weight loss and wounds there should have been additional interventions initiated such as high calorie protein shakes, vitamins, and Resident #3 should have been discussed with the team more thoroughly to promote wound healing. Subsequent to surveyor inquiry Resident #3's clinical record identified physician's orders directing to turn and reposition the resident every 4 hours while awake, a Liquid Protein Supplement Sugar Free Oral Liquid (Nutritional supplement) give 30 ml in the morning daily, Pro-stat Advanced Wound Care oral liquid 30 ml once daily to promote wound healing, vitamin C 500 mg 2 times a day for wound healing, Zinc Sulfate 220 mg once daily to promote wound healing, and a pressure relieving mattress set to weight. 2. Resident #11's diagnoses included severe protein calorie malnutrition, diabetes with neuropathy, and retention of urine. The admission Minimum Data Set assessment dated [DATE] identified Resident #11 had a Brief Interview for Mental Status score of 14 indicating no cognitive impairment and was totally dependent on staff for hygiene, dressing, toileting, and bed mobility, and had lower extremity limitation in range of motion on one side. Resident #11 required an indwelling urinary catheter and had a stage 4 pressure ulcer (severe wound exposing muscle, tendon, and bone) and 2 unstageable (full thickness wounds of indeterminate depth due to obscuring by slough: non-viable tissue) and was at risk for developing further pressure ulcers. a. The Resident Care Plan dated 10/30/25 identified indwelling urinary catheter due to a recent history of urinary retention and placement of foley while in the hospital. Interventions included provide catheter care daily and as needed, observe for signs and symptoms of discomfort with urination and frequency, observe and document pain or discomfort due to catheter, change the urinary drainage bag monthly and as needed. The Resident Care plan failed to include anchoring the indwelling urinary catheter to prevent pulling. The NA care card (directs care) directed float heels, observe for any new areas of skin breakdown catheter care daily and as needed. A nurse's note dated 11/7/25 at 5:38 PM identified Resident #11 had an excoriated area to the tip of the penis, the catheter was noted to be pulling, a new physician order to schedule a follow up with urology was obtained. The nurse's note failed to include further assessment or measurement of the area. A nurse's note dated 11/7/25 at 7:04 PM identified notification by a NA that Resident #11 had a tear at the tip of his penis due to the catheter pulling. The supervisor was notified. The area was cleansed and Triad ointment was applied. A new leg clip (decreases pressure from pulling the urinary catheter tubing away from the insertion site) was applied, and slack given on tube to eliminate further injury. The nurse's not failed to include further assessment or measurement of the area. A nurse's note dated 11/8/25 at 11:51 PM identified Resident #11 had a laceration to the penis observed with the presence of pus. The provider on call was notified, and an order was obtained to send Resident #11 to the Emergency Room. The nurse's note failed to include further assessment or measurement of the area. A readmission Nursing Assessment and nurse's notes from readmission dated 11/14/25 at 4:53 PM and nurses notes dated 11/14/25 through 11/17/25 at 6:53 AM failed to identify Resident #11 had a wound on his/her penis. Review physician orders from readmission on [DATE] through 11/17/25 failed to direct a treatment for the penis skin alteration until on 11/17/25 a physician's order directed to cleanse tip of penis with normal saline followed by Triad ointment every shift for excoriation and ensure that catheter was anchored to the thigh to prevent pulling and excoriation to the tip of the penis every shift for foley catheter care. A wound physician note dated 11/18/25 identified an initial evaluation of a stage 3 full thickness pressure wound to the penis measuring 1.2 cm length, 1 cm width, 0.5 cm depth and that the wound was a medical device (indwelling urinary catheter) associated pressure injury. A physician's order dated 11/20/25 directed mupirocin ointment 2% apply to tip of penis topically 2 times a day for open area to penis. A wound physician note dated 11/25/25 identified a stage 3 pressure wound to penis: full thickness 1 cm length, 0.8 cm width, 0.5 cm depth and treatment mupirocin 2% apply twice daily for 23 days. A nurse's note dated 11/27/25 at 11:18PM identified Resident #11 had redness and swelling to the tip of the penis. A wound physicians note dated 2/3/26 identified Resident #11's stage 3 pressure wound on the penis was resolved. Interview and record review with Assistant Director of Nursing (ADNS) on 2/26 at 2:00 PM identified she did not know how the pressure ulcer on the penis was first identified or how it would have developed. b. a. The Resident Care Plan dated 10/30/25 identified a left lateral plantar (sole) foot ulcer, stage 4, an unstageable left heel ulcer, a left plantar medial foot, diabetic ulcer, and a chronic left plantar foot ulcer had reopened. Interventions included keeping the skin clean and dry, offload the wound, wound physician visits as needed, report changes of discoloration to the area, pain, location, type, frequency and intensity, notify the physician of new, increased discoloration, pain, or if an intervention was ineffective. The NA care card (directs care) indicated to float (eliminate pressure) heels, observe for any new areas of skin breakdown. A wound physician note dated 11/5/25 identified Resident #11 had a left heel full thickness stage 4 pressure ulcer measuring 4.3 centimeters (cm) length, 4 cm width, 0.3 cm depth, and that the area had improved. A nurse's note dated 11/6/25 at 10:17 PM identified Resident #11 had a left heel pressure ulcer injury unstageable acquired in house, unknown how long it had been present, and was staged by the healthcare provider. A nurse's note dated 11/8/25 at 11:51 PM directed Resident #11 be sent to the Emergency Room. A nurse's notes dated 11/14/25 at 4:53 PM and nurse's notes through 11/17/25 at 6:53 AM failed to identify Resident #11 had any wounds. A physician's order dated 11/14/25 directed heel boots applied while in bed for protection, every shift, offload heels while in bed around the clock. Review of the facility weekly pressure injury report dated 2/17/26 identified Resident #11 with a community acquired stage 4 pressure ulcer to the left heel with an onset date of 9/30/25. Observation and interview with the ADNS and LPN #2 on 2/27/26 at 8:30 AM of Resident #11's left heel dressing change, identified his/her heels resting on the mattress without the benefit of heel boots or offloading. Resident #11's heel boots were approximately 5 to 6 feet from the resident's bed by the dresser. The ADNS indicated that Resident #11 kicked the heel boots off and LPN #2 indicated Resident #11 refused to wear the heel boots at times. Although both the ADNS and LPN #2 indicated kicking the boots off and refusals, they did not indicate why Resident #11 failed to have his/her heels offloaded off of the mattress and failed to have any alternate offloading device present in the bed or surrounding area. LPN #2 indicated that Resident #11 should have had his/her heels offloaded. Review of the clinical record, nursing notes and administration records from 11/8/25 through 2/27/26 failed to identify that Resident #11 had been refusing his/her heel boots. Interview with MD #1 on 2/27/26 at 3:00 PM identified that the pressure ulcer on the penis was a medical device pressure ulcer caused by the urinary catheter, likely from the weight of the drainage bag. Resident #11's urinary catheter tubing pulled on the penis and caused an opening. MD #1 further indicated that catheters should be anchored to the thigh for the prevention of pulling and/or pressure ulcer development but was unable to recall if Resident #11 had been using a urinary catheter leg anchor for prevention. MD #1 also indicated that Resident #11 should have been wearing heel boots or should have had his/her heels offloaded while in bed. Observation on 3/2/26 at 6:34 AM identified Resident #11 was without the benefit of heel boots or heels offloaded while in bed and heel boots remained on the floor beside the dresser. Observation on 3/2/26 at 6:59 AM identified Resident #11 was without the benefit of heel boots or heels offloaded while in bed. Resident #11 identified that the boots were not worn and heels were not offloaded. Interview and observation with LPN #2 on 3/2/26 at 7:15 AM identified that Resident # 11 was without the benefit of heel boots while in bed and the heels were against the mattress. LPN #2 could not explain why Resident #11 did not have the benefit of heel boots or offloading. Interview with RN #3 (Director of Clinical Services) on 3/2/26 at 11:35 AM identified that Resident #11's pressure ulcer to the penis should have been identified and documented on his/her readmission on [DATE]. Further, the facility had a system of chart checks upon admission/readmission that should have identified both the area of the penis and the left heel if the areas had not been noted on readmission. A review of Prevention of Pressure Ulcers/Injuries policy dated 2/26/2020 directed, in part, assesses the resident on admission within 8 hours for existing pressure ulcer/injury risk factors. Conduct a comprehensive skin assessment upon admission including skin integrity: any evidence of existing or developing pressure ulcers or injuries, tissue tolerance: the ability of the skin and supporting structures to endure the effects of pressure and areas of impaired circulation due to pressure from positioning or medical devices. Use pillows, wedges, or other off-loading devices to keep bony prominences such as knees or ankles from touching each other. When in bed, every attempt should be made to float heels (keep heels off bed) by placing a pillow from knee to ankle or with the devices as recommended by the physician. That skin should be kept free from moisture, nutritional supplements should be included in the resident's diet to increase calories and protein, repositioning should occur at least every 2 hours, provide appropriate support services based on the resident's mobility, continence, skin moisture, body size, weight and overall risk factors. Review the interventions and strategies for effectiveness on an ongoing basis. A review of the Pressure Ulcer/Injury Risk Assessment policy, directed in part, if the resident refused the treatment, document the reason for the refusal and the resident's response to the explanation of the risk of refusing the procedure, and the benefits of accepting any available alternatives. Document family and physician notification of refusal. Observations of anything unusual exhibited by the resident. That certain risk factors increase a resident's susceptibility to develop and heal a pressure ulcer/injury but are not limited to under nutrition, malnutrition, impaired/decreased mobility, exposure of skin to urinary and fecal incontinence, comorbidities such as renal disease and diabetes, cognitive impairments and resident refusal of certain aspects of the treatment. A risk assessment should be completed immediately after admission then weekly for 4 weeks. According to the pressure ulcer/skin breakdown protocol the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, and the nurse shall describe and document a full assessment of the pressure sore (ulcer) including locations, stage, width, depth, and presence of exudate and necrosis. Review of the Skin Prevention Care Policy dated 12/15/16 directed in part it was policy to identify residents who were at risk of skin breakdown and provide interventions to prevent skin breakdown whenever possible. Additionally, residents will be assessed on admission, readmission, quarterly and with change of condition and nursing measures will be instituted based on the risk assessment. Review of the Nutritional Assessment policy directed, in part, that the dietitian estimates calorie, protein, nutrient and fluid needs. A review of the Catheter Associated Meatal Pressure Injury in men from the clinical leadership program identified a number of different terms used to describe meatal injuries including iatrogenic hypospadias, penile cleft, ulceration of penis, broken urethra and penile erosion. ([NAME] et al 2022) Iatrogenic hypospadias is described as a preventable injury to the ventral male urethra, produced by the downward pressure of an indwelling urethral catheter ([NAME] et al, 1998) [NAME] and colleagues (2018) classified iatrogenic hypospadias into 4 types. Munien and colleagues (2024) built on this and other work including that of Shenhar et al (2020) to develop one term- catheter associated meatal injuries and a grading system for both male and female pressure injuries. Male catheter associated meatal injuries are divided into 4 grades, defined by the most proximal anatomical extent of the pressure injury.

Based on observation, interviews, record and policy reviews for 1 of 4 sampled residents (Resident #3) reviewed for nutrition, the facility failed to initiate timely interventions to prevent ongoing significant weight loss. The findings include: Resident #3's diagnoses included muscle weakness, diabetes, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status (BIMS) of 4 indicating severe cognitive impairment and required set up help for eating and supervision with personal hygiene and toileting. Additionally, the MDS identified Resident #3 weighed 121 pounds (lbs.), with no known weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status of 5 indicating severe cognitive impairment, required set-up help for eating and was totally dependent on staff for personal hygiene, toileting and transfers. Additionally, the MDS identified Resident #3 weighed 99 pounds (lbs.), had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The Resident Care Plan in effect from 7/14/25 through 2/25/26 identified Resident #3 had a nutritional problem or potential nutritional problem, and was at risk for malnutrition, due to dementia, diabetes, chronic kidney disease, congestive heart failure, poor intake. Interventions included Registered Dietician (RD) consultation and follow up, Occupational Therapy (OT) screen as needed, and supplements as ordered. Review of Resident #3's weight identified the following:113.8 lbs. on 7/14/25,111lbs on 8/4/25,109.5 lbs. on 9/1/25107.2 lbs. on 10/3/25,107 lbs. on 11/26/25,102.2 lbs. on 12/3/25,99.2 lbs.1/1/26,98.8 lbs. on 1/13/26 showing a weight loss of 15 lbs. (13.18%) in 6 months.98 lbs. on 2/3/26,96 lbs. on 3/1/26. (a 12.33%, 13.5 lb. weight loss in the last 6 months).Review of Dietitian #3's (previous dietitian) admission Nutritional assessment dated [DATE] at 9:57 AM identified Resident #3 was receiving Boost Glucose control (a nutritional diabetic supplement) 240 milliliters (ml) twice daily and nutritional interventions included continuing a regular texture diet, continue to monitor the need for a therapeutic diet related, continue Boost Glucose control 240 milliliters (ml) twice daily, add fortified cereal with breakfast and pudding with lunch and dinner. Resident #3 had poor intakes overall since admission, maybe related to acclimation to new environment and confusion related to dementia. Boost Glucose control 240 ml twice daily was added to promote adequacy, will also provide fortified pudding and cereal. A therapeutic diet was not indicated at this time related to quality of life.Review of Dietitian #3's quarterly Nutritional assessment dated [DATE] at 2:39 PM identified Resident #3 had fair intake of meals between 50 and 100%, nutritional interventions included continuing the regular diet, Boost Glucose twice a day, fortified pudding twice a day, fortified cereal once a day and deferring to the MD for blood sugar management. Review of Dietitian #1's (new dietitian) quarterly Nutritional assessment dated [DATE] at 10:33 AM identified Resident #3 had nutritional interventions, to discontinue the regular diet and provide a Consistent Carbohydrate diet (CCHO therapeutic diabetic) diet, monitor weights, intakes, medication and labs, defer to MD for blood sugar management, continue Oral Nutritional Supplement (ONS/Boost Glucose and fortified cereal). The note failed to indicate Resident #3 was still receiving fortified pudding twice daily.Review of Dietician #1's Comprehensive Nutritional assessment dated [DATE] at 4:10 PM identified Resident #3 had a current weight of 109.5 lbs. with a goal weight greater than 109.5 lbs., was receiving Boost Glucose twice a day and was independent for meals, weight trending down slightly but considered stable in 6 months, tolerating current diet order and eating sandwiches with some parts of the meal. Nutritional goals were identified as nutritional intake greater than or equal to 50% of meals and fluid and to remain free from significant weight loss. Nutritional interventions were to provide diet as ordered, monitor intake, diet tolerance, weights, labs and medications as ordered. The note failed to indicate Resident #3 was still receiving fortified pudding twice daily or fortified cereal once daily.Review of Dietitian #1's Comprehensive Nutritional assessment dated [DATE] at 4:10 PM identified Resident #3 had a current weight of 102.2 lbs. with a goal weight greater than 102 lbs., was receiving Boost Glucose 2 times a day and was independent for meals. Nutritional risk was identified as a weight loss of 12.8 lbs., (12.5%) in 6 months with occasional meal refusals, nutritional goal was to maintain adequate nutritional intake of meals and fluid and to remain free from significant weight loss, awaiting reweight for further interventions. Nutritional interventions were to provide diet as ordered, adjust order to finger foods as available, monitor intake, diet tolerance, weights, labs, and medications as ordered. (Resident #3's reweight was not repeated until the weekly weight was taken on 12/9/26) The note failed to indicate Resident #3 was still receiving fortified pudding twice daily or fortified cereal once daily.Review of the quarterly Nutrition Assessment and Nutrition progress note dated 1/15/26 identified Resident #3 was on a diabetic diet, receiving Boost Glucose 240 ml twice a day, independent with meals and nutritional interventions were to provide a diabetic diet for blood sugar management, monitor weights, intake, labs and medications as ordered with referral to the nutrition progress note for more information. Additionally, Resident#3 had been hospitalized on [DATE] to 11/26/25 and had a decline in intakes with a decrease of 15 lbs. from 7/14/25 with a change of 15.18% in 6 months. Weight had been maintained in the 98 to 99 lb. range for 1 month, weight gain would be beneficial, and the resident's current weight was 98.8 lbs. Resident #3 mostly consumed fluids with varied takes. Oral nutrition supplement order remained appropriate for adequacy, will continue to monitor weights, intakes, pertinent medications/labs. The note failed to indicate Resident #3 was still receiving fortified pudding twice daily or fortified cereal once daily.Review of physician's orders from 4/30/25 until 2/13/26 failed to identify any change in the residents nutritional supplements from Boost Glucose 240 ml twice daily and failed to direct Resident #3 was to receive fortified pudding or fortified cereal.Physician's order in effect from 7/31/25 to 2/27/26 directed a Consistent Carbohydrate Diet (CCHO, diabetic diet) regular consistency with thin liquids and to provide sandwiches and finger foods as needed. (Physician's orders were changed from receiving a regular diet to a therapeutic CCHO diabetic diet despite Dietitian #1's statement that a therapeutic diet was not indicated at this time related to quality of life.)A physician's order dated 2/13/26 directed to administer Boost Glucose control 240 ml 3 times a day for nutritional supplementation. (increased from twice daily).Observation on 2/27/26 at 12:06 PM identified Resident #3 in bed, with a lunch served consisting of kielbasa, carrots and roasted potatoes. Resident #3 did not attempt to eat independently and refused to eat when Nurse Aid (NA) #2 came to assist. Additionally, Resident #3 declined multiple offers to obtain a sandwich. Interview and meal ticket review with NA #2 on 2/27/26 at 12:11 PM identified Resident #3 was independent for meals but sometimes needed assistance due to lethargy and although she could eat the meal provided, she preferred sandwiches. Review of Resident #3's lunch meal ticket with NA #2 identified he/she was a regular texture and special instructions stating, likes ham and cheese sandwiches, provide sandwiches and finger food as needed, but failed to indicate Resident #3 should be provided with finger foods or sandwiches on a regular basis or with meals.Interview and meal ticket review with the Dietary Director on 2/27/26 at 1:45 PM identified staff picked the meals for residents that could not choose themselves, and any allergies, aversions and special preferences would be noted on the meal ticket. Review of Resident #3's meal ticket with the Dietary Director identified that Resident #3 was currently receiving a CCHO diet and failed to indicate the resident was receiving fortified cereal or fortified pudding. Although Resident #3's meal ticket indicated he/she likes ham and cheese sandwiches, provide sandwiches and finger food as needed, it did not specify to send sandwiches or finger foods as a replacement or in addition to a meal on a daily basis and staff had to call the kitchen to request sandwiches or finger foods for Resident #3 if needed.Interview and record review with the Registered Dietitian, Dietitian #1, on 3/2/26 at 10:25 AM identified the facility policy directed her to evaluate residents on admission, readmission, quarterly, if they had a significant change, and if she noticed anyone was struggling with nutrition or with eating. Dietitian #1indicated Resident #3's weight was 107 lbs. on 11/26/25 and 96 lbs. on 3/1/26, which indicated a significant weight loss of 11 lbs. (10.28 %) in 3 months. She stated she was aware of the weight loss through attending weekly at risk meetings. Dietitian #1 identified that she had first identified Resident #3's weight loss on 1/11/26 at which time the resident weighed 99 lbs. a significant weight loss of 8.0 lbs. (7.4%) in 1 month. After identifying Resident #3's significant weight loss on 1/11/26 she recommended interventions to provide finger foods/sandwiches, encourage the resident to eat meals out of bed, provide Boost Glucose supplement twice daily and as needed for meal refusals. Further, Resident #3 weighed 109.5 lbs. on 9/1/25 and 96 lbs. on 3/1/26 which was a 13.5 lb. (12.3%) significant weight loss in 6 months. Although the Dietitian indicated after determining Resident #3's weight loss on 1/11/26, she had placed Resident #3 on Boost Glucose twice daily, the resident had been given Boost Glucose twice daily since Dietitian #1's admission Nutritional assessment dated [DATE]. Additionally, Dietitian #1 indicated that she had also started sandwiches and finger foods in response to the identified weight loss on 1/11/26, however, the order for sandwiches and finger foods had been in place since 7/31/25. Interview and record review with Registered Nurse (RN) #4 on 3/2/26 at 12:19 PM identified Resident #3 was independent for meals, had eaten half a ham and cheese sandwich for lunch and had an order for Boost Glucose supplement 3 times per day. RN #4 was unable to find an order or nursing measure directing staff to provide a Boost Glucose supplement if his/her meal was refused (50 days after a recommendation had been given according to Dietitian #1).Interview and at-risk meeting minutes review with Dietitian #1 on 3/3/25 at 11:06 AM identified that although she was aware of Resident #3's weight loss, which was identified as significant, the only intervention put in place to prevent weight loss was an increase in Boost Glucose to 3 times a day on 2/13/26 (33 days after the significant weight loss was identified). Dietitian #1 could not identify why she did not institute more interventions for the prevention of further significant weight loss.Subsequent to surveyor inquiry Resident #3's clinical record identified physician's orders were put in place for LPS Sugar Free Oral Liquid (Nutritional supplement) give 30 ml in the morning daily, Pro-stat Advanced Wound Care Oral liquid 30 ml once a day, Vitamin C 500mg twice a day and , Zinc Sulfate 220 mg 1 cap once a day.Review of the undated facility RD assessment criteria for severe protein calorie nutrition identified it as an unplanned weight loss greater than 5% in 1 month, 7.5% in 3 months, 10 % in 6 months and 20% in 1 year.Review of the Nutritional Assessment Policy directed in part that the nutritional assessment will be a systemic, multidisciplinary process that includes gathering and interpreting data, and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.Review of the Weight Measurement Policy dated 12/2/16 directed in part that a significant weight change of 5% in 30 days, 7.5% in 90 days, or 10 % in 90 days required a weight reweight in 24 hours. Additionally, a weight variance must be reported to the provider.

Based on interviews, record, and policy reviews for 2 of 3 sampled residents (Resident #15 and Resident #40) reviewed for abuse, the facility failed to ensure a resident was free from physical abuse. The findings include:1. Resident #15's diagnoses included vascular dementia with behaviors, schizophrenia and paranoid personality disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 had a Brief Interview of Mental Status of 9 indicating moderate cognitive impairment and was independent for eating, transferring, and changing position. Additionally, the MDS identified Resident #15 had no potential indicators of psychosis.The Resident Care Plan dated 1/28/26 identified Resident #15 had a potential for behaviors related to a diagnosis of dementia, paranoia, delusions, a history of physical aggression and a resident to resident altercation (6/1/25). Interventions included approaching the resident in a calm manner, documenting behaviors and following up with psychiatry.Review of the psychiatry APRN progress note dated 2/10/26 identified Resident #15 was seen as a regular follow up due to a diagnosis of schizophrenia and dementia, presenting with a stable mood and no reports by nursing staff of behavioral disturbances, aggression, or unsafe behaviors.2. Resident #40's diagnoses included unspecified dementia, bipolar II disorder, and anxiety.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment and was independent for eating, changing position, and required partial/moderate assistance for transfers. Additionally, the MDS identified Resident #40 had no potential indicators of psychosis.The Resident Care Plan dated 11/19/25 identified Resident #40 was at risk for mood/behaviors due to a diagnosis of anxiety and depression, rummaging, anger, yelling at staff, increased delusions and confusion. Interventions included evaluations by psychiatry services, observation for changes in mood /depression and encouragement to talk about problems.Review of the Psychiatry APRN progress note dated 2/13/26 at 4:00 PM identified Resident #40 was seen due to increased agitation, demonstrating stability in mood and behavior with no delusions, hallucinations or safety concerns identified at the time.a. Review of a nurse's note dated 6/1/25 at 10:29 PM identified Resident #15 allegedly grabbed her roommate's arm after an exchange of words.Review of the Reportable Event investigation dated 6/1/25 identified that Resident #15 had a BIMS score of 1. Upon interview of both residents, they denied physical contact but indicated that words were exchanged. There were no other witnesses to the altercation, only statements that residents were agitated were immediately separated from each other. The social worker and psychiatric services followed up with both residents, and they expressed no harm/emotional distress. There were no injuries on initial or subsequent assessments.Review of the psychiatry Advanced Practice Registered Nurse (APRN) note dated 6/1/25 at 10:10 PM identified Resident #15 was seen due to an alleged interpersonal issue and presented in a calm pleasant and cooperative manner during the interview and was not a danger to self or others.Review of the nurse's note dated 6/2/25 at 9:00 AM identified Resident #15 was spoken to regarding a heated discussion he/she had with a roommate. At the time Resident #15 felt the roommate did not belong in the room but was agreeable to having another roommate.Review of nurse's notes dated 6/2/25 to 2/23/26 failed to identify any resident to resident altercations.b. Verbal notification by the Administrator to surveyors on 2/24/26 at 12:54 PM identified there was a report of a resident to resident altercation between Resident #15 and Resident #40.Review of the nurse's note dated 2/24/26 at 1:04 PM identified Resident #15 admitted to grabbing his/her roommate, Resident #40, around the neck.Review of the facility Reportable Event form dated 2/24/26 identified that on 2/24/26 Resident #40 reported to a Nurse Aide (NA) that Resident #15 grabbed him/her around the neck. The investigation identified Resident #40 rolled to the thermostat in his/her wheelchair and adjusted the temperature, which appeared to trigger an altercation. Resident #40 stated that Resident #15 grabbed his/her neck. The NA reported that Resident #15 admitted to putting her hands on Resident #40 and justified it by stating the resident had a foul mouth and deserved it. The roommate, Resident #46 witnessed Resident #15 place his/her hands on Resident #40's shoulders and confirmed an altercation occurred. During the investigation, both roommates felt the room placement was not appropriate for Resident #40, and Resident #40 was moved out of the room. The residents involved received 72 hour follow-up, and each reported feeling safe in their new rooms, including the roommate, Resident #46. No further incidents or concerns were identified.Review of the Psychiatry APRN progress note dated 2/24/26 at 2:36 PM identified Resident #15 was seen for follow up of a negative interaction with another resident, presented as pleasant, calm and engaged and the previous dose of Seroquel (an antipsychotic medication) would be resumed, noting the attempted gradual dose reduction had failed.Interview with Registered Nurse (RN) #4 on 2/24/26 at 1:43 PM identified he was the charge nurse on the unit where the resident-to-resident incident occurred, stating that although Resident #40 gets mad, loud and unpleasant with other residents and staff, even to him at times, in this scenario he/she was not the aggressor. Additionally, RN #4 stated Resident #15 who is usually very quiet was the aggressor and grabbed Resident #40's neck when he/she came to change the temperature setting on the heater, adding maybe Resident #15 just had enough of listening to Resident #40. The residents were immediately separated, and both were put under 1:1 observation at the time.Interview with Social Worker (SW) #1 on 2/25/26 at 11:01 PM identified Resident #15 and Resident #40 had a verbal disagreement over the temperature of the room that led to Resident #15 grabbing Resident #40 by the neck. Additionally, SW #1 identified Resident #40 had a feisty personality and although no issues were reported in the past with Resident #15 and Resident #40, the personalities were not a good match with resident #40 verbally initiating the disagreement that led to Resident #15 becoming physically aggressive. Subsequently both Residents were on 1:1 for 24 hours, cleared by psych and Resident #40 was being monitored for adjustment to a room change while Resident #15 stayed in the original room.Interview with NA #2 on 2/25/26 at 11:30 AM identified that Resident #40 was usually mild mannered, and there were no prior altercations between the 2 residents, and no indicators that the altercation would have occurred.Review of the Psychiatry APRN progress note dated 2/26/26 at 6:06 PM identified Resident #40 was seen due to an alleged incident with a peer, presented as calm, cooperative and engaged appropriately in conversation. Additionally Resident #40 reported feeling safe and denying any concerns?Resident #15 and Resident #40 both had Resident Care Plans indicating behavioral issues. Resident #15 had a history, per a past Reportable Event, of becoming agitated with others. According to RN #4 Resident #40, was known to get mad, loud and unpleasant with other residents and staff, even to him at times and according to SW #1, Resident #40 was known to have a feisty personality, and not a good match with Resident #15. Despite this, Resident #15 and #40 were deemed appropriate roommates leading to the physical altercation of Resident #15 grabbing Resident #40 around the neck.Review of the Abuse and Prohibition Policy revised 10/7/24 directed in part to maintain a zero-tolerance policy for any form of abuse or neglect of a resident by maintaining an environment free from abuse (verbal, physical, mental, psychological, or sexual), neglect, corporal punishment, involuntary seclusion, or misappropriation of property.

F812 Kitchen Harbor TW finalBased on observations, staff interviews and review of facility documents, the facility failed to ensure expired food items were identified and appropriately discarded. The findings included:Observation, interview and facility document review with the Food Service Director on 2/27/26 at 10:04 AM of kitchen food storage identified the following items were expired:Deluxe pulled chicken with broth 48 ounce (oz) can,12 cans, best by 10/17/25Ocean Spray Orange Juice 32 oz bottle, 24 bottles, best by 12/15/25Beef stew 48 oz can, 6 cans, best by 2/22/26The Food Service Director identified that it was his responsibility to ensure that items were checked for expiration dates and that checks should occur monthly or when new stock arrived. He indicated that he was newly hired and did not check the emergency food supply for expiration dates, as he should have because he was informed that it was good to go.Subsequent to surveyor inquiry, the expired items were discarded by the Food Service Director.Although requested from the facility, a food storage policy was not provided.

Based on interviews and facility documentation during a review of the Infection Control Program, the facility failed to ensure the Registered Nurse overseeing the Infection Prevention Licensed Practical Nurse had an Infection Preventionist specialized training certificate. The findings included:Interview and document review on 2/26/26 at 11:15 AM with the Infection Prevention Nurse LPN #3 identified that although she was the Infection Control Nurse, and had a Nursing Home Preventionist certificate dated 4/17/22, the Director of Nurses, who was an RN oversaw her Infection Control Nurse Prevention role, but the Director of Nurses was out of the facility on an extended leave.Interview and document review with Regional Clinical Registered Nurse (RN) #3 on 3/2/26 at 11:30 AM identified that she was certified as a Nursing Home Infection Preventionist as of 12/17/21, and although she oversaw the facility infection prevention program, she did not directly oversee the Infection Prevention Nurse currently in the role, LPN #3. Additionally, RN #3 stated the DNS could not locate her certificate, identifying she re-completed the Nursing Home Infection Preventionist Training course and identified a certificate for the DNS dated 3/1/26, however, she was still not overseeing LPN #3.

Based on interviews, review of the clinical record, and facility policy for 1 of 3 sampled residents (Resident #97) reviewed for smoking, the facility failed to provide access to the smoking activity per the residents choice. The findings include:Resident #97's diagnoses included chronic obstructive pulmonary disease, hyperlipidemia, and atherosclerotic heart disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #97 had a Brief Interview for Mental Status score of 13 indicating intact cognition, exhibited no signs or symptoms of delirium, and required substantial/maximal assistance with lower body dressing, required partial/moderate assistance with lying to sitting on the side of the bed, and substantial/maximal assistance to transfer from sitting to standing and chair/bed to chair transfers. The Resident Care Plan (RCP) in effect from 1/7/26 through 3/3/26 failed to identify a preference for smoking. An interview with the resident on 2/25/26 at 10:32 AM identified he/she smoked cigars and hadn't been able to smoke since his admission to the facility 1/7/26. Resident #97 identified he/she was not allowed to smoke due to the use of oxygen. Resident #97 indicated that he/she would like to have a cigar and was upset over being denied the opportunity to smoke. An interview with Registered Nurse (RN #1) on 3/3/26 at 9:23 AM identified the facility's process for assessing a resident's ability to smoke was to first find out if the resident was a smoker, or if they wanted to smoke upon admission. RN #1 indicated he, or the RN supervisor working at the time of a resident's admission to the facility, would perform a smoking evaluation which would determine if adaptive equipment was required as well as if a staff member was needed to assist the resident to smoke. RN #1 stated that the only limitation that would preclude a resident from participating in smoking if they desired, was exhibiting adverse behaviors and considered to be a risk to other residents. RN #1 identified residents were not required to have a physician order to participate in smoking groups, per the facility smoking policy. He indicated that Resident #97 had never been identified as a smoker due to not being evaluated or asked on admission if he/she would like to participate in the facility smoking activity. RN #1 stated that he had just performed Resident #97's smoking assessment the previous day, but he/she should have been given the opportunity on admission. A review of the facility policy for smoking directs, in part, that upon admission, residents and family members/responsible parties will be educated on the smoking policy and will sign an acknowledgement to adhere to the smoking policy. The policy also directs that a smoking assessment will be completed on smokers to ensure the functional ability to smoke safely, that a smoking assessment will be completed upon admission, quarterly, when a resident chooses to change their smoking decision, and with a change in resident condition. The smoking policy further directs if the resident is receiving oxygen, staff members will assist with removal of all oxygen equipment prior to entering the designated smoking area. Once the smoking session is completed the staff (will) escort residents out of the smoking area and assist in reapplying all oxygen equipment as ordered.

Based on interviews, review of the clinical record and policy for 1 of 4 sampled residents (Resident #3), reviewed for nutrition, the facility failed to notify the provider of a severe weight loss of 13.5 pounds in 6 months. The findings include:Resident #3's diagnoses included muscle weakness, diabetes, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status (BIMS) of 4 indicating severe cognitive impairment and required set up help for eating and supervision with personal hygiene and toileting. Additionally, the MDS identified Resident #3 weighed 121 pounds (lbs.), with no known weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment, required set up for eating and was totally dependent on staff for personal hygiene, toileting and transfers. Additionally, the MDS identified Resident #3 weighed 99 pounds (lbs.), had a significant weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The Resident Care Plan in effect from 7/14/25 through 2/25/26 identified Resident #3 had a nutritional problem or potential nutritional problem, and was at risk for malnutrition, due to dementia, diabetes, chronic kidney disease, congestive heart failure, poor intake. Interventions included Registered Dietician (RD) consultation and follow up, Occupational Therapy (OT) screen as needed, and supplements as ordered. Review of the nutrition note dated 1/15/26 at 3:57 PM identified Resident #3 had recent weight loss post hospitalization 10/21/25 to 11/26/25 related to behaviors. Resident #3 had a decline in intakes with a decrease of 15 pounds (lbs.) since 7/14/25 with a change of 15.18% in 6 months. His/her weight was maintained in the 98 to 99 lb. range for 1 month. Weight gain would be beneficial with a current weight of 98.8 lbs., and Resident #3 mostly consumed fluids with varied intakes. Oral nutritional supplement order remains appropriate for adequacy, will continue to monitor weights, intakes, and pertinent medications/labs.Interview and record review with Regional Clinical Registered Nurse (RN) #3 on 2/27/26 at 1:12 PM identified that the nutrition progress note dated 1/15/26 indicating Resident #3 was noted to have a significant weight loss of 15 lbs., a 15.18 % in 6 month loss. RN #3 identified that although it was the facility policy to update the provider on a change in status such as a weight loss, no one was updated but should have been.Interview and record review with APRN #1 on 3/3/26 at 10:29 AM identified it was facility policy for her to be updated on resident changes by reviewing concerns written down in the APRN/MD book located at the supervisor's desk, including notification of weight loss. Review of Resident #3's clinical record with APRN #1 identified on 1/15/26 the resident had a decline in intake with a decrease of 15 lbs. in 6 months (15.18%). APRN #1 identified she had not been notified of the significant weight loss and if she had been she would have monitored weights more closely, recommended protein shakes, and initiated a conversation with the family due to Resident #3's overall decline.Interview and at-risk meeting minutes review with the Dietitian #1 on 3/3/25 at 11:06 AM identified that she had been tracking Resident #3's weight loss and noted on 12/2/25 he/she has a 12.8 lb. (12.5%) weight loss in 6 months, and on 1/15/26 noted Resident #3 had a 15 lb. (15.18%) weight loss in 6 months. Dietitian #1 failed to identify that she updated the provider, stating she was under the impression that the APRN attended the at-risk meetings. Review of the at-risk meeting minutes dated 1/13/26-1/19/26, 1/20/26-1/26/26,1/27/26-2/2/26, 2/3/26-2/9/26 failed to identify the APRN was an attendee.Review of the Resident Change in Condition Policy revised 9/4/18 directed in part that all staff will communicate any information about resident change in condition to appropriate personnel, and notification of physician time and date are to be documented in the progress note.Review of the Weight Measurement Policy dated 12/2/16 directed in part that a weight variance must be reported to the provider.

Based on interviews, review of the clinical record, facility documentation, and policy for 1 of 3 sampled residents, (Resident #47) reviewed for abuse, the facility failed to report an injury of unknown origin to the State Agency. The findings include: Resident #47's diagnoses included dementia with agitation, cognitive communication deficit, Parkinson's Disease with dyskinesia with fluctuations.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment, required partial/moderate for transfers from sitting to lying and lying to sitting on the side of the bed. The MDS also identified the resident required substantial/maximal assistance for transferring to/from the toilet and was fully dependent on staff for upper and lower body dressing, rolling left and right in bed, and transferring from sitting to standing as well as chair/bed to chair transfers. The Resident Care Plan (RCP) in effect from 1/7/26 through 3/3/26 identified Resident #47 had an Activity of Daily Living (ADL)/Mobility deficit. Interventions included assistance of 2 for toileting, dressing, bathing, and assistance of 2 with a mechanical lift for all transfers. An interview with Person #1 on 2/26/26 at 12:43 PM identified Resident #47 had an unwitnessed injury to the left side of his/her forehead on the morning of 2/18/26 resulting in a hematoma (large, raised, painful, firm collection of clotted blood lasting longer than a bruise). When staff notified Person #1 they indicated it was believed Resident #47 had hit his/her head on the headboard of the bed, due to intermittent episodes of dyskinesia (increased involuntary movements).A Reportable Event dated 2/18/26 identified at 7:00 AM, while Resident #47 was seated in his/her wheelchair at the nurse's station, an LPN had noticed a hematoma to the left side of the resident's forehead. The cause of the hematoma was unknown as no one had witnessed what happened to cause the hematoma. Staff concluded the resident had hit his/her head on the headboard of his/her bed inside the room earlier in the morning. An interview with the Assistant Director of Nursing (ADNS) on 2/26/26 at 1:20 PM identified after conferring with the Regional Clinical Director, Registered Nurse (RN) #3, and indicating to her the cause of the injury was able to be explained by dyskinesia, RN #3 stated the facility was still within the 24 hour State Agency time reporting window, therefore the injury did not need to be reported as an injury of unknown origin. The ADNS indicated that although the policy directed her to go back 72 hours to interview staff with access to Resident #47 to determine the cause of the injury, she had not done so and interviewed only the 2 Nurse Aid (NA) staff who had cared for the resident the shift prior. She indicated that she had not spoken to the unit nurse who had interacted with the resident minutes prior the initial report of the hematoma stating she forgot and also did not feel it was necessary based on the 2 interviews obtained by the NAs.An interview with the Regional Director of Clinical Services Registered Nurse (RN) #3 on 2/26/26 at 1:31 PM identified that Resident #47's injury to his/her forehead was not reported to the State Agency as she was under the impression that a complete and thorough investigation had been performed with the cause being known and due to dyskinesia and bumping his/her head. RN #3 indicated had she known the investigation was incomplete, she would have had the ADNS report Resident #47's injury to the State Agency within the 24 hour time frame and classified it as an injury of unknown origin.A review of the facility policy for abuse directs, in part that an injury of unknown source is when both of the following conditions are met: 1) the source of the injury was not observed by any persons or the source of the injury could not be explained by the resident, and 2) the injury is suspicious because of the extent of the injury or the location of the injury. It also directs that the time periods for reporting reasonable suspicion of a crime depends on the seriousness of the event that leads to the reasonable suspicion, and that if there is a result of serious bodily injury or not, the individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; and in CT to the Department of Social Services within 24 hours after forming the suspicion.

Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents, (Resident #47) reviewed for abuse, the facility failed to thoroughly investigate an injury of unknown origin. The findings include:Resident #47's diagnoses included dementia with agitation, cognitive communication deficit, and Parkinson's disease with dyskinesia with fluctuations.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment, required partial/moderate for transfers from sitting to lying and lying to sitting on the side of the bed. The MDS also identified the resident required substantial/maximal assistance for transferring to/from the toilet and was fully dependent on staff for upper and lower body dressing, rolling left and right in bed, and transferring from sitting to standing as well as chair/bed to chair transfers. The Resident Care Plan (RCP) in effect from 1/7/26 through 3/3/26 identified Resident #47 had an Activity of Daily Living (ADL)/Mobility deficit. Interventions included assistance of 2 for toileting, dressing, bathing, and assistance of 2 with a mechanical lift for all transfers. An interview with Person #1 on 2/26/26 at 12:43 PM identified Resident #47 had an unwitnessed injury to the left side of his/her forehead on the morning of 2/18/26 resulting in a hematoma (large, raised, painful, firm collection of clotted blood lasting longer than a bruise). When staff notified Person #1 they indicated it was believed Resident #47 had hit his/her head on the headboard of the bed, due to intermittent episodes of dyskinesia (increased involuntary movements).A Reportable Event and investigation dated 2/18/26 identified at 7:00 AM, while Resident #47 was seated in his/her wheelchair at the nurse's station, an LPN noticed a hematoma to the left side of the resident's forehead. The cause of the hematoma was unknown as no one had witnessed what happened to cause the hematoma. The 2 NA statements were inconclusive, indicating an assumption Resident #47 had hit his/her head on the headboard of the bed inside the room earlier in the morning.An interview with the Assistant Director of Nursing (ADNS) on 2/26/26 at 1:20 PM identified after conferring with the Regional Clinical Director, Registered Nurse (RN) #3, and indicating to her the cause of the injury was able to be explained by dyskinesia, RN #3 stated the facility was still within the 24 hour State Agency time reporting window, therefore the injury did not need to be reported as an injury of unknown origin. The ADNS indicated that although the policy directed her to go back 72 hours to interview staff with access to Resident #47 to determine the cause of the injury, she had not done so and interviewed only the 2 Nurse Aid (NA) staff who had cared for the resident the shift prior. She indicated that she had not spoken to the unit nurse who had interacted with the resident minutes prior the initial report of the hematoma stating she forgot and also did not feel it was necessary based on the 2 interviews obtained by the NAs.An interview with the Regional Director of Clinical Services RN #3 on 2/26/26 at 1:31 PM identified that Resident #47's injury to his/her forehead was not reported to the State Agency as she was under the impression that a complete and thorough investigation had been performed with the cause being known and due to dyskinesia and bumping his/her head. RN #3 indicated had she known the investigation was incomplete, she would have had the ADNS report Resident #47's injury to the State Agency within the 24 hour time frame and classified it as an injury of unknown origin.Review of the abuse policy identified that a thorough investigation of alleged abuse or neglect would be conducted by the Administrator and/or Director of Nursing to determine if the conduct of the individual is in violation of any standard of care.

Based on observations, interviews, record and policy reviews for 2 of 3 residents (Resident #40 and Resident #97) reviewed for smoking and 1 of 6 residents (Resident #51) reviewed for accidents, the facility failed to perform assessments per the facility policy. The findings include:1. Resident #40's diagnoses included unspecified dementia, Bipolar II Disorder, and anxiety. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had a Brief Interview of Mental Status (BIMS) of 8 indicating moderate cognitive impairment and was independent for eating, changing position, requiring partial/moderate assistance for transfers, and currently used tobacco. The Resident Care Plan dated 2/25/24 identified Resident #40 was a current smoker. Interventions included observation of smoking safety and use of a smoking apron. A physician's order dated 9/8/25 directed that Resident #40 may participate in the supervised smoking program per the facility policy. Interview and record review with the Assistant Director of Nurses (ADNS) on 3/3/26 at 9:23 AM identified it was the facility policy for nurses to perform smoking evaluations on admission, readmission, quarterly, and with a change in condition. Review of resident #40's clinical record identified that he/she was currently a smoker, had smoking assessments completed on 7/4/24, 11/4/25, and 2/2/26 but was missing 4 smoking evaluations during that time period. The ADNS could not identify why the facility failed to perform smoking assessments on a resident who was currently allowed to smoke. 2. Resident #51's diagnoses included dementia with psychotic disturbances, delusional disorders and frontotemporal neurocognitive disorder. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status (BIMS) of 6 indicating severe cognitive impairment, was independent for changing positions and transfers but did not exhibit wandering. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status of 00 indicating severe cognitive impairment, was independent for changing positions and transfers, and exhibited wandering behaviors daily, with the wandering identified as same compared to the prior assessment. The Resident Care Plan dated 6/3/24 through 2/27/26 identified Resident #51 was at risk for elopement, was cognitively impaired and was independently mobile. Interventions included verifying placement and function of an elopement device as ordered, monitor for tailgating when visitors were moving throughout facility, and use verbal cues to minimize exit seeking. A physician's order dated 9/2/25 directed staff to check the elopement device placement to the left wrist every shift. Observation of Resident #51 on 2/27/26 at 9:25 AM identified he/she had a wander guard applied on the left wrist. Review of the undated Resident Care Card directed staff to check Resident #3 for elopement device placement to the left wrist, monitor for tailgating when visitors were in the facility and use verbal cues to minimize exit seeking. Interview and record review with Regional Clinical Registered Nurse (RN) #3 on 2/27/26 at 1:34 PM identified it was the facility policy for nurses to complete wander/elopement assessments on admission, quarterly, annually and with a change in condition. Review of Resident #51's clinical record with RN #3 identified he/she had elopement assessments completed on 7/8/24, 10/14/25 and 1/13/26. Additionally, RN #3 identified that an additional 4 elopement assessment should have been completed between 7/2024 and 10/2025 but could not identify why the elopement assessments were not completed for a resident who was identified as exhibiting wandering behaviors. Review of the Wandering/Unsafe Resident Policy directed in part that staff will assess individuals for possible correctible risk factors related to unsafe wandering. 3. Resident #97's was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, hyperlipidemia, and atherosclerotic heart disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #97 had a Brief Interview for Mental Status score of 13 indicating intact cognition, exhibited no signs or symptoms of delirium, and required substantial/maximal assistance with lower body dressing, required partial/moderate assistance with lying to sitting on the side of the bed, and substantial/maximal assistance to transfer from sitting to standing and chair/bed to chair transfers. Additionally, the MDS identified he/she was a non-smoker. The Resident Care Plan (RCP) in effect from 1/13/26 through 3/3/26 failed to identify Resident #97 currently smoked or desired to smoke. An interview with Resident #97 on 2/25/26 at 10:32 AM identified he/she smoked cigars and hadn't been allowed to smoke due to the use of oxygen while residing at the facility since his admission on [DATE] (55 days). Resident #97 indicated he/she was upset and would like to be able to enjoy a cigar stating he had told everyone but was unable to recall any staff names. An interview with Registered Nurse (RN #1) on 3/3/26 at 9:23 AM identified upon admission all residents were asked if smoking would be requested and had a smoking assessment completed per the facility process. RN #1 indicated he, or the RN supervisor working at the time of a resident's admission to the facility, would perform a smoking evaluation which would determine if adaptive equipment was required as well as if a staff member was needed to assist the resident to smoke. RN #1 indicated that Resident #97 had never been asked on admission or identified as a smoker due to never having a smoking assessment completed. RN #1 stated that he had just performed Resident #97's smoking assessment the previous day 3/2/26 (55 days after admission), but he/she should have been asked and given the opportunity to smoke on admission. Review of the Smoking Policy revised 10/11/23 directed in part that a smoking assessment will be completed upon admission, quarterly, when a resident chooses to change their smoking decision and with a change in condition.

Based on interviews, observations, review of clinical records and policy for 2 of 3 residents (Resident #8 and #93) reviewed for respiratory care, the facility failed to ensure a resident receiving oxygen had a physician's order for oxygen and failed to ensure oxygen administration was set according to the physician order. The findings include:1. Resident #8's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), acute pulmonary edema, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 15 indicating normal cognitive function, and was independent for oral hygiene, personal hygiene and transfers.The Resident Care Plan (RCP) dated 1/8/26 identified Resident #8 had COPD related to smoking. Interventions included monitoring difficulty breathing and elevating the head of bed or assist to an upright position in a chair during episodes of difficulty breathing.Observation on 2/25/26 at 11:05 AM identified Resident #8 lying in bed wearing a nasal cannula with the head of the bed elevated and being administered oxygen at 2 liters per minute.Review of Resident #8's physician's orders failed to identify an order for oxygen administration.Observation on 2/26/26 at 11:30 AM identified Resident #8 was lying in bed with the head of bed elevated wearing a nasal cannula and being administered oxygen at 2 liters per minute.2. Resident #93's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 had a Brief Interview of Mental Status score of 14 indicating normal cognitive function, and was independent for oral hygiene, personal hygiene and transfers.The Resident Care Plan (RCP) dated 3/5/26 identified Resident #93 had an altered respiratory status related to Chronic Obstructive Pulmonary Disease (COPD). Interventions included administering oxygen as ordered.A physician's order dated 1/14/25 for Resident #93 directed to administer continuous oxygen at 2 to 4 liters per minute via nasal canula to keep oxygen saturation level greater than 92 percent (%).Observation on 2/24/26 at 11:46 AM identified Resident #93 was lying in bed wearing a nasal canula with the head of the bed elevated being administered oxygen at 5 liters per minute.Observation on 2/26/26 at 11:11 AM identified Resident #93 was lying in bed with head of bed elevated wearing a nasal cannula and being administered oxygen at 5 liters per minute.Interview and observation with LPN #1 on 2/26/26 at 11:43 AM identified that oxygen administration should be set according to the physician's order and that it was the responsibility of the assigned nurse to ensure that it was set correctly. LPN #1 indicated that she checks the resident's oxygen administration setting numerous times a shift and that she had checked Resident #8's and Resident #93's when her shift started. LPN #1 identified that Resident #8 was lying in bed wearing a nasal canula on and his/her oxygen administration was set at 2 liters per minute, but he/she lacked a physician's order for oxygen indicating she was used to Resident #8 using oxygen prior to his/her being hospitalized . LPN #1 indicated that she should have checked the clinical record to ensure there was a physician order to administer Resident #8's oxygen. LPN #1 could not identify why Resident #93's oxygen administration was set incorrectly at 5, and adjusted the setting to 3 liters per minute.Subsequent to surveyor inquiry, a physician order was obtained for Resident #8 directing to administer oxygen via nasal canula at one (1) to four (4) liters per minute.Interview with Registered Nurse (RN) #1 on 3/2/26 at 11:02 AM identified that oxygen administration should be set according to the physician's order and that it was the responsibility of the assigned nurse to ensure that it was set correctly. RN #1 could not identify why Resident #8 was receiving oxygen without a physician's order or why Resident #93's oxygen was set incorrectly. RN #1 indicated that he would conduct training with the facility nurses on oxygen administration.Interview with the Assistant Director of Nurses (ADNS) on 3/2/26 at 1:50 PM identified oxygen administration should be set according to the physician's order and that it was the responsibility of the unit nurse. The interview failed to identify why Resident #8 was receiving oxygen without a physician's order or why Resident #93's oxygen was set incorrectly.Review of the facility's Oxygen Administration Policy dated October 2010 directed, in part for staff to verify that there is a physician's order for oxygen administration. Additionally, the policy directed staff to set the oxygen level to 2 to 3 liters per minute unless ordered otherwise.

Based on observations, reviews of the clinical record, policy and interviews for the only sampled resident (Resident #1) reviewed for hemolytic treatment, the facility failed to ensure a physician ordered fluid restriction was maintained. The findings include:Resident #1's diagnoses included end stage renal disease, diabetes and dependence on renal hemolytic treatment.The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status score of 15 indicating intact cognition and required set up assistance for eating and bed mobility, partial moderate assistance with dressing and toileting, supervision with hygiene and transfers.The Resident Care plan dated 1/27/26 identified hemolytic treatment related to renal failure. Interventions included hemolytic treatment on Tuesday, Thursday and Saturday, left chest catheter site, left arm Arteriovenous (AV) site (new), diet as ordered, and fluid restriction as ordered.A physician's order dated 1/29/26 directed a fluid restriction of 1500 milliliters (ml) per day.Review of the meal intakes on the documentation survey reports and review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for January 2026, February 2026, and March 2026, failed to identify fluid intakes recorded for any meals, failed to document fluid intake amounts to be given, and failed to indicate that Resident #1 was to maintain a fluid restriction.Review of the quarterly Nutrition assessment dated [DATE] identified a 1500 ml fluid restriction but failed to indicate compliance with or any non-compliance of the fluid restriction or fluid intake. Review of the hemolytic treatment communication forms dated 2/10/26, 2/17/26 and 2/24/26, (the only forms in the hemolytic treatment binder), failed to indicate any concerns or inability to follow the fluid restriction.Interview and record review with the supervisor, Registered Nurse (RN) #1 on 3/2/26 at 11:10 AM failed to identify Resident #1 had fluid intake amounts being monitored or documentation for staff to maintain a 1500 ml fluid restriction. RN #1 indicated Resident #1's fluid restriction was not and has not been monitored according to the physician order dated 1/29/26.Subsequent to surveyor inquiry, a physician's order dated 3/2/26 at 11:10 AM directed a fluid restriction of 1500 ml daily, due to hemolytic treatment, that the 3:00 PM to 11:00 PM nurse was to total fluid intakes every 24 hours, and that Resident #1 was to receive 300 ml of fluid with each meal, and 600 ml of free fluid to be given by the nursing staff.Interview and clinical record review with the Assistant Director of Nursing Services (ADNS) on 3/2/26 at 11:17 AM identified that although there was a physician order, there should have been written indication on the MAR and TAR directing staff to maintain the 1500 ml fluid restriction and to document the intake amounts of fluid Resident #1 was taking. Additionally, meal intake percentages should have been documented in the task section of the medical record. The RN supervisor's for the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts were responsible for reviewing fluid restrictions. The ADNS was unable to indicate why Resident #1's fluid intake was not being monitored, or how unit nurses would know to monitor fluid intakes/restriction since the information was not included on the MAR, TAR, and meals intake noted in the task section of the electronic record.In an interview and clinical record review with Dietitian #1 on 3/2/26 at 12:30 PM, the clinical record failed to reflect documentation breaking down the fluid restriction into increments to be given, per meal, per shift, or that the nutrition notes indicated a fluid restriction or monitoring. Dietitian #1 indicated that she communicated with Dietitian #2 (hemolytic treatment dietitian) and could not explain why the fluid restriction was not being monitored or why she or the nurses had not broken down the fluid restriction per shift and per meal.Interview with Dietitian #2 (the hemolytic treatment dietitian) on 3/2/26 at 1:47 PM indicated according to her records, she had spoken to the Dietitian #1 prior to Resident #1's hospital return on 1/29/26 to initiate a fluid restriction of 1000 ml daily. She indicated she had spoken with RN #1 on 1/9/26 to reinforce Resident #1's renal restrictions with the dietary staff. Dietitian #2 spoke with a facility RN on 1/29/26 following Resident #1's readmission, who had indicated that Resident #1 was on a renal diet without fluid restriction with blood sugars ranging from 34 to 600 and Resident #1 was not eating well at meals and often asked for cookies. The fluid restriction of 1500 ml and carb-controlled diet was added to the diet order. On 2/10/26 the Dietitian #2 indicated Resident #1's weight was high and he/she was overloaded with fluid. Additionally, the Dietitian #2 spoke to RN #1 on 2/11/26 requesting a fluid restriction be reduced to 1000 ml and that RN #1 was to reinforce the fluid restriction. On 2/24/26 the Dietitian #2 indicated Resident #1 was heavy, over 1 kilogram (2.205 pounds) over the target weight and his/her treatment weight had to be adjusted. She further indicated that the ill effects of Resident #1 not following the fluid restriction could impact the heart long term, elevate blood pressures, cause difficulty breathing, and edema to the legs, feet, and face. Dietitian #2 reviewed with Dietitian #1 on 3/2/26 at 4:38 PM labs as well as the fluid status, target weight change, and reviewed the fluid restriction and intent for the facility to follow the 1000 ml restriction. Dietician #2 further indicated she spoke with RN #1 to confirm the 1000 ml fluid restriction.Interview with RN #3 (Corporate Nurse) on 3/2/26 at 3:08 PM identified that the clinical record failed to reflect documentation indicating a conversation with the hemolytic treatment dietitian on 1/29/26 or on 2/11/26 regarding the fluid restriction for Resident #1. RN #3 indicated she would expect documentation in a nurse's note identifying any changes in the fluid restriction, intake, and communication with the hemolytic treatment center and could not explain why the clinical record failed to reflect this.Interview with APRN #1 on 3/3/26 at 11:35 AM indicated if there was a physician's order for a fluid restriction, intake should be monitored and if the facility was unable to monitor the intake she would expect to be notified. APRN #1 indicated she was not notified of the fluid restriction not being monitored and if she had been notified, she would have contacted the conservator and the hemolytic treatment center.Review of the Encouraging or Restriction Fluids policy directed, in part, verify there is a physician's order, follow specific instruction concerning intake or restrictions, be accurate when recording fluid intake, record fluid intake on the intake side of the intake and output record, record fluid intake in milliliters, when resident has been placed on restricted fluids, remove water pitcher and cup from room. Be sure the intake and output record is maintained in the resident's room.Review of the Nutritional Assessment policy directed, in part, the dietitian estimates calorie, protein, nutrient and fluid needs.

Based on observations, interviews and policy review, the facility failed to ensure medications were stored according to professional standards and that controlled substance narcotic medications were double locked per the requirement. The findings include:Observation on 2/27/26 10:01 AM identified the South-Central medication cart containing a singly locked narcotic box was stored in the hallway parallel to the front door, across the front lobby without the benefit of being locked, and without the benefit of a nurse in view of the medication cart. Additionally in the lobby, the ADNS was noted to walk by, and 3 residents were seated there, as well as 2 housekeeping staff and the receptionist. At 10:03 AM 4 Residents were identified to walk past the medication cart, along with the Dietary Director and a rehabilitation staff member. At 10:06 AM an APRN passed by, and at 10:07 AM a resident passed by as well as a visitor entered the lobby. At 10:09 AM the scheduler, and an LPN walked past, followed by the psychiatric APRN and a resident, and at 10:10 AM 2 Nurse Aids also passed by.Observation and interview with Licensed Practical Nurse (LPN) #3 on 2/27/26 at 10:12 AM identified that she was the nurse assigned to the South-Central medication unit and cart. LPN #3 stated the facility policy directed medication carts be locked when unattended, at which point she locked the medication cart. Additionally, LPN #3 identified she was responsible for locking the cart when walking away but got busy and then went on break.Interview with Registered Nurse Supervisor (RN) #1 on 2/27/26 at 11:16 AM identified it was the facility policy to lock medication carts when unattended or in the case of an emergency another nurse could keep watch if he or she was right next to the medication cart. Additionally, RN #1 identified that although he was at the nearest nurses' station, no one had asked him to watch over the cart nor would it be appropriate for him to watch an unlocked medication cart for a nurse taking her break, adding it should have been locked.Review of the Storage of Medications Policy directed in part the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Additionally, compartments containing drugs and biologicals are locked when not in use and unlocked medication carts are not left unattended.The Controlled Substances Policy directed in part that the facility complies with all law, regulations, and other requirements related to handling, storage, disposal and documentation of controlled substances.

Based on interviews, review of clinical records, and policy for the only sampled resident, (Resident #10) reviewed for dental, the facility failed to follow up on a request for upper-level denture replacement for a resident with Medicaid insurance. The findings include:Resident #10's diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and hypertension.The admission minimum data set assessment dated [DATE] identified Resident #10 had a Brief Interview of Mental Status score of 7 indicating moderate cognitive impairment, was independent for oral hygiene, and required supervision/touching assistance for transfers.The Resident Care Plan dated 3/25/26 identified Resident #10 had dental concerns related to broken and missing teeth. Interventions included dental consultation and treatment.A nurse progress note dated 3/21/25 at 9:03 PM identified that Resident #10 had lost upper dentures at the last facility to which he/she was previously admitted . Additionally, the note identified that Resident #10 would like the missing upper dentures replaced.A dental examination note dated 7/1/25 identified that Resident #10 would like to have a full maxillary (upper teeth) denture made.Interview and clinical record review with the Central Supply/Medical Records Manager on 3/2/26 at 10:52 AM identified that she was responsible for scheduling dental appointments for residents. She indicated that after she received the visit summary from a dental appointment, she would give them to the nurses for review. Additionally, she indicated that she does not review the notes from the appointment and that she was unaware that Resident #10 had requested new upper dentures.Interview with the dental provider representative on 3/2/26 at 11:01 AM identified that Resident #10 was seen for a dental appointment on 7/1/25 and that after that appointment they did not put a request in for the dentures because their clinical record for Resident #10 identified that he/she was not insured. After reviewing the documentation, the facility sent to the dental office prior to the appointment on 7/1/25, Person #3 identified that it was a data entry error on their part as the paperwork sent by the facility identified Resident #10 had Medicaid insurance. the dental provider representative indicated that he/she would submit a new request to the insurance for upper dentures for Resident #10.Interview and clinical record review with the Assistant Director of Nursing (ADNS) on 3/2/26 at 1:50 PM identified that Resident #10 had requested new upper dentures when he/she was admitted to the facility on [DATE] and at a dental appointment on 7/1/25. The ADNS indicated that the facility failed to follow up on the request which led to Resident #10 not receiving a new set of upper dentures. Additionally, the ADNS indicated that the facility started a new process for following up with vendors to prevent the mistake from happening again. The ADNS identified that although multiple staff were involved with the process, it was the overall responsibility of the ADNS and Director of Nursing (DNS) to ensure that follow up services with vendors were completed.Review of the facility's Dental Consultant Policy dated April 2007 directed, in part to provide necessary information regarding residents to appropriate staff, care planning conferences and/or committees.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #11) reviewed for pressure ulcers, the facility failed to perform hand hygiene while performing a dressing change and after cleaning a glucometer. The findings include:1. Resident #11's diagnoses included severe protein calorie malnutrition, diabetes with neuropathy and retention of urine.The admission Minimum Data Set assessment dated [DATE] identified Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment and was totally dependent on staff for dressing, toileting, and bed mobility. Additionally, Resident #11 currently had a stage 4 pressure injury/ulcer and 2 unstageable pressure injuries. The Resident Care Plan dated 10/30/25 identified an actual impairment to skin integrity related to a deep tissue injury, unstageable left heel. Interventions included keeping skin clean and dry, offload wound, and provide a wound physician as needed.The Resident Care Plan dated 10/30/25 identified indwelling catheter recent history of urinary retention and placement of foley while in the hospital. Interventions included provide catheter care daily and as needed, observe and document pain or discomfort due to the catheter, change the drainage bag monthly and as needed.Observation and interview of Resident #11's dressing change with the ADNS on 2/27/26 at 8:30 AM identified that the ADNS applied gloves and cleansed the penis area with normal saline, removed her gloves and applied new gloves without the benefit of cleansing or sanitizing her hands. When performing Resident #11's left heel dressing, she removed her gloves, performed hand hygiene and applied new gloves. The ADNS then removed the old dressing from the left heel, removed the dirty gloves and was stopped prior to applying new gloves as she had not performed hand hygiene. The ADNS indicated that she should perform hand sanitizing with each glove removal and prior to placing new gloves. The ADNS sanitized her hands, placed on new gloves and completed Resident #11's dressing change.2. Observation and interview during cleansing of the glucose testing device with LPN #3 on 3/2/26 at 7:44 AM with LPN #3 identified she applied gloves without sanitizing her hands, cleansed the glucose testing device and reapplied gloves without performing hand hygiene. LPN #3 indicated that she was distracted with another resident and did not perform hand hygiene but should have. Subsequent to surveyor inquiry LPN # 3 went to the bathroom and washed her hands.Review of the policy handwashing, hand hygiene directed in part, use of alcohol based handrub containing at least 62% alcohol or alternatively soap and water for the following situations: before handling clean or soiled dressings, gauze pads etc., before moving from a contaminated body site to a clean body site, during resident care, after contact with blood or body fluids, after handling dressings or contaminated equipment, after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections.

Based on interviews during the Resident Council meeting, and review of facility policy, the facility failed to consistently deliver mail on Saturdays. The findings include: F565 - Harbor Village - DHBased on interviews, and review of facility policy reviewed for a concern discussed during resident council, the facility failed to consistently provide mail to residents on Saturdays. The findings include: A Resident Council meeting on 2/27/26 at 11:00 AM identified that residents were not consistently receiving their mail on Saturdays. It also identified that the residents were not aware that they were supposed to receive their mail each Saturday. Interview with the Recreation Director on 2/27/26 at 11:30 AM identified that he personally delivered mail to the residents when he worked on Saturdays but stated that he would follow up with his staff to instruct them to deliver mail to the residents on Saturdays. The Recreation Director identified that he never formally received a complaint from the residents that they were not getting their mail on Saturdays. The residents identified that they were unaware they were able to/supposed to be able to get their mail on Saturdays. A review of the facility policy for mail, in part directed that residents' mail and packages will be delivered within twenty-four hours of delivery on premises or to the facility's post office box (including Saturday deliveries). Facility [NAME], [NAME] (53085) - Resident Council 03/03/2026 3:39 PM - facility failed to provide mail services consistently on Saturdays to residents. F576 Facility failed to provide privacy for residents during Resident council meetings.

Based on observations, interviews, and review of policy, the facility failed to ensure access to state survey results. The findings include:A Resident Council meeting on 2/27/26 at 11:00 AM identified that residents did not know where the previous state survey results were located or that it was their right to be able to review the results. Residents stated they would have reviewed previous state survey results had they known where the results were located.Observation on 2/27/26 at 12:43 PM of the facility entrance lobby failed to identify the previous state survey results.Observation and interview with the Administrator on 2/27/26 at 12:48 PM identified that the previous state survey results were in the main lobby, in a wall file holder approximately 4 feet off the ground, behind an artificial tree, not visible to the residents or visitors. The Administrator identified an artificial tree that was obscuring the state survey results binder. She subsequently moved the artificial tree to make the survey results visible. Additionally, she indicated that she was unaware that the residents were allowed access state survey results, would ensure the state survey results were in an area easily accessible to residents and visitors, and would let residents and staff know where the state survey results were located.Observation and Interview with the Administrator on 3/2/26 at 12:38 PM identified that no change to the area or visibility of the state survey results had occurred and that the artificial tree continued to block the area. The Administrator indicated that she did not know why the artificial tree was placed back in the same are again inhibiting view and accessibility of the state survey results. Additionally, the Administrator indicated she would move the state survey results to a more accessible location and inform the residents and staff of that location. Subsequent to surveyor inquiry, the Administrator moved the state survey results to the facility main lobby desk and placed a label indicating the previous state survey results location.Review of the facilities Resident Rights policy dated 10/26/22 directed in part that federal and state laws guarantee certain basic rights to all residents of the facility. Additionally, it identified that the rights included the residents' right to examine survey results.

Based on a review of clinical records, reportable events, staff interviews and policy review for one of three sampled residents identified to be at risk for elopement (Resident #1), the facility failed to provide the necessary supervision to protect the resident who subsequently left the building without the knowledge of staff and was found by the police on a busy street more than one quarter mile from the nursing home. The facility further failed to ensure that the resident's location in the building was monitored every fifteen minutes in accordance with the physician's orders and also failed to ensure that an outdoor search was immediately initiated when a wanderguard door alarm and exterior door alarm sounded or that the necessary procedure was implemented to determine if a resident was missing, resulting in a finding of immediate jeopardy. Immediate jeopardy was abated on 6/5/20 when the facility implemented an action plan to mitigate risk which was verified on 6/6/20. The finding includes: Resident #1 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] indicated the resident was independent with activities of daily living (ADL), ambulated independently and was not at risk for elopement. An admission history and physical dated 5/27/20 identified that the resident had been hospitalized after experiencing a [MEDICAL CONDITION] indicated the hospitalization was complicated by the resident's impulsive behaviors and frequent falls. The admission history and physical further identified that during the hospital stay the patient was seen by psychiatry due to the behaviors and was started on [MEDICATION NAME] 250 milligrams every eight hours and [MEDICATION NAME] 0.5 milligrams twice daily. The note further identified the resident's mood and affect were stable. Review of a psychiatry note dated 5/28/20 identified the resident's judgment, insight, mood and affect were impaired. The note identified the resident demonstrated impulsivity and disorganization, had no evidence of [MEDICAL CONDITION] and indicated that [MEDICATION NAME] would be discontinued with Trazadone 25 milligrams started every six (6) hours as needed for anxiety and agitation. A physician's progress note dated 5/29/20 indicated the resident continued to be impulsive and would be followed by psychiatry services. On 6/3/20 at 2:49 PM a nurse's note identified that the resident was upset and had attempted to leave through a back door. The note indicated that an elopement evaluation had been completed, and the resident was provided with a wanderguard device on the right wrist. A subsequent nurse's note dated 6/3/20 at 9:25 PM identified that the resident persisted in attempting to exit the building, and the wanderguard device was in place and active. The nurse's note further indicated that the resident had been moved to a room closer to the nurse's station and was placed on every fifteen minute checks. Review of a reportable event dated 6/5/20 at 6:45 PM identified Resident #1 had eloped from the facility. The documentation indicated that the resident was last seen at approximately 6:30 PM when Nurse Aide #3 provided assistance to the resident. The report identified that when alarms sounded on an outside door at 6:40 PM, the charge nurse (Licensed Practical Nurse #1) instructed Nurse Aide #1 to check the doors as the nurse was leaving for a meal break. The report further noted that LPN #1 received a call from the police station at 6:55 PM on 6/5/20 indicating that Resident #1 had been observed on a main street approximately one quarter mile from the facility. The resident was subsequently returned to the nursing home by emergency medical services on 6/5/20 between 7:15 PM and 7:20 PM. On 6/5/20 at 11:48 PM a nurse's note which was written by Nursing Supervisor #2 identified that at approximately 6:45 PM the facility had received a call from the local police department reporting that the resident had been found by the police. The note indicated that after returning to the nursing home, the resident was assessed and found without injuries. The note further identified the physician had been informed and directed the facility to provide the resident with one-to-one supervision until an evaluation was performed by psychiatry services. Although a monitoring tool that was initiated on 6/3/20 due to Resident #1's exit seeking behaviors identified that the resident's location and activity were to be checked every fifteen minutes, documentation failed to identify that any checks had been completed regarding the resident's location or activity on 6/5/20 from 3:15 PM to 6:45 PM when the resident was located by the police. Another monitoring sheet which was completed by the charge nurse indicated that Resident #1 was in his/her room on 6/5/20 throughout the period from 6:00 PM through 8:00 PM. Interview with the Director of Nursing (DON) on 6/6/20 at 10:10 AM identified she had received a call from the evening supervisor on 6/5/20 stating that Resident #1 had eloped and was found a distance away from the facility. The DON stated LPN #1 reported that when the door alarm sounded on 6/5/20 at approximately 6:40 PM, she was starting to leave for a meal break and instructed Nurse Aide #1 to check the door. The DON stated NA #1 was assigned to Resident #1 for the 3:00 PM to 11:00 PM shift on 6/5/20. The DON indicated NA #1 told her that she went to the doors, heard both the wanderguard alarm and an alarm on the exterior doors sounding and shut off the alarms. NA #1 further relayed when she saw that the outside door was ajar, she closed the door and returned to work without informing the nurse about her observations. Interview with NA #1 on 6/6/20 at 11:45 AM indicated that when she reached the two sets of doors where the alarms were sounding, she did not know the wanderguard alarm was sounding, and she entered a code to deactivate the alarm. NA #1 further stated that after continuing to hear an alarm, she saw the outside exterior door was ajar, looked outside without seeing anyone, closed the door and turned off the alarm, returning to work. NA #1 stated that she had received education regarding how to respond if the wanderguard system and the exterior door alarms sounded although she did not provide an explanation about why she had failed to inform the charge nurse or supervisor that she had not seen anyone when she looked outside after turning off the alarms. NA #1 stated that she was not familiar with Resident #1. NA #1 indicated that when she arrived on the floor to report for duty after the start of the shift, she did not ask a nurse about the needs of Resident #1 and could not recall that anyone provided information to her regarding the resident. NA #1 indicated she did not know the resident required every fifteen minute monitoring. Interview with LPN #1 on 6/6/20 at 12:00 Noon indicated that when she was starting to leave for a meal break on 6/5/20 at approximately 6:40 PM, an alarm on a back door sounded. LPN#1 stated that she directed NA #1 to check the door, and the alarm subsequently stopped sounding. LPN #1 further stated that while she remained on the break, the police called to report that a resident who was wearing a johnny coat and gripper socks had been found wandering on a main street which was a distance from the facility. LPN #1 indicated that when the door alarm was sounding, she did not consider the need to check to see if all residents could be located as staff have often gone through the rear door. LPN #1 noted that she had last seen Resident #1 at approximately 6:15 PM before leaving for a break. LPN #1 further identified that the resident required every fifteen minute checks, and both the nurse and nurse aide are responsible to check on the resident every fifteen minutes and document the checks on the resident monitoring tools. LPN #1 stated that she signed the resident monitoring tool ahead of time because the resident had been in his/her room when she made observations. Interview with the Director of Maintenance on 6/8/20 at 12:30 PM identified that during all staff orientation and annually, staff are educated on the wanderguard system and the exterior door alarms. The Maintenance Director stated that if an alarm sounds, staff are directed to check the area and if no one is observed, staff are expected to immediately report the incident to the nursing supervisor. Interview with RN Supervisor #2 on 6/8/20 at 12:35 PM identified that at the start of the shift on 6/5/20 she went to Resident #1's unit and gave report to all staff including LPN #1 and NA #1 regarding the resident's risk for elopement, the need for every fifteen minute checks as well as instructions to keep an eye on the resident. RN Supervisor #2 stated that when Resident #1 returned, he/she was dressed in a johnny and pants and was wearing gripper socks. She identified that she assessed the resident to have no injuries, notified the physician and placed the resident on one to one supervision. RN Supervisor #2 stated that after the incident, she spoke to staff and was told the wanderguard and door alarms had sounded earlier and had been turned off by NA #1 who did not inform her that the alarm was sounding. RN Supervisor #2 stated that if she had known about the incident, she would have immediately conducted a census count to ensure all residents were located. Interview with NA #2 on 6/8/20 at 2:05 PM indicated that NA #1, who was assigned to Resident #1 during the second shift on 6/5/20, would be responsible for conducting every fifteen minute checks. NA # 2 stated that the last time she saw the resident was at approximately 6:00 PM on 6/5/20 when she retrieved Resident #1's dinner tray. Interview with NA #3 on 6/8/20 at 2:30 PM indicated she last saw the resident around 6:30 PM on 6/5/20 as she walked by the resident's room and noticed that water had spilled on the resident. NA # 3 stated that she helped the resident change the pants and left the room afterward. Interview with the Director of Nursing on 6/8/20 at 1:00 PM identified that if door alarms sound, staff are to respond to the alarm, check the area for residents and if the staff do not see anyone, they are expected to report to the nurse immediately so that the supervisor can be made aware and a head count can be completed. The DON stated if a resident is not accounted for, a search would be started to locate the resident. Review of facility documentation dated 6/5/20 with the Director of Nursing on 6/8/20 identified that staff education was initiated during the evening of 6/5/20 and included the procedure for responding to door alarms as well as door security, all residents identified to be at risk for elopement/wandering were assessed for wanderguard placement and functioning, and all facility door alarms and wander guard alarms were tested for function. All staff were educated prior to working their next shift. Review of the facility policy entitled, Door Security, identified that it is the facility's standard to minimize safety risks to residents through the use of specialty alarms and locking devices on each nursing exit door. The policy identified that it is everyone's responsiblity to respond immediately to door alarms, and it is necessary for an incident that relates to an elopement to be reported immediately to a nursing supervisor. Although the facility was unable to provide a policy regarding the use of the resident monitoring tools, the Director of Nursing stated that the assigned nurse aide is responsible for conducting and documenting every fifteen minutes checks, and the charge nurse is responsible for ensuring that the monitoring of the resident is completed.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #4) who had acknowledged Full Cardio-Pulmonary Resuscitation (CPR) in the Advanced Directive and physician's order, the facility failed to initiate CPR when the resident was noted without a pulse and respirations. The findings include: Resident #4's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no memory or cognitive deficits and was able to make needs known to the staff. The Decree/Appointment of Conservatorship identified a Conservator of Person was appointed for Resident #4 back on (MONTH) 15, 2013. The Do Not Resuscitate Consent Form that was not signed and/or dated directed Full Code. A physician's order dated [DATE] directed Resident #4 was a Full Code. The nurse's note dated [DATE] written at 10:49 PM identified a nurse aide went into Resident #4's room to drain the foley bag, noticed the resident did not look good and the ,[DATE]PM Nursing Supervisor, Registered Nurse (RN) #3, was notified. The note indicated when RN #3 assessed the resident, Resident #4 was noted to have no heartbeat and/or respirations, CPR was started, Emergency Medical Services (EMS) was called, CPR commenced for five (5) minutes until EMS arrived and took over and then EMS transported Resident #4 to the hospital. The Emergency Department (ED) evaluation dated [DATE] identified Resident #4 was asystole, without a heartbeat when EMS arrived at the facility, CPR continued for approximately twenty (20) minutes that included the administration of three (3) doses of [MEDICATION NAME] and the resident was noted to have coffee ground emesis. The note indicated Resident #4 remained asystole on arrival to the ED at 10:48 PM. The ED note identified CPR continued with an additional fourth dose of [MEDICATION NAME], there was no response, the resident remained asystole and was pronounced deceased at 10:53 PM. The Reportable Event Form dated [DATE] identified on [DATE] Resident #4 was found at 10:07 PM without a pulse and/or respirations and there was a delay in initiating CPR. The report identified Resident #4 was last seen thirty (30) minutes prior to the event. The investigation identified a ,[DATE]PM nurse aide, Nurse Aide (NA) #5, went into Resident #4's room to empty the foley bag and she observed Resident #4 to be pale and gray and immediately notified the unit nurse, Licensed Practical Nurse (LPN) #6. The summary identified LPN #6 went into Resident #4's room, told NA #6 to call the Nursing Supervisor, and RN #3 came immediately. The summary identified RN #3 assessed the resident to be without a pulse and Resident #4 was not breathing. The investigation identified RN #3 initially believed Resident #4 was a Do Not Resuscitate (DNR), so she proceeded to leave the room to notify the Conservator and Medical Director and it was at that time she realized Resident #4 was a Full Code. The summary identified CPR was initiated and EMS called. Even though the nurse's note indicated CPR was started when RN #3 had assessed the resident, the investigation demonstrated that there was approximately a five (5) to ten (10) minute lapse before CPR was initiated. The investigation's conclusion identified the unit nurse, LPN #6, returned to work with disciplinary action and education and the Nursing Supervisor, RN #3, was terminated regarding the delay in the initiation of CPR. Interview with LPN #6 on [DATE] at 10:50 AM identified that he/she did not initiate CPR until after the resident was assessed by RN #3 and RN #3 had checked the clinical record. LPN #6 stated after RN #3 realized Resident #4 was a Full Code he/she went to gather the crash cart. LPN #6 indicated that he/she could not clearly recall the specifics of the incident. LPN #6 identified a back board was not utilized during the CPR because RN #3 believed the bed was a hard enough surface. Interview with RN #3 on [DATE] at 11:15 AM identified that she recalled assessing Resident #4 on [DATE] on the ,[DATE] PM shift some time after 9:30 PM and Resident #4 had no pulse and/or respirations. RN #3 stated she did not initially review Resident #4's code status and believed the resident had a DNR order in error. RN #3 indicated she left Resident #4's room, called the resident's conservator to inform the conservator of Resident #4's death. RN #3 stated after she completed the phone call she noted that Resident #4 was a Full Code and approximately five (5) to seven (7) minutes had lapsed before she started CPR. RN #3 identified that she thought the mattress had a CPR mode and felt when it was initiated the bed was hard enough. A review of the bed's manufacturer's manual indicated that the bed should be put in the firmest comfort level with a crash board under the mattress in order to meet the standard for life support recommended by the American Heart Association in the setting of CPR. Interview and review of the facility policy with the Director of Nursing (DON) on [DATE] at 1:50 PM, the DON identified that each nursing unit has a list of the residents and their code status on a clip board for emergency incidences. The DON stated the staff is expected to review the code status of a resident if they are found unresponsive and not breathing and should initiate CPR immediately.

Based on clinical record reviews, review of facility documentation, and interviews for one of two sampled residents (Resident #5) who were reviewed for medication administration, the facility failed to administer insulin to the correct resident to prevent a significant medication error. The findings include: Resident #5's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had no short and long term memory, was able to make reasonable decisions regarding tasks of daily living, utilized a wheelchair for mobility and was independent with moving about in the wheelchair. The Resident Care Plan dated 9/20/18 identified Resident #5 had diabetes mellitus. Interventions directed blood glucose monitoring as ordered and for blood sugars less than 70, administer [MEDICATION NAME], recheck the blood sugar in fifteen (15) minutes and notify the physician, to administer insulin as ordered, and to monitor for signs and/or symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. A (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The nurse's note dated 11/29/18 identified that at 5:10 PM Resident #5 was seen being assisted in the wheelchair, the blood sugar result was 110, and there was no diaphoresis or shortness of breath. The note indicated at 7:00 PM Resident #5's blood sugar was 69, Glucogon 1 milligram (mg) was administered intramuscularly and the blood sugar result was up to 84 and then 113 at 8:00 PM. The note identified the physician was notified and directed to monitor the resident's vital signs, frequent blood sugar testing and to obtain blood work in the morning. Review of the clinical record identified Resident #5's blood sugars were monitored every thirty (30) minutes from 8:00 PM to 10:00 PM and ranged between 96 and 117. The nurse's note dated 11/29/18 identified at 10:30 PM Resident #5's blood sugar was 78, Insta-glucose, a rapidly absorbed gel that contains twenty-four (24) Grams of carbohydrate for diabetic emergencies, was administered at 11:00 PM, the blood sugar was 62, Insta-glucose was administered again and a recheck at 11:20 PM identified the resident's blood sugars were 50 and 43. The note indicated at this time Resident #5 became drowsy and was nauseous, the physician was notified and Resident #5 was transferred to the Emergency Department for an evaluation. The Emergency Department (ED) note dated 11/30/18 identified Resident #5 presented to the ED complaining of being given an extra dose of insulin. The note identified a [DIAGNOSES REDACTED]. The nurse's note dated 11/30/18 at 12:45 PM identified Resident #5 returned to the facility at 7:15 AM, the vital signs were stable and a blood sugar of 83 was noted. The note indicated the physician was in and examined the resident. A physician's orders [REDACTED]. The Reportable Event Form dated 11/29/18 identified that at 5:10 PM Resident #5 received a fast-acting insulin, [MEDICATION NAME] 20 units in error. The investigation identified that the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #4, asked Resident #5 to validate her/his name, and although she checked the resident's identification band she failed to validate Resident #5's full name to include first name prior to administering the medications. The summary identified the medications were due to be given to another Resident #6 who had been transferred over to the Center wing from the North wing on 11/29/18 The summary identified Resident #6 had the same last name as Resident #5. The investigation identified LPN #4 became aware of the error when she went to the North wing and during a conversation realized she had given the wrong resident the medication and she immediately informed the Nursing Supervisor. In an interview and review of the clinical record and facility documentation on 12/19/18 at 12:50 PM, LPN #4 identified that Resident #5 was a new resident to her. LPN #4 stated when she checked Resident #5's identification band, the band was turned around so she only saw Resident #5's last and she failed to verify the resident's first name prior to administering the insulin. LPN #4 stated Resident #5 and Resident #6 have the same last name. In an interview and review of the clinical record and facility documentation on 12/19/18 at 1:15 with the Director of Nursing (DON) identified that LPN #4 was provided with education and competency evaluation regarding medication administration. The DON stated there have been no other medication errors since this incident. The Facility Policy identified that the nurse administering medications must verify the resident's identity before giving medication. Methods include; checking the identification band, checking photographs in the medical record, and/or verify the resident's identity with another staff member. The medication labels must be checked three times to ensure the five rights of medication administration. Subsequent to the incident, the facility developed and implemented a plan of correction on 11/30/18 and review of the facility's documentation identified the facility was in compliance on 12/5/18 and no further incidences had occurred from 12/5/18 through 12/19/18. The plan of correction was reviewed: -The resident was sent to the hospital and returned without any treatment. -House audits were conducted on all residents for identification bands and pictures and if missing were replaced. -Glucometers were checked for accuracy. -All licensed staff were provided education on medication administration, glucometer checks, and identification of residents. Medication administration competencies to be conducted on all licensed staff -Name alert stickers were placed on medication administration records and medical records. -Random audits for identification bands will be conducted weekly for four (4) weeks and then monthly and the findings will be brought to Quality Assurance Committee. - The Director of Nursing will monitor for compliance.

Based on clinical record review, facility documentation and staff interview for 2 of 3 sampled residents reviewed for medication errors, (Resident # 1 and Resident # 4) the facility failed to ensure the residents were administered their prescribed medications by RN #1 which resulted in immediate jeopardy and was corrected prior to the course of the investigation. The findings include: 1. Resident # 1's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident as alert and oriented, independent with ADL's, continent of bowel and bladder and receiving diuretics for the past 7 days. The RCP dated 6/22/17 identified the resident with a cardiovascular problem related to [DIAGNOSES REDACTED]. Interventions included administer medication as ordered, administer oxygen as ordered, and monitor for presence of [MEDICAL CONDITION]. Facility documentation dated 8/1/17 at 10:00AM identified Resident # 1 was administered Resident # 5's medications: [REDACTED]. The documentation further identified that RN # 1 prepared Resident # 1's medications, but the resident was unavailable, RN # 1 labeled the medication cup and started preparing Resident # 5's medications, but the resident walked away. The nurse then saw Resident # 1 coming down the hallway and gave the resident the medications that were in her hand. The documentation further identified that after she administered medications to Resident # 1 she saw that the pills she still had belonged to Resident # 1 and realized she had just given Resident # 5's medications to Resident # 1 in error. physician progress notes [REDACTED].#1 was asked to see Resident #1 related to being administered the wrong medications. The note identified the resident's neuro/vital signs were being monitored every 1 hour times 4 hours then every 2 hours for 4 hours then every shift. Review of the Vitals Summary dated 8/1/17 identified the residents blood pressure at 11:51AM was 120/90mmHg, (baseline 106/77-164/95 in the previous 2 months) at 12:00 PM 86/68 mmHg, at 1:00PM it was 80/56 mmHg, at 2:00PM it was 80/62 mmHg, at 4:00PM it was 60/42 mmHg, at 4:30PM it was 68/46 mmHg, at 5:00PM the blood pressure was 72/44 mmHg, at 5:30PM it was 70/50 mmHg and at 6:16PM the residents blood pressure was 64/40 mmHg. Nurse's Notes dated 8/1/17 at 8:38PM identified the resident had increasing [MEDICAL CONDITION] with a blood pressure of 60/42 at 4:00PM. The physician was updated and an IV was started at that time of Normal Saline at 200cc/hr. times 2 hours. The resident's blood pressure at 4:30PM was 68/46 and at 5:00pm the blood pressure was 70/50 and at 6:00PM the blood pressure was 64/40mmHg. The note identified the resident was alert and oriented but drowsy and tired. The resident's lung sounds were diminished and expiratory wheezing and mild upper airway congestion was heard. Additionally the resident was frequently incontinent of large amounts of urine and liquid stool since receiving the wrong medications. The physician was again updated and directed to decrease the IV to 100cc/hr. and to send the resident to the ER for an evaluation. physician progress notes [REDACTED]. The note further identified the resident was transferred to the hospital for closer monitoring. Review of the hospital history and physical dated 8/1/17 identified the resident was admitted with [MEDICAL CONDITION] and diarrhea related to receiving the wrong medications. The note identified that the facility had been monitoring the resident's blood pressure and around 3:00PM, it was noted to be hypotensive in the 60's over 40's. The patient complained of feeling weak and tired. The patient on arrival to the ED was having large amounts of diarrhea, most likely caused from the administration of [MEDICATION NAME]. The patient has a history of [MEDICAL CONDITION] and wass carefully bolused with IV fluids and the blood pressure was responding appropriately in the 90's systolically. Additionally the resident was noted with acute [MEDICAL CONDITION] which is possibly due to the medication error and the diarrhea. Additionally, the hospital paperwork identified the resident remained obtunded but arousable, audible wheezing, incontinent of urine, hypotensive throughout the day and received [MEDICATION NAME] (medication to treat low blood pressure). The resident was transferred to the ICU for closer observation. Interview with MD # 1 on 11/16/17 at 1:50PM stated that she was in the building and was made aware of the medication error on Resident # 1. MD # 1 stated that she went and assessed the resident and directed to hold the residents [MEDICATION NAME] 20mg, [MEDICATION NAME] 50mg and to monitor the residents blood pressure every hour for 4 hours, then every 2 hours for 4 hours and to do neuro checks. MD # 1 stated that the resident was fine until approximately 4:00PM when his/her blood pressure started to decline and was noted at 60/40 mmHg. The MD stated that at that time she started an IV of NS at 200ml/hr. times 2 hours and ordered every half hour monitoring. MD # 1 stated she decided to transfer the resident to the hospital for closer monitoring of the resident. Interview with RN # 2 (RNS) stated that she was made aware of the medication error with Resident # 1 when RN # 1 called her. RN # 1 stated she went and assessed the resident and notified the physician at that time who was in the building. RN # 2 stated that the physician assessed the resident and directed to monitor the resident's blood pressure. RN # 2 further stated that she re-educated the nurse on the 5 rights of administration after the incident. Interview with RN # 1 on 11/16/17 at 4:30PM stated that she poured Resident # 1's medications, but the resident was not available so she put them in the drawer of the medication cart. RN # 1 stated that she then went to administer Resident # 5's medications but that resident was also not available, she saw Resident # 1 coming down the hall, and administered the medications that where in her hand. RN # 1 stated that after she gave Resident # 1 the medication she realized that she had given Resident # 5's medication to Resident # 1. RN # 1 further stated that she was aware if a resident is not available for medications and they are poured she is to dispose of them and not label and place them in the medication cart. RN # 1 stated that it was a busy morning and that she did not want to have to re-pour the medications so she labeled them and put them aside. Interview with the DON on 11/16/17 5:00PM stated that when the nurse identified the resident wasn't available for medications the nurse should have discarded the medications and re-poured them when the resident was available. The DON further stated that after the incident the nurse (RN #1) was re-educated regarding the 5 rights of medications, observed by the facility pharmacist during a medication pass, and was re-oriented with facility staff. RN #1 failed to ensure that he/she followed the 5 rights of safe medication administration resulting in a significant medication error. 2. Resident # 4's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, independent with eating, as having Diabetes Mellitus and on a therapeutic diet. The RCP dated 6/22/17 identified the resident with Diabetes Mellitus. Interventions included blood glucose monitoring as ordered, routine insulin as ordered, and monitor for symptoms of hypo/[MEDICAL CONDITION]. Physician orders dated 7/2/17 directed to administer [MEDICATION NAME] 100units/ml via Flex pen, inject 14 units subcutaneously at breakfast (short acting insulin), administer 6 units subcutaneously at lunch (short acting insulin) and to administer Toujeo [MEDICATION NAME] 30units at 4:00PM (long acting insulin). Facility documentation dated 8/1/17 at 8:00AM identified Resident # 4 received the following medications in error: 14 units of Toujeo at 8:00AM and 6 units of Toujeo at 12:00PM. The documentation identified the resident was assessed, the physician was made aware, directed to monitor the residents blood sugars every 2 hours until 6:30AM on 8/2/17, then continue twice a day. Hold Toujeo 30 units at 4:00PM and to hold [MEDICATION NAME] units at 5:00PM. Further review of the facility documentation identified that when the second shift nurse went to administer the residents [MEDICATION NAME] at 5:00PM she could not locate it and asked the day shift nurse where the flex pen was located. RN # 1 went to the medication cart and picked up the residents Toujeo flex pen and realized she had administered Toujeo to Resident #4 at 8:00AM and 12:00PM instead of the prescribed [MEDICATION NAME]. Review of the Vitals Summary for 8/1/17 noted the resident's blood sugar was between 109mg/dl to 224mg/dl (baseline blood sugars range from 90mg/dl - 236mg/dl over past 2 months). Interview with MD # 1 on 11/16/17 at 1:50PM stated she was made aware of the medication error with the Toujeo, assessed the resident, directed to monitor the resident's blood sugars and to hold the Toujeo and [MEDICATION NAME] until re-evaluated on 8/2/17. Interview with LPN # 1 on 11/16/17 at 2:55PM stated that she went to administer Resident # 4's 5:00PM [MEDICATION NAME] and could not find the flex pen. LPN # 1 stated that she knew RN # 1 was still in the building so she asked her where the [MEDICATION NAME] pen was and RN # 1 went to the medication cart and picked up the flex pen for the residents Toujeo. LPN # 1 stated that she reported this to the Supervisor and physician right away and was directed to hold the residents Toujeo and [MEDICATION NAME] until 8/2/17, monitor the resident's blood sugars every 2 hours and monitor for symptoms of hypo/[MEDICAL CONDITION]. Interview with RN # 3 on 11/16/17 at 3:30PM stated that RN # 1 came to him in the evening and stated that she administered the wrong insulin to Resident #4 at both 8:00AM and 12:00PM. RN # 3 stated that he went and assessed the resident and reported to the MD who directed to hold Toujeo and [MEDICATION NAME] until 8/2/17 and to monitor the residents blood sugars. RN # 3 stated that he re-educated the nurse (RN #1) on the 5 rights of medication administration. Interview with RN # 1 on 11/16/17 at 4:40PM stated that she realized she administered Toujeo flex pen at 8:00am and 12;00PM when the 3-11 nurse came to her looking for the [MEDICATION NAME] flex pen. RN # 1 stated that she did not realize the Toujeo was also in a flex pen and that she did not read the label when she picked the pen up, and just assumed it was the [MEDICATION NAME] in a flex pen. RN # 1 stated that when she took the flex pen that she thought was [MEDICATION NAME] she felt things looked different and did not recall Resident #4 having a Flex pen for the [MEDICATION NAME] but did not ask anyone to verify the medication because she was busy and had a lot to do. RN # 1 stated that she failed to follow the 5 rights of medication administration: time, person, medication, dose and route. Review of the facility Policy and Procedure for medication administration identified the individual administering the medications must verify the residents identity before giving the resident his/her medications by checking the name band, photograph or verifying the identity with another staff personnel. Additionally the policy states that the individual must check the label 3 times to ensure the right medication, right dose, time, method before giving the medication, and all insulin pens will be clearly labeled with the residents name. RN #1 failed to ensure that he/she followed the 5 rights of safe medication administration resulting in a significant medication error. Interview with the DON on 11/16/17 at 2PM stated that subsequent to the medication errors RN # 1 made on both Resident # 1 and Resident # 4, RN #1 was re-educated on the facility's policy regarding medication administration including the 5 rights of medication administration. The RN was removed from the charge nurse position and re-oriented with a staff nurse for 3 weeks after the incident and the facility's pharmacist oversaw a medication pass with RN #1. Additionally, all staff was provided re-education regarding the 5 rights of medication after the 8/1/17 incident. The Immediate Jeopardy was verified as corrected as of 8/2/17 while on-site during the course of this investigation.

Based on clinical record review, facility documentation and staff interview for 3 of 3 sampled residents reviewed for medication errors, (Resident # 1, Resident # 4 and Resident # 6) the facility failed to ensure standards of practice were followed regarding medication transcription and/or administration according to physician orders. The findings include: 1. Resident # 1's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident as alert and oriented, independent with ADL's, continent of bowel and bladder and receiving diuretics for the past 7 days. The RCP dated 6/22/17 identified the resident with a cardiovascular problem related to [DIAGNOSES REDACTED]. Interventions included administer medication as ordered, administer oxygen as ordered, and monitor for presence of [MEDICAL CONDITION]. Facility documentation dated 8/1/17 at 10:00 AM identified Resident # 1 was administered Resident # 5's medications: [REDACTED]. The documentation further identified that RN # 1 prepared Resident # 1's medications, but the resident was unavailable, RN # 1 labeled the medication cup and started preparing Resident # 5's medications, but the resident walked away. The nurse then saw Resident # 1 coming down the hallway and gave the resident the medications that were in her hand. The documentation further identified that after she administered medications to Resident # 1 she saw that the pills she still had belonged to Resident # 1 and realized she had just given Resident # 5's medications to Resident # 1 in error. physician progress notes [REDACTED].#1 was asked to see Resident #1 related to being administered the wrong medications. The note identified the resident's neuro/vital signs were being monitored every 1 hour times 4 hours then every 2 hours for 4 hours then every shift. Review of the Vitals Summary dated 8/1/17 identified the residents blood pressure at 11:51 AM was 120/90 mmHg, (baseline 106/77-164/95 in the previous 2 months) at 12:00 PM 86/68 mmHg, at 1:00 PM it was 80/56 mmHg, at 2:00 PM it was 80/62 mmHg, at 4:00 PM it was 60/42 mmHg, at 4:30 PM it was 68/46 mmHg, at 5:00 PM the blood pressure was 72/44 mmHg, at 5:30 PM it was 70/50 mmHg and at 6:16 PM the residents blood pressure was 64/40 mmHg. Nurse's Notes dated 8/1/17 at 8:38 PM identified the resident had increasing [MEDICAL CONDITION] with a blood pressure of 60/42 at 4:00 PM. The physician was updated and an IV was started at that time of Normal Saline at 200 cc/hr. times 2 hours. The resident's blood pressure at 4:30 PM was 68/46 and at 5:00 PM the blood pressure was 70/50 and at 6:00 PM the blood pressure was 64/40 mmHg. The note identified the resident was alert and oriented but drowsy and tired. The resident's lung sounds were diminished and expiratory wheezing and mild upper airway congestion was heard. Additionally the resident was frequently incontinent of large amounts of urine and liquid stool since receiving the wrong medications. The physician was again updated and directed to decrease the IV to 100 cc/hr. and to send the resident to the ER for an evaluation. physician progress notes [REDACTED]. The note further identified the resident was transferred to the hospital for closer monitoring. Review of the hospital history and physical dated 8/1/17 identified the resident was admitted with [MEDICAL CONDITION] and diarrhea related to receiving the wrong medications. The note identified that the facility had been monitoring the resident's blood pressure and around 3:00 PM, it was noted to be hypotensive in the 60's over 40's. The patient complained of feeling weak and tired. The patient on arrival to the ED was having large amounts of diarrhea, most likely caused from the administration of [MEDICATION NAME]. The patient has a history of [MEDICAL CONDITION] and was carefully bolused with IV fluids and the blood pressure was responding appropriately in the 90's systolically. Additionally the resident was noted with acute [MEDICAL CONDITION] which is possibly due to the medication error and the diarrhea. Additionally, the hospital paperwork identified the resident remained obtunded but arousable, audible wheezing, incontinent of urine, hypotensive throughout the day and received [MEDICATION NAME] (medication to treat low blood pressure). The resident was transferred to the ICU for closer observation. Interview with RN # 2 (RNS) stated that she was made aware of the medication error with Resident # 1 when RN # 1 called her. RN # 1 stated she went and assessed the resident and notified the physician at that time who was in the building. RN # 2 stated that the physician assessed the resident and directed to monitor the resident's blood pressure. RN # 2 further stated that she re-educated the nurse on the 5 rights of administration after the incident. Interview with RN # 1 on 11/16/17 at 4:30 PM stated that she poured Resident # 1's medications, but the resident was not available so she put them in the drawer of the medication cart. RN # 1 stated that she then went to administer Resident # 5's medications but that resident was also not available, she saw Resident # 1 coming down the hall, and administered the medications that where in her hand. RN # 1 stated that after she gave Resident # 1 the medication she realized that she had given Resident # 5's medication to Resident # 1. RN # 1 further stated that she was aware if a resident is not available for medications and they are poured she is to dispose of them and not label and place them in the medication cart. RN # 1 stated that it was a busy morning and that she did not want to have to re-pour the medications so she labeled them and put them aside. Interview with the DON on 11/16/17 5:00 PM stated that when the nurse identified the resident wasn't available for medications the nurse should have discarded the medications and re-poured them when the resident was available. The DON further stated that after the incident the nurse (RN #1) was re-educated regarding the 5 rights of medications, observed by the facility pharmacist during a medication pass, and was re-oriented with facility staff. RN #1 failed to ensure that he/she followed the 5 rights of safe medication administration resulting in a significant medication error. 2. Resident # 4's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified the resident with moderately impaired cognition, independent with eating, as having Diabetes Mellitus and on a therapeutic diet. The RCP dated 6/22/17 identified the resident with Diabetes Mellitus. Interventions included blood glucose monitoring as ordered, routine insulin as ordered, and monitor for symptoms of hypo/[MEDICAL CONDITION]. Physician orders dated 7/2/17 directed to administer [MEDICATION NAME] 100 units/ml via Flex pen, inject 14 units subcutaneously at breakfast (short acting insulin), administer 6 units subcutaneously at lunch (short acting insulin) and to administer Toujeo [MEDICATION NAME] 30 units at 4:00 PM (long acting insulin). Facility documentation dated 8/1/17 at 8:00 AM identified Resident # 4 received the following medications in error: 14 units of Toujeo at 8:00 AM and 6 units of Toujeo at 12:00 PM. The documentation identified the resident was assessed, the physician was made aware, directed to monitor the residents blood sugars every 2 hours until 6:30 AM on 8/2/17, then continue twice a day. Hold Toujeo 30 units at 4:00 PM and to hold [MEDICATION NAME] 10 units at 5:00 PM. Further review of the facility documentation identified that when the second shift nurse went to administer the residents [MEDICATION NAME] at 5:00 PM she could not locate it and asked the day shift nurse where the flex pen was located. RN # 1 went to the medication cart and picked up the residents Toujeo flex pen and realized she had administered Toujeo to Resident #4 at 8:00 AM and 12:00 PM instead of the prescribed [MEDICATION NAME]. Interview with LPN # 1 on 11/16/17 at 2:55 PM stated that she went to administer Resident # 4's 5:00 PM [MEDICATION NAME] and could not find the flex pen. LPN # 1 stated that she knew RN # 1 was still in the building so she asked her where the [MEDICATION NAME] pen was and RN # 1 went to the medication cart and picked up the flex pen for the residents Toujeo. LPN # 1 stated that she reported this to the Supervisor and physician right away and was directed to hold the residents Toujeo and [MEDICATION NAME] until 8/2/17, monitor the resident's blood sugars every 2 hours and monitor for symptoms of hypo/[MEDICAL CONDITION]. Interview with RN # 3 on 11/16/17 at 3:30 PM stated that RN # 1 came to him in the evening and stated that she administered the wrong insulin to Resident #4 at both 8:00 AM and 12:00 PM. RN # 3 stated that he went and assessed the resident and reported to the MD who directed to hold Toujeo and [MEDICATION NAME] until 8/2/17 and to monitor the residents blood sugars. RN # 3 stated that he re-educated the nurse (RN #1) on the 5 rights of medication administration. Interview with RN # 1 on 11/16/17 at 4:40 PM stated that she realized she administered Toujeo flex pen at 8:00 am and 12;00 PM when the 3-11 nurse came to her looking for the [MEDICATION NAME] flex pen. RN # 1 stated that she did not realize the Toujeo was also in a flex pen and that she did not read the label when she picked the pen up, and just assumed it was the [MEDICATION NAME] in a flex pen. RN # 1 stated that when she took the flex pen that she thought was [MEDICATION NAME] she felt things looked different and did not recall Resident #4 having a Flex pen for the [MEDICATION NAME] but did not ask anyone to verify the medication because she was busy and had a lot to do. RN # 1 stated that she failed to follow the 5 rights of medication administration: time, person, medication, dose and route. Review of the facility Policy and Procedure for medication administration identified the individual administering the medications must verify the residents identity before giving the resident his/her medications by checking the name band, photograph or verifying the identity with another staff personnel. Additionally the policy states that the individual must check the label 3 times to ensure the right medication, right dose, time, method before giving the medication, and all insulin pens will be clearly labeled with the residents name. RN #1 failed to ensure that he/she followed the 5 rights of safe medication administration resulting in a significant medication error. Interview with the DON on 11/16/17 at 2 PM stated that subsequent to the medication errors RN # 1 made on both Resident # 1 and Resident # 4, RN #1 was re-educated on the facility's policy regarding medication administration including the 5 rights of medication administration. 3. Resident # 6's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified the resident as alert and oriented, without behaviors, and receiving antipsychotics and anti-anxiety medications. The RCP dated 9/24/17 identified the resident has behaviors: wanders, anxious, repetitive questions about medications and paranoia. Interventions included administer medications as ordered, and monitor behaviors. Review of the Psych Notes dated 9/29/17 identified resident with severe [MEDICAL CONDITION] disorder of the [MEDICAL CONDITION] type that was untreated for [REDACTED]. Recommendations are to do a small decrease in [MEDICATION NAME] at night. Physician orders dated 9/29/17 directed to discontinue the [MEDICATION NAME] 750 mg and to start [MEDICATION NAME] 500 mg at hour of sleep. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Nurse's notes dated 10/24/17 at 10:46 PM identified baseline anxiety, continues with repetitive questions per normal, no symptoms of psychiatric distress. The MD was notified and directed to do a Valporic Acid level. Facility documentation dated 10/24/17 at 6:00 PM identified the resident had not received the [MEDICATION NAME] 125 mg at noon for 21 days (10/3/17-10/24/17). Interview and review of the clinical record with the DON on 11/21/17 at 9:15 AM identified when the order was written and transcribed on 9/29/17, it was done correctly, discontinuing the [MEDICATION NAME] 750 mg and starting the [MEDICATION NAME] 500 mg at hour of sleep. The DON stated that when the orders were transcribed to the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The DON stated that the physician was notified and directed to draw a Valporic Acid level which was noted as within normal limits. The DON further stated that after the level was obtained the physician did not restart the [MEDICATION NAME] 125 mg at 12:00 PM. According to Basic Nursing, Mosby, Third Edition, the five guidelines to ensure safe drug administration include the right drug, the right dose, the right client, the right route and the right time and/or According to Basic Nursing, Mosby, Third Edition, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the physician. The nurse who gives the wrong medication or incorrect dose is legally responsible for the error.

Based on clinical record reviews, facility documentation and interviews for one of three sampled residents (Resident #31) reviewed for medication administration, the facility failed to ensure that the resident was free of a significant medication error. The findings include: Resident #31's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. greater than 300. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #31 had moderate cognitive impairments, required set up assistance for eating, on a mechanically altered, therapeutic diet and received insulin. The Resident Care Plan dated 4/13/17 identified diabetes mellitus, fluctuating blood sugars and frequent changes in insulin dosages. Interventions directed to monitor the blood glucose as ordered, routine insulin coverage, sliding scale coverage as ordered, monitor for symptoms of [DIAGNOSES REDACTED], [MEDICAL CONDITION], and/or ketoacidosis. The Weights and Vital Signs Summary dated 4/19/17 identified the resident's blood sugar level at 6:05 AM was 550 mg/dL. The documentation further identified at 7:45 AM the finger stick was 540 mg/dL, from 4/1/17 through 4/19/17 the resident's blood levels would range from 60-394. The nurse's note dated 4//19/17 at 9:56 AM identified Resident #31 complained of thirst and lightheadedness, and the 11PM-7AM shift reported the resident's blood sugar this morning was 550. The physician was notified and directed to administer an additional 6 units of [MEDICATION NAME]now. The note identified although the resident ate 100% of the breakfast meal, the resident came to the nurse' station at 9:00 AM complaining of lightheadedness, vision blurring, and increased thirst and urination. The note identified the physician was again notified and directed to transfer the resident to the hospital for an evaluation. The Reportable Event Form dated 4/19/17 at 9:30 AM identified the Medication Administration Record [REDACTED]. The Emergency Department (ED) report dated 4/19/17 identified the resident was transported to the hospital for an elevated blood sugar and upon review of the nursing home records, it did not appear the resident had been receiving the long acting insulin, Toujeo. The ED report identified the residents blood sugar was greater than 600 mg/dL, at 11:15 AM was 611, 4 units of [MEDICATION NAME] and then an additional 6 units were administered and the resident received two (2) liter bolus of intravenous 0.9% Sodium Chloride fluids. The resident's blood sugar at time of discharge, 3:18 PM was 318mg/dL. Review of the April 2017 Medication Administration Record [REDACTED]. The MAR failed to reflect documentation of the 6:30 AM fingerstick result of 550. Interview with a 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #5 on 5/24/17 at 10:15 AM identified that she was on the unit doing her medication pass when the other charge nurse yelled to her that Resident #31 needed insulin coverage. LPN #5 stated she went to the desk, asked the other charge nurse what the resident's blood sugar was and how much coverage was to be given. LPN #5 stated that she drew up and administered the [MEDICATION NAME] 6 units and went back to her medication pass. LPN #5 could not recall if she administered the Toujeo injection on 4/17/17 or 4/18/17, and indicated that she signs off the medications as she gets them ready to administer. Interview with a 7AM-3PM charge nurse, LPN #6, on 5/24/17 at 11:30 AM identified when she was getting report the 11PM-7AM nurse reported Resident #31's finger stick was 550. LPN #6 stated that the 11PM-7AM nurse did not report the 6:00 AM blood sugar result to the physician so she called and at 8:00 AM was directed to administer an additional 6 units of [MEDICATION NAME] insulin. LPN #6 stated that after breakfast the resident came to the desk complaining of lightheadedness, thirst and blurred vision and subsequent to physician notification the resident was sent to the hospital for evaluation. Interview with the attending physician, Medical Doctor (MD) #1, on 5/24/17 at 2:00 PM identified she was not informed the resident had not received the scheduled morning doses of the Toujeo and/or [MEDICATION NAME]on 4/19/17. MD #1 stated had she been aware the resident did not receive the insulin she would have ordered a higher dose of the [MEDICATION NAME] coverage, because the 6 units she did order would do nothing for the high blood sugar.

Based on a review of clinical records, facility documentation, resident and staff interviews, and facility policy review, the facility failed to provide adequate supervision for 17 of 17 residents during a designated smoking break and/or failed to prevent a hazardous situation when aware that one resident (Resident #14) obtained cigarettes and a lighter and was smoking in the facility resulting in finding of immediate jeopardy. The findings include the following: a. Resident (R) #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A smoking assessment dated [DATE] indicated that the resident understood the smoking policy and agreed to keep all smoking materials secured by the facility. An annual MDS assessment dated [DATE] identified that the resident had a BIMS of 15 (intact cognition), and ambulated independently throughout the facility. The care plan dated 2/23/16, updated on 6/1/16 reflected, in part, that the resident wishes to smoke and was assessed to smoke with supervision. Interventions included to educate the resident that smoking is only permitted under supervision of a staff member in the facility designated area during facility smoking times. The care plan further identified that Oxygen use is prohibited in the resident smoking areas. R #14 shared a room with R #24 who had [DIAGNOSES REDACTED]. The nurse's note dated 6/22/16 identified the resident was caught smoking in his/her room and cigarettes and lighter were confiscated. The Reportatble Event dated 6/22/16 identified that at approximately 12:00 PM, the NA entered R #14's room, smelled cigarette smoke and reported the incident to the LPN charge nurse. R #14 was removed from the room, asked to empty his/her pockets and a lighter and cigarettes were found. The investigation identified the resident was smoking in his/her room. Interview with the acting DNS on 7/26/16 at 11:45 AM identified that cigarettes are locked in a file cabinet in the Social Worker's office and on 6/22/16 the Social Worker (SW) left his/her office door open and the resident went in the office, found the key to the file cabinet and obtained the cigarettes and lighter. Interview with SW #1 on 7/26/16 at 12:55 PM identified he/she was notified of the 6/22/16 incident and upon interview with R #14, the resident stated the office was unlocked, and the key (kept on a hook on the side of the cabinet) to unlock the file cabinet was used to obtain cigarettes and a lighter. SW #1 further stated that the only other people with a key to the office was the Director of Maintenance and the off shift Nursing Supervisor. Subsequent to the incident, SW #1 stated during a clinical meeting it was reviewed and reiterated that the SW office door must be locked at all times. The resident's room was changed because the roommate was on continuous oxygen. Review of the facility investigation/documentation with the acting DNS on 7/27/16 failed to reflect education was provided to the off shift Nursing Supervisors. Interview with Resident #14 on 7/26/16 at 2:40 PM acknowledged that she/he had smoked in his/her room on 6/22/16. b. Review of facility documentation dated 7/12/16 identified that at approximately 9:45 PM, there was a smell of cigarette smoke in the hallway in front of R #14's room and the NA notified the Charge Nurse. The nurse's note identified that the charge nurse searched the resident's room and found two packs of cigarettes and a lighter. Interview with SW #1 on 7/26/16 at 12:55 PM identified he/she was notified on 7/13/16 that R #14 had been smoking in his/her room the prior evening. SW #1 further stated that R #14 informed her that the SW office door was unlocked, she/he entered the office, obtained the file cabinet key and again took two packs of cigarettes and a lighter. Interview with Resident #14 on 7/26/16 at 2:40 PM acknowledged smoking in his/her room on 7/12/16. Review of facility documentation with the Administrator and acting DNS on 7/27/16 at 3:00 PM failed to identify that the off shift Nursing Supervisors were educated following the 6/22/16 incident to ensure the SW office was locked at all times. Subsequent to the 7/12/16 incident, all smoking materials were to be locked in the medication room. Review of the Smoking Policy directed to supervise all residents while smoking, residents may not keep lighters/matches or any other smoking paraphernalia on their person, staff will control all smoking materials, and residents will smoke in designated smoking areas only. c. Observation on 7/26/16 at 11:30 AM, identified a locked medal cart in front of the medication room door. A key was observed hanging off the file cabinet in the nursing charting room. Interview with LPN #5 at 11:30 AM identified the cart contained the residents smoking materials and the key was kept on the file cabinet. LPN #5 indicated that the cart should be kept locked in the medication room, however, she was unaware the cart was not in the medication room because she /he was on the unit delivering medications and the NA did not notify her/him. On 7/27/16 at 2:30 PM, a locked medal cart was observed in the center wing nurses station. The key to unlock the cart was observed hanging off the file cabinet in the nursing charting room. Interview with NA #4 on 7/27/16 at 2:30 PM identified the cart was supposed to be locked in the medication room but she did not know where the nurse was, therefore left the cart at the nurse's station. On 7/27/16, the facility submitted an immediate action plan that identified all staff would be inserviced on the smoking policy to ensure compliance. The locked cart that contained smoking materials and the key would be secured in the medication room and the NA's would immediately notify the nurse/supervisor following designated smoking times who will be responsible to lock the cart in the medication room. The facility failed to ensure that smoking materials were secured in accordance with facility policy to prevent a resident from obtaining cigarettes and lighting materials and smoking in the facility which caused a hazardous situation resulting in the finding of immediate jeopardy. d. On 7/28/16 during the period of 9:20 AM through 9:45 AM, 17 residents and NA #3 were observed in a restricted smoking area. Throughout the smoking period, Maintenance Worker #1 was observed to bring residents to the smoking area, however, was not in attendance the entire time. NA #3 was observed to distribute two cigarettes to six (6) residents until Resident #5 informed the NA that only 1 cigarette was allowed at a time. NA #3 was observed at times to utilize his/her personal cell phone and have his/her back to the residents who were smoking. Resident #9 who had a smoking apron in place, was observed smoking with his/her eyes closed, dropped the cigarette onto the apron, then falling to the ground, when NA #3 picked up the cigarette, discarded it and provided the resident with a second cigarette. Resident #9 was observed to lower his/her hand while holding the cigarette resulting in the tip of the cigarette coming within one inch of another residents forearm. Resident #9 subsequently dropped the cigarette to the ground at which time the resident was informed by NA #3 that's it you're done. Resident #10 with a smoking apron in place was seated behind NA #3 in a wheelchair. The resident was observed holding two cigarettes, one in each hand, one lit. The resident was observed smoking with his/her eyes closed, dropping long ashes onto the apron. Further observation identified Resident #10 trying to light the second cigarette from the first cigarette. Resident #5 was heard informing NA# 3 whose back was to Resident #10, that Resident #10 needed a cigarette lit and NA #3 said where is the lighter? NA #3 was observed to proceed to Resident #11 to obtain the lighter and returned to light Resident #10's second cigarette. The Maintenance worker in an effort to assist residents to extinguish smoking materials in the rear of the smoking area, was observed to move residents and the smoking receptacles in order to freely access the residents. Observation further noted three (3) residents, at separate times, proceeded to the secured entry of the building and enter the security code unassisted by staff. Resident #5 yelled out the security code in front of the group to the Surveyor further rendering the code ineffective to secure the designated smoking area. Interview with NA #3 on 7/28/16 at 9:30 AM stated during the smoking period, up to 20 residents participate. NA #3 identified there should be two (2) staff people for supervision at all times. At 9:45 AM, the Administrator observed the positioning of the residents, observed residents accessing the building utilizing a secured code and staff failing to observe all residents while smoking. The Administrator stated she/he was unaware of the required number of residents to staff ratio during smoking. Review of the Smoking Policy directed that supervision will be a maximum of 14 residents to one observer, supervising staff must actively monitor while running the activity, and staff would control all smoking materials. On 7/27/16, the facility submitted an immediate action plan that directed two staff members to be present to supervise smoking breaks, each smoking group would not exceed 10 residents, with random audits to monitor compliance would be conducted. The facility failed to ensure staff provided adequate supervision during a supervised smoking break and failed to follow the facility smoking policy to ensure the safety of residents during a supervised smoking break which resulted in the finding of immediate jeopardy. Based on observation, a review of clinical records, and policy review for 20 of 20 sampled residents (Resident #31, 48, 115, 14, 20, 51, 66, 1, 102, 113, 9, 64, 52, 41, 75, 12, 25, 126, 5 and 129) observed during a scheduled smoking break, the facility failed to ensure that smoking assessments were completed in accordance with facility policy and/or for 1 of four residents reviewed for falls (Resident #27), the facility failed to ensure that interventions were in place to prevent a fall. The findings include: a. Review of the care plans of Resident #31, 48, 115, 14, 20, 51, 66, 1, 102, 113, 9, 64, 52, 41, 75, 12, 25, 126, 5 and 129 indicated that the resident's smoked with an intervention for staff to conduct smoking assessments. Review of the clinical records of all the aforementions resident's with the Acting DNS on 7/28/16 at 3:00 PM confirmed that smoking assessments were not completed upon admission and/or on a quarterly basis in accordance with facility policy. Review of the facility smoking policy directed in part, that a smoking assessment form will be completed to measure for safety, physical abilities, sensory function and need for adaptive equipment. Smoking assessments are to be completed at the time of admission, quarterly, and upon a significant change in the resident ' s functional ability. b . Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#27 was at risk for falls with a recent left hip fracture on 1/27/16 with interventions that included a toileting plan, a leg immobilizer, a referral to physical and occupational therapy, slipper socks, encourage the resident to wear eye glasses, call light within reach, adequate glare free lighting, and an area free of clutter. The Quarterly Minimum Data Set ((MDS) dated [DATE] identified severe cognitive impairment, extensive assistance with transfers, total dependence with ambulation with an assist of one and a history of falls. Review of nurse's notes dated 2/3/16 identified Resident #27 had an unwitnessed fall in his/her room and was subsequently placed on fifteen minutes checks. Further review of the nurses noted dated 2/15/16 indicated Resident #27 fell out of his/her geriatric chair and there were no injuries sustained. The plan of care was updated to include placing the resident in the geriatric chair next to the nurse's station. physician's orders [REDACTED]. Interview with PT #1 on 7/28/16 indicated Resident #27's functional status beginning on 2/15/16 was ambulation with an assist of two with a rolling walker and a wheelchair following behind. Review of the Resident Monitoring Tool identified fifteen minute checks were intermittently conducted from 2/3/16 through 2/19/16 and then were discontinued absent a physician's orders [REDACTED]. Further review of the nurses notes dated 2/16/16 through 2/19/16 identified Resident #27 attempted to stand without assistance on several occasions. Review of the facility documentation dated 2/23/16 identified at 10:58 PM Resident #27 had an unwitnessed fall from his/her bed sustaining a laceration to the right side of his/her head. Resident #27 was transferred to an acute care facility and imaging revealed a five millimeter subdural hematoma. Interview and review of the clinical record with Nursing Supervisor #1 on 7/28/16 at 1:30 PM indicated although additional nursing interventions were in place after each fall they did not prevent the resident from attempting to ambulate. Further interview with Nursing Supervisor #1 indicated it was the responsibility of nursing to ensure the interventions put in place for the resident were effective and if they were not, nursing was required to implement alternate measures to ensure the resident's safety.

Based on clinical record reviews, review the facility documentation and interviews for four of five sampled residents (Resident #14, 19, #105 and #115) who alleged an incident of abuse, the facility failed to ensure that when the first incident was reported, the Nurse Aide involved was removed from duty to prevent a second incident from occurring three hours later. The findings include: a. Resident #19's [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had no cognitive and/or memory deficits, exhibited no behavioral symptoms, and required extensive one person assistance with personal hygiene, toileting, bed mobility, transfers in and/or out of the bed, and dressing. The Resident Care Plan (RCP) dated 12/24/15 identified impaired cognitive skills. Interventions directed to explain care to the resident prior to providing care, request feedback to ensure understanding, promote dignity, talk with the resident and ensure privacy while providing care. The Reportable Event Form dated 2/8/16 indicated Resident #19 reported an allegation of abuse. The investigation dated 2/9/16 identified in an interview Resident #19 stated he/she reported to the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, a Nurse Aide (NA) said you had to change rooms because you are so crazy that nobody wants to live with you, while being toileted the NA said hurry up, I don't have time for your crazy a_ _ tonight and was rough while getting the resident into bed and pushed on the resident's forehead to get him/her to lie down. The nurse's note dated 2/12/16, identified a late entry for 2/8/16 at 7:30 PM, the resident stated the 3-11PM nurse aide had a sharp tongue and the nurse aide commented nobody wants to take care of you, that's why you had to switch rooms. The note indicated the incident was reported to the 3-11PM Nursing Supervisor and the nurse aide was not to go in to Resident #19's room again. Interview with the 3-11 PM charge nurse, LPN #1, on 7/26/16 at 4:00 PM identified that at approximately 7:30 PM she was told by Resident #19 the 3-11PM nurse aide, NA #1, had a sharp tongue with him/her. LPN #1 stated she notified the Nursing Supervisor, became caught up in her work and NA #1 remained on the unit caring for other residents. LPN #1 stated she knew NA #1 should be removed from the unit but thought the Nursing Supervisor was coming down. Interview with Resident #19 on 7/27/16 at 10:15 AM identified that NA #1 had a sharp tongue, was harsh, rude, and loud. Resident #19 stated NA #1 rushed him/her and because he/she was not quick enough NA #1 pushed on his/her forehead get him/her to lay down quicker. Resident #19 stated the incident was reported to the charge nurse, LPN #1 and he/she was afraid of NA #1. b. Resident #105's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #105 had no cognitive or memory deficits, exhibited moderate depression, daily preferences were very important to the resident and the resident required extensive to total two person assistance with most activities of daily living. The resident care plan dated 2/2/16 identified depression. Interventions directed to administer medications as ordered, monitor behaviors, psychiatry services, monitor effectiveness of medications, and encouraging talking about feelings. The Reportable Event Form dated 3/10/16 at 11:15 PM identified a verbal confrontation between Resident #105 and the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #6. During the altercation both parties made derogatory comments and LPN #6 was heard to say F_ _ k you to Resident #105 and then she walked out the door and went home. In a written statement LPN #6 identified that the comment was unprofessional of her and blamed the resident for verbal abuse towards her. The investigation identified LPN #6 admitted to saying F_ _ k you to the resident and the 11-7AM nurse aide witnessed LPN #6 make a hand gesture to the resident. The facility substantiated abuse and LPN #6 was terminated. The social service note dated 3/11/16 identified an incident occurred between the resident and a nurse. The note identified the resident was being inappropriate and rude to the nurse and the nurse eventually swore at the resident. The note indicated the resident had no ill effects from the incident but has requested that LPN #6 not care for him/her again. Interview with Resident #105 on 7/27/16 at 9:15 AM stated that LPN # 6 swore at him/her and gave him/her the middle finger. Interview with RN #1 on 7/27/16 at 9:40 AM identified, 11-7AM nurse aide, NA #5, came to her and reported that she witnessed LPN #6 make a hand gesture and say F_ _ k you to Resident #105. RN #1 stated she immediately started the investigation and spoke to the resident who was upset and mad at the nurse. Interview with the Acting Director of Nursing (DON) on 7/27/16 at 11:50 AM identified after LPN #6 made the comment to the resident, the nurse left and did not return. The Acting DON stated that verbal abuse was substantiated and the nurse was terminated. Several attempts made to contact LPN #6 and NA #5 were unsuccessful. c. Resident #115's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #115 had no cognitive and/or memory deficits, exhibited no behavioral symptoms and was totally dependent staff with personal hygiene, toileting, bed mobility, transfers in and/or out of the bed, and dressing. The RCP dated 1/30/16 identified a plan for psychosocial well-being, depression, mood and anxiety. Interventions directed speak softly, clearly, request feedback to ensure understanding, promote dignity, and talk with the resident. The Reportable Event dated 2/8/16 at 10:30 PM identified Resident #115 reported the 3-11PM nurse aide made an obscene gesture toward the resident and told the resident he/she needed to go to bed. The report identified the resident had stated he/she was afraid of the nurse aide taking care of him/her. The documentation indicated Resident #115 stated NA #1 was being spiteful, hateful, nasty and rude towards the resident. At the conclusion of the facility's investigation it was determined that Resident #19's allegation of verbal and physical abuse was substantiated. The social service note dated 2/10/16 identified during an interview Resident #115 stated NA #1 entered the resident's room and said get up, you are so lazy, do something for yourself and performed an obscene gesture with her finger. Interview with the 11-7AM charge nurse, LPN #3, on 7/27/16 at 10:15 AM identified at approximately 10:30 PM Resident #115 reported the 3-11PM nurse aide, NA #1, was rude and made an obscene gesture. LPN #3 stated she reported the incident to the Nursing Supervisor and the nurse aide needed to be removed from caring for residents based on the allegation. LPN #3 identified the Nursing Supervisor moved NA #1 to another unit to provide care to residents and was told by the Nursing Supervisor that NA #1 could not be sent home because the facility was short staffed. In an interview on 7/27/16 at 10:30 AM Resident #115 identified that NA #1 was rude, hateful and made an obscene gesture to him/her. Resident #115 stated that he/she was afraid of the nurse aide. Interview with the Nursing Supervisor, Registered Nurse (RN) #1 on 7/27/16 at 11:30 AM identified that LPN #3 reported to her an allegation of abuse involving Resident #115. RN #1 stated that when the resident was interview he/she reported NA #1 made an obscene gesture and was rude to her. RN #1 identified the 3-11 PM charge nurse, LPN #1, reported that NA #1 had been rude and pushed a resident in the head earlier in the shift. RN #1 stated she went to speak with the resident she thought was involved in the first incident and when the resident denied an allegation of abuse, RN #1 identified she failed to go back and clarify with LPN #1 which resident alleged the abuse earlier in the shift. RN #1 stated she did not find out which resident alleged the first incident of abuse until 2/9/16. RN #1 identified she moved NA #1 to another unit to work because the staffing would be short. RN #1 identified she had been educated on the abuse policy in November 2015. RN #1 stated she was unaware of what the facility abuse policy directed to do when an allegation of abuse was made, until she notified the DON later in the shift. RN #1 identified she was instructed to send NA #1 home at that time, 1:08 AM, five and one-half hours after the initial alleged abuse incident was reported Several attempts were made to contact NA #1 and the former DON without success. Interview with the acting Director of Nursing (DON) on 7/27/16 at 12:00 PM identified that according to facility policy when an allegation of abuse was made, the staff person should be removed from resident care immediately and placed on leave pending an investigation. Review of the facility policy for Abuse and Neglect directs that upon identification of a possible abuse or neglect, the facility should provide immediate safety of the resident, and remove the alleged perpetrator from the facility and place the employee on investigatory leave. The investigation identified the facility failed to ensure when Resident #19 reported an allegation of abuse at 7:30 PM the Nurse Aide involved was removed from duty to prevent a second incident from occurring three hours later. NA #1 continued to provide care to residents until she was sent home at 1:08 AM, five and one-half hours after the first alleged abuse incident was reported. Subsequent to inquiry, the facility submitted an immediate action plan that included interviews with residents by the Social Worker and administration to ensure that no other residents are at risk, the revision of the abuse policy, staff education on the new policy to ensure understanding and compliance. The Social Worker will interview alert residents weekly to ensure ongoing compliance for a period of three months. d. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] indicated that the resident had a BIMS of 15 indicating that the resident was alert. The Reportable Event Form dated 3/21/16 indicated Resident #14 reported an allegation of verbal and sexual abuse. Review of facility documentation identified that R #14 reported that NA #2 touched his/her chest during a smoking break and stated I want to get in your pants, approximately three (3) weeks ago. NA #2 was immediately suspended following the allegation. The investigation summary completed by RN #3 concluded that the allegation could not be substantiated because the resident experiences frequent delusions. Review of the psychiatric consult dated 3/21/16 indicated that the resident was alert and oreinted. The consult did not identify that the resident was experienceing delusions. Review of the clinical record during the period of 3/1/16 through 3/21/16 failed to reflect that the resident experienced delusions. Interview with the Nursing Supervisor on 7/27/16 at 2:20 PM inidcated that she was notified of the incident on 3/21/16 and sent the NA home at that time pending an investigation. The supervisor indicated that the resident is a reliable historian. Interivew and review of the clinical record with RN #3 on 2/27/16 at 3:10 PM indicated that she thought the psych APRN had indicated that the resident had delusions and that she was asked by the DNS at that time to write up the report however she had not conducted the investigation.

Based on clinical record review, review of facility documentation, and interviews for two of two residents reviewed for pressure ulcers, (Resident #29 and Resident #66), the facility failed to accurately assess and/or ensure necessary treatments and services were provided to promote healing of multple pressure ulcers. The findings include: a. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Assessment ((MDS) dated [DATE] identified Resident #29 was cognitively intact (BIMS 15), required total assistance for all activities of daily living except eating, and had 1 unstageable pressure ulcer which was present on admission measuring 4.0 centimeters(cm) long by 3.5cm wide by 0.6cm deep. The associated Care Plan identified a stage IV wound on the coccyx including interventions for an air mattress to the bed, pressure relieving cushion in wheelchair, and daily monitoring and documentation of wounds to coccyx and buttocks. The Physician's orders dated 4/12/16 directed to provide an air mattress to the bed and to turn and reposition every 2 hours. Review of the hospital discharge summary and wound team visit dated 4/11/16 identified buttock wound staging as unstageable slough and eschar with the following measurements: 4.0cm long by 3.0cm wide by 0.3cm deep. Review of the Skin Grid for Pressure Ulcers documentation failed to identify that an assessment was completed for the coccyx pressure ulcer on admission. Additionally, the first entry was dated 4/19/16, 1 week after admission, identifying an unstageable coccyx wound measuring 4.0cm long by 3.5cm wide by 0.6cm deep. Review of the Treatment Administration Record (TAR) for the month of April 2016 identified there was no coccyx ulcer treatment in place until 4/19/16, 7 days after admission to the facility. Review of the nurse's notes dated 4/13/16 at 10:00PM identified RN #2 documented a sacral wound measuring 10 centimeters (cm) by 10cm, center of wound appears grayish black 4cm by 4cm and was foul smelling with a moderate amount of serous drainage. Additionally, there was no documentation identifying that any treatment was performed or dressing applied. Interview on 8/3/16 at 12:30PM with RN #2 identified that although he/she did recall assessing Resident #29's coccyx pressure ulcer on 4/13/16, the day after resident was admitted , he/she could not recall what type of dressing was removed, but believes he/she applied a sterile dressing after assessing. Review of Resident #29's clinical record and interview with MD#1 on 8/4/16 at 9:25AM identified that although he/she was aware Resident #29 had a pressure ulcer present on admission on 4/12/16, there were no physician's orders in place for the treatment of [REDACTED]. MD #1 identified that the wound specialist comes weekly on Tuesday's. Resident #29 was admitted to the facility on a Tuesday evening and would be evaluated by the wound specialist the following Tuesday. MD #1 identified that she believed the nurses were covering the coccyx pressure ulcer with a sterile dressing until Resident #29 could be evaluated by the wound specialist. Additionally, it was his/her expectation that when a resident was admitted with a pressure ulcer with no treatment orders identified, the charge nurse or nursing supervisor should contact the physician to obtain treatment orders. MD#1 also identified that it was possible that the pressure ulcer could have deteriorated during the one week period where no treatment was in place. Review of the facility's Treatment Protocol for Pressure Areas identified, in part, to notify the physician and obtain orders, evaluate the wound daily or with dressing changes for periwound redness, swelling, warmth or coolness, a firm or boggy feel and assess for changes in sensation, pain, foul odor and increased drainage. Additionally, the Skin Grid for Pressure should be updated weekly and as needed with changes and the plan of care should be reviewed and revised as appropriate. b. Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] identified Resident #66 with a BIMs score of 15, indicative of no cognitive impairment and required extensive assistance with two people for all bed mobility. The care plan dated 7/26/16 identified Resident #66 with wounds located on the sacral area, the left heel, and the right thigh. Interventions directed nursing staff to provide the treatment as ordered and to monitor the wound weekly of location, highest stage and/or visual stage, measure length, width and depth, color of drainage, color of wound bed, presence of odor, tunneling or undermining, and review improvements and/or report decline to the physician. Physician's orders dated 7/26/16 directed nursing staff to protect the sacral wound with a foam dressing or [MEDICATION NAME] (a medicated dressing for pressure wound healing purposes) and change as needed, apply a [MEDICATION NAME] to the right thigh daily, and apply [MEDICATION NAME] to the left foot wound heel daily. Further review of Resident #66's clinical record identified the W-10 form prior to admission to the facility which reflected that the coccyx wound was an unstageable pressure ulcer and that the right upper and lower thigh and the left heel were stage 2 pressure ulcers. Review of Resident #66's clinical record which included the admission skin condition listed on the facility's skin grid tracking form indicated that the right lower thigh was an open lesion measuring 3cm x 2cm with no drainage. The second wound indicated that the right upper thigh was an open lesion measuring 4cm x 2cm with no drainage. The third wound on the skin grid indicated that the coccyx/sacral wound was an open lesion measuring 15cm x 6 cm with drainage. The fourth wound indicated that the left foot heel was an open lesion measuring 3cm x 2.5cm with drainage. Further review of the clinical record failed to identify the stage of the pressure areas indicated on the skin grid tracking form. 1. Review of Resident #66's clinical record which included the Treatment Kardex and the nursing notes indicated that the [MEDICATION NAME] dressing to the left heel and the [MEDICATION NAME] dressing applied daily to the right thigh were performed and completed per the physician's order. Interview with LPN #3 on 8/3/16 at 11:45 AM identified that Resident #66's coccyx wound was dressed with a foam dressing on 7/27/16 but that the [MEDICATION NAME] dressings were never applied to the other wounds because the facility does not supply [MEDICATION NAME] in stock. He/she further stated that if the physician orders [MEDICATION NAME] for a wound, it is the responsibility of the nurses to order the [MEDICATION NAME] medicated dressing. LPN #3 stated that he/she ordered the [MEDICATION NAME] on 7/27/16 and that the medication ([MEDICATION NAME]) had not been delivered to the facility as of 8/2/16. LPN #3 further stated that he/she did not know the treatment that was being used on the left heel and the right thigh. 2. Interview with LPN #4 on 8/2/16 at 10:35 AM identified that she/he did not know what the stage of the pressure area was on the coccyx, the thigh, and/or the left heel. Interview with The Nursing Supervisor (who is responsible for staging pressure ulcers) on 8/2/16 at 10:40 AM identified that no one in the facility does staging on the pressure ulcers. He/she further stated that it is the responsibility of the nursing supervisor to stage all of the wounds on admission. He/she further stated that the Wound Consult physician visits the resident about a week after admission to the facility and stages all of the pressure area wounds in the facility. The Nursing Supervisor further stated that she/he was never properly trained on how to identify and properly classify a stage of a pressure ulcer. She/he further stated that when a resident is admitted to the facility, the nursing supervisor only identifies and measures the pressure areas. He/she further indicated that the Wound Consult Physician was coming to the facility that day(8/2/16) and would be staging all of the wounds for Resident #66. The facility could not determine the stage of pressure areas and/or determine if the wounds had improved or worsened. Resident #66 was discharged to the hospital on [DATE] before the facility's Wound Consult physician examined the resident. Review of the Facility's Wound Prevention and Treatment Policy directed in part that the staging of pressure ulcers will be used to standardize communication and provide a universal method for documentation. The facility failed to follow the plan of care and/or policy to monitor the wound's highest stage and/or assess for improvement and/or decline for a resident with pressure wounds.

Based on observation, clinical record review, and staff interview for 1 of 4 sampled residents (Resident # 104) reviewed for pressure ulcers, the facility failed to implement interventions identified in the plan of care regarding skin integrity. The findings include: a. Resident #104's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified the resident as alert and oriented, requiring extensive assistance with bed mobility and transfers, as having 2 un-stageable pressure ulcers, and 7 venous/arterial ulcers. The resident care plan dated 11/22/10 identified a potential for pain related to wounds and [MEDICAL CONDITIONS]. Interventions included to monitor pain levels, monitor effectiveness of medications and interventions, and medicate for pain and/or dressing change as needed. Review of the pain assessment dated [DATE] identified pain as hot/ burning to the bilateral feet, relieved by medication. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on 1/10/11 at 10:35am identified Licensed Practical Nurse (LPN) #5 provide Resident # 104 with the treatments to the residents bilateral feet and buttocks. LPN #5 was observed to remove the right heel dressing and cleanse the wound. Resident # 104 was observed to pull the right foot away and stated "ouch." LPN # 5 was observed to continue on with the treatment. LPN # 5 was then observed to provide treatment to the left outer foot and as the LPN cleansed the wound bed Resident # 104 was observed to pull the left leg back and stated " that hurts." LPN # 5 then removed the dressing to the left inner foot and Resident # 104 was observed to pull back the leg again, stating "do you have to do that it hurts." LPN # 5 was heard stating " I'm sorry " . At 10:55am (20 minutes after the start of the treatment) the Assistant Director of Nursing Services (ADNS) was heard asking Resident # 104 if she needed something for pain. Resident # 104 responded " yes, it hurts " . The ADNS was observed to leave the room and returned with the medication nurse. LPN #1 asked Resident # 104 what the pain level was and Resident # 104 stated a 9 on a scale of 1 to 10. LPN # 1 returned at 11:00am and administered the pain medication while LPN # 5 continued with the resident's treatments. The treatments were finished at 11:05am. The resident was positioned for comfort. Interview with LPN #5 at that time identified that she did not ask the resident prior to starting the treatment if the resident had pain because she thought the medication nurse would have. Interview with LPN #1 on 1/10/11 at 11:15am identified that she had asked the resident at about 8:00am if Resident # 104 was having pain, but did not ask her prior to LPN # 5 starting the treatment. LPN failed to implement the intervention of providing medication for pain during the dressing change prior to the start of the treatment and/or upon the resident's complaint of pain during the treatment. b. R# 104's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident as alert and oriented, requiring extensive assistance with bed mobility and transfers, and as having 2 unstageable pressure ulcers and 7 venous/ arterial ulcers. The resident care plan dated 12/15/10 identified actual alteration in skin integrity related to severe bilateral arterial disease. Interventions included to off load feet. Intermittent observations on 1/10/11 from 10:08am until 1:40pm noted 2 pillows under R # 104's legs at the knee area, with the resident's feet directly on the mattress. Additionally, after the resident's treatment was finished, the nurse was noted to reposition the resident on their back, place the pillows under the legs and place the heels directly on the pillows. Interview with LPN #5 on 1/10/11 at 1:45pm identified that after LPN #5 repositioned R # 104 in bed, she should have repositioned her feet so they were off the pillow and not directly lying on it.

Based on review of clinical records, interviews, personel files, investigative report and policies and procedures for a resident reviewed for a falls (R#1), the facility failed to maintain a safe environment to prevent a fall. The findings include: R#1 was admitted with [DIAGNOSES REDACTED]. A NN dated [DATE] identified the resident was receiving Hospice Care and had increased joint/leg discomfort, and was wincing when moved. A [DATE] NN identified Hospice Care was discontinued. Physician orders [REDACTED]. A nursing assessment dated [DATE] indicated R#1 was dependent and required the assistance of one person for bathing and toileting. A Fall Risk assessment dated [DATE] indicated R#1's score was 14, placing R#1 at high risk for falls. A quarterly assessment dated [DATE] indicated R#1 had severely impaired cognition, partial loss of range of motion (ROM) of both legs and was dependent in all areas of ADLs. A physician's progress note dated [DATE] indicated R#1 was in the final stages of dementia, had contractures and required total care. A Resident Care Plan (RCP) addressing falls dated [DATE] indicated R#1 had a history of [REDACTED]. Interventions included a low bed with enablers, a winged mattress, and two staff members are to provide care. The RCP further indicated R#1 rolled out of bed during incontinent care on [DATE] and had bruising and swelling of the left hip. A self care deficit RCP dated [DATE] indicated R#1 was total care for all ADL's. A potential for pain RCP dated [DATE] indicated R#1 had pain related to osteoporosis, osteoarthritis, contractures and a fall on [DATE]. A NN dated [DATE] at 7:00 AM indicated at 5:10 AM NA#1 was providing incontinent care to R#1 and R#1 rolled out of bed to the floor. R#1 was assessed for injuries and redness to the left cheek was noted. R#1 was noted to moan during care with gentle touch. A NN dated [DATE] at 10:15 AM indicated R#1 had diminished lung sounds in the lower lobes of the lungs and the NN indicated R#1 had vomited after breakfast. A NN dated [DATE] 2:00 PM identified a 7.0 centimetere (cm) by by 4.0 cm diffuse bruise with lower lateral moderate swelling on R#1's left hip. A NN dated [DATE] at 6:00 PM identified that the resident received Physician orders [REDACTED].#1 every two hours, administer oxygen (O2) 2 liters per minute (L/min.) for comfort and to suction one time and prn for increased secretions. Physician orders [REDACTED].) intramuscular (IM) one time, obtain a chest x-ray, Duoneb 1 unit dose every six (6) hours for twenty-four (24) hours, may increase O2 to five (5) L/min. via mask continuously and may use 8 liters O2 with a non-rebreather mask. The Medication Administration Record dated [DATE] at 12:00 AM identified the resident received Morphine Sulfate 2.5 mg subcutaneous (sc). A NN dated [DATE] at 2:00 PM indicated the x-ray of the left hip was unobtainable due to R#1's contractures. The family was notified and would discuss if they wanted R#1 sent to the hospital for x-rays. A NN dated [DATE] at 5:30 PM indicated R#1's had a temperature and his/her lung sounds were auscultated for expiratory crackles. R#1 remained on oxygen. A NN dated [DATE] from 12:00 AM 1:45 AM identified a decline in R#1's condition. R#1 expired at 1:45 AM. During an interview on [DATE] at 11:55 AM wth the Director of Nursing (DNS), the DNS indicated that he/she had spoken with Nursing Assistant (NA) #1 on [DATE] and NA#1 indicated that when R#1 rolled off the bed NA#1 instinctively picked R#1 up and put R#1 on the bed and immediately realized he/she should not of moved R#1. Upon surveyor inquiry the DNS identified that employees are educated upon hire on what to do should a resident fall. During an interview on [DATE] at 12:15 PM with RN #1, RN#1 indicated that on [DATE] he/she was passing medications near R#1's room when NA#1 came out of the room and indicated R#1 fell out of his/her bed. RN#1 went into the room to assess R#1 and found R#1 in bed. RN#1 indicated NA#1 indicated he/she was providing care to R#1 when NA#1 turned and took several steps from the bed to retrieve supplies and R#1 fell off the low bed. RN#1 identified that NA#1 indicated everthing happened so fast he/she instinctively put R#1 back in bed. Upon surveyor inquiry RN#1 identified that NA#1 indicated NA#1 knew he/she should not have stepped away from the bed or moved R#1 from the floor. During an interview with NA#1 on [DATE] at 9:45 AM, NA#1 indicated he/she was providing incontinent care to R#1 when NA #1 needed more wipes located on the table a couple of steps away. NA#1 indicated he/she had put up the side rail (Low rail) before stepping away and then NA#1 heard a loud sound and found R#1 on the floor. Upon surveyor inquiry NA#1 indicated the bed was not in the lowest position at the time of the fall. NA#1 indicated the reason he/she put R#1 back in bed without calling for a nurse was that he/she just reacted and was concerned about R#1. Facility documentation identified NA#1 received written education pertaining to falls during orientation on ,[DATE] and [DATE]. Facility education records further identified NA#1 received education on falls during annual competencies on [DATE], [DATE] and [DATE].