Every finding on record at Havencare at Litchfield Woods

Based on clinical record review, facility documentation, facility policies, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation and controlled substances were properly accounted for and safeguarded from misappropriation. The findings include: Resident #1's diagnoses included intervertebral disc degeneration and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and received opioids in the prior seven (7) days. The Resident Care Plan (RCP) dated 2/9/26 identified pain medication therapy related to chronic pain. Interventions include administering analgesic medications as ordered by the physician. Physician orders dated 2/28/26 for Resident #1 directed to administer Morphine Sulfate Oral Solution 20mg/5mL, every four (4) hours, as needed for pain. The Facility Reportable Event (RE) form dated 4/1/2026 at 1:40 PM identified an allegation of misappropriation of Resident #1's Morphine (used to treat pain). Additional information identified Morphine 15 milliliters (mL) was missing, and the Morphine was still an active order for Resident #1. The medication had been delivered on 3/25/2026 and was last observed during the shift count on 4/1/2026. The facility RE Summary dated 4/11/2026 identified on 04/01/26, during the change of shift narcotic count between the off going 11-7 nurse and oncoming 7-3 nurse, it was noted that the liquid Morphine for Resident #1 was incorrect by 15 mL. The current physician order directed Morphine Sulfate oral solution 20mg/5mL, give 5 mL by mouth every four (4) hours as needed for pain. The 11-7 nurse signed out Two (2) doses of the medication (4/1/26 at 1:35 AM and at 6:30 AM). The count record went from 125 mL to 120 mL after the first dose, then from 120 mL to 115 mL after the second dose. At the time of the change of shift narcotic count, the count was noted to be 100 mL remaining in the bottle (off by 15 mL). Interview with Resident #1 identified he/she did not receive any Morhpine at 1:35, and did receive a dose at 6:30 AM. Facility investigation identified a suspected nurse, and the accused nurse denied the allegation. the accused nurse stated the count may have been off because she tilted the bottle when reading it (for counting) and state she should have placed the bottle on a level surface for better accuracy. Record review of the Controlled Substance Disposition Record for Resident #1's Morphine Sulfate oral solution (20 mg/5 mL) identified RN #1 documented administration of two PRN (as needed) doses on 4/1/26, at 1:35 AM and 6:30 AM. Although the documentation reflected the remaining volume decreased correctly to 115 mL, the documentation did not explain why the shift count was 100 mg at the end of the shift (off by 15 mL). Further review identified an additional entry dated 4/01/26 indicating a count correction, with a line drawn through the amount left column and the remaining volume documented as 100 mL, accompanied by a nurse signature. This entry reflects a 15 mL discrepancy from the expected remaining balance of 115 mL, with no corresponding documentation to account for the variance. Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #1 identified no documentation of the 1:35 and 6:30 AM PRN Morphine administrations reportedly provided by RN #1 on 4/01/26. The MAR/TAR lacked corresponding entries for these administrations. Interview with RN #2 on 5/5/26 at 11:45 AM identified the facility's process for controlled substance accountability includes completion of a narcotic count at each shift change for all residents receiving scheduled or PRN controlled medications. RN #2 reported that the off-going and oncoming nurses jointly verify the count for each medication, and upon completion, the off-going nurse transfers the medication cart keys to the oncoming nurse. RN #2 stated that on 4/1/26, while completing the change-of-shift narcotic count with RN #1 for their assigned medication cart, a discrepancy was identified involving Resident #1's morphine sulfate oral solution, with 15 mL unaccounted for. RN #2 reported that upon identification of the discrepancy, RN #1 did not provide an explanation or otherwise acknowledge the discrepancy and proceeded with her assigned duties. RN #2 reported the discrepancy to the RN Supervisor/Administration immediately following identification and continued with her assigned shift responsibilities. RN #2 further reported that Resident #1 did not exhibit increased complaints of pain and did not report concerns related to pain management during or immediately following the shift in question. Interview with RN #1 on 5/5/26 at 1:05 PM identified that at the beginning of her assigned shift (11:00 PM to 7:00 AM), she performed rounds on all assigned residents. RN #1 reported that prior to assuming responsibility for the medication cart, she completed a change-of-shift narcotic count with RN #3. RN #1 stated that RN #3 read aloud the expected controlled substance amounts from the count sheet, and RN #1 visually verified the remaining quantities in each medication container. RN #1 acknowledged that, although she agreed with the count at that time, she does not believe she performed a thorough verification of the morphine volume for Resident #1. RN #1 reported that following completion of the narcotic count, she met with Resident #1 to review PRN pain medication needs and provided education regarding the ordered frequency of administration. RN #1 stated that during her shift, she maintained possession of the medication cart keys at all times and did not provide access to other staff. RN #1 denied any incidents of spillage, leakage, or other events that could account for a 15 mL discrepancy in Resident #1's morphine sulfate oral solution. RN #1 described her medication administration process as withdrawing the prescribed dose into a syringe, transferring the medication into a medication cup, and administering it to the resident. RN #1 stated that she did not re-verify the remaining volume of the controlled substance following each PRN administration. RN #1 stated she was unable to provide an explanation for the 15 mL discrepancy and attributed the issue to a lack of thoroughness in completing the narcotic count verification, and denied diverting Resident #1's Morphine. Interview with the DON on 5/5/26 at 2:35 PM identified that on 4/1/26, the facility was notified by nursing staff of a narcotic discrepancy involving Resident #1, specifically an unaccounted loss of 15 mL of Morphine Sulfate oral solution identified during a change-of-shift count. The DON reported he conducted an interview with Resident #1, who stated he/she received only one of the two doses documented by RN #1 on the Controlled Substance Disposition Record. The DON stated that upon identification of the discrepancy and concern for potential misappropriation, the facility initiated required notifications to appropriate regulatory and law enforcement agencies, including the Connecticut Department of Public Health, the Drug Enforcement Administration, and local law enforcement, and initiated an internal investigation. The DON stated Drug Enforcement Administration conducted an interview with RN #1; however, details of the interview were not disclosed to the facility. The DON further reported that RN #1 declined to provide a statement as part of the facility's internal investigation and indicated she would communicate only with state and federal agencies. The DON concluded that, although the facility was unable to substantiate that RN #1 directly misappropriated the medication, the investigation determined that 15 mL of Resident #1's Morphine was unaccounted for and therefore considered misappropriation. Although attempted, interview with RN #3 was unable to be obtained. Review of the undated facility Abuse, Neglect, and Exploitation Policy directed the facility will provide protections and prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Misappropriation was defined as the means of deliberate misplacement, exploitation, or wrongful, temporary or permanent, used of a resident's belongings or money without the resident's consent.

Based on clinical record reviews, facility documentation, facility policies, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure a complete and accurate record to include accurate documentation of the resident's controlled medication administration record. The findings include: Resident #1's diagnoses included intervertebral disc degeneration and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and received opioids in the prior seven (7) days. The Resident Care Plan (RCP) dated 2/9/26 identified pain medication therapy related to chronic pain. Interventions include administering analgesic medications as ordered by the physician. Physician orders dated 2/28/26 for Resident #1 directed to administer Morphine Sulfate Oral Solution 20mg/5mL, every four (4) hours, as needed for pain. The Facility Reportable Event (RE) form dated 4/1/2026 at 1:40 PM identified an allegation of misappropriation of Resident #1's Morphine (used to treat pain). Additional information identified Morphine 15 milliliters (mL) was missing, and the Morphine was still an active order for Resident #1. The medication had been delivered on 3/25/2026 and was last observed during the shift count on 4/1/2026. The facility RE Summary dated 4/11/2026 identified on 04/01/26, during the change of shift narcotic count between the off going 11-7 nurse and oncoming 7-3 nurse, it was noted that the liquid Morphine for Resident #1 was incorrect by 15 mL. The current physician order directed Morphine Sulfate oral solution 20mg/5mL, give 5 mL by mouth every four (4) hours as needed for pain. The 11-7 nurse signed out Two (2) doses of the medication (4/1/26 at 1:35 AM and at 6:30 AM). The count record went from 125 mL to 120 mL after the first dose, then from 120 mL to 115 mL after the second dose. At the time of the change of shift narcotic count, the count was noted to be 100 mL remaining in the bottle (off by 15 mL). Interview with Resident #1 identified he/she did not receive any Morhpine at 1:35, and did receive a dose at 6:30 AM. Facility investigation identified a suspected nurse, and the accused nurse denied the allegation. the accused nurse stated the count may have been off because she tilted the bottle when reading it (for counting) and state she should have placed the bottle on a level surface for better accuracy. Record review of the Controlled Substance Disposition Record for Resident #1's Morphine Sulfate oral solution (20 mg/5 mL) identified RN #1 documented administration of two PRN (as needed) doses on 4/1/26, at 1:35 AM and 6:30 AM. Although the documentation reflected the remaining volume decreased correctly to 115 mL, the documentation did not explain why the shift count was 100 mg at the end of the shift (off by 15 mL). Further review identified an additional entry dated 4/01/26 indicating a count correction, with a line drawn through the amount left column and the remaining volume documented as 100 mL, accompanied by a nurse signature. This entry reflects a 15 mL discrepancy from the expected remaining balance of 115 mL, with no corresponding documentation to account for the variance. Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #1 identified no documentation of the 1:35 and 6:30 AM PRN Morphine administrations reportedly provided by RN #1 on 4/01/26. The MAR/TAR lacked corresponding entries for these administrations. Interview with RN #1 on 5/5/26 at 1:05 PM identified she did not document the administration of Resident #1's PRN morphine doses in the Medication Administration Record/Treatment Administration Record (MAR/TAR) during the 11:00 PM to 7:00 AM shift. RN #1 stated the shift was very busy and reported prioritizing medication administration over documentation, indicating she did not return to complete the required charting, and stated the care needs of multiple residents limited her ability to complete documentation in a timely manner. RN #1 stated all medication administrations are required to be documented in the MAR/TAR and confirmed that failure to do so was not consistent with facility policy or professional standards, and she should have completed the documentation. Interview with the DON on 5/5/26 at 2:35 PM identified RN #1 failed to document two (2) PRN Morphine administrations on the electronic Medication Administration Record/Treatment Administration Record (MAR/TAR), contributing to the inability to reconcile the controlled substance count. The DON stated RN #1 should have documented when the medication was administered. Review of facility Controlled Substance Handling Policy directed in part, immediately after a dose is administered, the licensed nurse administering the drug enters the date and time of administration, the dose administered, the signature of the nurse administering the dose. Review of the Policy failed to identify the Policy directed to record an accurate count after the dose was removed from the supply. Additional review failed to identify the policy directed the nurse to reconcile the count, or accurately count and record the amount of controlled substances remaining.

Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, Resident #2, and Resident #3) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Based on clinical record review, facility documentation review, facility policy review and interviews for three sampled residents (Residents #1, Resident #2, and Resident #3) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: 1. Resident #1 had diagnoses that included atrial fibrillation, atrioventricular heart block, heart failure, and depression. The physician orders dated 7/11/2025 directed to administer Apixaban (Eliquis; medication to prevent and treat blood clots) 5 milligrams (mg) by mouth two times per day at 9:00 A.M. and 9:00 P.M, Senna (used to treat constipation) 8.6 mg give 2 tablets by mouth at 9:00 P.M, Melatonin (sleep aid) 6 mg mouth at 9:00 P.M., Sodium Fluoride dental gel (prevent tooth decay) 1.1% apply to teeth at 9:00 P.M., Tamsulosin (Flomax; used to treat enlarged prostate symptoms) 0.4 mg daily at 9:00 P.M., Voltaren arthritis pain external gel (used to treat pain) 1% topical apply to shoulders topically two times per day at 9:00 A.M. and 9:00 P.M. and Lidocaine (used to treat pain) pain relief 4% patch apply to right shoulder topically at 9:00 A.M. and remove at 8:59 P.M. Review of the Medication Administration Record (MAR) identified on 7/28/2025 at 9:00 P.M., RN #4 did not sign off that she administered the Apixaban 5 mg, Senna 8.6 mg two (2) tablets, Melatonin 6 mg, Tamsulosin 0.4 mg, Sodium Fluoride dental gel 1.1%, Voltaren arthritis pain external gel 1% topical, failed to identified RN #4 signed to indicate removal of the Lidocaine pain relief 4% patch in accordance with physician orders. Interview with RN #4 on 9/4/2025 at 1:13 P.M. identified she was the charge nurse for Resident #1 on 7/28/2025 from 3:00 P.M. to 11:00 P.M. and the facility internet was not functioning (internet went down at the facility). RN #4 stated she could not access Resident #1's physician orders and could not access the MAR. RN#4 stated she did not administer Apixaban, Senna, Melatonin, Sodium Fluoride dental gel, Tamsulosin, Voltaren arthritis pain gel, and did not remove the Lidocaine patch. Further, RN #4 stated she did not administer the medications because she was not provided with a paper MAR. 2. Resident #2 had diagnoses that included dementia, depression, and constipation. Physician orders dated 7/24/2025 directed to administer Melatonin 6 mg by mouth at 9:00 P.M., Senna-time S oral tablet 8.6-50 mg give two (2) tablets by mouth at 9:00 P.M., and Memantine (used treat dementia) 10 mg give 1 tablet by mouth two times per day at 9:00 A.M. and 9:00 P.M. Review of the MAR identified on 7/28/2025 at 9:00 P.M., RN #4 did not sign the MAR to indicate she administered Resident #2's Melatonin 6 mg, Senna-S, or Memantine 10 mg in accordance with physician orders. Interview with Registered Nurse (RN) #4 on 9/4/2025 at 1:13 P.M. identified she was the charge nurse for Resident #2 on 7/28/2025 from 3:00 P.M. to 11:00 P.M. and when the internet went down at the facility, she could not access Resident #2's physician orders and the MAR. RN #4 stated on 7/28/2025 she did not administer Melatonin, Senna-S, or Memantine because she was not provided with a paper MAR. 3. Resident #3 had diagnoses that included gastro-esophageal disease, drug induced constipation, and anxiety. The physician orders dated 7/16/2025 directed to administer Clonazepam (used to treat panic disorder) 0.5 mg by mouth at 9:00 P.M., Dexilant (used to treat heartburn) oral capsule delayed release 60 mg give by mouth at 9:00 P.M., Docusate Sodium (stool softener) capsule 200 mg give by mouth at 9:00 P.M., Senna (used to treat or prevent constipation) 8.6 mg give 2 tablets by mouth at 9:00 P.M. Medical record review of the Medication Administration Record (MAR) identified on 7/28/2025 at 9:00 P.M. LPN #1 did not sign to indicate she administered Resident #3's Clonazepam, Dexilant, Docusate Sodium, and Senna in accordance with physician orders. Interview with LPN #1 on 9/4/2025 at 11:05 A.M. identified she was the charge nurse for Resident #3 on 7/28/2025 during the 3:00 P.M. to 11:00 P.M. shift and when the internet went down, she could not access Resident #2's physician orders and MAR. LPN #1 stated on 7/28/2025 she did not administer the Clonazepam, Dexilant, Docusate Sodium, or Senna. LPN #1 stated she did not administer the medications because she was not provided with a paper MAR. Interview, clinical record review and facility documentation review with RN #1/Regional Nurse #1 9/4/2025 at 3:15 P.M. identified resident medications should be administered in accordance with physician orders. RN #1 stated on 7/28/2025 at 3:15 P.M. there was a total of twenty (20) residents that missed their medications during the evening shift; the medications were not administered in accordance with physician orders because the internet access was not available. RN #1 identified on 7/28/2025 although paper MARs were printed for every resident, it was a long process to print the MARs. RN #1 further indicated that because it was taking a long time to print the MARs, the Administrator gave the nurses emergency remote access using their personal cell phones, however not all nurses were able to access the MARs using their personal cell phones. RN #1 stated a total of twenty (20) residents had medications omitted due to lack of access to the MARs. Interview with the Director of Nursing Services (Interim DNS) on 9/4/2025 at 10:50 A.M. identified was the RN supervisor on 7/28/2025 from 3 P.M. to 11:00 P.M. The DNS stated at approximately 7:43 P.M., the internet at the facility went down (was not accessible) and staff could not access the resident MARs, so medications could not be administered. The Interim DNS indicated staff were provided with paper MARs, were directed to administer the medications and to sign on the paper MARs when the medications were administered. The Interim DNS stated on 7/28/2025 she left the facility about around midnight and assumed medications were administered to the residents; the Interim DNS stated she did not check with the nurses to ensure all residents received their medications as ordered. The DNS indicated she was not aware that on 7/28/2025 during the 3 P.M. to 11 P.M. shift that medications were omitted for 20 residents. Interview with RN #5 (former Director of Nursing Services) on 9/4/2025 at 2:03 P.M. identified on 7/28/2025 she was notified at approximately 7:45 P.M. that the internet service was not accessible, and staff could not access the resident's physician orders and MARs; RN #5 stated without the internet, resident medications could not be administered. RN #5 stated she was in the facility printing paper MARs using the facility emergency back-up system, for approximately four (4) to five (5) hours for 149 residents, which resulted in late medication administration for residents throughout the facility. RN #5 stated she directed staff to use the paper MARs and to sign the paper MAR when they administered the medication (to indicate the medications were administered). Further, RN #5 stated she notified MD #1 (Medical Director) that medications were administered late, but she was unaware that medications were omitted for twenty (20) residents, including Resident #1, #2 and #3. Although RN #5 stated she checked with all the nurses before leaving the facility and the nurses told her all residents received their scheduled medications, RN #5 failed to identify why she was not aware twenty (20) out of 149 resident medications were omitted. Interview with APRN #1 on 9/4/2025 at 5:30 PM identified she was not notified on 7/28/2025 that access to the resident medical records was unavailable due to an internet outage in the facility. APRN #1 stated she was notified a day or two (2) later that the internet was not accessible, and the facility printed the MARs and all residents received their scheduled medications. A call was placed Call to MD #1 on 9/4/2025 at 12:08 P.M. regarding the late and omitted medications, with a message left requesting a call back. Subsequent to surveyor inquiry, MD #1 visited the facility regarding the medication errors. Interview with MD #1 (Medical Director) on 9/4/2025 at 1:34 P.M. identified he was in the facility regarding the late and omitted medications on 7/28/2025, and stated he was not notified that the internet access was unavailable for nurses on 7/28/2025, and indicated he became aware on 9/4/2025. MD #1 was not aware the staff had no access to medical records and the MARs or that the facility printed the MARs from the back-up system for staff to use. MD #1 stated he was not notified that any resident medications were late or not administered in accordance with physician/APRN orders; he was not aware medications were omitted for 20 residents. MD #1 indicated he would have expected to be notified that medications could not be administered timely, and if medications were omitted for 20 residents. MD #1 indicated if he was notified, he would have given additional orders and made any necessary adjustments to the resident's medication regimen. Interview with MD #1 on 9/4/2025 at 1:34 P.M. identified he reviewed all the omitted medications and identified there was no negative outcome as a result of late, or omitted medications, no adverse events and no hospitalizations. Review of facility undated Medication Administration policy, directed in part, to administer all medications within one hour before or after prescribed time, document all held or unavailable medications on the MAR, and inform the physician in a timely manner when medications are held, or otherwise unavailable. Review of facility undated Medication Error Policy, directed in part, if a medication error occurs in the administration of medications the physician must be notified immediately. Although requested, a policy for internet outage was not provided for surveyor review during the survey.

Based on clinical record review, facility documentation review, facility policy review, and interviews for three of three residents (Resident #1, Resident #2, and Resident #3) reviewed for medication errors, the facility failed to ensure the physician was notified timely of a facility internet outage, medication omissions and late medication administration. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for three of three residents (Resident #1, Resident #2, and Resident #3) reviewed for medication errors, the facility failed to ensure the physician was notified timely of a facility internet outage, medication omissions and late medication administration. The findings include: 1. Resident #1 had diagnoses that included atrial fibrillation, atrioventricular heart block, heart failure, and depression. The physician orders dated 7/11/2025 directed to administer Apixaban (Eliquis; medication to prevent and treat blood clots) 5 milligrams (mg) by mouth two times per day at 9:00 A.M. and 9:00 P.M, Senna (used to treat constipation) 8.6 mg give 2 tablets by mouth at 9:00 P.M, Melatonin (sleep aid) 6 mg mouth at 9:00 P.M., Sodium Fluoride dental gel (prevent tooth decay) 1.1% apply to teeth at 9:00 P.M., Tamsulosin (Flomax; used to treat enlarged prostate symptoms) 0.4 mg daily at 9:00 P.M., Voltaren arthritis pain external gel (used to treat pain) 1% topical apply to shoulders topically two times per day at 9:00 A.M. and 9:00 P.M. and Lidocaine (used to treat pain) pain relief 4% patch apply to right shoulder topically at 9:00 A.M. and remove at 8:59 P.M. Review of the Medication Administration Record (MAR) identified on 7/28/2025 at 9:00 P.M., RN #4 did not sign off that she administered the Apixaban 5 mg, Senna 8.6 mg two (2) tablets, Melatonin 6 mg, Tamsulosin 0.4 mg, Sodium Fluoride dental gel 1.1%, Voltaren arthritis pain external gel 1% topical, failed to identified RN #4 signed to indicate removal of the Lidocaine pain relief 4% patch in accordance with physician orders. Clinical record review failed to identify the physician/APRN was notified of the medications that were not administered on 7/28/2025. Interview with RN #4 on 9/4/2025 at 1:13 P.M. identified she was the charge nurse for Resident #1 on 7/28/2025 from 3:00 P.M. to 11:00 P.M. and the facility internet was not functioning (internet went down at the facility). RN #4 stated she could not access Resident #1's physician orders and could not access the MAR. RN #4 stated she did not administer Apixaban, Senna, Melatonin, Sodium Fluoride dental gel, Tamsulosin, Voltaren arthritis pain gel, and did not remove the Lidocaine patch. Further, RN #4 stated she did not notify the physician or APRN because she thought the DNS would do that. Interview with MD #1 (Medical Director) on 9/4/2025 at 1:34 P.M. identified he was not aware the listed medications were not administered as ordered on 7/28/2025 at 9:00 P.M. MD #1 stated he would have expected to be notified, and if he was notified, he would have given additional orders. 2. Resident #2 had diagnoses that included dementia, depression, and constipation. Physician orders dated 7/24/2025 directed to administer Melatonin 6 mg by mouth at 9:00 P.M., Senna-time S oral tablet 8.6-50 mg give two (2) tablets by mouth at 9:00 P.M., and Memantine (used treat dementia) 10 mg give 1 tablet by mouth two times per day at 9:00 A.M. and 9:00 P.M. Review of the MAR identified on 7/28/2025 at 9:00 P.M., RN #4 did not sign the MAR to indicate she administered Resident #2's Melatonin 6 mg, Senna-S, or Memantine 10 mg in accordance with physician orders. Clinical record review failed to identify the physician/APRN was notified of the medications that were not administered on 7/28/2025. Interview with Registered Nurse (RN) #4 on 9/4/2025 at 1:13 P.M. identified she was the charge nurse for Resident #2 on 7/28/2025 from 3:00 P.M. to 11:00 P.M. when the facility internet went down and she could not access Resident #2's physician orders and the MAR. RN #4 stated on 7/28/2025 she did not administer Melatonin, Senna-S, or Memantine, and she did not notify the physician or APRN because she thought the DNS would do that. Interview with MD #1 (Medical Director) on 9/4/2025 at 1:34 P.M. identified he was not aware the listed medications were not administered as ordered on 7/28/2025 at 9:00 P.M. MD #1 stated he would have expected to be notified, and if he was notified, he would have given additional orders. 3. Resident #3 had diagnoses that included gastro-esophageal disease, drug induced constipation, and anxiety. The physician orders dated 7/16/2025 directed to administer Clonazepam (used to treat panic disorder) 0.5 mg by mouth at 9:00 P.M., Dexilant (used to treat heartburn) oral capsule delayed release 60 mg give by mouth at 9:00 P.M., Docusate Sodium (stool softener) capsule 200 mg give by mouth at 9:00 P.M., Senna (used to treat or prevent constipation) 8.6 mg give 2 tablets by mouth at 9:00 P.M. Medical record review of the Medication Administration Record (MAR) identified on 7/28/2025 at 9:00 P.M. LPN #1 did not sign to indicate she administered Resident #3's Clonazepam, Dexilant, Docusate Sodium, and Senna in accordance with physician orders. Clinical record review failed to identify the physician/APRN was notified of the medications that were not administered on 7/28/2025. Interview with LPN #1 on 9/4/2025 at 11:05 A.M. identified she was the charge nurse for Resident #3 on 7/28/2025 during the 3:00 P.M. to 11:00 P.M. shift and when the internet went down, she could not access Resident #2's physician orders and MAR. LPN #1 stated on 7/28/2025 she did not administer the Clonazepam, Dexilant, Docusate Sodium, or Senna. LPN #1 identified she did not notify the physician or APRN because she thought the DNS or ADNS would notify them. Interview with RN #5 (former Director of Nursing Services) on 9/4/2025 at 2:03 P.M. identified on 7/28/2025 she did not notify MD #1 that the internet outage resulted in late medication administration for residents throughout the facility because she was focused on printing paper MAR's. RN #5 identified on 7/28/2025 she was not aware Resident #1, Resident #2, and Resident #3's had omitted medications and was unable to explain why she was not notified the medications were omitted. Interview, clinical record review and facility documentation review with RN #1/Regional Nurse #1 on 7/28/2025 at 3:15 P.M. identified there was a total of twenty (20) residents that missed their medications on 7/28/2025; the medications were not administered in accordance with physician orders because the internet access was not available. RN #1 stated the on-call physician/APRN, and the Medical Director/MD #1 should have been notified of all the late medication administration and that twenty (20) residents had medications omitted due to inability to access the MAR electronically. Interview with APRN #1 on 9/4/2025 at 5:30 PM identified she was not notified on 7/28/2025 that access to the resident medical records was unavailable due to an internet outage in the facility. APRN #1 stated she was notified a day or two (2) later that the internet was not accessible, and the facility printed the MARs and all residents received their scheduled medications. Interview with MD #1 (Medical Director) on 9/4/2025 at 1:34 P.M. identified he was not aware the listed medications were not administered as ordered on 7/28/2025 at 9:00 P.M. Further, MD #1 stated he was not aware a total of twenty (20) residents did not receive their medications as ordered. MD #1 stated he would have expected to be notified, and if he was notified, he would have given additional orders. Review of facility undated Medication Administration policy, directed in part, to inform the physician in a timely manner when medications are held, or otherwise unavailable. Review of facility Medication Error Policy, directed in part, if a medication error occurs in the administration of medications the physician must be notified immediately.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for medication administration, the facility failed to ensure the clinical record was accurate to include timely documentation when a medication was administered. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for medication administration, the facility failed to ensure the clinical record was accurate to include timely documentation when a medication was administered. The findings include: Resident #1 had diagnoses that included atrial fibrillation, atrioventricular heart block, heart failure, and depression. The physician orders dated 7/11/2025 directed to administer Apixaban (Eliquis; medication to prevent and treat blood clots) 5 milligrams (mg) by mouth two times per day at 9:00 A.M. and 9:00 P.M, Senna (used to treat constipation) 8.6 mg give 2 tablets by mouth at 9:00 P.M, Melatonin (sleep aid) 6 mg mouth at 9:00 P.M., Sodium Fluoride dental gel (prevent tooth decay) 1.1% apply to teeth at 9:00 P.M., Tamsulosin (Flomax; used to treat enlarged prostate symptoms) 0.4 mg daily at 9:00 P.M., Voltaren arthritis pain external gel (used to treat pain) 1 % topical apply to shoulders topically two times per day at 9:00 A.M. and 9:00 P.M. and Lidocaine (used to treat pain) pain relief 4% patch apply to right shoulder topically at 9:00 A.M. and remove at 8:59 P.M. The admission [NAME] Date Set (MDS) dated [DATE] identified Resident #1 was alert and oriented (had a Brief Interview for Mental Status (BIMS) score of fifteen). The Resident Care Plan dated 7/14/2025 identified Resident #1 received medication to increase blood to clotting time related to atrial fibrillation. Interventions directed to administer medication as ordered. Review of the Medication Administration Record (MAR) identified on 7/28/2025 at 9:00 P.M., RN #4 did not sign off that she administered the Apixaban (Eliquis) 5 mg in accordance with physician orders. Additional review failed to identify the Apixaban (Eliquis) was signed to indicate the dose due on 7/28/2025 was administered by any staff nurse. Interview with RN #4 on 9/4/2025 at 1:13 P.M. identified she was the charge nurse for Resident #1 on 7/28/2025 from 3:00 P.M. to 11:00 P.M. and the facility internet was not functioning (internet went down at the facility). RN #4 stated she could not access Resident #1's physician orders and could not access the MAR. RN#4 stated she did not administer Apixaban (Eliquis) to Resident #1 during her shift because she was not provided with a paper MAR. Interview with Licensed Practical Nurse (LPN) #5 on 9/4/2025 at 12:06 P.M identified she was the charge nurse from 11 PM on 7/28 ending at 7 AM on 7/29/2015. LPN #5 stated when her shift started she was informed the facility internet services was not accessible. LPN #5 further stated during shift report, RN #4 told her that she did not administer Resident #1's medications during the shift, including Apixaban (Eliquis). LPN #5 stated Resident #1 reported he/she had been waiting since 9 P.M. for his/her Apixaban (Eliquis) to be administered. LPN #5 indicated she connected the facility electronic medical record (EMR) to the hot spot on her iPhone and reviewed Resident #1's physician orders/MAR. LPN #5 identified that just before 12:00 A.M. on 7/28/2025 she administered Apixaban (Eliquis) 5 mg as requested by Resident #1; LPN #5 did not administer any other medications. LPN #5 stated she thought she signed the Apixaban (Eliquis) in Resident #1's electronic MAR to indicate that she had administered the Apixaban (Eliquis). Interview with RN #5 (former Director of Nurses) on 9/4/2025 at 2:03 P.M. identified the nurses should sign the MAR/medical record when a medication was administered. RN #5 was unable to explain why the Apixaban (Eliquis) was not signed as administered on 7/28/2025, and indicated she expected LPN #5 to sign off on Resident #1's paper MAR at the time she administered the medication. Review of the facility undated Medication Administration and Documentation Policy directed in part, to document administration of medication on the MAR immediately following administration.

Based on review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 5 residents reviewed for accidents (Resident #72), the facility failed to provide transfer assistance per the physician's order which resulted in a fall with a fracture. The findings include:Resident #72's diagnosis included dementia, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left dominant side, and right proximal humerus fracture.Review of the resident care card dated 10/18/24 indicated that Resident #72 was an assist of 1 for transfers with a rolling walker (RW)/four wheeled walker (FWW). A fall risk evaluation dated 11/16/24 identified Resident #72 was a moderate to high fall risk with a score of 10.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #72 was severely cognitively impaired and required partial/moderate assistance with bed mobility, and substantial/maximal assistance with toileting and transfers. The MDS indicated Resident #72 had not had any falls since admission/entry or reentry or on the prior assessment.The Resident Care Plan (RCP) dated 12/9/24 identified Resident #72 had left sided hemiplegia and required help with activities of daily living (ADL's) due to generalized weakness and had a risk for falls. Interventions included assistance of 1 with RW for transfers and toileting and to provide assistance with activities of daily living (ADL's). A physician's order dated 1/1/25 directed transfers with an assist of 1 and FWW for Resident #72.A Reportable Event form (RE) completed by Licensed Practical Nurse (LPN) #2 and dated 1/30/25 identified Resident #72 was being transferred to a shower chair and was lowered to the floor by Nurse Aide (NA) #4. The RE indicated the incident occurred on 1/30/25 at 7:30 AM in the shower room, NA #4 was a witness and an investigation was initiated.A nursing progress note written by RN #2 and dated 1/30/25 at 8:10 AM identified Resident #72 fell in the shower while being transferred from a wheelchair to a shower chair. The progress note indicated NA #4 stated he was transferring Resident #72, turned to move the wheelchair and the resident lost his/her balance and fell onto the floor. An In-service Attendance Sheet dated 1/30/25 identified NA #4 was educated on following a resident's transfer status and care plan when transporting a resident. The content of the in-service was indicated as It is important to follow policy when transferring a resident. Always check the care card prior to transferring a resident as their needs change constantly. The in-service attendance sheet was signed by NA #4 on 2/3/25.An Advanced Practice Registered Nurse (APRN) progress note dated 1/31/25 at 10:06 AM identified Resident #72 was status post (s/p) fall with x-ray of the pelvis and hip ordered. X-rays revealed no acute abnormality seen and the hip pain was resolved.An APRN progress note dated 2/1/25 at 7:54 AM identified Resident #72 had developed new bruising to his/her right medial arm at the elbow and an order for right arm x-rays was obtained to rule out a fracture were obtained.Review of Resident #72's clinical record identified a right shoulder/right forearm x-ray was completed on 2/1/25 with results indicating a right humeral neck non-displaced impact fracture. A nursing progress note dated 2/1/25 at 1:00 PM identified Resident #72 was observed to have a large area of bruising to his/her right inner arm proximal to the elbow and the resident had pain upon movement of his/her right arm. The progress note indicated Resident #72 was status post (s/p fall ) on 1/30/25 and the APRN was notified, and x-rays were ordered and results indicated a non-displaced fracture of the humeral head. An investigation statement, written and signed by NA #4, dated 2/3/25 for a date of occurrence of 1/30/25, identified he took Resident #72 to the bathroom for a shower and when transferring the resident from the wheelchair to the shower chair NA #4 was standing behind the resident holding him/her by the waist. NA #4 indicated he took his right hand off the resident to push the wheelchair out of the way and while holding the resident with only his left-hand, Resident #72 began to lean to the left and fell onto the floor.A consultant report from the Orthopedist dated 2/5/25 identified Resident #72 had a right proximal humerus fracture and was placed in a right [NAME] brace (a rigid, plastic shell type of brace used to treat a fracture of the upper arm bone). The brace was to be left on and could be removed for hygiene purposes daily.Interview and review of the clinical record with the DNS on 7/18/25 at 10:45 AM identified Resident #72 was an assist of 1 for transfers and on 1/30/25 when transferring the resident from a wheelchair to a shower chair, NA #4 should have always had both hands on the resident. The DNS indicated NA #4 was re-educated after the incident due to not following procedure which led to Resident #72's fall and subsequently identified fracture. Interview and review of the clinical record with the nursing supervisor (RN #2) on 7/18/25 at 2:20 PM identified she recalled Resident #72's fall on 1/30/25 and was called to the floor after the incident. RN #2 reviewed NA #4's statement and indicated that NA #4 should not have taken his hand off Resident #72 because as a transfer assist of 1 the NA should have kept both hands on the resident during the transfer. RN #2 identified that NA #4 did not follow procedure and was re-educated after the incident. Interview and review of the clinical record with the Administrator on 7/21/25 at 9:55 AM indicated Resident #72 was an assist of 1 for transfers and on 1/30/25 when transferring the resident from a wheelchair to a shower chair, NA #4 should not have taken his hand off the resident during the transfer and in doing so he caused the resident to fall. The Administrator identified that NA #4 did not follow procedure and was re-educated after the incident. Additionally, the Administrator was notified of the surveyor's inability to contact NA #4 by the means provided and the Administrator indicated NA #4 was out of the country.Interview and review of the clinical record with the Director of Rehab (PT #1) on 7/21/25 at 11:00 AM identified an assist of 1 transfer order meant one staff person assisted the resident and the staff should always have both hands on the resident during the transfer. After review of the 1/30/25 incident documents, PT #1 indicated NA #4 should not have taken one hand off Resident #72 while transferring the resident from a wheelchair to a shower chair. Per PT #1, doing so left Resident #72 without full support on both sides of his/her waist which caused the resident to fall towards his/her weakened left side and onto the shower room floor. PT #1 indicated he regularly provided education to the NA staff on resident transfers and would plan to do another training soon.Multiple attempts to interview NA #4 and were unsuccessful.Review of the facility policy, Activities of Daily Living, directed for each resident a program of assistance and instruction in ADL skills is developed and implemented based on the individual's evaluation to encourage the highest level of function.

Based on observations, interviews, facility documentation, and facility policy, the facility failed to ensure food served appeared appetizing, at appropriate temperatures and was palatable. The findings include: 1. Interview with Resident #135 on 7/15/25 at 10:00 AM identified the food was either undercooked or overcooked.Interview with the Director of Dining Services (DDS) on 7/15/25 at 10:17 AM identified that the facility used a point of service, steam table, system for meal service with breakfast items placed in the steam tray at 7:00 AM for service beginning at 7:30 AM, lunch items placed in the steam table at 11:00 AM for service beginning at 11:30 AM, and dinner items placed in the steam table at 4:30 PM for service beginning at 5:00 PM.Interview with Resident #136 on 7/15/25 at 10:20 AM identified the food was cold and the portions were small.Interview with Resident #145 on 7/15/25 at 10:38 AM identified the food was cold at times.Observation in the first-floor resident dining room on 7/15/25 at 11:47 AM identified that meals were portioned from a steam table plugged in for temperature maintenance, and ceramic plates were observed stacked without a warming device. Food was plated by a dietary aide, using a printed meal ticket for reference, onto the ceramic plates covered by clear plastic covers with a circular hole in the center. A second dietary aide then confirmed plated items and provided the prepared food plates to a nurse aide for delivery to the residents. Interview with the DDS on 7/17/25 at 12:42 PM identified that the facility does not use a plate warmer or insulated cover system.Observation of the tray line on 7/17/25 at 12:42 PM identified the ground-floor meal delivery cart was brought down the hall from the kitchen to the ground-floor nursing unit. All meal trays were plated by dietary staff and then delivered to the residents by nurse's aide staff on the unit. The test tray was the last tray plated in the nursing unit kitchenette at 12:53 PM and the following temperatures were obtained by the surveyor and DDS:The Shepherd's pie was 164.1 degrees Fahrenheit (F) with the surveyor's thermometer and 165 degrees F with the DDS thermometer; the Herbed baked fish was 127.9 degrees F with the surveyor's thermometer and 126 degrees F with the DDS thermometer. The string beans were temped at 151 degrees F with the surveyor thermometer and 149 degrees F with the DDS thermometer.Interview with DDS on 7/17/25 at 12:54 PM identified the food temperatures were low for the herb baked fish and further identified the temperature should be at or above 135 degrees (F) for hot hold temperature, 145 degrees (F) for cooked temperature.Review of documentation provided by the DDS included the following:Daily Temperature Log, dated 7/17/25, with recorded entree temperatures for each steam table indicated that the alternate entree of fish was placed into table 1 at 140 degrees (F) and table 2 at 137 degrees (F), with cook #1 initials on the log. Based on an interview with DDS on 7/17/2025 at 12:54 PM and review of the dining services staff training, this was below the acceptable internal temperature for fish.Dining Services Staff Training, revised February 2005, described the minimum safe internal cooking temperatures for all food types. Fish required an internal temperature of 145 degrees (F).Inservice Attendance from 6/2/25 regarding temperature logs, included content about completion of temperature logs daily including documentation of food temperatures.A page titled Holding Food from ServSafe Manager (facility reference) identified hot food should be held at a temperature of 135 degrees (F) or higher.2. Interview with Resident #86 on 7/15/25 at 10:38 AM identified the food was terrible.Observation in the first-floor resident dining room on 7/15/25 at 11:47 AM for lunch service identified the menu being served included herbed pork, polenta, carrots, and strawberry cake. The herb pork and polenta being served appeared visibly dry in texture/consistency.Interview with Resident #145 on 7/15/25 at 12:45 PM identified the food was tasteless at times.Interview with Resident #10 on 7/15/25 at 3:01 PM identified there was limited fresh fruit and he/she would love to have an apple every day, but they don't have them, and he/she stated there were limited diabetic food options.Observation of lunch service in the ground floor resident dining room on 7/17/25 at 12:42 PM identified a lunch menu of shepherd's pie, string beans and baked fish. The baked fish appeared to be heavily seasoned with a excessively thick layer of seasoning coating the fish.A food tray for tasting was conducted. The tray was delivered 7/17/25 at 12:55 PM, identified excessive and overly seasoned mashed potatoes used for the shepherd's pie, and further identified an unappealing visual consistency of the string beans (mushy).Interview with DDS on 7/17/25 at 1:21 PM identified that recipes were not routinely followed for food preparation and reported no formal policy to follow recipes. DDS identified [NAME] #1 had prepared the food for the day. DDS identified he tasted only the beef for the shepherd's pie prepared for lunch. DDS further identified there was no formal recipe for the herb baked fish served for the day and subsequently provided a recipe for the shepherd's pie and lemon baked fish as requested.Interview with [NAME] #1 on 7/18/25 at 9:46 AM, with the DDS present, identified that recipes were not routinely used to prepare food, and not all food items had a recipe in the recipe book available. When a recipe was not available, she stated that she googled heart healthy/low carb recipes for preparation or asked the DDS about preparation.Cook #1 described how the shepherd's pie was prepared, stating that she used Adobo seasoning for the mashed potatoes that had been identified as excessively seasoned the day before. She identified that when preparing the baked fish, she accidentally opened the incorrect side of the seasoning container resulting in more seasoning covering the fish than intended, which she then attempted to correct with limited result. She indicated that typically when she was unsure of preparation or there were any errors in preparation, the DDS was consulted for assistance, however on 7/17/25, she did not want to interrupt the DDS who she felt was busy throughout the building that day.Interview with DDS 7/18/25 at 9:46 AM identified that the cooks have been instructed to use recipes moving forward for all meal preparations to ensure consistency in preparation, and to seek his assistance whenever needed. Additionally, the DDS indicated that he will be testing a souffle cup of each food item before distribution to the residents to verify taste and consistency.Although requested, policies for food committee process and content, food preparation process, recording food temperatures were not provided. Per the DDS formal polices were not available, instead dining services staff training and in-services were provided as evidence of education about expected practices/procedures.

Based on observations, interviews, facility documentation, and facility policy, the facility failed to ensure that refrigerator/freezers out of range temperatures in 3 of 3 kitchenettes were identified and reported to the Director of Dining Services and failed to identify/recognize when low temperatures were displayed on the dial during the dishwasher cycle. The findings include: During a kitchen tour and interview with the Director of Dietary Services (DDS) on 7/15/25 at 10:17 AM it was identified that the dietary service department cooks completed the Daily Temperature Log for all refrigerators in the kitchen and the refrigerator logs that were on the resident units in the kitchenettes. The cooks also checked expiration dates for refrigerator contents while the Infection Control Nurse verified the expiration dates as well.On 7/15/25 at 12:40 PM, observation of the kitchenette area/nourishment room located within the 1st floor dining room, identified the refrigerator, located within the kitchenette, was observed to be at 38 degrees Fahrenheit (F) and to include the following items inside: (4) Lactaid bottles; (3) 1/2 cups of yogurt; (1) 1 oz. Sour Cream; (2) 4 oz. containers of nectar thick water; (1) 4oz. containers of nectar thick orange juice; (1) 24 oz. jar of pickles - resident labeled; (8) oz. containers of apple sauce; (1) resident takeout container of Thai food; (3) additional takeout containers of resident food; (1) 1/8 container of resident food; (1) resident fruit container; (1) resident takeout container of fettucine1.Review of the Nourishment Room Refrigerator/Freezer Temperature Logs for the first-floor refrigerator/freezer indicated that in July 2025, 10 of 15 recorded temperatures and in June 2025, 17 of 30 recorded temperatures were out of range. According to the log, acceptable ranges for the refrigerator were 35-41 degrees and the freezer was 0 degrees or less. The log instructed the reporter to report all temps out of range. Interview with the DDS on 7/15/25 at 12:40 PM indicated that the DDS to reviews the logs and explained what Report All Temps Out of Range meant. The DDS indicated that this meant that any abnormal temperatures should be reported to him, but identified he was not made aware of the out of range temperatures for June 2025 and July 2025. The DDS indicated that the cook who recorded the temperatures was present on the unit at that time, would verify with [NAME] #1 and return with copies of the logs. Upon return at 12:45 PM, The DDS reported that the [NAME] #1 informed him that she took the temp and twice got low readings, so adjusted the dial in the fridge herself to accommodate the issue, but didn't notify anyone. Observation on 7/16/25 at 3:00 PM of the second-floor resident kitchenette area/nourishment room which was located to the side of the resident dining room. The refrigerator, located within the kitchenette, was observed to be at 30 degrees (F) and to include the following items inside: (12) 1/2 cups of yogurt; (1) snack pack; (8) 4 oz. containers of nectar thick water; (7) 4 oz. containers of nectar thick apple juice; (1) chocolate syrup container; (9) 8 oz. containers of apple sauce; (1) Italian Dressing; (1) 1/4 full 2% milk; (3) covered jugs of orange juice; (1) resident ham and cheese sandwich dated; (1) resident salad dated; (3) 2 full and 1 partially full covered jugs of cranberry juice; (4) 3 full and 1 partially full covered jugs of milk; (1) 1/4 full whole milk; Freezer - (1) box popsicles; (1) box magic cups; (1) box regular ice cream 2. A review of the Nourishment Room Refrigerator/Freezer Temperature Logs for the second-floor refrigerator/freezer indicated that in July 2025, 10 of 15 recorded temperatures and in June 2025, 17 of 30 recorded temperatures were out of range According to the log, acceptable ranges for the refrigerator were 35-41 degrees (F) and the freezer was 0 degrees (F) or less. The log instructed the reporter to report all temps out of range.Interview with DDS on 7/16/225 at 3:18 PM indicated that he was not made aware of the multiple dates with out-of-range temperatures recorded on the second-floor resident Nourishment Room Refrigerator/Freezer Temperature Logs. The DDS indicated that subsequent to surveyor identification, he held an inservice with all cooks on 7/16/25 to review how to properly complete these logs as a manner of remediation for the observed issues reported. This inservice included notification criteria anytime out-of-range temperatures were obtained. Additionally, the DDS ordered new thermometers for all refrigerators and freezers, ten in total.An interview with [NAME] #1 on 7/17/25 at 9:41 AM regarding out of range temperatures from the resident nourishment room refrigerator/freezer indicated that she did not do anything about the out-of-range temperatures at the time she took them and that she was confused by the log [instructions]. 3.A review of the Nourishment Room Refrigerator/Freezer Temperature Logs for the ground-floor refrigerator/freezer indicated that in June 2025, 10 of 30 recorded temperatures were out of range with 2 missing recorded temperatures and in May 2025, 18 of 31 recorded temperatures were out of range. According to the log, acceptable ranges for the refrigerator were 35-41 degrees (F) and the freezer was 0 degrees (F) or less. The log instructed the reporter to report all temps out of range. This review was shared with the DDS. 4. The facility utilized a 3-bay sink with pre-diluted sanitizer, that was used primarily for soaking large pans only. The DDS indicated that all pots and dishes can fit into the high heat dishwasher, and therefore the dishwasher was used for most items.On 7/15/25 at 10:00 AM, the DDS indicated that the dishwasher temperatures were supposed to be 160 degrees (F) for the wash cycle and 180 degrees (F) for the rinse cycle, and that the temperatures were recorded on the Daily Temperature Log by the morning and evening cooks.Observation of a dishwasher cycle on 7/17/25 at 10:03 AM with the DDS, and observing Dietary Aide (DA) #1 and Dietary Aide (DA) # 2 in the dishwasher area processing dishes from breakfast service. DA #1 handled the dirty dishes exclusively and DA #2 handled the clean dishes exclusively. One (1) tray of 16 plates and one (1) tray of plate covers, approximately 8-10 covers, were passed through the dishwasher, however during surveyor observation of this cycle, the wash temperature was 129 degrees (F) and rinse temperature was 143 degrees (F), below the required 160 and 180 degrees (F) respectively. DA #1 and DA #2 did not identify low wash/rinse temperatures, did not view the wash/rinse cycle and continued passing the racks of dinnerware/plate covers through the machine. The plates and covers previously run through the dishwasher at below temperature range were put on a cart by DA #2 to be placed in circulation due to DA #1 and DA #2 not identifying low wash/rinse temperatures.The Director of Dining Services was immediately notified of the temperature by the surveyor, and came out to observed the dishwasher cycle. Subsequent to surveyor inquiry, the DDS instructions DA #2 to be put the plate covers and plates through the dishwasher again once it reached the appropriate temperature per the DDS direction.Interviews of DA #1 and DA #2 on 7/17/25 at 10:05 AM identified neither had checked the temperature of the dishwasher during the cycle because they were not aware to do so and therefore did not notice below normal wash/rinse temperatures. DA #1 stated he did not check the temperature between passing racks through the dishwasher because the machine was usually at 180 degrees (F) and he does not double check the temperature between passes. The Director of Dining Services indicated that the machine should be160 degrees (F) for the wash cycle and 180 degrees (F) for the rinse cycle.The Director of Maintenance was contacted by the DDS at 10:08 AM and reported that the storage tank for kitchen water, which he indicated was a separate tank from resident water, was checked every morning and was 172 degrees (F) the same morning. Prior to coming to the kitchen, the tank was at 142 degrees (F), indicating that a large amount of hot water had been used, or that some other potential problem was occurring with the dishwasher. The Director of Maintenance also reported that the dishwasher typically ranges between 158-162 degrees (F) and that he had contacted the vendor to check both the storage tank and the dishwasher for any other mechanical causes of the low temperatures.Review of the Daily Temperature Log for 7/17/25, completed by [NAME] #1 in the early morning at approximately 5:30 AM indicated that the dishwasher temperatures were 170 degrees (F) for the wash cycle and 180 degrees (F) for the rinse cycle.Interview with the DDS on 7/17/25 at 10:10 AM indicated that there was no written policy about checking that the dishwasher temperatures were at expected levels between wash cycles, but that this was a verbal policy, with the dietary staff being aware that each was to notify the DDS if the temperatures were not as expected.Although requested, policies were not received to illustrate refrigerator temperature recording (requested 7/15/2025) and verification of dishwasher wash/rinse cycle temperatures (requested 7/17/25). Per the DDS formal written policies are not in place, instead verbal instruction and dining services training and in-services were provided as evidence of education about expected practices/procedures.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #78) reviewed for Pre-admission Screening and Resident Review (PASRR), the facility failed ensure a Level 2 PASRR evaluation was completed after a new post-admission diagnosis of major depression. The findings include:Resident #78's diagnoses included major depression, post-traumatic stress disorder (PTSD) and anxiety disorder. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 was cognitively intact, and independent with toileting, transfers and bed mobility. Additionally, the MDS identified a diagnosis of depression, post-traumatic stress disorder (PTSD), and anxiety disorder despite being coded as 0 or No for PASRR 2/serious mental illness.The Resident Care Plan (RCP) dated 5/21/25 identified Resident #78 was at risk for behavior problems, verbal outbursts, refusals of daily care, and trouble sleeping due to diagnoses of depression, PTSD and anxiety with the use of psychotropic medications. Interventions included to monitor sleep, appetite, and level of participation and to redirect/explain/reinforce when the resident's behavior was inappropriate/unacceptable and to intervene as necessary to protect the rights and safety of others with psychiatric follow-up as needed/indicated. Interview and review of the clinical record with the Director of Social Work (SW #1) on 7/17/25 at 10:45 AM indicated Resident #78 had a negative Level 1 PASRR completed in January 2020 and while a resident of the facility in August 2023, Resident #78 was diagnosed with a major depressive disorder. SW #1 identified that although Resident #78 should have been referred for the completion of Level 2 PASRR in August 2023, the referral was not made, and she was not sure of the reason it was not done. SW #1 indicated it would have been the Social Service departments responsibility to ensure the Level 2 PASRR was requested and completed in August 2023.Subsequent to surveyor inquiry, on 7/17/25 at 12:55 PM, SW #1 provided a copy of the referral made on 7/17/25 for the completion of a Level 2 PASRR screening for Resident #78. The referral identified the resident had never had a Level 2 PASRR evaluation and showed signs and symptoms that indicated he/she may have a PASRR condition with mental health diagnoses of current major depression and current anxiety disorder.Review of the facility policy, PASRR Policy and Procedure, undated, directed that a new Level 2 PASRR screen will be completed by the social service staff when a resident experiences a significant change in status which indicates a worsening PASRR condition or the presence of a PASRR condition that was not previously identified.

Based on resident and staff interviews, facility tours, and review of facility policy for snacks, the facility failed to ensure adequate snacks were available and also distributed/offered to residents who were unable to request. The findings include: Interview with Resident #43 on 7/15/25 at 10:15 AM identified that the facility took all our snacks away, and our only option for snacks is saltines. During the kitchen tour on 7/15/25 at 10:17 AM, the Director of Dining Services (DDS) indicated that nourishments were available on each unit, including crackers, cookies, fruit, and sandwiches. The DDS indicated that these were stocked twice daily at 1:00 PM and by the night cook after dinner.Interview with Resident #136 on 7/15/25 at 10:20 AM identified that there were no snacks anymore.Interview with Resident #120 on 7/15/25 at 10:35 AM identified that snacks were not available unless you ask, and there were not many available.Observations on 7/15/25 at 12:40 PM on the first-floor kitchenette indicated that there were what appeared to be lock mechanisms attached to the refrigerator, freezer, and microwave. These appliances were not locked at any time during the survey period, however multiple staff reported that these were previously locked with padlocks as directed by an independent nurse consultant. There were no non-perishable items/food items in the cabinets of the kitchenette.Interview with Resident #10 on 7/15/25 at 3:01 PM identified that the facility limited snack choices now you have to ask for them, and anything good was gone by the time you get to something.Observation and review on 7/16/25 at 3:00 PM appear to indicate restricted access to snacks. Review 7/16/25 at 3:00 PM of the second-floor kitchenette refrigerator temperature logs from July 2025 noted that on 7/4/25, 7/5/25, 7/6/25 and 7/9/25 the freezer temperature was recorded as locked. Additionally, there was a sign on this refrigerator that stated: soda no longer kept in fridge, ask RN. Interview with the DDS on 7/17/25 at 9:41 AM identified that cabinets in each kitchenette were not stocked because some residents took multiple snacks, therefore non-perishable snacks, such as crackers, have been moved behind the nurse's station. The DDS indicated that since the new company acquired the facility, snack order options have been limited to graham crackers and saltines, versus the prior orders that included items such as cookies and cheese flavored crackers that residents enjoyed. The DDS indicated that any leftover sandwiches from the cold carts from lunch were stocked in the unit refrigerators (but that was not observed), and additional cold sandwiches were brought to the units after dinner service. Interview with Nurse Aide (NA) #5 on 7/17/25 at 3:25 PM identified that snacks were kept in the clean utility room, behind the nurse's station and not accessible to residents. NA #5 indicated that previously there were more options for snacks, but these had been reduced. She reported that she distributed snacks at approximately 8:00 PM nightly to the residents on her assignment, when she was able, however when she gets too busy she relied on the residents putting on a call light to request a snack. She was unable to quantify how often she was able to distribute snacks.A Resident Council Meeting, held on 7/17/25 at 2:34 PM, indicated feedback from residents that included Resident #135 reporting that graham crackers and saltines were the only available snacks, that snacks were not offered anymore, and that there were locks on the refrigerator.Review of the Policy and Procedure Manual dated August 2015, page two, titled Snacks, directed, in part the following: Snacks will be made available to residents/patients at designated times and whenever requested; Diabetic residents who have HS snacks recommended by Dietitian and Physician will have snacks documented on MAR by a licensed nurse. Subsequent to surveyor inquiry, the DDS provided a copy of a new HS Snack Sign-In on 7/18/25 at 10:00 AM, indicating that this process was instituted for the dietary staff to complete when distributing evening snacks with a signature from the unit nurse receiving the snacks to ensure these are delivered to each unit.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for the 3 sampled residents (Resident #56, Resident #86 and Resident #109) reviewed for respiratory care, the facility failed to ensure the portable oxygen E-tanks (tall steel tank) were safely stored in resident rooms. 1. Resident #56 had diagnoses that included diabetes, heart failure, and anemia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 was cognitively intact, required oxygen therapy, setup or clean-up assistance with eating, supervision or touching assistance with transfers, and was independent with walking 10 feet.The Resident Care Plan (RCP) dated 6/18/25 identified Resident #56 had anemia. Interventions included signs of anemia may include pallor, shortness of breath, fatigue, weakness, general malaise, palpitations or chest pain. The RCP failed to identify Resident #56 received oxygen therapy.An Interdisciplinary Care Plan Meeting form dated 6/18/25 at 10:45 AM identified Resident #56 required oxygen therapy at 2 liters per minute via nasal cannula tubing.Observation in Resident #56's room on 7/18/25 at 6:26 AM identified a freestanding oxygen E-tank by the room entry doorway that was not in a holder/stand.Observation in Resident #56's room on 7/18/25 at 7:45 AM identified the oxygen E-tank was no longer visible in the room.2. Resident #86 had diagnoses that included chronic obstructive pulmonary disease (COPD), bipolar disorder, and transient cerebral ischemic attack.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #86 was cognitively intact, required oxygen therapy, setup and clean-up assistance with eating, and was independent with transfers and walking.The Resident Care Plan (RCP) dated 4/21/25 identified Resident #86 had oxygen therapy related to COPD. Interventions included to provide extension tubing or portable oxygen apparatus. A physician order from April 2025 and currently in effect directed to administer oxygen via nasal cannula at 2 liters per minute (lpm) for oxygen saturation less than 92%.Review of the Resident Care Card dated 6/18/25 failed to identify Resident #86 was on oxygen and subsequently did not include directions for nursing staff related to care and storage of the portable oxygen tank for Resident #86.Observation in Resident #86's room on 7/16/25 at 11:43 AM and on 7/18/25 at 10:21 AM identified a full portable oxygen E-tank (needle in the green on the gauge) inside a transport bag. The oxygen tank was standing upright on floor leaning against the side of a chair and the wall. The oxygen tank was not secured inside a stand.Observation and interview with Nurse Aide (NA) #3 on 7/18/25 at 11:30 AM identified Resident #86 was provided a portable oxygen E-tank for use when he/she left the unit. NA #3 identified the 11:00 PM to 7:00 AM shift would go around in the morning and ensure everyone's portable oxygen tanks were full and they would leave the tanks in the room. NA #3 identified when Resident #86 wasn't using his/her portable oxygen tank, it was stored in it's current position (upright on the floor next to the chair and leaning against the wall) where Resident #86 could easily reach it.Observation in Resident #86's room on 7/21/25 10:21 AM identified a full portable oxygen E-tank (needle in the green on the gauge) inside a transport bag. The oxygen tank was standing upright on floor leaning against the side of a chair and the wall. The oxygen tank was not secured inside a stand.3. Resident #109 had diagnoses that included heart failure, chronic obstructive pulmonary disease (COPD), and anemia.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #109 was severely cognitively impaired and used a manual wheelchair. The MDS assessment further identified Resident #109 required oxygen therapy, setup or clean-up assistance with eating, partial/moderate assistance with chair/bed transfers, and substantial/maximal assistance with manual wheelchair mobility.The Resident Care Plan (RCP) dated 6/9/25 identified Resident #109 had COPD. Interventions included oxygen therapy via nasal cannula at 2-4 liters per minute (lpm) and change oxygen tubing weekly.A physician order dated 9/27/22 and currently in effect directed to administer oxygen via nasal cannula at 2 liters/pm.A physician order dated 8/24/23 and currently in effect directed to check and fill portable oxygen every shift. (portable oxygen tanks are no longer filled by staff and are instead pre-filled E-tanks)Observation in Resident #109's room on 7/18/25 at 6:26 AM identified a freestanding oxygen E-tank next to a wheelchair, that was not in a holder/stand.Observation in Resident #109's room on 7/18/25 at 7:45 AM identified the oxygen E-tank was secured in a holder on the back of the wheelchair.Interview with Licensed Practical Nurse (LPN) #1 on 7/18/25 at 9:40 AM identified that sometimes the portable oxygen E-tanks were stored in resident's rooms when not in use and there were rolling stands that the tanks could be placed in for storage in the room, but there were only approximately 5 of those stands available so some residents didn't have a stand and the oxygen tank would be placed next to a chair for support against the wall.Review of facility documentation obtained 7/21/25 identified In-service Attendance form(s) dated 5/14/25 for in-service topic oxygen portable tanks. The forms identified staff were provided demonstration of how to use the new oxygen cylinder regulators, use of the travel caddy, and use of the oxygen bag for attaching the oxygen tank/cylinder to the wheelchair and/or walker. The forms identified 57 staff members were provided education. The forms failed to identify LPN #1 had attended the in-service. Review of the Oxygen Administration policy directed, in part, the procedure for administering low-flow oxygen included the equipment of high-pressure oxygen cylinder. The policy directed proper handling and storage of oxygen tanks was crucial to prevent accidents and ensure resident safety. The policy further identified for storage to use a cart or stand designed for oxygen tanks to prevent them from falling and to handle tanks with care to avoid dropping or damaging them.

Based on review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 5 residents (Resident #72) reviewed for accidents, the facility failed to notify a resident's responsible party of a fall. The findings include: Resident #72's diagnosis included dementia, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left dominant side, and right proximal humerus fracture. The annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #72 was severely cognitively impaired and required partial/moderate assistance with bed mobility, and substantial/maximal assistance with toileting and transfers. The MDS indicated Resident #72 had not had any falls since admission/entry or reentry or on the prior assessment. The Resident Care Plan (RCP) dated 12/9/24 identified Resident #72 had left sided hemiplegia and required help with activities of daily living (ADL's) due to generalized weakness and had a risk for falls. Interventions included assistance of 1 with a rolling walker (RW) for transfers and toileting and to provide assistance with ADL's. A nursing progress note (RN #2) dated 1/30/25 at 8:10 AM identified Resident #72 fell in the shower while being transferred from the wheelchair to a shower chair. The progress note indicated NA #4 stated he was transferring the resident and he turned to move the wheelchair and the resident lost her balance and fell onto the floor. The progress note failed to indicate if the resident's responsible party had been notified of the fall. A nursing progress note (LPN #2) dated 1/30/25 at 8:20 AM identified Resident #72 was observed on the floor in the bathroom on 1/30/25 at 7:30 AM with a NA in the room and after the fall the resident complained of left hip pain and an x-ray was ordered. The progress note failed to indicate if the resident's responsible party had been notified of the fall. A Reportable Event Form (REF) completed by LPN #2 and dated 1/30/25 identified Resident #72 was being transferred to a shower chair and was lowered to the floor by NA #4. The REF indicated No for Family Notification and self was written below the No box. An interview with Person #3 on 7/18/25 at 9:53 AM identified he was emergency contact #2 for Resident #72. Person #3 indicated he did not recall being notified of Resident #72's fall on 1/30/25 and that the facility likely called Person #1 first. An interview with Person #1 on 7/18/25 at 9:56 AM identified he was the responsible party (RP) and emergency contact #1 for Resident #72. Person #1 indicated that he was unsure if he was notified of Resident #72's fall on 1/30/25 and would need to check his phone records. Another interview with Person #1 on 7/18/25 at 10:15 AM identified that he reviewed his phone records and did not have a call from the facility until 2/3/25. Person #1 indicated he was not notified of Resident #72's fall on 1/30/25 but he did recall being notified on 2/3/25 about the resident's subsequent fracture due to the fall. Interview and review of the clinical record with the DNS on 7/18/25 at 10:45 AM indicated it would have been the charge nurse or nursing supervisor's responsibility to inform Resident #72's RP of his/her fall on 1/30/25. The DNS was unsure why LPN #2 indicated No and self on the REF and review of RN #2 and LPN #2's progress notes for 1/30/25 failed to identify that Resident #72's RP was notified of the fall. The DNS indicated she was unable to find documentation which reflected Resident #72 was her own responsible party on 1/30/25 and that she would need to provide further education to RN #2 and LPN #2. Interview and review of the clinical record with LPN #2 on 7/18/25 at 2:05 PM identified she recalled the incident with Resident #72 on 1/30/25 and agreed with her documentation on the REF. LPN #2 indicated that since the REF and her progress note failed to identify that she had notified Resident #72's RP of the fall, then she did not notify the RP of the incident and she was not sure why. LPN #2 indicated that it would have been her or the nursing supervisor's responsibility to notify Resident #72's responsible party after the residents fall on 1/30/25. LPN #2 further identified Resident #72 was not her own responsible party and that she had made a mistake and checked No and wrote self on the REF in error. Interview and review of the clinical record with the nursing supervisor (RN #2) on 7/18/25 at 2:20 PM identified she recalled the incident on 1/30/25 and after review of her progress note which failed to indicate notification of Resident #72's RP, she stated if I did not note it, then I did not do it. RN #2 identified that it would have been her responsibility to notify Resident #72's RP of the fall on 1/30/25 and she was unsure why she did not do so. Review of the facility policy, Condition/Significant Change, undated, directed the responsible party will be notified by the nurse in the event of change in condition and this notification shall be documented in the clinical record. Review of the facility policy, Accident and Incident State Specific Reporting Department of Public Health (DPH)/Department of Health (DOH) Reportable Event, dated 4/2015, directed that accidents and incidents that occur in the facility will be reported in accordance with the requirements of the DPH. The Administrator, Director of Nursing or their designee assumes responsibility for the immediate VERBAL notification of the incident to the resident's conservator/responsible party.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #66) observed for medication administration, the facility failed to ensure the medication error rate was not greater than 5% (error rate was 6.9%). The findings include:Resident #66 had diagnoses that included chronic kidney disease, acute and chronic respiratory failure with hypoxia, and diabetes.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 was cognitively intact, required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility, and was dependent for transfers.The Resident Care Plan (RCP) dated 4/29/25 identified Resident #66 had a diagnosis of chronic obstructive pulmonary disease (COPD). Interventions included to elevate the head of bed to assist and maintain maximal lung expansion. The RCP further identified Resident #66 was incontinent of bowel and/or bladder with interventions that included to offer toilet assistance every 2 hours and as needed.a. A physician order dated 7/1/25 directed to administer Bethanechol Chloride (a medication to help stimulate bladder function and emptying) 25 milligrams (mg) by mouth 3 times a day for urinary retention.The Medication Administration Record (MAR) for July 2025 identified Bethanechol Chloride 25 mg was ordered for administration at 9:00 AM, 2:00 PM, and 9:00 PM. Observation of medication administration on 7/17/25 at 9:35 AM identified Registered Nurse (RN) #3 poured Bethanechol Chloride 25 mg for administration to Resident #66. The pharmacy label instructions directed to take on an empty stomach. Resident #66 stated he/she had already eaten breakfast that morning (consisting of toast with cream of wheat cereal). RN #3 was observed to set the medication cup in front of Resident #66 (which contained Bethanechol Chloride 25 mg), administered an inhaler to Resident #66, and as Resident #66 went to pick up the medication cup to take his/her medication, surveyor requested to talk to RN #3 and to bring the medication cup with him prior to Resident #66 consuming medication. Interview and record review with RN #3 on 7/17/25 at 9:50 AM identified the Bethanechol Chloride 25 mg tablet had directions on the pharmacy label which directed to take on an empty stomach. RN #3 identified he had not seen the pharmacy directions to take on an empty stomach. RN #3 could not identify how long Resident #66 had received this medication at the 9:00 AM time. RN #3 removed the Bethanechol Chloride 25 mg tablet from the medication cup and identified he would contact the Advanced Practice Registered Nurse (APRN) for further instructions on whether she wanted to change the administration times for the medication or approve administration with food.Subsequent to surveyor inquiry, an interview with RN #3 on 7/17/25 at 2:50 PM identified APRN #1 had ordered to change the administration times for Bethanechol Chloride to 6:00 AM, 2:00 PM, and 10:00 PM to avoid administration directly after a meal.Physician order dated 7/17/25 directed to administer Bethanechol Chloride 25 milligrams (mg) by mouth 3 times a day for urinary retention and give on an empty stomach.b. A physician order dated 7/1/25 directed to administer Guaifenesin extended release 12 hour 600 mg (medication for chest congestion) 2 tablets (1200mg total dose) by mouth 2 times a day for cough/congestion.The Medication Administration Record (MAR) for July 2025 identified Guaifenesin extended release 12 hour 600 mg 2 tablets was ordered for administration at 9:00 AM and 9:00 PM.Observation of medication administration with RN #3 on 7/17/25 at 9:52 AM identified he had administered 2 tablets of Guaifenesin 600mg/dextromethorphan 30 mg extended release to Resident #66.Interview with RN #3 on 7/21/25 at 9:40 AM identified he had not realized the Guaifenesin 600mg/dextromethorphan 30 mg extended release medication in his medication cart was not the same as the Guaifenesin extended release 12 hour 600 mg tablet, and he then obtained a box of the correct medication (Guaifenesin extended release 12 hour 600 mg tablets) for his medication cart.Interview with DNS on 7/21/25 at 12:35 PM identified Guaifenesin 600mg/Dextromethorphan 30 mg extended release was not interchangeable with Guaifenesin extended release 12 hour 600 mg and that the boxes were different colors which should alert the nurse that it wasn't the same medication. The DNS identified the nurses should verify the over the counter medications with the physician order before administration. DNS further identified that medications with pharmacy instructions to take on an empty stomach should not be administered after breakfast during the 7:00 AM to 3:00 PM morning medication pass at 9:00 AM.Review of the Medication Administration and Documentation-General Policy #PHNE69 directed, in part, the licensed nurse would compare the medication name, strength, route, and dosage schedule on the medication administration record against the prescription label.

Based on staff/resident interview, observations, review of facility documentation and facility policy for 1 of 1 sampled resident (Resident #65) reviewed for dental, the facility failed to assist Resident #65 to arrange a consultation with the dentist to discuss treatment options. The findings include: Resident #65's diagnosis included chronic obstructive pulmonary disease, depression, anxiety and dysphagia. Review of the face sheet in the clinical record identified Resident #65's payor source was Medicaid. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #65 had intact cognition, required set up assistance with eating, oral hygiene, and was independent with transfers. The MDS further identified Resident #65 required partial/moderate assistance with toileting, bathing and personal hygiene. Although Resident #65 was observed to have broken teeth, the MDS failed to identify broken teeth. A Resident Care Plan dated 1/25/25 identified a problem with being on a mechanical soft diet and being at risk for weight fluctuations. Interventions included to monitor for signs of dehydration, encourage the intake of foods/fluids and assist with meals as needed. An Advanced Practice Registered Nurse (APRN) order dated 3/30/25 directed a dental consult for teeth removal. A nursing note dated 4/1/25 at 5:25 PM identified the scheduler was notified to set up an appointment for a dental consultation as per the APRN order (from 3/30/25). An APRN order dated 4/11/25 directed a dental appointment for 4/28/25. An APRN order dated 5/8/25 directed a dental consultation regarding broken teeth, the need for extractions and dentures. A nursing note dated 5/19/25 at 2:41PM identified Resident #65 had left for a scheduled dental appointment and returned to the facility. Also, identifying the consultation identified Resident #65 needed extractions followed by dentures. Further, identifying the APRN reviewed the consultation report, and the resident was made aware. Results from the dental consultation report dated 5/19/25 identified recommendations for the extraction of Resident #65's remaining teeth and root tips. Also identifying the next step was dentures. Nursing note dated 5/22/25 at 3:15 PM and written by Registered Nurse (RN) # 2 identified that the dentist had called explaining that he agreed that Resident #65's teeth needed to be extracted and were rotten with roots exposed but felt Resident #65 was not a good candidate for dentures as the resident's mouth was too dry. Also identifying RN #2 provided information to the resident regarding the phone call she had from the dentist. Further identifying Resident #65 still wanted to explore the option of getting dentures. RN #2 gave Resident #65 the dentist's contact information and stated to give him a call to discuss the options and did not assist Resident #65 with contacting the dentist. An Advanced Practical Registered Nurse (APRN) order dated 5/23/25 directed to assist the patient in getting an insurance quote for dentures and a follow up appointment, he/she does not have the executive function to do this task him/herself. On 7/16/25 at 10:28 AM, Resident #65 was observed with many missing teeth and identified that he/she would like dentures. An interview with RN #2 on 7/17/25 at 9:28 AM identified Resident #65 did not have a follow up appointment with the dentist for dentures or teeth extractions. Also identifying nursing was responsible for assisting with this and it was an oversight. An interview with the DNS on 7/18/25 at 11:25 AM identified Resident #65 would be provided assistance with a follow-up phone call to the dentist and a follow-up appointment should have been made within 2 weeks of the appointment on May 19, 25. Also identifying she was unsure of the reason it wasn't completed timely. Follow up interview with Resident #65 on 7/18/25 at 11:45 AM noted the Assistant Director of Nursing (ADNS) having Resident #65 write a statement regarding the follow-up for the dentist. Resident #65 identified she/he was assisted with a phone call to dentist by a staff member but could not remember the staff member's name. Also identified Resident #65 told the staff member she/he wanted another opinion about having dentures, but no follow-up appointment was made at the time. Subsequent to the surveyor, inquiry the ADNS on 7/18/25 at 12:00 PM identified Resident #65 had a follow-up appointment scheduled for extractions and dentures on 9/12/25. Also identified the staff member at the time should have made a follow-up appointment for the resident for a second opinion as requested by the resident. Review of the facility policy for Resident Right's outlines the fundamental rights of all residents, ensuring that they are treated with dignity, respect, and compassion and that their individual needs and preferences are honored in accordance with federal and state regulations. Residents have the right to autonomy and self-determination to make informed choices about their care and services.

Based on review of the Grievance Log, staff and resident interviews, observations and facility policy regarding missing laundry items (Resident #118), the facility failed to resolve grievances regarding missing items. The findings include:Resident#118's was admitted to the facility on [DATE] with diagnoses that included dementia, congestive heart failure, and anxiety. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 was severely cognitively impaired, was dependent on bathing, toileting, and personal hygiene. Also identified Resident #118 required maximal assistance for eating, oral hygiene, dressing and transfers. The Resident Care Plan (RCP) dated 5/21/25 identified Resident #118 had an activities of daily living deficit related to cognitive loss and dementia. Interventions included assisting the resident with gathering and setting up clothing, toiletries and equipment, to keep the call bell and needed items within reach of the resident. An interview with Person #2 on 7/15/25 at 11:21 AM identified Resident #118 had numerous missing items since admission although all items were labeled with the resident's name in permanent black marker. Person #2 reported that she/he had purchased a new comforter set for a Christmas gift for Resident #118 and it went missing shortly after. Also identifying Resident #118 was missing numerous clothing along with a pair of shoes. Further identifying in May of 2025, Person #2 purchased a new blanket for Resident #118, and it went missing after one week. Person #2 reported the missing items to Social Worker (SW) #2 (but couldn't identify when) when all these items went missing. An interview with SW #2 on 7/17/25 at 10:30AM identified Person #2 had reported the missing shoes, clothing, comforter set and blanket when these items went missing but could not provide any documentation of the missing items or what was done to resolve the issue. Also identified that the policy for missing items was to go to the department and for her to speak to the department head regarding the missing items. Further identified the items were not found, no one followed up with Person #2 and SW #2 was responsible for the follow-up. An interview with the Environmental Director on 7/17/25 at 10:48 AM identified he was aware of Resident #118 missing clothing items but not aware of the missing comforter, blanket, and shoes. When the Environmental Director identified the labeling with a permanent marker was not permanent as it usually washes out. Additionally stating the facility has an iron on label maker for personal items and residents were directed to ensure the items were marked with an iron on label. Also identifying that admissions or the front desk would explain to families about this process and then items were brought to laundry to have an iron on identification label placed on the items. Further identifying the laundry has 8 large black bags filled with unidentified laundry. Although a policy for labeling laundry items was requested from the Environmental Director, one was not provided.

Based on observations, review of Resident Council minutes, resident/staff interviews and policy review for 2 of 3 resident lounge areas observed, the facility failed ensure wheelchairs were not stored in a resident area (lounges) and for 6 sampled residents (Resident #54, Resident #55, Resident #111, Resident #118, Resident #135, and Resident #153) , the facility failed to ensure personal laundry was returned and laundered appropriately. Additionally, the facility failed to ensure facility provided linens were not left in the washing machine, causing them to be odorous and stained. The findings include:1.Observations were made on 7/16/25 at 10:28 AM, 7/17/25 at 10:30 AM, and 7/18/25 at 10:15 AM of three wheelchairs and one geri-recliner being stored in the 1st floor resident lounge. For all observations, Resident #9 was seated in a wheelchair in the 1st floor resident lounge with a visitor completing a puzzle. Two of the wheelchairs were electric but not charging/plugged in and one wheelchair was a custom standard wheelchair. The geri-recliner was facing the window and blocked access to other chairs and furniture in the lounge.Observations were made on 7/17/25 at 10:35 AM and 7/18/25 at 10:30 AM of three wheelchairs being stored in the 2nd floor resident lounge (labeled chapel/lounge). Two of the wheelchairs were electric and not charging/plugged in and one of the wheelchairs was a custom standard wheelchair.Observation and interview with Resident #9 on 7/21/25 at 10:15 AM identified he/she completed puzzles in the 1st floor resident lounge daily, often in the company of visitors and other residents. Resident #9 indicated the wheelchairs and other equipment were kept in the 1st floor resident lounge all the time and he/she was not sure why. Resident #9 stated they use this room as a storage room and due to that, he/she often had trouble gaining access to the table in order to work on the puzzle.Observation and Interview on 7/21/25 at 10:20 AM with LPN #3 identified the 1st floor resident lounge is a resident area which is often utilized by residents and their families. LPN #3 indicated the wheelchairs were stored in the room all the time and she was unsure why the electric wheelchairs were in there and were not charging/plugged in. LPN #3 was unsure if there was another area on the unit where the equipment could be stored and she would need to check with the nursing supervisor about it.Observation and interview with Resident #90 in the 2nd floor resident lounge on 7/21/25 at 10:30AM identified he/she was seated in a wheelchair at the puzzle table and there were three wheelchairs (2 electric and not charging/plugged in and 1 custom standard wheelchair) being stored in the room. Resident #90 indicated the wheelchairs were always in the 2nd floor lounge and were being stored by the facility in that location. Resident #90 identified he/she frequently worked on puzzles in the lounge alone and with visitors and the room often felt cluttered due to the wheelchairs being stored in there. Interview with the Administrator on 7/21/25 at 12:16 PM identified he was aware that three wheelchairs and a geri-recliner were being stored in the 1st floor resident lounge and that three wheelchairs were being stored in the 2nd floor resident lounge. The Administrator indicated the 1st and 2nd floor resident lounges were frequently utilized by residents and visitors and the electric wheelchairs were not always being charged when stored in the lounges. The Administrator further identified the wheelchairs and geri-recliner should not have been stored in the 1st and 2nd floor lounges because they are resident areas and that he would have them removed and find an alternative location for them to be stored. Although requested, a policy on the storage of durable medical equipment was not provided. 2. Resident Council meeting minutes (20 residents were in attendance) dated 1/16/25 identified that laundry services was down a dryer and so turnaround time for laundry could be longer than usual. Resident Council meeting minutes (12 residents were in attendance) dated 3/20/25 identified residents were reminded that laundry was down a dryer and turnaround time could be longer for laundry services. Resident Council meeting minutes (38 residents in attendance) dated 5/29/25 identified there was still only 1 dryer working and several residents (5 rooms) were very upset about their clothing being missing. Resident Council meeting minutes (28 residents in attendance) dated 6/19/25 identified there was still only 1 dryer working and the equipment company had been out to the facility 2 times to do repairs. The minutes further identified several residents stated they were still not receiving their personal clothing back in a decent amount of time. The residents were reminded that the new company was looking into getting more dryers which would help with the turnaround of laundry. A Resident Council meeting was held with the State Agency on 7/17/25 at 2:34 PM with 13 residents present and had the following issues:Resident #54 had lost clothing in the facility laundry 3 times and after Resident #54 and the Social Worker going to the laundry department, clothing was not found except for a sweatshirt (labeled with Resident #54's name), which was returned months later. The Resident Council meeting further identified Resident #55 stated he/she had put 4 expensive pairs of jeans and sweaters to be washed by the facility laundry department and all items were returned bleached. When Resident #55 reported the bleaching, the facility provided no assistance to rectify the matter and Resident #55 stated he/she now washes his/her own clothing. Additionally, Resident #55 identified the bed sheets in the facility smell offensive and were returned from the in house laundry stained.The Resident Council meeting also identified Resident #111 stated the facility no longer laundered his/her laundry because he/she had lost thousands of dollars worth of clothing (which was labeled prior to sending down to the laundry), and didn't assist with rectifying the situation.Resident #135 stated he/she had been at the facility for 3 months and had to go out to do laundry (which costs $10.00 per week) because of the poor condition his/her clothes came back from the in house laundry, had reported the laundry issue to the Social Service department, but nothing had been done.Resident #153 stated he/she had lost a lot of shirts and pants when his/her clothes were sent to the facility laundry. Resident #153 noted he/she spoke with the Director of Environmental Services who was unable to locate the missing shirts/pants in the laundry. Also identifying he/she had colored clothing that was returned bleached. Resident #153 also identified the facility had an issue with the dryer not working for over a year.Interview with Nurse Aide (NA) #1 on 7/17/25 at 3:07 PM identified she frequently did not have personal clothes for the residents on her assignment to get them dressed when she worked on the 7:00 AM to 3:00 PM shift. NA #1 noted that she would go to the laundry room to see if there were any clean clothes for her residents to wear, but they were either not laundered or were missing. NA #1 identified the residents would get upset because they didn't have clothes to wear. Observation of the soiled laundry room on 7/18/25 at 6:00 AM identified 2 large rolling plastic bins overflowing with soiled laundry. Additionally, 1 large rolling bin and 2 medium rolling bins were identified as sorted laundry, that rose above the level of the bins. Laundry Aide (LA) #3 identified it was difficult to catch up on the laundry because only 1 of the 5 dryers and 2 of the 4 washers were working). Interview with LA #3 on 7/18/25 at 8:30 AM identified he dried laundry left inside the washers and sitting in the laundry baskets from the previous day when he arrived in the early morning. Additionally, he stated his focus each day was washing the linens first and when the linens were adequately stocked, he would try to get to the residents' personal clothes, but that he would often be asked for more linens so he would stop washing the personal clothes. Review of the Residents' Personal Clothing policy directed, in party that the facility would make every effort to safeguard the belonging of its residents. The policy directed that the facility would treat all residents' property in a respectful manner, and return clean clothing to the correct unit, room and closet. The policy failed to identify a timeline for the return of residents' personal clothing. Although requested, a policy for laundry services was not provided. 3.Resident#118's was admitted to the facility on [DATE] with diagnoses that included dementia, congestive heart failure, and anxiety.An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 was severely cognitively impaired, was dependent on bathing, toileting, and personal hygiene. Also identified Resident #118 required maximal assistance for eating, oral hygiene, dressing and transfers.The Resident Care Plan (RCP) dated 5/21/25 identified Resident #118 had an activities of daily living deficit related to cognitive loss and dementia. Interventions included assisting the resident with gathering and setting up clothing, toiletries and equipment, to keep the call bell and needed items within reach of the resident.An interview with Person #2 on 7/15/25 at 11:21 AM identified Resident #118 had numerous missing items since admission although all items were labeled with the resident's name in permanent black marker. Person #2 reported that she/he had purchased a new comforter set for a Christmas gift for Resident #118 and it went missing shortly after. Also identifying Resident #118 was missing numerous clothing along with a pair of shoes. Further identifying in May of 2025, Person #2 purchased a new blanket for Resident #118, and it went missing after one week. Person #2 reported the missing items to Social Worker (SW) #2 when all these items went missing. An interview with SW #2 on 7/17/25 at 10:30AM identified Person #2 had reported the missing shoes, clothing, comforter set and blanket when these items went missing but could not provide any documentation of the missing items or what was done to resolve the issue. Also identified that the policy for missing items was to go to the department and for her to speak to the department head regarding the missing items. Further identified the items were not found, no one followed up with Person #2 and SW #2 was responsible for the follow-up. An interview with the Environmental Director on 7/17/25 at 10:48 AM identified he was aware of Resident #118 missing clothing items but not aware of the missing comforter, blanket, and shoes. When the Environmental Director identified the labeling with a permanent marker was not permanent as it usually washes out. Additionally stating the facility has an iron on label maker for personal items and residents were directed to ensure the items were marked with an iron on label. Also identifying that admissions or the front desk would explain to families about this process and then items were brought to laundry to have an iron on identification label placed on the items. Further identifying the laundry has 8 large black bags filled with unidentified laundry. Although a policy for labeling laundry items was requested from the Environmental Director, one was not provided.

Based on interviews, record and policy review for 1 of 2 sampled residents (Resident #70) reviewed for personal funds, the facility failed to provide Resident #70 and multiple other residents with quarterly statements for the period of 1/1/25 to 3/31/25.Resident #70's diagnoses included heart failure, diabetes mellitus and anxiety disorder.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #70 was cognitively intact.On 7/15/25 at 11:29 AM an interview with Resident #70 identified he/she had not received a quarterly statement even though funds were kept in a trust account with the facility.An interview with the Accounts Receivable Assistant ([NAME]) on 7/18/25 at 12:42 PM identified Resident #70 had a $30.21 balance in the Resident Trust Account, and it was facility policy to provide residents and/or their responsible parties with patient trust fund quarterly statements every quarter and upon request. Additionally, she was responsible for generating/sending out the statements and kept track of quarterly statements generated by providing the residents and/or the responsible parties with a receipt that was signed and returned to her. (The [NAME] could not procure a log or tracking sheet identifying patient trust statements sent or received). An interview and record review with the [NAME] on 7/21/25 at 9:47 AM identified 23 personal trust accounts received quarterly statements for the period of 1/1/25 to 3/31/25. She identified there were 99 patient trust fund accounts eligible to receive quarterly statements and 130 total active patient trust fund accounts that quarter. However, 33 were not eligible to receive quarterly statement due to representative payee status, which meant the resident was unable to manage their funds, money was owed to the facility or the family/conservator stated they did not wish to receive statements. The accounts receivable assistant could not identify where the other receipts were, or the reason the receipts were not available on request.A review of the personal fund policy directed in part that a copy of the quarterly statement will be submitted to the resident or the resident's designated representative (if the resident is unable to comprehend or has requested that the statement be sent to the representative) on a quarterly basis and or the request of the resident or designated representative.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders which resulted in a medication error. The findings include: The facility admitted Resident #1 with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic kidney disease stage 2, and anxiety. A resident care plan dated 1/30/2025 identified Resident #1 was at risk for dehydration due to chronic kidney disease and had episodes of anxiety. Interventions directed adequate fluid intake. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she was alert and oriented. A facility reportable event report dated 2/7/2025 identified a medication error of clinical significance. LPN #1 reported at 11:30 AM she had given Resident #1 the medications that were scheduled to be administered to Resident #2, and no injury was identified. LPN #1 reported that she was feeling overwhelmed and was behind in her morning medication pass and did not accurately verify Resident #1's identity prior to administering medications. LPN #1 written statement dated 2/7/2025 identified it was her first time working 7 AM to 3 PM and she was feeling overwhelmed and behind with the medication pass. LPN #1's statement indicated she failed to properly verify the patient's identification before administering medication and gave the wrong medications to Resident #1. Nursing note dated 2/7/2025 at 11:30 AM identified Resident #1 was given the wrong medications including beta blockers, diuretics, anti-seizure and antidiabetic medications. The APRN was notified, evaluated Resident #1 at the bedside and ordered to transfer Resident #1 to the hospital for evaluation. Nursing note written, by the ADON, dated 2/7/2025 at 3:05 PM identified the APRN assessed Resident #1 after the resident was administered another resident's medications. Resident #1 was alert and oriented, had no word slurring, no anxious mood, denied any chest pain palpitations, difficulty breathing, dizziness or nausea. Initial vital signs were within normal limits and 911 was activated. Subsequent vital signs were: blood pressure 110/52, pulse 95, respirations 16; at 11:37 AM, blood pressure was 94/74, pulse 99; at 11:45 AM blood pressure was 86/46; and 11:50 blood pressure was 80/48 with pulse 102. EMS arrived and Resident #1 was transferred to the hospital. Record review identified Resident #1 was administered the following medications in error on 2/7/2025 (the medications were scheduled to be administered to Resident #2): 1. Sertraline Hydrochloride (treat depression) 75 milligrams (mg) 2. Hydroxyzine (treat anxiety) 50 mg tablet 3. Entresto (strengthen heart pumping) 24-26 mg 4. Keppra (treat seizures) 500 mg 5. Gabapentin (treat nerve pain) 400 mg 6. Metoprolol (treat high blood pressure) extended release 25 mg sprinkles 7. Senna (treat constipation) 8.6 mg 8. Spironolactone (treat high blood pressure and swelling) 12.5 mg 9. Lasix (treat swelling) 40 mg 10. Jardiance (treat diabetes) 10 mg 11. Januvia (treat diabetes) 100 mg 12. Metformin (treat diabetes) 1000 mg 13. Aspirin (prevent blood clots) delayed release 81 mg 14. Ticagrelor (prevent blood clots) 15. Multivitamin one tablet 16. Potassium (electrolyte replacement) chloride extended release 20 milliequivalents 17. Vitamin B12 (Cyanocobalamin)1 mg 18. Folic Acid (Vitamin B9)1 mg 19. Vitamin B1 (Thiamine) 100 mg 20. Vitamin D3 (Cholecalciferol) 1000 units. 21. Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder (treats COPD) one (1) puff A hospital discharge summary dated 2/7/2025 identified that upon assessment Resident #1 was negative for any congestion, SOB, chest pain, myalgias or rash. The resident was not in acute distress, not diaphoretic, lung and heart sounds were normal, skin was warm, and mental status was alert and oriented to person, place and time, with no behavioral issues. The residents' blood work showed baseline results. Nursing note dated 2/7/2025 at 10:24 PM identified Resident #1 returned from the hospital with no adverse effects identified and new orders. A facility summary dated 2/20/2024 identified Resident #1 was immediately assessed after the medication error with no injury, distress or discomfort identified. Allergies were evaluated and compared with the incorrect medications received and resident did not have any known allergies that correlated with the medications administered in error. Resident #1 returned from the hospital on 2/7/2025 at 11:02 PM and was discharged home as per prior plan, on 2/8/2025. Interview and record review with Pharmacist #1 on 2/27/2025 at 10:15 AM identified that Resident #1 received medications in error, and they would not cause a significant issue or lasting effects. Interview with MD #1 on 2/27/2025 at 12:48PM identified Resident #1 did not appear to have had any significant ill effects from the error and was discharged home as scheduled on 2/8/2025. Interview and review of the facility investigation with the DON on 2/27/2025 at 2:00 PM identified that LPN #1 was a newly graduated nurse, hired on 12/2/204 and completed her orientation to the facility on [DATE] . LPN #1's usual shift to work was 11 PM to 7 AM, and she had picked up 2/7/2025 to work as an extra shift. LPN #1 had not worked any day shifts previously. The DON stated LPN #1 did not verify Resident #1's identify prior to administering the medications; she did not verify the photo in the electronic medical record and LPN #1 did not check Resident #1's identification (ID) band prior to providing the medications. LPN #1 called Resident #1 by his/her first name only (Resident #1 and Resident #2 had the same first name) and then administered Resident #2's medications to Resident #1. When LPN #1 returned to her medication cart, she realized the error and she immediately reported it to the supervisor. The DON stated all nurses should check the resident's identification bracelet (or identification photo in the EMR) prior to administering medications. LPN #1 identified that she was behind with the medication pass, felt overwhelmed, did not ask for help when she was behind with the medication pass. Multiple attempts to contact LPN #1 were unsuccessful during the survey. The facility policy Medication administration-oral dated June 2015, directed in part, when administering medications the Resident should be identified. Facility documentation review identified staff education was initiated on 2/7/2025 regarding administering medications as prescribed to the right resident and a review of safe administration of medications. A QAPI meeting was held on 2/7/2025 to include correctly identifying residents when administering medications. Audits were initiated on 2/8/2025. Based on review of facility documentation, past non-compliance was identified on 2/8/2025.

Based on clinical record review, facility documentation review, facility policy review, and interviews for four of six residents (Resident #2, 3, 4, and 6) reviewed for abuse, the facility failed to report an allegation of misappropriation to the State Agency in a timely manner. The findings include: 1. Resident #2's diagnoses included dementia and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicative of being severely cognitively impaired and received opioids. The Resident Care Plan (RCP) dated 06/24/2024 identified Resident #2 had potential for pain related to osteoarthritis, back pain, and impaired mobility. Interventions directed to administer pain medications as ordered. Physician order dated 7/1/2024 directed to administer Oxycodone 5 milligrams (mg), every four hours, as needed, for pain. Review of the facilities internal narcotic diversion investigation identified the following occurrences for Resident #2: • Pharmacy had delivered Oxycodone 5 mg to the facility on 8/9/2024, a day after the last house audit was completed (with no issues noted). The next house audit was completed on 8/27/2024 and the medication blister pack and the white narcotic proof of use documentation sheet was missing. A quantity of 30 tablets were unrecovered. • On 9/30/2024, a narcotic audit was conducted that identified that twenty-nine (29) Oxycodone 5 mg tablets remaining and the white narcotic proof of use documentation sheet were identified to be missing and unrecovered. 2. Resident #3's diagnoses included chronic back pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicative of being cognitively intact and was identified to be receiving opioids. Physician orders dated 7/15/2024 directed to administer Oxycodone 5 mg, every eight hours, as needed, for pain. The Resident Care Plan (RCP) dated 7/26/2024 identified Resident #3 had pain/had potential for pain related to spinal stenosis of lumbar region. Interventions directed to administer pain medications as ordered. Review of the facility internal narcotic diversion investigation identified the following occurrences for Resident #3: • A facility narcotic audit was last conducted on 8/8/2024, with Resident #3's Oxycodone blister pack was identified to have 19 remaining tablets out of 30. • On 8/27/2024, the facility was unable to locate the Oxycodone medication blister pack or the white narcotic proof of use documentation sheet. Review identified, the order was discontinued on 8/2/2024 and the medication blister pack was never returned to the nursing supervisors office. Further, no notification was given to nursing management that the medication was discontinued. The medication was not recovered and a quality of 19 tablets remained missing. 3. Resident #4's diagnoses included bronchitis with respiratory syncytial virus, and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen (13/15), indicative of being cognitively intact and was identified to be receiving opioids. The Resident Care Plan (RCP) dated 8/1/2024 identified Resident #4 exhibits pain/has the potential for pain. Interventions directed to administer pain medications as ordered. Physician orders dated 8/7/2024 directed to administer Oxycodone 5 mg, every three hours, as needed, for severe pain. Review of the facility internal narcotic diversion investigation identified the following occurrences for Resident #4: • A facility narcotic audit was last conducted on 9/16/2024 and all medications were accounted for. Resident #4 had twelve (12) Oxycodone tablets remaining. • A facility narcotic audit conducted on 9/23/2024 identified Resident #4's Oxycodone 5 mg medication blister pack was missing, including the white narcotic proof of use documentation sheet. 4. Resident #6's diagnoses included chronic pain syndrome and diabetic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact, and was identified to be receiving opioids. The Resident Care Plan (RCP) dated 9/3/2024 identified Resident #6 exhibited pain/has potential for pain related to gout and chronic pain. Interventions directed to administer pain medications as ordered. Physician orders dated 9/4/2024 directed to administer Oxycodone 10 mg, every six hours, as needed, for pain. Review of the facility internal narcotic diversion investigation identified on 10/10/2024, during routine audits on Resident #6's unit at 10:45 AM, LPN #2 noted Resident #6 had received Oxycodone from LPN #1 at 10:00 AM. LPN #2 interviewed Resident #6 and asked the level of pain and Resident #6 replied it was a level 9 out of 10, and described it as pretty bad right now. LPN #2 asked if Resident #6 had received a pain pill and Resident #6 stated the last pain medication was administered at 5 AM. LPN #2 indicated a discussion with LPN #1, and LPN #1 stated she had already administered Resident #6 his/her pain medication, during the morning medication administration. Review of the State Agency FLIS Reportable Event Tracking System identified the facility failed to notify the State Agency of the allegation of misappropriation from08/27/2024 through 10/28/2024 at 12:00 PM. Interview with ADON on 1/29/2025 at 12:05 PM identified the facility reported the narcotic diversion in August 2024 to the DEA (Drug Enforcement Administration), and the ADON stated she believed this was only requirement for this type of adverse event. The ADON further stated she was unaware if the facility reported allegation of misappropriation to the State Agency, but indicated all allegations of abuse are reported to the State Agency per Public Health Code guidelines and facility policy. Review of the facility Abuse, Neglect, and Exploitation Policy dated 2/2023 directed in part, to report all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse.

Based on clinical record review, facility documentation review, facility policy review, and interviews for six of six residents (Resident #1, 2, 3, 4, 5, and 6) reviewed for abuse, the facility failed to ensure the residents were free from misappropriation. The findings include: 1. Resident #1's diagnoses included osteomyelitis, diabetes mellitus, peripheral vascular disease. Physician orders dated 10/11/2024 directed to administer Oxycodone 20 milligrams (mg), every four hours, as needed, for pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact. Resident #1 was identified to be receiving opioids. The Resident Care Plan (RCP) dated 10/28/2024 identified Resident #1 exhibited pain/has potential for pain related to osteomyelitis infection, neuropathy and wounds. Interventions directed to administer pain medications as ordered. The Facility Reported Incident form dated 10/28/2024 at 12:00 PM identified during a narcotic audit, it was noted that the count for Resident #1's Oxycodone 20 mg was incorrect, and one (1) Oxycodone 20 mg dose was missing. LPN #1 was interviewed by LPN #2 and stated that she had just administered the medication to Resident #1. LPN #2 reviewed the MAR (medication administration record), and noted that the medication was administered too soon (prior dose was administered at 9:01 AM - then next dose was not available to be administered until 1 PM in accordance with physician orders). LPN #2 interviewed Resident #1 immediately, and upon interview with the resident, he/she had a pain level of 8, and Resident #1 stated he/she did not receive the 9:00 AM dose of Oxycodone 20 mg. All information was brought to the DON and the DON interviewed Resident #1. Resident #1 signed a statement that he/she did not receive the 9:00 AM dose. Drug control and the Department of Consumer Protection were notified. 2. Resident #2's diagnoses included dementia and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of six out of fifteen (6/15), indicative of being severely cognitively impaired and received opioids. The Resident Care Plan (RCP) dated 06/24/2024 identified Resident #2 had potential for pain related to osteoarthritis, back pain, and impaired mobility. Interventions directed to administer pain medications as ordered. Physician order dated 7/1/2024 directed to administer Oxycodone 5 milligrams (mg), every four hours, as needed, for pain. Review of the facilities internal narcotic diversion investigation identified the following occurrences for Resident #2: • Pharmacy had delivered Oxycodone 5 mg to the facility on 8/9/2024, a day after the last house audit was completed (with no issues noted). The next house audit was completed on 8/27/2024 and the medication blister pack and the white narcotic proof of use documentation sheet was missing. A quantity of 30 tablets were unrecovered. • On 9/30/2024, a narcotic audit was conducted that identified that twenty-nine (29) Oxycodone 5 mg tablets remaining and the white narcotic proof of use documentation sheet were identified to be missing and unrecovered. Review of Resident #2's white narcotic proof of use documentation sheet for the month of August, September, and October 2024 identified Resident #2 received Oxycodone 5mg by LPN #1 on the following dates: a. 8/26/2024 at 10:50 AM b. 8/31/2024 at 9:00 AM and 2:30 PM c. 9/6/2024 at 7:45 AM d. 9/9/2024 at 8:00 AM and 1:00 PM e. 10/7/2024 at 8:30 AM f. 10/12/2024 at 8:00 AM and 2:00 PM g. 10/13/2024 at 7:30 AM, 11:00 AM, and 3:00 PM h. 10/17/2024 at 9:00 AM and 1:40 PM Review of Resident #2's MAR for the month of August, September, and October 2024 identified LPN #1 failed to document the administration of Oxycodone 5 mg on the following: a. 8/26/2024 and 08/31/2024 (all administrations) b. 9/6/2024 and 09/9/2024 at 1:00 PM. c. 10/7, 10/12 (for the 8:00 AM administration), 10/13, and 10/17/2024 (for the 1:40 AM administration). Interview with Resident #2 on 01/30/2025 at 12:50 PM identified he/she doesn't normally take any pain medication, occasionally Tylenol or Advil, but would not take Oxycodone or another type of narcotic. Interview with ADON on 01/30/2025 at 11:50 AM identified the Oxycodone 5 mg tablets provided by the pharmacy were round white pills. The ADON stated she interviewed Resident #2 regarding the administration of Oxycodone, and he/she indicated the nurse gave him/her a round yellow pill. The ADNS stated she thought the resident was administered an Aspirin tablet instead of the Oxycodone. 3. Resident #3's diagnoses included chronic back pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicative of being cognitively intact and was identified to be receiving opioids. Physician orders dated 7/15/2024 directed to administer Oxycodone 5 mg, every eight hours, as needed, for pain. The Resident Care Plan (RCP) dated 7/26/2024 identified Resident #3 had pain/had potential for pain related to spinal stenosis of lumbar region. Interventions directed to administer pain medications as ordered. Physician orders dated 8/2/2024 directed to discontinue Oxycodone 5 mg, every eight hours, as needed, for pain. Review of the facility internal narcotic diversion investigation identified the following occurrences for Resident #3: • A facility narcotic audit was last conducted on 8/8/2024, with Resident #3's Oxycodone blister pack was identified to have 19 remaining tablets out of 30. • On 8/27/2024, the facility was unable to locate the Oxycodone medication blister pack or the white narcotic proof of use documentation sheet. Review identified, the order was discontinued on 8/2/2024 and the medication blister pack was never returned to the nursing supervisors office. Further, no notification was given to nursing management that the medication was discontinued. The medication was not recovered and a quality of 19 tablets remained missing. Interview with the ADON on 1/30/2025 at 11:50 AM identified LPN #1 was only nurse that worked on this resident's unit during the time investigated. 4. Resident #4's diagnoses included bronchitis with respiratory syncytial virus, and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen (13/15), indicative of being cognitively intact and was identified to be receiving opioids. The Resident Care Plan (RCP) dated 8/1/2024 identified Resident #4 exhibits pain/has the potential for pain. Interventions directed to administer pain medications as ordered. Physician orders dated 8/7/2024 directed to administer Oxycodone 5 mg, every three hours, as needed, for severe pain. Review of the facility internal narcotic diversion investigation identified the following occurrences for Resident #4: • A facility narcotic audit was last conducted on 9/16/2024 and all medications were accounted for. Resident #4 had twelve (12) Oxycodone tablets remaining. • A facility narcotic audit conducted on 9/23/2024 identified Resident #4's Oxycodone 5 mg medication blister pack was missing, including the white narcotic proof of use documentation sheet. 5. Resident #5's diagnoses included chronic congestive heart failure and vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen (11/15), indicative of being mildly impaired cognition and was identified to be receiving opioids. The Resident Care Plan (RCP) dated 9/21/2024 identified Resident #5 has pain/has the potential for pain related to impaired mobility. Interventions directed to administer pain medications as ordered. Physician orders dated 10/3/2024 directed to administer Percocet (Oxycodone with Acetaminophen) 5-325 mg, every six hours, as needed, for pain. Review of Resident #5's white narcotic proof of use documentation sheet for the month of October 2024 identified Resident #5 received Percocet 5-325 mg by LPN #1 on the following dates: a. 10/3/2024 at 8:00 AM and 2:00 PM b. 10/12/2024 at 8:00 AM and 2:00 PM c. 10/13/2024 at 7:45 AM and 2:30 PM d. 10/17/2024 at 10:00 AM Additional review identified no other nurse administered Percocet to Resident #5 during the month of October 2024. Review of Resident #5's MAR for the month of October 2024 identified LPN #1 failed to document the administration of Percocet 5-325mg on the following dates: a. On 10/3/2024 (all administrations). b. On 10/12/2024 at 8:00 AM. c. On 10/13/2024 (all administrations). d. On 10/17/2024 (all administrations). Review of Resident #5's pain scale for the month of October 2024 identified he/she had a rating of zero (0) every day in the month of October. Interview with ADON on 1/30/2025 at 11:50 AM identified the Percocet 5-325 mg provided by the pharmacy was one white tablet. The ADON stated when she interviewed Resident #5 regarding the Percocet administration, Resident #5 stated he/she was given two (2) white pills. Interview with Resident #5 on 01/30/2025 at 12:30 PM identified he/she had not taken Percocet or any other narcotic in the recent months. Resident #5 identified if he/she has pain, Tylenol or Aspirin would be sufficient his/her needs. 6. Resident #6's diagnoses included chronic pain syndrome and diabetic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact, and was identified to be receiving opioids. The Resident Care Plan (RCP) dated 9/3/2024 identified Resident #6 exhibited pain/has potential for pain related to gout and chronic pain. Interventions directed to administer pain medications as ordered. Physician orders dated 9/4/2024 directed to administer Oxycodone 10 mg, every six hours, as needed, for pain. Review of the facilities internal narcotic diversion investigation identified on 10/10/2024, during routine audits on Resident #6's unit at 10:45 AM, LPN #2 noted Resident #6 had received Oxycodone from LPN #1 at 10:00 AM. LPN #2 interviewed Resident #6 and asked the level of pain and Resident #6 replied it was a level 9 out of 10, and described it as pretty bad right now. LPN #2 asked if Resident #6 had received a pain pill and Resident #6 stated the last pain medication was administered at 5 AM. LPN #2 indicated a discussion with LPN #1, and LPN #1 stated she had already administered Resident #6 his/her pain medication, during the morning medication administration. Interview with Resident #6 on 01/30/2025 at 10:45 AM identified he/she had no issues regarding pain control and was able to recall the event in October. Interview with ADON on 1/29/2025 at 12:05 PM identified the process for receiving controlled medications begins with an order in the electronic charting system. Once the order is placed the pharmacy will deliver the medication to the facility. The pharmacy delivery team will give the medications to the RN Supervisor only, and paperwork must be signed for receipt of the medication. This includes a white and yellow narcotic proof of use documentation sheet signed by the RN Supervisor. Next, the RN Supervisor will take the medication and deliver it to the resident's unit; the RN Supervisor will review the medication with the charge nurse on the unit, and both will verify the medication/order. Afterwards, the RN Supervisor will take the yellow narcotic proof of use documentation sheet, and file it in a binder located in the ADON's office. The floor nurse will maintain the white narcotic proof of use documentation sheet and place it in the narcotic book for the nurse to document the administration of the medication. The ADON further stated medication diversion first became an issue at the facility in August 2024. The facility immediately reported the concerns to the DEA (Drug Enforcement Administration) and began their own investigation. The ADON indicated the conclusion of the investigation determined LPN #1 was consistently identified to be involved with the missing medications and LPN #1 was subsequently terminated from her position. Review of the facility Abuse, Neglect, and Exploitation Policy dated 2/2023 directed in part, to prevent misappropriation of resident property. Misappropriation of Resident Property is defined as the means of deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for falls, the facility failed to identify a change in neurological status timely and failed to transfer the resident to the emergency room in a timely manner following a change in condition. The findings include: Resident #1 was admitted to the facility on [DATE] after a fall at home with diagnoses that included fracture of the hip after a fall, fractured left pubic rami, severe protein-calorie malnutrition, chronic myeloid leukemia (CML), and a history of deep vein thrombosis lower extremity (blood clot in the vein). The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was at risk for falls secondary to generalized weakness, a history of falls, and was able to make needs known. Interventions directed to instruct to ask for assistance prior to attempting to transfer or ambulation, place call light in reach, and use gripper socks while in bed. A 5-day MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required extensive assistance for bed mobility, limited assistance for walking with a walker or wheelchair and supervision for transfer. A physician's order dated [DATE] directed to administer Rivaroxaban (Xarelto) (blood thinner) 10 mg in the evening for history of atrial fibrillation (rapid irregular heartbeats) and Resident #1 was a full code. A facility incident report dated [DATE] at 6:07 PM identified Resident #1 was an assist of one (1) staff for transfers and ambulation and had moderately impaired cognition and had an unwitnessed fall while self-ambulating in the room (did not ring the call bell or call out for help, and indicated he/she was trying to get a washcloth), reported hitting his/her head on the dresser and had pain. An RN assessment was completed and identified no injury, neurological checks were initiated and were within normal limits. The physician was notified of the fall and ordered to monitor for a change in condition. The report identified about 8:00 PM Resident #1 became lethargic and responded to painful stimuli. The physician was notified and directed transfer to the hospital, and the resident was transferred immediately after being seen by the physician telehealth visit. During evaluation at the hospital a CT scan showed a subdural hematoma and cervical neck fracture. The hospital report identified a repeat CT scan revealed right holohemispheric (bleeding that covered the whole right side of the brain) subdural hematoma causing a 1.6-centimeter (cm) of midline shift and non-displaced cervical 2 (2nd vertebrae) fracture. After the CT scan Resident #1's Glascow Coma Scale (measures level of alertness from 3 to 15 with 15 being fully awake and alert) declined to seven (7), developed a dilated left pupil and was intubated for airway protection and Resident #2 was transferred to a higher level of care. At Hospital #2 a neurosurgical evaluation was completed which showed worsening midline shift and a right craniotomy (surgical opening into the skull) was performed. Two (2) hours later Resident #1 developed fixed pupils (pupils not responding), had no spontaneous movements and withdrawal times three (3) to noxious (stimuli). A CT scan showed a 2.4 cm midline shift, a discussion was held with the family, and Resident #1 was made Comfort Measures Only (CMO), extubated (remove tube for artificial ventilation/breathing) at 12:02 PM on [DATE] and Resident #1 expired at 12:48 PM. A nursing note dated [DATE] at 6:07 PM written by RN #2 identified Resident #1 vomited one (1) time after the fall, and Resident #1 had a history of intermittent nausea due to chronic myeloid leukemia (CML). Review of the clinical record failed to identify a history of nausea since admission. A nursing note dated [DATE] at 6:15 PM by RN #1 (nursing supervisor) identified the on-call provider was notified of Resident #1's fall and Resident #1 had no obvious signs of injury. Neurological checks, vital signs were within normal limits and range of motion was at baseline, and plan was to closely monitor for any changes with no new orders at that time. AA physician progress note dated [DATE] at 9:56 PM identified Resident #1 was seen on [DATE] at 8:03 PM via telehealth. Resident #1 had an altered mental status, was very drowsy, was not responding to questions and directed to transfer Resident #1 to the emergency room for an evaluation. Nursing post event note dated [DATE] at 11:37PM identified Resident #1 with mental status change since fall earlier in the shift and was unresponsive. An audio video visit (physician) was conducted with the nurse present, and orders obtained to transfer Resident #1 to the hospital. Review of facility documentation identified neurological checks were initiated after the fall on [DATE] at 6:15 PM and had a headache. The assessment completed at the 6:30 identified headache, new nausea, and vomiting, and the 6:45 PM assessment identified nausea. In addition, the 6:45 PM, 7 PM, 7:30 PM and 8 PM assessments identified a change in condition: Resident #1 was newly identified to be drowsy (prior assessments at 6:15 and 6:30 identified Resident #1 was not drowsy). The assessment at 9 PM (57 minutes after the physician telehealth visit) identified an additional change in condition: Resident #1 was not alert, was non-rousable, was lethargic, drowsy, and stuporous, did not respond to simple commands, did not verbalize appropriately, and could not follow a finger with his/her eyes. Although changes in the resident's condition were identified, the physician was not notified until 8:03 PM when a telehealth visit was conducted (1 ,d+[DATE] hours after the change was identified at 6:30 PM). Review of the Emergency Medical System (EMS) run sheet dated [DATE] identified EMS received the transfer call from the facility at 9:32 PM (1 hour and 29 minutes after the physician telehealth visit). The run sheet identified Resident #1 was lethargic, non-verbal, on blood thinners and had no signs of trauma. Mental status was identified as stupor (near-unconsciousness), and both eyes were reactive. Hospital #1 admission identified Resident #1 arrived at the hospital on [DATE] at 10:11 PM. Physical exam identified no head trauma, pupils were unequal, right eye pupil was reactive, left eye pupil was not reactive, normal pulses, heart sounds and pulmonary effort. Resident #1 was unresponsive and had a Glasco Coma Scale (measures level of alertness from 3 to 15 with 15 being fully awake and alert) (GCS) of six (6). A CT scan was performed with results that showed a large subdural hematoma with significant midline shift and possible herniation. Findings identified the greatest depth of the subdural collection measured 17 millimeters (mm) overlying the parietal (near back and top of the head) lobe and up to 16 mm overlying the frontal lobe with a significant midline shift up to 15 mm. Resident #1 was intubated for airway protection and was transferred to a higher level of care via Lifestar at 11:53 PM with diagnoses of subdural hematoma and closed non-displaced fracture of the second cervical (C 2) vertebra, unspecified fracture morphology (fractures that cannot be classified into specific categories based on their appearance or location; causes of unspecified fracture morphology include trauma, pathological conditions, and stress fractures). Hospital #2 discharge summary dated [DATE] at 4:04 PM identified Resident #1 was admitted from Hospital #1, after a fall hitting his/her head. CT scan revealed a large right holohemispheric subdural hematoma (bleeding that covered the whole right side of the brain) causing a 1.6 cm midline shift of the brain and a non-displaced cervical spine (C 2) fracture. Upon arrival, Resident #1's condition worsened, and his/her code status was changed to Comfort Measures Only (CMO). Resident #1's breathing tube was removed, and Resident #1 expired at 12:48 PM. Clinical record and facility documentation reviews failed to identify the physician was notified of the changes in condition identified on the neurological assessments at 6:30 PM, 6:45 PM, 7 PM, 7:30 PM, and 9 PM. Further review failed to identify why EMS was not notified until 9:32 PM (1 hour and 29 minutes after the physician telehealth visit) after the 8:03 PM telehealth visit. Interview with RN #1/nursing supervisor on [DATE] at 12:55 PM identified she recalled Resident #1 had hit his/her head on [DATE]. RN #1 could not recall if she was notified of any change in Resident #1's condition prior to the change to being unresponsive leading to Resident #1's transfer. RN #1 indicated she immediately contacted the provider when informed of the change in condition, was unable to identify the time, and RN #1 could not recall any delay. RN #1 recalled that the only other time she had contacted the on-call provider on [DATE] was at the time of Resident #1's fall. RN #1 did not identify the time of Resident #1's transfer, and indicated there was no delay in transfer to the hospital. Interview with RN #2/charge nurse on [DATE] at 3:15 PM identified on [DATE] Resident #1 reported hitting his/her head when the fall occurred and had complained of nausea and vomited after the fall. RN #2 indicated she attributed the nausea and vomiting to Resident #1's history of nausea, and she did not consider that a change in neurological status. RN #2 could not recall how long Resident #1 had drowsiness but recalled that she notified the supervisor when Resident #1 became lethargic, and Resident #1 was transferred to the hospital. RN #2 identified although there was documentation that Resident #1 had become drowsy at 6:45 PM, she could not recall a delay in acting on a change in condition timely and timely transfer to the hospital. Interview and clinical record review with the DON on [DATE] at 2:00 PM identified Resident 1's neurological observation record dated [DATE] indicated Resident #1 had complaints of a headache at 6:15 PM, after the fall at 6:07 PM. At 6:30 PM, Resident #1 had nausea, vomiting and headache, with nausea documented again at 6:45 PM and drowsiness noted at that time. Although the DON identified Resident #1 had a reported history of nausea, the medical record lacked documentation of nausea since admission on [DATE]. The DON was unable to identify why Resident #1 was not transferred to the hospital timely after the 8:03 PM MD telehealth visit, and indicated if there was a change in condition as documented, the physician should have been notified timely to obtain new orders. Interview with MD # 1/attending physician on [DATE] at 2:14 PM identified that when a resident is placed on neurological checks after a fall with a reported hitting of the head, the purpose of the neurological checks are to monitor for changes in the areas delineated on the sheet (vital signs, orientation, level of consciousness, pupil responses, extremities movement and presence or nausea, vomiting, headache, change in behavior, bleeding nose, or seizure activity). A documented change from a previous check should be responded to, and the physician should be notified as soon as possible to determine any changes needed in the treatment plan. The facility Neurological Signs policy dated [DATE], identified in part, that the findings of each evaluation are compared, analyzed, and documented in the medical record, the physician is promptly notified of any abnormal findings. The facility Condition: Significant change policy, dated [DATE], identified in part, that staff will communicate with the physician regarding changes in condition to provide timely communication which is essential to quality care management.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for falls, the facility failed to ensure the physician was notified timely of changes in condition timely. The findings include: Resident #1 was admitted to the facility on [DATE] after a fall at home with diagnoses that included fracture of the hip after a fall, fractured left pubic rami, severe protein-calorie malnutrition, chronic myeloid leukemia (CML), and a history of deep vein thrombosis lower extremity (blood clot in the vein). The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was at risk for falls secondary to generalized weakness, a history of falls, and was able to make needs known. Interventions directed to instruct to ask for assistance prior to attempting to transfer or ambulation, place call light in reach, and use gripper socks while in bed. A 5-day MDS assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required extensive assistance for bed mobility, limited assistance for walking with a walker or wheelchair and supervision for transfer. A physician's order dated [DATE]directed to administer Rivaroxaban (Xarelto) (blood thinner) 10 mg in the evening for history of atrial fibrillation (rapid irregular heartbeats) and Resident #1 was a full code. A facility incident report dated [DATE] at 6:07 PM identified Resident #1 was an assist of one (1) staff for transfers and ambulation and had moderately impaired cognition and had an unwitnessed fall while self-ambulating in the room (did not ring the call bell or call out for help, and indicated he/she was trying to get a washcloth), reported hitting his/her head on the dresser and had pain. An RN assessment was completed and identified no injury, neurological checks were initiated and were within normal limits. The physician was notified of the fall and ordered to monitor for a change in condition. The report identified about 8:00 PM Resident #1 became lethargic and responded to painful stimuli. The physician was notified and directed transfer to the hospital, and the resident was transferred immediately after being seen by the physician telehealth visit. During evaluation at the hospital a CT scan showed a subdural hematoma and cervical neck fracture. The hospital report identified a repeat CT scan revealed right holohemispheric (bleeding that covered the whole right side of the brain) subdural hematoma causing a 1.6-centimeter (cm) of midline shift and non-displaced cervical 2 (2nd vertebrae) fracture. After the CT scan Resident #1's Glascow Coma Scale (measures level of alertness from 3 to 15 with 15 being fully awake and alert) declined to seven (7), developed a dilated left pupil and was intubated for airway protection and Resident #2 was transferred to a higher level of care. At Hospital #2 a neurosurgical evaluation was completed which showed worsening midline shift and a right craniotomy (surgical opening into the skull) was performed. Two (2) hours later Resident #1 developed fixed pupils (pupils not responding), had no spontaneous movements and withdrawal times three (3) to noxious (stimuli). A CT scan showed a 2.4 cm midline shift, a discussion was held with the family, and Resident #1 was made Comfort Measures Only (CMO), extubated (remove tube for artificial ventilation/breathing) at 12:02 PM on [DATE] and Resident #1 expired at 12:48 PM. A nursing note dated [DATE] at 6:07 PM written by RN #2 identified Resident #1 vomited one (1) time after the fall, and Resident #1 had and had a history of intermittent nausea due to chronic myeloid leukemia (CML). Review of the clinical record failed to identify a history of nausea since admission. A nursing note dated [DATE] at 6:15 PM by RN #1/nursing supervisor identified the on-call provider was notified of Resident #1's fall and Resident #1 had no obvious signs of injury. Neurological checks, vital signs were within normal limits and range of motion was at baseline, and plan was to closely monitor for any changes with no new orders at that time. A physician progress note dated [DATE] at 9:56 PM identified Resident #1 was seen on [DATE] at 8:03 PM via telehealth. Resident #1 had an altered mental status, was very drowsy, was not responding to questions and directed to transfer Resident #1 to the emergency room for an evaluation. Nursing post event note dated [DATE] at 11:37PM identified Resident #1 with mental status change since fall earlier in the shift and was unresponsive. An audio video visit (physician) was conducted with the nurse present, and orders obtained to transfer Resident #1 to the hospital. Review of facility documentation identified neurological checks were initiated after the fall on [DATE] at 6:15 PM identified Resident #1 had a headache. The assessment completed at 6:30 PM identified headache, new nausea, and vomiting, and the 6:45 PM assessment identified nausea. In addition, the 6:45 PM, 7 PM, 7:30 PM and 8 PM assessments identified a change in condition: Resident #1 was newly identified to be drowsy (prior assessments at 6:15 and, 6:30 identified Resident #1 was not drowsy). The assessment at 9 PM (57 minutes after the physician telehealth visit) identified an additional change in condition: Resident #1 was not alert, was non-rousable, was lethargic, drowsy, and stuporous, did not respond to simple commands, did not verbalize appropriately, and could not follow a finger with his/her eyes. Although changes in the resident's condition were identified, the physician was not notified until 8:03 PM when a telehealth visit was conducted (1 ,d+[DATE] hours after the change was identified at 6:30 PM). Review of the Emergency Medical System (EMS) run sheet dated [DATE] identified EMS received the transfer call from the facility at 9:32 PM (1 hour and 29 minutes after the physician telehealth visit). The run sheet identified Resident #1 was lethargic, non-verbal, on blood thinners and had no signs of trauma. Mental status was identified as stupor (near-unconsciousness), and both eyes were reactive. Clinical record and facility documentation reviews failed to identify the physician was notified timely of the changes in condition identified on the neurological assessments at 6:30 PM, 6:45 PM, 7 PM, 7:30 PM, and 9 PM. Interview with RN #1/nursing supervisor on [DATE] at 12:55 PM identified she recalled Resident #1 had hit his/her head on [DATE]. RN #1 could not recall if she was notified of any change in Resident #1's condition after the fall prior to the change to being unresponsive leading to Resident #1's transfer. RN #1 indicated she immediately contacted the provider when informed of the change in condition when Resident #1 became unresponsive though she was unable to identify the time. RN #1 recalled that the only other time she had contacted the on-call provider on [DATE] was at the time of Resident #1's fall. RN #1 identified the physician should always be notified as soon as possible with any resident change in condition. Interview with RN #2/charge nurse on [DATE] at 3:15 PM identified on [DATE] Resident #1 reported hitting his/her head when the fall occurred and had complained of nausea and vomited after the fall. RN #2 indicated she attributed the nausea and vomiting to Resident #1's history of nausea, and she did not consider that a change in neurological status. RN #2 could not recall how long Resident #1 had drowsiness but recalled that she notified the supervisor when Resident #1 became lethargic, and Resident #1 was transferred to the hospital. RN #2 identified although there was documentation that Resident #1 had become drowsy at 6:45 PM, she could not recall a delay in acting on a change in condition timely, and she was unable to explain why the physician was not notified prior to the 8:03 PM telehealth visit. RN #2 indicated if there was a change in condition, she would have notified the supervisor, and she could not recall if she had contacted the supervisor more than once after Resident #1's fall. Interview and clinical record review with the DON on [DATE] at 2:00 PM identified Resident 1's neurological observation record dated [DATE] indicated Resident #1 had complaints of a headache at 6:15 PM, after the fall at 6:07 PM. At 6:30 PM, Resident #1 had nausea, vomiting and headache, with nausea documented again at 6:45 PM and drowsiness noted at that time. The DON indicated the physician was notified of a change in condition at approximately 8 PM, and Resident #1 was ultimately transferred to the hospital, the DON was unable to explain why the physician was not notified of the change in condition when it was first identified at 6:30 PM, and subsequently at 6:30 PM, 6:45 PM, 7 PM, and 9 PM. The DON identified although she did not know why the physician was not notified timely to obtain new orders, she indicated if there was a documented change in condition, the physician should have been notified. Interview with MD #1/attending physician on [DATE] at 2:14 PM identified the physician should be notified if there is change to the neurological status. MD #1 indicated the purpose of neurological checks are to monitor for changes in the areas delineated on the sheet (vital signs, orientation, level of consciousness, pupil responses, extremities movement and presence or nausea, vomiting, headache, change in behavior, bleeding nose, or seizure activity). MD #1 further indicated if there was a documented change from a previous check, the physician should be notified as soon as possible to determine a need to modify the treatment plan. The facility Condition: Significant Change dated [DATE], identified in part, that staff will communicate with the physician regarding changes in condition to provide timely communication which is essential to quality care management.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #124), reviewed for accidents, the facility failed to ensure the resident was provided assistance with ambulation to prevent a fall. The findings include: Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified Resident #124 was disoriented, and required supervision for ambulation. The Resident Care Plan (RCP) dated 5/1/19 identified a fall risk. Interventions directed Resident #124 must ambulate with assistance of one staff, a gait belt, and a rolling walker with attention to right foot drop. The physical therapy note dated 5/2/19 identified Resident #124 demonstrated decreased insight into his/her deficits which included right foot drop, decreased standing balance, and decreased coordination which made Resident #124 a high fall risk. The nurse's note dated 5/2/19 at 9:23 PM identified Resident #124 was observed by staff walking without his/her walker and before staff could reach Resident #124 he/she fell forward and landed on the floor. Resident #124 had no injury. The incident report dated 5/5/19 at 10:45 AM identified Resident #124 required assistance of one staff for mobility, and while NA #1 was walking Resident #124 to the shower room, Resident #124 lost balance, fell and hit his/her head suffering a cut on the back of the head. Resident #124 was transferred to the hospital. The hospital emergency report dated 5/5/19 identified Resident #124 had a two (2) centimeter (cm) laceration to the occiput, and three (3) staples were placed without any complications. A [DIAGNOSES REDACTED]. The hospital conducted imaging of the head on 5/5/19 that revealed the absence of bleeding. The nurse's note dated 5/5/19 at 8:29 PM identified Resident #124 returned from the hospital with staples noted to the back of the head, and to start antibiotic. Interview, clinical record review, and facility documentation review with NA #1 on [DATE] at 1:35 PM identified although Resident #124 required the assistance of one staff and a gait belt for ambulation, on 5/5/19 he did not provide assistance and/or did not use a gait belt when walking Resident #124 to the bathroom. NA #1 stated he walked in front of Resident #124 to lead him/her to the bathroom, and when he got to the bathroom door he opened the door and turned to see if Resident #124 was still behind him. NA #1 then saw Resident #124 let go of the walker and fall backwards onto the floor. NA #1 stated he should have used a gait belt and did not. In addition NA #1 indicated he should have stood to the side and behind Resident #124 while holding onto the gait belt and did not. Interview and observation with the Director of Maintenance on [DATE] at 2:12 PM identified the distance from the bathroom door where NA #1 stood, to where Resident #124 fell on [DATE] was 16.5 feet. Interview, record review and facility incident report reviewed with the Director of Nursing (DON) on [DATE] at 2:30 PM identified on 5/5/19 Resident #124 required one staff assistance and a gait belt for ambulation. When Resident #124 fell on [DATE], NA #1 did not provide staff assistance and/or use a gait belt. The DON stated NA #1 should have provided assistance and used a gait belt when ambulating Resident #124. Re-education was provided for NA #1, along with education for all staff. Quality Assurance (QA), and audits were completed. Interview and record review with the Director of Rehabilitation and Regional Therapist #1 on [DATE] at 3:50 PM identified on 5/5/19 Resident #124 required one staff assistance with a gait belt and rolling walker, with attention to the right foot drop for ambulation. Review of facility Gait Belt Use Policy directed in part, gait belts were to be used to prevent injury to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. Gait belts must be used when physically ambulating residents. The policy further directed gait belts are excluded if a resident requires support supervision only, or is independent for transfers per the care plan.

Based on clinical record review, observation and interviews for one of one sampled resident reviewed for accidents, (Resident#138), the facility failed to ensure appropriate equipment was utilized to prevent an accident and/or for one of one sampled resident reviewed for smoking (R#6) the facility failed to implement the plan of care related to smoking, and/or failed to ensure smoking evaluations were completed and accurate. The findings include: 1. Resident#138 's [DIAGNOSES REDACTED]. Resident care plan dated 3/05/18 identified and ADL deficit with interventions that included toileting at wheelchair level assist of 1, stand by assist (SBA) with grab bars to bariatric commode when able to tolerate. An admission MDS dated [DATE] identified the resident with intact cognition, required extensive assistance with two (2) plus staff physical assist for ADL's including bed mobility, transfers, and toilet use. Facility documentation dated 3/26/18 indicated R#138 complained of right hip pain after using the commode. Review of the facility investigation statement obtained from NA#7 identified that while transferring the resident onto the toilet, the resident started to sit down into the commode/chair and got stuck in the arms of the chair. The resident was assisted out of the chair and transferred into the larger one located in the corner of the bathroom. NA#7 further indicated that the resident never sat down completely onto the smaller commode/chair, only squatted above the seat while caught in between the arms. Interview of NA#7 completed by the ADNS dated 3/27/18 indicated, however, that as the resident was going to sit down the resident stated that he/she felt the arm of the commode touching his/her bottom and realized it was not the proper commode. NA#7 then changed the commode to the bariatric commode that was located in the corner of the bathroom. Interview with NA#7 on 7/06/18 at 11:47 AM indicated that when the resident went to sit down on commode, he/she got stuck and stated, they did it again, they changed the commode, they keep doing it. NA#7 further indicated the NA did not know that the other commode in the bathroom was for R#138 and had to hold the original (smaller) commode down when the resident stood up to get R#138 off the commode. NA#7 then got the larger commode that was in the bathroom, put it over the toilet and when the resident asked for privacy, NA left the bathroom. NA#7 indicated the resident did not complain of pain at that time. In addition, NA#7 indicated another NA assisted the resident back into the wheelchair and both NAs assisted the resident back to bed at which time R#138 complained of pain. The supervisor and APRN were notified and an x-ray of the pelvis was obtained. The x-ray identified a dislocated right hip prosthesis and the resident was transferred to the ER. The ER report dated 3/26/18 identified the resident developed severe acute pain in the right hip while transferring from the bed to chair at the facility. Portable film done and showed dislocation of the right hip prosthesis. Additionally, the prosthetic hip dislocation was reduced using traction and rotation manipulation. Staff inservice education was completed on 3/27/18 with instructions to determine, during evaluation, the appropriate commode for the resident, and if different from the roommate, both commodes need to be labeled with wrist bands and the care plan labeled with commode size, etc. The facility did not have a policy for transfers to a commode. 2. Resident # 6 [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident had current tobacco use. A quarterly MDS assessment dated [DATE] identified the resident had no cognitive impairment and required extensive assistance for bed mobility, transfer, dressing and personal hygiene. A care plan dated 7/02/18 identified focuses of smoking history, the resident was found smoking inside the building on 1/16/18 and smoking material was noted in the resident's room on 1/27/18. The care plan further identified that the resident had decided to smoke again on 3/23/18. Care plan interventions included room search as per policy, initiation date 1/16/18; room/belongings may be searched after leave of absence/visitors, initiation date 1/28/18; and staff to check small pockets on wheelchair when resident comes in from smoking, do not hand the resident the lighter when outside smoking, initiated date 4/27/18. Nursing smoking evaluation and safety screen dated 6/32/18 identified the resident was a current smoker and required routine supervision during scheduled smoking activity. Observation of smoking on 7/03/18 at 1:29 PM identified the resident putting out a partially-smoked cigarette and handed it to Social Worker #1 to put into her cigarette box to save for smoking at another time. Social Worker # 1 handed this partially smoked cigarette to NA#1, who then moved to place the partially smoked cigarette into the resident's cigarette box. Surveyor asked NA #1 if this should be done, NA #1 identified that the facility had allowed this, and agreed to wait for the Administrator to review this practice before continuing. No check of the resident's wheelchair pockets were observed. Observation and interview with the Administrator on 7/03/18 at 1:35 PM identified that a partially smoked cigarette should not be put out and placed back in the cigarette box. NA#1 indicated that this had been previously done, and identified a partially-smoked cigarette in Resident #6's cigarette box from a previous smoking session. Interview with Social Worker # 1 on 7/03/18 at 1:37 PM identified that he/she had been trained on smoking monitoring procedure, but the issue of partially smoked cigarettes was not included in the training. Interview and review of the clinical record and facility documentation with the DNS on 7/06/18 at 1:55 PM identified that the smoking evaluation should have reflected resident - specific information and interventions and was unsure why this was not done. The DNS indicated it is a nursing responsibility, and further identified that facility training records related to Resident #6 smoking and/or room searches identified that eleven nursing staff had been trained on 5/01/18. The training included: room searches were to be completed after any visitor and chair searches to be done after every smoking session the resident attends. The DNS further identified that this training was not completed for other nursing and facility staff and that the care plan interventions were not fully implemented. Additionally, staff education on room searches for medications were not conducted which were identified as an ongoing problem. The facility policy for smoking identified, in part, that it is the policy of the facility to provide a healthy and safe environment for residents, staff and visitors by limiting the use of tobacco smoking materials on its campus, and that all cigarettes, igniting and smoking materials will be kept in a secure location designated at the facility. The facilty policy did not address partially-smoked cigarettes.

Based on review of the clinical record review, facility documentation, facility policy, and interviews for one sampled resident (Resident #100) reviewed for medication administration, the facility failed to ensure the resident was free from a significant medication error. The findings include: Resident #100's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified severe cognitive impairment and extensive assistance of one staff for personal hygiene. The Resident Care Plan (RCP) dated 4/7/17 identified a potential for pain and ADL deficit. Interventions directed to administer medications as ordered, and assist with bathing and dressing. The nurse's note dated 6/5/17 at 8:43pm identified that around 6:00am the charge nurse administered another resident's medications in error to Resident #100. Resident # 100 was alert, verbal, with no respiratory or cardiac distress and stable vital signs. The resident was transferred to the emergency department per the APRN order. The reportable event dated 6/5/17 at 5:30am identified Resident #100 received the following medications in error: [MEDICATION NAME] Mono (Imdur) 60 mg, [MEDICATION NAME] 2.5 mg, [MEDICATION NAME] ([MEDICATION NAME]) 100 mg, Trajenta 5 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 20 mg, Multivitamin one tablet, Questran one packet, Levetiraceta ([MEDICATION NAME]) 500 mg. The investigation identified LPN# 2 who was being oriented by LPN#3, administered the medications without checking Resident #100's identification (ID) bracelet and without the supervision of the nurse orienting. Review of the hospital discharge summary dated 6/6/17 identified Resident #100 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The hospital discharge summary identified Resident #100 had a low blood pressure that required central line placement for intravenous fluids and blood pressure, telemetry, and finger stick blood sugar monitoring. Interview with LPN #2 on 6/21/17 at 12:51pm identified the medications poured for Resident #100 were for the resident's roommate. LPN #2 indicated she/he entered Resident #100's room, called Resident #100 by another resident's name and administered the medications. After the medications were administered, LPN # 3 entered the room and indicated he/she had medications for Resident #100. LPN #2 told LPN #3 that Resident #100 already received his/her medications. LPN #2 stated that although Resident #100 was wearing an ID bracelet, the ID bracelet was not checked before administering the medications because Resident #100 was the only resident in the room. Interview with LPN #3 on 6/22/17 at 1:04pm identified LPN #2 poured medications for Resident # 100's roommate who was sitting at the nurse's station. LPN #3 entered Resident #100's room and saw LPN #2 standing next to Resident #100. LPN #3 asked if the medications were administered to Resident #100. LPN #3 stated LPN #2 poured medications for the roommate who was at the nurse's station and gave the medications to the wrong resident. LPN # 3 notified the APRN and obtained an order to transfer Resident #100 to the hospital. Review of facility Medication Administration - Oral Policy directed in part, to identify the Resident/Patient before administering medication.

Based on review of the clinical record, interview and review of facility policy, the facility failed to ensure that for one of three residents reviewed for assistance with transfers, (R#22), the facility failed to ensure the transfer was completed according to the resident's plan of care to prevent injury. The finding includes: Resident #22 had [DIAGNOSES REDACTED]. Resident assessment dated [DATE] identified that the resident was moderately impaired for daily decision making and required a two person assistance for transfer between surfaces. Review of the plan of care dated 7/15/15, identified that the resident required an assistance of two caregivers using a stand aide when the resident transfers between the bed and wheelchair. A facility investigation dated 8/17/15 at 8:55 AM identified that the resident sustained [REDACTED]. The facility investigation included a statement from Nurse Aide (NA) # 1, the nurse aide who transferred the resident to the wheelchair on 8/17/15 at 8:55 AM, that identified that he/she sat the resident up on the side of the bed, put his/her arms aroud her and had the resident put her arms around NA#1's neck. According to NA#1's statement, he/she then lifted Resident # 22 up and over to the wheelchair and as he/she was fixing the resident's foot into the foot rest, he/she noted blood on Resident # 22's pants. On further inspection at that time, NA# 1 noticed a big gash on the resident's right leg. During an interview on 7/20/16 at 2:45 PM, NA #1 stated that she did not read the resident's care card and assumed the resident was a stand pivot. NA #1 stated that she had removed the leg rests from the chair prior to the transfer and there was no injury identified at that time, however, after the transfer NA#1 found blood on the resident's pant leg once she placed the resident in the chair. NA#1 identified that she thought the attachment for the leg rest cut the resident. The resident was subsequently sent to the Emergency Department (ED) of Hospital #1 where the wound was sutured closed. Review of the hospital documentation reflected that the wound was deep and irregular, involving avulsion of fascia and required suturing of multiple flaps and revision of wound margins.