Every finding on record at Lord Chamberlain Manor Nursing & Rehabilitation Ce

Based on observations, interviews, review of clinical record and facility policy for 1 of 1 resident (Resident #9) reviewed for glucometer use, the facility failed to perform hand hygiene before and after glucometer use and for 3 of 3 residents (Resident #14, Resident #65 and Resident #70) reviewed for pressure ulcers, the facility failed to ensure residents with a pressure ulcer had enhanced barrier precautions (EBP) implemented and failed to ensure appropriate infection control practices were followed during a dressing change. Additionally, for Resident #65, the facility failed to wear the appropriate personal protective equipment (PPE) during a dressing change and failed to ensure personal care items on 4 of 4 nursing units were labeled, covered and properly stored. The findings include: 1. Resident #9 had diagnoses that included Type 2 diabetes, dementia and behavioral disturbances. The Resident Care Plan (RCP) dated 4/29/26 identified Resident #9 was at risk for hypoglycemia and hyperglycemia related to a diabetes diagnosis, with interventions that included blood sugar checks per physician orders, reporting abnormal levels to the provider, monitoring lab work, and monitoring for signs and symptoms of hyperglycemia and hypoglycemia.A physician order dated 4/30/26 directed staff to obtain Resident #9's blood glucose level twice a day.The admission Minimal Data Set (MDS) assessment dated [DATE] identified that Resident #9 was cognitively intact, had an active diagnosis of Type 2 diabetes, was independent for eating but was dependent for showering.Observation and interview conducted on 5/21/26 at 6:12 AM with Licensed Practical Nurse (LPN) #4 identified LPN #4 obtained a blood glucose level on Resident #9 using a unit shared glucometer. LPN #4 failed to perform hand hygiene before or after entering and exiting Resident #9's room and failed to perform hand hygiene before or after obtaining Resident #9's blood glucose level. LPN #4 acknowledged that he should have performed hand hygiene both before and after obtaining the blood glucose level but stated he forgot. Review of the facility policy titled, Glucometer Disinfection, dated,10/16/25, identified that the procedure for obtaining a resident's blood glucose using a glucometer includes performing hand hygiene prior to obtaining the blood glucose sample and performing hand hygiene after removing gloves when the procedure is complete and before exiting the room. Review of the Centers for Disease Control and Prevention (CDC) recommendations titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, indicated that when performing a fingerstick blood glucose test, hand hygiene must be performed immediately after removing gloves and before touching medical supplies intended for use on other individuals. 2a. Resident #14 was admitted to the facility in May 2026 with diagnoses that included cellulitis of the lower right leg with multiple chronic foot wounds, recurrent bilateral pressure ulcers to buttocks, and type 2 diabetes. The admission Nursing assessment dated [DATE] and written by Registered Nurse (RN) #2 identified that Resident #14 was cognitively intact and able to make needs known, required the assistance of 1 staff member for activities of daily living except able to eat independently and had a Stage 2 (partial-thickness skin loss) pressure ulcer to the coccyx and right buttock with multiple bruising and abrasions to the right leg. The Resident Care Plan (RCP) dated 5/4/26 identified alteration in skin integrity as a concern with interventions that included avoiding uninterrupted sitting in the chair, floating heels off of the bed surface if indicated, moisture barrier per protocol if indicated, pressure reducing mattress on the bed, toilet and incontinent care with rounds, treatment and dressing changes as ordered and report to the nurse any areas of skin breakdown during care. Physician orders dated 5/7/26 directed to administer Prostat (a liquid protein supplement) 30ml (milliliters) twice a day to promote wound healing. Physician orders dated 5/12/26 directed to cleanse the coccyx area with Wound Wash, pat dry, apply Calcium Alginate (seaweed fibers combined with calcium used for wounds with moderate to heavy drainage) to the wound bed, cut to size and cover with a dry, clean dressing, change every other day and as needed.The RCP and physician orders failed to indicate enhanced barrier precautions (EBP) to be in place regarding Resident #14 having a Stage 2 pressure ulcer to the coccyx.A nursing note dated 5/14/26 and written by Registered Nurse (RN) #4 (Infection Control Nurse/ICN) indicated that Resident #14 had 3 loose stools. Resident #14 was placed on contact precautions (infection control measures for active infections that require the use of gloves, gown and mask whenever entering the room) as cautionary measures due to loose stools. Observation on 5/18/26 at 10:30 AM noted Resident #14 had a contact precaution sign outside of his/her doorway, no EBP signage was in place and a clean personal protective equipment (PPE) bin. Nursing notes dated 5/19/26 and 5/20/26 and written by RN#5 indicated that Resident #14 was no longer having loose stools. Interview with APRN #1 on 5/20/26 at 1:15PM indicated that Resident #14's loose stools were related to the Prostat and that Resident #14 did not have an infection in stool. APRN #1 indicated that she had discontinued the order for Prostat. Observations on 5/20/at 2:00 PM and on 5/21/26 at 11:00AM identified there was no precaution (EBP or contact precaution) signage or PPE bin outside of his/her room. Observation of Resident #14's dressing change to Resident #14's coccyx area on 5/21/25 at 11:00 AM with Licensed Practical Nurse (LPN) #2 identified LPN #2 failed to donn (put on) a gown when performing the treatment to Resident #14's coccyx/buttocks. Interview with LPN #2 on 5/21/26 at 1:45 PM identified that she should have worn a gown as Resident #14 should have been on EBP due to chronic open area to his/her coccyx/buttocks and legs. Interview with RN #4 on 5/21/26 at 2:00 PM indicated that Resident #14 should have been on EBP and it was an oversight that Resident #14 was not placed on EBP when contact precautions were discontinued. RN #4 indicated that EBP was used for any residents that had open, chronic wounds. b. Observation of the dressing change to Resident #14's coccyx and right buttock on 5/21/26 at 11:05 AM by LPN #2. LPN #2 brought the treatment cart into Resident #14's room with the supplies for Resident #14's treatment on top of the treatment cart. LPN #2 sanitized her hands and applied gloves. LPN #2 proceeded to remove the clean dressing from Resident #14's right buttocks. LPN #2 began cleaning the open area of the right upper buttock from outer to inner wound. LPN #2 then proceeded to clean another open area on Resident #14's right lower buttock located at the crease of right buttock and upper right thigh area. LPN #2 cleaned the wound from outer to inner wound. LPN #2 proceeded to go back and clean upper right buttock again with the same gauze. LPN #2 then changed her gloves without the benefit of sanitizing her hands in between glove changes. LPN # 2 cut the Calcium Alginate with scissors to fit on the open areas to the right upper buttock and placed the scissors on top of the treatment cart. LPN #2 then proceeded to place the Calcium Alginate to the upper right buttocks and apply a clean dressing. LPN #2 then proceeded to open the drawer to the treatment cart without the benefit of removing her gloves and used her gloved hands searching for barrier cream in the drawer. LPN #2 could not locate any barrier cream in the treatment cart. LPN #2 removed her gloves and sanitized her hands and exited the room to obtain barrier cream from the supply room. LPN # 2 reentered the room, sanitized her hands and applied gloves. LPN # 2 proceeded to apply barrier cream to the resident's right lower buttock/thigh area. LPN #2 then proceeded to remove her gloves and apply gloves without the benefit of sanitizing her hands to start a dressing to the vascular wounds on Resident #14's legs. Interview with LPN #2 on 5/21/26 at 1:45 PM indicated that she should have sanitized her hands each time she changed gloves, and she thought she had done that. LPN #2 also indicated that she should not have cleaned the upper buttock then the lower buttock wounds at the same time and that each wound should have been treated separately. Furthermore, LPN #2 stated that she should have removed her gloves and sanitized her hands before going into the treatment cart. LPN #2 was aware that she did not follow infection control standards of practice for dressing changes and could not explain the reason she did not follow infection control standards of practice. Interview with RN #4 at 2:00 PM indicated that LPN #2 should not have brought the treatment cart into Resident #14's room as the policy was to use an over the bed table as a clean surface. LPN #2 should have treated each wound separately and sanitized her hands with each glove change. In addition, RN #4 stated that LPN #2 should have removed her gloves and sanitized her hands before going into the treatment cart. The National Pressure Ulcer Injury Advisory Panel guidelines for wound care updated February 2025 indicates that cleaning wounds should be from the least contaminated area to the most contaminated, use new gauze with each cleansing pass, clean one wound completely before moving to the next , treat each wound separate and perform hand hygiene area and/or or change gloves between wounds. The Clean Dressing Change Policy dated 10/16/25 directed, in part that the facility will provide wound care in a manner to decrease potential for infection and/or cross contamination. A clean field will be set up using an over the bed table. Each wound will be treated individually. Hands will be washed when gloves are changed. Gloves will be changed and hands washed when going from a contaminated area to a clean area. 3a. Resident #65 was admitted to the facility in May 2026 with diagnoses that included a Stage II pressure ulcer to the coccyx, dementia, and high blood pressure. The Resident Care Plan (RCP) dated 5/11/26 indicated that Resident #65 required reorientation to person, place, and time as needed, had a Stage II pressure ulcer to the coccyx, and was at risk for delayed wound healing related to decreased activity and mobility. Interventions included providing incontinence care and applying a moisture barrier after incontinent episodes, as well as checking the coccyx dressing for placement and soilage and changing it as needed. However, the RCP did not identify Resident #65's need for enhanced barrier precautions. A physician order dated 5/11/26 directed staff to cleanse the coccyx with Wound Wash, pat dry, and apply a cushion bandage over the open area daily and as needed. The physician orders failed to direct staff to implement or maintain enhanced barrier precautions during high contact resident care activities. Observation of Resident #65's room on 5/18/26 at 1:46 PM and again on 5/19/26 at 3:28 PM noted that there was no enhanced barrier precaution signage or any indication that Resident #65 was under enhanced barrier precautions for a coccyx wound. Interview with RN #4 (Infection Preventionist) on 5/21/26 at 2:00 PM identified that enhanced barrier precautions should be utilized for any resident that had an open, chronic wound. Observation on 5/22/26 at 2:13 PM identified enhanced barrier precautions signage posted outside Resident #65's room.b. During an observation on 5/22/26 at 2:13 PM with RN #10 of Resident #65's daily dressing change to a Stage II pressure ulcer on the coccyx, RN #10 performed appropriate hand hygiene, changed gloves as needed, cleansed the wound, and replaced the coccyx dressing as ordered by the physician. However, RN #10 did not wear a gown as required for a resident that should have had enhanced barrier precautions initiated.Interview with RN #10 on 5/22/26 at 2:18 PM indicated that she should have worn a gown during Resident #65's dressing change because Resident #65 was required to be on enhanced barrier precautions for their chronic pressure ulcer.4. Resident #70 had diagnoses that included left femur fracture repair, diabetes, sickle-cell disease, and dementia.The Nursing admission assessment dated [DATE] identified Resident #70 was alert and oriented for person, place, and time and had mild cognitive impairment. The assessment identified Resident #70 had 2 open Stage 2 pressure injuries to the sacrum/coccyxThe Resident Care Plan (RCP) dated 5/7/26 identified Resident #70 was at risk for alteration in skin integrity related to decreased mobility. Interventions included avoiding uninterrupted sitting in a chair, turn and reposition with rounds and as needed, and a pressure reducing mattress on the bed.A physician order dated 5/20/26 directed to cleanse the sacrum with Wound Wash, pat dry, apply Calcium Alginate cut to size to area, cover with dry protective dressing 2 times a day and as needed every day and evening shift until 5/27/26.Observation of the treatment to Resident #70's sacrum completed by Licensed Practical Nurse (LPN) #1 and interview on 5/21/26 at 11:04 AM identified she had gathered all needed supplies which were inside a large plastic bag that she indicated was dedicated to Resident #70. She performed hand hygiene with an alcohol-based hand rub (ABHR) and cleaned her scissors with a sanitizing wipe prior to entering Resident #70's room. There was no sign for EBP posted at the doorway and she entered the room without donning personal protective equipment (PPE), greeted Resident #70, and explained what she was going to do. She then wiped down the overbed table with disinfectant wipes and pulled the privacy curtain. LPN #1 was observed to reach into the bag of supplies and place a package of gauze, a tube of Triad (topical barrier) cream, and a bottle of wound cleanser onto the uncovered table. She then opened 2 packages of adhesive foam dressings without wearing gloves and labeled them with the date and her initials and placed them down onto the uncovered table. She positioned Resident #70 onto his/her right side, unclasped their brief and pulled it down to expose the coccyx, there were 2 small, superficial wounds observed on Resident #70's sacrum/coccyx with pink, shiny, intact, fragile scar tissue observed to the peri wound of both wounds that connected in the middle. There was no dressing noted on Resident #70. She donned gloves and dated the outside of a package of Calcium Alginate (topical wound absorbent dressing) then proceeded to cut 2 pieces of the Calcium Alginate and allowed them to fall onto the outside of their packaging which was sitting on top of the uncovered table. LPN #1 indicated the dressing had fallen off during morning care after breakfast, and she had told the nurse aides she would be putting a new dressing on. She cleansed both wounds with wound cleanser and gauze, removed her gloves, used ABHR, placed clean gloves. She picked up one piece of calcium alginate and applied it to the left side wound and as she reached for the adhesive foam dressing, Resident #70's inner brief touched the top of the calcium alginate and the right-side wound which had already been cleansed. LPN #1 assisted Resident #70 to turn a little more to the right so obtain better access to the wounds, she then placed the adhesive foam dressing over the Calcium Alginate on the left coccyx wound. She then picked up the 2nd piece of Calcium Alginate and placed it onto the inside of the other adhesive foam dressing and proceeded to place that over the right-side coccyx wound. LPN #1 then reclasped Resident #70's brief, removed her gloves, cleansed her hands with ABHR, opened the privacy curtain, collected the unused supplies and placed them back into the bag and exited the room.a. Interview with LPN #1 on 5/21/26 at 11:36 AM identified Resident #70 was not on EBP. LPN #1 identified that any nurse could place a resident onto EBP if they saw that the resident required it and that an order was required in addition to an EBP sign on the doorway. She indicated that Resident #70 did not require EBP for his/her Stage 2 wounds because EBP was only required for residents with feeding tubes, intravenous catheters, or bad wounds which she indicated were Stage 3 or worse. LPN #1 was unaware of the Centers for Disease Control and Prevention (CDC) guidance which indicated EBP was required for all chronic wounds and that pressure ulcers of all stages were considered chronic wounds.Interview with RN #4 on 5/21/26 at 2:00 PM identified that EBP was used for any resident that had open, chronic wounds. Review of the Enhanced Barrier Precautions policy directed, in part, an order for EBP will be obtained for residents with chronic wounds such as pressure ulcers, and the facility will determine the method used to communicate to the staff which residents require EBP for high contact activities. The policy directed that performance of wound care for any wound that required a dressing was considered a high contact activity and required donning of PPE for EBP.b. Interview with LPN #1 on 5/21/26 at 11:34 AM identified she was unaware that cutting the Calcium Alginate and letting it fall onto the outside of the packaging was a source of contamination for the wound because the outside of the packaging was not considered a clean surface. Additionally, she was unaware that as she performed the dressing change the inside of the brief making contact with Resident #70's wound and the internal dressing (calcium alginate) was a source of contamination because the inside of the brief was not a clean surface due to its contact with Resident #70's skin prior to her cleansing the wounds with the wound cleanser. LPN #1 stated that she had not been aware of these sources of contamination during a dressing change, and that she would be more careful during future dressing changes.Review of the Pressure Injury Prevention Guidelines policy directed, in part, to promote healing of existing pressure injury it is the policy of the facility to use evidence-based interventions for all residents which pressure injuries. The policy directed effectiveness of interventions will be monitored through ongoing assessments of the wound. The policy directed for preventive skin care to keep the skin clean and dry. The policy failed to identify wound care directions for care of existing pressure injuries.Although requested, a facility policy for treatment/management of existing pressure injuries (Stage 2, Stage 3, etc.) was not provided. Review of the facility policy titled, Enhanced Barrier Precautions, undated, identified that an order for enhanced barrier precautions should be obtained for residents with chronic wounds such as pressure ulcers and that enhanced barrier precautions should be implemented during high contact activities, including dressing changes. 5. Observation made on 5/19/26 at 10:10AM identified the following:a. room [ROOM NUMBER]: 2 emesis basins stacked on top of each other located on the back of the toilet along with a basin filled with water in the sink containing a soiled washcloth.b. room [ROOM NUMBER]: a urinal was observed located on a round table in the room; a wash basin was uncovered located on the dresser.c. room [ROOM NUMBER]: a urinal was stored on the resident's bedside table.d. room [ROOM NUMBER]: a urinal was stored on the round table, a wash basin was unlabeled in the bathroom, placed in between the grab bar.e. room [ROOM NUMBER]: had uncovered items consisting of 2 bedpans, 1 wash basin and 1 insert for a commode stacked on top of each other on the shower bench, not labeled as to what resident they belonged to.f. Room17: had 2 bedpans and 2 wash basins in the bathroom, not covered.g. room [ROOM NUMBER]: had 2 basins and 1 bedpan in the shower, uncovered.h. room [ROOM NUMBER]: had 1 bedpan on the dresser not covered, 3 urinals in the room, 2 hanging from the garbage can and 1 on the dresser.i. room [ROOM NUMBER]: had 2 basins in the shower, uncovered.j. room [ROOM NUMBER]: had 2 basins and 1 bedpan in the shower, uncovered.Interview and observation made of all the rooms above on 5/19/26 at 12:30 PM with Registered Nurse (RN) #4 identified it was the Nurse Aides responsibility to properly store all personal hygiene equipment. Also, identifying the policy was for the items to be stored in the dresser, labeled and covered. Further identifying the nurses were responsible for the oversight. RN #4 was surprised that 10 of 30 resident occupied rooms had personal hygiene equipment not properly stored and hadn't done much education on proper storage.Review of the Disinfection of Bedpans and Urinal policy dated 10/16/25 directed, in part, bedpans and urinals are handled in a manner to prevent the spread of infection through personal equipment. Bedpans and urinals are for single resident use only. Marked with the resident's name and discarded upon discharge. Store bedpans and urinals in the resident's bedside cabinet or drawer after placing them in a plastic bag or as per facility policy. If the resident uses the bedpan and urinal at will, do not allow placement on the floor, or on a bedside table that is used for eating and drinking.

Based on facility documentation, facility policy and interviews for review of 2 of 2 Registered Nurse (RN) (RN #2 and RN #3) personnel files, the facility failed to ensure new hire RNs had the knowledge and skills required for care of residents prior to removal from orientation and allowing them to work shifts independently as the RN Supervisor. The findings include: Review of the Facility Assessment Tool dated 1/13/26 identified the following education was provided upon hire: resident rights, abuse, infection control (hand hygiene, isolation, use of PPE, MRSA/VRE/CDI precautions, environmental cleaning), person-centered care, change in condition, cultural competency, end of life care, death and dying, activities of daily living (bathing, bed-making, bedpan, dressing, feeding, nail care, perineal care, mouth care, providing privacy, transfers, use of gait belt, use of mechanical lifts), disaster planning (active shooter, elopement, fire, flood, power outage, tornado), medication administration (injectable, oral, subcutaneous, and topical), resident assessments and examinations (admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, pain assessment), dementia education. Additionally, the facility assessment identified that the facility offered ostomy care and tracheostomy care for their resident population. The assessment tool indicated that there were orientation day 1 packets, orientation day 2 packets, orientation day 3 packets, and orientation day 4 packets which include many of the above education/competency topics.1. RN #2's date of hire was 3/17/26 for the position of RN Supervisor for 40 hours per week.A General Orientation Checklist (from RN #2's file) dated 3/17/26 identified RN #2's name and position on page 1 and was signed by RN #2 on 3/17/26 on page 2. The Checklist contained 3 columns for the topic, preceptor initials, and date completed. The Checklist contained approximately 48 topics listed. On page 2 of the Checklist was a line: Successfully completed general orientation: with a space for the date. No areas on the checklist were filled out by a facility staff member to document the orientation of RN #2 beyond RN #2's name, position, signature, and date.Review of daily staffing schedules identified RN #2 was scheduled for orientation shifts on: 3/23/26 for the 3PM-11PM shift, 3/24/26 for the 3PM-11PM shift, 3/25/26 for the 3PM-11PM shift, 3/26/26 for the 3PM-11PM shift, 3/27/26 for the 3PM-11PM shift, 3/30/26 for the 3PM-11PM shift, 3/31/26 for the 3PM-11PM shift, 4/1/26 for the 3PM-11PM shift, 4/2/26 for the 3PM-11PM shift, 4/3/26 for the 3PM-11PM shift, 4/7/26 for the 3PM-11PM shift, 4/8/26 for the 3PM-11PM shift, 4/9/26 for the 3PM-11PM shift, 4/10/26 for the 3PM-11PM shift, and 4/11/26 for the 3PM-11PM shift. A total of 15 orientation shifts were worked by RN #2.Review of the daily staffing schedule dated 4/14/26 identified that RN #2 worked on her own as the RN supervisor for the 3PM-11PM shift.A Licensed Nurse Orientation Checklist (from RN #2's file) dated 3/17/26 identified RN #3's name. The Checklist was 3 pages long and contained 86 responsibilities which encompassed 17 different categories for the new hire nurse to be precepted on and there was a column for the preceptor initials and a column for the completion date. The bottom of page 2 contained the sentence: All the above areas have been covered with me during my orientation. Page 3 of the Checklist contained a line for the date of successful completion of orientation. The bottom of page 3 contained 3 signature lines: Employee, Orientator, and Director of Staff Development (DSD). The checklist indicated that the Staff Education nurse, RN #13, had initialed all sections of the checklist as completed on 3/27/26 (RN #2's 5th orientation day) except for ostomy care and tracheostomy care which were marked as N/A (not applicable).Review of Clinical Competency packet dated 3/17/26 but signed on 3/18/26 identified 17 competencies successfully completed by RN #2. The competency topics were: Hand hygiene, Putting on/Taking off PPE, Glucose testing, Coagucheck XS machine, Use of insulin pen, Syringe safety, Midline/Central Line Dressing Change, Electronic Infusion Pump checklist, Manual Flow meter, Clean Technique dressing change, Catheter insertion & Maintenance Indwelling Catheter, Post exposure to body fluids, Blood Spill Clean up (Kit unavailable), Blood Spill Cleanup (with kit), Choking and abdominal thrusts, Filling a portable oxygen unit, Transferring a resident using a mechanical lift. Additionally, the competency topic of Tracheostomy Care was signed as N/A (not applicable) for all steps of the competency. 2. RN #3's date of hire was 3/17/26 for the position of per diem RN supervisor.A Licensed Nurse Orientation Checklist (from RN #3's file) dated 3/17/26 identified RN #3's name. The Checklist was 3 pages long and contained 86 responsibilities which encompassed 17 different categories for the new hire nurse to be precepted on and there was a column for the preceptor initials and a column for the completion date. The bottom of page 2 contained the sentence: All the above areas have been covered with me during my orientation. Page 3 of the Checklist contained a line for the date of successful completion of orientation. The bottom of page 3 contained 3 signature lines: Employee, Orientator, and Director of Staff Development (DSD). All areas of the Checklist were blank and there were no signatures or items checked off or dated as completed.Review of Clinical Competency packet dated 3/19/26 identified 17 competencies successfully completed by RN #3. The competency topics were: Hand hygiene, Putting on/Taking off PPE, Glucose testing, Coagucheck XS machine, Use of insulin pen, Syringe safety, Midline/Central Line Dressing Change, Electronic Infusion Pump checklist, Manual Flow meter, Clean Technique dressing change, Catheter insertion & Maintenance Indwelling Catheter, Post exposure to body fluids, Blood Spill Clean up (Kit unavailable), Blood Spill Clean up (with kit), Choking and abdominal thrusts, Filling a portable oxygen unit, Transferring a resident using a mechanical lift. Additionally, the competency topic of Tracheostomy Care was signed as N/A (not applicable) for all steps of the competency.Review of daily staffing schedules identified RN #3 was scheduled for orientation shifts on: 4/6/26 for the 7AM-3PM shift, 4/7/26 for the 7AM-3PM shift, 4/8/26 for the 7AM-3PM shift, 4/9/26 for the 7AM-3PM shift, 4/13/26 for the 7AM-3PM shift, 4/14/26 for the 7AM-3PM shift, 4/20/26 for the 3PM-11PM shift, and 4/21/26 for the 3PM-11PM shift. A total of 8 orientation shifts were worked by RN #3.Review of the daily staffing schedule dated 5/14/26 identified that RN #3 worked on her own as the RN Supervisor for the 7AM-3PM shift.Interview with RN #3 on 5/19/26 at 3:00 PM identified she worked on 5/14/26 as the nursing supervisor for the first time on her own. She indicated she had received no supervisor training and that it had been terrible. She indicated she had worked with a Licensed Practical Nurse (LPN) twice on the 7AM-3PM shift while orienting, and an RN twice on the 3PM-11PM shift. She indicated she had not been trained adequately for the medication cart or with the medical record platform (Pointclickcare). She indicated prior to 5/14/26 she had not done an admission, and that on 5/14/26 the Director of Nursing Services (DNS) had yelled at her for only entering 1 medication for the admission, and had questioned her about what was taking her so long. She indicated when she had expressed that she needed more orientation time she had been told by the scheduler and/or human resources that the facility did not have enough money to keep her on orientation any longer. RN #3 further indicated that she had been a hospital emergency department nurse for many years and had never worked in this type of setting which was why she had wanted additional orientation. Additionally, she indicated that she should not have agreed to work on 5/14/26, but that the facility was desperate for help and she had thought there would be another person working who could assist her, but stated that no one had helped her through the shift. RN #3 indicated she did not want to return to the facility to work again.Although requested a General Orientation Checklist for RN #3 was not provided.Interview with RN #13 on 5/22/26 at 12:30 PM identified she had been the Staff Development nurse for about 1.5 years and had resigned from that position in March 2026. She indicated that she was now per diem for the nursing supervisor position only. She indicated that new hire nurses are given the Licensed Nurse Orientation Checklist at the end of their general orientation and are instructed to bring it with them when they shadow other nurses on orientation so that they can get everything they need signed off. She further indicated that it was the responsibility of the DNS to determine if a new hire nurse was ready to work on their own, or if they required additional orientation, and to notify the scheduler that they were ready. Additionally, she indicated that she had never been specifically told that it was her responsibility as the Staff Development nurse to determine when the new hire nurses were ready to work on their own, and that she herself had not made the decision for any new hire nurses to work on their own and come off orientation.Interview with the DNS on 5/22/26 at 12:50 PM identified that the Licensed Nurse Orientation Checklist should be completed and verified with the new hire nurse that they were ready to work on their own prior to coming off orientation. She indicated that it was the responsibility of the Staff Development nurse to make that determination, and that she herself did not tell the scheduler when a nurse was ready to be removed from orientation. She was unaware that RN #13 did not ensure the Licensed Nurse Orientation Checklist was completed, nor that RN #13 did not ensure the new hire nurses were ready to work on their own prior to the nurse scheduler scheduling them solo. She indicated that the scheduler would ask before scheduling a new hire nurse supervisor on their own, but was unable to identify who the scheduler would ask because she didn't make that determination. The DNS indicated that prior to having a new hire nurse work solo as the RN supervisor in charge of the facility it was contingent on the comfort level of the nurse and the completion of their orientation checklist and other education/competencies. She indicated that the RN supervisor position was typically a 4-6 week orientation period, and that there was training available for mock practice for those nurses who were unfamiliar with Pointclickcare. She was unaware that RN #3 did not have a completed Licensed Nurse Orientation Checklist, nor that she had not felt that she was oriented enough, and was unable to identify how they knew she had the knowledge and skills to work as the nursing supervisor without that education completed.Review of RN #2 and RN #3's personnel and education files failed to identify orientation day 1 packets, orientation day 2 packets, orientation day 3 packets, and orientation day 4 packets.Review of the Standard Operating Procedure-Hiring Process policy directed, in part, the scope of the policy was to ensure a hiring workflow from the time of application to interview to completion of onboarding tasks through to the date of hire. The policy does not address the procedure from the general orientation and beyond.Although requested, a facility policy for Licensed Nurse Orientation Requirements was not provided. The facility does not have a policy related to the orientation procedure for new hire nurses.

Based on tour of the dietary department, interviews, and facility policies, the facility failed to ensure food items were labeled and dated, expired food items were discarded, facial hair was covered, and ovens were clean. The findings include: A tour of the Dietary Department with the Food Service Director (FSD) on 5/17/26 at 9:20 AM identified the following:1a. A tray of sandwiches (15) in the reach in refrigerator was undated. The FSD indicated that the sandwiches were just made that morning. Post inquiry, sandwiches were removed and dated. b. Sliced ham covered with plastic wrap was located on a shelf in the walk-in refrigerator and dated 5/13/26 (4 days old). Post inquiry, the lunch meat was discarded. c. Five (5) small plastic condiment containers containing sour cream that were undated in the walk-in refrigerator. Post inquiry, the sour cream was discarded2. Three (3) dietary staff members, Dietary Aide (DA) #1, DA #2 and the FSD in the food preparation area, without the benefit of covering their facial hair (beards) with a beard guard. Post inquiry, the FSD instructed DA #1 and DA #2 to cover facial hair with face mask or beard guard.3. The 3 ovens and one convection oven had large amount of a dark, thick substance built up (appeared to be grease) on the inside of the oven doors and the oven floor beneath the bake element. A second tour of the Dietary Department with the FSD on 5/21/26 at 1:30 PM noted in the dry food storage room there were opened pastas in plastic bins that were not dated. Items were: Ditalini 2/3 full, Shells 2/3 full, Elbows 1/2 full, and rice 2/3 full.Interview with the FSD at the time of observations indicated that the sandwiches were just made that morning but should have been dated prior to being placed in the refrigerator and that sour cream containers from the weekend should have been dated and the pasta bins should have been dated when the pasta was opened and placed in the bins. The ham should have been discarded after 3 days based on facility policy; facial hair should be covered when in the food preparation area. Furthermore, the FSD stated that although the cleaning schedule indicated that the ovens were cleaned on 5/15/26 it was evident that they were not clean and the uncleanliness and build up in the stoves was unacceptable.After surveyor inquiries, the FSD initiated education for all dietary staff on dating food items, wearing beard guards, and cleaning of ovens per schedule and as needed when they are visibly dirty. The Dating Items policy (undated), directed, in part, items should be dated when container is opened if not used in its entirety, For example, opened on 10/14/16 and when food items are prepared such as sandwiches and stored in the refrigerator or later use. The Left-Over Food Storage policy (undated), directed, in part, all leftover food items must be cooled, labeled, dated and stored properly in refrigerators or freezers immediately after preparation or service. The [NAME] Guard policy (undated), directed, in part, all food service employees, contractors, volunteers and visitors in food preparation, food handling, dishwashing, or serving activities who have facial hair must wear an approved beard guard while working in food service areas. Facial hair is defined as any hair growth on the chin, jawline, cheeks, neck, mustache area or sideburns extending beyond a clean-shaven appearance. [NAME] guard is a disposable or useable cover designed to fully contain facial hair and prevent contamination of food, equipment, and surfaces. The Cleaning Schedule policy (undated) directed, in part, a weekly cleaning schedule will be posted for staff. Cleaning of equipment will be completed per schedule and as needed.

Based on interviews, observations, review of the clinical record and facility policy for 1 of 3 (Resident #14) residents reviewed for pressure ulcers, the facility failed to ensure the practitioner was notified when Resident #14 experienced a change in condition related to weight gain. The findings include: Resident #14 was admitted to the facility in May 2026 with diagnoses that included cellulitis of the lower right leg with multiple chronic foot wounds, lymphedema (lymph fluid accumulates in tissues causing swelling), and end stage kidney disease.The admission Nursing assessment dated [DATE] and written by Registered Nurse (RN) #2 identified that Resident #14 had intact cognition and was able to make his/her needs known, required the assistance of 1 staff member for activities of daily living and was able to eat independently.The Resident Care Plan (RCP) dated 5/4/26 identified nutrition as a concern with a goal to maintain a weight of 149.6 lbs. (pounds) plus or minus 5 lbs/% with no significant changes in 90 days. Interventions included monitoring weight and reporting any significant changes to the MD and dietitian, monitor food and fluid intake, provide Prostat (protein supplement) as ordered to promote wound healing, regular lactose reduced diet and providing set up and feeding assistance as needed.Physician orders dated 5/12/26 directed weekly weights and administer Lasix (a medication to reduce fluid) 20 mg (milligrams) daily.Resident #14's weight record noted a weight of 149.6 lbs. on 5/5/26, on 5/8/26 a weight of 156.6 lbs. (a weight gain of 7 lbs. in 3 days), on 5/12/26 a weight of 153.4 lbs., and on 5/19/26 a weight of 157 lbs. (a weight gain of 3.6 lbs. in 7 days). The nursing notes lacked documentation that the Advanced Practice Registered Nurse (APRN) #1 was made aware of Resident #14's weight changes/gains. A review of the nursing to APRN communication log failed to reflect any documentation regarding Resident #14's weight changes/gains to update APRN #1.Interview with the Dietitian on 5/19/26 at 11:00 AM identified that Resident #14 had an order for weekly weights. The Dietitian indicated that Resident #14's weight gains were not food/calorie related but related to his/her edema. The Dietitian stated that although Resident #14 had gained weight, it would be for the APRN to address as was related to Resident #14's edema. In addition, the Dietitian indicated that nursing had not updated her on Resident #14's weight gain. The Dietitian indicated that the facility policy was for nursing to update her on weight changes and she would determine if weight changes were significant and/or related to decreased food intake.Interview and a review of the clinical record with APRN #1 on 5/19/26 at 1:15PM identified that Resident #14 had a history of chronic edema to both lower legs with insufficient cardiac and kidney functions. APRN #1 indicated that Resident #14's edema was being followed closely due to his/her comorbidities (other disease that can increase the risk of complications) and abnormal lab values related to Resident #14's kidney function. APRN #1 indicated that licensed nursing staff had not made her aware of Resident #14's weight gains and that it was nursing's responsibility to notify her of Resident #14's weight gains. APRN #1 indicated that although she may have documented Resident #14's weights in her progress notes, her expectation was that nursing would update her when Resident #14 had an increase in his/her weight. A review of APRN #1 progress note for 5/8/26 indicated that Resident #14's weight was being monitored daily; however Resident #14's physician' s orders indicated weekly weights since his/her admission to the facility. APRN #1 could not explain why she documented in her notes that Resident #14 was a daily weight, and his/her order was for weekly weights. APRN #1 stated that she had thought Resident #14 was getting weighed daily when the resident allowed nursing staff to weigh him/her. In addition, APRN #1 documented in her 5/8/26 note that Resident #14 weight was 156.6 lbs. (a 7lb. weight gain since 5/5/26 which is a 4.7% increase in month). APRN #1 thought that she had ordered extra doses of Lasix at that time for Resident #14; however, an order could not be located. Furthermore, APRN #1 indicated that Resident #14 was followed by a cardiologist regarding his/her edema, received Lasix daily and that it would be appropriate for Resident #14's cardiologist to be updated on his/her weight changes.Interview with Registered Nurse (RN) #5 on 5/20/26 at 2:15 PM indicated that she had not updated APRN #1 regarding Resident #14's weight gains. RN #5 indicated that nursing was supposed to update the practitioner for weight gains especially for a resident that had chronic edema. RN #5 indicated that the standard policy of the facility was to update if there was a 3 lb. to 5 lb. change in a resident's weight. RN #5 indicated that she should have updated APRN #1 on weight gains.Subsequent to surveyor inquiry, APRN #1's progress note dated 5/19/26 indicated a diagnosis of abnormal weight gain/fluid retention with weight from 149 lbs. to 157 lbs. An order for a B-type Natriuretic Peptide (BNP-helps diagnose heart failure) and a comprehensive metabolic panel (CMP-evaluates fluid balance). In addition, a cardiology appointment was made for 6/4/26.A review of the Change in Condition Policy dated 8/2017, directed, in part, the facility will inform the resident's physician when there is a change in condition to ensure every change in condition is assessed and documented properly. The facility must consult with the physician when there is a need to alter treatment significantly, a need to change or discontinue an existing form of treatment due to adverse consequences or commence a new form of treatment.

Based on interviews, review of the clinical record, review of facility documentation and facility policy for 1 of 4 sampled residents (Resident #51) reviewed for mistreatment, the facility failed to ensure the abuse policy was fully implemented to protect residents during an investigation by allowing the Nurse Aide (NA) to return to work while an investigation of an allegation of abuse was ongoing. The findings include:Resident #51 was admitted to the facility in April 2026 with diagnoses that included cerebral vascular accident (CVA) with left side weakness, dysphagia (difficulty swallowing) and aphasia (difficulty speaking).A Nursing admission assessment dated [DATE] indicated that Resident #51 was alert with some confusion and forgetfulness but was able to make needs known. Physician orders dated 4/16/26 directed assistance of 1 for meals, activities of daily living (ADLs) and speech, occupational, and physical therapy evaluation and treatment as indicated.The Resident Care Plan (RCP) dated 4/18/26 identified a self-care deficit related to CVA and left sided weakness as an area of focus with interventions that included providing diet as ordered and assistance with meals, assistance of 1 staff member for ADLs, and transfers out of bed to wheelchair with 2 staff members via a mechanical lift.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #51 was severely cognitively impaired, was totally dependent on staff for activities of daily living (ADLS) including eating and required the assistance of 2 staff members for transfers into the wheelchair using a mechanical lift.Interview with Resident #51 on 5/18/26 at 11:10 AM indicated that a NA spoke roughly regarding his/her eating stating, you have to eat. Resident #51 indicated that he/she did not like the way the NA spoke and that this occurred about 3 weeks ago. Resident #51 noted he/she did not report the incident to any staff members at the facility. Resident #51 stated that his/her family member was aware of the incident and would be able to give the name of the NA involved in the incident.Interview with the DNS on 5/18/26 at 11:30 AM indicated that she was not aware of any concerns regarding Resident #51 and a NA speaking roughly and that the facility would initiate an investigation. Post inquiry with the DNS, a Reportable Event dated 5/18/26 at 12:07 PM was submitted to the State Agency regarding the alleged allegation of verbal abuse toward Resident #51 by NA #6. Interview with the DNS on 5/19/26 at 10:00 AM indicated that NA #6 was removed from the schedule pending investigation, that the facility was in the process of investigating Resident #51's concern and that an initial statement was obtained from Resident #51 prior to his/her discharge on [DATE].Interview with the DNS on 5/20/26 at 9:15 AM, 5/21/26 at 10:15 AM and 5/22/16 at 9:30 AM indicated that the investigation was still not complete as the facility was still gathering statements.A call was placed on 5/22/26 at 11:00 AM to NA #6 by surveyor for an interview regarding her statement related to the alleged verbal allegation. NA #6 returned call at 12:00 PM and indicated that she was at work at the facility and would provide a statement in person.Interview with NA #6 on 5/22/26 at 2:40 PM indicated that she denied speaking roughly with Resident #51 and that she was trying to encourage Resident #51 to eat as the resident needed to gain strength to go home. NA #6 indicated that Resident #51 was confused at times and was surprised that there was an allegation as Resident #51 would ask for NA #6 to provide care for him/her. NA #6 stated that on Monday, 5/18/26, she was at work and was asked to go to the Human Resource (HR) office. NA #6 stated she provided a written statement to HR regarding the alleged allegation from Resident #51 and took a test on abuse. NA #6 stated she was sent home pending the outcome of the investigation. NA #6 indicated that she had not spoken to the DNS or anyone else since she had been sent home on 5/18/26 for any clarifications or for further information. NA #6 stated she was informed in the morning on 5/22/26 that she could return to work and that she was cleared related to the alleged allegation but needed to see the nursing supervisor before the start of her shift. NA # 6 stated she was asked to take the abuse post-test on 5/22/26 from Registered Nurse (RN) #6 even though she had completed it on 5/18/26.Interview with the DNS on 5/22/26 at 3:15 PM stated she would be closing out the investigation related to Resident #51 and that the allegation of verbal abuse was unsubstantiated even though statements were still being obtained. The DNS indicated that statements were still being gathered on 5/22/26 by the nurse manager (RN #6) related to Resident #51. The DNS was not aware that RN #6 only obtained verbal statements from staff, and no written statements were documented. The DNS indicated that she had just become aware that RN #6 did not obtain written statements, and that RN #6 thought she only needed to provide education and the abuse post-test to the nursing staff. The DNS indicated that the facility policy was when a verbal statement was obtained from staff that 2 staff members needed to obtain the statement to verify the information was correct and that if it was completed on the telephone, one staff member listens in on the call while the other staff member writes the statement. Additionally, the facility policy directs that residents would be protected during and after an abuse investigation, the DNS indicated that she would not have had NA #6 work on 5/22/26 if she was aware that there were no other statements in writing besides NA #6's statement as the investigation was not completed. The DNS indicated that she was responsible for ensuring the investigation was accurate, completed timely, and the facility policy and procedures for an abuse investigation were implemented.Interview with RN #6 on 5/22/26 at 3:30 PM indicated that she was not aware that she needed to obtain statements from staff and that she was only aware that she needed to gather statements for 2 other residents. RN #6 stated she was not aware there was an alleged allegation for Resident #51. RN #6 stated that the DNS had called her at home prior to her shift on 5/22/26 informing her she needed to obtain a statement from NA #6 but did not inform her that Resident #51 was involved. RN #6 stated that on 5/22/26 at 2:45 PM the DNS asked her about the statements for Resident #51 and that was when RN #6 became aware there was an ongoing investigation. Furthermore, this was when the DNS became aware that written statements had not been obtained by RN #6.NA #6 returned to work on 5/21/26 prior to statements being obtained. A review of staff statements for the allegation for Resident #51 revealed that 28 statements were obtained for the investigation. Out of the 28 statements, only 9 statements were dated as to when they were obtained. There were 7 statements that were obtained on 5/22/26 (4 days after it was reported to the facility), 1 obtained on 5/23/26 (5 days after), and 1 one on 5/24/26 (6 days after). A review of the Abuse policy and procedures not dated directed, in part, an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures or investigation include identifying staff responsible for the investigation, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing complete and through documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional, during and after the investigation. The facility will delegate an Abuse Prevention Coordinator who is responsible for reporting to the state agency and other officials in accordance with state law. The facility will provide ongoing oversight and supervision of staff to ensure its policies are implemented as written.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #29 and Resident #75) reviewed for mistreatment, the facility failed to report abuse and neglect allegations to the State Agency. 1.Resident #29 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, anxiety, and failure to thrive. The admission nursing note dated 11/19/26 at 8:02 PM identified Resident #29 was alert and oriented and ambulated with assist of 1 person with a walker. The Resident Care Plan (RCP) dated 11/20/25 identified that Resident #29 demonstrated accusatory behaviors, with interventions that included allowing the resident to make decisions about treatments to provide a sense of control, anticipating needs and attempting to identify sources of anxiety and assist in resolving them, giving clear explanations of all care activities, using a calm and gentle approach, and simply explaining what staff were doing. A nursing note dated 11/20/25 at 4:15 AM, written by Registered Nurse (RN) #11, identified that Resident #29 became verbally disruptive, stated that he/she wanted to go home and was going to call the police, complaining that staff had been verbally inappropriate to him/her (but did not identify the actual verbiage used). The nursing note also stated that Resident #29's concern would be documented and addressed appropriately. A nursing note dated 11/20/25 at 12:05 PM, written by the DNS, documented an allegation and concern of abuse involving Resident #29. The note indicated that the DNS, an unidentified Social Worker, and an unidentified unit nurse met with the resident to discuss the incident (but did not identify the actual verbiage used). During the interview, the resident denied any physical abuse but reported that verbal abuse had occurred. The resident clarified that they did not feel the staff member was being threatening or acting intentionally.A grievance form dated 11/20/25, filed by Social Worker #3, documented an incident in which Resident #43 alleged that staff were being verbally abusive. Three statements, each identical to the nursing note dated 11/20/25 at 12:05 PM written by the DNS, were individually signed by the DNS, Social Worker #3, and LPN #1. The statements indicated that Resident #43 reported staff were being verbally abusive but did not believe the staff were acting intentionally and stated that the behavior was not threatening. During an interview with the DNS on 5/19/26 at 2:15 PM, the DNS disputed that the signed statement indicated verbal abuse had been alleged by Resident #43. The DNS explained that although the statement documented the resident reported verbal abuse, it also clarified that the resident also stated he/she did not feel threatened and did not believe the staff had intended to be verbally abusive. Based on this, the DNS believed the incident did not require reporting to the State Agency. Interview with Resident #29 on 5/21/26 at 1:20 PM identified that the resident did not remember all the details of the alleged incident that occurred on 11/20/25, but stated that the incident made him/her feel uneasy and verbally abused, causing the resident to feel like leaving the facility and ultimately sign himself/herself out the next day on 11/21/25. Resident #29 also alleged that multiple staff members were lined up in his/her room and made him/her feel uncomfortable, but the resident could not identify which staff members were present or why they were lined up in the room. 2.Resident #75 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety, cognitive communication deficit, spinal cord compression with inability to ambulate, and muscle weakness. A physician order dated 9/14/25 directed staff to complete activities of daily living (ADLs) and toileting at bed level only, as the resident was not yet safe for showering. An admission Minimum Data Set (MDS) assessment dated [DATE] identified that the resident was cognitively intact, was dependent on toileting hygiene, and required substantial assistance with eating. The Resident Care Plan (RCP) dated 9/19/25 identified that Resident #75 was incontinent of bowel and bladder, with interventions that included providing incontinence care as needed, providing the resident with adult briefs and pads, and updating the physician and family as needed. A grievance form filed on 9/29/25 by Social Worker (SW) #3 identified that Person #2 alleged that on 9/26/25 Resident #75 was not provided incontinent care from 5:30 AM to 11:00 AM (4.5 hours). In an attached statement, SW #3 documented that SW #3, Person #2, and Resident #75 met, and Person #2 and Resident #75 were asked if they had any concerns and that Resident #75 reported that he/she had been woken up once at 4:30 AM but otherwise had no concerns. The statement did not indicate that Person #2 or Resident #75 was asked whether incontinent care had been provided between 5:30 AM and 11:00 AM on 9/26/25. The grievance form also identified that the DNS at the time (not identified by name) spoke with Resident #75 and an unnamed resident representative; however, no written statement from the DNS was included. The grievance form further identified that Resident #75 and the unidentified resident representative denied the allegation, but no corresponding statement was provided. The grievance form also did not have any statements from staff on whether the resident was provided incontinent care during the alleged timeframe.Interview with the DNS on 5/19/26 at 2:15 PM identified that the allegation of incontinent care not being provided timely had not been reported to the State Agency but should have.An interview with Person #2 was attempted but not obtained.Review of facility policy, Abuse, Neglect and Exploitation, undated, identified that an allegation of neglect should be reported to the appropriate agency.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #29, and Resident #75) reviewed for mistreatment, the facility failed to thoroughly investigate an abuse and neglect allegation. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #29 and Resident #75) reviewed for mistreatment, the facility failed to thoroughly investigate an abuse and neglect allegation. 1. Resident #29 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, anxiety, and failure to thrive.The admission Nursing note dated 11/19/26 at 8:02 PM identified Resident #29 was alert and oriented and ambulated with assist of 1 person with walker.The Resident Care Plan (RCP) dated 11/20/25 identified that Resident #29 demonstrated accusatory behaviors, with interventions that included allowing the resident to make decisions about treatments to provide a sense of control, anticipating needs and attempting to identify sources of anxiety and assist in resolving them, giving clear explanations of all care activities, using a calm and gentle approach, and simply explaining what staff were doing. A nursing note dated 11/20/25 at 4:15 AM, written by Registered Nurse (RN) #11, identified that Resident #29 became verbally disruptive, stated that he/she wanted to go home and was going to call the police, complaining that staff had been verbally inappropriate with him/her (but did not identify the verbiage used). The nursing note also stated that Resident #29's concern would be documented and addressed appropriately. A nursing note dated 11/20/25 at 12:05 PM, written by the DNS, identified that there was an allegation and concern of abuse involving Resident #29. The note stated that the DNS, an unidentified Social Worker, and an unidentified unit nurse met with the resident regarding the incident, during which the resident denied any physical abuse. The DNS further clarified in the note that the resident did not feel the staff had intended to verbally abuse him/her and had not used threatening words, but Resident #29 did report having concerns about verbal abuse. A grievance form dated 11/20/25, filed by Social Worker (SW) #3, identified an incident in which Resident #29 alleged that staff were being abusive. Three statements all identical to the nursing note dated 11/20/25 at 12:05 PM written by the DNS, were individually signed by the DNS, SW #3, and Licensed Practical Nurse (LPN) #1. The statements indicated that Resident #29 alleged staff were being verbally abusive (but did not identify the specific verbiage used) but did not believe the staff were doing it intentionally and stated that the behavior was not threatening. Interview with the DNS on 5/19/26 at 2:15 PM identified she disputed that the signed statement indicated that verbal abuse had been alleged by Resident #29. The DNS explained that although the statement documented the resident reported verbal abuse, it also clarified that the resident later stated he/she did not feel threatened and did not believe the staff had intended to be verbally abusive; therefore, the DNS believed the incident did not require further investigation. Interview with Resident #29 on 5/21/26 at 1:20 PM identified that the resident did not remember all the details of the alleged incident that occurred on 11/20/25 but stated that the incident made him/her feel uneasy and verbally abused, causing the resident to feel like leaving the facility and ultimately sign himself/herself out. Resident #29 also alleged that multiple staff members were lined up in his/her room and made him/her feel uncomfortable, but the resident could not identify which staff members were present or why they were lined up in the room. 2. Resident #75 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety, cognitive communication deficit, spinal cord compression with inability to ambulate, and muscle weakness. A physician order dated 9/14/25 directed staff to complete activities of daily living (ADLs) and toileting at bed level only, as the resident was not yet safe for showering. An admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #75 was cognitively intact, was dependent for toileting hygiene, and required substantial assistance with eating. The Resident Care Plan (RCP) dated 9/19/25 identified that Resident #75 was incontinent of bowel and bladder, with interventions that included providing incontinence care as needed, providing the resident with adult briefs and pads, and updating the physician and family as needed. A grievance form filed on 9/26/25 by Social Worker (SW) #3 identified that Person #2 alleged that on 9/26/25 Resident #75 was not provided incontinent care from 5:30 AM to 11:00 AM (4.5 hours). In an attached statement dated 9/29/26, SW #3 documented that SW #3, Person #2, and Resident #75 met, and Person #2 and Resident #75 were asked if they had any concerns and that Resident #75 reported that he/she had been woken up once at 4:30 AM but otherwise had no concerns. The statement did not indicate that Person #2 or Resident #75 was asked whether incontinent care had been provided between 5:30 AM and 11:00 AM on 9/26/25. The grievance form also identified that the DNS at the time (not identified by name) spoke with Resident #75 and an unnamed resident representative; however, no written statement from the DNS was included. The form further identified Resident #75 and the unidentified resident representative denied the allegation, but no corresponding statement was provided. The grievance form also did not have any statements from staff on whether the resident was provided with incontinent care during the alleged timeframe. Interview with the DNS on 5/19/26 at 2:15 PM identified that a thorough investigation had not been completed regarding the alleged neglect incident that Person #2 reported on behalf of Resident #75 on 9/26/25, and that additional statements, including one from Person #2 and from staff members, should have been obtained to complete a thorough investigation. An interview with Person #2 was attempted but not obtained. Review of facility policy, Abuse, Neglect and Exploitation, undated, identified that an immediate investigation should take place when there is a report of abuse, neglect, or exploitation occur.

Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #29) reviewed for respiratory care, the facility failed to implement a respiratory care plan for a resident with a respiratory primary diagnosis. The findings include: Resident #29 had diagnoses that included asthma with acute exacerbation, diabetes, obstructive sleep apnea, and congestive heart failure.A physician order dated 4/29/26 directed to administer Symbicort inhalation aerosol (used for long-term maintenance of asthma) 160-4.5 micrograms (mcg) per actuation (act) (press of the inhaler to release a puff of medication) (160-4.5 mcg/act) of 2 puffs inhaled orally 2 times a day for asthma.A physician order dated 4/29/26 directed to administer Albuterol Sulfate (medication used to relax airway muscles for treatment of shortness of breath with asthma) HFA inhalation aerosol solution 108 (90 Base) mcg/act of 2 puffs inhaled orally every 6 hours as needed for wheezing.A physician order dated 4/30/26 directed to administer Albuterol Sulfate nebulization solution (2.5 milligrams (mg) per 3 milliliters (ml) (2.5mg/3ml)) 0.083% for a 3ml dose by oral inhalation via the nebulizer every 6 hours for asthma and every 6 hours as needed for shortness of breath.The Resident Care Plan (RCP) dated 4/30/26 identified Resident #29 had a self-care performance deficit for activities of daily living (ADL). Interventions included to ensure side rails were up at the top portion of the bed to assist with bed mobility, allow adequate time for Resident #29 to complete tasks, and Resident #29 required assistance of 1 staff member for completion of ADLs. The RCP failed to identify a care plan focus related Resident #29's primary diagnosis of asthma with acute exacerbation which was a respiratory/pulmonary diagnosis, failed to identify he/she required medication administered via a nebulizer machine (medical device which turns a liquid medication into a fine mist inhaled into the lungs by a mask or mouthpiece, and failed to identify he/she required a medication administered via an inhaler (medical device which uses a propellant (liquid gas) to deliver medication into the lungs).The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 was cognitively intact, required setup or clean-up assistance with eating, supervision or touching assistance with bed mobility, and partial/moderate assistance with personal hygiene and chair/bed transfers. The MDS assessment further identified Resident #29 had unspecified asthma with (acute) exacerbation.Interview and clinical record review with Registered Nurse (RN) #12 on 5/22/26 at 3:15 PM identified she was currently responsible for completing the MDS assessments and care plans while covering for 2 nurses on vacation and 1 out on medical leave. RN #12 identified the resident care plans could be updated by any of the nurses, but when the MDS assessment was completed, the MDS nurse would update the care plan to reflect the MDS assessment. She identified that Resident #29's MDS assessment indicated that Resident #29 had asthma, but she did not see anything in the care plan related to respiratory or asthma. She identified Resident #29 should have had a respiratory care plan for asthma, but she could not identify the reason it had not been implemented. She further indicated that the department had been short-staffed and they were trying to catch up with the fast-paced environment.Review of the Baseline Care Plan policy directed, in part, the facility will develop a baseline care plan within 48 hours of admission which will include the instructions needed to provide effective, person-centered care. The policy directed the baseline care plan would contain the minimum healthcare information necessary to properly care for the resident including initial goals based on admission orders and physician orders. The policy directed the admitting nurse and/or supervisor shall gather information from the admission assessment, hospital transfer information, and physician orders and develop interventions which address the resident's needs. Review of the Care Planning-Interdisciplinary Team policy directed, in part, a comprehensive care plan is developed within 7 days of completion of the resident assessment (MDS). The policy directed the care plan is based on the resident's comprehensive assessment and ongoing changes in resident status shall be updated by nursing or the interdisciplinary team as needed.

Based on interviews, review of the clinical record and facility policy for the only resident (Resident #7) reviewed for death, the facility failed to ensure a thorough Registered Nurse Pronouncement (RNP) was completed at the time of death and for 2 of 3 residents (Resident #29 and Resident #52) reviewed for respiratory care, the facility failed to ensure supervision was provided during nebulizer administration. Additionally, for 1 of 3 sampled residents (Resident #64) reviewed for activities of daily living (ADLs), the facility failed to ensure a Registered Nurse (RN) assessment was conducted on admission and for 1 of 5 residents (Resident #68) observed during medication administration, the facility failed to ensure a resident was identified prior to medication administration per the five rights of medication administration. The findings include: 1.Resident #7 was admitted to the facility in [DATE] with diagnosis that included heart disease, chronic kidney disease and chronic obstructive pulmonary disease (COPD).A Nursing admission assessment dated [DATE] identified Resident #7 was cognitively intact, was able to make his/her needs known, required assistance of 1 staff member for activities of daily living and was able to eat independently.Physician orders dated [DATE] directed, in part, no Cardiopulmonary Resuscitation (CPR), Do Not Resuscitate (DNR), Do Not Intubate (DNI) and Registered Nurse Pronouncement (RNP) of death.The Resident Care Plan (RCP) dated [DATE] identified code status as a focus area with interventions that included DNR/DNI, however the RCP did not address RNP.A nursing note regarding RNP and dated [DATE] indicated that Resident #7 was assessed after the charge nurse informed Registered Nurse (RN) #9 that Resident #7 was unresponsive. RN #9's nursing note indicated that Resident #7 had no vital signs including no pulse obtained (but failed to include pupillary response). Resident #7 was DNR/DNI/RNP and deceased at 12:30 AM. The next of kin, funeral home, and the Advanced Practice Registered Nurse (APRN) was notified of Resident #7's death.Interview and review of the clinical record with the Corporate Chief of Nursing on [DATE] at 12:35PM indicated that the facility had a form in the electronic medical record that was to be completed for a RNP to ensure all the components for a RNP were assessed/evaluated; however, the RNP assessment/evaluation in the electronic medical record could not be located. The Corporate Chief of Nursing indicated that it was the RN who was pronouncing the death who was responsible for completing the RNP assessment/evaluation or writing a complete RNP nursing note. The Corporate Chief of Nursing was unable to explain why there were components missing (pupillary response) from the RNP assessment. She indicated that RN #9 did document no vital signs. An interview and review of the clinical record with RN #9 on [DATE] at 12:50 PM identified a RNP assessment needed to include heartbeat, respirations, blood pressure, and to check if pupils are dilated or responsive. In addition, a heartbeat should be checked for 1 full minute. RN #9 acknowledged that the RNP nursing note written on [DATE] was incomplete as it was missing heartbeat checked for 1 minute, auscultation (listening with a stethoscope) of lung sounds, and pupil's reaction. RN #9 indicated that she was responsible for ensuring the RNP assessment and nursing note was complete. RN #9 indicated that another nurse had assisted her in completing the RNP, but she could not recall the nurse that helped. In addition, RN #9 was unaware that there was a RNP assessment/evaluation in the electronic medical record that should be completed.The RN Pronouncement of Death policy dated 11/2025, directed, in part, RNs determine and pronounce death in anticipated cases, in accordance with Connecticut Public Health Code Sections 7-62--1 through 7-62-3. The RN responsibilities are confirming absence of pulse, respirations, heart sounds, and pupillary response to light. All findings and notifications must be recorded in the resident's medical record.2a. Resident #29 had diagnoses that included asthma with acute exacerbation, diabetes, obstructive sleep apnea, and congestive heart failure.A physician order dated [DATE] directed to administer Albuterol Sulfate (medication used to relax airway muscles for treatment of shortness of breath with asthma) nebulization solution (2.5 milligrams (mg) per 3 milliliters (ml) (2.5mg/3ml)) 0.083% for a 3 ml dose by oral inhalation via the nebulizer every 6 hours for asthma and every 6 hours as needed for shortness of breath.The Resident Care Plan (RCP) dated [DATE] identified Resident #29 had a self-care performance deficit for activities of daily living (ADL). Interventions included to ensure side rails were up at the top portion of the bed to assist with bed mobility, allow adequate time for Resident #29 to complete tasks, and Resident #29 required assistance of 1 staff member for completion of ADLs.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #29 was cognitively intact, required setup or clean-up assistance with eating, supervision or touching assistance with bed mobility, and partial/moderate assistance with personal hygiene and chair/bed transfers.Observation on [DATE] at 11:28 AM identified Resident #29 was in bed with the head of bed elevated and a nebulizer mask observed in place on his/her face and a white mist was seen floating out of the mask's ventilation holes. There was no nurse observed inside or outside of Resident #29's room while the nebulizer medication was being self-administered. Licensed Practical Nurse (LPN) #2 was observed at the end of the hallway and out of sight of Resident #29.Observation and interview with LPN #2 on [DATE] at 11:30 AM identified she was assigned as the nurse for the entire wing. LPN #2 entered Resident #29's room, removed the nebulizer mask, turned off the nebulizer machine, and after storing the nebulizer mask exited the room.b. Resident #52 had diagnoses that included stroke, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen.The Resident Care Plan (RCP) dated [DATE] identified Resident #52 was at risk for respiratory distress, infections, and exacerbations related to COPD. Interventions included administer medications, inhalers, and nebulizer treatments per physician order and monitor for effectiveness, administer oxygen per physician order, and monitor oxygen saturation and report significant findings immediately.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 was cognitively intact, had shortness of breath when lying flat, received oxygen therapy, required setup or clean-up assistance with eating, partial/moderate assistance with personal hygiene and substantial/maximal assistance with bed mobility and chair/bed transfers.A physician order dated [DATE] directed to administer Albuterol Sulfate nebulization solution (medication used to relax airway muscles for treatment of shortness of breath with asthma) (2.5 milligrams (mg) per 3 milliliters (ml) (2.5mg/3ml)) 0.083% of 3 ml dose by oral inhalation via the nebulizer every 4 hours as needed for shortness of breath (SOB)/wheezing.A physician order dated [DATE] directed to administer Ipratropium-Albuterol solution 0.5-2.5 milligrams (mg) per 3 milliliters (ml) (0.5-2.5 mg/3ml) of 3 ml dose by oral inhalation via the nebulizer 4 times a day for 5 days for pneumonia.Observation on [DATE] at 11:28 AM identified Resident #52 was in bed with the head of bed elevated and a nebulizer mask observed in place on his/her face and a white mist was seen floating out of the mask's ventilation holes. There was no nurse observed inside or outside of Resident #52's room while the nebulizer medication was being self-administered. Licensed Practical Nurse (LPN) #2 was observed around the corner from Resident #52's room out of sight of Resident #52.Interview with LPN #2 on [DATE] at 11:31 AM identified when administering a nebulizer medication, she would place the mask, turn the machine on, and she would then leave the residents unattended during the medication administration. Additionally, she indicated she always set a timer for 15 minutes and would check on the resident every 5 minutes. She indicated she would return at the end of the 15 minutes and ask the resident if they had any shortness of breath. LPN #2 was unsure if residents required a physician order in place for self-administration of a nebulizer and Resident #29 and Resident #52 did not have a self-administration assessment or physician order in place.Interview with the Director of Nursing Services (DNS) on [DATE] at 3:45 PM identified the only time a resident may be left alone without the nurse present in the room during the administration of a nebulizer medication treatment was if they had a self-administration evaluation filled out. She further indicated the nurse should have been in the room with the resident while the nebulizer was being administered. The DNS identified she was unaware if education was provided to the nurses about nebulizer administration and the rationale for staying with the resident during the administration. Interview with the Respiratory Therapist on [DATE] at 4:15 PM identified residents should not be left unattended during the administration of a nebulizer treatment without a self-administration order in place. She further identified that Resident #68's oxygen should not be set at less than 4 lpm as that was his/her home regimen and the physician orders were for the 4 lpm.Review of the Nebulizer Therapy policy directed, in part, that once nebulizer treatments are ordered they were to be administered by nursing staff. The order directed for nebulizer therapy: verify the order; gather supplies; perform a respiratory assessment; place medication in nebulizer cup; position resident to encourage full lung expansion; instruct the resident how to use the nebulizer; turn the machine on; keep nebulizer vertical during treatment; observe the resident during the procedure for any change in condition; and when delivery is complete turn off machine and disassemble and rinse the nebulizer. The policy further directed to document the administration date and time, the resident response to treatment, any teaching provided, and the resident's understanding.3. Resident #64 was admitted to the facility in [DATE] with diagnoses that included fractured vertebra of T9 and T10 (thoracic spine), hearing loss and falls.An Advanced Practice Registered Nurse (APRN) #1 progress note dated [DATE] identified that Resident #64 was alert with confusion and had aggressive behaviors but able to make needs known, required assistance of 1 staff member for activities of daily living (ADLs) and needed supervision for ambulation.Physician orders dated [DATE] directed, in part, administer Trazadone (an antidepressant used for anxiety symptoms) 0.5 mg (milligrams) one time only for agitation and restlessness, Melatonin 5 mg one time only for restlessness, Methocarbamol (muscle relaxer) 500 mg 3 times a day for pain, Lidoderm patch 5% to lower back daily for pain, and wander guard bracelet every shift secondary to being an elopement risk.The Resident Care Plan (RCP) dated [DATE] identified psychotropic drugs and wandering/elopement as focus areas with interventions that included administer medications as ordered and monitor effectiveness, monitor and document behaviors per facility protocol, consult MD for medication adjustments, monitor therapeutic effects of medications, maintain daily routine, check identification bracelet every shift, introduce resident to all staff as a wander, and provide specific diversional activity. A review of the admission clinical record and interview with the DNS on [DATE] at 3:30 PM failed to identify a Registered Nurse (RN) assessment or nursing note when Resident #64 was admitted to the facility on [DATE] or thereafter. The DNS stated that a Licensed Practical Nurse (LPN) can also write an admission note if the RN signed off on the assessment; however, no admission notes or admission assessment could be found from either a RN or an LPN in the clinical record. The DNS stated that Resident #64 should have an RN assessment and nursing note completed by RN #2 when Resident #64 was admitted . The DNS stated the RN supervisor was responsible to ensure an RN assessment and corresponding nursing note was completed on all admissions as it was the policy of the facility. Interview and review of the clinical record with RN #2 on [DATE] at 3:45 PM identified that RN #2 did not complete a nursing admission assessment or complete a nursing note when Resident #64 was admitted to the facility. RN #2 indicated that it was a very busy night and she had residents falling, admissions and Resident #64 had behavioral issues. RN #2 indicated that Resident #64 was not being compliant and was hitting and kicking staff and extremely restless. RN #2 stated that Resident #64 was attempting to ambulate throughout the facility and wanted to leave. RN #2 indicated that it was very concerning as the resident was a high fall risk and had new fractures from a fall at home. RN #2 stated that the APRN was in the facility and saw the resident as someone had informed her about Resident #64's behavior. RN #2 indicated that she should have at least written a nursing note on admission regarding Resident #64's extreme aggressiveness and restlessness and that he/she was uncooperative with care. RN #2 indicated that it was her responsibility to assess and document in Resident 64's clinical record on admission. RN #2 indicated that the DNS was present when Resident #64 was admitted to the facility, but she had not informed her that she was overwhelmed with her workload and needed assistance. RN #2 indicated that she was aware that the facility policy was the admitting nurse needed to complete an RN assessment and document in the resident record when a resident was newly admitted . The clinical record identified that APRN #1 saw Resident #64 when he/she was admitted to the facility on [DATE]; however, there was no documentation regarding Resident #64's behaviors, wandering or agitation. An admitting progress note written by APRN #2 on [DATE] identified Resident # 64 was a high fall risk and was exhibiting intermittent confusion, agitation, and wandering behaviors with repeated attempts to get of bed and continue unsafe wandering behaviors that required close supervision by nursing staff. APRN #2 indicated that Resident #64 received Trazadone and Melatonin with minimal effectiveness on admission. APRN #2 identified that Resident #64 needed close skilled nursing supervision for ongoing monitoring for behavioral symptoms due to cognitive impairment, high fall risk, pain management, therapy and medical oversight.The Documentation policy dated 10/2025 directed, in part, each resident medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed nursing staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.Although requested, a policy on nursing assessment/new admissions was not provided. 4. Resident #68 had diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, and anxiety.A Nursing admission assessment dated [DATE] identified Resident #68 was alert and oriented to person, place, and time with no cognitive impairment. The assessment identified Resident #68 used a walker, had poor balance, and was bedfast all or most of the time. The assessment did not identify the amount of assistance Resident #68 required with his/her functional mobility.A physician order dated [DATE] directed to administer Aspirin 81 milligrams (mg) enteric coated tablet by mouth daily, Duloxetine Hydrocholoride (a medication to treat both mental health condition and chronic pain) delayed release capsule 20 mg, give 4 capsules (80 mg dose) by mouth daily for anxiety, Losartan Potassium (a medication to treat high blood pressure) 100 mg tablet by mouth daily, and Metformin Hydrochloride (a medication to treat Type 2 diabetes) 1000 mg tablet by mouth 2 times a day with breakfast and dinner.The Resident Care Plan (RCP) dated [DATE] identified Resident #68 required the use of psychotropic medication for the management of anxiety. Interventions included administering medications per physician orders, monitoring for therapeutic effects of medication, and obtaining psychiatric evaluation and follow-up per physician orders.A physician order dated [DATE] directed to administer Propranolol Hydrochloride (a medication used to treat high blood pressure, angina and irregular heartbeat) 20 mg tablet, give 2 tablets (40 mg dose) by mouth every 12 hours.A physician order dated [DATE] directed to administer Guaifenesin (a cough expectorant) 600 mg extended-release tablet by mouth every 12 hours.Observation of medication administration by Registered Nurse (RN) #5 on [DATE] at 8:50 AM identified hand hygiene was performed by RN #5, all Resident # 68's medications were prepared and placed inside a medication cup, and a cup of water was poured. RN #5 knocked on Resident #68's room door and entered the room, she greeted Resident #68, explained she was there to administer his/her medications, she explained the indication for the medications inside the medication cup to Resident #68 and asked if he/she had any questions. Resident #68 confirmed he/she had no questions. RN #5 did not check the identification name band on Resident #68's right arm (surveyor observed name on name band from right side of resident), and she handed the medication cup to Resident #68 with the cup of water. Resident #68 proceeded to take all medications whole and rinsed them down with water. RN #5 then thanked Resident #68 and exited the room.Interview with RN #5 outside of Resident #68's room on [DATE] at 9:10 AM identified she had identified Resident #68 prior to administration of his/her medication by checking the name on the door as she entered. She indicated that she usually checked the resident's name band and was not sure why she hadn't checked the name band today other than she had forgotten. Additionally, she indicated that checking the name on the door was not best practice for identification of the resident as the resident could be in the wrong room.Review of the Medication Administration policy directed, in part, to identify the resident by their photo within the electronic medical record. The policy directed to ensure the 6 rights of medication are followed during medication administration (right resident, right drug, right dose, right route, right time, right documentation).

Based on observations, interviews and facility policy for 1 of 2 residents (Resident #69) reviewed for activities of daily living (ADLs), the facility failed to ensure Resident #69's fingernails were clean and trimmed. The findings include:Resident #69 was admitted to the facility in May 2026 with diagnoses that included pulmonary embolism, Type 2 diabetes, and urinary tract infection (UTI).The Nursing admission assessment dated [DATE] identified Resident #69 was cognitively intact, able to make needs known, pleasant and cooperative and required assistance of 1 staff member with activities of daily living (ADLs) and was able to eat independently.Physician orders dated 5/9/26 directed to administer Eliquis (blood thinner) 5 milligrams (mg) two times a day, Aspirin 81 mg once a day and physical therapy (PT)/occupational therapy (OT) evaluation and treatment as indicated.The Resident Care Plan (RCP) dated 5/12/26 identified a self-care ADL deficit and bleeding as focus areas with interventions that included PT/OT assist of 1 for toileting and seated sink side in bathroom for ADLs, top portion of side rails up to assist with mobility, and use consistent routines, allow adequate time to complete tasks, monitor for signs and symptoms of bleeding, education to resident and family of the side effects of blood thinning medications, report any side effects to MD, and monitor and report lab values. Observations on 5/18/26 at 11:50 AM and 5/19/26 at 11:00 AM noted Resident #69 had lengthy nails on both hands and had his/her finger up his/her nose causing spots of bleeding from the nose.Observation and interview with Nurse Aide (NA) #10 on 5/22/26 at 9:00 AM noted Resident #69 was out of bed, dressed and sitting in a wheelchair in his/her room after breakfast. Resident #69 was noted to have long, irregular shaped fingernails on both hands with a dried, dark brown substance under the 3rd and 4th fingernails of his/her right hand. NA #10 indicated that Resident #69's fingernails were not clean, needed to be trimmed and was unsure what the substance under Resident #69's fingernails might be. NA #10 stated that Resident #69 was not on her assignment, but Resident #69's assigned NA had left after providing morning care to Resident #69 to accompany another resident on an appointment. NA #10 stated that it was the NAs responsibility to ensure fingernails were clean and trimmed for the residents on their assignments. NA #10 indicated that the facility policy was fingernails were trimmed and cleaned on shower days and as needed.Interview with the DNS on 5/22/26 at 11:00 AM indicated that fingernails should be clean and trimmed. The NA assigned to a resident was responsible for checking fingernails when ADL care was being provided to ensure they were cleaned and kept trimmed. The Nail Care policy dated 11/2025 directed, in part, that cleaning and inspection of the nails will be provided with ADL care on an ongoing basis. Routine nail care, including filing and trimming, will be provided on a regular schedule if needed for the resident. The principles of nail care are that nails should be kept smooth to avoid skin injury, each resident will have their own set of nail equipment (nail clippers, files, etc.), and equipment shall not be shared between residents.

Based on review of the clinical record, facility policy and interviews for the 2 of 5 sampled residents (Resident #41 and Resident #66) reviewed for unnecessary medication, the facility failed to ensure orthostatic blood pressures were completed per physician orders. The findings include: 1.Resident #41 had diagnoses that included seizures, stage 4 chronic kidney disease, schizoaffective disorder, and borderline personality disorder.A Nursing admission assessment dated [DATE] identified Resident #41 was alert and oriented to person, place, and time with no cognitive impairment. The assessment identified Resident #41 used a walker, had a steady gait, and no balance problems. The Resident Care Plan (RCP) dated 5/7/26 identified Resident #41 used psychotropic medication for the management of schizoaffective disorder and borderline personality disorder. Interventions included administering medications as ordered, monitoingr for side effects and effectiveness, and monitor for therapeutic effects of medication.A physician order dated 5/7/26 directed to administer Haloperidol (antipsychotic medication) 10 milligrams (mg) by mouth daily (administration time 8:30 AM) and Haloperidol 20 mg by mouth at bedtime.Review of the clinical record identified a BP for Resident #41 documented by Nurse Aide (NA) #7 on 5/8/26 at 7:26 AM of 159 millimeters of mercury (mmHg) /79 mmHg (resident position not indicated).A physician order dated 5/8/26 directed to obtain an orthostatic blood pressure (BP) weekly for 4 weeks, then monthly: Lying, Sitting, and Standing every Friday on the 7:00 AM to 3:00.A physician order dated 5/18/26 directed to administer Clozapine (antipsychotic medication) 250 mg by mouth at bedtime for schizoaffective disorder.Review of the clinical record identified a BP for Resident #41 documented by Nurse Aide (NA) #7 on 5/15/26 at 8:17 AM of 149/83 (resident position not indicated).a. Review of the Medication Administration Record (MAR) for May 2026 identified on 5/8/26 the nurse documented NA for the BP in the lying position.Review of the Medication Administration Record (MAR) for May 2026 identified on 5/8/26 the nurse documented NA for the BP in the sitting position.Review of the Medication Administration Record (MAR) for May 2026 identified on 5/8/26 the nurse documented NA for the BP in the standing position.Interview and clinical record review with Licensed Practical Nurse (LPN) #2 on 5/21/26 at 12:10 PM identified the nurses were responsible for obtaining orthostatic BPs. She indicated she had entered NA for the orthostatic BPs for Resident #41 on 5/8/26 in all 3 positions because it had probably been done recently and she didn't need to do it again. She was unable to demonstrate the method for how she determined that it had already been done, nor was she able to identify how she knew it didn't need to be obtained again even if it had already been recently done. She indicated that if a resident refused orthostatic BPs she would document it as refused in the EMR and there were no documented resident refusals.Review of the Medication Administration Record (MAR) for May 2026 identified on 5/15/26 the nurse documented 149/83 for the BP in the lying position, sitting and standing position (the same BP reading in all positions).Interview with NA #7 on 5/21/26 at 12:04 PM identified that she obtained BPs for Resident #41and then entered the readings into the electronic medical record (EMR). NA #7 identified that when she obtained BPs she took them herself in the morning, was unaware what an orthostatic BP was, and indicated that when she obtained a BP for Resident #41 she did it in only in one position and only took one BP for the day. NA #7 identified that she never took a BP in a lying, sitting position, and then a standing position.Interview with the Director of Nursing (DNS) on 5/21/26 at 3:45 PM identified the nurse was responsible for obtaining orthostatic BPs per physician orders. She further indicated that it was the responsibility of the nurse to actually obtain the blood pressures themselves in the different positions as indicated within the physician order, and the nurses were not to use the blood pressures entered into the EMR by the nurse aides, nor should they enter 1 blood pressure obtained by the nurse aide for all 3 positions. Additionally, she indicated that even if the nurse thought the ortho BPs had been done recently, it was still expected that they follow the physician order and obtain it again, and that it was not acceptable to document NA.Interview and clinical record review with Advanced Practice Registered Nurse (APRN) #1 on 5/22/26 at 11:40 AM identified the importance of obtaining orthostatic BPs on residents who have psychotropic medications was to be aware of any BP changes for the resident because it was a rehabilitation facility and these residents were getting physical therapy which could be affected if the resident was orthostatic. She indicated that Resident #41 was on 2 potent antipsychotic medications and that his/her orthostatic BPs should be monitored to ensure he/she wasn't having orthostatic changes even though Resident #41's BPs were often elevated.2. Resident #66 was admitted to the facility in May 2026 with diagnoses that included Parkinson's disease, dementia with hallucinations, and history of falls.An admission nursing note dated 5/13/26 at 9:15 PM identified Resident #66 was admitted and was taking Seroquel (an antipsychotic medication) for visual and auditory hallucinations. Additionally, the nursing note identified Resident #66 was only oriented to person and place.A Resident Care Plan dated 5/14/26 identified Resident #66 utilized psychotropic medication for the management of audio-visual hallucinations. Interventions included psychological evaluations, administration of medication as ordered, and behavioral monitoring.A physician order dated 5/13/26 directed to administer Seroquel 25 milligrams (mg) give 0.5 tablet by mouth twice daily. Additionally, the physician directed to complete orthostatic blood pressures weekly for 4 weeks and then monthly.Interview and review of the Medication Administration Record and vital sign section of the electronic health record on 5/21/26 at 12:13 PM with Licensed Practical Nurse (LPN) #1 identified on 5/14/26 and 5/21/26 she documented not applicable for orthostatic blood pressure readings because she thought Resident #55 was uncooperative but couldn't be sure and failed to report to the provider the inability to obtain orthostatic blood pressures as ordered. Additionally, LPN #1 indicated that physical therapy usually obtained orthostatic blood pressures for the nurses and reported readings back to the nurse to be documented.Interview with Physical Therapist #1 on 5/21/26 at 12:30 PM indicated that they will obtain orthostatic blood pressures when asked by nursing staff, but she had not been asked regarding Resident #66 and was unaware there was a weekly physician order for orthostatic blood pressures.Review of the Orthostatic Blood Pressure Measurement Policy directed, in part, the purpose was to identify orthostatic hypotension and assess resident risk for falls, dehydration, or cardiac instability. The policy defined orthostatic blood pressure as the measurement of blood pressure and heart rate in different positions (lying, sitting, standing). The policy directed to obtain orthostatic BPs when a resident has a history of falls, reports dizziness/lightheadedness, is on medication affecting BPs, or is dehydrated. The policy directed the procedure was to ensure resident lying supine for at least 5 minutes, measure BP and heart rate, document as supine; then assist resident to sitting position and wait 1 minute, measure BP and heart rate, document as sitting; then assist resident to standing position, measure BP and heart rate at 1 minute and 3 minutes, document.

Based on observation, interviews, review of the clinical record and facility policy for 1 of 3 residents (Resident #14) reviewed for pressure ulcers, the facility failed to ensure the appropriate physician ordered treatment was completed for a Stage 3 (full thickness of skin loss) pressure ulcer. The findings include: Resident #14 was admitted to the facility in May 2026 with diagnoses that included cellulitis of the lower right leg with multiple chronic foot wounds, recurrent bilateral pressure ulcers to buttocks, and Type 2 diabetes.The admission Nursing assessment dated [DATE] and written by Registered Nurse (RN) #2 identified that Resident #14 had intact cognition and able to make needs known, required the assistance of 1 staff member for activities of daily living except able to eat independently and had a stage 2 (partial-thickness skin loss) pressure ulcer to coccyx and right buttock with multiple bruising and abrasions to right leg.The Resident Care Plan (RCP) dated 5/4/26 identified alteration in skin integrity as a concern with interventions that included avoid uninterrupted sitting in chair, float heels off of bed surface if indicated, moisture barrier per protocol if indicated, pressure reducing mattress on bed, toilet and incontinent care with rounds, treatment and dressing changes as ordered and report to the nurse any areas of skin breakdown during care.Physician orders dated 5/12/26 directed to cleanse the coccyx area with wound wash, pat dry, apply Calcium Alginate (seaweed fibers combined with calcium used for wounds with moderate to heavy drainage) to the wound bed, cut to size and cover with a dry, clean dressing and change every other day and as needed.A review of weekly wound notes completed by MD #3 (wound physician) on 5/19/26 indicated that Resident #14 had a stable community acquired Stage 3 wound to the right buttock that measured length 4.0 cm (centimeters) by width 0.8 cm with 0.0 cm depth, no odor or exudate (fluid that comes from a wound). Nursing to continue with the same treatment of Calcium Alginate and cover with a dry, clean dressing every other day.Observation of the treatment to coccyx/buttock wound on 5/21/26 at 11:05 AM with Licensed Practical Nurse (LPN) #2 identified that Resident #14 had dime sized open area that was yellow in color to the right lower buttock at the crease of the buttock into the right upper thigh. LPN #2 was then noted to clean the area with wound cleaner and applied a barrier cream (a protective topical cream applied to the skin to shield to from breakdown and moisture) to the area but failed to cover the area to the lower right buttock with Calcium Alginate and a dry, clean dressing per physician's orders. Interview with LPN #2 on 5/21/26 at 1:45 PM could not explain the reason she did not cover the area to the lower right buttock with Calcium Alginate and a dry, clean dressing as physician directed.Interview with Registered Nurse (RN) #4 (the Infection Preventionist) on 5/21/26 at 2:00 PM indicated that if Resident #14 had an open area to his/her right lower buttock then it should have been covered with Calcium Alginate and a dry, clean dressing based on facility policy for a wound that had exudate.Interview with MD #3 on 5/22/26 at 8:46 AM indicated that if Resident #14 had an open area to right lower buttock that was yellow in color that an appropriate treatment would be to cover the area using Calcium Alginate and a dry, clean dressing. MD #3 indicated that a house barrier cream was not the ideal treatment and stated it would not cause harm or cause the wound to worsen but it did not provide optimal treatment. MD #3 indicated that a thick zinc-based paste that was occlusive (like a barrier cream) can manage mild to moderate wound exudate by forming a seal could be used for partial thickness skin loss would be more of an appropriate treatment if a barrier type of product was to be used.Although requested, a policy regarding staging and treatment for pressure ulcers was not provided.The National Pressure Injury Advisory Panel (NPUAP) 2016 states a Stage 2 pressure injury involves partial thickness loss with exposed dermis. It may appear as a shallow open ulcer or blister. Most wound healing is required with commonly used dressings such as hydrocolloid, foam, transparent film, or hydrogels and barrier creams used to protect surrounding skin. Recommended dressings for a stage 3 pressure injury which is full thickness skin loss include foam, calcium alginate, gelling fiber, collagen or antimicrobal/silver dressings.

Based on observations, clinical record review and interviews for 1 of 3 sampled residents (Resident #30) reviewed for nutrition, the facility failed to ensure a protein supplements was provided timely, failed to obtain a re-weight for a significant weight loss, failed to assist Resident #30 with meals to encourage intake and failed to document the amount of nutritional supplement and percentage of meals consumed. The findings include:Resident #30 had diagnoses that included human metapneumovirus pneumonia, diabetes, and metabolic encephalopathy.The Nursing admission assessment dated [DATE] identified Resident #30 was alert and oriented to person, place, and time with some forgetfulness. The assessment indicated Resident #30 used a walker, had a steady gait, and no balance problems, took nutrition and hydration orally and had no signs/symptoms of a swallowing disorder.A Resident Initial Interview form (for Dietary preferences) dated 5/3/26 identified Resident #30 had a fair appetite, no problems chewing or swallowing, there were no foods that he/she didn't like, and that he/she requested small portions. The Dietary preference form indicated that diet cola was his/her preferred beverage and that he/she liked all cold cereal options. The Dietary preference form further indicated that Resident #30 would like tossed salad, fruit, Jello, ice cream, pudding, yogurt, and soup at lunch.A physician order dated 5/3/26 directed to provide a low carbohydrate mediterranean diet: Low concentrated sweets (LCS), no added salt (NAS) of regular texture with thin liquids and to provide a bedtime snack every evening shift.a. A nursing note written by Registered Nurse (RN) #5 on 5/4/26 at 4:40 PM identified Resident #30 had a poor appetite and consumed 25% of his/her meals. The note indicated the Advanced Practice Registered Nurse (APRN) was notified and there were no new orders.A nursing note written by RN #5 on 5/5/26 at 4:34 PM and 5/6/26 at 4:22 PM identified Resident #30 had a poor appetite but consumed 50% of his/her meals.A nursing note dated 5/6/26 at 10:53 PM identified Resident #30 had poor appetite but enjoyed Ensure supplements.Review of the clinical record failed to identify a physician order for ensure supplements.A Nutrition Assessment completed by the Dietician on 5/7/26 at 10:23 AM identified Resident #30 had adult failure to thrive diagnosis, was on a LCS/NAS diet of regular texture with thin liquids, had a current weight of 155.2 pounds (lbs.) and was underweight with a body mass index (BMI) of 19.4. The assessment indicated Resident #30 ate 25 percent (%)-100% of meals per the electronic medical record (EMR) documentation. The assessment indicated Resident #30 reported a very poor appetite and recommendations were for a supplement of Magic Cup 2 times a day for poor appetite and 30 milliliters (ml) of oral protein 3 times a day for wound healing.The Resident Care Plan (RCP) dated 5/7/26 identified Resident #30 received nutrition with the goal to maintain the current weight of 155.2 lbs. Interventions included monitor oral intake, monitor weight and report any significant weight changes to the Medical Doctor (MD) and dietician, provide 30 milliliters (ml) of liquid protein 3 times a day to promote wound healing, provide magic cup 2 times a day to promote oral intake, and set-up/feeding assistance as needed.Review of the clinical record identified Resident #30's weight on 5/7/26 was 150.0 lbs. which was a decrease of 5.2 lbs. from the Dietician's progress note dated 5/7/26.An APRN progress note written by APRN #1 on 5/8/26 at 1:00 AM identified Resident #30 was seen for follow-up of oral intake and significant unintentional weight loss. The note indicated Resident #30 reported a large weight loss over the past year. The note indicated the plan was for weekly weights, nutritional monitoring with encouragement of high calorie/high protein meals, oral nutritional supplements and recommended a dietary consult to optimize nutrition.A nursing note written by Licensed Practical Nurse (LPN) #2 on 5/10/26 at 3:18 PM identified Resident #30 had decreased oral intake noted.A nursing note written by RN #1 on 5/10/26 at 9:51 PM identified he was notified by the nurse that Resident #30 refused all medications and meals despite family encouragement. The note indicated the APRN was notified and she increased the Mirtazapine (an antidepressant also used to increase appetite) order to 15 milligrams (mg) at bedtime and to provide assistance with set-up and feeding to Resident #30. The note indicated the NA care card was updated.A physician order dated 5/10/26 directed to administer Mirtazapine 15 mg by mouth at bedtime for appetite stimulant (This order was an increased dosage for use as an appetite stimulant from the prior physician order for 7.5 mg for depression). Additionally, the physician order directed Resident #30 required assistance in feeding (preparation (set-up) and actual feeding) every day (7:00 AM to 3:00 PM) and evening (3:00 PM to 11:00 PM) shift.A nursing note written by LPN #2 on 5/11/26 at 11:07 AM identified Resident #30 had improved oral intake and consumed cereal with milk and a banana for breakfast.An APRN progress note dated 5/12/26 at 1:00 AM identified Resident #30 was seen for follow-up of poor oral intake, dehydration, and weight monitoring. The note indicated oral intake had slightly improved with nursing assistance and family encouragement. The note indicated the plan for continuation of the Mirtazapine with encouragement of high calorie/high protein meals and supplements, weekly weights and dietary follow-up were recommended.A nursing note written by RN #5 on 5/12/26 at 2:37 PM identified Resident #30 had a poor appetite and ate 50% of his/her meals. The note indicated the nurse aide (NA) was reinforced on feeding assistance was required to facilitate meals.A nursing note dated 5/13/26 at 6:01 PM identified Resident #30 refused to eat dinner and stated he/she didn't like it and wanted fried chicken. The note indicated the family was notified and stated they would bring food in for him/her to eat.A nursing note dated 5/14/26 at 2:56 PM identified Resident #30 had a poor appetite.Review of the clinical record identified Resident #30's weight on 5/14/26 was 146.3 lbs. (a decrease of 8.9 lbs./5.7% in 8 days) with no documented reweight to confirm. A nursing note dated 5/15/26 at 1:06 AM identified Resident #30 had poor oral intake.A dietary note written by Dietician on 5/15/26 at 11:56 AM identified Resident #30 triggered for a significant weight loss of greater than 5% in 30 days. The note identified the current diet remained appropriate, that Resident #30's oral intake was 25%-75% with frequent refusals. The note identified he/she was receiving Magic Cup 2 times a day to promote oral intake, and that the recent order for Mirtazapine 15 mg at bedtime may stimulate the appetite. The note identified she recommended liquid protein 3 times a day for wound healing (although she previously recommended liquid protein on 5/6/26), that Resident #30 had a very poor appetite which wasn't improving and further identified a tube feed may be an option for the plan of care.A physician order dated 5/15/26 directed to administer 30 ml of liquid protein 3 times a day to promote wound healing (this was 8 days after the Dietician assessment and recommendation).A nursing note dated 5/15/26 at 7:21 PM identified Resident #30 refused to eat the facility food and requested food be brought in by family. The note identified he/she ate 75% of the food brought in by the family. The note failed to identify what food was brought in by the family member.An APRN progress note dated 5/16/26 at 1:00 AM identified Resident #30 was seen for dehydration follow-up. The progress note indicated Resident #30 had protein-calorie malnutrition with poor oral intake and continued with significant weight loss, meal refusals, poor appetite and the need for feeding assistance. The note further indicated continued nutritional oversight was needed due to the risk of further weight loss and functional decline.A nursing note dated 5/17/26 at 8:29 PM identified Resident #30 ate 75 % of dinner.Interview with Resident #30 on 5/18/26 at 10:42 AM identified he/she disliked institution food and indicated that he/she had lost weight since admission.A nursing note written by Licensed Practical Nurse (LPN) #2 on 5/18/26 at 12:55 PM identified Resident #30 had improved oral intake noted.A nursing note dated 5/19/26 at 12:51 AM identified Resident #30 had poor oral intake.b. Observation of Resident #30 in his/her room on 5/19/26 at 9:10 AM identified the breakfast tray brought into the room by a NA and placed on corner of bedside table with the cover in place.Observation and interview with Resident #30 in his/her room on 5/19/26 at 9:34 AM (24 minutes after Resident #30 was provided a breakfast tray) identified Resident #30 was lying in bed with the head of bed less than 30 degrees and his/ her face was at the level of the overbed table such that his/her neck and body were below the level of the table. Resident #30 had not eaten, and the food plate remained covered. He/she identified no one from the facility assisted him/her with eating and stated that it was difficult to eat when your face was at the same level as your food.Observation of Resident #30 in his/her room on 5/19/26 at 9:37 AM identified the Nurse Aide (NA) entered the room to bring a cup of tea that he/she had requested, repositioned Resident #30, raised the head of bed to fully upright but did not remove the breakfast plate cover or offer assistance.Observation of Resident #30 on 5/19/26 at 9:43 AM (33 minutes after Resident #30 was provided a breakfast tray) identified the NA left the room after assisting resident into an upright position and the breakfast plate remained covered. Resident #30 was observed sitting upright in bed with his/her eyes closed. Resident #30 had not been assisted to eat and the food remained covered.Interview with NA #9 on 5/19/26 at 10:00 AM identified she exited the room after collecting the breakfast tray for Resident #30 and discarded the remaining food in the trash. NA #9 indicated Resident #30 had drank a little bit of juice and had eaten a couple of bites of oatmeal and then stated that he/she didn't want anything else because his/her family member was going to bring something to eat.Observation on 5/19/26 at 10:00 AM identified a family member for Resident #30 arriving to his/her room with a brown paper bag.A nursing note written by RN #5 on 5/19/26 at 4:42 PM identified Resident #30 had poor appetite despite support from family, and that APRN #1 was updated. The note indicated that Resident #30 consumed 15% of meals.Interview and clinical record review with NA #8 on 5/20/26 at 12:30 PM identified the NA care card for Resident #30 directed that he/she could feed themselves and required set-up and assistance as needed. The care card failed to identify directions to assist Resident #30 with feeding for all meals to encourage oral intake. NA #8 indicated that Resident #30 had eaten 75 % of his/her breakfast that day with help/encouragement from a family member.c. Observation on 5/20/26 at 12:53 PM identified Resident #30's lunch tray was served.Interview and clinical record review with the Dietician on 5/20/26 at 1:10 PM identified she had recommended a Magic cup 2 times a day on 5/7/26 and that she had put the order in herself which should have been confirmed by the nurses. Record review at that time failed to identify the amount of Magic cup Resident #30 consumed and was unable to identify why the order for Magic cup did not include documentation for the amount consumed, nor was she able to identify why she had not realized the order was not in place when she evaluated Resident #30 for weight loss on 5/15/26. She indicated that when she followed up on a resident she asks the nurses how the oral intake was and did not always look at the supplement consumption documentation within the EMR. She indicated when she saw Resident #30 on 5/15/26 for a significant weight loss even after her recommendations for Magic cup 2 times a day, and liquid protein for wound healing, she had not recommended any additional food supplements because Resident #30 had initially declined all other supplements besides Magic cup and liquid protein even though there was a nursing note which indicated Resident #30 enjoyed an Ensure supplement. She indicated the Ensure was brought in by the family but could not identify how often they were offered to Resident #30, nor why she had not initiated an order for them to be provided between meals to supplement the resident's poor oral intake considering he/she liked them. The Dietician indicated that when the APRN wanted her to follow-up with a resident she would let her know directly, and that she would follow-up within the day or next day. Additionally, she indicated she had not been aware APRN #1 wanted her to follow-up with Resident #30 again after she saw him/her on 5/7/26, and that APRN #1 had recommended high protein/high calorie foods with oral nutritional supplements. Additionally, she indicated that she had suggested to APRN #1 that Resident #30 receive a feeding tube and that APRN #1 was supposed to have spoken with the family. She further indicated that she had offered additional supplements to Resident #30, but that he/she had refused, but she doesn't think that she documented that conversation in a note.A Nutritional Supplements list from the dietary department identified the following options for supplements available for residents: House milkshake, Hi-cal (calorie) supplement, Ensure clear (clear liquid supplement), Glucerna (diabetic friendly supplement), Nepro (kidney friendly supplement), ProMod (liquid protein), ProStat Advanced Wound Care (liquid protein), magic cup (ice cream type supplement), Thrive ice cream, and Ensure Plus (milk based liquid supplement).Observation on 5/20/26 at 1:23 PM identified NA #8 brought a cart down the hall to collect the food trays from the resident rooms following lunch.Observation on 5/20/26 at 1:26 PM identified NA #8 asking Resident #30 if he/she was done eating (only the salad was consumed 100%), no other food items were consumed and they remained covered, and Magic cup remained unopened. Resident #30 identified being done eating and NA #8 grasped the sides of the food tray, then looked into the hallway at the surveyor, and then let go of the food tray and picked up the cover off the plate of food. She asked Resident #30 if he/she wanted anything on the plate and was told No. She offered Resident #30 the Magic cup and called it ice cream, he/she said they would try it, if NA #8 fed it to them. NA #8 opened the Magic cup and gave Resident #30 a bite. NA #8 fed Resident #30 a total of 4 bites of the Magic cup and then Resident #30 stated that they would feed themselves. NA #8 gave Resident #30 the Magic cup to hold and he/she ate the remainder on their own. NA #8 then left the diet coke from the tray and removed all additional food and drink items. Interview with APRN #1 on 5/20/26 at 1:40 PM identified she had multiple progress notes related to her monitoring Resident #30 poor oral intake. APRN #1 indicated that the dietician had suggested placement of a feeding tube, but she had not approached the family to discuss that because she didn't feel they would want that. She was unable to identify how she knew the family would decline a feeding tube without speaking with them. She further identified that she thought there was a physician order in place for Magic cups and knew Resident #30 received Magic cups because she had fed Resident #30 a magic cup herself. She indicated that the physician order usually prompted the nursing staff to document the amount consumed.Subsequent to surveyor inquiry a physician order dated 5/20/26 directed to provide a Magic cup 2 times a day to promote oral intake for poor appetite. The order included supplemental documentation for percent consumed (This was 13 days after the Dietician assessment and recommendation).Subsequent to surveyor inquiry a physician order dated 5/20/26 directed to provide 237 ml of Ensure plus oral nutritional supplement 3 times a day for poor appetite. The order indicated the resident may self-administer without supervision and instructed for the nurse to give it after meals. The order failed to prompt supplemental documentation for percent consumed.A nursing note written by RN #5 on 5/20/26 at 5:30 PM identified Resident #30 had a fair appetite for breakfast, consumed 50% of his/her meals with assistance from family member. The note further indicated there was a new order for Ensure plus liquid supplement and Magic cup for poor oral intake.A nursing note written by RN #5 on 5/20/26 at 5:38 PM identified the weight for 5/20/26 was 150.7 lbs. (a 4.4 lb. weight gain in 6 days) was reported to the APRN with no new orders. The note indicated Resident #30 had a fair appetite for breakfast and lunch.A nursing note dated 5/20/26 at 9:06 PM identified Resident #30 had poor oral intake and drank 120 ml of Ensure as ordered. The note indicated Resident #30 ate 60% of food brought in by family and ate 25% of the bedtime snack.d. Observation on 5/21/26 at 12:55 PM identified NA #5 brought the lunch tray into Resident #30 who was sitting out of bed in the recliner. NA #5 set the tray down on the table and then left the room without setting the tray up or cutting up any of the food.Observation on 5/21/26 at 1:01 PM identified Resident #30 remained in the recliner and the overbed table holding the tray of food was out of the reach of Resident #30.Observation on 5/21/26 at 1:04 PM identified NA #5 looked into Resident #30's room and then walked away.Observation on 5/21/26 at 1:06 PM identified Resident #30's call light was on and NA #5 responded to the call light. Resident #30 asked her for a sweatshirt and stated he/she was cold. After assisting Resident #30 to don a sweatshirt NA #5 asked if he/she was going to eat and pushed the tray closer, removed the cover off the plate, but did not open any drinks or cut up any food, and then exited the room.Observation and interview with NA #5 on 5/21/26 at 1:10 PM identified this was her first time caring for Resident #30 and Resident #30 had told her he/she didn't want to eat. She indicated she would go back again and reapproach Resident #30. She was observed to stop and tell the LPN #2 that Resident #30 refused his/her lunch. She was unaware Resident #30 required assistance with feeding.Interview and clinical record review with LPN #2 on 5/21/26 at 1:15 PM identified Resident #30 refused to eat lunch and indicated the order in the EMR directed for Resident #30 to be assisted by the NA to eat his/her meal, and she indicated Resident #30 had refused NA #5's help (which had been first offered more than 15 minutes after the lunch tray was brought in the room). LPN #2 was unable to identify how NA #5 was to know she was responsible for setting up the tray and for actually assisting Resident #30 with eating when the meal was served if it wasn't on the NA care card to do so. LPN #2 was further unable to identify why Resident #30 was left for greater than 15 minutes without being assisted after the meal was served and how he/she was supposed to have eaten the meal considering it was left out of their reach.Interview with the Director of Nursing Services (DNS) on 5/21/26 at 3:45 PM identified when a resident had an order in place for feeding assistance both the NA and the nurse were responsible for ensuring the resident received assistance with each meal, and that it should be reflected on the NA care card. Additionally, she indicated that for residents with poor oral intake the NA care card should direct them to offer snacks, and encourage oral intake of food and fluids throughout the shift.Interview with the DNS on 5/22/26 at 12:50 PM identified when Magic cups were ordered there should be a physician order in place with supplemental documentation for the amount consumed to track how much the resident is consuming.Although requested NA documentation of the amount consumed from each meal was not provided to show the percentage consumed. The documentation provided for May 2026 meal intake percentage only indicated the NA initials for each meal. Additionally, the documentation failed to identify documentation of a meal being provided on 5/18/26 for breakfast, and on 5/19/26 for breakfast and lunch.Review of the Weight Monitoring policy directed, in part, the facility will ensure all residents maintain acceptable parameters of nutritional status. The policy directed the facility will use a systemic approach to optimize the resident's nutritional status including assessing risk factors, developing and implementing interventions, and monitoring the effectiveness of interventions to revise as needed. The policy directed the nutritional assessments are used to develop the plan of care which should address causes of impaired nutrition, resident preferences, interventions, and updated with condition changes. The policy directed the resident and/or family will be involved in the development of the plan of care. The policy directed weights will be obtained per the ordered schedule, and new weights should be compared with old weights to monitor for weight changes. The policy directed the physician should be notified of significant weight changes and may order nutritional interventions, and meal intake should be documented and referenced by the interdisciplinary team. The policy further indicated the dietician should be consulted to assist with interventions and their actions documented in progress notes.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, for 1 of 1 resident (Resident #43) reviewed for pain management, the facility failed to ensure that Resident #43 received appropriate pain management in accordance with the physician ordered pain medication instructions. The findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis of the left heel and midfoot with necrosis of the muscle and gangrene, managed with a vacuum bandage device, as well as anxiety disorder and Type 2 diabetes. A physician order dated 4/29/26 at 10:01 PM directed 5 milligrams (mg) of Oxycodone (an opioid pain medication), to be given every 6 hours for moderate pain. A physician order dated 4/29/26 at 10:46 PM directed 650 mg of Acetaminophen (a non-opioid pain medication) to be given every 6 hours as needed for pain. The Resident Care Plan (RCP) dated 4/30/26 identified that Resident #43 was at risk for pain, with interventions that included administering pain medications as ordered, monitoring the effectiveness of administered pain medication, reviewing the resident's satisfaction with pain relief results, assessing the impact of pain on functional ability and cognition, and monitoring for verbal and nonverbal signs and symptoms of pain such as verbalization of pain, irritability, and restlessness.A physician order dated 5/2/26 directed staff to administer either 5 mg or 10 mg of Oxycodone, every 6 hours as needed, depending on the resident's pain assessment. The directions specified to administer 5 mg of Oxycodone if Resident #43's pain was assessed between 1 and 5 out of 10, and to administer 10 mg of Oxycodone if the resident's pain was assessed between 6 and 10 out of 10.The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #43 was cognitively intact, required substantial assistance with bathing, was independent with eating, and frequently experienced pain, including pain rated at 10/10.Review of the Medication Administration Record (MAR) from 5/1/26 through 5/22/26 identified multiple instances in which opioid and non opioid medications were either administered or not administered according to physician ordered instructions. On 5/3/26 at 1:44 PM, Resident #43's pain was assessed at a level of 6/10, and although the resident was not yet due for Oxycodone, Acetaminophen was not administered for pain relief as ordered. On 5/9/26 at 3:04 PM, the resident was given 10 mg of Oxycodone for a pain level of 0/10, outside of physician ordered parameters. On 5/10/26 at 4:17 PM, the resident's pain level was a 4/10 on 5/10/26 at 4:17 PM and again received 10 mg of Oxycodone outside of ordered instructions. On 5/12/26 at 5:11 AM, the resident was given 5 mg of Oxycodone for a pain level of 7/10, although 10 mg should have been administered per the physician order. On 5/12/26 at 2:38 PM, the resident rated a pain level of 10/10, was not yet due for another dose of Oxycodone, nor did they receive Acetaminophen as ordered for interim pain relief. On 5/15/26 at 4:45 AM, the resident rated pain at 10/10 but received only 5 mg of Oxycodone instead of the required 10 mg. On 5/15/26 at 10:08 AM, the resident rated pain at 6/10 and received Acetaminophen but did not receive the ordered 10 mg of Oxycodone. On 5/19/26 at 7:05 PM, the resident rated pain at 4/10 but received 10 mg of Oxycodone, which was outside of physician ordered parameters. An interview with Resident #43 on 5/18/26 at 12:04 PM identified that he/she did not feel that pain was adequately managed and that sometimes he/she received only 5 mg of Oxycodone when he/she felt their pain warranted 10 mg. The interview further identified that Resident #43 frequently experienced pain due to a serious wound infection with gangrene and necrotizing muscle, which required a vacuum wound dressing that caused discomfort. Interview with Licensed Practical Nurse (LPN) #1 on 5/19/26 at 2:59 PM identified that physician orders and instructions within the orders of the pain scale should be followed when administering pain medications. LPN #1 identified that she administered 10 mg of Oxycodone with a pain scale lower than ordered on multiple occasions in order to attempt to control the resident's pain. An interview with LPN #3 on 5/20/26 at 12:09 PM identified that she was not aware of the specific physician ordered instructions that included a pain scale accompanying Resident #43's pain medication orders. Instead, she dosed the pain medication after speaking with the resident about whether their pain felt mild, moderate, or severe, and based medication administration on what the resident requested for their pain. An interview with the DNS on 5/13/26 at 1:30 PM identified that the pain scale should be followed when administering pain medications when it was included in the physician's orders. When made aware of doses that were administered incorrectly according to the physician's instructions, the DNS stated that staff should have followed the physician ordered directions. Review of the facility policy titled Pain Management, dated 10/16/25, identified that pain was to be managed in collaboration with the prescriber, the resident, and other members of the interdisciplinary team to develop and implement pain management as part of the comprehensive care plan. The policy further identified that opioid treatment for pain would be prescribed and dosed in accordance with current professional standards.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 resident (Resident #8) reviewed for anticoagulant therapy, the facility failed to prevent a duplicate transcription of a medication order resulting in Resident #8 receiving twice the dosage of Warfarin (an anticoagulant medication). The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses including venous thrombosis, embolism, and cerebral infarction.A Nursing admission assessment dated [DATE] identified Resident #8 was cognitively intact and required partial moderate assistance for transfers, eating, bathing, dressing and toileting. The Resident Care Plan dated 5/6/26 identified Resident #8 was at risk for bleeding and bruising due to the use of blood thinning medications. Interventions included administering medication per the physician's orders, monitor/report lab results to the physician and adjusting dosage of medication per order.An Advanced Practice Registered Nurse (APRN) order dated 5/6/26 directed to administer Warfarin Sodium (Coumadin), 4 milligrams(mg) by mouth one time a day every Monday, Tuesday, Wednesday, and Saturday. Also, Warfarin Sodium 3 mg administer 2 tablets by mouth every Friday and Sunday.An APRN progress note written by APRN #1 on 5/6/26 at 1:00 PM identified Resident #8 had long term use of anticoagulants, to continue with Warfarin order per discharge regimen from the hospital, monitor International Normalized Ratio (INR) and adjust per provider.A nursing note dated 5/6/26 at 7:43 PM identified Warfarin 4 mg was given as ordered and Resident #8 was to have a repeat Prothrombin Time (PT)/ International Normalized Ratio (INR) drawn by the lab on 5/7/26.A Warfarin tracking form identified on 5/7/26 a PT was 32.1 seconds (normal range 9.4 to 12.5 seconds) and an INR of 3.0 (normal 2.0 to 3.0).An APRN order dated 5/8/26 directed to administer Warfarin 4 mg by mouth at bedtime for 3 days (5/8/26, 5/9/26 and 5/10/26) and repeat a PT/INR on 5/11/26.Medication Administration Record (MAR) for May 2026 identified Resident #8 received 8 mg of Warfarin (twice the amount of dosage) on 5/9/26 (Saturday) in error by Licensed Practical Nurse (LPN) #6 (instead of 4 mg of Warfarin). A Warfarin tracking form dated 5/11/26 identified a Prothrombin Time (PT) of 73.9 seconds (normal range 9.4 to 12.5 seconds), an INR of 7.0 (normal range 2.0 to 3.0) and the order for Warfarin was to place it on hold for 2 days (5/11/26 and 5/12/26).A nursing note written by Registered Nurse (RN) #6 on 5/11/26 at 10:13 AM identified Resident #8 had been receiving Warfarin 4 mg 5 days a week, 6 mg 2 days a week and the INR goal was 2.0 to 3.0 per the cardiologist, Warfarin was discontinued and labs for INR were ordered for 5/13/26.A progress note written by APRN #1 on 5/11/26 at 1:00 PM identified Resident #8 was seen for a follow-up evaluation and laboratory review. APRN #1's progress note further identified labs were significant for a critically elevated INR of 7.0 with prolonged Prothrombin Time of 73.9 seconds while on chronic anticoagulation therapy of Warfarin. Also, identifying to hold Warfarin and repeat the PT/INR in 2 days (5/13/26).An APRN order dated 5/11/26 at 5:17 PM and written by APRN #1 identified bleeding precautions: monitor for signs and symptoms of bleeding to the following but not limited to bleeding gums, epistaxis, black, tarry stools, increased bruising, vomiting coffee ground or petechiae every shift for elevated INR 7.0.A facility-initiated Medication Discrepancy Report dated 5/11/26 identified Resident #8 received the wrong medication dose (no date or medication name identified). Additionally, the report noted the Warfarin order was not written correctly, was not written plainly and was not noted properly on the MAR. The report further identified there was an order for Warfarin 4 mg for three days a week (which included Saturdays) and also an order for Warfarin 4 mg for specific days including Saturdays (which resulted in Warfarin being listed in two separate administration sign off sections for Saturday 5/9/26). A progress note written by APRN #1 on 5/13/26 at 1:00 PM identified Resident #8 was seen for a follow-up evaluation and review of laboratory studies including the critical INR monitoring from 5/11/26. Also, identifying the repeat PT/INR had improvement from 7.0 to 5.7 which remains supratherapeutic. Further, identifying the Warfarin remained on hold and Resident #8 would have a repeat PT/INR on 5/15/26.Interview with Pharmacist #1 on 5/19/26 at 2:27 PM identified a critical INR would be anything over 3.5. Also, identifying an INR of 7.0 would warrant a physical evaluation, use of reversal agents depending on the resident's clinical condition and receiving a double dose of Warfarin would be a significant medication error. (Please refer to F 760)Interview on 5/21/26 at 10:40 AM with Licensed Practical Nurse (LPN) #6 identified Resident #8 had 2 different Warfarin sections listed on the MAR along with 2 different medication packets (bubble packages) dated 5/9/26. LPN #6 identified she administered Warfarin 4 mg twice because the section on the MAR read to administer 4 mg on Saturday 5/9/26 and the other section also included Saturday; LPN #6 identified she gave a total of 8 mg of Warfarin (instead of APRN ordered 4 mg).Interview on 5/21/26 at 12:13 PM with APRN #1 identified Resident #8 was only to receive 4 mg of Warfarin on 5/9/26 and Resident #8 was given a double(duplicate) dose. Also, identifying the Warfarin order should have contained a stop date along with scheduled lab work which one of the orders did not contain. Further, identifying RN #7 placed the order for Warfarin 4 mg by mouth Monday, Tuesday, Wednesday, Thursday and Saturday upon admission which lacked a stop date.Interview on 5/21/26 at 12:37 PM with RN #7 identified Resident #8 had 2 (duplicate) orders for Warfarin, one of the orders was not discontinued after the new order was placed on 5/8/26. Also, identifying the APRN should have discontinued the order for Warfarin 4 mg on Monday, Tuesday, Wednesday, Thursday and Saturday after starting the new order for 4 mg of Warfarin for 3 days, 5/8/26, 5/9/26, and 5/10/26 (Friday, Saturday and Sunday).Interview on 5/21/26 at 1:53 PM with the DNS and MD #2 identified the DNS was made aware on 5/11/26 of Resident #8 being administered the incorrect dosage of Warfarin 8 mg on 5/9/26 by RN #6 and she believed the resident had 2 orders for Warfarin. Also, identifying LPN #6 should have questioned the duplicate order before administering the medication. Interview on 5/22/26 at 9:54 AM with RN #6 identified the lab called the facility in the morning on 5/11/26 with a critical reading of the INR of 7.0 and she reviewed the Warfarin orders. Also, identifying LPN #6 administered Warfarin 8 mg on 5/9/26 and the order was placed without a stop date by RN #7. Further, identifying anyone who transcribed an order for Warfarin needed to put a stop date in.Interview on 5/22/26 at 10:03 AM with the DNS identified the medication error incident on 5/9/26 was not reported to the state, and being given a double dosage of Warfarin was not a significant medication error (a discrepancy with the Pharmacist interview identifying that receiving a double dose of Warfarin was a significant medication error).Interview on 5/22/26 at 10:17 AM with the DNS and RN #8 identified the Medication Discrepancy Report form was not completed timely, Resident #8 had the potential for bleeding which was significant and Resident #8 was administered a significant medication error on 5/9/26.Review of the policy dated 10/2025 for Anticoagulants directed, in part to recognize that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. Compliance guidelines: Target symptoms (lab values) and goals for use (prevention or treatment) of anticoagulants shall be documented in the resident's medical record. Durations of use shall be appropriate to the resident's condition and indication of use.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 resident (Resident #8) reviewed for anticoagulant therapy, the facility failed to prevent a duplicate transcription of a medication order resulting in Resident #8 receiving twice the dosage of Warfarin (an anticoagulant medication) resulting in a significant medication error. The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses including venous thrombosis, embolism, and cerebral infarction.A Nursing admission assessment dated [DATE] identified Resident #8 was cognitively intact and required partial moderate assistance for transfers, eating, bathing, dressing and toileting. The Resident Care Plan dated 5/6/26 identified Resident #8 was at risk for bleeding and bruising due to the use of blood thinning medications. Interventions included administering medication per the physician's orders, monitor/report lab results to the physician and adjusting dosage of medication per order.An Advanced Practice Registered Nurse (APRN) order dated 5/6/26 directed to administer Warfarin Sodium (Coumadin), 4 milligrams(mg) by mouth one time a day every Monday, Tuesday, Wednesday, and Saturday. Also, Warfarin Sodium 3 mg administer 2 tablets by mouth every Friday and Sunday.An APRN progress note written by APRN #1 on 5/6/26 at 1:00 PM identified Resident #8 had long term use of anticoagulants, to continue with Warfarin order per discharge regimen from the hospital, monitor International Normalized Ratio (INR) and adjust per provideA nursing note dated 5/6/26 at 7:43 PM identified Warfarin 4 mg was given as ordered and Resident #8 was to have a repeat Prothrombin Time (PT)/ International Normalized Ratio (INR) drawn by the lab on 5/7/26.A Warfarin tracking form identified on 5/7/26 a PT was 32.1 seconds (normal range 9.4 to 12.5 seconds) and an INR of 3.0 (normal 2.0 to 3.0).An APRN order dated 5/8/26 directed to administer Warfarin 4 mg by mouth at bedtime for 3 days (5/8/26, 5/9/26 and 5/10/26) and repeat a PT/INR on 5/11/26.A Medication Administration Record (MAR) for May 2026 identified Resident #8 received 8 mg of Warfarin (twice the amount of dosage) on 5/9/26 (Saturday) in error by Licensed Practical Nurse (LPN) #6 (instead of 4 mg of Warfarin). A Warfarin tracking form dated 5/11/26 identified a Prothrombin Time (PT) of 73.9 seconds (normal range 9.4 to 12.5 seconds), an INR of 7.0 (normal range 2.0 to 3.0) and the order for Warfarin was to place it on hold for 2 days (5/11/26 and 5/12/26).A nursing note written by Registered Nurse (RN) #6 on 5/11/26 at 10:13 AM identified Resident #8 had been receiving Warfarin 4 mg 5 days a week, 6 mg 2 days a week and the INR goal was 2.0 to 3.0 per the cardiologist, Warfarin was discontinued and labs for INR were ordered for 5/13/26.A progress note written by APRN #1 on 5/11/26 at 1:00 PM identified Resident #8 was seen for a follow-up evaluation and laboratory review. APRN #1's progress note further identified labs were significant for a critically elevated INR of 7.0 with prolonged Prothrombin Time of 73.9 seconds while on chronic anticoagulation therapy of Warfarin. Also, identifying to hold Warfarin and repeat the PT/INR in 2 days (5/13/26).An APRN order dated 5/11/26 at 5:17 PM and written by APRN #1 identified bleeding precautions: monitor for signs and symptoms of bleeding to the following but not limited to bleeding gums, epistaxis, black, tarry stools, increased bruising, vomiting coffee ground or petechiae every shift for elevated INR 7.0.A facility-initiated Medication Discrepancy Report dated 5/11/26 identified Resident #8 received the wrong medication dose (no date or medication name identified). Additionally, the report noted the Warfarin order was not written correctly, was not written plainly and was not noted properly on the MAR. The report further identified there was an order for Warfarin 4 mg for three days a week (which included Saturdays) and also an order for Warfarin 4 mg for specific days including Saturdays (which resulted in Warfarin being listed in two separate administration sign off sections for Saturday 5/9/26). A progress note written by APRN #1 on 5/13/26 at 1:00 PM identified Resident #8 was seen for a follow-up evaluation and review of laboratory studies including the critical INR monitoring from 5/11/26. Also, identifying the repeat PT/INR had improvement from 7.0 to 5.7 which remains supratherapeutic. Further, identifying the Warfarin remained on hold and Resident #8 would have a repeat PT/INR on 5/15/26.Interview with Pharmacist #1 on 5/19/26 at 2:27 PM identified a critical INR would be anything over 3.5. Also, identifying an INR of 7.0 would warrant a physical evaluation, use of reversal agents depending on the resident's clinical condition and receiving a double dose of Warfarin would be a significant medication error.Interview on 5/21/26 at 10:40 AM with Licensed Practical Nurse (LPN) #6 identified Resident #8 had 2 different Warfarin sections listed on the MAR along with 2 different medication packets (bubble packages) dated 5/9/26. LPN #6 identified she administered Warfarin 4 mg twice because the section on the MAR read to administer 4 mg on Saturday 5/9/26 and the other section also included Saturday; LPN #6 identified she gave a total of 8 mg of Warfarin (instead of APRN ordered 4 mg).Interview on 5/21/26 at 12:13 PM with APRN #1 identified Resident #8 was only to receive 4 mg of Warfarin on 5/9/26 and Resident #8 was given a double(duplicate) dose. Also, identifying the Warfarin order should have contained a stop date along with scheduled lab work which one of the orders did not contain. Further, identifying RN #7 placed the order for Warfarin 4 mg by mouth Monday, Tuesday, Wednesday, Thursday and Saturday upon admission which lacked a stop date.Interview on 5/21/26 at 12:37 PM with RN #7 identified Resident #8 had 2 (duplicate) orders for Warfarin, one of the orders was not discontinued after the new order was placed on 5/8/26. Also, identifying the APRN should have discontinued the order for Warfarin 4 mg on Monday, Tuesday, Wednesday, Thursday and Saturday after starting the new order for 4 mg of Warfarin for 3 days, 5/8/26, 5/9/26, and 5/10/26 (Friday, Saturday and Sunday).Interview on 5/21/26 at 1:53 PM with the DNS and MD #2 identified the DNS was made aware on 5/11/26 of Resident #8 being administered the incorrect dosage of Warfarin 8 mg on 5/9/26 by RN #6 and she believed the resident had 2 orders for Warfarin. Also, identifying LPN #6 should have questioned the duplicate order before administering the medication. Interview on 5/22/26 at 9:54 AM with RN #6 identified the lab called the facility in the morning on 5/11/26 with a critical reading of the INR of 7.0 and she reviewed the Warfarin orders. Also, identifying LPN #6 administered Warfarin 8 mg on 5/9/26 and the order was placed without a stop date by RN #7. Further, identifying anyone who transcribed an order for Warfarin needed to put a stop date in.Interview on 5/22/26 at10:03 AM with the DNS identified the medication error incident on 5/9/26 was not reported to the state, and being given a double dosage of Warfarin was not a significant medication error (a discrepancy with the Pharmacist interview identifying that receiving a double dose of Warfarin was a significant medication error)Review of the policy dated 10/2025 directed, in part to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. A significant medication error means one which caused the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medication will be administered as follows: in accordance with accepted standard and principles which apply to professional providing services. Medication errors, once identified, will be evaluated to determine if they are considered significant or not by utilizing the following guidelines: Resident's condition requires control such as monitoring of lab values. Drug Category if the medication such a Warfarin requires to be titrated to a specific blood level such as a medication with a narrow therapeutic index. An incident or occurrence report was to be completed once an error was discovered.

Based on observations, facility policy, record review, and interviews for 1 of 4 sampled residents (Resident #13) reviewed for accidents, the facility failed to properly secure an over the counter medication brought in by the resident's family and for 1 of 5 residents (Resident #68) reviewed for medication administration, the facility failed to ensure a prepared medication was stored appropriately. The findings include: 1. Resident #13's diagnosis included diabetes, heart failure, and peripheral vascular disease.The Resident Care Plan (RCP) dated 5/4/26 identified continence of bowel and bladder fluctuates. Interventions included providing incontinent care management as needed, report areas of skin redness or breakdown, and update the MD/Advance Practice Registered Nurse (APRN) as needed.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was cognitively intact and was dependent for toileting, bathing, and dressing, Also, identified Resident#13 was independent for eating and required maximal assistance for transfers.An observation and resident interview on 5/18/26 at 10:40AM noted a package of 30 chewable tablets of Pepto Bismol (an over-the-counter medication used to provide relief from indigestion) 262 milligrams on Resident #13's over the bed table. Resident #13 identified a family member had brought the medication in from home on 5/16/26 and was told last night by facility staff that she/he cannot have the medication but did not take it away.A second observation and interview on 5/19/26 at 12:40 PM with Registered Nurse (RN) #4 identified the open box of Pepto Bismol on Resident #13's over the bed table. RN #4 identified Resident #13 did not have a physician order for Pepto Bismol nor did she/he have an order to self-administer medication. Also, identifying all staff were responsible for ensuring residents do not have over-the- counter medications at the bedside.Interview on 5/19/26 at 1:00 PM with RN #5 identified she did not notice the medication at the resident's bedside today and she was unaware of any medications being in Resident #13's procession.Interview on 5/19/26 at 1:05 PM with Resident #13 identified she/he only took 1 chewable tablet, and the facility had since removed the medication from the resident's room.Interview on 5/22/26 at 10:50 AM with RN #8 identified the policy was for no medications to be at the resident's bedside and the family should have been called once discovering the medication in the resident's room. Also, identifying as soon as a staff member sees medication at the bedside the medication should be removed and the physician should be called. Further, identifying the MD was not called nor was the medication at the bedside documented.A late entry nursing note dated 5/22/26 at 12:47 PM and written by RN #4 identified Resident #13 had a box of Pepto Bismol in his/her room and Resident #13 identified a family member had brought the over-counter-medication into the facility. Also, identifying the box was open, no tablets seemed to be missing and the provider was notified.Review of the Medication Storage policy dated 11/2025 directed, in part to ensure all medications will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. All drugs and biologicals will be stored in locked compartments (med carts, medication rooms) under proper temperature controls.Review of the Resident Self-Administration of Medication policy dated 10/2025 directed, in part, to support each resident's right to self-administer medications. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other residents' rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. The medications provided to the residents for bedside storage are kept in containers dispensed by the provider pharmacy. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family.2. On 5/20/26 at 8:44 AM, observation of a medication cart located on the District 1 unit between Resident #29's and Resident #68's room on 5/20/26 at 8:44 AM identified a plastic cup approximately 3/4 full containing a clear liquid and a spoon inside the cup on top of the medication cart. Registered Nurse (RN) #5 was observed talking with Resident #29 in his/her room with her back to the doorway and the medication cart not within her line of sight.Interview and observation of the medication cart with RN #5 on 5/20/26 at 8:45 AM identified she moved the medication cart further up the hallway, away from Resident #29's room and a little past Resident #68's room. RN #5 was then observed to answer a call light and return to Resident #29's room. The plastic cup approximately 3/4 full containing a clear liquid and a spoon inside the cup was observed to remain in the same location on top of the medication cart while RN #5 was inside Resident #29's room and the medication cart was not within her line of sight.Observation on 5/20/26 at 8:46 AM identified RN #5 exited Resident #29's room and then proceeded to answer the call light for the shared room across the hall from Resident #68. Upon entering the room RN #5 was heard greeting a resident who then asked for assistance to the bathroom. RN #5 closed the door to the room and proceeded to assist the resident. While RN #5 was inside the room assisting the resident, the plastic cup approximately 3/4 full containing a clear liquid and a spoon inside the cup was observed to remain in the same location on top of the medication cart.Observation on 5/20/26 at 8:50 AM identified RN #5 prepare and administer medications for Resident #68. While RN #5 was inside the room of Resident #68 who was sitting in a recliner near the window of the room, the plastic cup approximately 3/4 full containing a clear liquid and a spoon inside the cup remained in the same location on top of the medication cart out of the line of vision of RN #5.Observation and interview with RN #5 upon completion of medication administration to Resident #68 on 5/20/26 at 9:10 AM identified the cup on top of her medication cart contained Miralax (laxative) mixed in water that was meant for administration to a resident further up the hallway, but the resident had not been ready to take the medication after it was already prepared. RN #5 identified the medication should not have been left on top of the medication cart unattended, was unable to identify why she had left the cup of prepared medication on top of the medication cart when it wasn't within her sight the entire time and then discarded the prepared medication.Review of the Medication Storage policy directed, in part, all drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms). The policy further directed that during a medication pass, the medications must be under the direct observation of the nurse administering the medications or locked within the medication cart.

Based on observations, medical record review, and interviews for 1 of 9 residents (Resident #67) reviewed for nutrition, facility failed to ensure Resident #67 received the correct consistency diet and that the physician order and diet slip matched. The findings include: Resident #67 was admitted to the facility on [DATE] with diagnosis that included unspecified severe protein calorie malnutrition, pneumonitis due to inhalation of food and vomit, and acute respiratory failure.A physician order dated 5/15/26 directed Resident #67 was to receive a regular, puree texture diet with thin liquids.The admission nursing note dated 5/16/26 at 12:26 AM identified Resident #67 was to receive a regular diet, mechanical soft texture, and thin liquids (a discrepancy with the physician order of puree texture diet).A Hospice care plan dated 5/16/26 identified Resident #67 was to receive a mechanical soft diet.The Initial Nutrition assessment dated [DATE] and written by Dietitian #1 identified Resident #67 was on a regular, mechanical soft diet, thin liquids and had an allergy to Lactose and dairy.Interview and observation of Resident #67 with Licensed Practical Nurse (LPN) #1 on 5/18/26 at 12:48 PM identified Resident #67 was sitting up in bed with the side table in front of him/her. The meal ticket located on Resident #67's lunch tray indicated a mechanical soft diet and 1/2 cup of canned fruit. Observation of the meal tray at that time with LPN #1 noted that Resident #67 was served and provided cut up chunks of cantaloupe and honey dew melon in a cup. Resident #67 had attempted to eat one piece of honeydew melon and had the chewed-up piece on his/her food plate. LPN #1 removed the cup of chunked melon from Resident #67's tray table and told him/her she would get him/her another fruit.Interview with the Food Service Director on 5/18/26 at 12:51 PM indicated Resident #67 should have received canned diced pears as it was on the resident's meal ticket. Additionally, Resident #67 should have been served canned fruit (and not chunks of melon) if the resident was on a ground diet (mechanical soft), and the Dietary Aide (DA) plating the food was responsible to read the meal ticket, serve the correct fruit and it was an oversight by the DA.Interview with Dietary Aide (DA) #1 on 5/18/26 at 12:53 PM identified he had made an error, saw on the ticket and should have served the resident ground/diced pears, as it was his responsibility.Interview with Nurse Aide (NA) #2 on 5/18/26 at 12:55 PM identified she served Resident #67 the meal and although she did ensure the meal was chopped, she did not notice that the fruit was chunks of cantaloupe and honey dew melon, the resident should have received ground food/canned fruit per meal ticket, it was her responsibility to serve residents the correct diet, and indicated she made a mistake.Interview with Licensed Practical Nurse (LPN) #1 on 5/19/26 at 12:59 PM indicated that Resident #67's diet slip stated regular, mechanical soft, thin liquid diet. LPN #1 indicated the physician order in the electronic health record (EHR) identified a regular, puree texture, thin liquid diet despite the dietary slip indicating regular, mechanical soft, thin liquid diet. LPN #1 indicated the physician order in the EHR and the diet slip should match.Interview with the DNS on 5/19/26 at 1:05 PM noted the diet order in the EHR and the diet slip should match. She noted that cut up melon or cantaloupe should not have been served to a resident on either a pureed or mechanical soft diet. The DNS further identified it was the responsibility of the admitting nurse and the nurse who audits new admissions to verify the orders.Interview with the Nursing Supervisor on 5/20/26 at 1:30 PM identified that she had admitted Resident #67 to the facility on 5/15/26 and requested a puree diet be ordered by the Advanced Practice Registered Nurse because Resident #67's family stated the resident was on a puree diet at home and prior to being admitted to the hospital. Interview with the admission Nurse on 5/20/26 at 1:45 PM identified that she had entered Resident #67's diet consistency as mechanical soft in the dietary section (the section that dietary uses to print the meal tickets) of the EHR based on the type of diet Resident #67 received in the hospital per the Interagency Referral (W-10) that accompanied Resident #67.Interview with the Dietician on 5/19/26 at 1:15 PM identified the physician order in the EHR noted puree consistency and the diet slip which noted a mechanical soft diet were not consistent and should match. She also indicated that cut up pieces of melon should not have been served to the resident as part of a pureed or mechanical soft diet. The Dietician indicated he completed a nutritional assessment on 5/19/26 and failed to notice the discrepancy.Subsequent to surveyor inquiry on 5/19/26 the diet order was corrected to a regular, mechanical soft, thin liquid diet in the EHR.Review of the policy Therapeutic Diet Orders dated 10/2024 indicates at the reason for a therapeutic diet is to be documented in the medical record and all diet orders are to be communicated to the dietary department. Dietary and nursing are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #43) reviewed for food, the facility failed to ensure that the resident was served food in accordance with their dietary preferences. The findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes, necrotizing fasciitis, end stage renal disease requiring dialysis, and anxiety.A physician order dated 4/29/26 directed that Resident #43 be provided a renal diet with regular texture and thin liquids. The Resident Care Plan (RCP) dated 5/5/26 identified Resident #43's nutrition focus, with interventions that included providing a renal diet with regular texture and thin liquids, honoring food preferences as possible, and providing the diet as ordered.An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was cognitively intact, was independent with eating, and required substantial assistance with toileting.An interview with Resident #43 on 5/18/26 at 12:11 PM identified that he/she did not like tilapia but was often served tilapia and other food items he/she did not prefer, which caused distress. Resident #43 reported that he/she did not like the food and that, even after complaining, was still sometimes served items he/she did not like. Observation of the lunch meal service on 5/18/26 at 12:37 PM noted Resident #43 was served tilapia by Dietary Aide (DA) #6, the resident immediately sent the plate back and was then served chicken. Interview with DA #6 identified that Resident #43 was supposed to be served chicken as their meal ticket stated however was accidentally given tilapia instead. A nursing note dated 5/19/26 at 10:13 PM identified that Resident #43 was in the hallway distressed and raising his/her voice to express concerns about not liking the food at the facility. An interview with Resident #43 on 5/20/26 at 1:20 PM identified that the resident admitted to yelling in the hallway the previous night because he/she had received peppers and onions after he/she had previously told staff that he/she did not like peppers or onions but could not recall what staff member he/she told. Resident #43 further indicated that after complaining about the peppers and onions, he/she was given meatloaf but thought the meatloaf still tasted like peppers and onions, and was eventually served chicken soup per request. An interview with the Food Service Director on 5/21/26 at 3:20 PM identified that he often spoke with Resident #43 about his/her likes and dislikes related to food but was not aware that Resident #43 did not like peppers and onions. The Food Service Director stated that they did not serve peppers and onions on 5/19/26 but had served chicken teriyaki, which did contain peppers and onions. The Food Service Director was made aware that Resident #43 had been served tilapia on 5/18/26 for lunch and stated that Resident #43 should not have been served that, as the meal ticket identified that the resident did not like seafood and should have received chicken. The Food Service Director did not know why Resident #43 had been served tilapia, as they used a software system that removed residents' dislikes from the menu so the resident would not be served food they disliked. Review of the facility policy titled, Nutritional Management, dated 11/2025, identified that the dietary manager was to obtain the resident's food and beverage preferences upon admission, upon a significant change in condition, and periodically throughout the resident's stay.

Based on interviews, record review and facility policy for 1 of 9 sampled residents (Resident #66) reviewed for Advanced Directives, the facility failed to ensure a Do Not Resuscitate (DNR) form located in the paper clinical record was completed in its entirety. The findings include: Resident #66 was admitted to the facility in May 2026 with diagnoses that included Parkinson's disease, and dementia with hallucinations.A physician progress note dated 5/13/26 identified Resident #66 was admitted for short term rehab and identified Resident #66 as Do Not Resuscitate (DNR), Do Not Intubate (DNI).Review of the face sheet located in the electronic health record identified Resident #66 code status was Do Not Resuscitate (DNR), Do Not Intubate (DNI), Registered Nurse may pronounce.A Resident Care Plan dated 5/14/26 identified Resident #66 with a code status of DNR/DNIThe Advanced Directive form located in the paper chart noted the bottom/lower section of the form was not completed or signed related to placing a DNR bracelet on the resident.Observation at Resident #66's bedside with Registered Nurse (RN) #1 and the DNS on 5/18/26 at 2:55 PM noted Resident #66 was not wearing a DNR bracelet.Interview with Registered Nurse (RN) #1 on 5/19/26 at 2:39 PM identified he needed to find the correct answer and returned with the Director of Nursing (DNS).Interview with the DNS on 5/19/26 at 2:45 PM noted the DNS returned with a blank copy of a DNR form to show what it looked like, indicated that the form should have been completed in its entirety and a DNR bracelet should have placed on the resident's wrist.Subsequent to surveyor on 5/21/26 at 11:19 AM the lower section of the Advanced Directives form was completed on 05/19/26 and a DNR bracelet was applied to Resident #66's left wrist.Facility policy titled Documentation in Medical Record dated 10/16/2025 item 4b states documentation shall be accurate, relevant, and complete, containing sufficient details about the residents care and/or responses to care.

Based on review of clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure Coumadin therapy to adequately maintain INR levels as ordered, failed to monitor the INR levels timely, and failed to act on the INR results timely in accordance with physician orders. The failures resulted in a finding of Immediate Jeopardy. The finding includes: The Hospital Discharge summary dated [DATE] directed Coumadin (Warfarin) (anticoagulant, used to prevent blood clots), 4 milligrams (mg) daily and to maintain an International Normalized Ratio (INR, blood test to measure how long blood takes to clot, used to monitor the effectiveness Coumadin) between 2.5 and 3.5. Further, the Summary directed to monitor INR every other day and adjust Coumadin dose if needed.Record review identified Resident #1 was admitted to the facility on [DATE].Resident #1's diagnoses included cerebral infarct with hemiplegia/hemiparesis (paralysis/weakness) affecting the right dominant side, atrial fibrillation (rapid irregular heartbeat), and antiphospholipid syndrome (autoimmune disorder that produces antibodies which can lead to blood clots).The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen (9/15), indicated moderate cognitive impairment, and received an anticoagulant during the last seven (7) days. Review of the clinical records identified the following timeline for Coumadin and INR monitoring: 8/1/2025 INR test results were 2.6 (within the goal of 2.5 to 3.5). New orders were obtained to administer Coumadin 4.5 mg and the next INR on 8/3/2025. APRN #1 signed acknowledgement on the Coumadin Tracking Form. INR results were not located for 8/3/2025. Record review identified Coumadin 4 mg was administered from 8/1 through 8/5/2025. 8/5/2025 INR test results level were 1.7 (under the goal by 0.8). The Coumadin Tracking Form indicated conflicting information, that the current Coumadin dose was 4 mg, and new orders were obtained for 4.5 mg with the next INR due on 8/8/2025. APRN #1 signed acknowledgement of the tracking form. Record review identified Coumadin 4.5 mg was administered from 8/5 through 8/7/2025. 8/8/2025 INR test results were 1.7 results (goal was 2.5 to 3.5). New orders were obtained to administer Coumadin 5 mg daily. Review of the Coumadin Tracking Form identified conflicting information, that new orders were not obtained. 8/11/2025 INR 2.0 (under goal INR by 0.5). No change in orders; continued to receive Coumadin 5 mg daily. 8/14/2025 Coumadin 5 mg was discontinued. No Coumadin was administered on 8/14 and 8/15/2025. 8/16/2025 INR test results 1.6 (under the goal INR of 2.5 to 3.5), new orders to administer Coumadin 2.5 mg daily and obtain a new INR on 8/18/2025. No physician or APRN acknowledged the Coumadin Tracking Form results. 8/18/2025 Coumadin 2.5 mg order was discontinued. 8/18/2025 INR test results 1.2 (under the goal INR by 1.3). No new Coumadin orders were obtained. APRN #1 progress note acknowledged the INR results with recommendations to monitor. No Coumadin was administered on 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, and 8/24/2025. 8/25/2025 an in-house INR level was performed; the results were not documented. APRN note dated 8/25/2025 identified Resident #1 was seen for follow up of Coumadin and ordered Coumadin 5 mg on 8/25/2025 (discontinue date of 8/26/2025) and obtain an INR on 8/26/2025. APRN #1 signed acknowledgement on the Coumadin Tracking Form. 8/26/2025 INR results 1.1 (under the goal INR by 1.4). APRN #1 evaluated Resident #1 for an unrelated issue. No Coumadin orders were obtained, and no Coumadin was administered on 8/26/2025. Review of the Coumadin Tracking Form dated 8/26/2025 identified conflicting information that new orders were obtained for Coumadin 7 mg with the next INR ordered on 8/28/2025. APRN #1 signed acknowledgement of the tracking form. No Coumadin was administered on 8/26/2025. 8/27/2025 APRN #1 ordered Coumadin 7 mg daily for two (2) days, and was administered on 8/27/2025. 8/28/2025 INR results 1.2 (under the goal INR by 1.3). The second day of Coumadin 7 mg was administered and was then discontinued. The Coumadin Tracking Form failed to identify new orders were obtained for Coumadin and the next INR due date. No Coumadin was administered on 8/29, 8/30 and 8/31/2025. 9/1/2025 INR level was 1.2 (under the goal INR by 1.3). APRN #1 ordered Coumadin 10 mg daily, with next INR due on 9/4/2025, and APRN #1 signed acknowledgement of the Tracking Form. Coumadin 10 mg was administered on 9/1 and 9/2/2025, and Resident #1 was transferred to the hospital on 9/3/2025 for an unrelated event.Review identified the INR was not maintained within the ordered therapeutic level of 2.5 to 3.5, and Resident #1 did not receive any Coumadin doses on thirteen (13) days (8/14, 15, 18, 19, 20, 21, 22, 23, 24, 26, 29, 30 and 8/31/2025). Interview and clinical record review with APRN #2 on 9/18/2025 at 12:15 PM identified Resident #1 received Coumadin for atrial fibrillation and antiphospholipid syndrome, and the therapeutic goal INR range was between 2.5 to 3.5, to reduce the risk of a blood clot. APRN #2 reviewed the Coumadin orders and INR results from 8/8 through 9/3/2025 and stated the INR levels were not maintained within the therapeutic level, which put Resident #1 at a higher risk for blood clots. APRN #2 further stated that she would consider the errors in the INR management a significant medication error.Interview and clinical record review with MD #2 on 9/23/2025 at 12:30 PM identified Resident #1 was at an increased risk of blood clots due to the INR was not maintained within the therapeutic range, and the Coumadin should have been ordered to maintain the INR of 2.5 to 3.5. Interview failed to identify why the INR levels were not maintained at the ordered levels. Interview with the DON, Administrator, and RN #2 on 9/23/2025 at 3:30 PM identified the INR results were ordered to be maintained between 2.5 and 3.5. The DON, Administrator, and RN #2 were unable to provide documentation Resident #1's Coumadin regime was managed efficiently to maintain the ordered therapeutic INR goal. Interview failed to identify why the INR levels were not maintained at the ordered levels. Review of the undated facility Coumadin Protocol Policy directed in part, the facility will implement a log and will indicate the INR date and result, current and new Coumadin orders, next INR ordered, and date/time of physician/APRN notification. The Policy further directed, the INR therapeutic range must be determined.