Every finding on record at Mansfield Center for Nursing and Rehabilitation

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for controlled substances, the facility failed to ensure controlled substances were securely stored in separately locked, permanently affixed compartments accessible only to authorized personnel, and failed to maintain accountability and chain of custody for controlled substances during reconciliation and disposal processes, resulting in one (1) bottle of Lorazepam becoming unaccounted for. The findings include:Resident #1 was admitted to the facility with diagnoses that included cerebral atherosclerosis, dementia and a cardiac pacemaker.The Change in Condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of one (1), was receiving hospital care while a resident and was taking antidepressant and antianxiety medications.The Resident Care Plan (RCP) dated [DATE] identified Resident #1 used psychotropic medications related to anxiety and depression. Interventions included to administer medications as ordered, monitor for side effects and effectiveness and document adverse reactions.The Hospice Evaluation dated [DATE] identified Resident #1 was being admitted for hospice services, was severely demented, was disoriented with intermittent agitation, anxiety, increased fatigue and lethargy.Physician's orders dated [DATE] to [DATE] directed Lorazepam 0.25 ml orally every four (4) hours as needed for anxiety/restlessness.Physician's orders dated [DATE] to [DATE] directed Lorazepam 0.25 ml orally every four (4) hours as needed for anxiety.The Controlled Substance Disposition Record (CSDR) identified Lorazepam 0.25 ml (30 ml bottle) was received to the facility on [DATE] and returned to the office on [DATE].Physician's orders dated [DATE] to [DATE] directed Lorazepam 0.25 ml orally every six (6) hours for anxiety/restlessness.Physician's orders dated [DATE] to [DATE] directed Lorazepam 0.25 ml orally every six (6) hours for anxiety/restlessness and 0.25 ml orally every two (2) hours as needed for restlessness/agitation.The CSDR identified Lorazepam 0.25 ml (30 ml bottle) was received to the facility on [DATE] and the date returned to the office and dual sign off section was blank.The Nurse Pronouncement Evaluation note dated [DATE] identified on [DATE] at 7:57 PM, Resident #1 was without respirations, blood pressure, pulse and pupil stimuli response. Resident #1 was transferred to the funeral home.The Reportable Event form by the DNS dated [DATE] identified on [DATE] at 10:30 AM while conducting a random controlled substance audit, the DNS identified a Lorazepam discrepancy (Resident #1's Lorazepam). The yellow reconciliation sheet, which was intended to remain with the controlled substance, remained in the controlled substance book and did not match the white sheet. The Drug Enforcement Administration (DEA) was notified and directed the DNS notify the DEA if more controlled substances were identified missing. No further discrepancies were identified. Camera footage review of [DATE] identified the ADNS and LPN #1 removed Resident #1's controlled substances from the unit controlled substance box (two (2) bottles of Lorazepam and one (1) bottle of Morphine) and completed a dual sign off. The footage captured the controlled substances being removed from the unit by the ADNS. The ADNS placed the controlled substances into a plastic bag and stored them in a locked controlled substance box in the ADNS office. The ADNS later transferred the controlled substances to the locked controlled substance box in the DNS office. The ADNS refused to provide a statement to the facility. It was identified that there was a breakdown in the chain of custody during the transfer of controlled substances from the ADNS office to the DNS office and the bottle was unaccounted for. The ADNS was suspended pending investigation and terminated.Observation on [DATE] of the DNS office identified a free standing five (5) drawer file cabinet with two (2) locked drawers. Observation of the inside of the file cabinet failed to identify a secondary locked compartment for controlled substances. Observation of the Staff Development office identified a five (5) drawer file cabinet with two (1) locked drawer. Observation of the inside of the file cabinet failed to identify a secondary locked compartment for controlled substances. Neither of the file cabinets were permanently affixed.Interview with the ADNS on [DATE] at 11:55 AM identified on [DATE] LPN #1 asked her to remove Resident #1's controlled substances from the medication cart because he/she expired. She identified she removed three (3) bottles (two bottles of Lorazepam and one bottle of Morphine) and two (2) blister card packs. She was unable to recall how many white controlled substance reconciliation sheets were removed along with the controlled substances. She identified LPN #1 and herself signed off on the controlled substances and she placed the controlled substances in a bag. She identified the normal process was to bring the controlled substances to the DNS office to reconcile and secure. She thought the DNS was out of the building, so she locked the controlled substances in a file cabinet, which was used for employee files, in the Staff Development office. She identified that only she had the key for the file cabinet. She identified the DNS was out sick and did not return until [DATE] (seven days later) and she then reviewed the controlled substances with the DNS. She identified the controlled substances were removed from the bag and the DNS compared the controlled substances and the yellow (DNS copy) and white reconciliation sheets. The ADNS could not identify how many controlled substances or how many reconciliation sheets were present. She denied taking the controlled substances.Interview with the DNS on [DATE] at 12:00 PM identified on [DATE] she conducted a random controlled substance audit. She identified she had one (1) yellow reconciliation sheet for the Lorazepam 30 ml bottle but did not have the white sheet. She identified she should have had the white sheet indicating the controlled substances were reconciled since Resident #1 expired. Her investigation identified on [DATE] the ADNS and LPN #1 dual signed for Resident #1's controlled substance removal from the unit medication cart. Video footage identified a total of five (5) white reconciliation sheets and five (5) controlled substances. The ADNS placed the controlled substances into a plastic bag. The ADNS should have brought the white reconciliation sheets with the corresponding controlled substances directly to the DNS, however, the ADNS stored the controlled substances in a locked file cabinet in the Staff Development office. The ADNS then transferred the controlled substances to the DNS for reconciliation and had four (4) white reconciliation sheets and four (4) corresponding controlled substances. A that time, the DNS was unaware a white reconciliation sheet and a controlled substance were not reconciled. The DNS further identified she was in the building on [DATE] (the day the controlled substances were removed from the unit medication cart), [DATE], [DATE] and [DATE]. She identified the controlled substances should have been brought directly to her for reconciliation after removal from the medication cart.Follow-up interview with the ADNS on [DATE] at 1:10 PM identified the DNS was in the building on [DATE], [DATE] and [DATE] and the ADNS was present for morning report those days along with the DNS. The ADNS could not remember why she waited seven days to reconcile the controlled substances with the DNS and identified she should have given the controlled substances directly to the DNS.Review of the Controlled Substance Handling policy directed that all controlled drugs will be subject to special receipt, handling, storage, disposal and record keeping. All controlled drugs shall be stored in a two (2) door double locked cabinet with two (2) separate keys designed for that purpose, separate from all other drugs. Discontinued controlled drugs are returned to the nursing office after count is verified. The drugs are then stored in a double locked cabinet in the nursing office until permission to destroy has been obtained.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications that were not administered per physician orders were reported to the physician. The findings include:Resident #1 was admitted to the facility with diagnoses that included anxiety, dermatitis and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and was taking antianxiety medication. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #1 had hypothyroidism. Interventions included to give thyroid replacement therapy as ordered, monitor/document/report signs of hypothyroidism, and stress the importance of taking the medication everyday. The RCP further identified Resident #1 had psychotropic medication use related to antianxiety. Interventions included medication as ordered and monitor/document/report adverse reactions. A Psychiatric progress note dated 3/12/16 identified Resident #1 was seen for a mood/behavior assessment in the context of depression and anxiety. Resident #1 identified his/her anxiety was improved. The plan was to continue all psychotropic medications.Review of the March 2026 physician's orders directed Levothyroxine 112 mcg once a day for hypothyroidism, Xanax 1 mg once a day for anxiety and Dupixent 2 ml subcutaneous every 14 days for dermatitis.Review of the Medication Administration Record (MAR) for March 2026 identified the following:1. Resident #1 was administered Levothyroxine 112 mcg on 3/16/26. On 3/17/26 Levothyroxine was not documented as administered with no documentation as to why. On 3/18/26 Levothyroxine was not documented as administered due to not available and on order by LPN #5. Resident #1 was administered Levothyroxine on 3/19/26 (2 daily doses missed). Review of the Pharmacy order form identified Resident #1's Levothyroxine was ordered on 3/14/26 and received by the facility on 3/15/26 (total of thirty tablets).Review of the nursing notes failed to identify the physician was notified that Resident #1 did not receive the prescribed Levothyroxine on 3/17/26 and 3/18/26.2. Resident #1 was administered Dupixent 2 ml on 3/5/26. On 3/19/26 Dupixent was not documented as administered due to not available. Resident #1 was administered Dupixent on 3/21/26 (dose administered 2 days late). Review of the Pharmacy order form identified Resident #1's Dupixent was ordered on 3/20/26 and received in the facility on 3/21/26. Review of the Physician's orders identified the physician was notified Dupixent was not available and renewed the Dupixent order date to 3/20/26. 3. Resident #1 was administered Xanax 1 mg on 3/27/26. On 3/28/26 Xanax was not documented as administered due to not available. Resident #1 was administered Xanax on 3/29/26 (1 daily dose missed).Review of the Pharmacy order form identified Resident #1's Xanax was ordered on 3/28/26 and received in the facility on 3/28/26. Review of the nursing notes failed to identify if the physician was notified that Resident #1 did not receive his/her prescribed Xanax on 3/28/26.Review of APRN #1's progress note dated 3/27/26 identified Resident #1 was seen for follow up of respiratory infection and heart failure. The progress note did not identify she was notified of the medication omissions.Review of the nursing notes for March 2026 failed to identify the physician was notified of the medication omissions. Review of APRN #1's progress note dated 4/6/26 identified Resident #1 was seen for follow up of anxiety. Resident #1 continued to intermittently experience episodes of seizure like activity when she missed the morning dose of Xanax. Interview and medical record review with the DNS and Administrator on 4/21/26 at 11:30 AM identified Resident #1's Levothyroxine was ordered on 3/14/26 and delivered to the facility on 3/15/26, therefore there should have been medication available for administration on 3/17/26 and 3/18/26. It was identified that there had been an issue with agency staff documenting medication as not available. The DNS identified the charge nurse was responsible for ensuring medications were ordered prior to not being available for administration. She further identified if a medication was not available, staff were to check the emergency stock (Pyxis), call the pharmacy, document and notify the physician.Interview with APRN #1 on 4/21/26 at 11:59 AM identified if she were notified that Resident #1 did not receive medications, it would have been documented in her progress notes. She identified she should be notified of medication omissions. Interview with LPN #5 on 4/21/26 at 1:17 PM identified on 3/18/26 Levothyroxine was not administered due to not being available. She identified it was not available or administered the previous day either, but was not ordered. She identified she ordered the medication and it was administered on 3/19/26. She identified she did not notify the provider that it was not administered.Interview with LPN #4 on 4/21/25 at 1:42 PM identified on 3/17/26 Levothyroxine was not administered. She identified if a medication was not available she would have checked the system to verify it was ordered, and if not, would have ordered it. She identified she did not notify the provider that it was not administered.The facility policy titled Medication Administration and Documentation directed all medications are to be administered within a two hour time frame (1 hour before or after the medication order time).

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications were administered as ordered. The findings include:Resident #1 was admitted to the facility with diagnoses that included anxiety, dermatitis and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and was taking antianxiety medication. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #1 had hypothyroidism. Interventions included to give thyroid replacement therapy as ordered, monitor/document/report signs of hypothyroidism, and stress the importance of taking the medication everyday. The RCP further identified Resident #1 had psychotropic medication use related to antianxiety. Interventions included medication as ordered and monitor/document/report adverse reactions.A Psychiatric progress note dated 3/12/16 identified Resident #1 was seen for a mood/behavior assessment in the context of depression and anxiety. Resident #1 identified his/her anxiety was improved. The plan was to continue all psychotropic medications.Review of the March 2026 physician's orders directed Levothyroxine 112 mcg once a day for hypothyroidism, Xanax 1 mg once a day for anxiety and Dupixent 2 ml subcutaneous every 14 days for dermatitis.Review of the Medication Administration Record (MAR) for March 2026 identified the following:1. Resident #1 was administered Levothyroxine 112 mcg on 3/16/26. On 3/17/26 Levothyroxine was not documented as administered with no documentation as to why. On 3/18/26 Levothyroxine was not documented as administered due to not available and on order by LPN #5. Resident #1 was administered Levothyroxine on 3/19/26 (2 daily doses missed).Review of the Pharmacy order form identified Resident #1's Levothyroxine was ordered on 3/14/26 and received by the facility on 3/15/26 (total of thirty tablets).Review of the nursing notes failed to identify the physician was notified that Resident #1 did not receive the prescribed Levothyroxine on 3/17/26 and 3/18/26.2. Resident #1 was administered Dupixent 2 ml on 3/5/26. On 3/19/26 Dupixent was not documented as administered due to not available. Resident #1 was administered Dupixent on 3/21/26 (dose administered 2 days late).Review of the Pharmacy order form identified Resident #1's Dupixent was ordered on 3/20/26 and received in the facility on 3/21/26.Review of the Physician's orders identified the physician was notified Dupixent was not available and renewed the Dupixent order date to 3/20/26.3. Resident #1 was administered Xanax 1 mg on 3/27/26. On 3/28/26 Xanax was not documented as administered due to not available. Resident #1 was administered Xanax on 3/29/26 (1 daily dose missed).Review of the Pharmacy order form identified Resident #1's Xanax was ordered on 3/28/26 and received in the facility on 3/28/26.Review of the nursing notes failed to identify if the physician was notified that Resident #1 did not receive his/her prescribed Xanax on 3/28/26.Review of APRN #1's progress note dated 3/27/26 identified Resident #1 was seen for follow up of respiratory infection and heart failure. The progress note did not identify she was notified of the medication omissions.Review of the nursing notes for March 2026 failed to identify the physician was notified of the medication omissions. Review of APRN #1's progress note dated 4/6/26 identified Resident #1 was seen for follow up of anxiety. Resident #1 continued to intermittently experience episodes of seizure like activity when she missed the morning dose of Xanax. Interview and medical record review with the DNS and Administrator on 4/21/26 at 11:30 AM identified Resident #1's Levothyroxine was ordered on 3/14/26 and delivered to the facility on 3/15/26, therefore there should have been medication available for administration on 3/17/26 and 3/18/26. It was identified that there had been an issue with agency staff documenting medication as not available. The DNS identified the charge nurse was responsible for ensuring medications were ordered prior to not being available for administration. She further identified if a medication was not available, staff were to check the emergency stock (Pyxis), call the pharmacy, document and notify the physician.Interview with APRN #1 on 4/21/26 at 11:59 AM identified if she were notified that Resident #1 did not receive medications, it would have been documented in her progress notes. She identified she should be notified of medication omissions. Interview with LPN #5 on 4/21/26 at 1:17 PM identified on 3/18/26 Levothyroxine was not administered due to not being available. She identified it was not available or administered the previous day either, but was not ordered. She identified she ordered the medication and it was administered on 3/19/26. She identified she did not notify the provider that it was not administered.Interview with LPN #4 on 4/21/25 at 1:42 PM identified on 3/17/26 Levothyroxine was not administered. She identified if a medication was not available she would have checked the system to verify it was ordered, and if not, would have ordered it. She identified she did not notify the provider that it was not administered.The facility policy titled Medication Administration and Documentation directed all medications are to be administered within a two hour time frame (1 hour before or after the medication order time).

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications were administered as ordered. The findings include:Resident #1 was admitted to the facility with diagnoses that included anxiety, dermatitis and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and was taking antianxiety medication. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #1 had hypothyroidism. Interventions included to give thyroid replacement therapy as ordered, monitor/document/report signs of hypothyroidism, and stress the importance of taking the medication everyday. The RCP further identified Resident #1 had psychotropic medication use related to antianxiety. Interventions included medication as ordered and monitor/document/report adverse reactions.A Psychiatric progress note dated 3/12/16 identified Resident #1 was seen for a mood/behavior assessment in the context of depression and anxiety. Resident #1 identified his/her anxiety was improved. The plan was to continue all psychotropic medications.Review of the March 2026 physician's orders directed Levothyroxine 112 mcg once a day for hypothyroidism, Xanax 1 mg once a day for anxiety and Dupixent 2 ml subcutaneous every 14 days for dermatitis.Review of the Medication Administration Record (MAR) for March 2026 identified the following:1. Resident #1 was administered Levothyroxine 112 mcg on 3/16/26. On 3/17/26 Levothyroxine was not documented as administered with no documentation as to why. On 3/18/26 Levothyroxine was not documented as administered due to not available and on order by LPN #5. Resident #1 was administered Levothyroxine on 3/19/26 (2 daily doses missed).Review of the Pharmacy order form identified Resident #1's Levothyroxine was ordered on 3/14/26 and received by the facility on 3/15/26 (total of thirty tablets).Review of the nursing notes failed to identify the physician was notified that Resident #1 did not receive the prescribed Levothyroxine on 3/17/26 and 3/18/26.2. Resident #1 was administered Dupixent 2 ml on 3/5/26. On 3/19/26 Dupixent was not documented as administered due to not available. Resident #1 was administered Dupixent on 3/21/26 (dose administered 2 days late).Review of the Pharmacy order form identified Resident #1's Dupixent was ordered on 3/20/26 and received in the facility on 3/21/26.Review of the Physician's orders identified the physician was notified Dupixent was not available and renewed the Dupixent order date to 3/20/26.3. Resident #1 was administered Xanax 1 mg on 3/27/26. On 3/28/26 Xanax was not documented as administered due to not available. Resident #1 was administered Xanax on 3/29/26 (1 daily dose missed).Review of the Pharmacy order form identified Resident #1's Xanax was ordered on 3/28/26 and received in the facility on 3/28/26.Review of the nursing notes failed to identify if the physician was notified that Resident #1 did not receive his/her prescribed Xanax on 3/28/26.Review of APRN #1's progress note dated 3/27/26 identified Resident #1 was seen for follow up of respiratory infection and heart failure. The progress note did not identify she was notified of the medication omissions.Review of the nursing notes for March 2026 failed to identify the physician was notified of the medication omissions. Review of APRN #1's progress note dated 4/6/26 identified Resident #1 was seen for follow up of anxiety. Resident #1 continued to intermittently experience episodes of seizure like activity when she missed the morning dose of Xanax. Interview and medical record review with the DNS and Administrator on 4/21/26 at 11:30 AM identified Resident #1's Levothyroxine was ordered on 3/14/26 and delivered to the facility on 3/15/26, therefore there should have been medication available for administration on 3/17/26 and 3/18/26. It was identified that there had been an issue with agency staff documenting medication as not available. The DNS identified the charge nurse was responsible for ensuring medications were ordered prior to not being available for administration. She further identified if a medication was not available, staff were to check the emergency stock (Pyxis), call the pharmacy, document and notify the physician.Interview with APRN #1 on 4/21/26 at 11:59 AM identified if she were notified that Resident #1 did not receive medications, it would have been documented in her progress notes. She identified she should be notified of medication omissions. Interview with LPN #5 on 4/21/26 at 1:17 PM identified on 3/18/26 Levothyroxine was not administered due to not being available. She identified it was not available or administered the previous day either, but was not ordered. She identified she ordered the medication and it was administered on 3/19/26. She identified she did not notify the provider that it was not administered.Interview with LPN #4 on 4/21/25 at 1:42 PM identified on 3/17/26 Levothyroxine was not administered. She identified if a medication was not available she would have checked the system to verify it was ordered, and if not, would have ordered it. She identified she did not notify the provider that it was not administered.The facility policy titled Medication Administration and Documentation directed all medications are to be administered within a two hour time frame (1 hour before or after the medication order time).

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for transfers, the facility failed to ensure two (2) staff members were present during a mechanical lift transfer resulting in the resident tipping in the lift, hitting his/her head and sustaining an injury. The findings include:Resident #1's diagnoses included severe dementia with agitation, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) affecting the left non-dominant side, muscle weakness and need for assistance with personal care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicative of severely impaired cognition, required substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan dated 11/7/25 identified Resident #1 had a self-care deficit and was dependent on staff for all Activities of Daily Living (ADL). Interventions directed, in part, to transfer the resident via a hoyer (mechanical) lift with the assistance of two (2) staff. A physician's order dated 11/16/25 directed to administer the blood thinner medication that prevents blood clots from forming, Xarelto 20 milligram (mg) tablet by mouth once daily. The nurse's note dated 11/17/25 at 11:56 PM identified at approximately 9:00 PM the charge nurse, Licensed Practical Nurse (LPN) #1, entered Resident #1's room to administer medications when she observed a quarter sized raised area above Resident #1's right eye with discoloration as well as an area to the top outside area of the right ear with minor bleeding. The note identified the areas were not observed during the 5:00 PM medication pass and due to Resident #1's cognitive status, Resident #1 was unable to communicate what had occurred when questioned. The note indicated the nursing supervisor, Registered Nurse (RN) #1, was notified, came to assess Resident #1, the areas were noticeably larger than the previous observation, so the on-call provider was notified, an order was obtained to send Resident #1 to the Emergency Department (ED) for evaluation and Resident #1 was transferred at 11:15 PM. The hospital documentation dated 11/18/25 identified Resident #1 sustained a forehead hematoma (a closed wound of localized bleeding outside of blood vessels due to an injury/trauma), receives an anticoagulant medication, no altered mental status was noted, head and cervical spine imaging was conducted and the results were negative for acute injuries, and Resident #1 was transferred back to the facility on [DATE]. The nurse's note dated 11/18/25 at 9:50 PM identified Resident #1 returned to the facility around 4:56 PM. Interview with the Director of Nursing (DON) on 12/4/25 at 10:05 AM identified initially they were unable to identify where Resident #1's injuries came from so they were treating the incident as an injury of unknown origin. The DON explained during their investigation a nurse aide, Nurse Aide (NA) #1, reported on 11/19/25 Resident #1 was accidentally hit by the hoyer lift on 11/17/25. The DON indicated the facility was unable to identify that a second nurse aide was present during the hoyer transfer, as all staff interviewed denied assisting NA #1 with the transfer of Resident #1 on 11/17/25. Interview with NA #1 on 12/4/25 at 10:28 AM identified on 11/17/25 between 7:00 PM and 8:00 PM, she went into Resident #1's room to get him/her ready for bed and transfer him/her from the wheelchair to the bed and she could not remember who assisted her with the hoyer lift transfer. NA #1 indicated although Resident #1 was fidgety, visibly anxious, restless, and flailing his/her arms around while sitting in the wheelchair she continued to hook up the lift and begin to mechanically lift Resident #1 out of the wheelchair. NA #1 identified as Resident #1 was lifted out of the wheelchair, one (1) of the loops above Resident #1 came detached from the hook, Resident #1 tipped forward in the sling, hitting his/her head on the middle supporting bar (the mast) of the hoyer lift. NA #1 stated she was in a rush and forgot to ensure that all the loops were securely attached. NA #1 identified she lowered Resident #1 back down into the wheelchair, secured the loop and then lifted Resident #1 back up again and into bed. NA #1 identified looking back she should not have transferred Resident #1 when Resident #1 was already restless and flailing around and although there was no mark or visible injury on Resident #1's head and face she should have notified the nurse of the behaviors and reapproached Resident #1 when it was safe to transfer Resident #1 back to bed. NA #1 indicated she should have ensured the loops of the hoyer pad were securely attached to the hooks on the lift prior to lifting Resident #1. Interview with LPN #1 on 12/4/25 at 10:49 AM identified on 11/17/25 prior to discovering the injuries to Resident #1's face and ear, she had previously seen Resident #1 around 5:00 PM for medication administration and Resident #1 had no injuries at that time. LPN #1 indicated NA #1 did not report to her Resident #1 was displaying any behaviors and NA #1 did not ask her for assistance with transferring Resident #1. LPN #1 explained she spoke with the two (2) other nurse aides, NA #2 and #3 following the incident, who identified they did not help NA #1 transfer Resident #1 and there was no other staff on the unit at the time that could have assisted NA #1. LPN #1 identified NA #1 should have notified her immediately of the incident so Resident #1 could have been assessed as Resident #1 was on anticoagulant therapy. Interviews with NA #2 and #3 on 12/4/25 at 11:30 AM identified on 11/17/25 NA #1 did not ask them for assistance with transferring Resident #1 from the wheelchair to the bed and Resident #1 was a hoyer lift transfer which required two (2) staff for safety. NA #2 indicated prior to going on her evening break Resident #1 was up in the wheelchair and when she returned Resident #1 was already in bed. Both NA #2 and #3 stated if they had witnessed Resident #1 hitting his/her head on the hoyer lift, they would have reported the incident immediately to LPN #1 or RN #1. Interview with the DON on 12/4/25 at 12:36 PM identified NA #1 failed to follow the plan of care and the facility policy when NA #1 observed Resident #1 with behaviors that were a safety concern and NA #1 continued to transfer Resident #1 without a second staff member present for assistance and NA #1 failed to conduct safety checks to ensure Resident #1 was safely secured in the lift. The DON stated although accidents can happen, the 11/17/25 injury would have been less likely to have occurred if two (2) staff were present. The DON identified NA #1 was terminated following the investigation. Review of the Mechanical Lift policy dated 1/2023 directed, in part, that two (2) staff members must be involved in the transfer of a resident with the mechanical lift. Adjustments to safety and comfort should be made before moving the resident. Resident's arms should be inside the straps and check again to make sure that the sling is properly connected to the hooks of the swivel bar. The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance as of November 19, 2025.All residents currently requiring mechanical lift transfers had their transfer assessments reviewed to ensure accuracy and confirm two (2) person assist status. Any updates needed were completed immediately. Licensed nurses, nurse aides and agency staff will be re-educated on proper mechanical lift operation, required two (2) person assist for all mechanical lift transfers, ensuring bars, slings, and components are safely positioned, as well as immediate reporting of any incident, equipment contact, or potential injury, completing incident reports and notifying the nurse/provider promptly. Competency check-offs will be completed for all staff who perform mechanical lift transfers and staff who fail the competency check will not perform mechanical lift transfers until successful completion. Education will include demonstration and return demonstration, a written post-test, and staff who fail the post-test must be re-educated and retested.The DON or designee will conduct an initial visual audit of all mechanical lift transfers to ensure: two (2) person assist used, proper positioning of bars and slings, safe execution of transfer and immediate reporting of any incidents. Ongoing audits will continue weekly for eight (8) weeks, the DON or designee will audit a minimum of ten (10) random mechanical lift transfers on all shifts and then five (5) random audits will be performed monthly for three (3) months thereafter.Audit findings will be reviewed in Morning Meeting and QAPI. Any failure results in immediate re-education and additional audits. Completion date: November 25, 2025.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for transfers and exhibited behavioral symptoms, the facility failed to follow the resident's plan of care when the resident exhibited behaviors during a mechanical lift transfer which resulted with the resident sustaining an injury. The findings include: Resident #1's diagnoses included severe dementia with agitation, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) affecting the left non-dominant side, muscle weakness and need for assistance with personal care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicative of severely impaired cognition, required substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan dated 11/7/25 identified that Resident #1 exhibited behaviors of intermittent resistance to care, combativeness and restlessness. Interventions directed in moments of restlessness or agitation offer the resident television programs of his/her choice, provide redirection as able, offer recreational/diversional activities, speak and approach in a calm, explain care step by step before proceeding, if combative or resistive to care, stop the task and/or leave the room, notify the provider if the behavior increases or persists, administer medications as ordered and monitor and document for side effects and effectiveness. The nurse's note dated 11/17/25 at 11:56 PM identified at approximately 9:00 PM the charge nurse, Licensed Practical Nurse (LPN) #1, entered Resident #1's room to administer medications when she observed a quarter sized raised area above Resident #1's right eye with discoloration as well as an area to the top outside area of the right ear with minor bleeding. The note identified the areas were not observed during the 5:00 PM medication pass and due to Resident #1's cognitive status, Resident #1 was unable to communicate what had occurred when questioned. The note indicated the nursing supervisor, Registered Nurse (RN) #1, was notified, came to assess Resident #1, the areas were noticeably larger than the previous observation, so the on-call provider was notified, an order was obtained to send Resident #1 to the Emergency Department (ED) for evaluation and Resident #1 was transferred at 11:15 PM. The hospital documentation dated 11/18/25 identified Resident #1 sustained a forehead hematoma (a closed wound of localized bleeding outside of blood vessels due to an injury/trauma), receives an anticoagulant medication, no altered mental status was noted, head and cervical spine imaging was conducted and the results were negative for acute injuries, and Resident #1 was transferred back to the facility on [DATE]. The nurse's note dated 11/18/25 at 9:50 PM identified Resident #1 returned to the facility around 4:56 PM. Interview with the Director of Nursing (DON) on 12/4/25 at 10:05 AM identified initially they were unable to identify where Resident #1's injuries came from so they were treating the incident as an injury of unknown origin. The DON explained during their investigation a nurse aide, Nurse Aide (NA) #1, reported on 11/19/25 Resident #1 was accidentally hit by the hoyer lift on 11/17/25. Interview with NA #1 on 12/4/25 at 10:28 AM identified on 11/17/25 between 7:00 PM and 8:00 PM, she went into Resident #1's room to get him/her ready for bed and transfer him/her from the wheelchair to the bed. NA #1 indicated although Resident #1 was fidgety, visibly anxious, restless, and flailing his/her arms around while sitting in the wheelchair she continued to hook up the lift and begin to mechanically lift Resident #1 out of the wheelchair. NA #1 identified as Resident #1 was lifted out of the wheelchair, one (1) of the loops above Resident #1 came detached from the hook, Resident #1 tipped forward in the sling, hitting his/her head on the middle supporting bar (the mast) of the hoyer lift. NA #1 identified she lowered Resident #1 back down into the wheelchair, secured the loop and then lifted Resident #1 back up again and into bed. NA #1 identified looking back she should not have transferred Resident #1 when Resident #1 was already restless and flailing around and although there was no mark or visible injury on Resident #1's head and face she should have notified the nurse of the behaviors and reapproached Resident #1 when it was safe to transfer Resident #1 back to bed. Interviews with both LPN #1 and RN #1 on 12/4/25 identified that on 11/17/25 prior to discovering the injuries to the Resident #1's face and ear, NA #1 did not report to them Resident #1 was displaying any behaviors and NA #1 did not ask for assistance with the hoyer transfer which required two (2) staff be present for safety and if NA #1 had, they could have assisted in calming Resident #1 down, redirecting and assisting with the transfer and if needed providing as needed medication for agitation and anxiety. Interview with the DON on 12/4/25 at 12:36 PM identified NA #1 failed to follow the plan of care and the facility's policy when she observed Resident #1's behaviors and she continued to transfer Resident #1. The DON indicated although accidents can happen, the 11/17/25 injury would have been less likely to occur if the behaviors had been addressed. The DON identified that NA #1 was terminated following the investigation. Review of the Behavior Management Program policy dated 10/2022 directed, in part, that the Behavioral Management Program will provide necessary healthcare and services to residents with dementia, Alzheimer's, mental and/or substance use disorders in order to attain and maintain the highest practicable physical, mental and psychosocial well-being in accordance with their comprehensive assessment and plan of care. Interventions for changing behaviors include reapproaching, asking the resident vs. telling the resident, using a different staff member and when all else fails do not proceed with care unless safety dictates otherwise. Common interventions include redirection, diversion, re-approaching and acting on a resident's feelings.

Based on review of clinical records, review of facility documentation, review of facility policy, and interviews, for two of six sampled residents (Residents #13 and #47) reviewed for accidents, the facility failed to ensure the required staff assistance was utilized during the use of the mechanical lift, and for one of six sampled residents (Resident #33) the facility failed to ensure the required staff assistance was in place during a mechanical lift transfer and failed to ensure the resident was attached to the lift correctly, which resulted in an accident and injury. The findings include: 1. Resident #13 was admitted to the facility in January 2025 with diagnoses that included metabolic encephalopathy, dementia, and renal failure. The admission MDS assessment dated [DATE] identified Resident #13 had intact cognition, functional limitation in range of motion of the bilateral upper extremities, utilized a wheelchair for mobility, was dependent on staff for toileting hygiene, toileting and transfers from the bed to the wheelchair, and was always incontinent of bowel and bladder. The physician's order dated 3/17/25 directed Resident #13 be transferred with the assistance of two staff members. The care plan dated 1/31/25 identified Resident #13 had a deficit in Self Care Function with interventions that direct 2 staff for bathing/showering, 2 staff for dressing, and 2 staff for toileting. Observation on 4/9/25 at 9:40 AM identified NA#7 and NA#6 utilizing the mechanical lift to transfer Resident #13 from the bed (a seated position) to the bathroom, to be seated on the toilet. Both NA#6 and NA#7 completed the transfer. Resident #13 was seated on the toilet and disconnected from the lift. NA#7 directed NA#6 to call him when she was finished with care and left the room. NA#6 completed care and dressed the resident in the bathroom with the door closed. Observation on 4/9/25 at 9:55 AM identified NA#6 operating the mechanical lift independently without assistance to transfer Resident #13 out of the bathroom and into the wheelchair which was located in the room next to the bed. Interview on 4/9/25 at 10:04 AM with NA#6 identified she has worked at the facility since 9/2024 and identified she is a full-time employee. NA#6 further identified that she looks at the care card to identify what type of care the resident needs and indicated that all residents required two staff members when utilizing the sit to stand mechanical lift. Interview on 4/9/25 at 10:24 AM with RN#1 identified that all of the staff is aware that mechanical lift transfers require the assistance of two staff members. Interview on 4/9/25 at 12:39 PM with the ADNS identified that NA competencies are done annually and as needed and that all nurses' aides are aware that two staff members are required when utilizing the mechanical lift. Interview on 4/9/25 at 2:15 PM with the Administrator and RN#4 identified that the facility policy identifies that mechanical lift transfers require the assistance of 2 staff members. The policy on use of the mechanical lifts identified that two staff members must be involved in the transfer of a resident with the mechanical lift. 2. Resident #33's diagnoses included Alzheimer's disease, aphasia, muscle weakness and chronic kidney disease. The annual MDS assessment dated [DATE] identified Resident #33 had intact cognition (BIMS of 13), required maximal assistance with bed mobility, and upper body dressing, required total assistance with lower body dressing and toileting hygiene. The assessment further identified Resident #33 did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The care plan dated 8/21/24 identified Resident #33 had an activities of daily living (ADL) self-care performance deficit due to Alzheimer's/dementia. The care plan interventions directed: transfer status of [NAME] (which is a sit to stand mechanical lift) or Hoyer lift (which is a total mechanical lift) with assist of two (staff), back to bed with Hoyer at night, and toilet transfer status of Sara lift assist of two if able otherwise back to bed with the Hoyer lift. The care plan also identified Resident #33 had limited physical mobility related to Alzheimer's dementia and osteoarthritis. Review of the Nurse Aide care card instructions in effect for the month of October 2024 identified the need for two staff with the use of the Sara lift and the Hoyer lift. The physician's orders for the month of October 2024 directed Acetaminophen (Tylenol) tablet 650 milligrams (mg), administer two tablets orally in the morning for pain. Review of the medication administration record identified that on 10/8/24, the resident was administered Tylenol 650 mg at 10:07 AM for complaint of discomfort in addition to his/her regularly scheduled Tylenol. The nurse's note dated 10/8/24 at 10:46 AM written by RN #5 identified Resident #33 had pain in the left knee, tibia and fibula area with some increased warmth and swelling. The note further identified that APRN #1 was notified, and an x-ray was ordered. APRN 1's progress note/assessment via telehealth visit dated 10/8/24 identified Resident #33 reported left knee pain and the inability to help with Sara lift transfer as usual. The note further identified that per nursing the left knee had slight edema, a negative [NAME] sign, was warm to the touch without erythema and an x-ray of the knee was ordered. The x-ray results dated 10/8/24 identified the resident had a fracture of the left tibia and fibula. It further noted that the resident had mild degenerative changes and diffuse osseous demineralization. The nurse's note dated 10/9/24 at 12:30 AM identified the x-ray results were positive for fracture of the left tibia/fibula and that an order was obtained to send the resident to the hospital emergency department. Review of the hospital discharge paperwork dated 10/9/2024 identified bruising and tenderness in the left proximal tibia and an x-ray was performed in the emergency department which showed an oblique left proximal tibia fracture. The leg was splinted with instructions to follow up with orthopedic surgery. The facility's reportable event report and investigation dated 10/9/24 at 9:30 AM identified Resident #33 complained of having pain in the left leg, with increased warmth and swelling to the area. In addition, an order was received to have an x-ray performed which indicated a left lower leg fracture involving the proximal tibia and fibula with minimal callus and mild displacement, and an order was received to send the resident to the emergency department for further evaluation. The report further identified the hospital identified a fracture of the left tibia, placed a long leg splint, and noted the resident a status of non-weight bearing until follow-up with orthopedic surgery. The facility submitted the report to the state survey agency with the classification as an injury of unknown origin, the reportable event report did not acknowledge the incident with the Sara lift that occurred on 10/7/25. The reportable event report identified a written statement by NA #2 dated 10/9/24 that identified she washed and got Resident #33 prepared for the transfer to his/her wheelchair, she placed the straps around the resident's torso, and attached the straps to the lift, placed the resident's feet on the lift platform, The statement further identified that during the transfer from the bed to the wheelchair, she noticed one of the resident's feet fell off the lift, and the resident told her that his/her leg was weak. The documentation further noted NA #2 lowered the resident down and went to get the nurse. The reportable event report investigation further identified that on 10/15/24 The DNS (former) spoke to NA #2 who identified that Resident #33's left foot slipped off the lift platform, causing the resident to kneel on the left knee. Interview with NA #2 on 4/3/25 at 2:20 PM identified that in the morning she assisted Resident #33 to sit on the edge of the bed to transfer him/her using the Sara lift to the wheelchair. She further identified that while the resident was attached to the Sara lift via the straps and in the process of transferring the resident she noticed that the resident's left foot slipped off the Sara lift platform. She noted that she locked the Sara lift and went in the hallway to get the nurse (LPN #2). LPN #2 came and asked the resident if she had any pain and assisted NA #2 in transferring the resident to the bed with the Sara lift. She further noted that they used the Hoyer lift to transfer the resident from the bed to the wheelchair. NA #2 identified that she was aware that Resident #33 required assistance from two staff to use the Sara lift, however, she transferred the resident by herself because there was nobody available to assist with the transfer. LPN #2's written statement dated 10/9/24 identified on 10/7/24 around 9:30 AM she was called by NA #2 to Resident #33's room. She noted that on arrival to the room she observed Resident #33 hooked up on the Sara lift and noted the left leg was bent behind the resident and was not on the lift platform (where the feet should be placed). She further identified that immediately the resident was safely transferred back to bed with assistance of two and noted Resident #33 appeared calm, denied pain or discomfort, had no visible bruises, lacerations or swelling and was able to move extremities without pain. Interview with the Charge Nurse (LPN #2) on 4/3/25 at 2:35 PM identified she was the nurse on duty on 10/7/24 for the 7:00 AM to 3:PM shift. LPN #2 identified she was taking care of another resident in a nearby room when NA #2 called her to come to Resident #33's room. She identified that when she entered the room, Resident #33 had the lift pad around her upper torso with the straps attached to the lift, but the resident was hanging freely from the lift with the knees not touching the padding on the lift where the knees are supposed to touch to support the resident, her left leg was also bent back and was not on the lift platform. LPN #2 further noted that NA #2 was in the process of transferring the resident from the bed to the wheelchair. LPN #2 identified that the leg straps (supports) were not in place (as they should be) around the resident's lower legs. LPN #2 further identified that the resident required two staff to assistance with the transfer and that NA #2 had not requested assistance. Additionally, LPN #2 identified that she notified the nursing supervisor of the incident. Interview with LPN #2 on 4/8/25 at 1:44 PM identified that on 10/8/24 Resident #33 complained of pain in the left lower extremity. LPN #2 noted that the left lower extremity was noted with swelling and redness. She identified that she notified the nursing supervisor on duty and x-rays were ordered. LPN #2 further identified Resident #33 should absolutely have the lift leg support straps in place when using the Sara lift. The physical therapy (PT) note dated 10/9/24 at 2:44 PM by PT #2 identified Resident #33 was referred to PT due to significant decline in his/her transfer abilities that was noted on 10/8/24, and the resident was found to have a deformity of the left lower extremity with increased edema to the left lower extremity and was sent out for x-rays which revealed a fracture of the left fibula/tibia. Interview with MD #1 (Orthopedic Surgeon) on 4/9/25 at 9:26 AM identified Resident #33 was seen in the office due to a fracture and based on the x-ray results, and his examination of the resident, he identified Resident #33 had an acute fracture. He further noted that the accident with the Sara lift could definitely have caused the fracture, and because of the resident's dementia, the response to pain may be atypical and the resident may not remember what occurred. Interview with the Physical Therapist (PT #1) on 4/8/25 at 8:33 AM identified that if the resident transfer status fluctuates between the use of a Sara lift and Hoyer lift then the leg straps should be utilized. PT #1 further identified if the leg straps on the Sara lift are not used as indicated and secured it can cause injuries to the resident. PT #1 further identified that if the leg straps on the Sara lift are used and secured properly, a resident's leg would not slip off the platform/foot support. PT #1 added that when using the Sara lift with Resident #33, two staff members are needed to prevent the resident from getting hurt and for safety. PT #1 added that two staff members are needed in Sara lift transfers as one staff would aid in positioning residents who are unable to position themselves in a seated position to be connected to the Sara lift and guide the resident during the transfer while the other staff manages the Sara lift. Interview with the Staff Development Nurse (RN #2) on 4/7/25 at 10:56 AM identified that two staff members are required when using the mechanical lift as one staff operates the machine/lift and the other staff guides the resident, and legs support straps are to be utilized during the transfers as it is a part of the training. Interview with the current DNS and the Administrator on 4/9/25 at 1:39 PM identified that NA #2 was an agency staff and was provided with education following the incident. Review of the [NAME] 3000 (Sara lift) instructions for use manual identified that the foot support is used for positioning before and supporting the resident's feet during raising and transferring. In addition, the lower leg straps accessory is used to ensure that the lower parts of the resident's legs stay close to the knee support as they pass around the knee supports, then around the resident's lower calves. Also to ensure that the straps are firm but comfortable for the resident. In addition, the manual further identified in the warning section that the residents' feet shall always remain in full contact with the foot support and when raising, check to ensure that the resident's feet do not lift from the foot support. Review of the policy and procedure for Sara lift (partial weight bearing/standing lift) identified a mechanical lifting device is utilized to safely move a patient/resident from bed to chair or to the commode/bathroom and two staff are utilized to perform the procedure unless it is specified by physical therapy that the transfer can be completed with one person assisting. The policy and procedure for using the Sara lift in part, identify to place the resident's feet onto the foot support, adjust the resident's leg so that they are in full contact with the knee support of the lift, attach sling to the lift at the designated spots and attach the support strap to the resident's legs for safety. 3. Resident #47's diagnoses included dementia, type 2 diabetes, anemia and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The quarterly MDS assessment dated [DATE] identified Resident #47 had severe cognitive impairment, had no behaviors, was dependent for hygiene, lower body dressing, and bed mobility. The assessment further identified Resident #47 did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The care plan dated 2/9/25 identified Resident #47 had an ADL self-care performance deficit related to cognitive impairment /history of CVA with left sided hemiplegia. Care plan interventions included transfer with two staff assist using the Sara lift (sit to stand lift). The Nurse Aide care card instruction for April 2025 identified Resident #47 required the assistance of two 2 staff members when using the Sara lift. Observation on 4/2/25 at 12:19 PM identified Resident #47 seated in his/her adaptive wheelchair located on the right-side of the resident's bed. NA #5 wheeled the resident to the end of the bed facing the entrance door of the room. NA #5 positioned the Sara lift in front of the resident, then applied the sling to Resident #47 followed by attaching the sling to the Sara lift followed by applying the leg support straps and she ensured the resident placed his/hand on the support grips. NA #5 then utilized the control to raise the resident up, then transferred the resident to the bathroom and lowered the resident to the toilet seat. Interview with NA #5 on 4/2/25 at 1:06 PM identified the care card indicated Resident #47 required two staff members for transfers with the Sara lift. NA #5 further identified that she should have had a second staff member with her during the transfer, but she transferred the resident by herself. She added that when she first started orientation on the unit, she was trained and told by staff that Resident #47 only needed one person to use the Sara lift for transfers. Interview with the DNS on 4/2/25 at 3:10 PM identified that two staff members are required to use the Sara lift. The DNS reviewed Resident #47's care plan and indicated that he/she required two people when utilizing the Sara lift. Interview with the Staff Development Nurse (RN #2) on 4/7/25 at 10:56 AM identified that staff are trained to use two staff members when using the Sara lift. RN #2 further identified she provided education and/competency to the nurses' aides including NA #5 in December of 2024. She noted that during the transfer, one staff member operates the lift, and one staff member provides hands on guidance to the resident. Interview with the Physical Therapist (PT #1) on 4/8/25 at 8:25 AM identified Resident #47 requires two staff members for transfers using the Sara lift. PT #1 noted that when using the Sara lift for this resident that two staff members are needed to prevent the resident from getting hurt and for safety, as one staff member operates the Sara lift, and the other staff member guides the resident and ensures the resident is positioned properly. The Mechanical Lift policy identified two staff members must be involved in the transfer of a resident with the Mechanical Lift.

Based on observation, review of facility policy/procedures and interviews, the facility failed to ensure that food stored in the refrigerator and freezer was labeled with an expiration and open date, and the staff failed to wear beard restraints. The findings include: During the initial brief tour of the kitchen on 4/2/25 at 9:41 AM with the Dietary Manager identified cooler #2 contained eight waffles in an open package stored with no expiration date and no open date as well as a Starbucks mocha drink that was 2/3 full. Interview on 4/2/25 at 9:42 AM with the Dietary Manager identified the waffles should be labeled with the open date and the expiration date. Observation on 4/2/25 at 9:46 AM identified the walk-in refrigerator contained shredded cabbage that was opened with no open date label and no expiration date and Parmesan cheese wrapped with saran wrap with no open date and no expiration date. Interview on 4/2/25 at 9:48 AM with the Dietary Manager identified the cabbage was recently opened to make coleslaw and that it should have been labeled with the date opened and date it needed to be discarded. He further identified that the Parmesan cheese should be labeled with the same information. Observation on 4/2/25 at 9:50 AM identified the walk-in freezer contained a box of pizza slices that was ¾ full and open to air. It was not labeled with date of expiration or date it was opened. A beef patty package of twelve patties with no expiration date, there was an opened package of hot dogs with no expiration, and oatmeal raisin cookie dough in saran wrap with no expiration date. Interview on 4/2/25 at 9:55 AM with the Dietary Manager identified that food items should not be left open to air, and they should have an expiration date. Observation on 4/3/25 at 11:52 AM of the tray line identified the Dietary Manager was plating food, and did not have a beard restraint in place. Additionally, Dietary Aide #1 had a full beard and mustache and was also plating food without a beard restraint in place. Interview with the Dietary Manger on 4/7/25 at 11:30 AM indicated that there should have been facial coverings worn by himself and the Dietary Aide #1 on 4/3/25 when plating food for the lunch meal. The Storage of Food and Supplies policy identified that food from non-approved sources should not be stored in the kitchen, ie. staff food. Food products that are open and not completely used and/or food transferred from their original package to another storage container; or prepared at the facility and stored should be labeled with the contents and the use by date. The Personal Hygiene for Food Handlers identified hair restraints such as hats, hair coverings or nets, and beard restraints are worn at all times when in the kitchen. Hair is to be fully contained inside the covering. Facial hair should be neatly trimmed and covered by a mask or beard guard.

Based on observation, review of the clinical record, review of facility policy/procedures and interviews for 1 of 3 residents (Resident #57) reviewed for pressure injuries, the facility failed to ensure facility staff used appropriate PPE when providing care to a resident on Enhanced Barrier Precautions (EBP) and failed to ensure infection control surveillance data collection reports were complete and compiled on a monthly basis. The findings include: 1. Review of the infection control program for the period of April 2023 to January 2024 with the Regional Director of Clinical Operations (RN #7) and the Infection Preventionist (IP) Nurse (RN #4) on 4/7/25 at 12:57 PM failed to identify that monthly surveillance infection reports and analysis of infection trends were completed from April of 2023 through January 2024 within the monthly Antibiotic Report as well as the quarterly reports provided for April 2023, July 2023, and October 2023. The Antibiotic Report was provided by RN #7, which indicated that this was what the facility was apparently using during those periods for their infection surveillance, however the reports were incomplete. Review of the monthly Antibiotic Reports (RN #7 indicate was used for surveillance) provided by the facility identified incomplete information in various columns such as: the Healthcare Associated infection (H) or Community Acquired Infection (C), met or did not meet (McGeer's), and new prophylactic for the period of April 2023 through January 2024. Interview with RN #4 on 4/7/25 at 12:57 PM identified that she was not working at the facility in 2023 and had only started working at the facility in February 2024. She identified that she currently completes her infection surveillance on a monthly basis, and she analyses the data to identify any trends or clusters and provides education to staff as needed based on the data. Interview with RN #7 on 4/8/25 at 3:15 PM identified the infection control surveillance reports were incomplete. She further identified that the facility had an IP at the time, and it was his/her responsibility to complete the surveillance reports and to analyze infection rates with the facility. Review of the Infection Control Program policy directed to maintain a separate record of infection for each resident who has an infection, analyze clusters of infection, changes in prevalent organisms, and any increase in the rate of infection in a timely manner. The policy further identifies the infection control program will be monitored quarterly or as indicated at the quality improvement meeting. 2. Resident #57 was admitted to the facility October 2023. Diagnoses include neurocognitive disorder with Lewy bodies dementia, trigeminal neuralgia, and pressure ulcer of sacral region Stage 3. The annual MDS assessment dated [DATE] identified Resident #57 had severely impaired cognition, was dependent for oral care, toileting, and personal hygiene, and dependent for transfers and mobility in a manual wheelchair. The MDS indicated the resident was at risk for developing pressure ulcers and had one unhealed Stage 4 pressure ulcer. The care plan dated 3/11/25 identified Resident #57 required Enhanced Barrier Precautions due to chronic wound pressure ulcer with interventions that included don gown and gloves when performing high contact care activities including dressing, bathing, transferring, changing linens, assisting with toileting or changing brief, care or use of indwelling medical device and providing wound care, evaluate EBP upon resolution of wound or discontinuation of indwelling medical device that places them at risk. The physician's orders dated 4/1/2025 directed to cleanse wound with a quarter (¼) strength Dakins, pat dry, pack with gauze loosely and apply dry clean dressing daily and as needed. The order was updated on 4/9/25 to cleanse wound with wound cleanser, pat dry and pack wound with ½ Dakins and apply 4x4 gauze daily and as needed. Additional orders included to monitor sacral wound for signs and symptoms of infection and ensure dressing is in place every shift and limit in chair time to 1 hour daily. Observation on 4/7/25 at 10:38 AM identified Resident #57 in bed positioned on the right side and appeared to be asleep. The name plaque on the outside of the room had a round blue sticker next to the resident's name. Interview on 4/7/25 at 11:49 AM with LPN#6 identified that rooms with a blue sticker next to a resident's name indicated that resident was on enhanced barrier precautions and noted that all residents on contact precautions have signage on the door frame indicating what type of precautions are required. Interview on 4/7/25 at 12:00 PM with NA#5 identified that the blue dots on the name plaques next to resident names are for the long-term care for those residents who have some issue and require PPE with care. The nursing progress note dated 4/8/25 at 3:34 PM identified the nurse was asked to view the resident's wound by the NA. The LPN indicated that above the present wound, there was an open area that was leaking large amounts of brown fluid. Observation on 4/9/25 at 10:35 of NA#7 at the bedside of Resident #57 finishing incontinent care and situating resident in bed identified NA#7 did not have any PPE in place and verbalized providing a brief change for the resident. Observation on 4/9/25 at 10:38 AM of LPN #7 identified LPN #7 entered Resident #57's room to provide wound care. LPN #7 was assisted by NA #7 who stayed in the room to help with resident positioning. LPN#7 placed a towel over the bedside table and placed the bottle of Dakin's solution, sterile gauze unopened, an opened multipack of non-sterile cotton tipped applicators on the towel. NA #7 had gloves in place, but no gown or mask, and held the resident up on the resident's left side so LPN #7 could access the sacral wound dressing. LPN #7, wearing only gloves, took down the dressing and as she removed the wound covering, an area close to the border of the dressing, up the back from the packing area, that oozed brownish, grey colored drainage as LPN#7 removed the dressing. The wound dressing was saturated in the brownish/grey colored drainage. LPN #7 replaced the dressing and explained that she was going to go notify the supervisor. Continued observation on 4/9/25 at 10:45 AM identified LPN#7 returned to Resident #57's room and put on new gloves, but no other PPE. LPN #7 identified that the supervisor was aware of the drainage and began to take the dressing off once again. At this time the Infection Prevention nurse (RN #4) entered the room. RN#4 was actively putting on a precautions gown and directed NA #7 and LPN #7 to put on PPE and indicated that the resident was on EBP. RN #4 took over wound care and sent LPN #7 out of the room to obtain additional sterile items for wound care. Interview on 4/9/25 at 11:06 AM with LPN #7 identified that Resident #57 had a blue dot on the name plaque and that the blue dot indicated the resident was on EBP and required PPE with care. LPN#7 identified that she should have had PPE on when providing wound care and could not identify why she did not put it on. Interview on 4/9/25 at 1:00 PM with RN #4 identified that all staff are educated on EBP, contact precautions, and use of PPE. RN#4 indicated that NA#7 was a long-term employee and had been educated on use of PPE and EBP. RN#7 also worked at the facility frequently and was aware of EBP and use of PPE. Interview on 4/9/25 at 1:57 PM with the ADNS who identified that all staff are educated on EBP and PPE use. Agency staff are oriented but have no formal education by the facility. The ADNS indicated that RN #4 does the staff competencies, and the expectation is that the rooms with the blue dots indicated residents who require EBP. Facility policy regarding Clinical Services: precautions to prevent infection identified that Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities that include chronic wounds, pressure ulcers.

Based on clinical record review, review of facility documentation, facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to ensure that the facility's antibiotic surveillance tracking report of antibiotic use, patterns and resistant trends was completed and reviewed at the quarterly medical staff meetings and for one of five sampled residents (Resident #13) reviewed for unnecessary medications, the facility failed to ensure that the antibiotic stewardship was followed for a resident receiving antibiotics. The findings include: 1. Review of the antibiotic stewardship program for the period of April 2023 to January 2024 with the Regional Director of Clinical Operations (RN #7) and the Infection Preventionist (IP) Nurse (RN #4) on 4/7/25 at 12:57 PM failed to identify any completed documentation presented quarterly at the Medical Staff meeting that included rates of antibiotic usage, patterns and resistance trends, and infections which meet McGeer for the use of Antibiotic therapy for their antibiotic stewardship program for the period of April 2023 to January 2024. Review of the monthly Antibiotic Reports provided by the facility identified incomplete information in various columns such as: the Healthcare Associated infection (H) or Community Acquired Infection (C), met or did not meet (McGeer's), and new prophylactic for the period of April 2023 through January 2024. Review of the quarterly reports for April 2023, July 2023 and October 2023 failed to identify any information regarding the facility's antibiotic stewardship program. Interview with RN #4 on 4/7/25 at 12:57 PM identified she was not working as the IP at the time and had only started working as the IP in February of 2024. Interview with RN #7 on 4/8/25 at 3:15 PM identified the monthly Antibiotic Reports were incomplete as she had some information from pharmacy reports for August 2023 through December 2023. She further identified that the facility had an IP at the time, and it was their responsibility to complete the monthly Antibiotic Report and quarterly reports for medical staff meetings. Review of the Antibiotic Stewardship policy identifies data and stewardship initiatives will be reviewed on a quarterly basis. 2. Resident #13's diagnoses included metabolic encephalopathy, chronic kidney disease stage 4, urge incontinence, and altered mental status. The admission MDS assessment dated [DATE] identified the resident had intact cognition, was dependent with toileting, was always incontinent of bowel and bladder, required partial/moderate assistance with personal hygiene, and substantial/maximal assistance to dependent for all transfers and mobility. The current care plan in place identified the resident had a urinary tract infection (UTI) and was receiving antibiotics in addition to being on prophylactic antibiotic therapy for UTI prevention with interventions to administer antibiotic medications as ordered by the physician, assist resident with hand hygiene, monitor/document/report adverse reactions to antibiotic therapy and signs and symptoms of secondary infection related to antibiotic therapy. Physician's orders dated 3/28/25 directed to administer Ciprofloxacin (antibiotic) oral tablet 250 mg by mouth two times a day for UTI for 7 days (ending 4/5/25). Additionally, physician's orders directed to administer Methenamine Hippurate (antibiotic used to prevent and control UTI's) oral tablet 1 GM by mouth two times a day for UTI and was on hold from 3/31/25 to 4/5/25. The APRN's progress note dated 3/21/25 identified Resident #13 had a recent hospitalization for acute metabolic encephalopathy, likely secondary to infection (UTI) and received three antibiotics as treatment. The note further identified that Resident #13 continued to have altered mental status and dementia, received a neurology consult and was started on Trazodone (antidepressant) 25 mg every 6 hours for agitation and anxiety with plan to evaluate urine culture and sensitivity. The APRN's progress note dated 3/24/25 identified the Resident #13 had a urinalysis that showed greater than 100,000 bacteria which suggested contamination or colonization; however, the urine culture was negative, and the resident denied bladder pain, fever, chills, or sweats, and will recollect urine ensuring straight catheterization with a clean sample to obtain more accurate results. The lab results report dated 3/23/25 identified the urine culture collected via straight catheter showed the growth of multiple gram positive and negative organisms with three or more species recovered, none predominant and suggested either specimen contamination or patient colonization. The APRN's progress note dated 3/28/25 identified the resident was seen for follow-up evaluation of urinary tract infection. Assessment and plan identified the urinalysis was discussed with medical director and revealed greater than 100,000 bacteria with no species predominant, suggesting colonization versus contamination. The note indicated the resident was symptomatic with mild altered mental status, bladder distention, and costovertebral angle tenderness (CVA). Although likely colonization, will treat to decrease bacterial load with Cipro 250 mg twice daily for 7 days. Additionally, the resident reported feeling constipated despite having a bowel movement and Senna was increased to 2 tablets twice daily. The lab results report dated 3/28/25 identified the urine culture, collected via straight catheter showed the growth of multiple gram positive and negative organism with three or more species recovered, none predominant and indicated the culture results suggest either specimen contamination or patient colonization. The March 2025 MAR (medication administration record) identified Resident #13 was administered Methenamine Hippurate oral tablet 1 GM by mouth two times a day for UTI every day of the month with the exception of the 2nd dose on March 31st. The MAR for April 2025 identified Resident #13 was administered Cipro oral tablet 250 mg by mouth two times daily for UTI on April 1st, 2nd, 3rd, and 4th. It further identified Resident #13 was administered Methenamine Hippurate Oral Tablet 1 GM by mouth two times a day for UTI was held from 4/1 through 4/5/25 and was administered as ordered beginning 4/5/25 through 4/10/25. Interview on 4/7/25 at 11:58 AM with LPN#6 identified Resident #13 had a decline in cognitive ability and indicated that the antibiotic was completed the previous day, and the altered mental status persisted. The March 2025 MAR identified the resident was administered Cipro oral tablet 250 mg by mouth two times a day for UTI as ordered on March 29th, 30th, and 31st. Interview on 4/8/25 at 2:42 PM with RN#4 identified when she receives culture results, she fills out and reviews the McGeer's criteria and if the resident does not meet criteria, she notifies the APRN. RN#4 indicated she noticed an increase in prescribing antibiotics for UTIs that are continued even though the resident doesn't meet the criteria. RN #4 indicated the McGeer's criteria is in place to prevent multi drug resistant organisms from developing but indicated the process was not being followed by the providers. Interview on 4/9/25 at 11:09 AM with APRN#1 identified that she was aware there was a set of criteria used to determine continuation of an antibiotic and acknowledged the McGeer's criteria from her training and indicated that she doesn't use it 100% because it doesn't take into account altered mental status changes. APRN#1 identified that if there is no growth found in a culture she would discontinue the antibiotic. APRN#1 indicated that she starts the antibiotic while waiting for culture and sensitivity results. In reference to Resident #13, APRN identified that the family was difficult and wanted the resident to have antibiotics because the family refused to acknowledge the progression of the dementia, so APRN#1 indicated she gave the resident the antibiotic because of excessive colonization, although there was not one bacteria identified as predominant. APRN#1 indicated the prophylactic antibiotic should be discontinued while the resident was receiving another antibiotic. APRN#1 identified she was aware the facility had recommendations for prescribing antibiotics but has not addressed anyone regarding her thoughts or practice preferences. Interview on 4/10/25 at 12:05 PM with RN#4 (IP) identified that when she reviews the McGeer's criteria she speaks with the APRN and identified why the resident did not meet criteria to continue antibiotics. RN#4 indicated the APRN identified that the resident had altered mental status and continued the antibiotic despite not meeting criteria. Interview on 4/11/25 at 11:50 AM with the Medical Director identified that he would never agree to keeping a resident on an antibiotic if the culture growth did not come back with a sensitivity. The medical director indicated there were other ways to treat UTI using probiotics or prophylactics and indicated that overuse of a broad-spectrum antibiotic would make a resident more susceptible to additional infection. Review of the Antibiotic Stewardship Policy identified the physician, nursing, and pharmacy leads will be responsible for promoting and overseeing antibiotic stewardship activities and to promote safe and effective use of antibiotics that will adequately treat the patient for susceptible bacterial infections and minimize the emergence of bacterial resistance in the facility and community by monitoring and changing broad spectrum antibiotics to appropriate narrowed therapy. Review of the Clinical services 72-hour UTI tracking and pathway identified if empiric antibiotics are prescribed, collect urine specimens for culture and sensitivity before antibiotic therapy is initiated, review urine culture results and indicated that more than two different organisms indicate contamination. The facility failed to ensure that Resident #57 was not administered Ciprofloxacin when there was no laboratory indication for the medication and the signs and symptoms did not meet McGeers criteria.

Based on review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a complete system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation. The findings include: Review of the bi-monthly narcotic drug audit form dated [DATE] identified the facility was auditing to ensure that medication carts were locked, all controlled drugs have a proof of use sheet, the narcotic count was correct, all change of shift narcotic count sheets were signed, all narcotic medications were labeled correctly, and no expired narcotic medication was stored in the medication cart. Review of the narcotic reconciliation with the ADNS on [DATE] at 1:40 PM identified that there were four binders in the ADNS office that contained the yellow Controlled Substance Disposition Records (CSDR), the CSDR sheets were organized by nursing unit and arranged in alphabetical order. Additionally, the oldest yellow CSDR sheet was dated [DATE] and had not yet been reconciled with the white CSDR nor were the medications identified as having been destructed. The book did not contain any audit sheets. Interview with the ADNS on [DATE] at 2:00 PM identified that she was responsible for conducting the controlled drug medication auditing and she also identified that she completed her audit twice a month. She identified that her narcotic audit consisted of ensuring the narcotic medications were locked when not in use, the narcotic count was correct, the shift change count were sign by the nurse, and no expired narcotic medication kept in the cart; however, she identified that she was waiting to receive the white CSDR sheet from the nurse and she will then reconcile to ensure that white CSDR match to the yellow CSDR to ensure the count were accurate. She further identified that she was not auditing the yellow CSDR in her binder until the nurse gave her the white CSDR from the nursing units. The facility Controlled Substance Handling policy identified that all controlled drugs will be subject to special receipt, handling, storage, disposal, and record keeping. The facility failed to ensure there was an adequate medication reconciliation practice to ensure medications are not diverted.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of six sampled residents (Resident #33) reviewed for accidents and required a mechanical lift for transfers, the facility failed to ensure the resident was assessed by a registered nurse following an incident that occurred during a transfer with the mechanical lift. The findings include: Resident #33's diagnoses included Alzheimer's disease, aphasia, muscle weakness and chronic kidney disease. The annual MDS assessment dated [DATE] identified Resident #33 had intact cognition, did not display behaviors, required maximal assistance with bed mobility, upper body dressing and was dependent on care for lower body dressing and toileting hygiene. The assessment further identified the resident did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The care plan dated 8/21/24 identified Resident #33 had an activities of daily living (ADL) self-care performance deficit due to Alzheimer's/dementia. The care plan interventions directed a transfer status of [NAME] (which is a sit to stand mechanical lift) or Hoyer lift (which is a mechanical lift) if unable with assist of two (staff), back to bed with Hoyer at night, and toilet transfer status of Sara lift assist of two if able otherwise back to bed with the Hoyer lift. The care plan also identified Resident #33 had limited physical mobility related to Alzheimer's dementia and osteoarthritis with interventions that included physical therapy and/occupational therapy referrals as ordered and as needed. The Nurse Aide care card for the month of October 2024 identified Resident #33 required the assistance of two staff with the use of the Sara lift and for the Hoyer lift. The acute care hospital's Discharge summary dated [DATE] identified Resident #33 had bruising and tenderness to the left proximal tibia and an x-ray indicated an oblique left proximal tibia fracture. It further noted the resident was placed in a long leg splint and to follow-up with orthopedic surgery. The facility's reportable event report and investigation dated 10/9/24 at 9:30 AM identified Resident #33 complained of having pain in the left leg with increased warmth and swelling to the area. In addition, an order was received to have an x-ray performed which indicated a left lower leg fracture involving the proximal tibia and fibula with minimal callus and mild displacement. An order was given to send the resident to the emergency department for further evaluation. The report identified that at the hospital the resident was noted to have a fracture of the left tibia, and placed in a long leg splint, non-weight bearing until follow-up with orthopedic surgery. The facility noted the injury was of unknown origin. NA #2's written statement dated 10/9/24 identified she washed and got Resident #33 ready to be transferred to the wheelchair, the resident was strapped to the lift, the resident's feet were placed on the lift platform, everything was on correctly and ready to lift. The statement further identified she noticed the resident's left foot fell off the lift platform, and the resident told her that his/her leg got weak. The statement further noted NA #2 identified that she lowered the resident down and went to get the nurse. In a second statement from NA #2 obtained via telephone on 10/15/24 by the former DNS (RN #3) identified Resident #33's left foot slipped off the Sara lift and the resident kneeled on the left knee slightly and the Charge Nurse (LPN #2) assisted the nurse aide in transferring the resident back to bed. Interview with NA #2 on 4/3/25 at 2:20 PM identified she worked the 7:00 AM to 3:00 PM shift on 10/7/24. NA #2 identified that in the morning she assisted Resident #33 to sit on the edge of the bed to transfer him/her using the Sara lift to the wheelchair. She further identified that while the resident was connected to the Sara lift and in the process of the transfer, she noticed that the resident's left foot had slipped off the foot support/platform. She then locked the machine (Sara lift) and went in the hallway to get the nurse (LPN #2). The nurse came and asked the resident if she had any pain and assisted her in transferring the resident to the bed with the Sara lift then they used the Hoyer lift to transfer the resident from the bed to the wheelchair. NA #2 identified that she was aware that Resident #33 required assistance from two staff to use the Sara lift, however, she transferred the resident by herself as there was nobody available to assist with the transfer. LPN #2's written statement dated 10/9/24 identified on 10/7/24 around 9:30 AM she was called by NA #2 to Resident #33's room. On arrival LPN #2 observed Resident #33 hooked up on the Sara lift with his/her leg bent behind the resident, and the resident was unable to complete the transfer. She further identified that immediately the resident was safely transferred back to bed with the assistance of two. The statement further identified that Resident #33 appeared calm, denied pain or discomfort, no visible bruises, lacerations or swelling was noted, and the resident was able to move extremities without pain. Review of Resident #33's clinical record failed to identify a registered nurse assessment or nurses note following an incident which occurred on 10/7/24 during a transfer using the Sara lift. Interview with the Nursing Supervisor (RN #1) on 4/8/25 at 11:48 AM identified she had not done an assessment, nor had she written a nurse's note based on what the charge nurse had told her that had occurred. She indicated that LPN #2 indicated that Resident #33 was having difficulty transferring using the Sara lift and that she had to assist with the transfer. She further identified that LPN #2 indicated Resident #33 was unable to bear weight on his/her leg, so she recommended that the resident be screened for a physical therapy evaluation as the resident struggled with the transfer which was not uncommon for this population. RN #1 identified when she reported to work on 10/9/24 and found out the resident had a fracture, she then went to LPN #2 to find out what happened when LPN #2 expressed that Resident #33's knee almost touched the platform/foot support during the transfer and had to assist with getting the resident back in to the bed/chair, she could not recall if it was the bed/chair. RN #1 identified that had she been made aware of all the circumstances, she would have assessed the resident, wrote a note, initiated an accident report and notified the provider. Interview with the Charge Nurse (LPN #2) on 4/8/25 at 1:44 PM identified she told the nursing supervisor about what had happened during the transfer wherein the resident's leg was bent towards his/her back, and she had assisted the nurse aide with the Sara lift to transfer the resident back to bed. LPN #2 indicated that she expressed to the nursing supervisor that when the resident was back in bed, she removed his/her pants to check the leg for any bruising, Resident #33 denied pain, no sign of deformity, had no grimacing and was then transferred to wheelchair using a Hoyer lift. The resident had no further complaints throughout the shift. LPN #2 added that the next morning Resident #33 complained of pain in the left lower extremities, swelling and a little redness was noted, so she informed the nursing supervisor on duty. LPN #2 indicated that she was not sure if RN #1 had gone to see the resident or had written a note. LPN #2 identified looking back at the incident she should have written a note and started the accident/incident report on 10/7/24, as the resident was a two-person assist with transfers using the Sara lift. Interview with the Administrator, and the DNS on 4/9/25 at 1:39 PM identified that based on what occurred during the transfer, it would be considered an incident, which would indicate that a nursing assessment and note should have been initiated. Review of the Accident/Incident policy and procedure identified staff will notify the nursing supervisor/licensed nurse when an incident occurs. The policy further identified the licensed nurse, or the supervisor will complete and document the evaluation of the resident's condition. This evaluation is to include but is not limited to vital signs and neuro signs if applicable, type of injury with location on body, include measurements if the injury is a skin tear or bruise, evaluation of pain, range of motion of all extremities.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure a controlled medication prescribed for Resident #1, Ativan, was not removed from the facility. The findings include: Resident #1's diagnoses included cerebral infarction, anxiety, and depressive disorder. A physician's order dated 10/20/24 directed to administer Ativan 1 milligram (mg) every eight (8) hours as needed for anxiety. The Resident Care Plan dated 10/22/24 identified Resident had a history of depression and anxiety. Interventions directed to administer medications as ordered, monitor for effect, and psych consultation as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time, experienced delusions, exhibited no behavioral symptoms, and received an antidepressant medication. The nurse's note dated 10/29/24 at 12:52 AM identified Ativan 1mg was administered with effect. The Facility Reported Incident form dated 11/6/24 at 1:00 PM identified on 11/2/24 the former Director of Nursing, Registered Nurse (RN) #2, was notified by the 7AM-3PM Nursing Supervisor, RN #1, Resident #1's bubble pack of Ativan 0.5 mg tablets was unable to be located, there was a total of twenty-nine (29) tablets from the thirty (30) that was delivered on 10/22/24. An investigation including audit of narcotics, review of the nurse shift to shift narcotic sign off sheets and staff interviews was conducted 11/2/24 and the Drug Enforcement Agency (DEA) was contacted. The investigation identified RN #2 explained to the DEA agent twenty-nine (29) tablets of Ativan 1 mg belonging to Resident #1 was discovered missing at 7:00 AM on 11/2/24. On 11/1/24 at the 3:00 PM shift change the Ativan was verified as present by the 7AM-3PM and 3-11PM nurses during the controlled medication count. RN # 2 stated the 3-11PM nurse, Licensed Practical Nurse (LPN) #1, informed her that at she, LPN #1, had counted with the 11PM-7AM nurse, LPN #2. RN #2 identified the 11PM-7AM nurse informed her that she did not remember the count, even though her initial were on the shift change sheet with LPN #1's. RN #2 explained LPN #1 worked a double shift so at 11:00 PM, LPN #1 left the keys to the medication cart on top of the medication cart and proceeded to go to the unit she was scheduled to work on. The 11PM-7AM nurse, LPN #2, stated although she signed that at 11:00 PM she counted the controlled medications and took the keys, LPN #2 did not get to the cart and took the keys until sometime after 11:00 PM. In an interview on 1/13/25 at 11:24 AM the Administrator identified he was made aware on 11/4/24 of the missing medication that was reported to RN #2 on 11/2/24. In an interview with the Drug Enforcement Agency (DEA) agent on 1/13/25 at 11:55 AM he was notified on 11/6/24 of the missing Ativan medication. The agent stated he met with RN #2 and the Administrator at the facility 11/7/24 and investigated the discrepancy. The DEA agent identified although he reviewed records, conducted interviews and toured the facility he was unable to identify how the medication was unable to be located in the facility. Although attempted, an interview with RN #1 and RN #2 were not obtained. Review of the Abuse policy dated 12/23 directed Misappropriation of Resident Property means the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for misappropriation of the resident's controlled medication, the facility failed report the missing medication to the state agency within the noted two (2) hours. The findings include: Resident #1's diagnoses included cerebral infarction, anxiety, and depressive disorder. A physician's order dated 10/20/24 directed to administer Ativan 1 milligram (mg) every eight (8) hours as needed for anxiety. The Resident Care Plan dated 10/22/24 identified Resident had a history of depression and anxiety. Interventions directed to administer medications as ordered, monitor for effect, and psych consultation as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time, experienced delusions, exhibited no behavioral symptoms, and received an antidepressant medication. The nurse's note dated 10/29/24 at 12:52 AM identified Ativan 1mg was administered with effect. The Facility Reported Incident form dated 11/6/24 at 1:00 PM identified on 11/2/24, four (4) days earlier, the former Director of Nursing, Registered Nurse (RN) #2, was notified by the 7AM-3PM Nursing Supervisor, RN #1, Resident #1's bubble pack of Ativan 0.5 mg tablets was unable to be located, there was a total of twenty-nine (29) tablets from the thirty (30) that was delivered on 10/22/24. An investigation including audit of narcotics, review of the nurse shift to shift narcotic sign off sheets and staff interviews were conducted 11/2/24. An email correspondence to the Drug Enforcement Agency (DEA) identified on 11/6/24 RN #2 reported the missing Ativan medication and RN #2 also reported the missing medication to the Department of Public Health. The investigation identified RN #2 explained to the DEA agent twenty-nine (29) tablets of Ativan 1 mg belonging to Resident #1 was discovered missing at 7:00 AM on 11/2/24. On 11/1/24 at the 3:00 PM shift change the Ativan was verified as present by the 7AM-3PM and 3-11PM nurses during the controlled medication count. RN # 2 stated the 3-11PM nurse, Licensed Practical Nurse (LPN) #1, informed her that at she, LPN #1, had counted with the 11PM-7AM nurse, LPN #2. RN #2 identified the 11PM-7AM nurse informed her that she did not remember the count, even though her initial were on the shift change sheet with LPN #1's. RN #2 explained LPN #1 worked a double shift so at 11:00 PM, LPN #1 left the keys to the medication cart on top of the medication cart and proceeded to go to the unit she was scheduled to work on. The 11PM-7AM nurse, LPN #2, stated although she signed that at 11:00 PM she counted the controlled medications and took the keys, LPN #2 did not get to the cart and took the keys until sometime after 11:00 PM. In an interview on 1/13/25 at 11:24 AM the Administrator identified he was made aware on 11/4/24 of the missing medication that was reported to RN #2 on 11/2/24. The Administrator stated he was notified on 11/4/24, two (2) days later by RN #2, however he did not report the incident to The Department of Consumer Protection, the Drug Enforcement Division (DCP), Department of Public Health (DPH) or local law enforcement until 11/6/24, four (4) days later. In an interview with the Drug Enforcement Agency (DEA) agent on 1/13/25 at 11:55 AM he was notified on 11/6/24 of the missing Ativan medication. The agent stated he met with RN #2 and the Administrator at the facility 11/7/24 and investigated the discrepancy. The DEA agent identified although he reviewed records, conducted interviews and toured the facility he was unable to identify how the medication was unable to be located in the facility. Review of the Abuse policy dated 12/2023 and Procedures directed The facility must ensure that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and exploitation are reported immediately to the Administrator and Director of Nurses of the facility utilizing the chain of command.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for hospitalizations, the facility failed to notify the provider timely of a change in condition leading to a hospitalization. The findings include: Resident #1 's diagnoses included hemiplegia and hemiparesis (paralysis and/or weakness) following a cerebral infarction (ischemic stroke where the blood flow to the brain is blocked) affecting the left dominant side and dysphagia (difficulty swallowing) following a cerebral infarction. The Admission/readmission Evaluation dated 8/27/24 identified that Resident #1 was cognitively intact and did not exhibit any Activities of Daily Living (ADL) impairments. Additionally, it identified that Resident #1's lung sounds were diminished on both the right and left sides and no cough was noted. The Resident Care Plan (RCP) dated 8/28/24 identified that Resident #1 had a deficit in self-care functioning and decreased mobility secondary to cerebral vascular accident with interventions that included to provide staff set-up for eating. A nurse's note dated 8/30/24 at 2:58 identified that Resident #1 was noted with a non-productive cough (a dry cough that doesn't produce mucus or phlegm) and crackles (abnormal lung sounds) were heard when auscultating (listening) to lung sounds. A nurse's note dated 8/31/24 at 10:23 PM identified that Resident #1 was noted with a productive cough (producing mucus or phlegm), a moderate amount of white secretions and crackles were heard when auscultating lung sounds. A nurse's note dated 9/1/24 at 10:31 PM identified that Resident #1 was noted with a productive cough, a moderate amount of white secretions and crackles were heard when auscultating lung sounds. The note reported that the resident had a body temperature of 99.4 degrees Fahrenheit (low-grade fever) and Tylenol (fever reducer) was given with good effect. A nurse's note dated 9/2/24 at 10:45 PM identified that Resident #1 was noted with a productive cough, a moderate amount of white secretions and crackles were heard when auscultating lung sounds. The note reported that the resident denied any shortness of breath and the head of the bed was elevated. An SBAR (Situation, Background, Assessment and Recommendation) form (a reporting tool for a change in condition) dated 9/3/24 at 6:40 PM identified that Resident #1 was noted with an altered mental status and a fever, reporting increased confusion and requiring more assistance with Activities of Daily Living (ADLs). A transfer form dated 9/3/24 identified that Resident #1 was alert but disoriented and able to follow simple commands but reported that the resident had a body temperature of 100 degrees Fahrenheit and an oxygen level of 91% on room air. It identified that the provider was notified, and the resident was sent to the ED for evaluation at 7:00 PM. Review of progress notes from 8/30/24 through 9/2/24 failed to identify that the provider was notified that Resident #1 had a change in condition as noted in the 8/30/24, 8/31/24, 9/1/24 and 9/2/24 nurse's notes until 9/3/24 (4-days after the initial observation) when the resident was noted with a fever, decreased oxygen level and altered mental status. Review of hospital progress note dated 9/8/24 identified that Resident #1 arrived to the ED on 9/3/24 with an oxygen level of 90% on room air, a body temperature of 101.9 degrees Fahrenheit and a heart rate of 104 (all irregular). It identified that blood work and a chest x-ray were obtained and signified an infection, reporting a probable aspiration pneumonia (lung infection that occurs when a person inhales food, liquid, saliva or stomach contents into their lungs instead of swallowing) as etiology for acute hypoxemic respiratory failure, identifying that the resident was treated with antibiotics. The report identified that the resident stated he/she had been coughing for a while. Interview with APRN #1 on 1/2/25 at 2:12 PM identified that if Resident #1 had developed a productive cough and abnormal lung sounds, she would expect that a provider be notified immediately. She reported that she could not recall being notified regarding a change in respiratory status with Resident #1 but identified that all providers document their communication with nursing in the clinical record, and if the provider doesn't see the resident in person, it's documented as a 'Telemedicine Visit'. She reported that if both nursing and the provider didn't document a communication, it was unlikely that the provider was notified. APRN #1 identified that if she had been notified of Resident #1's change in status, she would have most likely ordered a chest x-ray. Interview with RN #1 (previous DNS) on 1/2/25 at 3:13 PM identified that nursing should have notified the provider immediately regarding a resident with a change in lung sounds and/or the development of a productive cough. She identified that she was unaware that nursing had documented that they had observed crackles and a productive cough several days prior to Resident #1 being transferred to the hospital on 9/3/24 and was unsure why they had not notified the provider. Review of the Change of Condition Notification policy dated 4/2023 directed, in part, that the facility will inform the resident's healthcare provider when there is a change of condition. When the staff identifies a change in condition, they will notify the licensed nurse and the licensed nurse, per state regulations, will conduct a complete physical/mental evaluation and document the findings in the medical record including the resident's reactions to symptoms. The licensed nurse per state regulations notifies the resident, the attending physician and the family/responsible party of the change in condition. The facility must inform the resident's healthcare provider when there is an incident involving the resident which may result in an injury or requires medical treatment or the need to alter treatment significantly.

Based on review of clinical records, interviews, and review of facility documentation for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to update the resident's care plan and card regarding the resident's care preferences/concerns. The findings included: Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, anxiety, and abnormalities of gait and mobility. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 a Brief Mental Interview for Mental Status (BIMS) of fifteen (15), indicative of intact cognition. The MDS further identified Resident #1 required moderate assistance with toileting hygiene, bathing, and lower body dressing, and utilization of a wheelchair and walker. Review of Resident #1's Care Plan dated 10/30/24 identified a deficit in self-care related to cerebral vascular accident with left hemiplegia. Interventions directed to assistance of one staff member with bathing, dressing and toileting. Review of the November 2024 grievance entries identified a grievance was placed by Resident #1 requesting additional care checks from nursing staff, more frequent changes of soiled linens (which have remained on the resident's bed and resident for several days), and a request to scrub the resident's scalp and jawline area when bathed to remove dry skin flakes. Interview with the Administrator on 11/26/24 at 4:00 PM identified that the facility had received a list of Resident #1's care requests/preferences and provided a copy to the Director of Nurses to address the personal care items. The Administrator further identified holding an impromptu care plan meeting two (2) days after receiving this list of concerns with the interdisciplinary team, resident, and the resident's spouse to discuss what the facility was going to do, what could be done, and what was already in place. The Administrator indicated items listed on the grievance were to be added to the resident's care plan. Review of Resident #1's Care Plan failed to identify the resident's care preferences were updated. Review of Resident #1's November 2024 Care Card failed to identify Resident #1's care preferences were updated. The facility was unable to provide documentation identifying staff was educated on the aforementioned care concerns/preferences. Review of the Resident Rights policy directed the right to receive quality care and services with reasonable accommodation of the resident's individual needs and preferences, the right to have prompt efforts made by the facility to resolve any grievances the resident may have, and the right of the resident to participate in the planning of care and treatment.

Based on review of clinical records, interviews, and review of facility documentation for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that once a new piece of equipment was ordered the equipment had the necessary fall prevention measures in place. The findings included: Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, anxiety, and abnormalities of gait and mobility. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 a Brief Mental Interview for Mental Status (BIMS) of fifteen (15), indicative of intact cognition and required moderate assistance going from a sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfers, and utilized a walker and wheelchair. Review of Resident #1's Care Plan dated 10/30/24 identified the potential for falls due to a cerebral vascular accident with left side weakness and psychotropic medication use with interventions that directed to place bed in low position, appropriate footwear non-skid socks while in bed ,and non-slip soles on shoes/sneakers when ambulating or mobilizing in wheelchair. Review of the Facility Licensing and Investigations Section Reportable Event Form dated 11/3/24 at 5:45 PM identified Resident #1's left leg slid off the side of the bed, which pulled the rest of his/her body off the bed and onto the floor, The report further identified a disposition/action taken of bolsters to Resident #1's mattress. Review of a receipt dated 11/4/24 identified one (1) thirty-six (36) by eighty-four (84) inch Relief Max Non-Powered Surface mattress and one (1) eighty-four (84) inch perimeter cover (which included bolsters) was ordered, however review of a receipt dated 11/7/24 at 12:40 PM identified an order for a Matrix Bed Frame, extension kits, and a Reduce Max Preventative Mattress thirty-six (36) by eighty-eight (88) inches (without bolsters) to replace the previous mattress ordered. Review of the dated 11/16/24 at 9:30 AM identified Resident #1 lying on the floor next to the bed in his/her room resulting in left shoulder pain, and without serious injury. Review of Resident #1's Care Plan update dated 11/16/24 identified the potential for falls with/without injury due to: cerebral vascular accident with left side weakness and psychotropic medication use and an intervention which directed wedge cushions to be placed on the both sides of the bed to prevent his/her leg from falling off the side of the bed. Interview with the Facility Administrator (FA) on 11/26/24 at 1:35 PM identified bolsters were on the mattress ordered following Resident #1's initial fall (order dated 11/4/24), however the Administrator did not specifically order bolsters for the new, larger mattress (order dated 11/7/24), did not ask if the new mattress came with bolsters, and thought placement of pillows underneath the sheet on both sides of Resident #1's bed had been added as an intervention to prevent the resident from sliding/falling out of the non-bolstered bed.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication administration, the facility failed ensure medications were administered in accordance with physician orders, failed to ensure a medication was administered in accordance with physician orders. The findings include: Resident #1's diagnoses included essential tremor. Review of hospital discharge orders dated 6/21/2024 directed Propranolol (used to tremors) 60 milligram (mg) 24-hour capsule by mouth daily. Physician order dated 6/21/2024 directed administer Propranolol HCL oral tablet 60 milligrams (mg) give one by mouth daily to start on 6/22/2024. Review of the June 2024 Medication Administration Record (MAR) identified the Propranolol HCL oral tablet 60 mg was administered on 6/22/2024 at 9 AM. Additional record review failed to identify Resident #1 received the Propranolol 60 mg 24-hour capsule by mouth daily, and identified Resident #1 received Propranolol HCL oral tablet 60 mg (a non-24-hour dose). Interview and record review with the DNS on 7/18/2024 at 11:15 AM identified when Resident #1 was being discharged from the facility, he/she notified the facility that he/she was given non-extended-release Propranolol during his/her stay. The DNS stated an investigation was conducted and identified on 6/22/2024 Resident #1 did not receive the 24-hour capsule. The DNS stated the error was a transcription error, and the Propranolol administered was obtained from the facility emergency supply, and staff were provided with education after the error was identified. Although requested, a facility policy regarding transcribing orders was not provided for surveyor review. Facility documentation review identified staff education was initiated on 6/27/2024 regarding transcription of physician orders. Audits were initiated on 7/12/2024, and a QAPI meeting was held on 7/12/2024. Based on review of facility documentation, past non-compliance was identified. a. A physician order dated 6/21/2024 directed to administer Bupropion HCL ER (XL) 150 mg oral tablet extended release 24 hours, by mouth daily. Review of the June 2024 MAR identified Resident #1 did not receive the Bupropion HCL ER (XL) 150 mg oral tablet extended release 24 hour, on 6/22/2024 at 9:00 AM in accordance with physician orders. Interview and record review with the DNS on 7/18/2024 at 11:15 AM identified the Bupropion HCL ER 150 mg was omitted in error on 6/22/2024 at 9 AM. The DNS stated the medication had not been received from the pharmacy and there was none in the facility emergency supply. Facility documentation review identified staff education was initiated on 6/27/2024 regarding transcription of physician orders. Audits were initiated on 7/12/2024, and a QAPI meeting was held on 7/12/2024. Based on review of facility documentation, past non-compliance was identified.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (2) of six (6) residents reviewed for (Resident #204), the facility failed to ensure a resident had appropriate supervision while in the bathroom, and that leg rests were removed from the wheelchair prior to a transfer, resulting in an injury and for accidents for (Resident # 31), the facility failed to ensure staff remove the plastic covering from a hot beverage within accordance to facility practice to prevent a burn and . The findings included : 1. Resident #204 had diagnoses that included Alzheimer's disease, and weakness of right dominant side following a stroke. The admission nursing assessment dated [DATE] at 5:30 PM identified Resident #204 was alert only to person, had problems with his/her memory, and had fallen within the last month. The fall risk assessment dated [DATE] identified Resident #204 had a fall within the previous six (6) months and was identified as a fall risk. The baseline care plan dated 10/14/21 at 5:45 PM identified Resident #204 was confused, and had impaired vision which required glasses and further identified that Resident #204 had a history of falls and fall related injuries with interventions that included flat bells (flat pad a resident presses for assistance) and transfer, walking and toileting assist of one staff. A Physical Therapy plan of care dated 10/15/21 identified Resident #204 was referred for short term rehab due to recently being diagnosed with vertebrae compression fractures due to a fall at home. It further identified Resident #204 was orientated to person and had severely impaired safety awareness/judgement. An Occupational Therapy plan of care dated 10/15/21 identified Resident #204 was very forgetful and required one assist for transfers and toilet use, with recommended supervision and assistance for safety awareness and judgement. A Social worker admission assessment dated [DATE] identified Resident #204 was alert and pleasantly confused. She further identified Resident #204 was very forgetful and relied on his/her husband to answer much of the intake questions. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #204 had severely impaired cognition, required extensive assistance with transfers and toilet use, balance to move on and off the toilet was impaired and the resident was only able to stabilize self with staff assistance. A nurse's note dated 10/21/21 at 8:42 PM identified Resident #204 was alert and pleasantly confused. It further identified Resident #204 had poor safety awareness and had self-transferred at times. A progress note written by Registered Nurse (RN) #1 dated 10/24/21 at 7:49 PM identified she was called to Resident #204's room by Nurse Aide (NA) #1. Resident #204 was noted with a 6.5 centimeter (cm) in length by 1 cm in width cut to the Right lower leg. First aid was rendered, the cut was cleansed with normal saline and a dressing applied. The physician and spouse were notified and 911 was alerted. An Accident & Incident (A&I) report dated 10/24/21 at 7:15 PM identified that the resident had obtained a laceration to the right lower leg. A statement written by NA #1 dated 10/24/22 identified she assisted Resident #204 into the bathroom and after placing the resident on the toilet, asked the resident to pull the cord when finished, and Resident #204 replied h/she would. She then went to another resident's room to assist the nurse with another resident. A statement written by NA#2 identified that he heard Resident # 204 calling for help, he saw blood on the floor and called for the nurse. The record of conversation form dated 10/24/22 for NA #1 identified that the RN supervisor discussed with NA#1 that a patient with dementia who required an assist of one staff member for toileting, transfers, and ambulation should not be left unattended in the bathroom. Review of the hospital emergency room encounter dated 10/24/21 identified Resident #204 had a laceration to his/her right lower leg that required a repair with eight (8) sutures. A Nurse's note dated 10/25/21 at 4:24 AM identified Resident #204 returned to the facility after emergency department visit for laceration of right lower extremity. Resident #204 received 8 sutures at the hospital. Multiple attempts made to contact NA #1, however attempts were unsuccessful. Interview with the Director of Nursing Services (DNS) on 4/5/23 at 2:00 PM and 4/6/23 at 11:28 AM identified that Resident # 204 had attempted to independently transfer from the toilet, and Resident #204's injury was caused by the wheelchair footrest's. The NA had failed to remove the footrests prior to the transfer but had positioned Resident #204's wheelchair footrests to the side for the transfer to the toilet. The DNS further identified that the resident should not have been left in the bathroom unattended because of cognitive impairment and risk for falls, further identified that the facility policy directs for footrests to be removed prior to a transfer, however the resident was left unattended and the footrests were not removed prior to the transfer. She further identified Resident #204's care plan was updated to have staff present with Resident #204 while in the bathroom. Review of the transfer of resident policy directed, in part, footrests should be off the wheelchair prior to transfer to reduce tripping or injury. 2. Resident # 31's diagnoses included dementia, anxiety, chronic kidney disease stage 3, hypothyroid and hypertension. A physician's order dated 1/25/22 directed to every 15 minutes check due to wandering in and out of resident's room. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 31 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicative of severe cognitive impairment and noted the resident required supervision to limited assist of 1 person with bed mobility, transfer, ambulation, hygiene and toileting. Resident #31 was independent with eating and only required set-up during meal time. The Resident Care Plan (RCP) dated 2/14/22 identified Resident # 31 required assistance with Activity Daily Living (ADL) related to impaired cognition, dementia and osteopenia. Interventions directed to assist with dressing, bathing, hygiene and grooming, to maintain privacy and dignity, Occupational Therapy (OT) screen as needed and to provide verbal cuing for safety. Review of temperature log dated 3/3/22 identified that the hot beverage at dinner time was 181 degree. The facility Accident and Incident Report dated 3/3/22 at 5:30 PM identified Resident #31 had an accident that cause a second-degree burn on his/her bilateral thighs. The report also indicated the nursing staff did not removed the lid cover from the hot water cup per facility practice causing the resident to spill hot water on his/her lap when he/she tried to remove the lid cover from the cup independently. The nurse's note dated 3/3/22 at 5:38 PM identified Resident # 31 was yelling from her/his room and dinner tray was on the floor. A cup of hot tea had fallen on Resident # 31's lap. The RN assessment at the time of the incident identified redness with a raised area to the resident's bilateral inner thigh, groin and posterior thigh. The nurse's note dated 3/4/22 at 4:23 AM identified Resident #31 was awake and located at the nursing desk at 1:00 AM with a little teary eye. The inner right thigh with large fluid filled blister developed and measure 1.5 inches x 2.0 inches surrounded with deep pink skin and several tiny fluids filled areas. The left inner thigh with 1 inch's fluid filled blister area surrounded with multiple smaller fluid filled blister. Silvadene 1% cream arrived from the pharmacy was applied to the burn area and Resident # 31 expressed relief. A physician's order dated 3/4/22 directed to administered 1 gram of Silvadene 1% cream to each thigh twice a day for 7 days then re-evaluate. A physician's order dated 3/7/22 directed to monitor burn to bilateral thighs daily for 7 days. A physician's order dated 3/11/22 directed to administered 1 gram of Silvadene 1% cream to each thigh twice a day for 14 days then re-evaluate. A physician's order dated 3/22/22 directed to monitor inner thighs with dried scab for on-going healing daily. Interview with Dietary Director on 4/4/23 at 1:55 PM identified the kitchen staff log the temperature of hot beverage water daily. She identified that the hot water beverage would have a temperature between 180 to 200 degrees from the kitchen. She also indicated the water would cool down about 10 to 20 degree when the nursing staff started passing the tray. Interview with RN # 3 on 4/5/23 at 10:55 AM identified Resident # 31 could eat independently and required set-up during mealtime. RN # 3 indicated the nursing staff would open the food packaging, open container and removing the lid from a cup prior to leaving the resident's room. She also indicated Resident # 31 had been receiving hot tea beverage in the facility. Interview with (NA # 5) on 4/5/23 at 11:10 AM identified that Resident #31 was independent with eating and required set-up assist during mealtime. He/she indicated that she/he would open the food packaging, open container and remove the lid from a cup prior to leaving the resident's room. NA # 5 also indicated Resident #31 had been getting a hot tea beverage. Interview with RN # 2 on 4/5/23 at 1:25PM identified Resident #31 was yelling from his/her room and the food tray was on the floor. She identified Resident # 31 had a pre-pour hot water included in his/her meal tray. She further indicated that the hot water spilled on Resident #31's lap. She identified Resident #31 was independent with eating and required set-up with his/her meal. She further indicated that the hot water had a lid cover on the cup Resident #31 tried to take it off independently. She was not sure why the plastic lid cover on the hot water cup was not removed. She further indicated the plastic lid cover should had been removed. Interview with DNS on 4/6/23 at 1:10 PM identified Resident #31 required set-up with his/her meal. She expected the nursing staff to open all food packaging and remove the plastic lid cover from the cup before the staff would leave the resident room. She indicated that she was aware of Resident #31 hot water accident that cause the second-degree burn to the bilateral thighs. The DNS also identified the accident and incident report indicated the NA # 4 did not removed the plastic lid cover from the cup that cause the second-degree burn on his/her bilateral thighs when the hot water cup spilled on his/her lap. The DNS also indicated that she updated the hot water policy to prevent the accident from happening to all residents. Observation on 4/6/23 at 12:00 PM identified Resident #31 received food prior to receiving the hot beverage. Resident #31 received a 120 ml cranberry juice and 240 ml of hot tea with plastic lid removed from the cup. Observation on 4/6/23 at 12:10 PM in the dining room identified the nursing staff prepared the utensil, open food packages and removing all the plastic cover lid from the cup. Attempted to interview NA # 4 was unsuccessful during the survey. Review of policy titled Hot Water for Beverages Policy dated 3/22 and revised on 4/22 and 5/22 directs to provide beverages at a temperature that is both acceptable for resident's enjoyment and safety. The policy indicated that water for tea or hot beverages would be dispensed from the coffee machine in the main kitchen into carafes and placed on the dietary cart at each meal. 46117

Based on clinical record reviews, observations and interviews for two out of seven residents (Residents #2 and #23) reviewed for dining, the facility failed to provide a homelike environment. The findings included: 1. Resident #2's diagnoses included gastro-esophageal reflux disease (GERD) without esophagitis, generalized anxiety disorder, and chronic obstructive pulmonary disease. The physician's orders dated 9/9/22 directed to provide a cardiac diet, with special instructions: Aspartame allergy and wheat allergy, Lactulose intolerance, and resident requested a regular diet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident#2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicating no cognitive impairment. The resident required extensive assistance of two people for dressing and transfers, and set-up for eating. The resident was always incontinent of urine and bowel. The Resident Care Plan ( RCP) dated 2/10/23 identified a nutritional risk due to congestive heart failure, and histories of hyponatremia (low sodium) and hypokalemia (low potassium). Interventions included providing built up utensils, divided plate, and covered liquids. The Resident Care Card directed to set-up the resident for meals. 2. Resident #23 ' s diagnoses included gastro-esophageal reflux disease (GERD) without esophagitis, Alzheimer's Disease, and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident#23 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen, indicating moderate cognitive impairment. The resident was independent with activities of daily living and required set-up with meals. S/he was always continent of urine and bowel. The physician's orders dated 11/23/22 directed to provide resident with a regular diet and small portions as per resident request. The RCP dated 2/1/23 identified a potential for complications from GERD. Interventions included assisting with meals as needed, encourage remaining upright for 30 minutes following meals, diet as ordered, and monitor for the ill effects of GERD, such as esophageal irritation and bleeding. The Resident Care Card directed to set-up the resident for meals. 0 4/11/23 12:15 PM on the second floor during dining identified the following : Seven residents were observed being served mid-day meals in the lounge/dining room: four residents at one table, two residents at two other tables. Meals were served on plates and cups on trays. On 4/11/23 12:25 PM interview with Nurse Aide ( NA #5 )identified they usually served meals on trays in the lounge/dining room except if special occasions like parties. S/he indicated s/he did not know if there was a policy on serving meals. NA #5 indicated some residents would have difficulty with feeding themselves because the plates would slide if the trays were not used, and the residents needed the trays to keep the cups and plates stable. On 4/11/23 12:27 PM interview with NA #6 identified some residents needed the lips of the trays to help feed themselves and be independent. On 4/11/23 12:30 PM interview with the Director of Dietary indicated the dietary staff members deliver the tray carts to the units and leave them in front of the nursing station on each unit. The NAs deliver and serve the meals to the residents. S/he additionally indicated s/he did not think there was a dietary policy addressing residents being served meals from trays in the dining room. On 4/11/23 12:40 PM interview with the dietician identified the residents' being served meals would be a nursing policy and not a dietary policy since the nursing staff serve food to the residents. On 4/11/23 12:45 PM interview with the DNS identified they did not have a policy addressing residents being served from trays in the dining rooms. The DNS also indicated s/he did not think this was a problem because the trays helped the residents to eat independently since the plates would slide on the table if the trays were not used. Additionally, s/he indicated if they used non-slid place mats, the plates would still slip.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #1) reviewed for a significant medication error, the facility failed to ensure a narcotic medication was administered according to the physician's order resulting in the resident receiving 10 times the dose of the medication ordered and requiring hospitalization and multiple doses of [MEDICATION NAME] (a medication used to treat opioid overdose). The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, dressing, eating, personal hygiene. Additionally, Resident #1 received an antidepressant medication daily. The care plan dated 5/7/19 identified Resident #1 had a potential for alteration in comfort related to diabetic [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included to monitor and evaluate the resident for pain, provide assistance to position for comfort using pillows and positioning devices, and medicate with [MEDICATION NAME] per physician's orders. A prescription order dated 5/29/19 directed to administer [MEDICATION NAME] 10mg/5ml; give 5mg as needed; give 5mg (2.5ml) every 4 hours prn pain. The pharmacy fill status identified the pharmacy changed the drug from [MEDICATION NAME] oral solution 10mg/5ml, to [MEDICATION NAME] concentrate oral solution 100mg/5ml. Pharmacy directions included 0.25mg (5mg) every 4 hours prn pain. The physician's order dated 5/29/19 directed to administer [MEDICATION NAME] concentrate - Schedule II solution; (a narcotic medication used to treat pain), 100 mg/5 ml; (20 mg/ml) give 5mg (5mg = 0.25ml) every 4 hours as needed for severe pain. The controlled substance disposition record for [MEDICATION NAME] concentrate 100 mg/5 ml solution, (0.25 ml = 5 mg) identified that on 5/29/19 at 5:00 PM, Resident #1 received 2.5 ml (50 mg of [MEDICATION NAME]). A reportable event form dated 5/29/19 identified that on 5/29/19 at 5:00 PM a nurse administered 50 mg of [MEDICATION NAME] to Resident #1 (10 times the dose ordered by the physician). MD #1 was contacted and Resident #1 was given 0.4 mg of [MEDICATION NAME], nursing stayed with the resident as 911 was called and the resident was then transferred to the emergency room for evaluation. A physician's order dated 5/29/19 directed to administer [MEDICATION NAME] ([MEDICATION NAME]) 0.4 mg/ml injectable immediately. A nurse's note dated 5/29/19 at 6:26 PM identified that RN #2 updated MD #1 of the [MEDICATION NAME] administration error. The physician ordered [MEDICATION NAME], which was administered approximately 5 minutes after the reported administration of [MEDICATION NAME]. Resident #1's status had not varied from his/her baseline as resident was responding to name, verbal, eyes open and respirations were even. Resident #1 was transferred to the emergency department. Review of the (MONTH) 2019 identified that Resident #1 received a stat dose of [MEDICATION NAME] on 5/29/19. Hospital documentation dated 5/29/19 identified that Resident #1 arrived to the emergency department at 5:52 PM after an accidental medication overdose, (Resident #1 was given 50 mg of [MEDICATION NAME] instead of 5 mg of [MEDICATION NAME]). Additionally, at 7:39 PM the resident became more somnolent after initially arriving awake and was responding to touch but not answering questions. When left alone, the resident closes eyes and becomes somewhat apneic with decreased respirations and oxygen saturation maintains but respirations showed need for repeat dose of [MEDICATION NAME]. At 7:46 PM, Resident #1 has been hypo-ventilating and dropping oxygen saturations. The resident received sodium chloride 0.9% at 125ml/hr and respirations were identified as 8 per minute. Verbal order for [MEDICATION NAME] 0.4mg IV, given with good effect. As of 9:56 PM, Resident #1 was becoming less easily arousable, oxygen saturations down to 88% on room air. At 10:02 PM a third dose of [MEDICATION NAME] 0.4 mg was administered. Oxygen saturation at 95%. Interview with RN #4 on 6/20/19 at 9:25 AM identified that it is licensed nurse's responsibility to ensure that transcription of physician orders into the resident's electronic medical records is done correctly. Additionally, nursing can add special instructions in the electronic medical record. Furthermore, the EMAR is not the mechanism to order narcotics from the pharmacy, the pharmacy requires a fax order with a physician signature be sent when ordering schedule II drugs. RN #4 identified that when narcotic medications are received from the pharmacy, nursing is to ensure that the narcotic sheet matches the physician medication orders and correspond with the EMAR. RN #4 identified that in order to administer narcotics accurately, a nurse needs to read the physician order, medication container, narcotic sheet, and EMAR, to ensure the right medication and dose is administered to a resident. Interview with the DNS on 6/20/19 at 10:20 AM identified that the physician order for [REDACTED]. On 5/21/19, Resident #1's family wanted the [MEDICATION NAME] dose to be decreased, so the facility contacted MD #2 to share the family's concern and obtained a physician order for [REDACTED]. Interview with RN #1 on 6/20/19 at 12:31 PM identified that on 5/29/19 at approximately 5:00 PM he/she administered 2.5 ml of [MEDICATION NAME] sulfate to Resident #1. RN #1 indicated he/she did not look at the concentration of the medication on the bottle of [MEDICATION NAME] bottle. RN #1 identified that a 1 ml syringe was in the narcotic drawer with the [MEDICATION NAME]. RN #1 identified that to draw up 2.5 ml of [MEDICATION NAME] with the 1ml syringe, he/she had to draw up 1 ml twice and then 0.5 ml and add it to a medication cup to give to the resident. Additionally, RN #1 identified that he/she may not have looked at the narcotic count sheet for the resident until after administering the [MEDICATION NAME] to Resident #1. RN #1 identified that after administering the medication to Resident #1, he/she had a feeling he/she had given the wrong dose so he/she called the supervisor immediately. Interview with the Nursing Supervisor, (RN #2), on 6/20/19 at 1:50 PM identified that she was the charge nurse on 5/29/19 and was called by RN #1 for assistance related to administration of incorrect dose of [MEDICATION NAME] to Resident #1. RN #2 identified that he/she immediately contacted the physician to obtain an order for [REDACTED]. RN #2 identified that his/her investigation related to the situation identified that the EMAR included directions to administer 2.5 ml of [MEDICATION NAME] to the resident, however, the controlled substance disposition sheet for Resident #1's [MEDICATION NAME] directed to administer 0.25 ml of the [MEDICATION NAME] to the resident. RN # 2 identified that nursing is to check the concentration of [MEDICATION NAME] to administer with the physician orders and the EMAR to ensure that the correct dose of [MEDICATION NAME] would be administered to the resident. RN #2 identified that nursing was directed to review and sign the controlled substance disposition sheet prior to administration of medications to a resident. Furthermore, RN # 2 identified that the supervisors were responsible for the special instruction documentation in the EMAR and he/she could not explain why the supervisor who verified the transcription of the [MEDICATION NAME] order did not delete the instructions upon receipt of Resident #1 [MEDICATION NAME] that was used for administration beginning on 5/25/19. Interview with Pharmacist #1 on 6/20/19 at 2:00 PM identified that the pharmacy requires signed physician orders be faxed for schedule II medications. Additionally, the pharmacy does not document special instructions in the EMAR. The pharmacy expects that upon receipt of a narcotic, nursing will verify that the medication matches the physician order, is the correct dose with the concentration and is for the right resident. Additionally, nursing would be responsible to ensure the EMAR reflects the correct medication information and aligns with the physician order. Interview with the DNS on 6/20/19 at 2:30 PM identified that RN #1 should have checked the concentration of [MEDICATION NAME] prior to administering it to Resident #1 and broke protocol by not doing so. Additionally, although DNS could not identify why the EMAR had instructions to administer 2.5 ml of [MEDICATION NAME] for 5 mg dose because the controlled substance disposition record directed administration of 0.25 ml for 5 mg dose. The DNS indicated the nurse was responsible to ensure the right dose of medication was given to the resident and identified that a medication error occurred and subsequent to the error he/she provided staff with education for controlled substance prescription review. The educational content included instruction to assure that the new prescription matches exactly the order in the EMAR, the prescription and medication order is the same, the concentrations of medications are the same, and the special instruction box in the EMAR is correct and matched the order. Although requested, a facility policy for transcription of orders was not provided. Review of facility policy for general dose preparation and medication administration identified staff should verify each time a medication is administered that it is the correct medication, the correct dose, at the correct rate, at the correct time for the correct resident. Although a prescription order and physician's order dated 5/29/19 directed to administer [MEDICATION NAME] concentrate 100 mg/5 ml; (20 mg/ml) give 5mg (5mg = 0.25ml) every 4 hours as needed for severe pain, on 5/29/19, RN #1 administered [MEDICATION NAME] 50mg in error. Subsequently, Resident #1 received an immediate dose of [MEDICATION NAME] at the facility and required transfer to the hospital for evaluation. At the hospital Resident #1 required 2 more doses of [MEDICATION NAME] due to low oxygen saturations and respiratory rate.