Every finding on record at Meriden Health and Rehab

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure carpeting throughout resident occupied areas were maintained in a clean and sanitary manner. The findings include: Observation on units identified as CH1, CH2 and Center Memory Care had wall to wall carpeting extending throughout all hallways that was heavily stained with brown/black discoloration and emitted an unpleasant odor. All areas were accessed by residents on a daily basis as they entered and exited their rooms. Interview with the Director of Housekeeping on 7/13/26 at 8:39 AM identified she was responsible for ensuring the cleanliness of the carpeting. The Director of Housekeeping indicated all carpets were shampooed and scrubbed twice weekly. An extractor (used to extract soil) was previously used in the past but had broken and the facility was looking to having it replaced. When soiling/staining was excessive, an extractor was rented in the past. The Director of Housekeeping further identified that although the current method of cleaning the carpets was ineffective due to the large amount of residual staining, an extractor was not obtained to enhance cleaning as there was consideration to possibly remove the rugs. The Housekeeping Supervisor was unable to provide any documentation supporting communications regarding plans to replace the carpet when requested. Interview and facility documentation review with the Administrator on 7/13/26 at 8:53 AM identified a request was made to remove carpeting in one resident room. Asbestos testing was required before any carpet removal which was completed in the preceding week with pending results. The Administrator was unaware there was a broken extractor and received no requests from housekeeping staff to acquire one. The Administrator indicated the current method of cleaning the carpets was ineffective due to the large amount of residual staining, and she would acquire an extractor to address the concern. The Administrator further identified there was consideration to replace all carpeting at some point but did not provide any documentation with communications for a plan to remove all carpeting upon request. Subsequent to surveyor inquiry, an extractor was rented and hallways through all units were cleaned in the two days that followed. A large amount of persistent staining and discoloration remained on all carpeting throughout the halls following extraction. Review of the facility housekeeping policies ensured a safe, clean and comfortable environment while supporting infection control and resident wellbeing. Carpets are to be inspected for hazards with no specific language for maintaining carpets in a clean and sanitary manner.

Based on review of the clinical record, facility documentation, facility policy, facility assessment and interviews for 3 of 3 residents (Resident #2, 44 and 76) reviewed for dementia, the facility failed to ensure the clinical record included documentation, by the resident's physician, that the resident met the clinical criteria for placement in the secured/locked area, documentation that reflected the resident and resident representative's involvement in the decision for placement in the secured/locked area, documentation reflecting whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure his/her health and safety, and ongoing documentation of the review and revision of the resident's care plan, including whether the resident continued to meet the criteria for remaining in the secured/locked area, and if the interventions continued to meet the needs of the resident. The findings include: 1. Resident #2 was admitted to the facility in July 2025 with diagnoses that included dementia with behavioral disturbance and anxiety disorder. Review of the census list identified that Resident #2 was placed to the secured/locked unit on 7/30/25. The significant change MDS dated [DATE] identified Resident #2 had severely impaired cognition and was dependent with transfers to wheelchair. The care plan dated 5/20/26 identified Resident #2 was at risk for elopement related to cognitive impairment and confusion. Intervention included resident on a locked dementia unit. The physician's order dated 7/1/26 directed staff to provide assistance of one for stand-pivot transfers to a wheelchair using a rolling walker. Review of the physician's orders dated 7/1/26 failed to reflect placement of the resident on the secured/locked unit. Review of the clinical record failed to reflect documentation to identify a voluntary placement on the secured unit, physician documentation of the clinical criteria supporting placement in the secured unit, a physician's documentation identifying that on the secured unit was the least restrictive environment appropriate to meet the resident's needs, and failed to ensure quarterly or annual assessments were completed to evaluate the resident's continued need for placement on the secured unit. Although requested, the facility did not identify any secured unit consents, assessments or resident's access to exit the floor independently. 2. Resident #44 was admitted to the facility in June 2024 with diagnoses that included vascular dementia with agitation and anxiety disorder. Review of the census list identified Resident #44 was placed on the secured/locked unit on 6/27/24. The annual MDS dated [DATE] identified Resident #44 had severely impaired cognition and was independent with transfers and ambulation with walker. The physician's order dated 7/1/26 directed that the resident was independent with a rolling walker and that the rolling walker was to be used during ambulation. Further, the physician's order directed that the resident may reside on the Memory Care Unit (original date 4/2/26). The physician's orders failed to reflect an order for Resident #44 to reside on the secure/locked unit prior to 4/2/26. The care plan dated 7/9/26 identified Resident #44 met the criteria for placement in a secured/locked unit, and the resident representative had given consent for the resident to voluntarily reside in a secured unit to protect the resident and/or other residents from leaving the unit. Interventions included to allow the resident to express feelings of being in a secure unit as needed. Further, the care plan identified Resident #44 was an elopement risk and wanderer due to disorientation to place, impaired safety awareness, a history of exit-seeking behaviors related to dementia. Interventions included resident required a secured unit. Review of the clinical record failed to reflect documentation to identify physician documentation of the clinical criteria supporting placement in the secured unit, physician's documentation identifying that the secured unit was the least restrictive environment appropriate to meet the resident's needs, and failed to ensure quarterly or annual assessments were completed to evaluate the resident's continued need for placement on the secured unit. Although requested, the facility did not identify any secured unit consents, assessments or resident's access to exit the floor independently. Interview with the DNS on 7/13/26 at 9:15 AM identified that he has been employed by the facility for 2 months. The DNS indicated the facility maintained a secured memory care unit for residents with dementia diagnoses and residents exhibiting behavioral issues. The DNS indicated that he was not aware residents residing on the memory care unit did not meet the criteria for the unit. The DNS indicated he would review the memory care unit policy and discussed the clinical criteria needed for the resident to be admitted to the unit and the process for on-going evaluations to ensure a secure unit remains the resident's least restrictive environment with the interdisciplinary team (IDT). Interview with the Administrator on 7/14/26 at 6:39 AM identified that she has been employed by the facility for 1 year. The Administrator indicated she was not aware the policy did not include clinical criteria for placement on the memory care unit, documentation that the resident representative participated in the placement decision that the criteria for resident admitted to the memory care unit was not identified on the facility's memory care policy. The Administrator indicated the residents admitted to the memory care unit were required to have a diagnosis of dementia with behaviors. The Administrator indicated she was not aware that the criteria for the memory care unit included the resident clinical criteria for being on the memory care unit, documentation that the resident representative was involved in the decision for placement on the secure unit, and on-going assessment for the resident to remain on the secure unit. 3. Resident #76 was admitted to the facility in October 2024 with diagnoses that included dementia, schizophrenia, and schizoaffective disorder. The Census List identified that Resident #76 had resided in the facility's Memory Care Unit since admission. A physician's order dated 4/2/26 directed that Resident #76 may reside on the Memory Care Unit. The quarterly MDS dated [DATE] identified Resident #76 had intact cognition, did not have the following potential indicators for psychosis: hallucinations or delusions, did not have the presence of the following symptoms: physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others, and wandering behavior was not present. The care plan dated 6/8/26 identified Resident #76 was at risk for elopement and wandering related to impaired safety awareness secondary to dementia diagnosis, with interventions that included requiring a secured unit (initiated 4/6/26). The Social Service Care Plan Meeting note dated 6/9/26 identified Resident #76's meeting was held and the Conservator was called but did not answer the phone and a message was left with a return phone number. Per nursing, Resident #76 was medically stable with no significant changes, had an advance directive in place of full code, and the resident would remain in the Memory Care Unit (secured unit) for long term. Review of the clinical record failed to identify documentation by the resident's physician, of the clinical criteria Resident #76 met for placement in the secured/locked unit. Review of the clinical record failed to identify documentation that reflected Resident #76 and his/her conservator were involved in the decision for placement in the secured area. Review of the clinical record failed to identify documentation reflecting whether placement in the secured area was the least restrictive approach that was reasonable to protect Resident #76 and assure his/her health and safety. Review of the clinical record failed to identify ongoing documentation of the review and revision of the resident's care plan, following Resident #76's admission on the secured/locked unit, identifying whether he/she continued to meet the criteria for remaining in the secured/locked area, and if the interventions in place continued to meet the needs of the resident. Interview with the DNS on 7/13/26 at 9:15 AM identified that he began working at the facility, as the DNS on 5/11/26, and that the facility did have a secured/locked memory care unit for residents with dementia that exhibited behaviors. The DNS indicated that he would review the facility's Memory Care Unit policy and discuss the clinical criteria needed for a resident to be admitted to the unit as well as the process for on-going evaluations to ensure a secure unit remains the resident's least restrictive option with the interdisciplinary team (IDT). Interview with the Administrator on 7/14/26 at 6:39 AM identified that she began working at the facility on 7/9/25, and that the clinical criteria for a resident's admission to the Memory Care Unit was not identified in the facility's Memory Care Unit policy but that residents residing in the secure memory care unit required a diagnosis of dementia with behaviors. The Administrator indicated that she was not aware of the clinical criteria for resident's residing on the secure/locked Memory Care Unit including the resident's clinical criteria for being admitted into the secure/locked unit, documentation that the resident and resident representative were involved in the decision for placement on the secure/locked unit, and ongoing evaluations identifying the resident continued to meet the criteria to remain on the secure/locked unit. During an interview with the DNS and Administrator on 7/14/26 at 7:24 AM, the DNS identified that the IDT did meet on 7/13/26 to discuss putting together criteria for resident placement on the secure/locked unit, including clinical criteria for placement, documentation of communication with the resident and resident representative regarding the placement on the secure unit, and implementing an admission assessment, as well as, quarterly and as needed assessments evaluating if the secure/locked unit remains the resident's least restrictive option. The Administrator identified that she was not sure who initiated obtaining physician's orders to reside on the memory care unit for the residents residing on the there (including Resident #76), in early April or who initiated care plan interventions requiring a secure unit, for all residents residing in the memory care unit, in early April. The Administrator further indicated that there had been a number of audits occurring within the facility and that she would have expected that the previous DNS would have been made aware of the findings and the corresponding plan of correction related to the secure memory unit. Interview with the Independent Nurse Consultant (ICN) on 7/14/26 at 7:47 AM identified that several discussions were had with the previous owner regarding the memory care unit, but a formal tool for the memory care unit was not developed until this change of ownership when it was identified that documented clinical criteria, care plans, and evaluations were missing from all of the memory care residents' clinical records. [NAME] an interview with the DNS and Administrator on 7/14/26 at 12:41 PM, the DNS identified that the current documentation of the physician's clinical rational for placement on the secure/locked unit and documentation that the resident and/or resident representative had involvement in the decision to be placed on a secured unit were weak, and that initial and ongoing assessments had not been implemented. The DNS further indicated that in collaboration with the IDT and the INC, the Memory Care policy would be updated, and the memory care residents' clinical records would also be updated with the appropriate documentation and reevaluated quarterly and as needed. The Memory Care policy directs the facility to provide specialized care and services to residents with cognitive impairment in accordance with federal, state, and local regulations. Care will be individualized, focused on maintaining dignity, maximizing function, and ensuring resident safety. Residents will receive a comprehensive assessment upon admission and periodically thereafter, assessments shall include cognitive status, behavioral symptoms, functional abilities, communication needs, and safety risks. An individualized care plan will be developed and reviewed at least quarterly or with significant changes in condition. Families and responsible parties will be encouraged to participate in care planning and education and support regarding dementia progression and care strategies will be provided when appropriate. Memory care services will be monitored through the facilities quality assurance and performance improvement program and incidents, behavioral events, falls, elopements, and family concerns will be reviewed for opportunities to improve care. The administrator, director of nursing, interdisciplinary care team, and all direct care staff are responsible for implementing this policy. The Facility Assessment failed to identify the level of care needed for the Memory Care Unit.

Number of residents sampled: Number of residents cited: Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #8) reviewed for UTI/catheter, the facility failed to ensure a resident readmitted to the facility with a foley catheter had been assessed for the removal of the catheter, in a timely manner, and failed to ensure orders were in place for the ongoing care of the foley catheter care. The findings include:The Hospital Discharge summary dated [DATE] identified Resident #8 had a foley catheter placed on 6/8/26 given ongoing urinary retention and would need a voiding trial on 6/14/26. Resident #8 was admitted to the facility in June 2026 with diagnoses that included acute kidney failure, urinary tract infection, and chronic kidney disease. A physician's order dated 6/9/26 directed to complete foley catheter care every shift, attach the foley catheter to a drainage bag while in bed and to a leg bag when out of bad, to change foley catheter 16 French every 6 weeks, once daily every 42 days, and to change foley catheter leg and drainage bag every Sunday night shift. The nurse's note dated 6/10/26 at 3:23 AM identified that Resident #8 had a primary admission diagnosis of disorientation and a past medical history that included protein calorie malnutrition, sepsis with acute renal failure, agitation, CKD stage 3, hypertension, and acute cystitis. Resident #8's breathing was spontaneous and non-labored, would continue hospital course of IV antibiotics for sepsis with acute renal failure, foley catheter 16 French/30cc balloon in situ and draining 200 cc of amber colored urine at the present time, no signs and symptoms of pain noted, and vital signs were stable. The physician's note dated 6/15/26 at 9:00 AM identified that Resident #8 was noted to have a foley catheter in place, which appeared to have been placed during his/her hospitalization due to urinary retention. The decision was made to hold off on a voiding trial at this time, as the resident remained suspicious of nursing staff and it was suspected he/she would not allow staff to obtain a bladder scan or straight catheterization, if necessary. The nurse's note dated 6/15/26 at 9:14 PM identified Resident #8 was seen by the consultant psychiatrist. A Physician's Emergency Certificate (PEC) was signed and sent to an outside facility. Resident #8 was placed on a 1:1 observation and transportation was booked. The nurse's note dated 6/15/26 at 9:50 PM identified Resident #8 was picked up at 9:30 PM and transported to an outside facility. The nurse's note dated 6/30/26 at 10:26 PM identified Resident #8 was readmitted to the facility at 3:45 PM. Resident #8 presented with a pleasant mood and was able to make his/her needs known, denied pain, breathing was non-labored, no signs/symptoms of cardiac distress were noted, skin was noted to be clean, dry, and intact, and a foley catheter was patent and draining clear yellow urine with 400 cc of output this shift. The physician's admission note dated 7/1/26 at 10:57 AM identified Resident #8 had a foley but failed to identify a rationale for the foley and/or an assessment for the removal of the foley catheter. The admission MDS dated [DATE] identified Resident #8 had intact cognition and had an indwelling catheter. The APRN progress note dated 7/6/26 at 9:30 AM identified Resident #8 had a foley catheter in place but failed to identify a rationale for the foley and/or an assessment for the removal of the foley catheter. The care plan dated 7/9/26 identified Resident #8 had an indwelling catheter, with interventions that included a blank catheter type/size, a blank last changed date, and a blank catheter next change date. Review of the physician's orders dated 6/30/26 through 7/11/26 failed to identify orders for ongoing catheter care. Review of the nurse's notes dated 6/30/26 through 7/11/26 failed to identify documentation that foley catheter care had been completed on all shifts. Interview with Resident #8 on 7/12/26 at 9:00 AM identified that he/she had been in and out of a few facilities recently and that the foley catheter had been in place for a long time. Resident #8 indicated that he/she had asked multiple staff members why the foley catheter was still in place and asked to have it removed because it was uncomfortable while lying in bed. Resident #8 indicated that he/she was told that the foley catheter was in place due to urosepsis. Review of the clinical record with the DNS on 7/12/26 at 2:52 PM failed to identify that a clinical indication to continue the foley catheter was documented by the medical provider upon Resident #8's readmission and failed to ensure orders were in place for the ongoing care of the foley catheter care. Interview with the DNS on 7/12/26 at 2:52 PM identified that Resident #8 was admitted to the facility on [DATE], went out on a MLOA on 6/15/26, and came back to the facility on 6/30/26; the foley catheter orders dropped off when he/she went out and were not reentered when he/she was readmitted . The DNS indicated that Resident #8 had the foley catheter placed on 6/8/26, while at the hospital for urinary retention and AKI; a voiding trial was scheduled for 6/14/26, but the psychiatric and medical providers felt that the voiding trial should be postponed pending a psychiatric evaluation and behavioral improvements, as Resident #8 was having aggressive behaviors towards staff and was refusing to be touched. Resident #8 went out on a MLOA on 6/15/26, and when he/she returned the orders for foley catheter care were not reinstated. The DNS identified that he would expect ongoing foley catheter care orders to be in place, including foley catheter care every shift and bag changes every 30 days. The DNS indicated that he was unaware Resident #8 had been requesting to have the foley catheter removed, and he would speak to the IDT to discuss the plan of care for the foley catheter.Subsequent to survey inquiry, the physician's orders dated 7/12/26 directed to complete foley catheter care every shift, to attach the foley catheter to a drainage bag while in bed and to a leg bag when out of bad, to change foley catheter, 16 French, every 6 weeks, and to change foley catheter leg and drainage bag every Sunday night shift. Interview with APRN #1 on 7/13/26 at 12:41 PM identified that she had just began working at the facility a week prior, and while the clinical record did not address an assessment for discontinuing the foley catheter, upon Resident #8's readmission on [DATE], she would have a conversation with the psychiatric APRN and see if a voiding trial could be attempted in the upcoming days/week. APRN #1 indicated that Resident #8 had not expressed concern regarding the foley catheter or asked to have it removed.Interview with RN #1 on 7/14/26 at 3:19 PM identified that he was the nursing supervisor when Resident #8 was readmitted to the facility on [DATE] and that he would have been responsible to initiate the foley catheter orders, and that it was an oversight that it was not completed.Although requested a foley catheter policy was not provided.The foley catheter insertion, care, and removal guidelines directed that insertion of the foley catheter should only be done when clinically necessary. The need for a foley catheter should be assessed daily by the attending physician or the APRN. Routine Foley catheter care should be performed twice daily and after bowel movements, including cleaning the catheter and surrounding area to prevent infection, and monitoring should include regularly assessing the catheter for signs and symptoms of an infection, leakage, or blockage. The catheter should be removed as soon as it is no longer clinically indicated.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident # 5) reviewed for PASARR, the facility failed to ensure that social services provided assistance after the resident requested to be transferred to a smoking facility. The findings include: Resident #5 was admitted to the facility in December 2025 with diagnoses that included bipolar disorder, alcohol abuse disorder, and diabetes.Review of the hospital discharge documentation identified Resident #5 reported active smoking of 4 cigarettes per day. A smoking evaluation dated 12/24/25 identified Resident #5 used smoking or vape devices. Further review of the clinical record failed to identify additional smoking evaluations after 12/24/25.An APRN admission note dated 12/26/25 identified that Resident #5 had a diagnosis of bipolar disorder versus schizoaffective disorder and alcohol use disorder. The admission notes further identified there were concerns that Resident #5 had impaired decision-making abilities due to underlying psychiatric disease and repeated refusals of care.A psychiatric APRN admission note dated 12/26/25 identified Resident #5 had a history of documented alcohol use disorder, bipolar disorder, and reported daily cigarette smoking with cravings. The treatment plan identified orders that included Nicorette (a nicotine replacement) lozenges 2 mg every two hours as needed for 14 days then reevaluate, and NicoDerm transdermal patch 21 mg every day for nicotine dependence for six weeks.A physician's admission note dated 12/29/25 identified that Resident #5 had a previous history of alcohol use disorder, prior substance abuse disorder which included benzodiazepine, cocaine, cannabinoids, and opiates, and was an active cigarette smoker. Resident #5 had chronic delusions from schizoaffective bipolar disorder and had impaired decision-making capacity. The note also identified Resident #5 reported doing well except for cravings to smoke cigarettes and indicated Resident #5 was counseled on smoking cessation for approximately 3 minutes, but that Resident #5 continued to smoke.The admission MDS dated [DATE] identified Resident #5 had moderately impaired cognition, was always continent of bowel and bladder, and was independent with toileting, bathing, and transfers. The MDS also identified Resident #5 as a current tobacco user, required daily antipsychotic medication and had a diagnosis of bipolar disorder. A nurse's note dated 12/31/25 identified Resident #5 expressed a desire to leave the facility against medical advice. The note further identified MD #1 was contacted and instructed facility staff Resident #5 had impaired decision-making capacity and was in the process of obtaining conservatorship.A psychiatric APRN note dated 12/31/25 identified that the APRN was asked to see the resident due to the request to leave the facility against medical advice. The note identified that Resident #5 was requesting to leave the facility due to nicotine cravings.Review of the care plan dated 1/9/26 failed to identify interventions related to smoking or nicotine dependence.A social service note dated 1/15/26 identified Resident #5 requested to be transferred to another facility that would allow smoking. The note identified that attempts were made to 2 other facilities but no beds were available and that Resident #5 was put on a waiting list for one of the facilities. A social service note dated 1/19/26 identified Resident #5 was notified that there were no available beds at other facilities but that social services would continue to search for smoking facilities with available beds. Review of the clinical record failed to identify that further attempts were made by the facility to assist Resident #5 with a transition of care to a smoking facility after 1/19/26. A psychiatric APRN note dated 1/21/26 identified Resident #5 reported heightened anxiety due to a strong desire to return home due to craving nicotine. The note identified a new order for Xanax 0.25 mg every 12 hours as needed for anxiety for 14 days.A psychiatric APRN note dated 1/30/26 identified Resident #5 having significant nicotine cravings due to dependence. The note further identified Resident #5 was refusing nicotine replacement treatments due to an allergy to transdermal nicotine patches, inability to chew nicotine gum and was unable to use nicotine loss ages due to just swallowing them.A physician's note dated 2/12/26 identified Resident #5 was seen due to concerns with agitation, and that Resident #5 was agitated due to wander guard and was trying to leave the building but was redirectable. The note further identified to administer Xanax 0.5 mg tablet one time and 0.25 mg tablet every 8 hours as needed for 10 days. Review of Resident #5's care plan failed to identify any review, revisions, or interventions following 2/12/26 when Resident #5 attempted to leave the facility due to agitation. A psychotherapy note dated 2/19/26 identified that Resident #5 was preoccupied with wanting to smoke outside of the facility. The note further identified the provider discussed the smoking policy outside of the facility with the resident. A nurse's note dated 3/24/26 identified Resident #5 had removed and refused the wander guard. A psychotherapy note dated 6/23/26 identified that Resident #5 discussed wanting to smoke cigarettes to manage anxiety with the clinician.A psychiatric APRN note dated 7/7/26 identified Resident #5 reporting being upset due to not being able to go outside and smoke and because he she did not have any cigarettes.Interview with SW #1 on 7/16/26 at 6:52 AM identified that she recently started employment with the facility around 4/18/26. SW #1 identified that she was not aware of any issues related to Resident #5's desire to smoke and was not aware that Resident #5 had ever requested a transfer to a smoking facility. Interview with the DNS on 7/15/26 at 11:56 AM identified that he was not aware of any issues related to Resident #5's desire to smoke and was not aware that Resident #5 had ever requested a transfer to a smoking facility. The DNS identified it would be the responsibility of the social worker to coordinate a transfer of care in conjunction with the resident's representative. Although requested, the facility policy on social services was not provided. The facility policy on resident rights directed that residents of the facility had the right for self-determination. The policy also directed that residents of the facility had the right to exercise their rights as a resident of the facility, be supported by the facility and exercising those rights, and participate in his or her care planning and treatment.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #74) reviewed for environment, the facility failed to ensure an appropriately sized bedside commode was provided, in a timely manner. The findings include:The hospital Discharge summary dated [DATE] at 2:20 PM identified Resident #74's primary discharge diagnosis included a chronic left hip infection and status post total hip revision on 7/2/26. Secondary discharge diagnoses included class 2 obesity and weight bearing orders directed touchdown weightbearing, left lower extremity, posterior precautions, and an assistive device-walker.Resident #74 was admitted to the facility in July 2026 with diagnoses that included aftercare following joint replacement surgery and infection and inflammation reaction due to internal left hip prosthesis. The Admit/Readmit Screener dated 7/7/26 at 8:58 PM identified Resident #74 was alert and oriented to person, place, time, and situation, short term and long term memory were intact, he/she was independent for cognitive skills for daily decision making, had appropriate verbal communication, was able to make him/herself understood and could understand others, and toilet transfers were non applicable.The baseline care plan dated 7/7/26 identified Resident #74 required substantial/maximal assistance with personal hygiene, rolling left and right and sitting to lying; sitting to standing, chair/bed-to-chair transfers, and toilet transfers were not attempted due to medical condition or safety concerns.A physician's order dated 7/8/26 directed to provide an assist of 1 for dressing, bathing, and toileting. The nurse's note dated 7/9/26 at 7:30 PM identified that Resident #74 was alert and oriented and reported pain. As needed (prn) medication was administered and effective, he/she was lying in bed but could ambulate in bed independently. Vital signs were stable, no adverse effects noted from IV antibiotics, lungs were diminished bilaterally, Resident #74 was encouraged to sit up, deep breath, and cough, but he/she refused; bowel sounds were present in all 4 quadrants, abdomen was soft and non-distended, denies nausea, vomiting, diarrhea, or constipation, and was continent of bowel during this shift. Interview with Resident #74 on 7/12/26 at 8:45 AM identified that on the day of admission and the following day a commode was not available in his/her room, on Day 2 following admission a standard sized bedside commode was brought into the room. On Day 3 following admission, he/she rang the call bell for assistance to use the commode, but after waiting for over an hour the resident self-ambulated to the commode and struggled to get out of the commode because the commode was not wide enough. Resident #74 further indicated that the next time he/she had to have a bowel movement, he/she rang the call bell and waited close to an hour for assistance, then self-ambulated into the bathroom because he/she could not hold it any longer. Resident #74 identified that he/she had reported to multiple staff members that the current commode was too small and did not accommodate his/her body size, but nobody had brought a larger commodeThe nurse's note dated 7/13/26 at 10:56 AM identified that it was brought to this writer's attention that Resident #74's call bell was not working and maintenance was notified. Interview with NA #4 on 7/14/26 at 11:04 AM identified that she had worked with Resident #74 twice, but he/she did not have a bowel movement on her shift and did not require assistance transferring to the commode. NA #4 indicated that Resident #74 did say that he/she was too big for the commode, and that she thought therapy may have heard him/her say that, and she did not notify anyone of Resident #74's concerns with the commode. NA #4 indicated that she had only worked at the facility for 2 months and that she was not sure if larger commodes were available. During an interview with the Regional Director of Rehabilitative Services and OT #1 on 7/14/26 at 11:15 AM, OT #1 indicated that Resident #74 was toe touch weight bearing status on the left due to a left total hip revision. The facility had been pivoting from the wheelchair with Resident #74 and would not be working on ambulation until he/she was cleared by the orthopedic surgeon and obtained a change in weight bearing status. OT #1 indicated that he had only worked with Resident #74 a few times since admission, most recently on 7/10/26, but had not worked on getting to the commode. OT #1 indicated that he was just made aware that Resident #74 reported that the commode in his/her room was too small, and he would evaluate him/her for a larger commode today. The Regional Director identified that therapy would usually provide a commode based on body size, but sometimes it was a trial-and-error process to identify the best fit, and the resident and/or nursing could always communicate directly to the rehab staff if there was a need for a larger commode. Observation with OT #1 on 7/14/26 at 11:35 AM identified a bariatric commode at Resident #74's bedside.Interview with LPN #6 on 7/14/26 at 3:37 PM identified that he works the 3:00 -11:00 PM shift and had only worked at the facility since April of 2026. While he had not provided Resident #74 with assistance to the commode, the resident had reported that the commode in his/her room was too small. LPN #6 indicated that he did look for a larger commode but was unable to find one; additionally, the rehab therapy staff were not in the building at that time, and the Nursing Supervisor was an agency nurse who also did not know where additional supplies were located. LPN #6 further indicated that he had forgotten to communicate Resident #74's concern with the commode to the next shift.Interview with the DNS on 7/15/26 at 7:49 AM identified that Resident #74 had initially expressed concern that there was no commode available in his/her room, and he was only recently made aware that Resident #74 had brought forth concerns regarding the size of the bedside commode. The DNS indicated that there was room for improvement in the admission process, ensuring that the proper durable medical equipment, including a bariatric bedside commode, would be made available upon the resident's arrival and also ensuring that overstock and specialty equipment were readily available for staff in a central location for easy access, when a need arises.The Bedside Commode policy directs that a bedside commode would be provided for residents that can get out of bed.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Residents #4, 12 and 7) the facility failed to notify the physician and/or resident representative with a change in condition. For Resident #4, reviewed for pain management, the facility failed to ensure that the resident representative was notified following multiple changes of condition. For 1 of 5 residents (Resident #11) reviewed for hospitalization, the facility failed to ensure the APRN/physician was notified of 2 missed doses of an oral antibiotic. For 1 resident (Resident #7) reviewed for nutrition, the facility failed to notify the physician and resident representative when the resident had a significant weight loss. The findings include: 1. Resident #4 was admitted to the facility in August 2025 with diagnoses that included ulcerative colitis with ileostomy, congestive heart failure, and chronic pain syndrome. Review of the clinical record identified Resident #4 had a conservator as his/her resident representative. The quarterly MDS dated [DATE] identified Resident #4 had moderately impaired cognition, was occasionally incontinent of bladder and had a colostomy in place for bowel, and was dependent on staff for assistance with toileting, bathing, and dressing. The care plan dated 12/5/25 identified that Resident #4 had a nutrition problem due to recent hospitalization. Interventions included to obtain weights as ordered. Review of the clinical record identified that Resident #4 had a weight of 196.6 lbs. on 12/3/25. A physician's order dated 12/7/25 directed to obtain weekly weights every Friday on day shift. Review of the clinical record failed to identify that any weekly weights were obtained or documented for Resident #4 for 12/2025. An APRN note dated 1/20/26 by APRN #2 identified that Resident #4 had a history of abnormal weight loss and had not been weighed due to decreased mobility. The note further identified that APRN #2 directed nursing staff to obtain a weight for Resident #4 that week. Review of the clinical record failed to identify that any weekly weights were obtained or documented for Resident #4 for 1/2026. An APRN Note dated 2/12/26 identified Resident #4 was seen due to nausea and vomiting for 2 days. The note identified that there were cases of influenza in the facility and that Resident #4 also had a previous history of ileus with vomiting. The note further identified that the treatment plan included a stat viral panel for COVID, influenza, and RSV testing; monitor oral intake, hydration and ostomy output closely, and nursing staff to report any worsening symptoms or inability to tolerate oral intake. a. Review of the clinical record failed to identify documentation that Resident #4's resident representative was notified regarding Resident #4's symptoms and need for viral panel testing due to an outbreak in the facility. An APRN Note dated 2/13/26 identified Resident #4 was seen for follow up and reassessment after an acute episode that began on 2/12/26. The note identified Resident #4 had a previous history of ileus with vomiting and diagnostic testing was ordered. The note further identified that imaging study showed a colonic ileus with moderate stool in the colon however the finding was incongruent with the resident's surgical history as the resident had no colon. The report further identified that a repeat imaging study was ordered and that an emergency room transfer was recommended. The note further identified that Resident #4 declined emergency room transfer and wished to remain at the facility and that IV fluids were ordered. b. Reviewed the clinical record failed to identify documentation that Resident #4's resident representative was notified regarding the need for repeat imaging, recommendation of an ER transfer or that Resident #4 declined ER treatment, or need for IV fluids. A change of condition evaluation dated 2/16/26 identified Resident #4 had behavioral changes was transferred to the hospital. The change of condition evaluation identified Resident #4's resident representative was contacted regarding a change of condition on that date. Review of the clinical record identified Resident #4 was hospitalized from [DATE] to 2/18/26 due to Klebsiella UTI with right pyelonephritis. Review of the clinical record failed to identify that any weekly weights were obtained or documented for Resident #4 for 2/2026. An APRN note dated 3/6/26 by APRN #2 identified that Resident #4 had a recent cardiology consult completed and recommendations were made that included weekly weights, protein supplementation 1 - 2 times daily with a liberalized diet. The note identified that a current weight was obtained which was 173.6 lbs. (an 11.1% weight loss since 12/3/25) down from a previous weight of 196.6 lbs. in 12/2025. The note further identified that Resident #4 had abnormal weight loss and APRN #2 provided education to the staff and the resident regarding the issue. The note further identified the treatment plan included a diabetic supplement that was reordered, weekly weights, and nutrition to ensure protein supplementation and a liberal diet. c. Review of the clinical record failed to identify documentation that Resident #4's resident representative was notified regarding the significant and abnormal weight loss identified on 3/6/26. Interview with the DNS on 7/15/26 at 11:56 AM identified that he was aware there were issues with change of condition notification for residents of the facility and that he had already begun measures to address the issue. The DNS identified that the facility recently underwent a change of ownership in 5/2026, and he began employment around that date, and prior to the transition that there were multiple nursing staff changes which impacted care of the residents including assessments and notifications to family and resident representatives. The facility policy on change of condition and a resident status directed that the facility should notify the resident, his or her attending physician, and resident representative of [NAME] have changes in the residence medical and mental condition. The policy further directed that a significant change of condition was a decline or improvement in the residence status that would not normally resolve itself without interventions by staff or by implementation of standard disease related clinical interventions; impacted more than one area of the resident's health status; and required interdisciplinary review and or revision to the care plan. 2. Resident #11 was admitted to the facility in October 2025 with diagnoses that included spontaneous bacterial peritonitis, alcoholic cirrhosis of the liver with ascites, and thrombocytopenia. The quarterly MDS dated [DATE] identified Resident #11 had intact cognition and was taking medications from the following high-risk drug classifications in the last 7 days: antibiotic and diuretic. The care plan dated 4/13/26 identified Resident #11 had liver disease related to alcoholic cirrhosis with ascites, alcoholic hepatitis, hepatic encephalopathy, and splenomegaly, with interventions that included giving medications as ordered and monitoring and documenting effectiveness and side effects. The nurse's note dated 6/18/26 at 8:57 AM identified Resident #11 complained of 10/10 pain when lying on his/her back. Resident #11's vital signs were 130/38 (diastolic baseline is low), 18, 82, 99.3, and 97, he/she had paracentesis on Tuesday and 7 liters were removed. Resident #11 stated pain has been persistent since then with intermittent sharp pain. The Medical Director was notified, and Resident #11 was sent to the hospital for evaluation. The Inter-Agency Patient Referral Report dated 6/25/26 at 4:17 PM identified Resident #11 problem list included C. difficile colitis (C-Diff) and abdominal pain. Recommendations included Vancomycin 125mg every 6 hours around the clock stop taking on 6/30/26. The nurse's note dated 6/25/26 at 9:07 PM identified that Resident #11 returned from the hospital at 5:00 PM status post hospital stay related to sepsis secondary to cirrhosis and ascites, positive for C-Diff, Vancomycin 125 mg by mouth every 6 hours for 18 doses, medication orders verified, and the physician was aware of the readmission. The APRN note (written by APRN #3) dated 6/26/26 at 8:00 AM identified Resident #11 was previously admitted to the hospital on [DATE] with worsening abdominal pain, vomiting, and a concern for sepsis. Diagnostic paracentesis revealed fluid consistent with spontaneous bacterial peritonitis (SBP), and stool studies confirmed C. difficile colitis. Resident #11 was treated with IV Vancomycin for SBP and was started on oral Vancomycin 125 mg every six hours for C. difficile colitis. Resident #11 was discharged on 6/25/26 with instructions to continue oral Vancomycin 125 mg, every six hours through 6/29/26. Resident #11 will require secondary C. difficile prophylaxis with oral Vancomycin 125 mg daily for the duration of any future antibiotic course plus five days post completion, over the next year. A physician's order dated 6/25/26 directed to administer Vancocin (Vancomycin HCL) 125 mg, 1 capsule by mouth every 6 hours for 18 administrations, start date 6/26/26. The Medication Administration Record dated 6/26/26 through 6/30/26 identified Resident #11 did not receive Vancocin on 6/26/26 at 12:00 AM or 6:00 AM. The first dose of Vancocin administered was on 6/26/26 at 12:00 PM (12 hours after the first missed dose) and 16 of the 18 administrations were completed. The nurse's note dated 6/26/26 through 6/30/26 failed to identify the on-call physician or APRN was notified that Resident #11's Vancocin was unavailable and not administered on 6/26/26 at 12:00 AM or 6:00 AM. Interview with Resident #11 on 7/12/26 at 9:30 AM identified that he/she went to the hospital and returned to the facility on 6/25/26 with a diagnosis of C-diff. Resident #11 indicated that the facility did not have Vancomycin when he/she came back to the facility, and he/she missed 3 doses. Interview with the Infection Preventionist (LPN #3) on 7/14/26 at 2:16 PM identified that he was initially not made aware that Resident #11 was readmitted on [DATE] with C-Diff and on oral Vancocin. LPN #3 was first made aware on 7/1/26 (6 days following readmission) by one of the nurses, and he was not made aware of the 2 missed Vancocin administrations on 6/26/26. Interview with RN #1 on 7/14/26 at 3:05 PM identified that he was the 3:00 PM - 11:00 PM nurse supervisor when Resident #11 was readmitted to the facility on [DATE] and did not recall being notified that the Vancocin was not available. RN #1 did not see documentation in the clinical record that the physician had been notified of the 2 missing Vancocin doses. Clinical record review with the DNS on 7/15/26 at 7:55 AM failed to identify documentation that the physician or APRN was notified that Resident #11 did not receive the 12:00 AM and 6:00 AM doses of Vancocin on 6/26/26. Interview with the DNS on 7/15/26 at 7:55 AM identified that oral Vancocin was not available in the e-box or pyxis and it would have to come from the pharmacy. The DNs indicated his expectation would be that the physician or APRN would have been notified that Resident #11 did not receive the 12:00 AM and 6:00 AM doses of Vancocin on 6/26/26, as the physician or APRN may altered the treatment plan or maybe would have tacked on the 2 missed doses to the end of the treatment course. The DNS further indicated that he would have also expected the medical provider's notification to have been documented in the clinical record. Although attempted an interview with APRN #3 was not obtained. Interview with APRN #1 on 7/15/26 at 12:10 PM identified that she had not started working at the facility on 6/26/26, so she could not speak to if a notification of the missed Vancocin doses was made or not, but she would have expected that a medical provider be notified of the 2 missed Vancocin doses because the provider could have extended the treatment to ensure all 18 doses were administered. The Administration of Medications Policies and Procedures directs that medications are to be given at the time ordered or within 60 minutes before or after the time designated. The facility does recognize that medication administration may be delayed due to an immediate resident need and/or emergency situation. The facility will require documentation and notification to the provider of medication, administration at 15 minutes or greater. These instances are also required to be reported to the shift supervisor. 3. Resident #7 was admitted to the facility in February 2025 with diagnosis that included ulcerative colitis, congestive heart failure and dementia. The weights and vitals summary identified Resident #7 weighed 130 lbs. on 9/9/25. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition, no weight loss in the past 6 months and weighed 130 lbs. The weights and vitals summary identified Resident #7 weighed 114 lbs. on 9/17/25, a 16 lbs. or 12.3% weight loss. The weights and vitals summary identified Resident #7 weighed 114.8 lbs. on 9/24/25. a. Review of the clinical record failed to reflect that the physician and resident representative had been notified of the residents 16 lbs. or 12.3% weight loss. The weights and vitals summary identified Resident #7 weighed 108.4 lbs. on 10/28/25 a 6.4 lbs. or 5.57% weight loss. A dietary note (weight warning) dated 10/28/25 identified Resident #7 weighed 108.4 lbs. indicative of decrease of 6% loss in 30 days and 18% loss in 180 days. Met with the resident who at times dislikes food choices, alternative choices offered within modified dietary restrictions, receiving supplements twice daily with variable intake. Resident #7 not concerned about weight loss and not receptive to additional supplements or fortified foods. b. Review of the clinical record failed to reflect that the physician and resident representative had been notified of the residents 6% weight loss in 30 days and 18% weight loss in 180 days. Physician's order dated 12/7/25 directed to obtain a weekly weight. The annual MDS dated [DATE] identified Resident #7 had moderately impaired cognition, no weight loss in the past 6 months and weighed 107 lbs. The clinical record identified Resident #7 was transferred to the hospital on 3/8/26 and readmitted to the facility on [DATE]. The weights and vitals summary identified Resident #7 weighed 99.8 lbs. on 3/12/26. A dietary note dated 3/31/26 (weight warning) identified Resident #7 weighed 98.7 lbs. on 3/26/26, indicative of a 7% weight loss since previous nutritional intervention 3/14/26. Weights are on a downward trend despite nutritional interventions. Supplements twice daily with variable intake. Recommend assistance with meals as resident allows. Note: not receptive to assistance at lunch today. c. Review of the clinical record failed to reflect that the physician and resident representative had been notified of the residents 7% weight loss since previous nutritional intervention 3/14/26. The clinical record failed to reflect weights had been obtained during the month of May 2026. The care plan dated 5/1/26 original date (7/8/25) identified Resident #7 has nutritional problems or potential nutritional problems related to variable intake, fair-poor appetite and weight fluctuates related to localized edema, congestive heart failure and diuretic use. Interventions include to provide diet and supplements as ordered, and registered dietitian to evaluate and make recommendations as needed. The resident often refuses to be weighed. Physician's orders for July 2026 (original order date 12/7/25) directed to provide house 8 oz supplement twice daily. The weights and vitals summary identified Resident #7 weighed 93.5 lbs. on 7/11/26, a 5.27% weight loss since 3/31/26. Interview with the DNS on 7/15/26 at 10:18 AM identified after review of the clinical record, there was no documentation that the physician or resident representative had been notified of the weight losses of September and October 2025 or that the resident representative had been notified of the weight loss in March 2026. Review of a care plan conference note dated 6/23/26 indicated the resident representative had been updated on the resident's condition. The policy on weight measurement dated 7/2023 is to ensure all resident's weights are routinely checked, to assess any variation, and implement appropriate intervention for significant weight loss or gain. The procedure included a resident weight variance of 5 lbs. or more in 1 month, or 7.5% in 3 months, or 10% in 6 months will be reweighed. Resident's who experience a weight loss of 5 lbs. or more in 1 month, or 7.5% in 3 months, or 10% in 6 months will be reviewed by the dietitian. The dietitian will review with resident weight and make recommendations accordingly. The resident plan of care will be updated accordingly. Review of the physician notification policy dated 7/2023 is to ensure the RN Supervisor will call the physician with a change of status or condition. The purpose is to ensure that providers are notified of resident changes of status or condition in an appropriate and timely manner where interventions are deemed necessary in accordance with advance directives and resident wishes. If a resident is assessed to have a change in condition it is the responsibility of the charge nurse to notify the RN supervisor on duty. It is then the RN supervisor's responsibility to do a follow up assessment and to report changes to the physician.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #35 and 68) reviewed for resident-to-resident abuse, the facility failed to protect Resident #35 and Resident #68 from physical abuse by Resident #37, who wandered into both residents' rooms prior to the altercations. Resident #37 punched Resident #35 in the face causing the resident to fall on the floor where Resident #37 continued to assault the resident. The findings include:1. Resident #35 was admitted to the facility in December 2025 with diagnoses that included dementia with psychotic disturbance and history of delirium.The care plan dated 12/27/25 identified Resident #35 uses psychotropic medications related to depression, dementia with behaviors, and history of delirium. Interventions included to administer medications as ordered. Monitor and record occurrence for target behaviors: violence/aggression towards staff and others.The quarterly MDS dated [DATE] identified Resident #35 had severely impaired cognition and was dependent with transfer to wheelchair. Additionally, Resident #35 exhibited no physical and verbal behaviors toward others.The facility's monthly census report for April 2026 identified that on 4/19/26, the total facility census was 82 residents. The census for the Memory Care Center was 21 residents.The physician's order dated 4/1/26 directed that Resident #35 required assistance of one for transfers and ambulation using a rolling walker.The reportable event form dated 4/19/26 at 8:48 PM identified Resident #37 was observed by staff to enter Resident #35's room, pus Resident #35 to the floor, and hit Resident #35. Both residents were separated immediately and 1:1 monitoring was initiated for both residents. Resident #37 was transferred to the hospital for evaluation. Resident #35 complained of right shoulder pain and was transferred to the hospital for evaluation.The change in condition evaluation dated 4/19/26 at 10:41 PM identified Resident #35 had a physical altercation with another resident. Resident #35 complained of acute pain to the right anterior shoulder; potential injury related to the physical altercation. A written statement by NA #8 dated 4/19/26 (no time) identified she observed Resident #37 attempting to enter Resident #35's room while Resident #35 was standing in the doorway with a walker, repeatedly saying to move back, this is not your room. NA #8 indicated that Resident #37 had a history of wandering into other residents' rooms, pushed Resident #35, causing Resident #35 to fall to the floor. NA #8 indicated she immediately ran to get LPN #7. A written statement by LPN #7 dated 4/19/26 (no time) identified at approximately 8:30 PM, NA #8 notified LPN #7 that Resident #37 had pushed Resident #35 to the floor. LPN #7 indicated at that time she was in another resident's room managing a combative resident. LPN #7 instructed NA #8 to notify RN #5 (RN Supervisor) to report to the unit immediately. LPN #7 proceeded to Resident #35's room after directing NA #8 to remain with the combative resident. LPN #7 indicated upon entering Resident #35's room, Resident #37 was sitting on Resident #35's bed and punching Resident #35 while Resident #35 was on the floor attempting to defend himself/herself. LPN #7 indicated she attempted to separate the residents by holding each resident's wrists. Resident #37 continued attempting to hit Resident #35 and also struck LPN #7. LPN #7 indicated she positioned herself between both residents as Resident #35 stood up from the floor. Resident #37 continued attempting to kick Resident #35. LPN #7 indicated another nurse aide arrived assist. Together, they escorted Resident #37 from the room while Resident #37 remained combative. The RN supervisor remained in Resident #35's room to assess Resident #35. LPN #7 indicated Resident #37 was escorted away from the hallway until the police arrived. The nurse's note dated 4/19/26 at 10:48 PM identified Resident #35 was involved in a physical altercation with Resident #37. Resident #35 was attempting to ask Resident #37 to leave his/her room. The physical altercation was witnessed by staff, who were attempting to remove Resident #37 from Resident #35's room. Resident #35 was transferred to the hospital for further evaluation.The care plan dated 4/19/26 identified Resident #35 had the potential to be physically aggressive. Resident #35 had a physical altercation with another resident when the other resident attempted to enter his/her room and he/she resisted. Interventions included to administer medications as ordered, and to intervene when the resident becomes agitated before the agitation escalated. The nurse's note dated 4/20/26 at 4:24 AM identified Resident #35 returned to the facility at 3:15 AM. Resident #35 denied pain or discomfort and x-rays and CT scan results were negative. The APRN progress note dated 4/20/26 at 11:00 AM identified Resident #35 was evaluated status post a hospital visit for physical assault. Appropriate workup was initiated at the hospital. Resident #35 was seen today in no acute distress, denies and does not exhibit headache, vision changes, nausea, vomiting, dizziness, and loss of consciousness, denies pain at this time. Full range of motion to right and left shoulder. Resident #35 was alert and oriented to self, at baseline per dementia. No visible bruising, abrasion, or swelling to head, face, or right upper arm. Continue neurological monitoring due to reported head trauma and resident's anticoagulation therapy. Monitor for signs of delayed intracranial bleeding or behavioral changes. The social service note dated 4/21/26 at 3:56 PM identified SW #1 follow up with Resident #35 after an incident that occurred on 4/19/26. Emotional support was provided. Resident #35 was in his/her room eating lunch with his/her representative. Resident #35 reported doing okay and appeared to be in good spirits. Resident representative was offered a room change and agreed to the change. Interview with LPN #7 on 7/17/26 at 1:56 PM identified on 4/19/26 during the 3:00 PM - 11:00 PM shift, two nurse aides were assigned to the Memory Care Center. LPN #7 indicated Resident #37 had exhibited no behavioral issues during the 7:00 AM - 3:00 PM shift. LPN #7 indicated while responding to a combative resident in another room, NA #8 informed her that Resident #37 had pushed Resident #35 to the floor. LPN #7 indicated she instructed NA #8 to notify the RN #5 immediately. LPN #7 indicated after directing NA #8 to remain with the combative resident, she responded to Resident #35's room. LPN #7 indicated she observed Resident #37 sitting on Resident #35's bed punching (closed fist) Resident #35 in the face and chest while he/she was on the floor trying to defend himself/herself. LPN #7 indicated she immediately intervened to separate the residents. LPN #7 indicated Resident #35 got up from the floor, and she positioned herself between the two residents while yelling for assistance. LPN #7 indicated she and nurse aide each held one of Resident #37's arms and escorted Resident #37 from the room. LPN #7 indicated Resident #37 remained combative during the escort. LPN #7 indicated she remained with Resident #37 in the television lounge until the police arrived. LPN #7 indicated Resident #37 was transferred to the hospital for evaluation.Interview with RN #5 on 7/17/26 at 5:01 PM identified on 4/19/26 during the 3:00 PM - 11:00 PM shift, there were 2 nurse aides assigned to the Memory Care Center. RN #5 indicated that NA #8 called her and requested assistance. Upon entering the Memory Care Center, RN #5 observed LPN #7 struggling with Resident #37, who was combative in the television lounge. RN #5 indicated Resident #35 was in the room and reported that (a man came in my room and beat me up). RN #5 performed an assessment of Resident #35 and observed no bruising or discoloration to the resident's skin. RN #5 indicated she was unable to complete an assessment on Resident #37 due to the resident's combative behavior. RN #5 indicated that both residents were transferred to the hospital for further evaluation.Interview with NA #9 on 7/20/26 at 8:48 AM identified on 4/19/26 at approximately 8:30 PM she heard a loud commotion coming from the hallway and ran to see what was happening. NA #9 indicated NA #8 told her that Resident #37 had beaten and attacked Resident #35. NA #9 indicated she observed Resident #35 lying on the floor and Resident #37 standing next to Resident #35. NA #9 indicated NA #8 instructed her to remain with Resident #37 while NA #8 went to get LPN #7. NA #9 indicated she remained with Resident #37 while Resident #35 continued to lie on the floor. NA #9 indicated LPN #7 and RN #5 entered the room. NA #9 indicated LPN #7 and NA #8 escorted Resident #37 from the room. NA #9 indicated Resident #37 was combative during the escort. NA #9 indicated RN #5 assessed Resident #35, and NA #9 remained with Resident #35.Interview with NA #8 on 7/20/26 at 10:57 AM identified she was an agency staff who worked 4/19/26 during the 3:00 PM - 11:00 PM. NA #8 indicated there were 2 nurse aides assigned to the shift and that it was her first time assigned to the Memory Care Center. NA #8 indicated that at approximately 8:30 PM, after exiting another resident's room across the hall from Resident #37's room, she observed Resident #35 standing in the doorway of her room while Resident #37 was attempting to enter Resident #35's room. NA #8 indicated Resident #35 told Resident #37 to move back, this is not your room. NA #8 indicated Resident #37 forcefully pushed Resident #35, causing Resident #35 to fall to the floor. NA #8 indicated she attempted to redirect Resident #37 out of Resident #35's room but was unable to do so because Resident #37 was physically resisting her and was larger than her. NA #8 indicated NA #9 entered the room, and NA #8 instructed NA #9 to remain with Resident #37 while she went to get LPN #7. NA #8 indicated she found LPN #7 responding to another resident who was combative. NA #8 indicated LPN #7 instructed her to remain with the combative resident while LPN #7 responded to Resident #35's room.Although attempted, an interview with the previous DNS was not obtained.The reporting abuse to facility management policy identified it is the responsibility of the employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incidents of neglect or resident abuse, including injuries of unknown sources, exploitation and theft or misappropriation of resident property to facility management. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.The abuse prevention program policy identified the residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion. 2a. Resident #68 was admitted to the facility in December 2023 with diagnoses that included dementia with anxiety, hemiplegia and hemiparesis affecting the left side. The quarterly MDS dated [DATE] identified Resident #68 had severely impaired cognition and exhibited no physical and verbal behaviors toward others.The physician's order dated 5/1/26 directed to provide assistance of one for transfers and out of bed to customized wheelchair per 24-hour positioning plan with pelvic belt for positioning.The reportable event form dated 5/20/26 at 7:00 PM identified Resident #37 was involved in an unwitnessed physical altercation with Resident #68. Resident #68 sustained a laceration above the right eyebrow. Both residents were separated and placed on 1:1 monitoring and transferred to the hospital for evaluation. The nurse's note dated 5/20/26 at 8:25 PM identified Resident #68 was observed lying on the floor at the foot of his/her bed with blood on his/her face and chest. Resident #37 was sitting on the edge of Resident #68's bed. Resident #68 indicated that Resident #37 came into the room, wearing his/her sweatshirt. Resident #68 stated he/she told Resident #37 to take off the sweatshirt, both residents yelled, and Resident #37 punched him/her in the face. A neurological assessment was initiated and an RN assessment identified Resident #68 denied any pain, had range of motion within normal limits, and mentation remained at baseline. Both residents were placed on 1:1 monitoring. Both residents were transferred to the hospital for evaluation.The change in condition evaluation dated 5/20/26 at 8:43 PM identified Resident #68 sustained a 3.0 cm x 1.0 cm laceration above the right eye with active bleeding after being punched in the face by another resident and a fall. Resident #68 denied pain; however, the assessment identified sad and frightened facial expressions, a frown, and tense body language, distress, and fidgeting. The nurse's note dated 5/21/26 at 12:17 AM identified the hospital reported the CT scan of the head and cervical spine were negative. The resident's right eyebrow laceration was treated with medical glue, with instructions not to wash the area until a scab had formed. The resident was reported to be stable for return to the facility.The nurse's note dated 5/21/26 at 1:52 AM identified that Resident #68 returned to the facility at approximately 1:40 AM alert and verbal with staff. The social service note dated 5/21/26 at 2:26 PM identified SW #1 followed-up with Resident #68 following a resident-to-resident altercation that occurred on 5/20/26. SW #1 provided emotional support and encouragement. Resident #68 was unable to recall the incident and appeared to be doing well during the visit.The summary report dated 5/28/26 at 2:43 PM identified following an investigation, Resident #37 entered Resident #68's room wearing Resident #68 sweatshirt. This resulted in a verbal altercation that escalated to a physical altercation. Upon return from the hospital, Resident #37 was placed on 1:1 monitoring for 72 hours and followed by transition to every 15 minutes checks. A written statement by NA #9 dated 5/20/26 (no time documented) identified NA #9 entered Resident #68's room and observed Resident #68 lying on the floor and Resident #37 sitting on Resident #68's bed. When NA #9 asked Resident #68 what happened, Resident #68 pointed toward Resident #37. NA #9 indicated she placed a pillow under Resident #68's head and called for the nurse.A written statement by LPN #9 (no time documented) identified she was with an orientee nurse (LPN #8) passing out medication when NA #9 came and reported that there was an altercation between two residents. LPN #9 indicated they walked into the Resident #68 room and Resident #68 was on the floor and Resident #37 was sitting on Resident #68's bed.A written statement by LPN #8 (no time documented) identified she was with LPN #9 passing out medication when NA #9 came and informed them that there was an altercation between two residents. Interview with the Administrator on 7/14/26 at 10:00 AM identified she was aware of the resident-to-resident altercation. The Administrator indicated she was not involved in the clinical operations of the facility and that the DNS was responsible for overseeing the clinical department.Interview with the DNS on 7/15/26 at 6:00 AM identified the staff immediately separated both residents and both residents were placed on 1:1 monitoring until transferred to the hospital for evaluation. The DNS indicated Resident #37 was placed on every 15 minutes monitoring upon returned from the hospital.Although attempted, an interview with the previous DNS, RN #1, LPN #9, and NA #9 were not obtained.The reporting abuse to facility management policy identified it is the responsibility of the employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incidents of neglect or resident abuse, including injuries of unknown sources, exploitation and theft or misappropriation of resident property to facility management. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.The abuse prevention program policy identified the residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion.

Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #1) reviewed for unnecessary medications, the facility failed to ensure an as needed (PRN) order for a psychotropic medication was limited to 14 days. The findings include:Resident #1 was admitted to the facility in January 2026 with diagnoses that included depression, dementia, and psychosis. The admission MDS dated [DATE] identified Resident #1 had intact cognition and had taken medications from the following high-risk drug classifications in the past 7 days: antipsychotic, antidepressant, and hypoglycemic. The care plan dated 2/15/26 identified Resident #1 used psychotropic medications, with interventions that included administering medications as ordered by the physician and monitoring for side effects or adverse reactions. A physician's order dated 1/30/26 through 6/17/26 directed to administer Trazadone HCl 100mg, give 2 tablets by mouth every 24 hours, as needed for sleep. The Monthly Medication Regimen Review dated 2/12/26 identified the consultant pharmacist made the following recommendation: Resident #1 has an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber.The Monthly Medication Regimen Review dated 3/12/26 identified the consultant pharmacist made the following recommendation: Resident #1 has an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber.The Monthly Medication Regimen Review dated 4/13/26 identified the consultant pharmacist made the following recommendation: Resident #1 had an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber.The clinical record dated 2/12/26 through 4/30/26 failed to identify the physician or APRN documented, in the resident's medical record, that the PRN Trazadone irregularity had been reviewed. Further, the clinical record indicated no action had been taken to provide an evaluation for the continuation of the PRN Trazadone order, discontinue the PRN Trazadone order, or scheduling the Trazadone.Interview with the DNS on 7/15/26 at 7:43 AM identified that since the facility's Change of Ownership on 5/1/26, they have transitioned to a new pharmacy, and they were in the process of revamping and streamlining the process for reviewing the recommendations made by the consultant pharmacist's during the monthly regimen review. The DNS indicated that he was not the DNS when the consultant pharmacist's recommendations to review Resident #1's PRN Trazadone order were made so he could not speak to the process at that time, but his expectations would be that the recommendation would have been reviewed by the provider and implemented in a timely manner.The Medication Pharmacist Reports policy directs that the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and director of nursing, at a minimum. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. The Director of Nursing or designated licensed nurse address and document recommendations that do not require physician intervention.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #2 and 78) reviewed for hospitalization and for resident hospital transfers occurring between May 2025 through December 2025, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in accordance with regulatory requirements when the residents were transferred to the hospital. The findings include: 1. Resident #2 was admitted to the facility in July 2025 with diagnoses that included dementia with behavioral disturbance and congestive heart failure. A nurse's note dated 4/12/26 identified at 5:32 AM Resident #2 was transferred to the hospital and was readmitted on [DATE]. 2. Resident #78 was admitted to the facility in April 2026 with diagnoses that included chronic viral hepatitis C, and pneumonia.The census list identified Resident #78 was transferred to the hospital on 4/13/26 and returned to the facility on 4/14/26. The resident was transferred again on 4/17/26 and returned to the facility on 4/18/26.A nurse's note dated 4/27/26 at 10:30 AM identified Resident #78 was transferred to the hospital.Review of facility documentation failed to reflect that the Office of the State Long-Term Care Ombudsman had been notified when Resident #2 and 78 were transferred to the hospital.Review of the action summary form (transfer to hospital) failed to reflect documentation that the Office of the State Long-Term Care Ombudsman had been notified of residents transferred to the hospital between May 2025 through December 2025 on a monthly basis. Review of the monthly transferred file uploaded forms identified the action summary for May 2025 through December 2025 were not submitted to the Office of the State Long-Term Care Ombudsman until 2/2026.Interview with SW #1 on 7/14/26 at 11:00 AM identified she has been employed by the facility for approximately 2 months. SW #1 indicated the previous social worker sent the wrong action summary form for the month of April 2026 to the Office of the State Long-Term Care Ombudsman. SW #1 indicated the previous social worker was responsible for notifying the Office of the State Long-Term Care Ombudsman monthly of residents who had been transferred to the hospital.Interview with the DNS on 7/14/26 at 11:14 AM identified he has been employed by the facility for approximately 2 months. The DNS indicated he was not working for the facility at that time and he was not aware that the Office of the State Long-Term Care Ombudsman had not received the correct transfer to the hospital form for April 2026. Interview with the Administrator on 7/14/26 at 11:15 AM identified she has been employed by the facility for approximately one year. The Administrator indicated she was not aware that the Office of the State Long-Term Care Ombudsman had not received the correct transfer to the hospital form for April 2026. The Administrator indicated she was not involved in the clinical operations of the facility and that the previous DNS was responsible for overseeing the clinical department.Although attempted, an interview with the previous DNS, and previous SW was not obtained.Although requested, a facility policy was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 7 residents (Resident #5) reviewed for preadmission screening and resident review (PASARR), the facility failed to ensure that a Level I rescreen was completed timely for a resident with identified serious mental health diagnoses. The findings include:Resident #5 was admitted to the facility in December 2025 with diagnoses that included bipolar disorder, alcohol abuse disorder, and diabetes.Review of a Level I PASARR report dated 12/16/25 (prior to admission) identified Resident #5 had a mental health disability and identified an exempted approval for 30 days (until 1/15/26) due to hospital discharge. The PASARR identified that if Resident #5 required a stay at the facility for longer than 30 days, a facility representative must update the Level I PASARR and perform a full PASARR level II evaluation. The admission MDS dated [DATE] identified Resident #5 had moderately impaired cognition, was frequently incontinent of bowel and bladder and was independent with toileting, bathing, and transfers. The MDS also identified required a walker, was a current tobacco user, and required daily psychotropic and antipsychotic medications. The MDS identified Resident #5 did not exhibit any wandering behaviors.Review of the care plan dated 12/30/25 failed to identify interventions related to any mental health issues or psychotropic medications.Review of the clinical record failed to identify a Level I PASARR rescreen was initiated or completed for 1/2026, 2/2026, or 3/26 for Resident #5. Review of clinical record identified a Level I PASARR rescreen was completed on 4/23/26 (98 days after the expiration of the initial Level I PASSAR. The report identified a referral for a Level II PASARR evaluation. Review of a Level II PASARR report dated 5/1/26 identified Resident #5 has a positive Level II finding due to bipolar disorder, anxiety and depression with short term approval through 7/30/26. Interview with SW #1 on 7/16/26 at 6:52 AM identified that she recently started employment with the facility around 4/18/26 and following the review of resident PASARR reports, she identified that Resident #5 required a Level I PASARR rescreen due to the previous screening being out of date. SW #1 identified that the Level I PASARR rescreen should have been completed around 1/15/26 but due to staffing and a recent change in facility ownership, Resident #5 did not have a rescreen completed timely. The facility policy on PASARR directed that admission staff would obtain and review a PASARR Level I screening prior to admission to the facility. The policy further directed that residents requiring a Level II evaluation would not be admitted to the facility unless an allowable exemption applied and that staff would also comply with all applicable state and federal PASARR requirements. The policy also directed it was the responsibility of the social services department to coordinate PASARR evaluations when required. The facility policy on behavior assessment, intervention, and monitoring directed that behavioral symptoms would be monitored. The policy also directed that all residents of the facility would receive a PASARR Level I screen for admission and if the PASARR Level I screen indicated the individual met the criteria for mental illness, intellectual disability, or related condition, he or she would be referred to a state PASARR representative for a Level II evaluation and determination screening. The policy also directed that the Level II evaluation report would be used when conducting the resident assessment and development of a care plan.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #5) reviewed for PASARR, the facility failed to ensure the care plan reflected the resident's serious mental health diagnoses following admission to the facility. The findings include:Resident #5 was admitted to the facility in December 2025 with diagnoses that included bipolar disorder, alcohol abuse disorder, and diabetes.Review of the hospital discharge documentation identified Resident #5 reported active smoking of 4 cigarettes per day. A smoking evaluation dated 12/24/25 identified Resident #5 used smoking or vape devices. A physician's order dated 12/24/25 directed to administer Olanzapine (an antipsychotic medication used to treated bipolar disorder) 10 mg by mouth nightly at bedtime.An APRN admission note dated 12/26/25 identified that Resident #5 had a diagnosis of bipolar disorder versus schizoaffective disorder and alcohol use disorder. The admission notes further identified there were concerns that Resident #5 had impaired decision-making abilities due to underlying psychiatric disease and repeated refusals of care.A psychiatric APRN admission note dated 12/26/25 identified Resident #5 had a history of documented alcohol use disorder, bipolar disorder, and reported daily cigarette smoking with cravings. The treatment plan identified orders that included Nicorette (a nicotine replacement) lozenges 2 mg every two hours as needed for 14 days then reevaluate, and NicoDerm transdermal patch 21 mg every day for nicotine dependence for six weeks.A physician's admission note dated 12/29/25 identified that Resident #5 had a previous history of alcohol use disorder, prior substance abuse disorder which included benzodiazepine, cocaine, cannabinoids, and opiates, and was an active cigarette smoker. The note further identified that Resident #5 had chronic delusions from schizoaffective bipolar disorder and had impaired decision-making capacity. The note also identified Resident #5 reported doing well except for cravings to smoke cigarettes. The note identified Resident #5 was counseled on smoking cessation for approximately 3 minutes, but that Resident #5 continued to smoke.The admission MDS dated [DATE] identified Resident #5 had moderately impaired cognition, was independent with toileting, bathing, and transfers, was a current tobacco user, required daily antipsychotic medication and had a diagnosis of bipolar disorder. A nurse's note dated 12/31/25 identified Resident #5 expressed a desire to leave the facility against medical advice. The note further identified MD #1 was contacted and instructed facility staff Resident #5 had impaired decision-making capacity and was in the process of obtaining conservatorship.A psychiatric APRN note dated 12/31/25 identified that the resident was seen due to his/her request to leave the facility against medical advice. The note identified that Resident #5 was requesting to leave the facility due to nicotine cravings but was declining interventions.Review of Resident #5's care plan failed to identify interventions related to alcohol use disorder, prior history of substance abuse, current tobacco use, or impaired decision-making capacity.Interview with the DNS on 7/15/26 at 11:56 AM identified that Resident #5's comprehensive care plan should have reflected the resident's serious mental health diagnoses, refusals of care, impaired decision making, or need for daily antipsychotic medications following admission to the facility. The DNS identified that the facility recently underwent a change of ownership in May 2026, and prior to the transition that there were multiple nursing staff changes which impacted review of and revisions of the resident's care plans. The facility policy on care plans directed that it was the policy of the facility to have an interdisciplinary care plan to achieve and maintain the optimal status for each resident. The care plan would be developed no later than seven days after the completion of the comprehensive assessment (MDS). The resident care plan would include the resident's needs, realistic goals, and the care and services needed to meet these goals. The resident care plan would also identify which discipline was responsible for providing the care and services required, and the date of the expected achievement of the goals. The policy also directed that the resident care plan would include physical, cognitive and psychosocial problems, and would address the resident's needs on an individualized basis.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #5) reviewed for PASARR, the facility failed to ensure that the care plan was revised to reflect cigarette cravings, which led to anxiety and wandering behaviors. The findings include: Resident #5 was admitted to the facility in December 2025 with diagnoses that included bipolar disorder, alcohol abuse disorder, and diabetes. Review of the hospital discharge documentation identified Resident #5 reported active smoking of 4 cigarettes per day. A smoking evaluation dated 12/24/25 identified Resident #5 used smoking or vape devices. A physician's order dated 12/24/25 directed to administer Olanzapine (an antipsychotic medication used to treated bipolar disorder) 10 mg by mouth nightly at bedtime. Review of the clinical record failed to identify any additional smoking evaluations after 12/24/25. An APRN admission note dated 12/26/25 identified that Resident #5 had a diagnosis of bipolar disorder versus schizoaffective disorder and alcohol use disorder. The admission notes further identified there were concerns that Resident #5 had impaired decision-making abilities due to underlying psychiatric disease and repeated refusals of care. A psychiatric APRN admission note dated 12/26/25 identified Resident #5 had a documented history of alcohol use disorder, bipolar disorder, and reported daily cigarette smoking with cravings. The treatment plan identified orders that included Nicorette (a nicotine replacement) lozenges 2 mg every two hours as needed for 14 days then reevaluate, and NicoDerm transdermal patch 21 mg every day for nicotine dependence for six weeks. A physician's admission note dated 12/29/25 identified that Resident #5 had a previous history of alcohol use disorder, prior substance abuse disorder which included benzodiazepine, cocaine, cannabinoids, and opiates, and was an active cigarette smoker. The note further identified that Resident #5 had chronic delusions from schizoaffective bipolar disorder and had impaired decision-making capacity. The note also identified Resident #5 reported doing well except for cravings to smoke cigarettes. The note identified Resident #5 was counseled on smoking cessation for approximately 3 minutes, but that Resident #5 continued to smoke. The admission MDS dated [DATE] identified Resident #5 had moderately impaired cognition, and was independent with toileting, bathing, and transfers. The MDS also identified Resident #5 as a current tobacco user, required daily antipsychotic medication and had a diagnosis of bipolar disorder. Review of Resident #5's care plan dated 12/30/25 failed to identify mental health issues, refusals of care, impaired decision making, current tobacco use, or need for daily antipsychotic medications. A nurse's note dated 12/31/25 identified Resident #5 expressed a desire to leave the facility against medical advice. The note further identified MD #1 was contacted and instructed facility staff Resident #5 had impaired decision-making capacity and was in the process of obtaining conservatorship. A psychiatric APRN note dated 12/31/25 identified that the APRN was asked to see the resident due to the request to leave the facility against medical advice. The note identified that Resident #5 was requesting to leave the facility due to nicotine cravings. A physician's order dated 1/2/26 directed to apply a wander guard to the left ankle with function checks every night shift. Review of the care plan dated 1/9/26 (16 days after admission and 12 days following the MDS assessment) identified Resident #5 required psychotropic medications related to bipolar disorder, anxiety, and depression. Interventions included provide psychiatric services as needed. The care plan dated 1/9/26 also identified that Resident #5 was an elopement risk/wanderer due to impaired safety awareness. Interventions included identifying a pattern of wandering to include: if wandering was purposeful, if the resident was looking for something and intervene. Review of the care plan dated 1/9/26 failed to identify interventions related to smoking or nicotine dependence. A social service note dated 1/15/26 identified Resident #5 requested to be transferred to another facility that would allow smoking. The note identified that two other facilities were contacted regarding transferring the resident however, no beds were available and Resident #5 was put on a waiting list for one of the facilities. A social service note dated 1/19/26 identified Resident #5 was notified that there were no available beds at other facilities but that social services would continue to search for smoking facilities with available beds. Review of the clinical record failed to identify any documentation that attempts were made by the facility to assist Resident #5 with a transition of care to a smoking facility after 1/19/26. A psychiatric APRN note dated 1/21/26 identified Resident #5 reported heightened anxiety due to a strong desire to return home due to craving nicotine. The note identified a new order for Xanax 0.25 mg every 12 hours as needed for anxiety for 14 days. A psychiatric APRN note dated 1/30/26 identified Resident #5 having significant nicotine cravings due to dependence. The note further identified Resident #5 was refusing nicotine replacement treatments due to an allergy to transdermal nicotine patches, inability to chew nicotine gum and was unable to use nicotine lozenges because he/she would swallow them. A physician's note dated 2/12/26 identified Resident #5 was seen due to concerns with agitation, and that Resident #5 was agitated due to the wander guard and was trying to leave the building but was redirectable. The note further identified a new order to administer Xanax 0.5 mg tablet one time and 0.25 mg tablet every 8 hours as needed for 10 days. Review of Resident #5's care plan failed to identify any review, revisions, or interventions following 2/12/26 when Resident #5 attempted to leave the facility due to agitation. A psychotherapy note dated 2/19/26 identified that Resident #5 was preoccupied with wanting to smoke outside of the facility. The note further identified the provider discussed the smoking policy outside with the resident. A nurse's note dated 3/24/26 identified Resident #5 had removed and refused the wander guard. A psychotherapy note dated 6/23/26 identified that Resident #5 discussed wanting to smoke cigarettes to manage anxiety with the clinician. A psychiatric APRN note dated 7/7/26 identified Resident #5 reporting being upset due to not being able to go outside and smoke and because he she did not have any cigarettes. Review of Resident #5's care plan failed to identify any review, revisions, or interventions related to wandering behaviors and Resident #5's repeated reports of nicotine cravings. Interview with SW #1 on 7/16/26 at 6:52 AM identified that she recently started employment with the facility around 4/18/26. SW #1 identified she was not aware of any issues related to Resident #5's desire to smoke and was not aware that Resident #5 had ever requested a transfer to a smoking facility. Interview with the DNS on 7/15/26 at 11:56 AM identified that Resident #5's comprehensive care plan should have reflected the resident's serious mental health diagnoses, refusals of care, impaired decision making, or need for daily antipsychotic medications following admission to the facility. The DNS identified that the facility recently underwent a change of ownership in 5/2026, and prior to the transition that there were multiple nursing staff changes which impacted review of and revisions of the resident's care plans. The DNS further identified he was not aware of any issues related to Resident #5's desire to smoke and was not aware that Resident #5 had ever requested a transfer to a smoking facility. The facility policy on care plans directed that it was the policy of the facility to have an interdisciplinary care plan to achieve and maintain the optimal status for each resident. The care plan would be developed no later than seven days after the completion of the comprehensive assessment (MDS). The resident care plan would include the resident's needs, realistic goals, and the care and services needed to meet these goals. The resident care plan would also identify which discipline was responsible for providing the care and services required, and the date of the expected achievement of the goals. The policy also directed that the resident care plan would include physical, cognitive and psychosocial problems, and would address the residents needs on an individualized basis.

Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #11) reviewed for hospitalization, the facility failed to ensure contact precautions were initiated immediately upon the resident's return from the hospital with a diagnosis of C. difficile colitis, and for 1 resident (Resident # 51), who was on enhanced barrier precautions (EBP) the facility failed to put on personal protective equipment (PPE) prior to obtaining a fingerstick for blood sugar for a resident on enhanced barrier precautions according to infection control practices. The findings include: 1. Resident #11 was admitted to the facility in October 2025 with diagnoses that included spontaneous bacterial peritonitis, alcoholic cirrhosis of the liver with ascites, and thrombocytopenia. The quarterly MDS dated [DATE] identified Resident #11 had intact cognition, was always continent of bowel and bladder, and was independent with toilet transfers and toileting hygiene. The care plan dated 4/13/26 identified Resident #11 had an ADL self-care performance deficit related to admitting diagnoses of increased weakness and decreased mobility, with interventions that included assisting as needed to meet toileting needs and incontinent care per policy. The nurse's note dated 6/18/26 at 8:57 AM identified Resident #11 complained of 10/10 pain that has been persistent with intermittent sharp pain. The Medical Director was notified, and Resident #11 was sent to the hospital for evaluation. The Inter-Agency Patient Referral Report dated 6/25/26 at 4:17 PM identified Resident #11 problem list included C. difficile colitis (C-Diff). The nurse's note dated 6/25/26 at 9:07 PM identified that Resident #11 returned from the hospital at 5:00 PM status post hospital stay related to sepsis secondary to cirrhosis and ascites, positive for C-Diff, Vancomycin 125 mg by mouth every 6 hours for 18 doses, medication orders verified, and the physician was aware of the readmission. A physician's order dated 6/25/26 directed for the administration of Silver Nitrate External Solution 0.5%, apply topically to groin, 3 times daily for wound care and a physician's order dated 6/30/26 directed Resident #11 to remain on contact precautions for C-Diff. Interview with Resident #11 on 7/12/26 at 9:30 AM identified that he/she went to the hospital and returned to the facility on 6/25/26 with a diagnosis of C-diff. Resident #11 indicated that the facility staff did not begin to use personal protective equipment (PPE) when entering the room for 3 days following his/her readmission; Resident #11 indicated that he/she was readmitted on [DATE] and the use of PPE was not started until 6/28/26. Interview with the Infection Preventionist (LPN #3) on 7/14/26 at 2:16 PM identified that he was not made aware that Resident #11 was readmitted on [DATE] with C-Diff until 7/1/26 by one of the nurses. LPN #3 indicated that when he went to Resident #11's room on 7/1/26 the PPE bin was already outside the room, and he was not sure who placed the bin there, but he initiated the order for contact precautions on 7/1/26 when he was first made aware of Resident #11's C-Diff diagnoses and treatment orders. Interview and clinical record review with RN #1 on 7/14/26 at 3:05 PM identified that he was the 3:00 PM - 11:00 PM nurse supervisor when Resident #11 was readmitted to the facility on [DATE] at 5:00 PM and he did not initiate contact precautions at that time, and he could not recall when contact precautions were initiated. RN #1 indicated that a PPE bin was located outside of Resident #11's room prior to his/her transfer to the hospital on 6/18/26. Review of the clinical record failed to identify an order or rationale for the use of PPE prior to 6/18/26, but RN #1 indicated the PPE was outside of Resident #11's room for staff use while providing wound care to the genital area. Interview with the DNS on 7/15/26 at 7:55 AM identified that he was not aware that there was a delay in implementing contact precautions for Resident #11 following his/her readmission to the facility on 6/25/26, and it was his expectation that a resident returning from the hospital with a diagnosis of C-Diff would immediately be put on contact precautions by the nursing supervisor or the Infection Preventionist. The Contact Precaution policy directs that the purpose of contact precautions is to prevent the spread of microorganisms that are transmitted by direct contact with the resident. Contact precautions are required when performing resident care, activities that require touching the resident's dry skin, or touching environmental surfaces which could have been contaminated from care of specified residents with documented or suspected infections from highly transmittable or epidemiological significant pathogens, used in addition to universal precautions. Once a resident has been determined to have an infection or condition that can be spread by skin to skin contact obtain and write a doctor's order for contact precautions for the affected area or infection, place a see nurse before entering sign on the resident's door, notify the infection control nurse and director of nursing, cohort the resident or place with a low risk roommate if no private room is available, limit the movement or transport of the resident if infected body substance cannot be contained, clean the environment and resident care equipment thoroughly or have dedicated items, the resident may leave the room if the infected body substance is contained, strict gloving, hand washing and gowning when there is potential to come in contact with affected body substance, and terminally clean the room when the precautions are discontinued. 2. Resident #51 was admitted to the facility in June 2026 with diagnoses that included pressure ulcer of the right heel and buttock. The admission MDS dated [DATE] identified Resident #51 was moderately cognitively impaired, required one person assist with bed mobility, two person assist with transfers and one or more unhealed pressure ulcers. The care plan dated 6/23/26 identified Resident #51 had Type II diabetes and an alteration in skin impairment related to decreased immobility. Interventions included obtaining fasting blood sugars and follow facility protocols for treatment of injury. Physician's order dated 6/30/26 directed Novolog injection insulin 100 units per milliliter. Inject per sliding scale subcutaneously before meals. Blood sugar 151-199, give 1 unit; blood sugar 200-249, give 2 units; blood sugar 250-299, give 4 units; blood sugar 300-349, give 6 units; blood sugar 350-399, give 8 units; blood sugar 400-450, give 10units; call for blood sugar over 450. Blood sugar to be obtained at 7:30 AM, 11:30 AM and 5:00 PM. Observation on 7/12/26 at 8:15 AM identified signage for enhance barrier precautions (EBP) and an isolation cart containing gowns, gloves and masks just outside Resident #51's room. LPN #2 entered Resident #51's room without the benefit of PPE and informed the resident she was going to obtain a fasting blood sugar. LPN #2 preceded to lift Resident #51's right finger to obtain a fingerstick. The task was interrupted. Interview with LPN #2 on 7/12/26 at 8:15 AM identified Resident #51 had a pressure ulcer, therefore required PPE while providing direct care. LPN #2 indicated she did not put on PPE prior to attempting to obtain a fingerstick as an oversight. Interview with the DNS on 7/13/26 at 6:38 AM identified all staff entering a resident room with EBP were expected to wear gowns and gloves prior to providing direct care according to policy. The facility policy for enhanced barrier precautions directs the use of gowns and gloves during high contact care activities with the resident that may provide opportunities to transfer multidrug resistant organisms, MDRO's onto hands and clothing, thus, to other residents and staff. Residents with wounds are at especially high risk for acquiring and colonizing (organism is present but not causing illness) MDRO's. Examples of high contact activities include device care or use such as central lines, urinary catheter, feeding tube or ventilator/tracheostomy care. American Diabetes Association (ADA) standards of care in diabetes specifies that EBP should be used when performing high-contact care activities such as obtaining a blood glucose level that could involve contact with blood, body fluids, secretions, or excretions. American Diabetes Association [2025].

Based on review of employee records, facility documentation, and interviews, the facility failed to ensure sufficient licensed nursing staff who had current certification in Cardiopulmonary Resuscitation (CPR) were assigned per shift and in accordance with standards of nursing practice. The findings include:Review of the facility's licensed nursing staff roster identified a total of 19 licensed nurses on staff consisting of 7 Registered Nurses (RNs) and 12 Licensed Practical Nurses (LPNs). Review of the facility's CPR certification binder for licensed nurses identified 14 of 19 licensed nurses did not have valid, current CPR certification cards on file.The monthly census report for [DATE] identified the facility census was 75 residents in the facility.Review of the daily staffing schedule dated [DATE] identified on the 7:00 AM - 3:00 PM shift, 4 licensed nurses (2 facility staff and 2 agency staff) were without a current CPR certification, there were no other CPR certified licensed staff on duty. On the 3:00 PM - 11:00 PM shift, 1 facility licensed nurse with a current CPR certification and 3 licensed nurses (1 facility staff and 2 agency staff) without a current CPR certification. On the 11:00 PM - 7:00 AM shift, 3 facility licensed nurses without a current CPR certification, there were no other CPR certified licensed staff on duty. The monthly census report for [DATE] identified the facility census was 72 residents in the facility.Review of the daily staffing schedule dated [DATE] identified on the 7:00 AM - 3:00 PM shift, 4 facility licensed nurses without a current CPR certification, there were no other CPR certified licensed staff on duty. On the 3:00 PM - 11:00 PM shift, 4 facility licensed nurses without a current CPR certification, there were no other CPR certified licensed staff on duty. On the 11:00 PM - 7:00 AM shift, 3 facility licensed nurses without a current CPR certification, there were no other CPR certified licensed staff on duty. The monthly census report for [DATE] identified the facility census was 80 residents in the facility.Review of the daily staffing schedule dated [DATE] identified on the 7:00 AM - 3:00 PM shift, 4 licensed nurses without a current CPR certification, there were no other CPR certified licensed staff on duty. On the 3:00 PM - 11:00 PM shift, 4 facility licensed nurses (3 facility staff and 1 agency staff) without a current CPR certification, there were no other CPR certified licensed staff on duty. On the 11:00 PM - 7:00 AM shift, 3 facility licensed nurses without a current CPR certification, there were no other CPR certified licensed staff on duty. Interview with RN #6 on [DATE] at 9:45 AM identify that he does not oversee staff CPR certification cards as the previous DNS was responsible for maintaining CPR certification cards. RN #6 indicated that the current DNS had requested the CPR certification binder and indicated that he would assume responsibility for overseeing the CPR certification cards.Interview with the DNS on [DATE] at 10:20 AM identified he recently reviewed the facility's CPR certification binder and was aware that some licensed nurses did not have current CPR certification cards on file. The DNS indicated he assumed responsibility for overseeing the CPR certification card binder and ensuring licensed nurses maintain current CPR certification cards on file. The DNS indicated he met with the licensed nurses the previous week to request updated CPR certification cards. The DNS indicated it is his expectation that licensed nurses maintain a current CPR certification. The DNS identified he would reach out to a CPR facility to have someone come in and train the licensed nurses without a current CPR certification card as soon as possible. The DNS also indicated there would be a CPR certified supervisor on each shift until all certification matters have been resolved.Interview with the Administrator on [DATE] at 10:21 AM identified she was not aware licensed nurses did not have valid, current CPR certification cards on file until the previous week, when she observed the DNS meeting with licensed nurses and directing them to provide a valid, current CPR certification card. The Administrator indicated the previous DNS was responsible for oversight of the nursing department.Although requested a policy on CPR for employees was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #12) reviewed for activities, the facility failed to ensure that activities of interest were provided based on the resident's preferences. The findings include:Resident #12 was admitted to the facility in February 2025 with diagnoses that included a stage 4 sacral pressure ulcer, sickle cell trait, and depression.An activities assessment dated [DATE] by the Recreation Director identified Resident #12 had no interest in any arts and crafts activities.The annual MDS dated [DATE] identified Resident #12 had intact cognition, was frequently incontinent of bowel and bladder, and was independent with eating, toileting and showering. The care plan dated 1/25/26 identified Resident #12 required continued support with for independence and access to meaningful activities. Interventions included for the recreation staff to use a soft supportive tone allowing the resident to choose activities without feeling obligated, offer the resident materials for in room activities, respect the resident's right to refuse recreational services, and visit the resident 1:1 to determine the residence interest and offer support and encouragement.Observation and interview with Resident #12 on 7/12/26 at 11:00 AM identified that he/she had issues related to recreational activities and interactions with recreational staff. Resident #12 identified he/she did not like to participate in group recreational activities and instead chose to complete solo craft projects in his or her room. During the interview, observations of the resident's room identified multiple craft projects completed or in progress including decorated cardboard boxes and cut outs and collages on the resident's walls. Resident #12 identified that he/she had requested construction paper from the Recreation Director one 1 - 2 months prior and the Recreation Director initially identified that there was no construction paper available. Resident #12 identified that the interaction occurred in the recreation room, and that the Recreation Director was positioned in front of the activity supplies, and a stack of construction paper was visible on the shelves behind the Recreation Director. When Resident #12 identified there was construction paper on the shelves, the Recreation Director identified that it was for group activities only and that Resident #12 would have to participate in a group if he/she wanted to utilize the paper. Resident #12 further identified that the Recreation Director identified that if Resident #12 wanted construction paper for self-directed projects, he/she could purchase it on his/her own. Resident #12 identified that a few days later, Recreation Aide #1 was working and new to the facility. Resident #12 identified that since Recreation Aide #1 was new to the facility, Resident #12 attempted again to obtain construction paper for self-directed craft projects. Recreation Aide #1 identified that the construction paper was purchased by the Recreation Director and could only be utilized for group activities. Resident #12 identified she instructed Recreation Aide #1 that the construction paper was purchased by a fund allocated to the recreation department. Resident #12 identified that Recreation Aide #1 then said to the resident (oh don't you know everything). Resident #12 identified that following these two interactions with the recreation staff and attempts to obtain the construction paper, he/she did not pursue any additional attempts. Resident #12 also identified he/she felt disrespected and that if he/she decided to do craft activities in his/her room that was his/her choice. Interview with the Recreation Director on 7/13/26 at 11:34 AM initially identified that residents of the facility were allowed to self-direct their own arts and crafts and could access any craft or art supplies by asking the recreational staff. The Recreation Director then identified that she did recall the incident 1-2 months ago with Resident #12 and identified the resident requested construction paper. The Recreation Director identified that she instructed Resident #12 that there was no construction paper available and that Resident #12 became upset. The Recreation Director also identified initially that the recreation department previously had construction paper but had not had it in a couple of months. The Recreation Director then identified that during her discussion with Resident #12, she was unsure if there was any construction paper on the shelves behind her as she did not direct arts and crafts activities with the residents and that this was the responsibility of another staff member, and that she did not check. The Recreation Director also identified that Resident #12 had a habit of taking things and did not like being told no. The Recreation Director identified that she did not direct Resident #12 to buy her own craft supplies but did identify that she did buy many of the supplies for the recreation department with her own money, and that while the facility did provide reimbursement, she often did not submit for reimbursement due to it taking too long to get her money back. The Recreation Director identified that she would ensure that going forward Resident #12 had access to construction paper.Subsequent to surveyor inquiry, Resident #12 was provided with construction paper by the facility on 7/14/26. Review of the clinical record failed to identify any documentation that Resident #12 had issues taking others' belongings or facility property.Although attempted, an interview with Recreation Aide #1 was not obtained.The facility policy and procedure for recreational activities in a nursing home directed that recreational activities should be person centered, legally compliant, and staffed by qualified professionals to ensure safe, engaging, in a variety program that supported the physical, mental, and social well-being of all the facility residents.The facility policy on the recreation department directed that the recreation department would enhance the resident's quality of life, promote social interaction and community involvement, respect the resident's rights, preferences, and cultural diversity, and encourage maintenance or improvement of the residence physical and cognitive function. The policy further directed that the resident's choice to participate in activities was voluntary, residents had the right to refuse any activity, alternative choices should be offered whenever possible, and staff would encourage participation without coercion.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #51) reviewed for medication administration, the facility failed to accurately transcribe a physician's order to administer Magnesium Oxide 2 hours apart from other medications which resulted in the medication being administered with other prescribed medications, and for 1 resident (Resident #75) reviewed for care planning, the facility failed to schedule a neurology consultation according to the physician's order in a timely manner following a resident reported concern. The findings include: 1. Resident #51 was admitted to the facility in June 2026 with diagnoses that included pressure ulcer of the right heel and buttock. The admission MDS dated [DATE] identified Resident #51 was moderately cognitively impaired, required one person assist with bed mobility, two person assist with transfers and one or more unhealed pressure ulcers. The care plan dated 6/23/26 identified Resident #51 had Type II diabetes and an alteration in skin impairment related to decreased mobility. Interventions included obtaining fasting blood sugars and following facility protocols for treatment of injury. Physician's order dated 6/23/26 directed to administer Magnesium Oxide 400mg one time a day for supplementation with food and two hours apart from other medications. The administration time was directed to be administered at 9:00 AM. Observation on 7/12/26 at 8:15 AM identified LPN #2 administered Magnesium Oxide 400mg along with 8 other prescribed medications also ordered to be administered at 9:00 AM. Interview on 7/12/26 at 12:33 PM identified prior to medication administration, she reviews the order, dose and time and any special instructions. LPN #2 indicated she did not notice instructions to administer the medication two hours apart from other medications and instead administered the medication according to the time on the Kardex and with the other prescribed medications at 9:00 AM. Interview with the DNS on 7/13/26 at 6:38 AM identified nurses were expected to follow special instructions when transcribing physician orders. Interview with APRN #1 on 7/13/26 at 9:11 AM identified the rationale for the special instructions to administer apart from other medications was to maximize absorption. While there was no harm, APRN #1 intended on ordering a magnesium level. Review of the facility policy for Medication Orders dated 11/2021 directed medications are administered only upon clear, complete signed orders of the person lawfully authorized to prescribe. The order must specify the name of the medication, strength, dose, time and route of administration, duration of time and diagnoses. Each medication order is documented in the clinical record on the medication administration record and includes the date, time and signature of the person receiving the order. Attempts to interview RN #7, the transcribing nurse, were unsuccessful. 2. Resident #75 was admitted to the facility in February 2026 with diagnoses that included gout and chronic pain syndrome. The quarterly MDS dated [DATE] identified Resident #75 was cognitively intact, independent with bed mobility and transfers; mobile with the use of a wheelchair/walker. The care plan dated 5/26/26 identified Resident #75 had the potential for alteration in discomfort related to chronic pain syndrome. Interventions included administering pain medications as ordered and monitor/report resident complaints of pain or requests for pain treatment. An APRN progress note dated 7/1/26 identified Resident #75 was admitted with bilateral lower extremity weakness and had a history of peripheral neuropathy. Resident #75 reported continued tremors despite receiving prescribed Propranolol for tremors. Resident #75 was awaiting a neurology consult as provider suspects he/she may be suffering from Parkinson's disease. Physician's order dated 7/1/26 directed a neurology consult to be set up by the scheduler. Interview with Resident #75 identified he/she was admitted with difficulty walking with a previous history of neuropathy and was experiencing symptoms. Resident #75 requested a neurology consultation from the APRN. An order was written, then cancelled. Resident #75 further identified he/she still has not seen a neurologist. Interview with the Administrator on 7/13/26 at 6:19 AM identified NA #1 was responsible for scheduling medical appointments once a physician's order was received by nursing staff. The Administrator further identified she had no knowledge that the appointment had been cancelled. Interview with RN #2 on 7/13/26 at 9:15 AM identified NA #1 was newer to the role for scheduling medical appointments and did not yet have computer access to view internal communications requesting medical appointment scheduling. RN #2 indicated she verbally instructed NA #1 to schedule a neurology appointment for Resident #75, but it was not completed. Interview with NA #1 on 07/13/26 at 2:12 PM identified she assisted in scheduling medical appointments. NA #1 indicated she did not have computer access to acquire information regarding medical consults. NA #1indicated medical appointments were scheduled once nursing staff provided a copy of the physician's order for the consult referral. NA #1 further identified she did not have any discussion with RN #2 regarding scheduling a neurology appointment for Resident #75. Although requested, a facility policy detailing the provision of specialty services was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #49) reviewed for accidents, the facility failed to complete a smoking assessment on admission, for a resident with a known history of nicotine dependance, and failed to evaluate repeated smoking/contraband violations to identify root causes to reduce the risk of future violations. The findings include: Resident #49 was admitted to the facility in November 2025 with diagnoses that included hemiplegia and hemiparesis (weakness and paralysis) following a stroke affecting the right non-dominant side and post-traumatic stress disorder (PTSD). Review of admission documentation identified Resident #49 was conserved. The APRN admission note dated 11/6/25 identified Residet #49 was a former smoker with personal history of nicotine dependence; quit date not documented.The note did not include a documented plan to support smoking cessation. The admission MDS dated [DATE] identified Resident #49 required two person assist with bed mobility and transfers and was mobile with the use of a wheelchair/walker. The care plan dated 11/20/25 identified Resident #49 had an ADL deficit related to hemiplegia/hemiparesis, with interventions included to provide assistance with fluctuating ADL's. There was no care plan related to Resident #49's smoking history. The clinical record did not include a documented smoking assessment on admission or interventions for smoking cessation or ongoing support. Social service progress note dated 1/19/26 at 3:44 PM identified Resident #49 was observed smoking outside. Resident #49 stated he/she did not know smoking was not permitted at the facility. Resident #49 was educated about smoking in the facility and signed the smoking policy and procedure notification for the facility. The physician and APRN were notified. The APRN progress note dated 3/9/26 at 8:15 AM identified Resident #49 had a history of anxiety, PTSD and depression, nicotine dependance and substance abuse. Staff reported concerns related to Resident #49 smoking on facility property. Resident #49 endorses anxiety and irritability and utilizes psychiatric medications. Social work is looking into transferring Resident #49 to another facility. Resident #49 declined a nicotine patch but verbalizes understanding of the policy. A plan included to provide smoking cessation resources as appropriate. Social service progress note dated 3/9/26 at 11:31 AM identified Resident #49 consented to search his room where vaping materials were found in the bedside stand. Resident #49 was educated on the facility no smoking policy regarding smoking. Social service progress notes dated 4/10/26 at 4:40 PM identified LPN reported vaping material were found in Resident #49's room. A room search was completed with permission and Resident #49 was educated on facility prohibited items policy which was signed by Resident #49. A nicotine patch was offered which was agreed to. The nursing supervisor and conservator were notified. Resident #49 and responsible party were notified of 30-day involuntary discharge notice for future violations. Physician's order dated 4/10/26 directed Nicotine patch 21 milligrams (MG)/24HR Apply 1 patch transdermal (applied to the skin) one time a day for smoking cessation for one week and remove per schedule. The revised care plan dated 4/22/26 (81 days after the first violation and 32 days after the second violation) identified Resident #49 had a history of smoking. Interventions included offering nicotine replacement therapy and reinforce the policy regarding smoking in the facility. Review of clinical record and facility documentation dated 1/19/26 through 4/10/26 identified all smoking and contraband violations were not evaluated to identify root causes of how Resident #49 acquired smoking materials/contraband to reduce future violations. Interview with the Administrator on 7/13/26 at 12:23 PM identified Resident #49 always wanted to smoke and obtain smoking materials but had no history of smoking violations to her knowledge. Interview with MD #1, the Medical Director on 07/13/26 at 12:54 PM identified he was notified of two smoking/contraband violations, one inside the facility and one outside on the grounds of the facility but could not recall specific details. Interview with LPN #1 on 07/13/26 at 1:33 PM identified she had observed a few smoking/contraband violations by Resident #49. LPN #1 indicated she has observed Resident #49 smoking in his/her room in the past and has found contraband in his/her recliner on a couple of occasions with SW #2. All instances were also reported to the nursing supervisor. Interview with the DNS on 7/14/26 at 6:32 AM identified he was new to the facility as of May 2026 and unaware of any previous smoking violations. The DNS further identified all incidents of smoking/contraband violations should be examined for underlying causes to with interventions implemented to prevent future violations. Interview with the (former) DNS on 07/16/26 at 11:21 AM identified Resident #49 had incidents where smoking materials were located in his/her room but was unable to recall where smoking took place in the facility. The DNS indicated the Administrator was aware of the violations and wanted to remove leave of absence privileges as it was felt that was how materials were being obtained. The (former) DNS further identified all RN's and LPN's were responsible for examining all smoking/contraband violations during her tenure at the facility. Review of the facility Smoking policy dated 4/2024 directs that the facility is a non-smoking facility. Smoking of any kind including cigarettes, cigars, vaping devices, etc. is not permitted in the facility or on facility grounds. This is to ensure the highest quality of safety for the serious consequences of smoking for the staff and residents. Smoking paraphernalia is not permitted on the premises. The facility also prohibits the use of recreational marijuana or other recreational non-tobacco products in or on the facility property.The smoking policy is to be reviewed, when possible, prior to admission as part of the admission documentation. Should the resident/agent refuse to agree to the terms of the policy, the admission process may halt, with an alternative safe placement sought.The policy did not include information regarding smoking assessments for new admissions/quarterly and care planning.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #1 and 32) reviewed for unnecessary medications, the facility failed to ensure the pharmacist's monthly medication regimen review recommendations were reviewed by the facility provider and acted upon. The findings include: 1. Resident #1 was admitted to the facility in January 2026 with diagnoses that included dementia, psychosis, and asthma. A physician's order dated 1/30/26 directed to administer Trazadone HCl 100mg, give 2 tablets by mouth every 24 hours, as needed for sleep, and a physician's order dated 1/31/26 directed to administer Fluticasone HFA Inhalation Aerosol 110mcg/act, 1 puff inhale orally twice daily for asthma. The admission MDS dated [DATE] identified Resident #1 had intact cognition and had taken medications from the following high-risk drug classifications in the past 7 days: antipsychotic, antidepressant, and hypoglycemic. The care plan dated 2/15/26 identified Resident #1 had asthma, with interventions that included giving medications as ordered and monitoring for side effects and effectiveness. The care plan further identified Resident #1 used psychotropic medications, with interventions that included administering medications as ordered by the physician and monitoring for side effects or adverse reactions. The Monthly Regimen Review dated 2/12/26 identified the consultant pharmacist made the following recommendations: Resident #1 was taking Fluticasone inhaler. As this medication is a corticosteroid, please consider adding, rinse mouth after use to this order to prevent thrush. Resident #1 has an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber. The Monthly Regimen Review dated 3/12/26 identified the consultant pharmacist made the following recommendations: Resident #1 was taking fluticasone inhaler. As this medication is a corticosteroid, please consider adding, rinse mouth after use to this order to prevent thrush. Resident #1 had an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber. The Monthly Regimen Review dated 4/13/26 identified the consultant pharmacist made the following recommendations: Resident #1 was taking fluticasone inhaler. As this medication is a corticosteroid, please consider adding, rinse mouth after use to this order to prevent thrush. Resident #1 had an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber. Review of the clinical record failed to identify the consultant pharmacist's recommendations for Resident #1 to rinse his/her mouth following the administration of inhaled Fluticasone and to consider discontinuing or scheduling the PRN Trazodone as it had no stop date had been reviewed and/or acted upon by the provider. Interview with the DNS on 7/15/26 at 7:43 AM identified that since the facility's Change of Ownership on 5/1/26, they transitioned to a new pharmacy, and they were in the process of revamping and streamlining the process for reviewing both nursing and medical provider recommendations made by the consultant pharmacist's during the monthly regimen review. The DNS indicated that he was not the DNS at the time of the consultant pharmacist's recommendations that were made on 2/12/26, 3/12/26, and 4/13/26 and could not speak to the process at the time, but his expectation would be that the nursing and physician recommendations would have been reviewed and implemented, if appropriate, in a timely manner. The Medication Pharmacist Reports policy directs that the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and director of nursing, at a minimum. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. The Director of Nursing or designated licensed nurse address and document recommendations that do not require physician intervention. 2. Resident #32 was admitted to the facility in May 2024 with diagnoses that included Primary progressive multiple sclerosis, neuralgia and neuritis, and magnesium deficiency. The quarterly MDS dated [DATE] identified Resident #32 had intact cognition, was always incontinent of bowel and bladder and dependent on staff to assist with eating, toileting, and showering. The care plan dated 5/27/25 identified Resident #32 had impaired cognitive function and thought processes related to a history of hallucinations and altered perception due to multiple sclerosis. Interventions included administering medications as ordered and monitor and document for side effects and effectiveness. Review of the monthly pharmacy recommendation dated 8/4/25 identified Resident #32 was receiving a Magnesium supplement. The recommendation included to consider checking a magnesium level to monitor Magnesium Oxide therapy. Further review of the clinical record identified the same recommendation was made on 9/2/25 10/1/25, 11/7/25, 12/1/25 and 1/7/26. Review of the clinical record failed to identify that the pharmacy recommendation related to monitoring Magnesium Oxide had been reviewed or addressed by the facility from 8/2025 through the last recommendation of 1/2026. Review of the clinical record failed to identify orders or documentation of Magnesium Oxide results for Resident #32 from 8/2025 through the last recommendation of 1/2026. Further review identified a magnesium level was obtained on 4/2/26, 8 months after the initial recommendation. Interview with the DNS on 7/15/26 at 11:56 AM identified he was unable to locate any pharmacy regimen reviews that were addressed for Resident #32 from 8/2025 through 4/2026. The DNS identified that due to a recent change of ownership, and that he recently started in his position in 5/2026, there were issues locating pharmacy recommendations prior to his employment, but that the recommendations should have been addressed timely and included with the resident's clinical record. Interview with APRN #2 on 7/16/26 at 3:12 PM identified that she was no longer a provider at the facility. APRN #2 identified that the facility had 4 - 5 DNS's in place from 5/2025 until she left the facility in 6/2026 and did not recall if she ever was provided with or reviewed any pharmacy recommendations for Resident #32. APRN #2 identified that pharmacy recommendations were rarely provided to her to address. APRN #2 identified that this rarely happened and in part was one of the reasons she left the facility. The facility policy on consultant pharmacist reports directed that resident specific irregularities and/or clinically significant risk resulting from/or associated with medications would be documented in the resident's active record and reported to the DNS, medical director, and/or prescriber as appropriate and the notification mode was dependent on the severity of the irregularity and would be determined through consultation between the consultant pharmacists and the DNS. The policy further directed that recommendations would be acted upon and documented by the facility staff and/or prescriber and would include the prescriber accepting and acting upon the suggestion or rejecting and providing an explanation for disagreement. Resident #1 was admitted to the facility in January 2026 with diagnoses that included dementia, psychosis, and asthma. A physician's order dated 1/30/26 directed to administer Trazadone HCl 100mg, give 2 tablets by mouth every 24 hours, as needed for sleep, and a physician's order dated 1/31/26 directed to administer Fluticasone HFA Inhalation Aerosol 110mcg/act, 1 puff inhale orally twice daily for asthma. The admission MDS dated [DATE] identified Resident #1 had intact cognition and had taken medications from the following high-risk drug classifications in the past 7 days: antipsychotic, antidepressant, and hypoglycemic. The care plan dated 2/15/26 identified Resident #1 had asthma, with interventions that included giving medications as ordered and monitoring for side effects and effectiveness. The care plan further identified Resident #1 used psychotropic medications, with interventions that included administering medications as ordered by the physician and monitoring for side effects or adverse reactions. The Monthly Regimen Review dated 2/12/26 identified the consultant pharmacist made the following recommendations: Resident #1 was taking Fluticasone inhaler. As this medication is a corticosteroid, please consider adding, rinse mouth after use to this order to prevent thrush. Resident #1 has an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber. The Monthly Regimen Review dated 3/12/26 identified the consultant pharmacist made the following recommendations: Resident #1 was taking fluticasone inhaler. As this medication is a corticosteroid, please consider adding, rinse mouth after use to this order to prevent thrush. Resident #1 had an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber. The Monthly Regimen Review dated 4/13/26 identified the consultant pharmacist made the following recommendations: Resident #1 was taking fluticasone inhaler. As this medication is a corticosteroid, please consider adding, rinse mouth after use to this order to prevent thrush. Resident #1 had an order for a psychoactive PRN Trazodone which had been in place for greater than 14 days without a stop or evaluation date recorded. After 14 days, the use of psychoactive PRN may be continued if it is determined the benefit of treatment outweighs the potential/actual risk of continued PRN therapy. Please consider discontinuing this medication or scheduling it if necessary. If the continuation of this PRN is necessary, please conduct a risk versus benefit analysis to stay in compliance with regulations. If this medication is continued as PRN, a stop date or evaluation date must be added to the order, when this date is met, a review of the psychoactive PRN is required for continuation. A new stop or evaluation date must be implemented in a reasonable amount of time as determined by the prescriber. Review of the clinical record failed to identify the consultant pharmacist's recommendations for Resident #1 to rinse his/her mouth following the administration of inhaled Fluticasone and to consider discontinuing or scheduling the PRN Trazodone as it had no stop date had been reviewed and/or acted upon by the provider. Interview with the DNS on 7/15/26 at 7:43 AM identified that since the facility's Change of Ownership on 5/1/26, they transitioned to a new pharmacy, and they were in the process of revamping and streamlining the process for reviewing both nursing and medical provider recommendations made by the consultant pharmacist's during the monthly regimen review. The DNS indicated that he was not the DNS at the time of the consultant pharmacist's recommendations that were made on 2/12/26, 3/12/26, and 4/13/26 and could not speak to the process at the time, but his expectation would be that the nursing and physician recommendations would have been reviewed and implemented, if appropriate, in a timely manner. The Medication Pharmacist Reports policy directs that the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and director of nursing, at a minimum. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. The Director of Nursing or designated licensed nurse address and document recommendations that do not require physician intervention.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #4) reviewed for pain management, the facility failed to ensure that a resident with an identified weight loss had weekly weights obtained per the physician's order for multiple months and subsequently had an identified significant weight loss. The findings include: Resident #4 was admitted to the facility in August 2025 with diagnoses that included ulcerative colitis with ileostomy, congestive heart failure, and chronic pain syndrome. Review of the clinical record identified Resident #4 had a conservator as his/her resident representative. The quarterly MDS dated [DATE] identified Resident #4 had moderately impaired cognition, was occasionally incontinent of bladder and had a colostomy in place for bowel, and was dependent on staff for assistance with toileting, bathing, and dressing.The care plan dated 12/5/25 identified that Resident #4 had a nutrition problem due to recent hospitalization. Interventions included to obtain weights as ordered.Review of the clinical record identified that Resident #4 had a weight of 196.6 lbs. on 12/3/25.A physician's order dated 12/7/25 directed to obtain weekly weights every Friday on day shift.a. Review of the clinical record failed to identify that any weekly weights were obtained or documented for Resident #4 for 12/2025.An APRN note dated 1/20/26 by APRN #2 identified that Resident #4 had a history of abnormal weight loss and had not been weighed due to decreased mobility. The note further identified that APRN #2 directed nursing staff to obtain a weight for Resident #4 that week. b. Review of the clinical record failed to identify that any weekly weights were obtained or documented for Resident #4 for 1/2026 or 2/2026.A quarterly nutritional assessment dated [DATE] identified Resident #4 had an overall stable weight for the quarter and had recent episodes of nausea/vomiting on 2/12/26. The note further identified that resident number for symptoms had now resolved and oral intake and appetite were back at baseline. Further review of the nutritional assessment identified Resident #4 had a current weight as 196.6 lbs. obtained on 10/8/25 (4 months prior). Review of the nutritional assessment identified a signature by Dietitian #1 on 2/21/26.Review of the clinical record identified Resident #4 was hospitalized from [DATE] to 2/18/26 due to Klebsiella UTI with right pyelonephritis.c. Review of the clinical record failed to identify that any weekly weights were obtained or documented for Resident #4 for 2/2026.An APRN note dated 3/6/26 by APRN #2 identified that Resident #4 had a recent cardiology consult completed and recommendations included weekly weights, protein supplementation one to two times daily with a liberalized diet. The note identified that a current weight was obtained which was 173.6 lbs. (an 11.1% weight loss since 12/3/25) down from a previous weight of 196.6 lbs. in 12/2025. The note further identified that Resident #4 had abnormal weight loss and APRN #2 provided education to the staff and the resident regarding the issue. The note further identified the treatment plan included a diabetic supplement that was reordered, weekly weights, and nutrition to ensure protein supplementation and a liberal diet.d. Review of the clinical record failed to identify any additional weights obtained following the identified weight loss on 3/6/26 for the rest of March 2026. Further review of the clinical record identified weekly weights were obtained beginning on 4/2/26 and Resident #4 weighed 178.5 lbs.e. Review of the clinical record failed to identify any nutritional assessments by Dietician #1 regarding the identified weight loss on 3/6/26 in March or April 2026. Interview with APRN #2 on 7/16/26 at 3:12 PM identified that she was no longer a provider at the facility and that she recalled multiple issues with obtaining weights for Resident #4. APRN #2 identified that Resident #4 would at times refuse weights, but she could not recall specific days or how often this occurred. APRN #2 identified that she and Dietician #1 did have discussions regarding the issues with obtaining weights. APRN #2 also identified that following the identification of Resident #4's significant weight loss on 3/6/26 she and the dietitian also discussed the time frame between the weights and could not determine if the weight loss was gradual or acute. APRN #2 also identified she could not recall if any of these discussions were documented in the clinical record. APRN #2 also identified that there were multiple issues with nursing staff at the facility either not following physicians' orders or only partially completing the orders during her time at the facility. APRN #2 identified that she left the facility in 6/2026 in part due to these issues.Review of the clinical record failed to identify any documentation that Resident #4 refused any weekly weights from 12/2025 through the time weekly weights were documented beginning 4/2026.Although attempted, an interview with Dietician #1 was not obtained.The facility policy on weight measurements directed that all residents' weights were routinely checked to assess any variations and implement appropriate interventions for significant weight loss or weight gain. The policy further directed that newly admitted or readmitted residents would be weighed weekly for four weeks and then monthly unless otherwise noted. The policy also directed that residents would be reweighed with a weight variance of 5 or more lbs. from the previous month and residents who experienced a significant weight loss of 5% in one month, 7.5% in three months, or 10% in six months would be reviewed by the dietician. The policy directed that the dietitian would review the resident weight and make recommendations accordingly and the resident care plan would be updated.The facility policy on nutritional management directed that all residents would have their nutritional needs assessed and receive diets as prescribed by the physician. The licensed nurse and registered dietitian would monitor weight and dietary intake and significant changes in weight and or food intake would be identified and interventions would be initiated. The policy further directed that all residents would be weighed upon admission, readmission and weekly. If the residents' weekly weight differ by 5 lbs. or more the resident was to be reweighed. The policy also directed that upon admission, quarterly, with a significant change in status, and annually the dietitian would evaluate each residence nutritional needs and any resident who experienced an unplanned significant weight loss or gain of more than 5% in a month, 7.5% in three months, and or 10% in six months, would be referred to the dietician and physician for further evaluation.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #12 and 20) reviewed for dignity, the facility failed to treat the residents in a respectful and dignified manner. The findings include: 1. Resident #12 was admitted to the facility in February 2025 with diagnoses that included depression. An activities assessment dated [DATE] by the Recreation Director identified Resident #12 had expressed no interest in any arts and crafts activities. The annual MDS dated [DATE] identified Resident #12 had intact cognition. The care plan dated 1/25/26 identified Resident #12 required continued support with for independence and access to meaningful activities. Interventions included for the recreation staff to use a soft supportive tone allowing the resident to choose activities without feeling obligated, offer the resident materials for in room activities, respect the resident's right to refuse recreational services, and visit the resident 1:1 to determine the residence interest and offer support and encouragement. Observation and interview with Resident #12 on 7/12/26 at 11:00 AM identified that he/she had issues related to recreational activities and interactions with recreational staff. Resident #12 identified he/she did not like to participate in group recreational activities and instead chose to complete solo craft projects in his or her room. During the interview, observations of the resident's room identified multiple craft projects completed or in progress including decorated cardboard boxes and cut outs and collages on the resident's walls. Resident #12 identified that he/she had requested construction paper from the Recreation Director 1 - 2 months prior and the Recreation Director initially identified that there was no construction paper available. Resident #12 identified that the interaction occurred in the recreation room, and that the Recreation Director was positioned in front of the activity supplies, and a stack of construction paper was visible on the shelves behind the Recreation Director. When Resident #12 identified there was construction paper on the shelves, the Recreation Director then identified that it was for group activities only and that Resident #12 would have to participate in a group if he or she wanted to utilize the paper. Resident #12 further identified that the Recreation Director identified that if Resident #12 wanted construction paper for self-directed projects, he/she could purchase it on his/her own. Resident #12 identified that a few days later, Recreation Aide #1 was working and new to the facility. Resident #12 identified that since Recreation Aide #1 was new to the facility, Resident #12 attempted again to obtain construction paper for self-directed craft projects. Recreation Aide #1 identified that the construction paper was purchased by the Recreation Director and could only be utilized for group activities. Resident #12 identified she informed Recreation Aide #1 that the construction paper was purchased by a fund allocated to the recreation department to which Recreation Aide #1 said (oh don't you know everything). Resident #12 identified that following these two interactions with the recreation staff and attempts to obtain the construction paper, he/she did not pursue any additional attempts. Resident #12 also identified he/she felt disrespected and that if he/she decided to do craft activities in his/her room that was his/her choice. Interview with the Recreation Director on 7/13/26 at 11:34 AM initially identified that residents of the facility were allowed to self-direct their own arts and crafts and could access any craft or art supplies by asking the recreational staff. The Recreation Director then identified that she recalled the incident 1 - 2 months ago with Resident #12 and identified the resident requested construction paper. The Recreation Director identified that she instructed Resident #12 that there was no construction paper available and that Resident #12 became upset. The Recreation Director also identified initially that the recreation department previously had construction paper but had not had it in a couple of months. The Recreation Director identified that during her discussion with Resident #12, she was unsure if there was any construction paper on the shelves behind her as she did not direct arts and crafts activities with the residents and that this was the responsibility of another staff member, and that she did not check. The Recreation Director also identified that Resident #12 had a habit of taking things and did not like being told no. The Recreation Director identified that she did not direct Resident #12 to buy her own craft supplies but did identify that she did buy many of the supplies for the recreation department with her own money, and that while the facility did provide reimbursement, she often did not submit for reimbursement due to it taking too long to get her money back. The Recreation Director identified that she would ensure that going forward Resident #12 had access to construction paper. Subsequent to surveyor inquiry, Resident #12 was provided with construction paper by the facility on 7/14/26. Review of the clinical record failed to identify any documentation that Resident #12 had issues of taking others' belongings or facility property. Although attempted, an interview with Recreation Aide #1 was not obtained. The facility policy on resident rights directed that residents of the facility had the right to be treated with respect, kindness, and dignity and had the right to self-determination. The policy also directed that residents had the right to exercise their rights without interference, coercion, discrimination or reprisal from the facility. The facility policy on the recreation department directed that the recreation department would enhance the resident's quality of life, promote social interaction and community involvement, respect the resident's rights, preferences, and cultural diversity, and encourage maintenance or improvement of the residence physical and cognitive function. The policy further directed that the resident's choice to participate in activities was voluntary, residents had the right to refuse any activity, alternative choices should be offered whenever possible, and staff would encourage participation without coercion. The policy also directed that the recreation department would ensure the residents had the right to participate in activities of their choosing, refuse participation without penalties, be treated with dignity and respect, and express personal interest and preferences. 2. Resident #20 was admitted to the facility in March 2026 with diagnoses that included glaucoma. The admission MDS dated [DATE] identified Resident #20 was cognitively intact, required supervision with bed mobility, transfers, was mobile with the use of a wheelchair and wore corrective lenses. The care plan dated 6/4/26 identified Resident #20 was at risk for impaired visual function related to cataracts and glaucoma. Interventions included identifying factors that affect visual function light sensitivity and refusing to turn on lights. Interview with Resident #20 on 7/12/26 at 10:55 AM identified he/she was legally blind and wore sunglasses. Resident #20 indicated that shortly after admission, the Director of Recreation began calling him/her ([NAME] Wonder). Although the resident indicated he/she laughed it off, it felt disrespectful. Resident #20 shared his/her concern with other staff who agreed the Director of Recreation should not be referring to him/her as [NAME] Wonder. Resident #20 further identified on another occasion within the preceding two weeks, he/she went to a planned activity and requested the lights to be turned down. The Director of Recreation would not allow it and indicated there were other residents to think about and that Resident #20 wore sunglasses to address light sensitivity. Resident #20 identified he/she felt the response was disrespectful and that Director of Recreation could have accommodated his/her needs. Resident #20 still attends activities but now wears two pairs of sunglasses while in the activity room due to the bright lighting and feels that he/she should not have to. The concern was immediately reported and a grievance was initiated. Interview with the Director of Recreation on 7/12/26 at 11:47 AM identified she did call Resident #20 [NAME] Wonder when he/she was first admitted but stopped when Resident #20 asked her not to call him/her that. The Director of Recreation further identified that in recent weeks Resident #20 attended an activity and asked Recreation Aide # 1 to turn the lights off during the activity as he/she was sensitive to bright lights and had his/her rights. The Director of Recreation indicated she told Resident #20 that she had other residents to think of and instructed Recreation Aide #1 to turn the lights back on. Resident #20 became upset stating he/she was going to file a complaint. The Director of Recreation further identified at no time did she ask the other residents arriving for the activity if they minded if the lights were turned off to accommodate Resident #20's needs. Observation of the activity room with the Director of Recreation identified windows extending from one end of the room to the other on the outside wall and from ceiling to floor with adequate lighting with the lights were turned off. Interview with the DNS on 7/13/26 at 6:38 AM identified he would expect all residents to be treated in a dignified and respectful manner. Review of the facility policy for Dignity directs each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life and feelings of self-worth and esteem. The facility supported a culture of dignity and respect for residents by honoring goals. choices, preferences, values and beliefs beginning on admission and continued throughout a residents stay. Attempts to interview Recreation Aide #1 were unsuccessful.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #3) reviewed for medication errors, the facility failed to prevent a significant medication error by failing to accurately transcribe Providers order's and verify Provider's orders for a resident readmitted to the facility. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #3 was admitted to the facility in September of 2024 with diagnoses including type 2 diabetes mellitus, Parkinson's disease, anxiety disorder and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 12) and required supervision assistance with transfers and moderate assistance with bed mobility. The Resident Care Plan (RCP) dated 1/7/25 identified that Resident #3 had diabetes mellitus. Interventions included to monitor/document/report as needed any signs and symptoms of hypoglycemia to include sweating, tremors, increased heart rate (tachycardia), change in skin color, nervousness, confusion, slurred speech, lack of coordination and staggering gait and diabetes medication to be administered as ordered by physician and staff to monitor/document for side effects and effectiveness. Review of facility Reportable Event (RE) dated 3/6/25 identified a medication transcription error upon readmission to the facility, from the hospital, on 3/2/25. The report identified that Levemir insulin 5 units was renewed (mechanism within the electronic medical record (EMR) which allows the selection of previously discontinued orders to be reactivated, as previously ordered, but with a current start date. The discontinued order section of the EMR contains a select all option, which will renew all previously discontinued orders within the EMR, if selected) within the EMR, but not listed as an active order on hospital discharge documents and was not ordered by the readmitting provider (NP #1). Review of the hospital discharge documents dated 3/2/25 identified Resident #3 was admitted to the hospital from 2/25/25 through 3/2/25 and contained no documentation that Levemir insulin was administered throughout the hospital admission or should be started upon discharge. Medications that the discharge documents identified as stopped, during the hospital admission, included tradjenta (oral anti-diabetic medication) 5 milligrams (mg) tablet, metformin (oral anti-diabetic medication) 1000 mg tablet, and metformin 500 mg tablet. A physician's order dated 3/2/25 directed to administer Levemir insulin subcutaneous (under the skin) solution 100 units (u) per milliliter (mL), inject 5 units subcutaneously one time a day for type 2 diabetes mellitus and to hold for a blood sugar less than 80. Review of the facility Medication Administration Record (MAR) for March 2025 identified an order for Levemir insulin 5u daily was administered at 9:00 AM on 3/3/25 (by LPN #3), 3/4/25 (by LPN #2), and 3/5/25 (by LPN #1). Further review of the clinical record identified that an order directing Levemir insulin subcutaneous solution 100 u per mL, inject 5 units subcutaneously one time a day for type 2 diabetes mellitus and to hold for a blood sugar less than 80, was initially ordered at the facility on 3/27/24 and was discontinued at the facility on 5/16/24. Review of the MAR for March 2025 identified an order for tradjenta 5 mg once daily had a start date of 10/10/24 and was administered at 5:00 PM on 3/2/25 (by LPN #4) and subsequently discontinued at 5:45 PM. Review of the MAR for March 2025 identified an order for metformin 500 mg twice daily had a start date of 10/10/24 and was administered at 5:00 PM on 3/2/25 (by LPN #4) and subsequently discontinued at 5:45 PM. Review of the Order Audit Report for Resident #3 identified the DNS discontinued the tradjenta 5 mg and metformin 500 mg orders on 3/2/25 at 5:45 PM, after the medications were administered at 5:00 PM. Review of Nurse Practitioner (NP) visit notes dated 3/3/25 and 3/4/25 failed to identify the four (4) transcription errors. Review of the clinical record failed to identify that blood sugars were obtained from 3/2/25 through 3/5/25. A Nurse's note dated 3/5/25 at 10:22 PM identified that RN #3 was notified Resident #3 was experiencing a change in condition, and was observed in bed leaning to the left, flailing his/her arms and legs around. The note identified that staff were unable to obtain a blood pressure due to Resident #3's movement, that Resident #3 was alert but unable to answer questions or produce any noise, and both pupils were nonresponsive to light. NP #1 was notified and directed RN #3 inquire with Resident #3 ' s family on transfer to the Emergency Department (ED) for evaluation. The note identified that Resident #3's family sent a relative to see Resident #3, and once the relative arrived, they demanded Resident #3 be sent to the ED. Emergency Medical Services (EMS) were called and Resident #3 was transferred to the ED for evaluation. Review of the Prehospital Care Report (ambulance run sheet) dated 3/5/25 identified that EMS arrived at the facility at 6:30 PM and Resident #3 was observed in bed, moving around like he/she was in pain but unresponsive to commands and questions. The report identified LPN #4 stated she last saw Resident #3 around 4:00 PM and when she entered Resident #3's room around 6:00 PM, she found Resident #3 in the above-mentioned state, and stated Resident #3 was normally alert and oriented so this was not his/her normal behavior. The report identified that clinical paperwork was reviewed and identified Resident #3 had a diabetic history. LPN #4 was asked if she obtained Resident #3's blood sugar level, and she reported she had not. The report identified Resident #3's blood sugar was obtained with a result of 29, Resident #3 was administered a 250 mg bag of D10 (dextrose) in route to the hospital, responded well, and the involuntary body movements subsided. Review of the hospital ED note dated 3/5/25 at 7:24 PM identified that Resident #3 presented at the ED for hypoglycemia (low blood sugar) and was found to have a blood sugar of 29 (critically low level) by EMS and dextrose (sugar) was given on route to the hospital. The note identified that Resident #3 became more responsive and his/her sugar level improved. The note further identified that blood work and an ECG (electrocardiogram) were obtained and resulted within normal limits and Resident #3 was discharged back to the facility on [DATE]. Review of RN #2's statement dated 3/6/25 identified that, as an agency nurse, she was instructed for the readmission process, to discontinue all medication orders and then renew the medication orders so the pharmacy was alerted that the resident returned to the facility. The statement identified RN #2 renewed all of Resident #3's previously discontinued medication orders during the readmission process, including the Levemir insulin. Interview with RN #2 on 3/19/25 at 11:49 AM identified she was the nursing supervisor on 3/2/25 responsible for readmitting Resident #3 to the facility. RN #2 identified the DNS instructed her to discontinue all active EMR orders from prior to the hospitalization and then renew all of the discontinued EMR orders. RN #2 reported that after discontinuing and renewing all of the EMR orders, she reviewed the hospital discharge documents with NP #1 and entered new orders subsequent to the hospitalization . RN #2 identified that she then signed and activated all of the orders without the benefit of verifying the orders she was signing and activating for accuracy. She identified that she inadvertently renewed previously discontinued EMR orders to include Levemir insulin which was discontinued nearly a year prior to the hospitalization and tradjenta, metformin and Seroquel orders which were to be stopped according to the hospital discharge documents. RN #2 identified that she should have verified the orders before signing and activating them to ensure accuracy. Interview with NP #1 on 3/19/25 at 12:02 PM identified that when there is a new admission, the RN Supervisor sends her a copy of the discharge documents and medication list which she reviews and approves as appropriate. She identified that on 3/2/25, the hospital discharge documents directed to stop tradjenta, metformin and Seroquel and further identified RN #2 never reported an order for Levemir insulin. She identified when she saw Resident #3 on 3/3/25 and 3/4/25 she did not review the active medication list in the EMR as she should have. She identified that Resident #3 receiving Levemir insulin was a significant medication error, which could have led to seizures and/or death if EMS did not arrive when they did. NP #1 identified that a third shift nurse is supposed to verify the orders for accuracy, which did not occur, and could have identified the error. NP #1 identified that for all residents who are administered insulin, a standard of practice and facility policy, is that a blood sugar is obtained prior to administration, and the Levemir insulin order directed to hold the Levemir insulin for a blood sugar less than 80, which could have prevented the hypoglycemic episode. Interview with LPN #1 on 3/19/25 at 12:35 PM identified that on 3/5/25 she administered Levemir insulin to Resident #3 without first obtaining his/her blood sugar although she knew obtaining a blood sugar was required. She further identified that she did not completely read the order. Interview with RN #3 (Nursing Supervisor) on 3/19/25 at 1:20 PM identified that on 3/5/25 between 6:00 PM and 7:00 PM, LPN #4 reported Resident #3 was unresponsive. RN #3 indicated she assessed Resident #3 and thought he/she may have had a stroke, then further indicated she should have obtained a blood sugar but did not think to do so. Interview with LPN #4 on 3/19/25 at 2:34 PM identified that on 3/2/25, RN #2 notified her Resident #3's readmission orders were complete and she (LPN #4) administered all medications reflected on the EMR. LPN #4 identified no one instructed her to verify the readmission orders. LPN #4 identified that on 3/5/25, sometime after dinner, Resident #3 had a change in condition, she immediately notified RN #3, and they attempted to obtain vital signs but were unsuccessful due to Resident #3's uncontrolled body movements. She identified she was unaware Resident #3 received Levemir insulin since readmission to the facility, but was aware that Resident #3 was diabetic and received oral anti diabetic medications. LPN #4 identified she did not think to check Resident #3 ' s blood sugar when the change in condition was identified. Interview with the DNS on 3/19/25 at 2:14 PM identified that RN #2 should have verified the readmission orders for Resident #3 prior to activating them, should have instructed LPN #4 (3:00 PM to 11:00 PM charge nurse on 3/2/25) to verify the orders and LPN #5 should have verified the readmission orders on third shift (11:00 PM to 7:00 AM). The DNS identified that LPN #1, LPN #2 and LPN #3 should have obtained Resident #3 ' s blood sugar prior to administering the Levemir insulin on 3/3/25, 3/4/25 and 3/5/25 according to the provider's order instructions and that LPN #4 or RN #3 should have checked Resident #3 ' s blood sugar on 3/5/25 when a change in condition was identified. Although attempted, interviews with MD #1, LPN #2 , LPN #3 and LPN #5 were not obtained. Review of the Agency Orientation Acknowledgement packet provided by the DNS identified a table of contents including policies, in part, for Care Plans/Resident Care Cards, Documentation and paper/EMR plan of care. The packet failed to identify the admission/readmission process to include order transcription and medication reconciliation. The Agency Orientation Acknowledgement was manually signed by RN #2 on 5/17/24 and electronically signed by RN #3 on 3/5/25 at 12:36 AM. Review of the Insulin Administration policy (undated) directed, in part, that the type of insulin, dosage requirements, strength and method of administration must be verified before administration, to ensure that it corresponds with the order on the medication sheet and the physician's order. The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin. Document the resident's blood glucose result, as ordered. Review of the Diabetes- Clinical Protocol policy (undated) directed, in part, that the risk for hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. For the resident receiving insulin who is well controlled: monitor blood glucose levels twice daily if on insulin. Review of the Adverse Consequences and Medication Errors policy (undated) directed, in part, that the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. Review of the Telephone/Verbal orders policy (undated) directed, in part, that orders must be entered by the person receiving the orders and telephone orders must be countersigned by the physician during his or her next visit. Although requested, policies on Medication Transcription and Medication Reconciliation were not provided. The Immediate Jeopardy template was presented to the Administrator by the State Agency on 3/20/25 at 1:30 PM. The facility immediately initiated a removal plan which included ensuring Resident #3 was receiving all medications according to Provider order, education for all nursing staff to include medication reconciliation and diabetes management, auditing of all residents prescribed insulin and auditing of all readmission orders. The removal plan was verified and accepted by the State Agency during an on-site visit on 3/20/25 at 5:21 PM and the Immediate Jeopardy was removed.

Based on clinical record review, review of facility documentation, and staff interviews for one (1) of three (3) residents (Resident #1), reviewed for diabetic management, the facility failed to notify the physician of a decreased blood glucose measurement prior to administering a dose of insulin (that was based on a higher blood glucose result) resulting in Resident #1 being found unresponsive approximately 3 hours later with a blood glucose level of 28 (a normal blood glucose level is between 70 and 120). Additionally, the facility failed to ensure emergency glucagon was readily available for a resident who was unresponsive and experiencing a hypoglycemic event. These failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included type 2 diabetes mellitus with long term use of insulin. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition, required minimum assistance with activities of daily living, and received insulin injections daily. The Resident Care Plan (RCP) dated 3/13/2024 identified Resident #1 is at risk for complication related to diabetes mellitus as evidenced by hypo/hyperglycemia with interventions that directed to monitor for signs/symptoms of hypo/hyperglycemia, administer medications as ordered, assess, monitor, record, and report any changes, concerns to MD and family/conservator, and to monitor diet. The physician orders dated 4/1/24 directed to administer Humalog KwikPen (U-100) Insulin 100 units/milliliter (a fast acting insulin), subcutaneous (under the skin). Inject the insulin by subcutaneous route once daily in accordance to the sliding scale every day at 6:00 AM. The sliding scale directed to administer 3 units of Humalog for a blood sugar of 250 to 300, to administer 5 units of Humalog for a blood sugar of 301 to 350, and to administer 7 units of Humalog for a blood sugar of 351 to 450, and to call the physician for a blood sugar greater that 450. Review of the nursing progress note dated 4/07/24 at 6:00 AM written by RN #1 identified Resident #1's blood glucose level was 420, the physician was made aware, and a new order for 10 units Humalog was obtained as a one time dose to be administered after breakfast. A nurse's note dated 4/07/2024 at 1:37 PM written by RN #2 identified Resident #1's blood glucose result (finger stick) was re-checked at 9:00 AM with a result of 269, prior to administering new order of one-time dose of Humalog Insulin (10 units). The one-time Humalog dose was administered as ordered at 9:00 AM. At approximately 12:10 PM, Resident #1 was unresponsive, diaphoretic with twitching and jerky movements. The blood glucose level was obtained and resulted at 28. Resident #1 unable to take oral intake. A call was placed to Emergency Medical Services (EMS) who arrived at approximately 12:19 PM. A dose of glucose was administered by EMS personnel prior to transfer to hospital. All responsible parties were notified. Review of the EMS run sheet dated 4/07/2024 identified that the facility called for emergency services at 12:06 PM and arrived at Resident #1's bedside at 12:15 PM. Resident #1's blood glucose level was 18 mg/dl upon arrival, an intravenous access was obtained, and Resident #1 received 250 milliliters of 10 % Dextrose (a sugar solution) intravenously. A repeat blood glucose level was 170 prior to transport to the hospital. Interview with RN #2 on 4/22/2024 at 11:10 AM identified she was the RN supervisor and Resident #1's charge nurse for the 7:00 AM to 3:00 PM on 4/07/24. RN #2 identified that during 11:00 PM to 7:00 AM shift report from RN #1 it was identified that Resident #1's blood glucose level was 420, and Physician #1 was notified and a one-time physician's order was received for 10 units of Humalog insulin to be administered after breakfast. RN #2 obtained a blood glucose level at 9:00 AM, that resulted at 269. RN #2 indicated she did not question the physician order (although she had obtained a lower blood result) as she was not aware that Resident #1 had a sliding scale, and she had a physician's order to follow, so she administered the 10 units of Humalog insulin to Resident #1. RN #2 identified at approximately 12:10 PM, Resident #1 was unresponsive, making twitching/jerking movements, and was diaphoretic with a blood sugar of 28. RN #2 called 911 and attempted to locate the emergency glucagon (an injectable medication used to treat low blood sugar in an emergency), but was unable to locate it, despite looking in the code cart, emergency box, medication room, and medication cart. EMS personnel arrived at Resident #1's bedside at approximately 12:19 PM and took over care. RN #2 identified that she was not aware where the glucagon was stored in the facility, however, subsequent to Resident #1 leaving to go to the hospital the glucagon was found on another unit, located on the second floor (Resident #1 resides on the 1st floor). Interview with Physician #1 on 4/22/2024 at 11:30 AM identified Resident #1's hypoglycemic event was likely related to receiving the 10 units of Humalog Insulin he/she received on 4/7/2024 at 9:00 AM for the blood glucose of 269, as the 10 units of Humalog insulin was intended for a blood sugar of 420. Physician #1 identified he would have expected to be notified of the new blood glucose of 269 that was obtained at 9:00 AM, as he would have given new orders to address the new, lower blood sugar. Physician #1 identified that he believed there was always emergency medications readily available, such as glucagon, and his expectation for nursing staff would be to administer glucagon as fast and as quickly as possible to prevent any adverse events. Interview with Director of Nurses (DON) on 4/22/2024 at 10:00 AM identified RN #2 should have notified Physician #1 after obtaining the new blood glucose level of 269, and should have administered glucagon during the hypoglycemic episode, as she believed RN #2 knew where the medication was located but failed to administer it. The DON further identified that is was unclear why RN #1 called the physician on 4/7/24 when the sliding scale insulin coverage included blood sugars up to 450, subsequently, RN #1 received additional education to include reviewing physician orders prior to notifying the physician about a blood sugar and to communicate what current interventions were in place to aid the physician with decision making. Multiple attempts to contact RN #1 were unsuccessful Review of the Insulin Reaction-Medical Emergencies Policy (undated) directed to remain with and reassure the individual, and call for assistance. Take vital signs. If conscious, give whole milk. Utilize blood glucose monitoring equipment located in each medication room. Notify the physician and responsible party. prepare a W-10 for any emergency room transfers, if ordered by physician. Document as appropriate in the clinical record. If a reportable event, follow the policy and procedure for reporting. The policy failed to identify guidance on what to do when a resident is unconscious and unable to take oral intake.

Based on clinical record review, facility policy review, and interview for 1 of 3 sampled residents reviewed for intake and output, (Resident #1) the facility failed to ensure the resident met their fluid goals to prevent dehydration, failed to ensure weekly weights were conducted, and failed to document the amount consumed at meals. The findings include: Resident # 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Nutrition and Hydration assessment dated [DATE] identified the resident's daily fluid need was 2200cc per day. The note further identified to offer the resident snacks and fluids between meal. Review of laboratory data dated 9/15/21 noted the resident's BUN was 24mg/dL (norm 7-25 mg/dL), creatinine was 1.07mg/dL (norm 0.70-1.18 mg/dL) and the resident's sodium level was 142 (norm 135-146 mmol/L). Review of the Dietary Progress notes dated 12/12/21 identified the resident's weight was 216.4 pounds, weight stable and will consume 75% of meals. The note failed to identify if the resident was meeting their fluid needs. The quarterly MDS dated [DATE] identified the resident with severe cognitive impairment, rejection of care behaviors, total dependence on staff for eating and without weight loss. The Resident Care Plan (RCP) dated 12/16/21 identified potential for fluid volume deficit related to variable intake. Interventions included encourage fluids, record refusals, monitor intake and output, monitor weight, assess for symptoms of dehydration and report to MD. Review of the intake and output sheets dated from 12/14/21 through 12/29/21 (date the resident was admitted to the hospital) identified the resident failed to meet their fluid goal of 2200cc per day for all 16 days. The documentation identified the intake ranged from zero to 1560cc, 1 day (12/16/21) with no documentation of fluid intake, and 4 days (12/21/21, 12/24/21, 12/25/21 and 12/27/21) only documentation the resident's fluid intake of 120cc to 200cc's on the 11PM to 7AM shift. Review of the Activity of Daily Living (ADL) flow sheets dated from 12/14/21 through 12/29/21 identified out of 47 meal opportunities for fluid intake, 28 times there was no documentation of fluids consumed by the resident. Review of Resident #1's clinical record including nurse's notes from 12/14/21 through 12/27/21 identified fair to poor PO intake, refusal of care and spoon fed. Nurse's notes dated 12/28/21 for 7-3 shift noted poor appetite. Nurse's notes dated 12/28/21 on the 3-11 shift noted resident with poor appetite at supper, fluids taken fair, sluggish throughout shift, placed on MD list to evaluate, will continue to monitor. Nurse's notes dated 12/29/21 on the 11-7 shift noted resident sleeping, seems to be losing weight, no energy per usual, will write in MD book. Nurse's notes dated 12/29/21 on 3-11 shift noted resident remains sluggish, poor appetite, fluids taken fair, supplement taken 50%, bed rest provided this shift, no symptoms of pain, MD and POA aware, labs ordered to be done in AM, will continue to monitor. The note failed to identify if fluids were encouraged. Review of the laboratory data dated 12/30/21 identified the resident's BUN was 74 (norm 7-25mg/dL), creatinine 2.35 (norm 0.70-1.18 mg/dL) and sodium was 165 (norm 135-146 mmol/L). Nurse's notes dated 12/30/21 at 12:00 PM noted resident's creatinine, BUN, WBC, and sodium elevated; MD aware with order to transfer to ER for evaluation. Review of the hospital admission documentation dated 12/30/21 noted the resident's laboratory data as BUN was 70 mg/dL, creatinine was 1.8 mg/dL, and sodium was 173 mmol/L. The documentation noted the resident had severe dehydration with remarkable [CONDITION(S)] and the plan was to gently hydrate the resident. Interview with the DON on 3/20/22 at 10:30 AM stated that when a resident is on I&O, the 3-11 shift adds up the intake and output and passes it on to the 11-7 shift. The DON stated that if a resident is not meeting their fluid goals for 3 days, the 11-7 shift Supervisor is to do a dehydration assessment and document their findings and depending on their findings they would notify the MD. Review of the clinical record at that time with the DON from 12/14/21 through 12/30/21 failed to identify that a dehydration assessment was completed. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #1 on 3/23/22 at 10:05 AM stated that when the resident was first admitted the resident would feed self but now required staff to feed him/her. LPN #1 stated that the resident would have aggressive behaviors and at times could be difficult to feed. LPN #1 stated that a few days before the resident was sent to the ED for evaluation, the resident started to have a poor appetite, took fluids fair and was sluggish. LPN #1 stated that on 12/29/21 the MD was notified, and labs were ordered for the next day. LPN #1 stated that although he directed staff to increase fluids for the resident, the I&O sheets identified the resident only received 300cc of fluid during the 3-11 shift. LPN #1 further stated that he thinks he made the RN Supervisor aware of the resident's poor PO intake but does not know if the Supervisor assessed the resident. Interview with the Registered Dietician (RD) on 3/24/22 at 9:34AM stated Resident #1 required 2200cc per day. The dietician stated that she was not made aware of the resident not meeting their fluid goals between 12/14/21 through 12/30/21. The Dietician stated that had she been made aware she would have recommended to increase the resident's fluids throughout the day by extra fluids on meal tray and with medication pass. Interview with MD #1 on 3/24/22 at 9:40 AM stated that he was not made aware of the resident not meeting their fluid needs until they notified him on 12/29/21 when he ordered labs. MD #1 stated that had he been made aware sooner he would have ordered to increase fluids and notify the RD. MD #1 stated that he expects to be made aware if a resident is not meeting their fluid needs after 3 days. Interview with APRN #1 on 3/24/22 at 1:50 PM stated that she was not made aware the resident was not eating or drinking well during the time frame of 12/14/21 through 12/29/21. APRN #1 stated that had she been made aware she would have reviewed the resident's chart, look at the Dietician recommendations, evaluate the resident, increase fluids, and may order a workup. Review of the facility's policy for Intake and Output identified to document 8-hour totals of intake and output on each shift, the 3-11 nurse will total the 3 shift and if the resident did not meet their fluid goals for a 72 hour period, the nurse will complete an assessment for dehydration including updating the physician and family of change of condition. Review of the facility's policy for dehydration identified if a resident has a noticeable decrease in intake and PO fluids, the facility will assess the resident for signs of dehydration, and notify the physician and family. b. Review of Resident #1's Resident Care Plan (RCP) dated 9/11/21 identified the resident was at risk for weight loss related to dementia. Interventions included regular diet, monitor weights, monitor percentage of meals eaten, monitor labs and offer snacks and fluids between meals. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietician note dated 12/12/21 identified the resident's weight was 216.4 pounds, and weight was stable. The note further identified the resident was at risk for weight loss as dementia progresses and continue to monitor weights, meal percentage taken and will consume 75% of meals. Review of the weekly weights identified the resident was weighed on 12/8/21 and weighed 216.4 pounds, on 12/15/21 the resident's weight was 214 pounds, on 12/22/21 the resident's weight was 216.2 pounds and on 12/28/21 the resident's weight was 190 pounds. A weight loss of 26.4 pounds in 20 days. Further review of the weekly weight sheet noted that a reweight was to be done on 12/28/21 but was not completed. Review of the meal documentation for December 2021 identified from the 1st through the 29th out of 89 meals, 54 meals were not documented on what percentage the resident consumed. Additionally, for the remaining 35 meals the resident consumed 75%. Review of the clinical record and interview with the DON on 3/20/22 at 11:00 AM failed to identify the resident was reweighed after the 12/28/21 weight of 190 pounds, or that the MD or Dietician was made aware of the weight loss. The DON stated that when a weight loss is identified staff are to reweigh the resident the following shift to ensure accuracy. The DON stated that after 3 days of the resident not eating what the dietician's set goal was, nursing staff is to make the MD and Dietician aware and implement the recommendations. Interview with the Dietician on 3/24/22 at 9:34 AM stated that she was not made aware of the resident's 26.4 pound weight and that had she been made aware she would have added fortified foods and supplements. Interview with MD #1 on 3/24/22 at 9:40 AM stated that he expects to be made aware of a resident not eating well after 3 days. MD #1 stated that had he been made aware he would order labs to evaluate the resident's electrolytes, increased the resident's food and fluid intake and have the Dietician evaluate the resident. Review of the facility's policy for weight change identified to obtain accurate weights of each resident, increases, or decreases greater than 5 pounds is an automatic re-weight, and the charge nurse will notify the supervisor who will notify the MD, dietician and family. The policy further identified the dietician will review the clinical record, discuss with the nurse, and recommend to the MD and follow the resident at the weight committee meeting.

Based on clinical record reviews, review of facility documentation and interview for one of three sampled residents (Resident # 7) who was reviewed for a fall, the facility failed to ensure the correct number of staff assisted with a transfer and toileting in accordance with the plan of care to prevent a fall with injury and/or for one of four sampled residents reviewed for accidents ( Resident #10), the facility failed to implement interventions for a resident who was at risk for elopement . The findings include: 1. Resident #7's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 as alert and oriented, required extensive two person assistance with transfers in and/or out of the bed and chair, balance moving from a seated to standing position was not steady and the resident was only able to stabilize with staff assistance, utilized a walker and wheelchair for mobility, had no history of falls and received an anticoagulant medication. The Resident Care Plan dated 9/27/16 identified a self-care deficit related to a history of a cerebrovascular accident with right side weakness. Interventions directed a two person assistance with the Sarita lift for toileting and/or incontinent care, may transfer with the assist of two with a rolling walker for other transfers on the 7-3 shift, and on 3-11 and 11-7 shifts transfer with the Sarita lift and an assist of two staff. A physician's orders [REDACTED]. The nurse's note dated 10/6/16 at 10:15 AM identified the resident was lying on the floor with a large laceration to the forehead and the back of the head. A pressure dressing was applied to the head, the resident was assessed and transferred to the hospital. The note identified while the resident was standing during the provision of incontinent care, the resident fell forward. The Reportable Event Form dated 10/6/16 at 9:50 AM identified while standing in front of the recliner chair the resident was witnessed to fall and had sustained large lacerations to the left forehead and back of head. The documentation identified the nurse aide transferred the resident alone. The hospital report dated 10/9/16 identified the resident received two (2) units of packed red blood cells due to an acute blood loss, anemia, a fifteen (15) centimeter (cm) C-shaped laceration to the left superior scalp required sutures and staples, a 6 cm linear laceration to the inferior orbit required sutures, and a left inferior orbit blowout fracture. Interview with the 7-3PM nurse aide, Nurse Aide (NA) #2 on 11/15/16 at 5:15 PM identified that Resident #7 was ringing the call bell requesting to be changed. NA #2 stated she told the resident she had to get assistance to stand and transfer the resident but the resident was agitated and being impatient so she stood the resident herself using the rolling walker. NA #2 stated that as she stood the resident up Resident #7 fell forward. NA #2 stated that she has provided care for the resident before and that she knew the resident required an assist of two (2), but thought it would be okay if she just stood Resident #7 up to change the brief. Interview with the 7-3PM Nursing Supervisor, Registered Nurse (RN) #2 on 11/15/16 at 11:35 AM she was called to Resident #7's room and noted the resident lying on the floor bleeding from the head. RN #2 stated she assessed the resident, had another nurse apply pressure to the laceration, notified the physician and called 911. RN #2 stated that she spoke to NA #2 after the incident who told her that the resident was becoming impatient and she thought she could stand the resident on her own and change him/her. Interview with the Director of Nursing (DON) on 11/16/16 at 10:35 AM identified that she spoke to the nurse aide after the incident and was told that the resident wanted to be changed so she stood the resident alone and the resident fell . The DON stated that the nurse aide was terminated for not following the resident's plan of care. 2a. Resident#10's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified severe cognitive impairment, required extensive assistance for transfers, total staff dependence for locomotion on and off the unit, and limited assistance for eating. The elopement assessment dated [DATE] identified the resident at a moderate risk for elopement. The care plan dated 3/8/16 identified a potential for elopement / injury secondary to dementia with interventions which included roam alert to wheelchair, check function and placement every shift and change roam alert as needed and by expiration date, redirect when noted at exit or in an unauthorized area, and call family when resident is seeking to exit in order to comfort. Facility documentation dated 4/30/16 identified the resident was found outside the building in the parking lot at 7:45AM by a staff nurse and was immediately returned to the nursing unit. Review of the nurses notes dated 4/30/16 at 10:00PM identified the resident was calm, cooperative with care and with no attempts of further elopement. Demonstration and interview with the DNS on 11/14/16 at 9:47am identified that the facility was equipped with a roam alert system. The DNS indicated that when a resident with a roam alert approached an exit door, the alarm sounds and the doors automatically lock to prevent egress. The DNS further indicated that the resident exited the building through one of two entrance doors near the unit where the resident resided. However, since the resident did not have the benefit of the roam alert at the time of the elopement, the alarm did not sound and the doors opened automatically to allow exit out into the parking lot. Interview with RN#1 on 11/14/16 at 10:59AM identified that she checks the function of the roam alert when the alarm sounds as the resident is wheeled near the doors on his/her way to activity programs. However interview with the Therapeutic Recreation Director (TRD) on 11/14/16 at 2:45pm identified that several residents are wheeled and or assisted to recreation at the same time and the alarm sound may not be specific to Resident#10's roam alert. In addition RN#1 was unable to demonstrate on how to check for the function of the roam alert using the manufacturer's recommended device to check for function.Interview with LPN#1 on 11/15/16 at 10:00AM identified that the resident self-propels his/her wheelchair and did not have a roam alert when he/she was found in the parking lot outside the building. LPN#1 indicated the roam alert is placed on the resident's wheelchair which was the main mode for mobility. Review of the treatment administration record (TAR) identified that the entry for the presence and function of the roam alert was signed off every shift for the month of April despite its absence on 4/30/16. LPN#1 identified she did not check its placement and function as ordered. Clinical record review with the Occupational Therapist on 11/15/16 at 9:00am identified that the resident's wheelchair was changed on 3/1/16 with recommendations for nursing to apply a roam alert to the newly issued wheelchair. Further review indicated that the wheelchair was again changed on 4/5/16, however, no recommendations on applying a roam alert were evident in the clinical record. Interview however with the OT indicated that she cut off the roam alert device on the previous chair and gave instructions to the nurse to apply a roam alert to the newly issued chair. Interview with the DNS on 11/14/16 at 3:00PM indicated that despite interviews and review of the clinical record, an explanation of the absence of the roam alert on 4/30/16 cannot be identified. b. Observation with RN#6 and RN#7 on 11/14/16 at 7:29AM identified the resident seated in the hallway in a wheelchair without the benefit of a roam alert. RN#1 and RN#2 could not explain why the resident did not have a roam alert despite continued risk for elopement. Review of the TAR with the DNS and RN Supervisor at 9:30AM on 11/14/16 identified that entry on checking the placement and function of the roam alert was consistently signed off across all shifts since the start of the month of November. The DNS indicated that it seems staff sign-off without the benefit of performing the task. Review of the clinical record with the OT on 11/15/16 at 9:00AM identified that a new custom wheelchair was issued for the resident's use on 6/27/16. However review of therapy notes, nurses' notes and supervisor's shift reports failed to provide documentation that a roam alert was applied to the new custom wheelchair. Interview with the RN Supervisor who is in charge of issuing roam alert devices identified that there was no system in place to track/monitor when issuing roam alert devices.

Based on review of the clinical record, review of facility documentation and interview for two of six resident's reviewed for accidents (R#48, #86), the facility failed to provide supervision or assistive devices to prevent accidents. The findings include: 1. Resident #48's [DIAGNOSES REDACTED]. The RCP dated 7/30/15 identified the resident was at risk for falls related to poor safety awareness. Interventions directed the staff to monitor for and correct unsafe practices when observed. Nurse's notes dated 8/9/15 at 4:15 PM identified that while the resident was being assisted, NA #2 pulled back on the wheelchair while the resident was holding onto a stationary chair next to him/her. The resident fell out of the wheelchair onto the floor. A complete assessment was done by the charge nurse including ROM to all extremities with no injuries noted. The resident was assisted to bed and at that time complained of right thigh pain. At 9:20 PM the resident continued to complain of pain. The physician was notified and directed the staff to obtain an x-ray of the right hip and thigh. Nurse's notes dated 8/10/15 at 4:05 AM identified the x-ray results noted a right subcapital hip fracture with a slight displacement. At 3:30 AM the resident was sent to the ED for evaluation and treatment. A Hospital Discharge Summary dated 8/13/15 identified the resident underwent [REDACTED]. Interview, review of the clinical record, and facility documentation on 10/22/15 at 9:15 AM with the acting DNS and the acting Administrator identified NA #2 received a written warning for attempting to move the resident without first ensuring the resident was safe. 2. Resident #86's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] indicated the resident was cognitively impaired, required extensive assist with transfer, limited assist with walking, and had 2 or more falls since the last assessment. A resident careplan dated 7/23/15 identified a risk for falls secondary to dementia. Interventions included a bed and chair alarm. A physician's orders [REDACTED]. Check placement every shift. A nurse's note dated 10/3/15 at 5:45 AM indicated the resident was noted not to be in his/her bed. The resident was found in the bathroom on the floor. A bruise was noted over his/her left eye and a bump on the left side of the forehead. The bed alarm did not alarm. At that time, a chair alarm was noted in the bed instead of a bed alarm. The chair alarm was replaced with a bed alarm and was noted to be functioning. A review of the clinical record and interview on 10/21/15 at 0:30 AM with LPN #1 indicated a chair alarm can not be used in a bed because it will not sense the resident leaving the bed. A bed alarm is larger to accommodate the bed surface.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for 1 out 6 residents reviewed for pain management (R # 115), the facility failed to notify the physician/APRN when a resident ' s scheduled pain medication was not administered for 2 doses. The findings include: Resident #115 ' s [DIAGNOSES REDACTED]. The 30 day MDS dated [DATE] identified that the resident was alert and oriented with no cognitive deficits, required extensive assistance with all mobility, was unable to walk, and had received scheduled and as needed medications for pain in the prior 5 day period. A resident care plan last updated on 11/30/15 identified that the resident had potential for pain because of multiple fractures with interventions that included to give medications as ordered, and to assess, monitor, record, and report any changes or concerns to the physician. Current physician orders [REDACTED]. An interview with R #115 on 12/3/15 at 10:30 AM identified that on 12/2/15, s/he was in pain all day because he/she had last received his/her pain medicine at 9:00 AM and did not receive another dose until 11:00 PM because the facility had run out of the [MEDICATION NAME]. R#115 further stated that his/her leg pain level was a 10 out of 10 all day. Review of a Schedule 2 prescription form dated 12/1/15 identified that although the form was filled out on 12/1/15 by the APRN for a refill of the [MEDICATION NAME] -[MEDICATION NAME] 7.5-325 mg, it was not faxed to the pharmacy until 12/2/15. Review of the medication kardex for December 2015 identified that on 12/2/15, the resident had received the [MEDICATION NAME] as ordered at 4:00 AM and 9:00 AM. At 2:00 PM, a nurse initialed the kardex (RN # 1), but then crossed off the initials, and at 7:00 PM the nurse had circled her signature (RN # 2) indicating that the medication was not administered. Interview with RN #1 on 12/3/15 at 11:00 AM identified that he/she was the nurse for R # 115 (orienting to the floor with RN # 2) on 12/2/15. RN # 1 identified that he/she had administered the last [MEDICATION NAME] in the blister pack to the resident at 9:00 AM but did not re-order it because s/he thought it would be coming in from the pharmacy before the next dose was due. RN # 1 indicated that he/she gave the resident Tylenol 650 mg for a pain level of 7 out of 10 because he/she did not have the [MEDICATION NAME] available at 2:00 PM and that is why s/he crossed out his/her initials on the kardex. RN # 1 further stated that he/she did not notify the physician that the resident did not receive his/her scheduled [MEDICATION NAME] at 2:00 PM. Interview with RN # 2 on 12/3/15 at 1:00 PM identified that he/she was orienting on 12/2/15. RN #2 identified that RN # 1 did not inform him/her that the resident was out of the [MEDICATION NAME] until around 2:00 PM, when the second dose was due and at this time, he/she faxed the prescription written on 12/1/15 to the pharmacy. RN # 2 further identified that he/she did not call in a stat order or call the physician because the alternative of Tylenol seemed to be effective; if it was not, he/she would have called the physician. Interview with RN # 3 on 12/3/15 at 1:05 PM identified that he/she was the supervisor on 12/2/15 for the 7-3 shift and was not made aware that the resident did not get his/her scheduled dose of [MEDICATION NAME] at 2:00 PM and if he/she had been aware, he/she would have called the pharmacy to place a stat order and notified the physician. Interview with LPN #3 on 12/3/15 at 1:20 PM (the 12/2/15 nurse on the 3-11 shift) identified that he/she did not give the resident his/her scheduled 7:00 PM dose of [MEDICATION NAME] because the facility did not have any in house. LPN # 3 stated that he/she did not call the physician to inform him/her about the missed 7:00 PM dose of [MEDICATION NAME]. Interview with APRN #1 identified that he/she was not made aware of the resident missing the 2:00 PM and/or 7:00 PM doses of [MEDICATION NAME] and if he/she had been aware, he/she would have asked the nursing staff to call the pharmacy and request a stat order. APRN # 1 further stated that this resident had chronic pain and regular Tylenol may have only held her for about an hour or so. Interview with Pharmacy Technician # 1 on 12/3/15 at 2:00 PM identified that the prescription request was received by the pharmacy around 3:00 PM on 12/2/15, and was scheduled to leave the pharmacy on the night run which usually leaves around 7:30-7:45. The pharmacy technician further identified that if the medication was called in as a stat order it would have left the pharmacy within a 2 hour window. Interview with the Director of Nurses on 12/3/15 at 2:10 PM identified that it would be his/her expectation for a nurse who administers the last dose of the medication to immediately call the pharmacy to make sure it will come in before the next dose is due, and if it will not be in, to order the medication stat. It is also the responsibility of the nurse who had the APRN fill out the prescription on 12/1/15 to fax it to the pharmacy once it was completed. Additionally the nurses should have notified the physician of the missed medication doses. The medication ordering policy directed to review the pharmacy's delivery schedule to ensure the medication will arrive prior to the next administration time and that in the event that a medication is unavailable or the pharmacy is unable to deliver it, to call the physician to obtain new orders if necessary.

Based on clinical record reviews, observations and interviews for three sampled residents (Resident #11, #92,and #115), the facility failed to provide appropriate care and services related to advanced directives, bowel regime and pain management. The findings included: 1. Resident #92's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Nurse ' s notes dated [DATE] at 2:00 PM identified the resident complained of constipation. On [DATE] at 1:30 PM the resident was calling out need to go, need to go. Prune juice was given to the resident for constipation with no effect. Nurse ' s notes dated [DATE] at 3:00 PM identified the resident had not had a bowel movement since [DATE] (six days). When offered, the resident spit out the MOM. At 10:00 PM the resident had a loose BM. Review of the MAR for [DATE] identified the resident had a small BM on [DATE] during the 3:00 to 11:00 shift. No further BM ' s were documented until [DATE] during the 3:00 to 11:00 shift (9 shifts later). The MAR indicated [REDACTED]. Nurse ' s Notes dated [DATE] at 3:00 PM identified the resident called out intermittently throughout the day I got to go. Multiple visits to the bathroom were made with no success and MOM was not effective. The resident was seen by the APRN and a new order was obtained for Senna-S. At 4:40 PM, a Fleet enema was administered with no results and a mild amount of rectal bleeding was noted. The APRN was notified and the resident was transferred to the ED for evaluation ¿@ A hospital discharge summary dated [DATE] documented that a CT scan of the abdomen identified a massive stool impaction measuring ,[DATE] cm in diameter. The rectum was disimpacted by hospital staff and a large amount of stool was removed. Nurses notes dated [DATE] identified the resident was returned to the facility after treatment of [REDACTED]. Interview and review of the clinical record on [DATE] at 9:15 AM with the acting DNS identified after three days of no BM the bowel protocol should be initiated (MOM, followed by [MEDICATION NAME] suppository, followed by a Fleet enema). ¿@ 2. Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#,[DATE], left ribs #,[DATE], an open right distal femur fracture, mediastinal contusion, and cervical spine [MEDICAL CONDITION] with severe stenosis and impaired swallowing/[DEVICE] insertion. The nursing admission assessment dated [DATE] identified that the resident was alert and oriented and required assistance with all ADL's. Physician orders [REDACTED]. Physician orders [REDACTED]. On [DATE] at 11:50 AM, the BFSI inspector summoned the nurse consultant to see why Resident #115 was crying in his/her room. Interview with the resident at that time noted the resident crying and complaining about pain and burning in his/her leg after participating in Physical Therapy. Further interview with the resident noted he/she was crying due to pain and because the nurse aides refused to assist him/her into bed to rest; the resident indicated that s/he still hadn't gotten pain medication that was due before therapy this am (approximately 9 AM). Observations at that time noted the resident's right leg with a brace in place and a quarter sized black scab visible. The leg was elevated on the wheelchair leg rest with no pillows and/or cushioning visible. Subsequent to surveyor inquiry, the resident was assisted to bed by the staff. Interview with RN#1 on [DATE] at 12 noon noted that he/she was behind in administering medications and was just getting to R#115 to administer his/her 9 AM medications (3 hours late). S/he had not asked the supervisor for assistance. 3. Resident #11 was a [AGE] year old admitted to the facility on [DATE] after hospitalization for [MEDICAL CONDITION] and acute kidney injury. The hospital discharge summary dated [DATE] indicated that the resident and family decided on DNR status. Upon admission, the resident reviewed the advanced directives form provided by the facility and chose no CPR, no artificial nutrition and no intubation. The attending physician signed the form indicating that he/she reviewed it on [DATE]. The resident was also assessed on three occasions by the facility APRN. DNR orders were never entered into the computerized physician ordering system. On [DATE], the resident was found without respiration or a heartbeat. CPR was initiated, 911 called, paramedics intubated him/her and transported the resident to the hospital with advanced cardiac life support in progress. The resident was pronounced expired at the hospital. On [DATE] at 1:08:16 PM, review of Resident #11's clinical record and interview with the acting DNS noted that only the MD can write an order for [REDACTED].

Based on clinical record review and interview for 1 of 3 residents in survey sample reviewed for pressure ulcers (R#107) facility failed to provide interventions to promote healing and/or prevent pressure sores from developing. The findings included: Resident #107's [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified the presence of a stage II pressure ulcer located on the resident's medial left buttock that measured 1.2 cm x 1.0 cm. It further identified that the buttock area was red and not blanching. An initial (MDS) assessment dated [DATE] identified R#107 was without cognitive problems, required extensive assistance with bed mobility and transfers, and had a stage II pressure ulcer upon admission. An interim care plan dated 8/14/15 identified a problem with pressure ulcers. Interventions included to assess for need for pressure relieving devices, turning /positioning as indicated and treatments as ordered. physician's orders [REDACTED]. Pressure ulcer assessment form noted a stage II located on left buttock present on admission with subsequent measurements as follows: 8/19/15 - 1.2 cm x 1.0 cm 8/26/15 - 1.5 cm 1.2 cm 9/2/15 - 1.9 cm x 1.5 cm Triad cream treatment continued 8/15/15 through 9/2/15. Pressure ulcer assessment report dated 8/26/15 identified two (2) new facility acquired stage II pressure ulcers located on the right buttock; bottom 0.3 cm x 0.2 cm and right top 0.1 cm x 0.1. It identified Triad cream as treatment. physician's orders [REDACTED]. A physician wound note dated 9/2/15 identified new facility acquired pressure ulcers with an onset date of 8/26/15 located on the right top and bottom buttock, a new unstageable area located on left buttock and a new stage II pressure ulcer located on coccyx with both areas with a onset date of 9/2/15. The care plan (RCP) dated 9/2/15 identified an unstageable area to the left buttock and a facility acquired stage II pressure ulcer located on the coccyx. Interventions included provision of an air mattress. Physician orders [REDACTED].#107 side to side while in bed every day. Review of turning and repositioning schedule dated 8/15/15 through 8/25/15 noted that Resident #107 was positioned on his/her back without the benefit of offloading pressure the majority of the time while in bed. During an interview and review of R#107's clinical record with RN #2 on 10/21/15 at 9:10 AM s/he was unable to provide documentation that treatment modalities were changed when the left buttock pressure sore continued to decline, and/or that assistance with repositioning was provided, and/or that the plan of care was reviewed and revised as the initial wound declined or new wounds developed, and/or that an air mattress was provided to promote healing and/or prevent development of new pressure ulcers.

Based on clinical record reviews, observations, review of facility documentation and interviews for one of three sampled residents (Resident #2) who required staff assistance with an activity of daily living, the facility failed to implement a system to ensure that beverages and/or food when reheated in the microwave were at appropriate temperatures. The findings include: Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2 had severe cognitive impairment, difficulty focusing attention, easily distracted, disorganized thinking and was independent with eating after set-up. The nurse's note dated 1/14/15 at 3:15 PM identified the Nursing Supervisor was informed by the charge nurse that Resident #2 had spilled hot coffee that caused an open blister to the right thigh. The area measured 8.0 centimeters (cm) x 4.0 cm x 0.1 with surrounding [DIAGNOSES REDACTED]. The Reportable Event Form dated 1/14/15 at 2:50 PM identified Resident #2 was seated in a recliner chair in the common area and spilled a cup of coffee on his/her lap. The report indicated that when the nurse aides removed the resident's pants an open blister was noted on the right upper thigh. Subsequent to physician notification a treatment was initiated. The care plan was revised to direct not to microwave beverages and to provide the resident cool to room temperature beverages and not hot beverages. The physician's progress note dated 1/15/15 identified Resident #2 had sustained a second degree burn to the right thigh. The wound note dated 1/16/15 identified a second degree scalding injury with cellulitis, that was a stage two, measured 8.0 cm x 3.0 cm, was very tender, the wound bed was yellow and red, and there was significant surrounding bright red [DIAGNOSES REDACTED]. Review of the wound notes from 1/16/15 through 2/25/15 identified the wound area resolved on 2/25/15, six weeks later. Observations of Resident #2 while in bed on 7/1/15 at 9:15 AM identified a discolored marking on the upper thigh in the right groin area. Interview with the charge nurse Licensed Practical Nurse (LPN) #1 on 7/1/15 at 11:00 AM identified that she heard Resident #2 say Oh, I spilled my coffee. LPN #1 indicated that Resident #2 denied any pain and the nurse aides took the resident back to the room to be changed. LPN #1 identified that the nurse aides informed her of the red mark and when she first saw the area there was no blister and that she thought the blister developed on the next shift or next day. Observations of the kitchenette on 7/1/15 at 11:05 AM identified a sign that directed no microwave beverages at any time for only Resident #2. Upon further observations, there was no documentation to reflect instructions related to power levels and/or the time frames food and/or fluids should be reheated. Interview with the Acting Administrator on 7/1/15 at 11:10 AM she was unable to provide a facility policy for heating liquids in a microwave and/or a protocol to direct staff as to the length of time to heat liquids in the microwave to ensure safe temperature of liquids. Interview with the Dining Service Manager on 7/1/15 at 11:20 AM identified that she had purchased the microwave several years earlier and the former Director of Maintenance would have kept the instruction manual. The Dining Service Manager indicated that the coffee was brewed in the coffee machine to 180 degrees. Review of the instruction manual for the Magic Chef microwave identified that the microwave was a 0.9 cubic foot and the energy output was 900 watts. Interview with Nurse Practitioner on 7/1/15 at 1:45 PM identified that she was not sure in degrees how hot a beverage had to be to cause a second degree burn, but indicated that the beverage would have to be hot to cause a burn through clothing. Interview with NA #5 on 7/2/15 at 7:36 AM identified that Resident #2 had complained the coffee was not hot enough. NA #5 indicated that the cup was about three quarters full and she heated the thermal cup up for less than thirty seconds. NA #5 explained that she tested a beverage by looking at the cup for steam and/or putting her hand over the top and the coffee on 1/14/15 was not steaming but hot and she instructed that resident the coffee was hot. NA #5 identified that after spilling the coffee Resident #2 yelled out Oh it's hot, it's hot. According to the Burn care .Everywhere Foundation Inc., a person will receive a second degree burn in three (3) seconds of exposure to water of 140 degrees.

Based on clinical record review, review of facility documentation and interviews for 3 of 5 residents reviewed for pressure ulcers (R#46, R#24, R#65) the facility failed to provide care and services for the prevention and/or to promote healing. The findings include: 1. Resident #46 [DIAGNOSES REDACTED]. An MDS dated 6/24/13 identified the resident as severely cognitively impaired and totally dependent on staff for all activities of daily living and required 1-2 persons physical assist. A review of the resident's Pressure Ulcer Evaluation report indicated that the resident was admitted to the facility on [DATE] with a stage 1 pressure ulcer to the left buttock. Further review of the report indicated that the wound measured 1.0 cm x 2.8 cm, was red in color with no drainage, or odor. Triad is documented as being the treatment applied every shift. Further review of the report dated 6/26/13 identified the wound was reclassified (by RN#3) as a stage 2 pressure ulcer and the measurements noted as 1.6 cm x 2.6 cm, red and scabbed and a treatment of [REDACTED]. On 7/03/13 and 7/10/13 the wound measured 1.6 cm x 1.9 cm and 1.4 cm x 2.0 cm with a (none descript) drainage. On 7/24/13 the wound measurements are documented as 2.5 cm x 1.5 cm and on 8/8/13 the measurements are 2.1 cm x 1.3 cm and small serosanguineous drainage. A review of the clinical record and the APRN referral sheet failed to document that the MD and or the APRN was informed of the wound until 8/08/13. Interview with RN#3 on 12/09/13 at 1:30 PM indicated that although the facility has a Pressure Ulcer protocol, it is the responsibility of the nurse to consult with the APRN with wounds that are worsening; RN#3 was not sure why APRN#1 wasn't consulted until 8/08/13. Interview with the Director of Nurse on 12/10/12 at 11:00 AM indicated that the nurse should have informed the APRN with the reassessment on 6/26/13 and again when it was noted that the wound had worsened. Interview with APRN#1 on 12/9/13 at 12:30 PM indicated that a different treatment could have been introduced if he or she was informed sooner. On 8/09/13 the APRN assessed the wound and the treatment was changed from Triad every shift to Santyl daily. One month later 9/27/13 the wound was documented as healed. 2. Resident # 24's was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] as cognitively intact, requiring extensive assist of two staff for bed mobility, transfer, and toilet use, and total assist of two staff for transfers and at risk for pressure ulcers and (1) stage 2. A RCP dated 9/23/13 identified a potential for alteration in skin integrity and an alteration in skin integrity related to stage 2 to left buttock and unstageable to coccyx, and non-compliant with turning and repositioning. Interventions included to monitor skin with all care, incontinent care every two hours and as needed, barrier cream for prevention, report changes/concerns to physician & family. Review of the coccyx wound tracking dated 9/05/13 identified a community acquired stage 2 measuring 2.1 cm by 0.9 cm by 0.1 cm, on 9/12/13 2.3 cm by 0.9 cm by 0.1 cm, on 9/16/13 an unstageable measuring 3.9 cm by 2.8 cm by 0.2 cm. Although review of the clinical record identified R#24's wound was assessed upon admission with a care plan and treatment in place, and was currently followed by a wound consultant the wound progressed to become unstageable. Interview with ADON on 12/10/13 at 9:37 AM and clinical record review and review of facility documentation identified the resident as alert and oriented, and the wound became unstageable due to R#24 ' s non-compliance with turning and repositioning. Review of the clinical record at the time failed to reflect any documentation of any education provided to the resident regarding the risks and/or benefits of turning and repositioning. 3. Resident #65's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified R#65 as cognitively intact and totally dependent for bed mobility, hygiene, non-ambulatory and required extensive assistance with transfers. A RCP dated 10/09/13 identified R#65 with a potential for alteration in skin integrity related to decreased mobility and had developed a stage 2 to the mid back with interventions to provide a treatment as ordered, turn and reposition in bed every 2 hours, provide barrier cream at each incontinent episode and provide a pressure reducing chair cushion. Interview and review of facility documentation with the ADNS on 12/9/13 at 11:55 AM identified that he/she had destroyed the original weekly wound measurement depicting the unstageable wound documentation which was reviewed by the surveyor on 12/05/13 at 1:00 PM and identified R#65 with an unstageable wound. The ADN'S identified he/she had discussed wound staging with the APRN and identified that the wound was incorrectly staged as an "unstageable" wound and was really a stage 2. Further, the ADN'S stated he/she used Santyl on the wound because slough was present in the wound bed but, because there was some granulating tissue, was able to identify the R#65's pressure ulcer as a stage 2. Interview and review of facility documentation with the APRN on 12/09/13 1:00 PM identified he/she had spoken to the ADN'S about staging of the wounds in the past but doesn't remember when. The APRN indicated that on October 14, 2013 the pressure ulcer was a stage 2, that there was no drainage or slough and that this was the first time he/she saw R#65's pressure ulcer. The APRN identified he/she saw R#65 on November 4, 2013, that the pressure ulcer had worsened, meaning there was slough in the wound, but that the pressure ulcer was still a stage 2 and ordered Santyl. The APRN identified that the last time he/she observed R#65's pressure ulcer was on November 19, 2013 and the pressure ulcer remained a stage 2. Finally the APRN identified that a wound that is completely covered by slough would be untraceable but that if he/she could see the bottom of the wound he/she would have considered it to be a stage 3 or unstageable. Interview and review of facility policy with the DNS on 12/09/13 at 2:15 PM identified that errors in documentation should be corrected by drawing a single line through the error and initialing it according to the facility policy. Interview and observation of R#65's pressure ulcer with the Infection Control Nurse on 12/09/13 at 3:00 PM identified a center area of slough from the top (head) area to mid wound, approximately 0.5 cm long and 1-2 cm in width. Interview and review of facility documentation with the ADN'S on 12/09/13 at 3:30 PM identified that the pressure ulcer assessment and documentation policy does not have an unstageable description in the policy but that they go by the NPUAP guidelines which are kept on the treatment cart. Additionally the ADN'S identified that he/she had rewritten the initial weekly wound measurement sheet and shredded the original documentation because it became messy when he/she changed the unstageable documentation to a stage 2 pressure ulcer, but should not have altered the original documentation and should have followed the facility policy. Additionally when the ADN'S reviewed the NPUAP guidelines he/she identified that a stage 2 pressure ulcer has no slough. According to the National Pressure Ulcer Advisor Panel (NPUAP) restaging in 2007, the definition of a stage 2 pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguinous filled blister. Present as a shiny or shallow ulder without slough or bruising. An unstageable/unclassified full thickness skin or tissue loss, depth unknown, is a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be either a category/Stage 3 or 4.

Based on clinical record review and interview for two (R#1, R#3) of five residents reviewed for hydration assessments, the facility failed to assess the resident's hydration status. The findings include: 1. R#1's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified short and long term memory deficits, impaired cognition, and required extensive assistance with eating. Review of the resident care plan dated 7/27/10 identified a potential for fluid volume deficit related to a history of [MEDICAL CONDITION], variable intake by mouth intake due to the aging process with interventions to encourage fluids, record fluid refusal, monitor for signs and symptoms of dehydration and place on intake and output when necessary. Review of physician orders [REDACTED]. Review of the total intake and output (I and O) records dated 9/16/10 to 9/29/10 identified that R#1 met fluid needs and I and O was discontinued 9/29/10 and initiated again on 10/27/10. The NA Flowsheets dated 10/25/10 to 10/27/10 identified that the resident consumed 25% to 75% of meals. Although the medication kardex dated 10/2010 identified documentation to reflect that the resident was offered 120ml of fluid by mouth every two hours, documentation failed to identify the amount of fluids taken by the resident. Review of the nurse's notes dated 10/26/10 at 10:00 PM identified R#1 as somnolent, easily arousable and refused meals and several attempts of fluids, a foul urine odor, a positive test to a urine sample and stable vital signs. The laboratory data dated 10/27/10 identified a BUN of 143 (was 34 on 7/2/10) and a Creatinine of 4.9 (was 1.1 on 7/2/10). Review of the Inter-Agency Referral Report dated 10/27/10 identified R#1 was transferred to an acute care facility with dehydration, a urinary tract infection and [MEDICAL CONDITION] congestion. Review of the clinical record and interview with the Director and the Assistant Director of Health Care Services on 3/28/11 at 1:00 PM. failed to identify that R#1 had been assessed for the signs and symptoms of dehydration. Interview with the MD#1 on 3/28/11 at 1:30PM identified that R#1 was at risk for dehydration and would not necessarily be required to be on I and O monitoring all the time but would expect dehydration assessments. 2. R#3 ' s [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status Score as unable to complete secondary to the resident rarely or never understood, urinary incontinence and required extensive assistance with eating. Review of dietary re-admission note dated 12/1/10 identified daily fluid needs as 1475 cc daily. Review of the resident care plan dated 12/27/10 identified potential for fluid volume deficit related to the [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of resident I and O monitoring identified a required intake of 1475 cc within twenty-four hours. Intakes included 1440cc on 3/25/11, 1080cc on 3/26/11, and 1080cc on 3/27/11. Review of the clinical record and interview with the Director of Health Care Services on 3/28/11 at 2:30 PM failed to identify that hydration assessments had been obtained after forty-eight hours of insufficient fluid intake. Review of facility policy directs that if a resident has not met required intake for a forty- eight hour period, complete assessment for dehydration on intake and output, including updating physician and family of change in condition.