Every finding on record at Milford Health and Rehabilitation Center

Based on review of the clinical record and facility documentation, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure staff notified the State Agency timely when a new fracture of indeterminate age was identified. The findings include: Resident #1's diagnoses included dementia, vascular parkinsonism, and epilepsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS), had severe cognitive impairment and was dependent for all ADLs (activities of daily living) and transfers. The Resident Care Plan dated 3/19/26 identified a deficit in self-care function related to left side hemiplegia and dementia. Interventions directed to provide personal care, and therapy referral as indicated. APRN #1 progress note dated 4/1/26 at 10:34 AM identified Resident #1 was seen for follow-up regarding continued overall decline, goals of care, dementia, and dehydration. The note indicated oral intake had declined to minimal or no intake, representing a worsening from the poor appetite noted the previous day. Additionally, Resident #1 was not taking medications as ordered, which represented an escalation from the prior day's difficulty with medication administration. An extensive discussion was held with the resident's significant other and Person #1 regarding advanced care planning and goals of care. Hospice consultation was recommended at that time. The resident's significant other and Person #1 expressed their wish for Resident #1 to be transferred to the emergency department for a higher level of care. A nursing note dated 4/1/26 at 12:00 PM identified Resident #1's responsible party met with APRN regarding Resident #1's status, and Person #1 had previously expressed a desire for all available treatment measures to be pursued, including consideration of a feeding tube, and discussed transfer to the hospital. Nursing note dated 4/1/26 at 1:10 PM identified Person #1 spoke with the APRN #1 by telephone and agreed with transferring Resident #1 to the hospital for further evaluation. The Hospital Discharge summary dated [DATE] identified imaging results from the CT chest, abdomen, and pelvis without contrast, identified age-indeterminate compression deformities of the T3 and T4 (spine) vertebral bodies that were new compared to imaging from 6/3/25. The report recommended correlation with point tenderness in the affected region. The imaging also identified a subacute-to-chronic right acetabular (hip socket) fracture and a varus-impacted subcapital fracture of the left femur (neck of the femur), with a recommendation to correlate the findings with any recent history of trauma. Resident #1 was seen by orthopedics with a plan to continue conservative management and weight-bearing as tolerated. Review of CT's Department of Health's FLIS Events Report Tracking System identified the facility did not submit a reportable event for Resident #1's injury of unknown origin noted on the hospital Discharge summary dated [DATE]. Interview and medical record review with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/16/26 at 12:40 PM identified they were not aware that Resident #1 had been diagnosed with age-indeterminate fractures of the hip. Upon review of the Hospital Discharge Summary and imaging findings, the DON and ADON confirmed the diagnosis and acknowledged the fractures constituted an injury of unknown origin that should have been reported to the State Agency. The DON and ADON stated the event was not reported to the State Agency. Interview with the Director of Nursing (DON) on 6/16/26 at 2:00 PM revealed the facility was unable to provide a policy regarding reporting of adverse events to the State Agency. The DON stated the facility relied upon and followed the requirements of the Connecticut Public Health Code for adverse event reporting.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure a thorough investigation was completed timely after an injury of unknown origin was identified. The findings include: Resident #1's diagnoses included dementia, vascular parkinsonism, and epilepsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to complete a Brief Interview for Mental Status (BIMS), had severe cognitive impairment and was dependent for all ADLs (activities of daily living) and transfers. The Resident Care Plan dated 3/19/26 identified a deficit in self-care function related to left side hemiplegia and dementia. Interventions directed to provide personal care, and therapy referral as indicated. APRN #1 progress note dated 4/1/26 at 10:34 AM identified Resident #1 was seen for follow-up regarding continued overall decline, goals of care, dementia, and dehydration. The note indicated oral intake had declined to minimal or no intake, representing a worsening from the poor appetite noted the previous day. Additionally, Resident #1 was not taking medications as ordered, which represented an escalation from the prior day's difficulty with medication administration. An extensive discussion was held with the resident's significant other and Person #1 regarding advanced care planning and goals of care. Hospice consultation was recommended at that time. The resident's significant other and Person #1 expressed their wish for Resident #1 to be transferred to the emergency department for a higher level of care. A nursing note dated 4/1/26 at 12:00 PM identified Resident #1's responsible party met with APRN regarding Resident #1's status, and Person #1 had previously expressed a desire for all available treatment measures to be pursued, including consideration of a feeding tube, and discussed transfer to the hospital. Nursing note dated 4/1/26 at 1:10 PM identified Person #1 spoke with the APRN #1 by telephone and agreed with transferring Resident #1 to the hospital for further evaluation. The Hospital Discharge summary dated [DATE] identified imaging results from the CT chest, abdomen, and pelvis without contrast, identified age-indeterminate compression deformities of the T3 and T4 (spine) vertebral bodies that were new compared to imaging from 6/3/25. The report recommended correlation with point tenderness in the affected region. The imaging also identified a subacute-to-chronic right acetabular (hip socket) fracture and a varus-impacted subcapital fracture of the left femur (neck of the femur), with a recommendation to correlate the findings with any recent history of trauma. Resident #1 was seen by orthopedics with a plan to continue conservative management and weight-bearing as tolerated. Interview and record review with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/16/26 at 12:40 PM identified they were not aware that Resident #1 had been diagnosed with age-indeterminate fractures of the hip. Upon review of the Hospital Discharge Summary and imaging findings, the DON and ADON confirmed the diagnosis and acknowledged the fractures constituted an injury of unknown origin that should have been assessed and investigated. Interview identified although Resident #1 had no recent falls, the facility had not conducted an investigation because they were unaware of the diagnosis. Interview with the Director of Nursing (DON) on 6/16/26 at 2:00 PM revealed the facility was unable to provide a policy governing the identification and investigation of injuries of unknown origin. The DON stated the facility relied upon and followed the requirements of the Connecticut Public Health Code for adverse event reporting.

Based on review of the clinical record, facility policy and interviews for 2 of 4 residents (Resident #2 and Resident #16) reviewed for nutrition, the facility failed to ensure a significant weight loss of 18.6 pounds (lbs.) in 31 days was identified timely for Resident #2 which resulted in a delay of Resident #2 receiving a nutritional supplement and failed to ensure nutritional supplements were administered per physician orders for a resident with significant weight loss of 20.4 lbs. in 6 months for Resident #16. The findings include: 1.Resident #2's diagnosis included Type 2 diabetes mellitus, dysphagia, (difficulty swallowing) and Barrett's esophagus (a condition affecting the lining of the esophagus). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired and required set-up/clean up assistance with eating, partial/moderate assistance with bed mobility, substantial/maximal assistance with toileting and was dependent with transfers. The MDS identified Resident #2 had no significant weight loss but indicated the resident had malnutrition as an active diagnosis. The MDS further noted Resident #2 was on a mechanically altered and therapeutic diet. The Resident Care Plan (RCP) dated 1/7/26 identified Resident #2 had oral/dental health problems, diabetes mellitus and was at risk for malnutrition. Interventions included consulting with the dietician, provide a therapeutic diet as ordered, and to monitor and evaluate Resident #2's weight and weight changes. The RCP further indicated to obtain and record weights per facility protocol and to notify the registered dietician (RD), family and physician of any significant weight changes. A physician's order dated 1/20/26 directed Resident #2 was a monthly weight on the evening shift on the 1st of the month. Review of the Weight and Vitals summary identified that Resident #2 on 10/1/25 weighed 122.8 pounds (lbs.), on 11/2/25, weighed 122.4 lbs., on 12/31/25 weighed 122.0 lbs., on 2/1/26 weighed 103.4 lbs. (which was documented by LPN #2) (an 18.6 lbs./15.2% loss in 31 days), on 2/5/26 weighed 101.0 lbs., and on 2/12/26 weighed 101.6 lbs. (a 20.4 lb./16.7% loss in 43 days from 12/31/25 to 2/5/26). A dietician progress note written by Dietician #2 and dated 2/12/26 at 10:55 AM identified Resident #2 had triggered for a 21-pound weight loss which equaled a 17% weight loss since December 2025. Additionally, Dietician #2 recommended to start Glucerna 8 ounces (oz.) daily. Physician order dated 2/12/26 directed Glucerna shake 8 ounces, every day shift for weight loss. Interview and review of the clinical record with the unit manager (RN #1) on 2/17/26 at 3:38 PM identified that on 2/12/26 she was given a list from the Dietician of residents with weight changes, and she informed APRN #1 on 2/16/26 of Resident #2's significant weight loss via telephone call and spoke to APRN #1 (15 days after an 18.6 lbs./15.2% loss was documented on 2/1/26) but APRN #1 directed no new orders. A nursing note dated 2/16/26 and written by RN #1 indicated she received no new orders regarding Resident #2's significant weight loss from APRN #1. RN #1 identified she would have expected the resident to have been put on weekly weights due to his/her weight loss, but she forgot to ask the APRN #1 about it. Review of the clinical record with RN #1 identified on 12/31/25 Resident #2 weighed 122.0 pounds and on 2/1/26 the resident weighed 103.4 lbs., with a continued steady decrease in weight noted on 2/5/26 when Resident #2 weighed 101.0 lbs. RN #1 was unable to identify the reason Resident #2 was not weighed in January 2026 and stated monthly weights on the residents were the responsibility of Nurse Aides to obtain the weights and the licensed nursing staff to document in the weight/vital section of the electronic health record. Subsequent to surveyor inquiry, a nursing note written by RN #1 and dated 2/17/26 at 9:04 PM indicated the in-house APRN had been notified regarding Resident #2's significant weight loss and a new order was obtained for weekly weights for 4 weeks. Interview and review of the clinical record with Dietician #2 on 2/18/26 at 10:30 AM indicated because nursing had not obtained a weight for Resident #2 in January 2026 and did not inform her of the weight taken on 2/1/26 (weight of 103.4 lbs.) or 2/5/36 (weight of 101 lb.), the significant weight loss was not identified until she reviewed the resident's chart on 2/12/26 (12 days later). Dietician #2 was unable to identify the reason Resident #2 was not weighed in January 2026 and stated monthly weights were the responsibility of the nursing staff to obtain and document. Additionally, Dietician #2 indicated had she been made aware of the resident's significant weight loss on 2/1/26, she would have recommended weekly weights, Glucerna Shake and ensured nursing monitored Resident #2 closer at mealtime. Interview and review of the clinical record with the DNS on 2/18/26 at 3:05 PM identified Resident #2 should have been weighed monthly, and it was the responsibility of the nursing staff to obtain and document resident's weights per the physician's orders. The DNS noted when LPN #2 documented Resident #2's weight of 103.4 lbs. in the clinical record on 2/1/26, LPN #2 should have reviewed the resident's prior weights, identified the significant weight loss, obtained a reweight and physician's order directing weekly weights. Subsequent to surveyor inquiry, a physician's order dated 2/18/26 directed weekly weights every day shift every Wednesday for 4 weeks. Interview and review of the clinical record with APRN #2 on 2/19/26 at 10:20 AM identified nursing should have notified her or APRN #1 on 2/1/26 about Resident #2's significant weight loss and had she been notified she would have ordered weekly weights. Due to not being notified by nursing of Resident #2's significant weight loss on 2/1/26, APRN #2 indicated that 2/18/26 was the first time she addressed Resident #2's weight loss (17 days after a significant weight loss was documented by LPN #2). APRN #1 was unable to identify the reason Resident #2 was not weighed in January 2026 and stated monthly weights on the residents were the responsibility of the nursing staff to obtain and document. Interview with LPN #2 on 2/19/26 at 2:35 PM identified she was the charge nurse on 2/1/26 and she and the nurse aide obtained the residents weight of 103.4 lbs. LPN #2 stated although she documented Resident #2's weight in the clinical record on 2/1/26, she failed to notice the resident's prior weight of 122 lbs. documented on 12/31/25, which indicated a significant weight loss. LPN #2 identified she was unsure of the reason she did not compare Resident #2's prior weights, but had she done so, she would have notified her supervisor and ensured the physician was notified and the resident was put on weekly weights. Additionally, LPN #2 indicated she weighed Resident #2 on 2/1/26 because that was the date for the resident's monthly weight, and she was not aware Resident #2 was not weighed in January 2026. Attempts to contact APRN #1 were unsuccessful. Attempts to contact LPN #6 (documented Resident #2's weight in the clinical record on 2/5/26) were unsuccessful. Review of facility policy, Weight Policy and Procedure, dated10/2023, directed each resident's weight will be obtained and documented upon admission, re-admission, monthly or for significant change in condition in the electronic medical record. Monthly weights are to be obtained and recorded each month and significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates a significant weight change the plan of care will be revised as appropriate. Residents with significant unintended weight changes will be added to weekly weights x four weeks or until weight stabilizes as determined by the interdisciplinary team. 2. Resident #16 had diagnoses that included end stage renal disease (ESRD), diabetes, and a protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was moderately cognitively impaired, required hemodialysis, was on a therapeutic diet, had no weight loss of 5% or more in the last month or 10% or more in the last 6 months and weighed 152 pounds (lbs.). The MDS assessment further identified Resident #16 required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for chair/bed transfers. The Resident Care Plan (RCP) dated 11/28/25 identified Resident #16 was at risk for malnutrition related to end stage renal disease and community-acquired pneumonia (CAP). Interventions included providing medical food supplements, obtain weights as ordered, and monitor/evaluate Resident #16's food and fluid intake via intake records and observation. A physician order dated 1/9/26 directed for Resident #16 to be transported to hemodialysis 3 times per week every Monday, Wednesday, and Friday (M-W-F) with a pickup time of 6:00 AM for a chair (treatment) time of 6:30 AM. A physician order signed 1/20/26 directed to administer 8 ounces (240 milliliter (ml)) of Nepro supplement one time a day at 9:00 AM for malnutrition. An Annual Nutritional Evaluation dated 2/3/26 at 7:25 AM and written by Dietician #1 identified Resident #16 was on a renal consistent carbohydrate diet and his/her average food intake met 51-75% of estimated needs. The evaluation identified Resident #16's most recent weight was 143.7 pounds (lbs.) and his/her usual body weight was 164 lbs. Additionally, the evaluation identified Resident #16 weighed 145.8 lbs. on 1/1/26, 152.6 lbs. on 11/4/25, and 164.1 lbs. on 7/14/25 and had a significant weight change of greater than or equal to 10% in 180 days. The evaluation identified the weight change was a significant weight loss of 20.4 lbs. in 6 months (12% loss) with prior hospitalization for Community Acquired Pneumonia/CAP (10/27/25-11/1/25). The evaluation identified Resident #16 received a 240 milliliter (ml) Nepro supplement daily, Resident #16 had end stage renal disease (ESRD), received hemodialysis M-W-F and the plan was to increase the Nepro supplement to 240 ml twice a day, maintain a 1500 ml fluid restriction, and maintain open communication with Dietician #3 at hemodialysis. An updated physician order dated 2/3/26 directed to administer 8 ounces (240 ml) of Nepro supplement two times a day at 9:00 AM and 4:00 PM for malnutrition. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was moderately cognitively impaired, required hemodialysis, was on a therapeutic diet, had a weight loss of 5% or more in the last month or 10% or more in the last 6 months, was not on a physician prescribed weight loss regimen and weighed 144 lbs. The MDS assessment further identified Resident #16 required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for chair/bed transfers. The Medication Administration Record (MAR) for February 2026 identified Resident #16 had failed to receive 240 ml Nepro supplement 14 out of 33 opportunities (42.4%). The MAR identified 7 out of 14 missed opportunities were because Resident #16 was out to his/her hemodialysis appointment. The MAR further identified 5 out of 14 missed opportunities were coded as other and directed to reference the nursing note. Review of nursing notes dated 2/1/26 through 2/19/26 identified the 5 nursing notes triggered by the other code in the February 2026 MAR were all written by LPN #8 who noted on 2/5/26 at 5:53 PM, 2/7/26 at 5:31 PM, 2/9/26 at 5:25 PM, 2/10/26 at 5:56 PM, and 2/11/26 at 5:25 PM the 240 ml Nepro supplement was unavailable. The 5 notes all failed to identify that the dietician, nursing supervisor, and/or Advanced Practice Registered Nurse (APRN) had been notified of the supplement being unavailable. Interview with Dietician #1 on 2/17/26 at 2:38 PM identified he had identified a significant weight loss for Resident #16 on 2/3/26 and had increased the Nepro supplement order to 240 ml twice a day for the reason of malnutrition. Dietician #1 identified in the event the Nepro supplement was unavailable, the nurses could substitute a different nutritional supplement (Ensure) or they could call him and he would direct them to provide the Ensure supplement until the Nepro supplement was available. Dietician #1 identified he had not been called or notified that the Nepro supplement was unavailable at any time in February 2026. Dietician #1 identified he had entered the Nepro supplement administration times of 9:00 AM and 4:00 PM and that he was unaware of the time of day Resident #16 attended hemodialysis, nor that the nurses signed that Resident #16 was on therapeutic leave and therefore did not administer the 240 ml Nepro supplement. Dietician #1 identified he was unaware Resident #16 had missed 12 of the 240 ml of Nepro supplements (as of 2/17/26), for either the reason of therapeutic leave or that the Nepro supplement was unavailable, that Resident #16 should not have missed any of the ordered Nepro supplements and that he could adjust the time to allow the nurse to administer after Resident #16 returns from hemodialysis on M-W-F. (please refer to F 580). Subsequent to surveyor inquiry, an updated physician order dated 2/17/26 directed to administer 8 ounces (240 ml) of Nepro supplement every day (7:00AM to 3:00 PM) and evening (3:00 PM to 11:00 PM). Review of the Nutrition policy directed, in part, the facility maintained adequate nutritional status for the residents which was assessed on admission, quarterly, and when a significant change occurred. The policy directed the dietician would complete a nutritional assessment that identified those factors that placed the resident at risk for inadequate nutrition, the nutritional needs of the resident, and the nutritional goals for the resident. The policy identified the dietician implements individualized interventions for the resident to address nutritional needs. The interventions are then evaluated for effectiveness (meal intake, supplement acceptance/intake). The policy further directed that the nutritional status was reassessed with a significant change of condition.

Based on observations, interviews, review of clinical records, and facility policy for 2 of 2 residents (Resident #3 and Resident #16) reviewed for dialysis, the facility failed to ensure an emergency dialysis kit was at the bedside per policy (Resident #3) and for Resident #16, failed to document/tally Resident #16's actual fluid intake and failed to ensure administration of medication per physician orders. The findings include: 1.Resident #3 was admitted to the facility in January 2026 with diagnoses that included end stage renal disease, renal dialysis dependent, and hemiplegia affecting the nondominant left side. Physician orders dated 1/29/26 directed a dialysis emergency kit every shift prophylaxis at the bedside, emergency kit: hemo-stats (clamp tool that controls bleeding) if resident had central venous access device (CVAD) and clean gauze pads if resident had an arteriovenous (AV) fistula (a link between an artery and vein) and every shift prophylaxis with resident when not in bed hemo-stats if resident had CVAD and clean gauze pads if resident had an AV fistula. Additionally, the physician orders directed access port/CVAD on left chest, monitor every shift for signs and symptoms of infection and hemodialysis 3 times a week on Monday, Wednesday and Friday. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had intact cognition, required maximum assistance from staff for washing, dressing, toileting and bed mobility. Additionally, the MDS noted Resident #3's special treatments included hemodialysis and transfusions. The Resident Care Plan (RCP) dated 2/4/26 identified hemodialysis related to end stage renal disease as a concern with interventions that included dialysis 3 times a week, fluid restrictions as ordered, enhanced barrier precautions, post and pre dialysis weights, labs as ordered, observe site for signs and symptoms of infection, send dialysis communication book with resident on dialysis days to the center and notify MD of any changes. Observation on 2/13/26 at 9:20AM identified that no emergency dialysis kit (hemo-stats) was noted at the bedside. Observation and interview with Licensed Practical Nurse (LPN) #1 on 2/17/26 at 11:49 AM identified that no emergency dialysis kit was observed at Resident #3's bedside. LPN #1 searched through Resident #3's bedside table and dresser drawers but could not locate an emergency dialysis kit. LPN #1 stated that Resident #3 previously had an emergency kit hanging on the wall in the bedroom but was unsure when it went missing. LPN #1 stated that she had a difficult time with the emergency dialysis kit remaining intact on the wall behind Resident #3's bed and stated that the kit must have fallen or someone discarded the emergency dialysis kit. LPN #1 indicated that she had not made maintenance or anyone aware that she was having difficulty adhering the emergency dialysis kit to the wall. LPN #1 indicated that the policy was that dialysis residents have an emergency dialysis kit at the bedside and on person when not in the bedroom. Resident #3 had an emergency dialysis kit at the bottom of a tote bag that was hanging off the back of Resident #3's wheelchair for when Resident #3 left the room and/or went on leave of absence from the facility. The emergency dialysis kit contained a hemo-stat clap and gauze that was in a sealed bag. Resident #3's Treatment Administration Record (TAR) was signed by licensed nursing staff on every shift from 2/1/26 through 2/17/26 that an emergency dialysis kit was at the bedside. Interview with the Corporate Regional Nurse on 2/17/26 at 12:07 PM identified that residents receiving hemodialysis were to have an emergency kit at the bedside and with person when not in bed per facility policy. She indicated that there should be an emergency dialysis kit visible in the resident's room and nursing was responsible to ensure that both emergency dialysis kits were available. A review of the Hemodialysis Policy dated 1/26 directed, in part, a resident admitted to the facility requiring hemodialysis will have their dialysis needs met. Hemodialysis residents will have a bedside emergency dialysis kit: Hemo-stats if resident has a CVAD and clean gauze pads if resident has an AV fistula. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #16) reviewed for dialysis, the facility failed to document/tally Resident #16's actual fluid intake and failed to ensure administration of medication per physician orders. The findings include: Resident #16's diagnoses included end stage renal (kidney) disease (ESRD), diabetes, and protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was moderately cognitively impaired, required hemodialysis, was on a therapeutic diet, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for chair/bed transfers. The Resident Care Plan (RCP) dated 11/28/25 identified Resident #16 required hemodialysis related to kidney failure. Interventions included a 1500 milliliter (ml) per day fluid restriction with 240 ml on the day shift (7:00 AM-3:00 PM), 240 ml on the evening shift (3:00 PM-11:00 PM), 180 ml on the night shift (11:00 PM-7:00 AM), and 840 ml provided by dietary with meals (breakfast, lunch, dinner). Additionally, interventions included to observe fistula for bleeding, and notify the medical doctor (MD)/Advanced Practice Registered Nurse (APRN) of any concerns noted on Resident #16's return from his/her dialysis treatment. The RCP dated 11/28/25 further identified Resident #16 was at risk for malnutrition related to end stage renal disease. Interventions included to monitor/evaluate Resident #16's food and fluid intake via intake records and observations, and monitor Resident #16's food/beverage preferences and eating patterns. A physician order dated 1/9/26 directed for Resident #16 to be transported to hemodialysis 3 times per week every Monday, Wednesday, and Friday (M-W-F) with a pickup time of 6:00 AM for a chair (dialysis treatment) time of 6:30 AM. a. A Dialysis Communication Form dated 2/2/26 noted Resident #16 had a complication of hypotension during dialysis and stated, Please monitor adherence to fluid restrictions. A Dialysis Communication Form dated 2/3/26 identified the facility documented on the top portion of the form Resident #16 was on a 1500 ml fluid restriction and there were no changes in condition since the last treatment A physician order dated 2/3/26 directed to administer 8 ounces (240 ml) of Nepro supplement two times a day at 9:00 AM and 4:00 PM for malnutrition and directed a fluid restriction of 1500 ml per day (24 hour period): 660 ml provided by dietary with meals, 360 ml provided for medication administration (120 ml with each medication (med) pass), and 480 ml of Nepro supplement, every shift related to hemodialysis. A physician order dated 2/3/26 for the 1500 ml fluid restriction for 24 hours identified on the day shift (7:00 AM-3:00 PM) Resident #16 was allotted a total of 800 ml (220 ml for breakfast + 220 ml for lunch + 120 ml for day shift med pass + 240 ml for a Nepro supplement = 800 ml). The order identified on the evening shift (3:00 PM-11:00 PM) Resident #16 was allotted a total of 580 ml (220 ml for dinner + 120 ml for evening shift med pass + 240 ml for a Nepro supplement = 580 ml) and on the night shift (11:00 PM-7:00 AM) Resident #16 was allotted a total of 120 ml provided on the night shift med pass. The total of all 3 shifts (day, evening, and night) would be 800 ml + 580 ml + 120 ml = 1500 ml in 24 hours. A Dialysis Communication Form dated 2/11/26 identified the facility documented on the top portion of the form Resident #16 was on a 1500 ml fluid restriction and there were no changes in condition since the last treatment. Observation on 2/17/26 at 8:22 AM identified Resident #16 sitting upright in bed with the breakfast tray in front of him/her. Resident #16 ate all the eggs, half the waffle and was drinking 8 ounces (240 ml) of hot tea. Interview and clinical record review with Registered Nurse (RN) #1 on 2/17/26 at 12:30 PM identified the facility did not maintain/calculate intake and output (I&O) for residents. RN #1 identified Resident #16 was on a fluid restriction and therefore had an order which specified the allotted amount of fluids that could be provided to Resident #16 on each shift, but that Resident #16's total intake was not measured in order to identify if he/she was meeting/not meeting or exceeding the physician ordered 1500 ml fluid restriction. RN #1 identified staff were expected to provide only those fluid amounts allotted within the physician order and that residents on a fluid restriction would have an alert in the electronic medical record (EMR) which directed the staff to review the physician orders to see how much was allowed each shift. Review of the fluid restriction order dated 2/3/26 in the EMR failed to identify supplementary documentation was triggered/alerted within the order to prompt for nurses to input this information each shift. Observation on 2/17/26 at 12:43 PM identified Resident #16 sitting upright in bed with a family member visiting. A 16 oz bottle of iced tea that was 1/2 empty was observed on the overbed table in front of Resident #16 and Resident #16 was observed drinking the iced tea. A full 16 oz. electrolyte drink was observed on the nightstand in the corner next to Resident #16. Observation on 2/17/26 at 1:50 PM identified Resident #16 sitting upright in bed eating a snack and drinking a 16 oz. electrolyte l drink which was observed to be half consumed, and there was no longer the electrolyte drink on the nightstand in the corner next to Resident #16 which was observed at 12:43 PM. Interview and observation of Resident #16 with Nurse Aide (NA) #2 on 2/17/26 at 1:50 PM identified she documented Resident #16's fluid intake with meals in the electronic medical record (EMR). NA #2 identified she had documented Resident #16 consumed 480 ml at breakfast and 360 ml at lunch and although she could see Resident #16 drinking an electrolyte drink the system did not allow for her to enter how much liquid was consumed. NA #2 identified she was unaware Resident #16 was on fluid restriction, that she had not been told, and she wasn't sure what she was supposed to do differently than any other resident. NA #2 identified she had not and would not enter the iced tea consumed earlier or the electrolyte drink consumed by Resident #16 because it would require her to strike out the earlier entry because additional fluids could not be added after the meal was documented. Review of the nurse aide (NA) documentation report for dates 1/21/26 to 2/19/26 identified from 2/3/26 to 2/19/26 the total of fluid consumed at meals each day for Resident #16 exceeded the 660 ml fluid allotment designated for meals 12 out of 17 times: 2/3/26 1300 ml total, 2/5/26 1160 ml total, 2/6/26 920 ml total, 2/7/26 960 ml total, 2/8/26 1200 ml total, 2/10/26 800 ml total, 2/12/26 840 ml total, 2/13/26 780 ml total, 2/14/26 940 ml total, 2/15/26 1160 ml total, 2/16/26 840 ml total, and 2/17/26 1200 ml total. Additionally, the report failed to identify/include fluid intake consumed by Resident #16 between meals (see surveyor observations). Interview with Registered Nurse (RN) #3 (dialysis facility nurse) on 2/18/26 at 9:45 AM identified the importance of a fluid restriction for a dialysis resident was to prevent fluid overload which could cause pulmonary edema, edema in the lower extremities, and exacerbation of heart failure. RN #3 indicated dialysis residents have little or no kidney function and therefore their kidneys were unable to filter the blood to remove excess fluid and produce urine. RN #3 further identified he would need to refer to Resident #16's chart, but he did not think Resident #16 produced urine anymore. Interview with RN #3 and Dietician #3 (dialysis dietician) on 2/18/26 at 11:58 AM identified Resident #16 has required extension of his/her dialysis treatments on the last several treatments related to fluid overload. RN #3 and Dietician #3 identified their orders reflected Resident #16's fluid restriction was 1000 ml and indicated the facility should have called them to inform them of the increased fluid restriction. Additionally, they identified if the facility had called, they would have had the discussion that the higher fluid restriction was not beneficial for Resident #16. RN #3 and Dietician #3 identified the facility had been notified more than once that Resident #16 needed to maintain his/her fluid restriction both via the Dialysis Communication form, and by phone to the nursing supervisor. Additionally, they identified Resident #16 required an additional treatment day and the facility nursing supervisor had been called and notified that Resident #16 required this additional treatment due to fluid overload. The dialysis center requested the facility monitor Resident #16's intake to ensure the fluid restriction was being maintained and requested the facility to schedule transportation to get Resident #16 to the additional treatment on 2/3/26. RN #3 and Dietician #3 further identified they were unaware the facility did not maintain intake and output records to monitor Resident #16's fluid restriction and indicated fluid overload did not always present with visible signs. b. review of Resident #16's meal tickets for breakfast, lunch, and dinner for 2/19/26 identified items provided by the dietary department for each meal. The breakfast section of the slip identified Resident #16 received an 8 ounce (oz) (240 ml) hot tea, a 4 oz (120 ml) cranberry juice, 1 serving of Cheerios, and 8 oz. of whole milk with a note at the bottom of the slip which directed to limit fluid to 10 oz (a discrepancy from 20 oz of fluids were provided/served to Resident #16 on the breakfast tray). The lunch section of the slip identified Resident #16 would receive 8 oz of hot tea with a note at the bottom of the slip which directed to limit fluid to 8 oz. The dinner section of the slip identified Resident #16 would receive 8 oz of hot tea with a note at the bottom of the slip which directed to limit fluid to 8 oz. The total expected fluids provided by the dietary department for Resident #16 were 1080 ml for the day provided at the 3 meals of breakfast, lunch and dinner. Interview with Director of Dietary (Dir Dietary) on 2/19/26 at 8:07 AM identified any dietary worker could enter the information on the dietary tickets, and that the information related to the diet, allergies, and fluid needs came from nursing and the EMR. Dir Dietary further identified the fluid restriction information was entered by Dietician #1 and Dietician #2 and was reflected at the bottom of the diet slip, but he was unable to identify whose responsibility it was to ensure the fluid items listed for distribution at each meal were within the fluid restriction parameters set by the dieticians. Interview with Dietician #2 on 2/19/26 at 8:15 AM identified she and Dietician #1 entered the fluid restriction parameters at the bottom of the diet slip, but neither her nor Dietician #1 entered the actual food/drink items in the top portion of the diet slip. Dietician #2 was unable to identify whose responsibility it was to ensure the fluids listed for distribution at mealtime fit within the parameters set by her and Dietician #1. Interview with Dietary Aide (DA) #1 on 2/19/26 at 8:20 AM identified she had provided Resident #16 with the following liquids on his/her breakfast tray that morning: an 8 oz. hot tea and a 4 oz. cranberry juice (totaling 12 oz). DA #1 identified she did not put the 8 oz. carton of whole milk on the tray because it was used for the cereal and the NAs on the unit would have provided a couple ounces of milk for the cereal. DA #1 identified she noticed the note at the bottom which instructed to limit fluids to 10 oz for breakfast but that she did not do the math to calculate what she was actually putting on the tray and indicated that she now realized she had placed 12 oz. of liquid on the tray that morning. DA #1 further identified the dieticians would inform the dietary staff to remove drink items if there was a fluid restriction that limited what the resident could receive, but she had not been told to withhold all the listed drinks for Resident #16. Interview with APRN #1 on 2/19/26 at 1:30 PM identified Resident #16 was on a fluid restriction, and the amount of the fluid restriction comes directly from dialysis. APRN #1 identified the fluid restriction order identified how much fluid should come from each source (meals, nurses administering medications, supplements) and that there were multiple areas within the EMR which showed fluid intake, but she wasn't sure how the facility calculated, totaled, or monitored that Resident #16 maintained the fluid restriction, and indicated that if a family brought in extra fluids it made it more difficult to maintain the fluid restriction. APRN #1 identified that typically the facility would notify her if a resident was exceeding their fluid restriction but was unable to recall if the facility had specifically identified Resident #16 was exceeding the fluid restriction. APRN #1 identified she was aware that Resident #16 had required an additional treatment session recently this month. Observation and interview with Resident #16 on 2/19/2026 at 2:25 PM identified Resident #16 sitting upright in bed with a family member visiting. A 1/2 consumed bottle of a16 oz. iced tea was observed on the overbed table in front of Resident #16. Resident #16 identified he/she had heard at some point that he/she should be mindful of the fluids that he/she drank throughout the day but could not identify when he/she had been told this or how much he/she should consume. Resident #16 was unaware of being on a 1500 ml fluid restriction, and his/her visitor indicated Resident #16's fluid restriction was 1200 ml per day when he/she was living at home. Resident #16 was unable to identify how many mls. were in the iced tea he/she was drinking and when told the number was 480 ml per bottle, he/she did not understand the correlation to the 1500 ml fluid restriction. Resident #16's visitor identified he/she brought drinks in for Resident #16 and no staff had provided education regarding the fluid restriction or reporting how much Resident #16 consumed of the drinks he/she brought in when visiting Resident #16. c. A physician order dated 1/21/26 directed to administer Sevelamer Carbonate 800 milligram (mg) tablet (phosphate binder for use in residents with chronic kidney disease receiving dialysis to bind phosphorus in the diet to help maintain strong bones) by mouth with meals at 8:00 AM, 12:00 PM, and 5:00 PM for supplement. The Medication Administration Record (MAR) for February 2026 identified Resident #16 failed to receive the Sevelamer Carbonate 800 mg tablet 12 out of 56 opportunities (21.4%). The MAR identified 9 out of the 12 missed doses were for the 8:00 AM administration time and the reason for not administering was coded as therapeutic leave (out to his/her hemodialysis appointment). Additionally, 3 out of the 12 missed doses were for the 12:00 PM administration time and the reason for not administering was also coded as therapeutic leave. Interview with RN #1 on 2/18/26 at 3:00 PM identified the charge nurses were responsible for reviewing the dialysis communication book for new information when Resident #16 returned from dialysis. RN #1 identified she was not aware Resident #16 did not receive Sevelamer Carbonate on dialysis days and would have the order changed. Subsequent to surveyor inquiry, a physician order dated 2/19/26 directed to administer Sevelamer Carbonate 800 mg tablet by mouth with meals every Monday, Wednesday, Friday at 6:00 AM, 1:00 PM, and 5:00 PM for supplement. Additionally, a physician order dated 2/19/26 directed to administer Sevelamer Carbonate 800 mg tablet by mouth with meals every Tuesday, Thursday, Saturday, and Sunday at 8:00 AM, 12:00 PM, and 5:00 PM for supplement. Interview with Registered Nurse (RN) #6 (dialysis facility nurse) on 2/19/26 at 12:20 PM identified dialysis had notified the facility that Resident #16 needed to receive Sevelamer Carbonate 800 mg with each meal, and she was unaware Resident #16 missed doses due to being at dialysis at the scheduled administration time. RN #6 asked if the facility could adjust the time of that medication administration to allow for Resident #16 to receive the medication because his/her phosphorus levels were increased and missed medication doses even 3 times per week could have contributed to that increase. Interview with APRN #1 on 2/19/26 at 1:30 PM identified she was aware Resident #16 had an order to receive Sevelamer Carbonate 800 mg with meals but was unaware Resident #16 missed doses every dialysis treatment day due to the timing of the medication and indicated that nursing could adjust the medication administration time to permit giving it on off shifts prior to dialysis. APRN #1 further identified she was unaware that Resident #16's phosphorus levels were elevated and indicated the blood work was obtained and managed by dialysis. The Hemodialysis policy directed, in part, residents will have their dialysis needs met. The policy directed the licensed nurse was responsible for obtaining physician orders for hemodialysis which should include dialysis treatment days and location of the clinic, scheduled treatment time, possible fluid restriction, labs if needed, clarification of medications to be administered pre-dialysis or held, and dietary needs such as renal. The policy directed a hemodialysis care plan would be implemented, the AV fistula would be monitored daily for signs and symptoms of infection, and the AV fistula (bruit and thrill) would be monitored every shift. The policy directed the nurse will document in the EMR when the resident goes and returns from dialysis. The policy directed forming of a communication book to include pertinent information, medication changes, lab values, and any significant changes since the last treatment. The policy further directed to notify dietary for meal preparation needs prior to the appointment and any snacks required to go with the resident to dialysis.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #2) reviewed for nutrition, the facility failed to ensure timely notification to the physician, dietician, and responsible party of a significant weight loss resulting in a delay in providing nutritional supplements and for the only sampled resident (Resident #68) reviewed for constipation/diarrhea, the facility failed to notify the Advanced Practice Registered Nurse (APRN) of loose stools for Resident #68 who was on a laxative. The findings include: 1.Resident #2's diagnosis included Type 2 diabetes mellitus, dysphagia, (difficulty swallowing) and Barrett's esophagus (a condition affecting the lining of the esophagus). The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 was severely cognitively impaired and required set-up/clean up assistance with eating, partial/moderate assistance with bed mobility, substantial/maximal assistance with toileting and was dependent with transfers. The MDS further identified Resident #2 did not have a significant weight loss, but indicated the resident had malnutrition as an active diagnosis. The MDS further noted Resident #2 was on a mechanically altered and therapeutic diet. The Resident Care Plan (RCP) dated 1/7/26 identified Resident #2 had oral/dental health problems, diabetes mellitus and was at risk for malnutrition. Interventions included to consult with the dietician, provide a therapeutic diet as ordered, and to monitor and evaluate the residents weight and weight changes. The RCP further directed to obtain and record weights per facility protocol and to notify the registered dietician (RD), family and physician of any significant weight changes. Review of the Weight and Vitals summary identified that Resident #2 on 10/1/25 weighed 122.8 pounds (lbs.), on 11/2/25, weighed 122.4 lbs., on 12/31/25 weighed 122.0 lbs., there was no documented weight for January 2026, on 2/1/26 weighed 103.4 lbs (which was documented by LPN #2) (an 18.6 lb./15.2% loss in 31 days), on 2/5/26 weighed 101.0 lbs., and on 2/12/26 weighed 101.6 lbs. (a 20.4 lb./16.7% loss in 43 days from 12/31/25 to 2/5/26). A physician's order dated 1/20/26 and currently in effect directed Resident #2 was a monthly weight on the evening shift on the 1st of the month. A dietician (Dietician #1) progress note dated 2/12/26 at 10:55 AM identified Resident #2 had triggered for a 21-pound weight loss which equaled a 17% weight loss since December 2025. Additionally, Dietician #2 recommended to start Glucerna 8 ounces (oz.) daily. Physician order dated 2/12/26 directed Glucerna shake 8 ounces, every day shift for weight loss. Interview with Person #1 on 2/17/26 at 12:34 PM identified he/she was the resident representative for Resident #2, was concerned Resident #2 was losing weight and was not notified of the resident's significant weight loss. Person #1 further identified that at the last RCP meeting (on 12/30/25) he/she was not provided with Resident #2's current weight because he/she was told a current weight was not available. Person #1 indicated that although he/she visited Resident #2 almost every day and was at the facility on 2/16/26, he/she was not informed by RN #1 on 2/16/26 of Resident #2's significant weight loss and had not been informed by anyone at the facility (in person or by phone) at any other time. Additionally, Person #1 indicated he/she was not informed that on 2/12/26, Resident #2 was ordered to start a Glucerna Shake as a nutritional supplement for weight loss. Interview and review of the clinical record with the unit manager (RN #1) on 2/17/26 at 3:38 PM identified that on 2/12/26 she was given a list from the Dietician of residents with weight changes, but she did not inform APRN #1 or Person #1 of Resident #2's significant weight loss until 2/16/26 (16 days after Resident #2 had an 18.6 lb/15.2% weight loss in 31 days). RN #1's nursing note dated 2/16/26, indicated she received no new orders for Resident #2 from APRN #1. Additionally, review of the clinical record with RN #1 identified on 12/31/25 Resident #2 weighed 122.0 pounds and on 2/1/26 weighed 103.4 lbs. (an 18.6 lb./15.2% loss), with a continued steady decrease in weight noted on 2/5/26 when Resident #2 weighed 101.0 lbs. (a 20.4lb./16.7% loss in 43 days). RN #1 identified it would have been the responsibility of LPN #2 (who obtained and documented the residents weight on 2/1/26) to notify the physician, Dietician and Person #1 of the residents significant weight loss. RN #1 was unable to indicate the reason the physician, dietician and Person #1 were not notified timely of the resident's significant weight loss (on 2/1/26 and/or with a re-weight on 2/5/26). RN #1 further indicated it would have been the responsibility of the charge nurse who transcribed the order on 2/12/26 to notify the resident representative regarding the Glucerna Shake but could not identify the reason notification did not occur. Subsequent to surveyor inquiry a nursing note written by RN #1 and dated 2/17/26 at 9:04 PM indicated the in-house APRN had been notified regarding the resident's significant weight loss, new orders for weekly weights for 4 weeks and lab work in the AM were obtained. The nursing note further identified Person #1 had been updated by RN #1. Interview and review of the clinical record with Dietician #2 on 2/18/26 at 10:30 AM indicated because nursing had not obtained a weight for Resident #2 in January 2026 and did not inform her of the resident's 2/1/26 weight, the residents significant weight loss was not identified until she reviewed the resident's chart on 2/12/26. Dietician #2 stated it would have been the responsibility of the unit manager or charge nurse to inform her, the physician, and Person #1 about Resident #2's significant weight loss (on 2/1/26) and to inform the resident representative of the new order for the Glucerna Shake (on 2/12/26). Dietician #2 indicated had she been made aware of the resident's significant weight loss on 2/1/26, she would have recommended weekly weights, Glucerna Shake and ensured nursing more closely monitored Resident #2 at mealtime. Interview and review of the clinical record with the DNS on 2/18/26 at 3:05 PM identified she would have expected the charge nurse or unit manager to notify the physician, dietician, and RP of Resident #2's significant weight loss timely. The DNS stated when LPN #2 documented Resident #2's weight in the clinical record on 2/1/26, LPN #2 should have reviewed Resident #2's prior weights, identified the resident's significant weight loss and reported it to the nursing supervisor, physician, dietician, and resident representative. The DNS further identified the resident representative should have been notified on 2/12/26 when Resident #2 was started on Glucerna Shake for weight loss. Subsequent to surveyor inquiry, a physician's order dated 2/18/26 directed weekly weights for 4 weeks every day shift every Wednesday for 4 weeks. Interview and review of the clinical record and facility documents with APRN #2 on 2/19/26 at 10:20 AM identified nursing should have notified her or APRN #1 on 2/1/26 regarding Resident #2's significant weight loss and although she had a visit with Resident #2 on 2/18/26 and ordered Mirtazapine (to improve appetite and weight gain) that was the first time she addressed Resident #2's weight loss. Review of the communication book (the means of communication between the facility and APRN) with APRN #1 indicated on 2/17/26 a request for follow-up of Resident #2's significant weight loss was listed in the communication book (17 days after a significant weight loss was documented from a weight obtained), was not notified by nursing at any other time (by phone or in person) about Resident #2's weight loss and she should have been. Interview with LPN #2 on 2/19/26 at 2:35 PM identified she was the charge nurse for on 2/1/26 and she and the nurse aide obtained the residents weight of 103.4 lbs. LPN #2 stated although she documented Resident #2's weight in the clinical record on 2/1/26, she failed to notice the resident's prior weight of 122 lbs. on 12/31/25, which indicated a significant weight loss. LPN #2 identified she was unsure of the reason she did not look at the resident's prior weights, but had she done so, she would have notified her supervisor and ensured the physician, dietician and the RP were notified on 2/1/26 regarding Resident #2's significant weight loss. Additionally, LPN #2 indicated she weighed Resident #2 on 2/1/26 because that was the date for the resident's monthly weight. Attempts to contact APRN #1 were unsuccessful. Attempts to contact LPN #6 (documented Resident #2's weight in the clinical record on 2/5/26) were unsuccessful. Review of facility policy, Weight Policy and Procedure, dated10/2023, directed each resident's weight will be obtained and documented upon admission, re-admission, monthly or for significant change in condition in the electronic medical record. Monthly weights are to be obtained and recorded each month and significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates significant weight changes the resident and/or family representative and interdisciplinary team will be notified, and the plan of care will be revised as appropriate. 2.Resident #68 had diagnoses that included Parkinson's disease, diabetes, and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was moderately cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, and required substantial/maximal assistance with toilet hygiene, bed mobility, and transfers. The Resident Care Plan (RCP) dated 1/20/26 identified Resident #68 had a self-care performance deficit related to Parkinson's disease. Interventions included Resident #68 required assist of 2 staff members for transfers, required substantial/maximal assistance with dressing, and required assistance of 1 staff member for toileting. The RCP further identified Resident #68 had occasional bowel and/or bladder incontinence related to impaired mobility and Parkinson's disease. Interventions included to cleanse the peri-area after each incontinence episode, monitor for signs and symptoms of urinary tract infection, and use disposable briefs only if requested by Resident #68. The RCP failed to identify interventions related to Resident #68's physician order for a laxative and had potential for constipation and/or loose stools. A physician order dated 1/23/26 (original order date 11/24/25) directed to administer Glycolax powder (a bowel laxative) 17 grams (gm) with 6 to 8 ounces of water by mouth one time a day for reason of constipation and to administer Glycolax powder 17 gm with 6-8 ounces of water by mouth as needed for constipation. The physician order failed to identify directions to hold the medication for loose stools. A progress note written by APRN #2 on 2/3/26 at 12:30 PM identified Resident #68 was seen for coordination of care following a podiatry consultation. The progress note identified in Resident #68 had no diarrhea/constipation and had an order for Glycolax powder medication administered daily and as needed for constipation. A progress note written by APRN #1 on 2/6/26 at 8:24 AM identified Resident #68 was seen for an unresponsive episode during transfer. The progress note identified Resident #68 had no diarrhea/constipation and had an order for Glycolax powder medication administered daily and as needed for constipation. Interview with Resident #68 on 2/11/26 at 11:43 AM identified he/she had loose stools/diarrhea every day. Resident #68 was unable to identify if he/she received any stool softeners or laxatives that might be contributing to the loose stools/diarrhea. A progress note written by APRN #2 on 2/18/26 at 10:15 AM identified Resident #68 was seen for a globulus sensation (feeling of food stuck). The progress note identified Resident #68 had no diarrhea/constipation and had an order for Glycolax powder medication administered daily and as needed for constipation. Review of the Nurse Aide (NA) documentation reports titled POC Response History and Follow up Question Report for dates 2/6/26 through 2/19/26 identified Resident #68 had 33 bowel movements and had loose stools/diarrhea for 16 out of 33 bowel movements. Additionally, the NA documentation reports titled POC Response History and Follow up Question Report identified Resident #68 had loose stools/diarrhea on 2/6/26 at 2:08 PM and 4:24 PM; 2/7/26 at 1:27 PM and 4:54 PM; 2/9/26 at 10:30 AM; 2/10/26 at 2:15 PM; 2/11/26 at 2:38 PM and 10:49 PM; 2/12/26 at 2:08 PM; 2/13/26 at 1:07 PM; 2/14/26 at 4:11 PM; 2/15/26 at 2:19 PM; 2/16/26 at 2:14 PM; 2/17/26 at 2:12 PM; and 2/18/26 at 1:56 PM and 8:16 PM. Nursing notes dated 1/19/26 through 2/19/26 failed to identify Resident #68 having loose stools or constipation. The Medication Administration Record (MAR) for February 2026 identified Resident #68 received the Glycolax powder 17 gm with 6 to 8 ounces of water by mouth every evening at 5:00 PM from 2/1/26 to 2/18/26. Interview with Licensed Practical Nurse (LPN) #8 on 2/19/26 at 9:00 AM identified that the NAs will often let her know if a resident had loose stools/diarrhea, but that she had not been informed of any loose stools/diarrhea for Resident #68 from the NA. Interview with NA #5 on 2/19/26 at 9:10 AM identified she provided care for Resident #68 often and that Resident #68 had a bowel movement sometimes 2 times on her shift and that Resident #68 had loose stools/diarrhea as often as 3 times a week. NA #5 identified she always told the nurse when Resident #68 had loose stools/diarrhea. Interview with Registered Nurse (RN) #5 on 2/19/26 at 9:15 AM and 9:35 AM identified she was the Unit Manager for the unit on which Resident #68 resided. RN #5 identified she was unaware Resident #68 had loose stools multiple times a week. RN #5 identified that she discussed the bowel status of the residents often and the nurses had not reported that Resident #68 had loose stools multiple times a week. RN #5 identified the nurses were responsible for monitoring the NA documentation of bowel movements (BM) in the electronic medical record (EMR), and the nurses were supposed to check the BM documentation every shift to determine if any resident required a laxative. RN #5 identified the NAs should notify the nurses when residents had loose stools/diarrhea, but even if they NA forgot to let the nurse know, the nurse would identify it when they reviewed the BM documentation. RN #5 identified when the nurse became aware a resident had loose stools they should write a note, notify the APRN to determine if they should hold the next dose of laxatives. RN #5 identified if Resident #68 had loose stools at 2:00 PM or later, the nurse should not give the 5:00 PM dose of Glycolax powder. Interview with APRN #1 on 2/19/26 at 1:30 PM identified she had not been notified of Resident #68 having loose stools/diarrhea and had she been notified, would have asked how frequent the loose stools were occurring. If the loose stools were very frequent she would have recommended sending out a stool specimen for testing to rule out an infection. If the loose stools were less frequent and the resident received laxatives or stool softeners she would have recommended to hold the medication for additional review to determine if a change in the laxative order was necessary. APRN #1 further identified that she would consider adding directions to hold administering Glycolax powder if Resident #68 had loose stools. Review of the Change in Condition Notification policy directed, in part, the facility will notify the resident, responsible party, and healthcare provider of a change in condition for the resident. The policy directed the healthcare provider is to be consulted with a significant change in the resident's physical, mental, or psychosocial status and or with the need to alter or discontinue a treatment due to adverse consequences, or when starting a new form of treatment. The policy directed the nurse is to be notified of changes in condition so they can perform an evaluation and document findings in the medical record. The policy further directed the nurse is to notify the physician of the change in condition and document the update in the medical record.

Based on interviews and review of the clinical record for the only sampled resident reviewed for laboratory results (Resident #84), the facility failed to ensure required blood work was completed in the time frame required prior to the resident's appointment. The findings included:Resident #84 was admitted to the facility in March 2025 with diagnoses that included anemia related to chronic kidney disease, type 2 diabetes, and cardiovascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #84 had intact cognition, required maximum assistance with washing, dressing, was incontinent of urine, and required set up for eating and oral hygiene. The Resident Care Plan (RCP) dated 11/20/25 identified cardiovascular disease as a concern with interventions that included obtaining labs as ordered, medications as ordered, follow up with cardiologist as needed, monitor for signs and symptoms of cardiopulmonary distress and notify the physician (MD) if exhibiting symptoms. Resident #84's care plan failed to reflect diagnosis of anemia with chronic kidney disease that require frequent monitoring of blood work as he/she receives Retacrit injections (man-made protein that produces red blood cells to treat anemia) at the kidney center.Physician orders dated 1/19/26 directed a Nephrology appointment on 3/5/26. Physician orders dated 2/11/26 and written by APRN #5 directed for labs to be completed one week prior to the Nephrology appointment on 3/5/26. The physician order written by APRN #5 also directed blood work for a complete blood count, a basic metabolic panel, Vitamin D and a urinalysis and to fax all results to the kidney center prior to appointment. Interview with Resident #84 on 2/11/26 at 2:15 PM stated that he/she was very upset because the facility had sent him/her out to an appointment for iron injections but did not receive the iron injections because the facility did not do the blood work that was ordered prior to the appointment. Resident #84 stated that he/she went out on 2/10/26 for no reason because the blood work was never ordered. Resident #84 stated that the nurse from the kidney center tried to call the facility several times to let them know not to send him/her, but no one at the facility responded to her call.A consultation sheet dated 1/13/26 identified that Resident #84 went to the kidney center and returned with a progress note indicating that 40,000 units of Retacrit injection was given and Resident #84 was to return in 4 weeks (on 2/10/26) at 1:00 PM with labs hematocrit and hemoglobin (H/H measures percentage of red blood cells in the body). The consultation sheet was signed by APRN #3 and dated 1/14/26 (indicated recommendations reviewed by APRN #3). A consultation sheet dated 2/10/26 from the kidney center indicated that Resident #84 was unable to be seen due to labs not being drawn within 30 days (although Resident #84 was transported to the appointment and had to return without receiving the iron injection).A consultation sheet dated 2/17/26 indicated that Resident #84 received 40,000-units Retacrit injection to the left arm due to anemia and to return in (DID IT SAY HOW MANY WEEKS?)______weeks with H/H to be done one week prior to 3/17/26 appointment at 1:00PM.An interview with the kidney center Nurse Coordinator on 2/18/26 at 1:00 PM identified that Resident #84 was not seen on 2/10/26 (although he/she arrived at the appointment) because blood work was not completed 30 days prior to his/her appointment. The Nurse Coordinator indicated that she made at least 3 attempts to contact the facility prior to Resident #84 coming to the center to inform Resident #84's nurse that he/she would not be seen if blood work was not completed withing the specific timeframe. The Nurse Coordinator indicated that she got disconnected two times and the last call she had explained that Resident #84 should not come to the appointment due to incomplete blood work to the receptionist who deferred her to the nursing unit. The Nurse Coordinator could not recall the name of the receptionist. An interview with Registered Nurse (RN) #5 on 2/18/26 at 2:00 PM indicated that the process for consultation sheets was when a resident returned from an appointment the consult sheet was reviewed by the unit manager and/or charge nurse. Any recommendations either get called into the APRN for approval if immediate approval was needed or they were given to the APRN on his/her next visit at the facility. RN #5 indicated that the consultation sheet was placed in the appropriate APRN binder for his/her signature and approval. RN #5 indicated that it was nursing's responsibility to transcribe in the resident's medical record and follow through with any new orders. RN #5 stated she recalled Resident #84's appointment on 2/10/26 and had blood work attached but it was not within the 30 days so the office would not accept the blood work for the appointment for Resident #84's injection. Interview with the facility receptionist on 2/19/26 at 10:30 AM indicated that she did not recall any phone calls from the kidney center for Resident #84 indicating that he/she should not go to his/her scheduled appointment on 2/10/26 because of not having blood work drawn 30 days before the appointment.Interview with the unit secretary on 2/19/26 at 11:00 AM (covers the facility phones when the receptionist was on lunch and/or break) did not recall any calls related to Resident #84 and the kidney center.Interview with APRN #5 on 2/19/26 at 11:47 AM indicated that she recalled the incident regarding Resident #84 not being seen for his/her Retacrit injection due to blood work not being completed timely. APRN #5 indicated that she had signed off on the consultation sheet for 1/13/26 and that she should have checked to make sure the blood work was ordered by the nursing staff. APRN #5 indicated that a new process was put in place due to the error and that she would be in direct communication with the kidney center Nurse Coordinator for all of Resident #84's appointments regarding his/her blood workAlthough requested, a policy on consultations was not provided.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #11) reviewed for positioning, the facility failed to apply bilateral hand splints per physician orders. The findings include: Resident 11's diagnoses included dysphagia, dementia, and pressure ulcers.An Occupational Encounter Note dated 5/21/25 identified that the use of bilateral soft hand splints were tolerated well by Resident #11. An Occupational Discharge summary dated [DATE] identified Resident #11 had tolerated wearing the soft hand splints, reducing risk for contractures to develop and skin breakdown. Recommendations were for Resident #11 to continue to wear soft hand braces as tolerated, remove with care and skin checks.(the physician orders did not include the application of bilateral soft hand splints)The Resident Care Plan (RCP) dated 1/20/26 identified Resident #11 had a deficit in functional mobility weakness. Interventions included applying splint/ brace to bilateral hands, removing with care and while performing skin checks.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was severely cognitively impaired, dependent on bathing, eating, transfers, toileting and dressing. Also, the MDS failed to identify Resident #11 had hand splints/braces.Observation on 2/11/26 at 11:51 AM noted Resident #11 to be sitting in the dining room in his/her adaptive wheelchair without the benefit of wearing bilateral soft hand splints.Observation on 2/11/26 at 1:18 PM noted Resident #11 to be in sitting in his/her adaptive wheelchair in his/her room without her/his bilateral soft hand splints in place.Observation on 2/17/26 at 12:45 PM noted Resident #11 seated in his/her adaptive wheelchair in his/her room, both hands were noted to be clenched with contractures without the benefit of wearing bilateral soft hand splintsReview of the Nurse Aid Care Card identified Resident #11 required the application of soft hand braces to bilateral hands, and to remove braces with care and skin checks.The Treatment Administration Record for February 2026 failed to include the use of bilateral soft hand braces. Observation on 2/18/26 at 11:07 AM noted Resident#11 with both fista clenched and bilateral soft hand splints not in place, sitting in an adaptive wheelchair in the her/his room.Interview on 2/18/26 at 11:07 AM with Nurse Aid (NA) #4 identified that although she was familiar with Resident #11, she was not aware that Resident #11 was to wear bilateral soft hand splints.Interview on 2/18/26 at 11:08 AM with Registered Nurse (RN) #5 identified Resident #11 was to wear bilateral soft hand braces and was unsure of the reason they were not applied because it was directed on the Nurse Aid Care Card. RN #5 further identified the charge nurse on the unit was responsible for oversight of making sure the soft hand splints were applied.Interview on 2/18/26 at 11:19 AM with Licensed Practice Nurse (LPN) #5 identified although she usually works on Resident #11's unit, she was unaware that Resident #11 required bilateral soft hand splints. LPN #5 further noted bilateral soft hand splints were put in place on 1/20/26 as per the RCP and she had never seen Resident #11 wearing bilateral soft hand splints.Interview on 2/19/26 at 9:50 AM with Physical Therapist (PT) #1 (who was also the Rehab Director), identified bilateral soft hand splints were not included in the physician orders because that was not the facilities practice but were to be included on the Nurse Aid Care Card and in the RCP. Also, identifying he was not aware Resident #11 had not been wearing bilateral soft hand splints.Subsequent to the surveyor's inquiry on 2/19/26 at 10:35 AM Resident #11 was observed with bilateral soft hand splint in place.Review of the facility policy for Person Centered Care Plan identified all department heads are responsible to ensure that there was a system for monitoring implementation of the residents' care plan. Also, identifying observations and rounds should be conducted and corrective action should be carried out when problems with implementation of care plans have been modified.

Based on observation, interviews, and facility policy for 1 of 6 resident units (unit C1), the facility failed to ensure egress pathways remained free of obstructions. Observation of unit C1 on 2/18/26 at 6:32 AM noted 4 wheelchairs blocking both sides of an exit door (which totally obstructed the entrance to the exit door) that directly leads to a vestibule with 3 doors, one leading to an outside exit, one to a stairwell and one to a janitor's closet. An interview with Nurse Aide (NA) # 6 on 2/18/26 at 6:35 AM noted that the wheelchairs in front of the exit door were recently cleaned by her and were in the hallway to dry. NA #6 stated she did not place the wheelchairs there and was unsure of how they were moved or by who, however she identified the wheelchairs were usually left in the hallway to dry after cleaning but usually were pushed to one side as to not block the exit door. An observation and interview with the Director of Maintenance on 2/18/26 at 6:49 AM identified the 4 wheelchairs blocking the exit and stated that they should be left in the lounge and out of the way to dry after cleaning. An interview with the nursing supervisor (RN # 5) on 2/18/26 at 11:30 AM identified the blocked exit on unit C1 is an egress route and should not be obstructed at any time in case of an emergency. A follow-up interview with the Director of Maintenance on 2/19/26 at 10:29 AM identified that all exits should be free of obstructions in case of emergencies in accordance with facility policy. A review of facility policy, Fire Procedure, dated 7/2019 directs that the facility utilizes the defend in place strategy in case of a fire which includes securing residents, clearing egress pathways, and closing and latching doors.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for skin conditions, the facility failed to implement enhanced barrier precautions (EBP) for a resident with a chronic pressure ulcer and a chronic diabetic wound. The findings include: Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes, chronic kidney disease, and heart failure.The admission Minimum Set Data (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS assessment further indicated Resident #1 had a stage 2 pressure ulcer and did not indicate any other wounds including diabetic ulcers at the time of assessment.A Skin Issue Assessment dated 2/1/26 at 1:46 PM identified Resident #1 had two active wounds, a Stage 2 pressure ulcer to the coccyx and a diabetic ulcer to the left heel.A physician order dated 2/2/26 directed the application of Triad to the buttocks every shift and as needed for a Stage 2 pressure ulcer on Resident #1's coccyx.A physician order dated 2/4/26 directed cleansing of the left heel diabetic ulcer with Betadine and covering it with a Kerlix dressing daily and as needed.A physician order dated 2/9/26 directed that Resident #1's heels be free-floated when in bed for the diabetic ulcer and specified air mattress settings based on the resident's weight.Physician order failed to include directives for implementing enhanced barrier precautions (EBP) for Resident #1's active left heel diabetic ulcer and Stage 2 pressure ulcer on the coccyx.The Resident Care Plan (RCP) dated 2/9/26 identified a diabetic ulcer to the left heel and interventions for the wound included weekly wound evaluations, treatments as ordered and update the physician with any changes to the wound. The RCP failed to indicate implementation of EBP for Resident # 1. Observations on 2/11/26 at 1:35 PM, 2/13/26 at 12:35 PM, and 2/18/26 at 1:47 PM noted that although Resident #1 was receiving daily wound care for a diabetic ulcer on the left heel and a Stage 2 pressure ulcer on the coccyx, there was no signage posted outside the resident's room and no personal protective equipment cart in close proximity of Resident #1's room indicating EBP An interview with the Infection Preventionist (RN #4) on 2/18/26 at 1:46 PM identified that she typically places residents with severe wounds (Stage 3 or 4 pressure ulcers) or wounds with drainage on EBP. However, after reviewing the facility's policy, Precautions to Prevent Infections (dated 6/24), and the Centers for Medicare & Medicaid Services (CMS) EBP Memorandum (dated 3/20/24), she acknowledged that Resident #1 should have been placed on EBP due tohis/her chronic coccyx pressure ulcer and chronic left heel diabetic ulcer, despite only minimal drainage from the wounds. A review of the Centers for Medicare & Medicaid Services (CMS) Enhanced Barrier Precautions in Nursing Homes Memorandum dated 3/20/24 established guidelines requiring nursing home residents with chronic wounds to be placed on Enhanced Barrier Precautions (EBP). These precautions require the use of gown and gloves during high-contact resident care activities, regardless of the resident's multidrug-resistant organism (MDRO) status. According to CMS, examples of chronic wounds include diabetic foot ulcers and pressure ulcers. Review of the facility's policy, Precautions to Prevent Infections, dated 6/2024, directed staff to implement enhanced barrier precautions for residents with chronic wounds, such as diabetic and pressure ulcers. Enhanced barrier precautions require staff to wear gowns and gloves during high-contact resident care activities.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for injury of unknown origin, the facility failed to report an injury of unknown origin to the state agency within the required time frame. The findings include: Resident #1 had diagnoses that included Alzheimer's disease, muscle weakness, difficulty walking, osteopenia, and expressive aphasia. The quarterly MDS dated [DATE] identified Resident #1 had short- and long-term memory problems, severely impaired cognitive skills, was always incontinent of bowel and bladder, and dependent with bed mobility, transfers, and ADLs. The care plan dated 8/30/24 identified Resident #1 has an ADL self-care performance deficit, decreased mobility, and does not walk. Interventions directed to provide extensive assistance of 2 staff to turn and re-position in bed, assistance of 2 for toileting and transfers, and assistance of 1 staff for dressing and bathing. Review of APRN #1's note dated 9/11/24 at 7:56 A.M. identified nursing reported Resident #1 noted with swelling to right hip. APRN #1 identified Resident #1 is unable to contribute to history of present illness secondary to cognitive status. APRN #1 indicated Resident #1 does not express pain with range of motion to right hip. APRN #1 identified Resident #1's right hip is red, swollen, and tender to palpation. APRN #1 identified an X-ray was ordered. The nurse's note dated 9/11/24 at 7:58 A.M. by LPN #2 identified Resident #1 has right hip swelling with no complaints of pain. LPN #2 identified a STAT X-ray was ordered. Review of Resident #1's radiology report dated 9/11/24 at 10:36 A.M. and reviewed by APRN #1 at 11:07 A.M. identified Resident #1 has an acute-appearing fracture of the proximal right femur with mild displacement of the distal fragment. The nurse's note dated 9/11/24 at 1:09 P.M. written by LPN #1 identified Resident #1's X-ray results are positive for a right hip fracture. LPN #1 identified APRN #1 was updated and APRN #1 ordered Resident #1 to be sent to the emergency room for further evaluation per request of Resident #1's family. LPN #1 identified Resident #1 was transferred via ambulance to the emergency room . Review of the facility's accident and incident report dated 9/11/24 identified at 8:00 A.M. on 9/11/24 Resident #1 was noted with a reddened area to the right hip, with no warmth, or grimacing noted, an Xray was ordered and it was identified that Resident #1 has a right hip fracture and Resident #1 was sent to the emergency room for evaluation. Review of the State's Reportable Event portal identified the facility initiated a reportable event for Resident #1 on 9/19/24 (8 days after the X-ray was positive for a right hip fracture) with the date and time of event first known as 9/16/24 at 4:00 P.M. The facility's event description identified: Resident #1 was noted with redness, slight swelling to right hip without warmth or sign of skin irritation. APRN #1 evaluated and ordered right hip X-ray. The X-ray impression of possible non displace fracture and APRN ordered resident sent to ER for further evaluation to verify fracture to right hip. Resident #1 returned on 9/16/24 with a noted right hip fracture. The facility did a 72 hour look back and investigation due to Resident #1 being a poor historian. Further review of the State's Reportable event portal identified on 9/23/24 the reportable event dated 9/16/24 for Resident #1 was rescinded. On 9/23/24 the facility initiated the Class B with the event type as injury of unknown origin for Resident #1 with the injury of a right hip fracture (11 days after the X-ray confirmed the right hip fracture). Interview with the DNS on 10/15/24 at 11:40 A.M. identified on 9/11/24 LPN #2 reported that Resident #1's hip was swollen, dark pink in color, without any warmth. The DNS identified Resident #1 was unable to articulate what occurred. The DNS indicated APRN #1 assessed Resident #1 and APRN #1 ordered a STAT right hip X-ray. The DNS identified on 9/11/24 Resident #1's X-ray report showed an acute hip fracture and Resident #1 was sent out to the hospital for further evaluation. The DNS identified she is aware injuries of unknown origin are required to be reported within 2 hours. The DNS indicated on 9/16/24 after reviewing Resident #1's hospital documentation it was confirmed Resident #1 had a right hip fracture, so she initiated a class D reportable event on 9/19/24. The DNS identified based on the investigation Resident #1's right hip fracture was a pathological fracture secondary to osteoporosis. The DNS identified she is aware injuries of unknown origin are Class B reportable events and need to be reported within 2 hours. The DNS could not explain why on 9/11/24 Resident #1's acute right hip fracture of unknown origin was not reported to the state agency within the required time frame. Review of the facility abuse policy, in part, directed the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown origin are reported immediately within the reporting timeline of a 2-hour requirement to report to Department of Public Health.

Based on review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #52) reviewed for Activities of Daily Living (ADL's), the facility failed to maintain proper fingernail hygiene and care. The findings include: Resident # 52's diagnoses included cerebrovascular accident (CVA) with left sided paralysis, muscle weakness, difficulty in walking, and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 was cognitively impaired and required staff assistance with personal hygiene and substantial staff assistance with bed mobility and transfers. The Resident Care Plan dated 3/21/24 identified Resident #52 had an ADL self-care performance deficit CVA with left side deficit. Interventions included assistance with personal and oral hygiene, bed mobility and transfers. Physician's order in effect from 5/1/24 through 6/3/24 directed to perform a total body skin assessment every Monday on the day shift and document in the clinical record. Observation's on 5/28/24, 5/29/24, 5/30/24 and 6/3/24 identified Resident #52 with excessively long, jagged fingernails with brown debris underneath. Review of the Treatment Administration Record and nursing progress notes for March 2024, April 2024 and May 2024 identified that weekly body audits were signed off by nursing staff on 3/29/27, 4/1/27, 4/8/24, 4/15/24, 4/22/24, 4/30/24,5/6/24, 5/13/24, 5/21/24, and 5/27/24, but failed to note Resident #52's long, jagged fingernails. Interview and observation with LPN #1 (Unit Nurse Manager) on 6/3/24 at 10:30 AM identified that Resident #52's fingernails were excessively long, possibly infected with fungus and in need of fingernail care. LPN #1 indicated she was previously unaware of the situation. She further identified that nurse aides (NA's) were responsible for fingernail care and reporting of any irregularities to licensed nursing staff. Subsequent to surveyor inquiry, Resident #52's fingernails were cleaned and trimmed on 6/3/24 and the Advanced Practice Registered Nurse (APRN) was notified of a possible fungal infection of Resident #52's fingernails. Interview and record review with APRN #1 on 6/3/2024 at 1:30 PM identified that the previous APRN had been informed of a possible fungal infection of Resident #52's fingernails in 3/24 and that Vicks Baby Rub External Cream was recommended. Further review of the physician orders identified that there was a physician's order in place for application of Vicks Baby Rub External Cream to be applied to Resident #52's toenails, but nothing for the fingernails. Subsequent to surveyor inquiry, APRN #1 indicated that he would place an order for Vicks Baby Rub for Resident #52's fingernails. Interview with the Assistant Director of Nursing Services (ADNS) on 6/4/24 at 8:52 AM identified that fingernail care was to be done by nursing staff on a weekly basis on shower days and with full body audits and that Resident #52's fingernail issues should have been identified by the licensed staff conducting the skin audit. The facility policy for Activities of Daily Living directed in part that staff were to provide assistance with the completion of ADL activities per the person-centered evaluation and care plan. The activities are broken down into eight areas including personal hygiene and grooming.

Based on the tour of the Dietary Department, staff interview, facility documentation and facility policy, the facility failed to ensure the Dietary Department consistently labeled opened dry food with the date opened and expiration dated and failed to ensure canned goods identified an expiration date. The findings included: Tour of the Dietary Department on 5/28/24 at 10:46 AM with the Food Service Director identified the following: a. Large plastic bulk bins containing flour which was approximately 1/4 full, rice which was approximately 1/4 full, sugar which was approximately 3/4 full and oatmeal approximately 1/2 full without the benefit of identifying the date the contents were poured into the bin, and lacking an expiration date. b. An opened 34 ounce (oz) plastic bag, approximately 3/4 full, which contained a round cereal without the benefit of identifying the date the contents were opened and lacking an expiration date. c. An opened 34 oz plastic bag, approximately 1/4 full, which contained [NAME] bran cereal, without the benefit of identifying the date the contents were opened and lacking an expiration date. d. An opened 34 oz plastic bag, approximately 1/4 full, which contained corn cereal without the benefit of identifying the date the contents were opened and lacking an expiration date. e. An opened 1/2 bag full of dry pasta without the benefit of identifying the date the contents were opened and lacking an expiration date. f. An opened loaf of bread, approximately 1/3 full without the benefit of identifying the date the contents were opened and lacking an expiration date. g. Three 6 pound (lb) 10 oz cans of creamed corn, nine 6 lb and 11 oz cans of pizza sauce, five 6 lb and 12 oz cans of pinto beans, nine 6 lb and 9 oz cans of diced peaches, eleven 6 lb and 9 oz cans of diced pears, fifteen 10 lb and 6 oz cans of spaghetti sauce and five 55 oz cans of sliced olives identified an expiration date in code, the code was unable to be deciphered. Interview and observation with Food Service Director on 5/28/24 at 10:46 AM indicated that Dietary staff were responsible for dating food products after opening them. Interview with the Food Service Director on 5/30/24 at 11:45 AM noted that he was unsure of the expiration dates on the canned items because the cans contained a code and not an expiration date. The Food Service Director stated he thought the cans were good for 1 to 2 years. Although the Food Service Director provided a document USDA canned food shelf-life healthcare guidelines that identified low acid canned food will keep for 2 to 5 years if unopened and high acid canned foods for best quality 12 to 18 months, he was unable to provide documentation as to the expiration dates. The facility policy for Labeling and rotating food supply: food products that are opened and not completely used: transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. Food removed from its original container must be labeled with the common name of the food. Rotate food products to ensure the oldest inventory is used first commonly known as first in first out (FIFO). A product used by date or delivery date is marked on the product. Employees stock shelves with earliest used by dates or delivery dates in front of products with later dates. Additionally, before shelving new stock, mark all containers currently on the shelf with a FIFO sticker or a color coded sticker.

Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #89) reviewed for nutrition, the facility failed to notify the provider of weight loss. The findings include: Resident #89's diagnoses included heart failure, hypertension, and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #89 was cognitively intact, required set up assistance for eating and assistance of 2 staff for bed mobility and transfers. The Resident Care Plan in effect from April 1, 2024, through May 30, 2024, identified Resident #89 was at risk for nutritional deficit due to diuretic use. Interventions included monitoring weights, diet, and notifying dietician, family, and physician of significant weight changes. A physician's order dated 4/5/24 directed to weigh Resident #89 daily and notify the provider of a weight change of 3 pounds (lbs.) daily or 5 lbs. weekly. Review of Resident #89's clinical record identified that on 5/6/24 he/she weighed 377.0 lbs. and on 5/10/2024 he/she weighed 367.8 lbs (a loss of 9.2 lbs.). Review of the nursing and physician progress notes from 5/10/23 through 6/3/24 failed to indicate that the provider had been notified of Resident #89's weight loss, according to the physician order. An interview and record review with LPN #1 (Unit Nurse Manager) on 6/3/24 at 12:10 PM failed to identify that the physician was notified when Resident #89 had a weight loss of 9.2 lbs. in 5 days. LPN #1 was unable to explain the omission but identified that if there was a physician order, then the physician should have been notified. Interview with Advanced Practice Registered Nurse #1 on 6/3/24 at 1:30 PM identified that he had not been notified when Resident #89's weight changed by 9.2 lbs. in 5 days. He further identified that he would have had the opportunity to decide if Resident #89's diuretic (water pill) should have been adjusted had he been notified. Review of facility policy identified, in part, that each resident will be weighed upon admission, monthly and when indicated. Significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight change indicates significant weight change, the resident and/or family representative and interdisciplinary team will be notified, and plan of care will be revised as appropriate.

Based on interviews and review of the clinical record for 1 of 5 residents reviewed for unnecessary medications, the facility failed to ensure Resident #1's abnormal laboratory results were addressed. The findings include: Resident #1's diagnoses included schizoaffective disorder, left-sided weakness, and hypertension. The readmission nursing assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, needed supervision for personal hygiene, and needed set up assistance with eating. An APRN's order dated 4/19/24 directed staff to complete laboratory work for Resident #1 to obtain a thyroid stimulating hormone (TSH) level. laboratory results dated [DATE] identified Resident #1 had a TSH level of 9.487 milliunits per liter (mU/L) (normal range 0.48 - 4.17 mU/L). Interview and clinical record review with APRN #1 on 6/3/24 at 1:42 PM identified that although he signed the 4/19/24 laboratory results as reviewed, APRN #1 did not notice Resident #1's abnormal TSH level and failed to address it. APRN #1 subsequently indicated that he would write an order to redraw the TSH level. Interview and review of the clinical record with the DNS on 6/4/24 at 10:18 AM failed to identify APRN #1 had written any new orders requesting Resident #1's TSH level be redrawn. Subsequent to surveyor interview, the DNS identified she would be contacting APRN #1 for to order a redraw of a TSH level. Although requested, a facility policy for addressing abnormal laboratory results was not provided.

50177 Based on interviews, review of the clinical record, and facility policy, for 2 of 7 residents (Resident #3 and Resident #26) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to notify the state mental health authority promptly after a new psychiatric diagnosis. The findings include: 1. Resident 3's diagnoses included delusional disorders, psychotic disorder with delusions due to known physiological condition. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had intact cognition and required total dependence with bathing, substantial/maximal assistance with toileting, and upper/lower body dressing. The Resident Care Plan dated 6/7/23 identified Resident #3 had behavior problems-refused to get out of bed, and used antidepressant medication related to having a depressed mood. Interventions included to monitor and document side effects and effectiveness every shift, anticipate and meet resident needs, and monitor for target behaviors: yelling out/profane language. Clinical record review identified Resident #3 had a diagnosis of delusional disorder on 8/7/23, but failed to identify the state contracted agency was notified to complete a Level II assessment. Further record review of the Medication Administration Record (MAR) identified Resident #3 was prescribed an antipsychotic on 2/28/24. A Psychiatric progress note dated 5/15/24 identified Resident #3 was on Aripiprazole (an antipsychotic) for major depressive disorder (MDD). Interview with Person #2 on 6/4/24 at 11:57 AM (the lead clinician for the state contracted Level II evaluation agency) identified Resident #3 should have had a Level II PASARR submitted because the resident had a diagnoses of delusional disorders and according to the psychiatric progress note, Resident #3 was receiving an antipsychotic for major depressive disorder. Additionally, the state contracted Level II evaluation agency indicated that even though it was not on the resident diagnoses list, a diagnoses of delusional disorder was obtained on 8/7/23, the resident was prescribed an antipsychotic on 2/28/24 and a Psychiatric progress note dated 5/15/24 that identified major depressive disorder was sufficient enough to report to the state contracted Level II agency. Interview with Social Worker #1 on 6/4/24 at 12:37 PM identified that a Level II PASARR was not submitted in a timely manner because they typically do not report delusional disorder and major depressive disorder, and the diagnoses' were not a part of Resident #3 diagnoses list. The facility PASARR policy dated 4/2023 directed, in part, that routine clinical record reviews and facility communication would assist the facility to identify residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition after admission to the facility. Additionally, the PASARR policy directed that the facility designee (social worker) would be responsible for making the referral to the appropriate state designated authority when a resident is identified as having an evident or possible mental disorder, intellectual disability, or related condition. 2. Resident #26's diagnoses included chronic atrial fibrillation, muscle weakness, and acute kidney failure. A PASARR Level 1 evaluation dated 6/10/22 identified Resident #26 was approved indefinitely for long term care and did not identify a psychiatric diagnosis (require a Level II screen). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was cognitively intact and was dependent with showers/bathing, toileting hygiene, and chair to bed transfers. Additionally, the MDS identified Resident #26 had little interest or pleasure in doing things, was feeling down, depressed, or hopeless, and felt tired or had little energy for several days. A Psychiatric progress note dated 6/6/23 identified Resident #26 had a psychiatric diagnosis of adjustment disorder with mixed anxiety and depressed mood and was taking Sertraline (an antidepressant medication) 75 mg daily. A Psychiatric progress note dated 7/3/23 identified Resident #26 had a new diagnosis of major depressive disorder (which replaced the previous diagnosis of adjustment disorder with mixed anxiety and depressed mood) and Sertraline was increased from 75 mg to 100 mg daily. A Social Service note dated 9/21/23 identified Resident #26 experienced episodes of depression and was followed by a psychiatric Advanced Practice Registered Nurse (APRN), last being seen in August of 2023. The Resident Care Plan (RCP) dated 1/11/24 identified Resident #26 used antidepressant medication related to behavior disturbances. Interventions included to administer antidepressant medication as ordered, to monitor, document, and report adverse reactions from the medication, and to monitor and record the occurrence of target behaviors. A PASARR Level 1 screen dated 5/13/24 identified Resident #26 was referred for a Level 2 screen and identified a psychiatric diagnosis of major depression. A PASARR Level 2 screen dated 5/17/24 identified Resident #26 was approved without specialized services for long term care and identified a psychiatric diagnosis of major depressive disorder with recommendations of a minimum of yearly comprehensive psychiatric evaluations to clarify the current psychiatric diagnosis and appropriate treatments, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. Interview with Social Worker #1 (the Director of Social Services) on 6/4/24 at 8:25 AM identified that the state contracted agency was not notified that Resident #111 had a new psychiatric diagnoses until she completed an annual audit on 5/10/24 (although Resident #111 was diagnosed with major depressive disorder on 7/3/23) because she was not made aware of Resident #26's diagnosis of major depressive disorder. Additionally, Social Worker #1 identified that it was the responsibility of the social workers to ensure completion of PASARRs and to notify the state contracted agency when a resident was identified with a new psychiatric diagnosis. An additional interview with Social Worker #1 on 6/4/24 at 10:02 AM identified that she did not complete the request for a PASARR Level 2 when Resident #26 was first diagnosed with major depressive disorder on 7/3/23 because the psychiatric APRN did not notify social services of the change in diagnosis. Social Worker #1 identified new diagnoses or changes are not discussed in RCP meetings because the psychiatric APRN does not attend care plan meetings. Interview with Social Worker #1 and Social Worker #2 on 6/4/24 at 10:30 AM identified that social services will review the psychiatric progress notes to verify dates that the residents were seen, and that the social workers do not review the notes in depth unless there was a reason for concern. Additionally, Social Worker #1 identified that if she had seen the new diagnosis of major depressive disorder on 7/3/23, she would have immediately requested a PASARR Level 2 be completed. Social Worker #1 identified that a new PASARR Level 1 was completed along with a PASARR Level 2 when there was a new diagnosis but not until 5/17/24 (10 months after Resident #26 received a new psychiatric diagnoses). Review of the PASARR policy dated 4/2023 directed, in part, that routine clinical record reviews and facility communication would assist the facility to identify residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition after admission to the facility. Additionally, the PASARR policy directed that the facility designee (social worker) would be responsible for making the referral to the appropriate state designated authority when a resident is identified as having an evident or possible mental disorder, intellectual disability, or related condition.

Based on staff interview and review of 1 of 2 Nurse Aide (NA #3) personnel files, the facility failed to complete a yearly performance review. The findings include: NA #3's date of hire was 1/20/23. On 6/4/24 at 1:30 PM, interview and review of NA #3's employee file identified that NA #3 was currently employed at the facility and failed to identify a yearly performance review had ever been completed (4 months since a performance appraisal was due). Additionally, the DNS identified that NA #3's performance appraisal had been completed but not reviewed or signed by NA #3 because NA #3 currently only works weekends and the DNS had not seen NA #3 to review the performance appraisal. A review of NA #3's Employee Punch Card History revealed there were at least two occasions where NA #3 worked a weekend 3:00 PM to 11:00 PM shift. These dates included 3/8/24 and 5/23/24.

Based on observation, review of facility documentation, review of facility policy, and interviews during a review of the facility's medication storage and reconciliation program in 1 of 2 medication rooms, the facility failed to appropriately store and reconcile a discontinued controlled substance (narcotic). The findings include: Resident #62's diagnosis included dementia, depression, psychotic disorder, and anxiety. A physician's order dated [DATE] directed to administer Lorazepam concentrate liquid 2 milligrams (mg)/milliliter (ml) ), give 0.25 ml(0.5 mg) by mouth three times daily as needed for anxiety. A physician's order dated [DATE] discontinued Resident #62's liquid Lorazepam. During an observation and interview of the second floor medication storage room with the Registered Nurse Supervisor (RN #2) on [DATE] at 12:10 PM an open vial of Lorazepam concentrate liquid 2 mg/ml, belonging to Resident #62, was noted in a locked storage box in the locked refrigerator. Review of the medication label for the liquid Lorazepam identified the medication was ordered on [DATE] and received into the facility on [DATE]. RN #2 stated that although she was aware that the vial of Lorazepam was stored in the locked refrigerator, she indicated that the Lorazepam did not have a corresponding Controlled Substance Disposition Record (CSDR) (document identifying the amount of controlled substance was used and how much remained in the container). RN #2 indicated that CSDR are used to ensure that the appropriate amount of medication had been administered, how much medication remained in the container, and was used to count narcotic medications during each change of shift for reconciliation custody purposes. RN #2 stated that only Registered Nurse Supervisors (RNS) possessed keys to the locked medication box and that the keys were passed from RNS to RNS with each change of shift. RN #2 further indicated that unit charge nurses were responsible to count all resident narcotics every shift but was unable to explain why the Lorazepam had not been counted and was unable to explain how the unit charge nurse would count the Lorazepam as only the RN Supervisors had keys to access the medication. An interview on [DATE] at 12:15 PM with the second floor unit charge nurse, LPN #2 identified that he had worked at the facility for about 1.5 years, and he had no knowledge that liquid Lorazepam had been stored in a locked container in the refrigerator. LPN #2 indicated that RN #2 (the RNS) was the only nurse on the second floor with keys to the locked med storage box where the Lorazepam had been stored. Further LPN #2 indicated that he had never had a key to access the locked container and he did not have a CSDR in his narcotic book which would have indicated that the Lorazepam needed to be counted during shift change. An interview with the Director of Nurses (DNS) on [DATE] at 12:33 PM indicated that she had no knowledge of the Lorazepam concentrate liquid stored in the locked medication box on the second floor. Review of Resident #62's CSDR sheet with the DNS identified the Lorazepam had arrived at the facility on [DATE]. The CSDR identified that the last dose of medication that was administered to Resident #62 was on [DATE], the medication was subsequently discontinued on [DATE], but another entry had been noted on [DATE] that showed the medication had been administered on that date. Review of Resident #62's Medication Administration Record failed to reflect that Resident #62 had received the dose of Lorazepam administered on [DATE]. The DNS was unable to explain, why the Lorazepam remained on the unit without a CSDR , why the Lorazepam had not been counted for the past approximately 2.5 years to prevent diversion, why the Lorazepam had not been returned to the DNS office for appropriate destruction following discontinuance, or why the medication had been recorded as dispensed on [DATE] after being discontinued with no record indicating that Resident #62 had received the [DATE] dose signed out. The DNS indicated that it was ultimately her responsibility to ensure medications were disposed of properly per facility policy, but this event had occurred prior to her employment with the facility and she was unaware of the presence of the medication in the building. Subsequent to surveyor inquiry, the Lorazepam was returned to the DNS off for appropriate disposal. Review of the policy for Controlled Substance Destruction, directs any unused or expired controlled substances will be destroyed in a manner consistent with Connecticut Department of Consumer Protection regulations. The policy also stated that Nurses shall document and destroy unused and expired controlled substances in accordance with the following statute Connecticut DCP regulation 21a-262(g).

Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident # 418) reviewed for Discharge Planning, the facility failed to provide diabetic education and teaching. The findings include: Resident #418's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] identified Resident #418 was admitted to the facility on [DATE] from an acute hospital. The assessment further identified that Resident #418 had intact cognition, no identified behaviors, required extensive assistance with bed mobility, limited assistance with transfers, did not ambulate, required supervision with locomotion and was independent with eating. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders further directed the administration of [MEDICATION(S)] (fast acting insulin) on a sliding scale for blood sugars. In addition, the orders directed to administer [MEDICATION(S)] (long acting insulin) 58 units subcutaneously in the evening and [MEDICATION(S)] 16 units three times a day before meals. Further review of the orders identified a diet order for low concentrated sweets with no added salt and a diabetic snack. The Physical Therapy Evaluation and Plan of Treatment dated 8/1/21 noted Resident #418's goals were to go home, and he/she needed to handle his/her insulin better. The Physical Therapy referral identified that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Worker Initial assessment dated [DATE] indicated Resident #418 wanted to discharge to the community and discharge care plan intervention was to provide education to resident and family for medications. The APRN progress note dated 8/5/21 at 12:35 PM noted Resident #418 had uncontrolled [CONDITION(S)] with blood sugars ranging from 400-520 on 8/4/21 and in the morning on 8/5/21. The note further identified that the resident had severe [CONDITION(S)] due to diabetes mellitus with a plan to discontinue the [MEDICATION(S)] three times a day and start [MEDICATION(S)] Insulin sliding scale coverage 4 times a day at meals and bedtime and increase the [MEDICATION(S)] from 58 units to 63 units at bedtime. The care plan dated 8/5/21 identified Resident #418 was an insulin dependent diabetic with interventions that included; patient/family teaching of administration of insulin, medications and potential side effects, recognizing signs and symptoms of hypo/[CONDITION(S)], nutrition and meal planning, the need for a safe discharge plan to home with home care services in place. Review of the Vital Sign Summary from 8/1/21- 8/15/21 indicated Resident #418's blood sugars fluctuated daily ranging from 103- 523. Review of the clinical record identified a discharge MDS assessment dated [DATE] that noted that the resident was discharged to the community. Interview with the Person #1 on 1/18/22 at 11:15 AM identified that prior to Resident #418's discharge home, the facility failed provide Resident #418 with diabetic teaching inclusive of glucometer use, checking of blood sugars, drawing up the correct dose and injection of insulin, the signs and symptoms of [CONDITION(S)] and [CONDITION(S)]. Interview with SW #1 on 1/19/22 at 10:00 AM indicated the discharge planner (LPN #1) was responsible for the discharge process for Resident #418. SW #1 indicated the discharge plan and goals are documented in the progress notes. SW #1 indicated LPN #1 works with the IDT (interdisciplinary team) and the resident or family to determine what the needs for the resident to be discharged home safely. SW #1 noted any conversations of meetings would be documented in the progress notes. SW #1 indicated diabetic teaching would be done by nursing but did not know where it would be documented. SW #1 indicated she does the discharge care plan that indicated there would be medication teaching but just puts education with medications for the day of discharge for nursing to go over the medications. SW #1 indicated she was not sure if the care plan should be more specific about what education needs to be completed for discharge. SW #1 indicated they missed that Resident #418 should have had diabetic teaching. Interview on 1/19/21 at 10:20 AM with LPN #1 indicated she was responsible for the discharge process for Resident #418. LPN #1 indicated she starts the discharge process on admission and the Director of Rehab, the social worker, nursing, the unit manager for the floor, and herself goes to meet the new admissions from the night before to assess the needs for discharge. LPN #1 indicated they meet the new resident and ask them questions and determine the goals for discharge. LPN #1 noted the goals were set by the resident and the hospital discharge paperwork and noted that if a resident was confused, the family is called. LPN #1 further noted that Resident #418 was alert and oriented and his/her goal was to go home with his/her significant other. LPN #1 indicated her role was to secure homecare. She indicated that if Resident #418 was a new diabetic teaching would have been done, but the resident was not a new diabetic. LPN #1 indicated there were no orders in place for diabetic teaching for Resident #418 during his/her stay at the facility and based on the clinical record there was no diabetic teaching done with Resident #418. LPN #1 identified that diabetic teaching should have done and documented. Interview on 1/19/22 at 10:40 AM with the DNS noted the IDT meets daily and any education needed, or goals would be documented by the discharge planner from the time of admission. The DNS noted LPN #1 and the unit manager were responsible for determining the goals for discharge and documenting them in the progress notes. The DNS indicated nursing should have done education and teaching in regard to the resident's diabetic regimen and it should have been documented in the clinical record. Review of the facility's policy for Discharge Planning identified Team Based Assessment (TBA) completed at bedside within 48 hours and would include anticipated teaching needs, patient goals, and identification of barriers to progress and discharge. Although requested, a facility policy on Resident Education, was not provided.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of two sampled residents (Resident #44) reviewed for activities of daily living, the facility failed to provide necessary services to maintain personal hygiene. The findings include: Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] identified Resident #44 was cognitively intact, had no noted behaviors, required extensive assistance with bed mobility and personal hygiene and required total assistance for bathing. The care plan dated 11/19/21 identified Resident #44 had an ADL self-care performance deficit with interventions that included, shower two times a week on Wednesday on the 7AM-3PM shift and Friday 3PM-11PM shift, resident requires assistance of one staff with bathing/showering, check nail length and trim and clean on bath day and as necessary and report any changes to the nurse. A review of Resident #44's nursing progress notes from 10/1/21 through 1/20/22 failed to identify any documented refusals of care. Review of the Shower List Schedule on 1/20/22 at 10:00 AM identified Resident #44 was scheduled for showers on the 3PM-11PM shift on Tuesdays. Interview with Resident #44 on 1/20/22 at 10:10 AM identified he/she had not received a shower since Christmas, and prior to Christmas she had last received a shower in October. Resident #44 identified he/she use to get showers twice a week prior to his/her room change and noted that he/she had requested to be showered but had not been provided a shower. Interview with NA #2 on 1/20/22 at 10:25 AM identified showers are given per the shower schedule sheet. Nurse Aides are expected to follow a resident's care plan to provide resident directed care. Residents can receive more than one shower a week but will need to ask staff in advance so we can accommodate. NA #2 identified nurse aides are required to document showers in the electronic medical records including refusals and should notify an RN if a resident refuses a shower. RN's document the refusal in the electronic charting system as well as progress notes. Interview with the ADNS on 1/20/22 at 10:45 AM identified nursing staff should follow a resident's plan of care accordingly to provide quality care. The ADNS identified it is the nurse aides' responsibility to perform showers for the residents and to notify the RN if the resident refuses a shower. The refusal should be documented in the electronic medical records under the ADL - Shower tab and RNs should document the refusal in a nursing progress note. The ADNS reviewed Resident #44's shower documentation in the electronic medical records and identified Resident #44 had no documented showers in the last 30 days. She also reviewed the nursing progress notes and identified there were no documented occurrences of refusals noted by the nursing staff within the last 3 months. The ADNS identified that she would request staff to offer Resident #44 a shower that day and update the care plans and educate staff accordingly. Interview with NA #5 on 1/20/22 at 11:45 AM identified she worked on 1/18/21 on the 3PM-11PM shift, but only worked for 4 hours between 3PM-7PM. NA #5 identified she knew it was Resident #44's shower day, but the resident prefers it happen in the late afternoon before bed. NA #5 identified she did not give Resident #44 a shower but verbalized in report to NA #3 regarding the task needing to be performed on her shift. NA #5 identified showers are given per the shower schedule sheet and the nurse aides are expected to follow a resident's care plan to provide resident directed care. Residents can receive more than one shower a week but will need to ask staff prior to so we can accommodate. NA #5 identified nurse aides should document showers in the electronic medical records including refusals and will notify an RN if a resident refuses a shower. RN's will document the refusal in the electronic charting system as well under progress notes. Interview with NA #3 on 1/20/22 at 1:00 PM identified she worked on 1/18/21 on the 3PM-11PM shift, but only worked for 4 hours between 7PM-11PM. NA #3 identified she knew it was Resident #44's shower day but was unable to provide a shower as the nursing staff were handling an emergency and were unable to provide the shower. NA #3 identified she did not recall if she reported it to the RN or following NA on night shift. NA #3 was unable to remember if Resident #44 received a shower on the 1/11/21. NA #3 identified the same routine for documentation identified by NA #2 and #5. Interview with the DNS on 1/21/22 at 10:15 AM identified nursing staff should directly follow a resident's plan of care when providing care. Residents should receive at minimum, a weekly shower and any additional showers per the president's request or plan of care. Review of the Standard of Care Policy identified each of the following is part of the routine of care provided by the nursing assistants, each item is based on the abilities of the resident to participate in their care based on individual physical and mental limitations. The list contains but is not limited to: Shower or tub bath 1x week and as needed or per resident request.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #5) who utilized oxygen, the facility failed to ensure physician's orders were in place for the use of oxygen. The findings include: Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission MDS assessment dated [DATE] identified Resident #5 was admitted to the facility from an acute hospital on 1/8/22 and had moderately impaired cognition, required extensive assistance with all ADL's and required oxygen. An observation of Resident #5 on 1/18/22 at 11:00 AM identified Resident #5 with an oxygen concentrator in his/her room beside the bed, in use with tubing and a nasal cannula in the resident's nose. An observation of Resident #5 on 1/20/22 at 9:08 AM identified Resident #5 with an oxygen concentrator in the resident's room, beside the bed, in use with tubing and the nasal cannula in the resident's nose. An interview with NA#1 on 1/20/22 at 9:14 AM indicated Resident #5 was wearing oxygen when she arrived for her shift. Additionally, NA#1 indicated the resident wore oxygen at all times. An interview with LPN #2 on 1/20/22 at 9:16 AM identified Resident #5 did use oxygen. Additionally, LPN #2 indicated there was no order for oxygen use in the resident's medical record. An interview and observation of the medical record with LPN #1 on 1/20/21 at 9:18 AM identified there was no order for oxygen use in Resident #5's medical record. Additionally, LPN #1 indicated she would call the PA to inform and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview and review of Resident #5's medical record with the DNS on 1/20/22 at 9:20 AM identified there was no order in the medical record for Resident #5 to use oxygen. Additionally, the DNS indicated the expectation would be to have an order prior to application. A review of the facility policy titled Oxygen Therapy directs, in part, to verify the physician's order which should include liter flow and type of oxygen delivery device. Subsequent to surveyor inquiry, a physician's order was written to address the resident's oxygen use.

Based on observation, staff interview, review of the clinical record, and review of facility documentation, the facility failed to ensure a hazard free enviornment during portable oxygen tank filling and/or for two of 6 sampled residents reviewed for accidents, (Resident #152 and Resident #59) the facility failed to provide adequate supervision and/or assistive devices. The findings include: a. Observation on 6/13/12 at 10:23AM identified that LPN #1 was noted to open the door to the oxygen filling room on the second floor while an oxygen tank was being filled. Interview with LPN#1 at that time identified that she opened the door to the oxygen room during portable tank refilling to hand the staff member eye protection and gloves. Review of the facility policy on filling liquid portable tanks failed to direct staff to ensure the door is closed during filling. b. Resident #152's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified usually understands and is understood, Brief Interview of Mental Status ( BIMS) score of 9 (moderately impaired range 8-12), extensive assistance of 2 staff for bed mobility, transfer (with walker), and toilet use; extensive assistance of 1 staff for locomotion with wheelchair, dressing, and personal hygiene; and independence with supervision for eating; balance moving from seating to standing position not steady, stabilized with human assistance, surface to surface transfer not steady, only able to stabilize with human assistance; functional limitations in range of motion on one side of upper and lower extremities; always continent of urine and bowel and 1 fall without injury since the prior assessment. A Nurse Fall Risk assessment dated [DATE] identified a fall risk score of 12 (10 or more equaled high risk). A physician's order dated 07/06/11 directed activity with assistance of 2 staff and 2 staff for care. A Nurse Aide (NA) Assignment for July 2011 identified transfer with assist of 2 staff with rolling walker, assist of 2 staff for ambulation with rolling walker (RW), and 2 staff for care. Review of a facility investigation dated 07/25/11 identified that at 8:15 PM, Nurse aide (NA) #1 was in the bathroom, assisting the resident with toileting. During a stand pivot transfer from the toilet to the wheelchair, Resident #152 got his/her feet tangled and caught in the commode leg, and fell down to the left side. The resident sustained [REDACTED]. A Fall Investigation documented 07/25/11 by RN #5 failed to identify whether the transfer and care was provided with assistance of 2 and/or with a gaitbelt and/or rolling walker. A Summary of the Investigation documented by the former Director of Nurses (DNS) identified that NA #1 was in the bathroom with Resident #152 and witnessed the fall, but failed to identifiy another staff memeber was present. Review of the Activities of Daily Living (ADL) Flowsheet for the 3:00 PM to 11:00 PM shift on 07/25/11 identified that transfers were performed with assistance of 2 staff, however assistance with briefs and/or incontinent care after voiding and/or assistance with sponge bath was provided with assistance of 1 staff by NA #1. NA #1 was the only staff listed as a witness to the fall. NA #1 was unavailable for interview. Interview with NA #4 on 06/13/12 at 1:30 PM who was the only other NA assigned to the unit on 07/25/11 at 8:00 PM, identified that although he/she was unable to recall the incident clearly, he/she did not provide assistance with the transfer off the toilet or with personal care. Interview with Registered Nurse (RN) #4 on 06/15/12 at 11:15 AM, the Charge Nurse on duty at the time, identified that he/she had not assisted NA #1 with a toilet transfer and could not recall if R #5 had a gaitbelt on at the time of the fall. Interview with RN #5 on 06/10/12, the evening supervisor, identified that, he/she was unable to recall if Resident #152 was wearing a gaitbelt at the time of the fall, but believed that there was only 1 aide with the resident when the fall occurred. Review of NA #1's personnel file identified that he/she was terminated on 07/26/11 for not following job assignment. Interview with the former DNS on 06/19/12 as a follow-up to a call placed 06/15/12, identified that the termination was not related to the accident with Resident #59, but, rather, because he/she had refused to accept an assignment. c. Resident #59's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified unclear speech, sometimes understands, sometimes understood, impaired vision, BIMs score of 0 (severely impaired range 0-7), extensive assistance of 2 staff for bed mobility, transfer, and extensive assistance of 1 staff for ambulation, locomotion in wheelchair, toilet use, personal hygiene; limited assistance of 1 staff for eating, bathing; not steady when moving from seated to standing position, not steady for transfer between bed and wheelchair; frequently incontinent of urine and occasionally incontinent of bowel, and 2 or more falls with no injury since the last review. A fall risk assessment dated [DATE] identified a score of 16 ( high risk 10 or above) An RCP dated 04/13/12 identified Risk to Fall with interventions that included tilt in space adapted custom wheelchair. An RCP identified the problem of mobility with interventions that included keep resident in view after supper Physician's orders dated 04/24/12 directed transfer with rolling walker (RW) and assistance of 1 staff and ambulate up to 100 feet with RW and assist of 1. Review of a facility investigation dated 04/29/12 identified that a 5:15 AM R #59 was toileted and washed in the bathroom while using the rolling walker for support and fell backward towards the open door and sustained a laceration to the back of the head. Resident #59 was transferred to Acute Care Hospital #1 and received 6 sutures. Review of a facility documented statement and interview with NA #5 on 06/13/12 at 2:00 PM identified that NA #5 had ambulated NA #5 from the bed to the bathroom with a rolling walker as the resident had been incontinent of stool. The resident was seated on the toilet with the walker in front of him/her as the resident finished toileting. Then, NA #5 assisted the resident to stand and face the NA, using the walker for support as he/she provided incontinence care. When care was nearly complete, NA #5 turned towards the sink to rinse the wash cloth and the resident began to fall backwards. NA #5 identified that he/she was unable to prevent the fall and, further, that a gaitbelt had not been used for the ambulation, transfers, or during the time when the resident was standing for incontinence care. Review of a facility NA Standard of Care/Information Sheet identified to use a gait belt for all ambulation and transfers