Every finding on record at Montowese Center for Health & Rehabilitation

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure food, dishwasher temperatures and ph results from the 3-bay sink were documented timely and out of range rinse cycle temperatures were followed up on. The findings include: Initial tour of the kitchen with the Food Service Director (FSD) on 5/5/26 at 10:10 AM identified the breakfast mealtime started at 7:45 AM and that there was 1 cook working for breakfast1a. Review of the food Daily Temperature Logs and interview with the FSD on 5/5/26 at 10:45 AM identified the Daily Temperature Log dated 5/5/26 was completely blank with no data logged for temperatures for each food type served for the breakfast meal, dishwasher temperatures for the breakfast meal, and the pH log for the 3-bay sink for the breakfast meal. The FSD indicated it was the responsibility of the cooks to fill out those sheets, that he checked them daily, but he hadn't checked them on that day due to the arrival of the state surveyors. He indicated that [NAME] #4 was responsible for completing the log and that he should have logged the Breakfast food names/items and temperatures prior to plating the breakfast meal, and the rest of the morning documentation (dishwasher temperatures and the pH log for the 3 bay sink) should have been completed after serving was completed for breakfast meal service. Interview with [NAME] #4 on 5/5/26 at 10:50 AM identified he was responsible for logging the temperatures and other information on the Daily Temperature Log sheet, but that he had been short staffed for somebody in the kitchen which caused a delay in getting things completed. He identified that he took the food temperatures as he prepared the food for service, that he remembered what the results were and would document them and the rest of the items later in the shift. He indicated he could provide the food temperatures from memory and identified the food was at the following temperatures for the breakfast meal service: scrambled eggs temperature was 167 F, pureed eggs were 167 F , toast was room temperature, oatmeal was160 F, water for coffee/tea was 150 F-155 F, and pork sausage was 168 F.Subsequent to surveyor inquiry, review of the Daily Temperature Log sheet dated 5/5/26 identified the food temperatures logged by [NAME] #4 for the breakfast meal service were scrambled eggs--168 F (1 F warmer than he reported from memory to surveyor), toast-room temperature, bagel-room temperature, oatmeal--155 F (5 F cooler than he reported from memory to surveyor), water for coffee--150 F, milk--39 F, juice--39 F, pureed eggs--168 F (1 F warmer then he reported from memory to the surveyor), and pork sausage--170 F (2 F warmer than he reported from memory to the surveyor).b. Review of the Daily Temperature Logs and interview with the Food Service Director on 5/5/26 at 10:45 AM identified the Daily Temperature Log dated 5/4/26 was partially blank with no data entered on the evening shift. The log failed to identify temperatures for the supper meal, evening refrigerator temperatures, dishwasher temperatures for the supper meal, food samples taken for the supper meal, pH log for the 3-bay sink for the supper meal, and the evening cook initials. The FSD indicated it was the responsibility of the cooks to fill out those sheets, that he checked them daily, but he hadn't checked them today due to the arrival of the state surveyors. He indicated that [NAME] #1 was responsible for filling out the log the evening of 5/4/26.Interview with [NAME] #1 on 5/5/26 at 11:10 AM identified he was responsible for filling out the Daily Temperature Log but that he was training a new cook yesterday (5/4/26) and the new cook had told him that he would complete the log. [NAME] #1 indicated that he should have checked the logs to make sure it was completed but that he had forgotten.Interview with the Food Service Director on 5/7/26 at 12:30 PM identified he had kept the Daily Temperature Log sheets for over a year, but that he had disposed of all of them (except for the current sheets for May 2026) prior to his last day worked on 5/6/26 because he didn't think anyone would need them.Although requested, Daily Temperature Log sheets prior to 5/1/26 were not available or provided.Review of the Culinary Services: Food Temperature Measurement policy directed, in part, the internal temperature of food is measured to ensure food is at appropriate temperatures to decrease the risk of pathogen growth which causes foodborne illness. The policy directed the danger zone for food temperature is above 41 F and below 135 F which allow rapid growth of foodborne illness pathogens. The policy directed to take the food temperature and if it is not within the acceptable range to take action.Review of the Culinary Services: Monitoring Refrigerator/Freezer Temperature policy directed, in part, ambient temperatures of refrigerators and freezers used for food storage are monitored to verify proper functioning of the equipment. The policy directed that recommended ambient cold storage temperature ranges are 32-39 F for refrigerators and -10 F-0 F for freezers. The policy directed to check and record refrigerator and freezer temperatures at least twice daily in the morning and the evening, and to report out of range temperatures to the maintenance department as soon as possible. The policy further directed to check the temperature of food items in a malfunctioning refrigerator or freezer prior to use and if the internal temperature of refrigerated food items are above 41 F or frozen food is not frozen solid, do not use and discard.The policy failed to identify directives to log food temperatures on the log sheets used by the dietary department to ensure all foods are within appropriate food temperature range. 2. Observation of the dishwasher cycle for the wash/rinse cycles and interview with the Interim Food Service Director (IFSD) on 5/8/26 at 10:35 AM identified the dishwasher was a high temperature dishwasher and required a hot water sanitizing rinse temperature of at least 180 F to adequately sanitize the dishes during the rinse cycle. Review of the Daily Temperature Log sheets and interview with the IFSD and Director of Maintenance (DOM) on 5/8/26 at 10:45 AM identified on 5/1/26 the dishwasher rinse temperature was 175 F (5 F below the minimum required rinse temperature), for the lunch service, the rinse cycle was identified as 170 F (10 F below the minimum required rinse temperature), and for supper was 180 F. For 5/2/26 the dishwasher rinse cycle temperature for breakfast was 168 F (12 F below the minimum required rinse temperature), for lunch was 178 F (2 F below the minimum required rinse temperature), and for supper was 180 F. For 5/3/26 the dishwasher rinse cycle temperature for breakfast was 172 F (8 F below the minimum required rinse temperature), for lunch was 170 F (10 F below the minimum required rinse temperature), and for supper was 170 F (10 F below the minimum required rinse temperature). For 5/4/26 the dishwasher rinse cycle temperature for breakfast was 168 F (12 F below the minimum required rinse temperature), for lunch was 175 F (5 F below the minimum required rinse temperature), and for supper there was no documented dishwasher rinse cycle temperature. On 5/5/26, the dishwasher rinse cycle temperature for breakfast was 176 F (4 F below the minimum required rinse temperature), for lunch was 178 F (2 F below the minimum required rinse temperature), and for supper was 178 F (2 F below the minimum required rinse temperature). The documentation identified 12 out of 14 documented dishwasher rinse cycle temperatures from 5/1/26-5/5/26 were below the minimum required temperature.The IFSD indicated that the moment a dietary staff member identified an out-of-range temperature below the minimum required temperature shown on the log sheet, they were expected to stop use of the dishwasher and to notify the Nursing Supervisor and the maintenance department that the dishwasher was not functioning properly and needed to be checked out. The IFSD further indicated the dietary staff were required to use only the 3-bay sink until they were notified by the maintenance department that the dishwasher was functioning properly. The DOM identified he had not been notified of any out-of-range dishwasher temperatures for either the wash cycle or the rinse cycle. Interview with the IFSD on 5/8/26 at 12:00 PM identified she had spoken with the dietary staff and they had told her the DOM had been notified about the dishwasher rinse temperatures being below the minimum required temperatures. She was unable to identify the reason the DOM denied being notified. She further indicated that the dietary staff needed re-education on the policy for using only the 3-bay sink when out of range dishwasher temperatures were identified.Review of the Culinary Services: Monitoring Dish Machine Temperatures and Sanitizer policy directed, in part, water temperatures and sanitizer levels are monitored to verify proper equipment functioning and adequate sanitizing of dishware and surfaces. The policy directed the FSD posts a log sheet at the beginning of the month to record temperatures and sanitizer levels. The policy directed the staff dishwasher, or designee checks the temperature and if applicable the sanitizer concentration before washing dishes from each meal (breakfast, lunch, supper) and records them on the log sheet. The policy directed the FSD should review the logs each working day, and maintain the logs in a file for at least 6 months. Additionally, the FSD or designee should notify maintenance and/or the vendor as needed for repairs or adjustments. The policy directed for high-temperature dish machines to refer to the data plate on the machine for appropriate water temperatures. The policy directed the wash temperature range should be 150 F-165 F and the final rinse temperature not less than 180 F.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews during the initial tour and thereafter, the facility failed to ensure personal care items were stored according to standards of care for infection prevention for Resident #8, Resident #14, Resident #45, Resident #47, Resident #70, and Resident #121 and in the bathrooms of room [ROOM NUMBER], 207, 209, 211 and 213. Additionally, for the only resident (Resident #114) reviewed for transmission-based precautions, the facility failed to appropriately cohort a resident with a transmissible respiratory infection. The findings include: 1. Observation in the shared bathroom (toilet and sink area) for Resident #14 and Resident #121 on 5/5/26 at 11:44 AM identified an unlabeled denture cup sitting on the left side of the sink. Additionally, an unlabeled and uncovered denture brush was observed sitting side by side with an unlabeled and uncovered toothbrush with both items laying directly on the top ledge of the sink without use of a container to hold them or a protective covering.2. Observation in the shared bathroom (toilet and sink area) for Resident #45 and Resident #70 on 5/5/26 at 2:02 PM identified 3 unlabeled wash basins (gray, pink, and gray) stacked within each other sitting on the right edge of the sink resting against the wall. The top gray basin was noted to have crumpled paper towels lining the bottom of the basin.3. Observation in the shared bathroom (toilet and sink area) for Resident #8 and Resident #47 on 5/5/26 at 2:06 PM identified 2 unlabeled wash basins stacked within each other sitting inside the basin of the sink. The top basin was noted to have a dark brown colored liquid with sediment inside it. Additionally, sitting on the floor between the sink and toilet were an unlabeled gray basin and gray bedpan.4. Observation in the shared bathroom for Resident #45 and Resident #70 on 5/6/26 at 3:26 PM identified 2 unlabeled wash basins (pink and gray) stacked within each other sitting on the right edge of the sink resting against the wall. The top pink basin was noted to have crumpled paper towels lining the bottom of the basin. Additionally, an unlabeled urinal was noted to be hanging from the grab bar in front of the toilet with the lid unattached and sitting on top of the toilet paper dispenser.5. Observation in the shared bathroom for Resident #8 and Resident #47 on 5/6/26 at 3:27 PM identified sitting on the floor directly next to the toilet near the wall were an unlabeled gray basin with an unlabeled bedpan sitting inside it.6. Observation in the shared bathroom for Resident #14 and Resident #121 on 5/6/26 at 3:28 PM identified an unlabeled denture cup sitting on the left side of the sink. Additionally, an unlabeled and uncovered denture brush was observed sitting side by side with an unlabeled and uncovered toothbrush with both items laying directly on the top ledge of the sink without use of a container to hold them or a protective covering. All items were observed to be in slightly different positions than the previous days observation.Interview with observations of the shared bathrooms with Licensed Practical Nurse (LPN) #10 and LPN #11 on 5/6/26 at 3:30 PM identified the denture brush and toothbrush in the shared bathroom for Resident #14 and Resident #121 should not be stored uncovered directly in contact with the sink surface (in proximity to the toilet) and all items including the denture cup should be labeled with the resident name(s). Additionally, LPN #10 indicated that all 3 items could also be stored within the wall cabinet behind the mirror. LPN #10 and LPN #11 identified the basins and urinal in the shared bathroom for Resident #45 and Resident #70 should not be stored in their current locations but should be stored within the nightstand of the resident, and all items should be labeled with the resident name(s). LPN #10 and LPN #11 further identified the basin and bedpan on the floor in the shared bathroom for Resident #8 and Resident #47 should not be stored in their current locations but should be stored within the nightstand of the resident, and all items should be labeled with the resident name(s). 7a. Observations on 5/5/26 at 10:45 AM and on 5/6/26 at 8:00 AM in room [ROOM NUMBER]'s bathroom, an uncovered bed pan, not labelled with a resident's name and located on the safety bar was observed.b. room [ROOM NUMBER]'s bathroom was noted to have an uncovered bed pan and wash basin located on the safety bar in proximity to the toilet. The bed pan and wash basin was not labelled with a resident's name.c. room [ROOM NUMBER]'s bathroom had 2 wash basins uncovered and not labelled with a resident's name located behind the toilet.d. room [ROOM NUMBER]'s bathroom had 2 wash basins uncovered and not labeled with a resident's name located behind the toilet.e. room [ROOM NUMBER]'s bathroom had 2 wash basins and a urinal uncovered and not labeled with a resident's name located against the wall near the toilet. Interview and observations with Licensed Practical Nurse (LPN) #1 (the Infection Control Nurse) on 5/6/26 at 11:50 AM identified that Rooms 205, 207, 209, 211 and 213 still had items in bathrooms uncovered and not labeled. LPN #1 stated that items should be covered and labeled and that was the Nurse Aide's (NA) responsibility to ensure items were covered and labeled after use. LPN #1 indicated she was unsure why items were not stored properly and it was the policy to ensure items were labeled and bagged. LPN #1 stated wash basins should be stored in the residents' nightstand and that she recently educated the NAs regarding appropriate storage of personal items.Although requested, the facility was unable to provide a policy on the storage of personal 8.Resident #114's diagnoses included Human Metapneumovirus (a highly contagious respiratory virus), pneumonia, asthma, and bronchiectasis. A Hospital Interagency referral report (W-10) dated 5/2/26 identified Resident #114 had a diagnosis of Human Metapneumovirus and the residents isolation status was contact isolation. Review of the facility daily census list dated 5/2/26 identified a private room (room [ROOM NUMBER]-1) was available on 5/2/26 when Resident #114 was admitted to the facility. An admission assessment dated [DATE] identified Resident #114 had no cognitive impairment and was dependent with toileting, transfers and bed mobility. The admission assessment indicated Resident #114 required droplet precautions for human metapneumovirus until 5/8/26. The Resident Care Plan (RCP) dated 5/4/26 identified Resident #114 had a respiratory infection and altered respiratory status related to Human Metapneumovirus. Interventions included administering medications as ordered, encouraging coughing and deep breathing and monitoring/documenting changes in orientation, increased restlessness, anxiety and air hunger. The RCP failed to indicate Resident #114 was to be on droplet or contact precautions. A Physician's Assistant (PA) admission history and physical progress note dated 5/4/26 at 8:30 AM identified Resident #114 tested positive for viral pneumonia on 4/30/26 and required droplet and contact precautions for 7 days (or 5 days if clinically improved if cough resolved). A physician order dated 5/5/26 directed single room isolation related to Human Metapneumovirus, all services must be provided in room every shift. An observation on initial tour on 5/5/26 at 10:30 AM identified a contact precautions sign was posted outside of Resident #114's private room and the door was closed. A PA (PA #1) progress note dated 5/5/26 at 11:00 AM identified Resident #114 presented with shortness of breath and a productive cough. The resident expressed unhappiness about being in a private room due to contact precautions and PA #1 reiterated the importance of contact precautions to the resident and he/she was informed he/she could be moved to a different room once off contact precautions. An observation on 5/5/26 at 1:25 PM identified 2 staff were donning N95 masks, an isolation gown and gloves before entering Resident #114's room. The door to the resident's room was reclosed after the 2 staff entered room. Interview and review of the clinical record with the Infection Preventionist (LPN #1) identified although Resident #114 was admitted to the facility on [DATE] on contact precautions the resident was cohorted with Resident #4 and not placed in a private room. LPN #1 indicated she was not notified Resident #114 was being admitted to the facility on [DATE] and when she found out on 5/4/26 that the resident required contact precautions, she moved the resident into a private room and set up isolation. LPN #1 identified she would have expected the Nursing Supervisor to contact her when the resident was admitted , and the resident should have been admitted into a private room with isolation set up the day of admission (and not 2 days later) by the Nursing Supervisor. Interview and review of the clinical record with the DNS on 5/7/26 at 3:40 PM identified although Resident #114 was admitted to the facility on [DATE] on contact precautions the resident was cohorted with Resident #4. The DNS indicated she was not notified Resident #114 was being admitted to the facility on [DATE] and when she found out on 5/4/26 that the resident required contact precautions, she had the resident moved into a private room and isolation was set up. The DNS stated the weekend Nursing Supervisor was responsible for determining cohorting for new admissions and if the nursing supervisor had questions she should have reached out to her. Review of the resident's discharge documents from the hospital indicated contact isolation was to continue, and it would have been the responsibility of the Nursing Supervisor to properly cohort and implement precautions when Resident #114 was admitted to the facility on [DATE]. Interview and review of the clinical record with the Director of Admissions (DOA) on 5/7/26 at 4:03 PM identified although Resident #114 was admitted to the facility on [DATE] on contact precautions the resident was cohorted with Resident #4. The DOA indicated she was not aware Resident #114 was being admitted to the facility on [DATE] because the facility utilized a central admission team on the weekends and when she found out on 5/4/26 that Resident #114 required contact precautions the resident was moved to a private room right away. Review of the resident's hospital discharge documents with the DOA indicated Resident #114 was to be on contact isolation and she stated it would have been the responsibility of the Nursing Supervisor to properly cohort and implement isolation precautions when Resident #114 was admitted to the facility on [DATE]. The DOA further identified there were private rooms available on 5/2/26, so Resident #114 could have been placed there and she was unsure why that was not done. Interview with the Nursing Supervisor (RN #4) on 5/8/26 at 10:22 AM identified she was the admitting nurse supervisor for when Resident #114 was admitted to the facility on [DATE] but could not remember the resident's diagnosis. RN #4 stated although she recalled Resident #114's hospital discharge indicated 'contact isolation' she was told by the DOA to put the resident in the semi-private room with Resident #4. RN #4 indicated although the hospital discharge paperwork directed contact precautions, she assumed the resident was cleared and did not question the DOA room choice. RN #4 further identified if the resident was supposed to be on contact isolation the resident should not have been placed in a semiprivate room but she assumed management would have known if the resident should be in a private room or not. RN #4 further indicated she did not set up isolation precautions on admission for Resident #114 because she did not know she should have. Another interview with the DOA on 5/8/26 at 11:30 AM identified she recalled she was texting with RN #4 on 5/2/26 about Resident #114's admission but she was not informed by RN #4 that the resident had a respiratory diagnosis or a need for contact isolation. Thus, her decision to cohort Resident #114 with Resident #4 was based on the information she was given by RN #4 but had she known about the resident's infection and need for contact isolation there was a private room available that Resident #114 should have gone into. The DOA indicated RN #4 should have informed her of Resident #114's transmissible respiratory infection and need for contact isolation and she was unsure why that was not done. Interview and review of the clinical record with PA #1 on 5/8/26 at 1:24 PM identified Resident #114 should have been in a single room since admission due to the resident's transmissible respiratory infection and the need for contact isolation. PA #1 indicated she was not aware Resident #114 was cohorted with Resident #4 from 5/2/26 to 5/4/26 and stated Resident #114 should not have been cohorted. Additionally, PA #1 identified the resident had a frequent congested cough which required a private room to prevent transmission of Resident #114's respiratory infection. Review of the facility policy, Precautions to Prevent Infection, dated 6/24, directed contact precautions are intended to prevent transmission of infectious agents. A single patient room is preferred for patients who require contact precautions and when a single patient room is not available, consultation with infection control personnel is recommended. Review of the facility policy, Admission, Discharge Policy, dated 6/25, directed it is the policy of the facility to provide each patient with a safe transition of care and the licensed nurse will complete the admission evaluation which encompasses a systematic review of the patient's condition on admission.

Based on review of the clinical record, facility policy and interviews for the 2 of 3 residents (Resident #68 and Resident #112)) reviewed for advanced directives, the facility failed to ensure advanced directives were consistent with the resident/resident representatives request. The findings include: 1.Resident #68's was initially admitted to the facility on [DATE] with diagnoses that included congestive heart failure, end stage renal disease, and atrial fibrillation.A facility Advanced Directive Consent/Acknowledgement and Release Form signed by Resident #68 on [DATE] identified he/she did not want Cardiopulmonary Resuscitation (CPR), Artificial Respiration and Artificial Nutrition administered. The signed form was retained in Resident #68's medical record.An admission assessment dated [DATE] identified Resident #68 was cognitively intact, required substantial/maximal assistance with bed mobility and was dependent with transfers.A physician's order dated [DATE] and currently in effect directed to provide Cardiopulmonary Resuscitation for Resident #68 (an inconsistency from Resident #68's signed advanced directive dated [DATE] identifying he/she did not want CPR).The Resident Care Plan (RCP) dated [DATE] identified Resident #68's Advanced Directive Guidelines Code Status was to provide CPR. Interventions included to honor advanced directives as directed by the resident and reviewing advanced directives with the resident on admission and at least quarterly. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was cognitively intact and required partial/moderate assistance with toileting, bed mobility and transfers. Interview and review of the clinical record with Licensed Practical Nurse (LPN) #3 on [DATE] at 11:09 AM identified Resident #68 was to be administered CPR per the electronic health record (EHR) and on the face sheet, while the advanced directive form signed by the resident and in the located in the medical record directed Resident #68 was a Do Not Resuscitate (DNR). LPN #3 indicated the physician's order in the computer and on the face sheet were incorrect and he was unable to indicate why a physician's order was not written for Resident #68 to be a DNR.Subsequent to surveyor inquiry, physician's orders dated [DATE] directed Do Not Resuscitate, do not intubate, and do not hospitalize. Subsequent to surveyor inquiry, the RCP was revised on [DATE] and identified Resident #68's Advanced Directive Guidelines Code Status: DNR, Do Not Intubate (DNI), Do not hospitalize (DNH), Registered Nurse Pronouncement (RNP). Interview and review of the clinical record with the DNS on [DATE] at 3:30 PM identified the physician was notified on [DATE] and a DNR order was obtained after it was discovered that Resident #68 was to be administered CPR in the EHR and on the resident's face sheet, despite the advanced directive form signed by the resident and in the resident's medical record directed Do Not Resuscitate (DNR). The DNS indicated the resident was readmitted to the facility on [DATE] and it would have been the responsibility of the admitting nurse or nursing supervisor to obtain the residents code status order and ensure it reflected what was on Resident #68's advanced directive form and the error must have been an oversight. 2. Resident #112 was initially admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies, atrial fibrillation and diverticulosis of the large intestine with perforation.A facility Advanced Directive Consent/Acknowledgement and Release Form signed by Resident #112's responsible party on [DATE] identified the resident wanted Cardiopulmonary Resuscitation (CPR), Artificial Respiration, Artificial Nutrition, and IV hydration administered. The signed form was retained in Resident #112's medical record.An admission assessment dated [DATE] identified Resident #112 was cognitively impaired, required partial/moderate assistance with bed mobility and was dependent with transfers.A physician's order dated [DATE] and currently in effect directed Do Not Resuscitate (an inconsistency from the responsible parties signed form dated [DATE] requesting CPR be performed).The Resident Care Plan (RCP) dated [DATE] identified Resident #68's Advanced Directive Guidelines Code Status: Do Not Resuscitate. Interventions included honoring advanced directives as directed by the resident and reviewing advanced directives with the resident on admission and at least quarterly. Interview and review of the clinical record with Licensed Practical Nurse (LPN) #3 on [DATE] at 11:09 AM indicated Resident #112 was identified as a DNR in the electronic health record (HER) and on the resident's face sheet, despite the advanced directive form signed in the resident's medical record directing Resident #112 was to be provided CPR. LPN #3 indicated the physician ordesr in the computer and on the face sheet were incorrect and he was unable to indicate why a physician's order was not written for Resident #112 to be a Full Code.Subsequent to surveyor inquiry, physician's orders dated [DATE] directed to provide Cardiopulmonary Resuscitation.Subsequent to surveyor inquiry, the RCP was revised on [DATE] and identified Resident #68's Advanced Directive Guidelines Code Status: Full Code. Interview and review of the clinical record with the DNS on [DATE] at 3:30 PM identified the physician was notified on [DATE] and a CPR order was obtained after it was discovered that Resident #112 was listed as a DNR in the EHR and on the resident's face sheet, despite the advanced directive form signed by the resident and in the resident's medical record directed Resident #112 was to be provided CPR. The DNS indicated the resident was readmitted to the facility on [DATE] and it would have been the responsibility of the admitting nurse or nursing supervisor to obtain the residents code status order and ensure it reflected what was on Resident #112's advanced directive form and the error must have been an oversight. Review of facility policy, Advanced Care Planning Code Status, dated 2/25, directed upon admission the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident and a physician's order must be written accordingly. The healthcare provider who is provided with consent for an order not to resuscitate must promptly issue an order not to resuscitate. When the consent of the resident has been obtained and the DNR decision has been made, the directive shall be written as a formal order by the healthcare provider in the medical record.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #1 and Resident #115) reviewed for general/edema, the facility failed to notify the physician of a weight gain according to physician ordered parameters. The findings include: 1.Resident #1's diagnoses included chronic diastolic congestive heart failure (CHF), chronic kidney disease, chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia.A physician's order dated 4/14/25 and currently in effect directed daily weights and to notify the healthcare provider of a 3-pound weight change/daily or a 5-pound weight change/week every day shift every other day for hypervolemia (fluid overload), COPD and CHF.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and was dependent with transfers, toileting and bed mobility. The MDS further indicated Resident #1 had heart failure and renal insufficiency.The Resident Care Plan (RCP) dated 4/25/26 identified Resident #1 had a risk for altered fluid balance and an altered respiratory status with difficulty breathing related to a diagnosis of CHF. Interventions included monitoring the resident for increased restlessness, anxiety or air hunger and abnormal breathing patterns or respiratory distress and report to the physician. A physician's order dated 4/15/26 directed Furosemide (Lasix) (a diuretic) 40 milligrams (mg) by mouth twice daily for CHF and edema.A Physician's Assistant (PA #1) progress note dated 4/16/26 at 8:42 PM identified Resident #1's most recent chest x-ray had increased bilateral effusions (abnormal accumulation of fluid) and to increase Lasix to 40 mg twice daily. The progress note directed to monitor Resident #1's fluid balance with Lasix increase. Review of the weight and vitals summary identified Resident #1 on 4/17/26 weighed 142 pounds (lbs.) and on 4/18/26 weighed 145 lbs. (a gain of 3 pounds in one day). Subsequent weights identified Resident #1 on 4/20/26 weighed 142 lbs. and on 4/23/26 weighed 144 lbs.Interview and review of the clinical record with LPN #3 on 5/7/26 at 11:20 AM identified Resident #1 on 4/17/26 weighed 142 pounds (lbs.) and on 4/18/26 weighed 145 lbs. (a gain of 3 pounds in one day). LPN #3 stated he failed to notify the physician of the weight gain because the Nurse Aide (NA) who documented the residents' weight did not inform him of the residents' weight once taken. LPN #3 indicated he did not notice the residents' 3-pound weight gain in the clinical record once it was documented and needed to pay closer attention. LPN #3 identified it would have been his responsibility to inform the nursing supervisor or the physician of Resident #1's weight gain on 4/18/26. Interview and review of the clinical record with NA #4 on 5/7/26 at 12:00 PM identified she obtained and documented Resident #1's weight in the clinical record on 4/18/26 and reported the weight to LPN #3. NA #4 indicated she did not notice the resident's prior weight and was not informed Resident #1 was being monitored for weight gain. Interview and review of the clinical record with the Nursing Supervisor (RN #3) on 5/7/26 at 11:40 AM identified Resident #1 on 4/17/26 weighed 142 pounds (lbs.) and on 4/18/26 weighed 145 lbs. (a gain of 3 pounds in one day). RN #3 indicated the physician should have been notified of the resident's weight gain and he was unsure why it was not done. RN #3 identified LPN #3 should have informed the nursing supervisor of the resident's weight gain on 4/18/26 and ensured the physician was notified. Interview and review of the clinical record with the DNS on 5/7/26 at 3:30 PM identified Resident #1 on 4/17/26 weighed 142 pounds (lbs.) and on 4/18/26 weighed 145 lbs. (a gain of 3 pounds in one day). The DNS indicated the physician should have been notified of the resident's weight gain and she was unsure why it was not done. The DNS identified LPN #3 should have informed the nursing supervisor of the resident's weight gain on 4/18/26 and ensured the physician was notified. Interview and review of the clinical record with (PA #1 on 5/8/26 at 1:10 PM identified Resident #1 on 4/17/26 weighed 142 pounds (lbs.) and on 4/18/26 weighed 145 lbs. (a gain of 3 pounds in one day) and she was not notified of the resident's significant weight gain on 4/18/26 and should have been. PA #1 indicated Resident #1 had hypovolemia and she had increased the residents Lasix on 4/15/26. PA #1 identified it would have been the responsibility of the charge nurse or nursing supervisor to notify her of the significant weight gain, and she was unsure why it was not done. PA #1 indicated although she would not have ordered anything additional on 4/18/26, she should have been informed timely and weight monitoring needed to continue due to Resident #1's potential for fluid overload. 2.Resident #115's diagnosis included congestive heart failure (CHF), chronic kidney disease, acute pulmonary edema and chronic obstructive pulmonary disease (COPD). The Nursing admission assessment dated [DATE] identified Resident #115 had a cognitive impairment, required partial/moderate assistance with toileting and transfers and required set up/clean up assistance with bed mobility. The admission Assessment also indicated Resident #115 weighed 179.2 pounds and had edema present. The Resident Care Plan (RCP) dated 4/29/26 identified Resident #115 had a potential for altered cardiac status related to CHF and increased nutrient needs. Interventions included observing and evaluating the resident's respiratory status and signs of shortness of breath, dyspnea on exertion, fatigue, anxiety and cyanosis. The RCP further directed to monitor and evaluate the resident's weight and weight changes. A physician's order dated 5/1/26 directed daily weights and to notify the provider of a 3-pound weight change/daily and/or a 5-pound weight change/week every day shift for edema. Review of the Weight and Vitals summary identified Resident #115 on 5/2/26 weighed 179.2 pounds (lbs.), on 5/4/26 weighed 180.6 lbs., on 5/5/26 weighed 188.2 lbs. (a gain of 7.6 lbs. in one day), on 5/6/26 weighed 188.2 lbs., and on 5/7/26 weighed 188.6 pounds. Interview and review of the clinical record with LPN #3 on 5/7/26 at 11:18AM identified Resident #115 on 5/4/26 weighed 180.6 lbs., and on 5/5/26 weighed 188.2 lbs. (a gain of 7.6 lbs. in one day). LPN #3 stated although he documented Resident #1's weight in the clinical record on 5/5/26, he failed to notify the physician of the weight gain because he did not notice the resident's prior weight on 5/4/26 (which indicated a weight gain of 7.6 pounds in one day). LPN #3 indicated he needed to pay closer attention and identified it would have been his responsibility to inform the nursing supervisor or the physician of Resident #1's weight gain on 5/5/26. Interview and review of the clinical record with the Nursing Supervisor (RN #3) on 5/7/26 at 11:40 AM identified Resident #115 on 5/4/26 weighed 180.6 lbs., and on 5/5/26 weighed 188.2 lbs. (a gain of 7.6 lbs. in one day). RN #3 indicated the physician should have been notified of the resident's weight gain and he was unsure why it was not done. RN #3 identified LPN #3 should have informed the nursing supervisor of the resident's weight gain on 5/5/26 and ensured the physician was notified. RN #3 further indicated he would notify the physician today. Subsequent to surveyor inquiry, a nursing note written by LPN #3 and dated 5/7/26 at 11:54 AM identified the physician's assistant (PA #1) had been notified of Resident #1's weight gain and elevated blood pressure.Subsequent to surveyor inquiry, a physician's order dated 5/7/26 directed Lasix (a diuretic) 40 milligrams (mg), give one tablet by mouth one time a day for fluid retention for 3 days. Interview and review of the clinical record with the DNS on 5/7/26 at 3:30 PM identified Resident #115 on 5/4/26 weighed 180.6 lbs., and on 5/5/26 weighed 188.2 lbs. (a gain of 7.6 lbs. in one day). The DNS indicated the physician should have been notified of the resident's weight gain and she was unsure why it was not done. The DNS identified LPN #3 should have informed the nursing supervisor of the resident's weight gain on 5/5/26 and ensured the physician was notified. Interview and review of the clinical record with PA #1 on 5/8/26 at 1:10 PM identified Resident #115 on 5/4/26 weighed 180.6 lbs, and on 5/5/26 weighed 188.2 lbs. (a gain of 7.6 lbs. in one day). PA #1 indicated Resident #115 had significant weight gain and she should have been notified sooner but was just notified yesterday (5/7/26) of the weight gain (from 5/5/26). After being informed of the weight gain on 5/7/26, PA #1 stated she ordered Lasix 40 mg daily for 3 days for Resident #1 to address the weight gain the because the resident presented with a lot of edema. PA #1 indicated it would have been the responsibility of the charge nurse or nursing supervisor to notify her timely of Resident #1's significant weight gain and she was unsure why it was not done. Review of the facility policy, Weight Policy and Procedure, dated 10/2023, directed weights will be monthly unless physician's orders or the residents condition warrants more frequency as determined by the Interdisciplinary Team. A residents significant weight change should be reported to the physician and the plan of care will be revised as appropriate. If a resident refuses weighing or circumstances prevent weighing the resident the reason should be documented in the resident's medical record, and an attempt should be made to weigh the resident at another time.

Based on interviews, review of clinical record, review of facility documentation and facility policy for 1 of 4 residents (Resident #5) reviewed for mistreatment, the facility failed to protect Resident #5's resident rights to be free from verbal abuse by staff. The findings include: Resident # 5 was admitted to the facility in May 2021 with diagnoses that included major depressive disorder, schizoaffective disorder, and chronic pain.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was cognitively intact and was dependent on staff for activities of daily living except being able to eat independently and was always incontinent of urine.Physician orders dated 3/17/26 directed to administer Sertraline (an antidepressant) 25 milligrams (mg) every evening for depression, Duloxotine (antidepressant) 30 mg once a day for depression and Seroquel (an antipsychotic) 20 mg at bedtime for insomnia (hold if lethargic).The Resident Care Plan dated 4/20/26 identified a concern regarding psychosocial well-being related to an allegation of abuse. Interventions included to offer emotional support as needed, to be seen by psychiatric services for emotional needs, to be seen by social worker daily for 3 days, and provide emotional support related to alleged incident.Interview with Resident #5 on 5/5/26 at 2:00 PM identified that he/she had a verbal altercation with a nurse's aide (NA). Resident #5 indicated that he/she could not recall the date or the name of the NA #5, but the NA #5 used profanity toward Resident #5. Resident #5 indicated that he/she was arguing back and forth with NA #5 and that NA #5 was angry because the resident used the call bell too much and requested assistance with urinary incontinence. Resident #5 indicated that he/she did not report the incident until the next day because he/she was also yelling at NA #5 and used profanity back to NA #5.A facility initiated Reportable Event form dated 4/16/26 identified that Resident #5 and Nurse Aide (NA) #5 had a verbal altercation on 4/15/26 on the 3:00 PM to 11:00 PM shift. Resident #5 reported the following day (4/16/26) that NA #5 used profanity directed to Resident #5 several times in the evening of 4/15/26 ( You need to stop ringing the f.king call bell so much. didn't another NA f.ing tell you to stop and stop being so f.king annoying. I have no f.king time for you, I'm leaving in a few minutes). Resident #25 who was Resident #5's roommate witnessed profanity being used toward Resident #5 by NA #5. Resident #25 was cognitively intact with recent BIMS score of 15 on 4/15/26. NA #5's written statement indicated that profanity was used toward Resident #5 by her as they were arguing and that Resident #5 was using profanity towards NA #5. The A/I noted a written summary by the facility substantiated that verbal abuse from NA #5 toward Resident #5 occurred.Interview and review of investigation with the DNS on 5/8/26 at 10:45 AM indicated that NA #5 admitted to using profanity to Resident #5. The DNS stated the incident was substantiated as NA #5 acknowledged the use of profanity and that the incident was also witnessed by Resident #25. Resident #25 had stated that Licensed Practical Nurse (LPN) #4 was the charge nurse on the 3:00 PM to 11:00 PM shift on 4/15/26 and had also witnessed the profanity being used toward Resident #5 as she was standing in the doorway when it occurred. However, LPN #4's statement denied that she had witnessed profanity being used by NA #5, but she heard Resident #5 using profanity toward NA #5 and that they were arguing. The DNS stated she could not confirm that LPN #4 heard NA #5 use profanity towards Resident #5.Interview with LPN #4 on 5/8/26 at 2:00 PM indicated that she heard loud volumes of voices coming from Resident #5's room and that Resident #5 and NA #5 were having some type of disagreement. LPN #4 stated that she was frustrated as she was trying to finish her medication pass. LPN #4 stated that she overheard Resident #5 using profanity towards NA #5 but did not hear NA #5 use any profanity. LPN #4 indicated that Resident #5 was upset with NA #5 so she instructed NA #5 to leave the room and not provide assistance to Resident #5 for the rest of the shift. LPN #4 indicated that she did not report anything to the nursing supervisor as she thought everything was taken care of and she smoothed things over. LPN # 4 indicated that she was provided re-education by the DNS on resident rights and abuse and now she would report a similar type of incidents immediately to the nursing supervisor. Subsequent to the incident of verbal abuse, the facility initiated a Quality Assurance Improvement Plan (QAIP) on 4/17/26. A root cause analysis was completed. Education provided to all staff on the Abuse and Resident Rights policies with emphasis on speaking to residents in a dignified manner and removal of self before negative interaction escalates. Random audits with residents were initiated regarding abuse monitoring weekly for 4 weeks then monthly for 3 weeks and thereafter random audits. All results from audits to be reviewed at QAIP meetings.The facility alleges past non-compliance and was accepted by the State Agency.The Abuse Policy and Procedures dated 12/2023 directed, in part, that verbal abuse is defined as the use of written, oral or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Abuse allegations require immediate action, reporting to nursing supervisor, to the DNS and facility administrator, immediate suspension of alleged employee pending investigation and 2 hours reporting to Department of Public Health and local Law Enforcement. The Resident Rights Policy dated 2/2024 directed, in part, residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality and the right to receive quality care and services.

Based on interviews, observation, clinical record review and facility policy for 1 of 3 residents (Resident #8) reviewed for accidents, the facility failed to ensure Resident #8's bed was in the low position per the Resident Care Plan (RCP). The findings include: Resident #8 diagnoses included diabetes, vascular dementia, and Parkinson's disease.The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was moderately cognitively impaired, used a wheelchair, required substantial/maximal assistance with eating, and was dependent with bed mobility and chair/bed transfers. The MDS assessment further identified Resident #8 had no falls since the prior assessment.The Resident Care Plan (RCP) dated 3/9/26 identified Resident #8 had potential for falls due to a history of falls. Interventions included placement of bilateral floor mats, bed in low position, and offer diversional activities.Interview with Person #1 on 5/6/26 at 12:56 PM identified that he/she had concerns related to Resident #8 having had several falls at the facility.Observation of Resident #8 in his/her room on 5/8/26 at 6:30 AM identified Resident #8 was lying in bed, turned slightly onto his/her right side with his/her head near the right edge of the bed, his/her knees at the left edge of the bed, his/her left leg extended straight off the left side of the bed and rotated so that the tops of his/her toes touched the floor mat positioned next to the bed. The bed was positioned so the top of the mattress was at knee height.Interview and observation of Resident #8 with Licensed Practical Nurse (LPN) #7 and Nurse Aide (NA) #11 on 5/8/26 at 6:35 AM identified Resident #8 was in the position detailed above (at 6:30 AM) upon room entrance. LPN #7 identified he and NA #11 had just been in the room a few minutes ago to provide care to Resident #8 and he/she had been placed on their back in the center of the bed. LPN #7 indicated that Resident #8's bed should be in the lowest position, and that he didn't think the bed could go any lower than its current position with the top of the mattress at knee height. Subsequent to his comment, NA #11 pressed the bed controls and the bed lowered down until the top of the mattress was at mid-shin (approx. 6 inches lower). LPN #7 identified he had thought the bed was all the way down in the lowest position and didn't realize it could have gone lower when he finished providing care earlier and left Resident #8's bed in the height see upon room entry. He indicated that this was a new bed for Resident #8 and it was better than her previous bed, but that he had noticed this bed lost some functionality such as the ability to elevate the foot end of the bed when it was in the lowest position. He further identified that he had not had the opportunity to notify anyone of his concerns.Observation on 5/11/26 at 8:00 AM noted Resident #8 lying in bed in his/her room with the head of the bed elevated. The bed was positioned at a height which had the top of the mattress at knee height (not in a low position per the RCP). Interview and observation with NA #2 on 5/11/26 at 8:05 AM identified that Resident #8 was a fall risk. He indicated the bed could go lower than it's current position. NA #2 could not identify how low the bed was supposed to be positioned and indicated that it should be at a height that was low enough Resident #8 wouldn't get hurt if he/she fell out of the bed. NA #2 was unable to identify what the appropriate height would be to prevent injury in a fall, and he then lowered the bed to it's lowest position which placed the top of the mattress at mid-shin level. NA #2 further identified that he had not received education from the facility or his nurse aide training which adequately instructed as to what was expected from the NA when the care card directed for a low bed. Interview with RN #1 on 5/11/26 at 8:30 AM identified when a physician order or NA care card read low bed the nursing staff member should put the bed down into its lowest position almost touching the floor. She identified that some beds were able to go lower than others, so the staff member should ensure the bed is in the lowest position for that bed. She further identified that Resident #8's bed should be in the lowest position and not with the mattress at knee height because he/she was a fall risk.Interview with the Director of Nursing (DNS) on 5/11/26 at 9:40 AM identified there was no education provided to nursing staff that was specific to placement of a bed in lowest position. She indicated that it was part of fall prevention, and the NAs should know what bed in the lowest position means. She further identified that even when the plan of care or care card indicated for a low bed, the NA should realize that means to put the bed in its lowest position.Review of the Fall Prevention Program policy directed, in part, residents at risk for falls are identified on the NA Kardex (care card) and in the care plan. The policy directed residents at risk for falls will have interventions for fall prevention in their care plan such as environmental hazards (bed height).

Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 4 (Resident #17) residents reviewed for mistreatment, the facility failed to ensure a Registered Nurse (RN) assessment was conducted when bruising of unknown origin was identified. The findings include: Resident #17 was admitted to the facility in November of 2018 with diagnoses that included dementia with behavioral disturbances and thrombocytopenia (low platelet count/causes bleeding and bruising) The Resident Care Plan (RCP) dated 11/7/25 identified a concern related to thrombocytopenia with interventions to monitor for signs and symptoms of bleeding, monitor vital signs and notify MD of significant abnormalities.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was moderately cognitively impaired, required maximum assistance from 1 staff member for activities of daily living and was independent in wheelchair. Physician orders dated 12/12/25 directed to perform skin checks weekly and document and report any findings.A facility Accident and Incident Report (A/I) dated 1/16/26 identified that Resident #17 had bruising of unknown origin on his/her bilateral legs and arms which was identified by the hospital during his/her hospital stay from 1/14/26 through 1/16/26. The facility initiated an investigation of Resident #17's bruising at that time and a statement provided by Nurse Aide (NA) #3 who was Resident #17's primary NA on the 7:00 AM to 3:00 PM shift identified that she had reported bruising to Resident #17's arms and legs to Licensed Practical Nurse (LPN) #2.Nursing notes and weekly skin check assessments dated 1/12/16 through 1/14/26 (when Resident #17 was admitted to the hospital) lacked documentation of bruising from LPN #3 nor was new bruising identified on a weekly skin check evaluation and there was no Registered Nurse (RN) assessment conducted for the bruising (bruising was identified by LPN #2 on 1/12/26).Interview with Registered Nurse (RN) #1 on 5/11/26 at 10:50 AM identified that she could not recall if she was the RN Supervisor on 1/12/26; however, if nursing staff had reported Resident #17's bruising to her on 1/12/26 she would have initiated an A/I report, obtained statements from staff to determine if bruises were injuries of unknown origin, complete and document an RN assessment and ensure the physician and responsible party were notified. In addition, RN #1 stated she would have informed the DNS of the bruising to determine if it needed to be reported to the State Agency per the facility's policy when unexplained bruising was identified. Furthermore, RN #1 recalled that something was placed in the Advanced Practice Registered Nurse (APRN) communication book regarding Resident #17 bumping into walls with his/her wheelchair but could not remember the date nor could RN #1 locate the communication sheet as she stated they are discarded after a month or two. A review of the nursing schedules for 1/12/26 identified that LPN #12 who was from a nursing agency was on the schedule on 1/12/26 on the 7:00 AM to 3:00 PM shift and RN #5 was the RN supervisor on that shift. Calls were placed on 5/11/26 and 5/12/26 to LPN #12 and RN #5 with no response or call back. Interview with LPN #2 on 5/11/26 at 1:04 PM identified that NA #3 probably did report that Resident #17 had bruising on 1/12/26 to him because an agency nurse was on the unit on that day. LPN #2 indicated that he should have reported the bruising to the RN supervisor himself and wrote a nursing note to ensure there was appropriate follow-up. Interview, review of Resident #17's nursing notes and A/I reports with the Assistant Director of Nursing on 5/11/26 at 2:30 PM identified that there was no RN assessment or documentation of bruising to Resident #17 on 1/12/16. Furthermore, there was no A/ I report completed 1/12/26 when the bruising was first identified by NA #3 until 1/16/26 (4 days after the initial bruising was first identified). The ADNS stated it was facility policy that an RN assessment was completed and documented when new bruising was identified and that an A/ I report was to be completed. A review of the Charting and Documentation Policy dated 1/2025, directed, in part, authorized individuals may provide documentation in the clinical record that will include the medical plan of care, assessments, evaluations, responses to care, identification of significant change, accidents, and unusual occurrences. Documentation shall be completed at the time of services but no later than the shift in which assessment, observation or care services occurred. Documentation shall be complete, accurate and relevant containing sufficient details about the patient's care and/or responses to care.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #1) reviewed for edema, the facility failed to obtain and document weights per the physician's order for a resident with congestive heart failure (CHF). Additionally, for 1 of 3 residents (Resident #7) reviewed for activities of daily living (ADLs), the facility failed to ensure offloading of the heel and for the only sampled resident (Resident #17) reviewed for skin issues, the facility failed to ensure proper fitting and clean Tubi Grip (protective sleeves) were in place. The findings include: 1.Resident #1's diagnoses included chronic diastolic congestive heart failure (CHF), chronic kidney disease, chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and was dependent with transfers, toileting and bed mobility. The MDS indicated Resident #1 had heart failure and renal insufficiency. The Resident Care Plan (RCP) dated 4/25/26 identified Resident #1 had a risk for altered fluid balance and an altered respiratory status with difficulty breathing related to a diagnosis of congestive heart failure (CHF). Interventions included monitoring the resident for increased restlessness, anxiety or air hunger and abnormal breathing patterns or respiratory distress and report to the physician. A physician order dated 4/14/25 and currently in effect directed daily weights and to notify the healthcare provider of a 3 pound weight change/daily or a 5 pound weight change/week every day shift every other day for hypervolemia (fluid overload), COPD and CHF. A Physician's Assistant (PA #1) progress note dated 4/16/26 at 8:42 PM identified Resident #1's most recent chest x-ray had increased bilateral effusions (abnormal accumulation of fluid) and to increase Lasix (a diuretic) to 40 mg twice daily. The progress note directed to monitor Resident #1's fluid balance with Lasix increase. Review of the Treatment Administration Record (TAR) for April 2026 and May 2026 identified weights were not obtained or documented for 4/19/26, 4/21/26, 4/27/26 and 5/3/26 (4 out of 12 opportunities). Interview and review of the clinical record with Licensed Practical Nurse (LPN) #3 on 5/7/26 at 11:20 AM identified he was unsure why Resident #1's weights were not obtained and documented on 4/19/26, 4/21/26, 4/27/26 and 5/3/26 (4 out of 12 opportunities) and stated if a weight was not obtained or the resident refused a weight there should have been a nursing note in the clinical record reflecting a reason but there was not. Review of the TAR for April 2026 and May 2026 with LPN #3 indicated his initials were documented in the TAR but the resident's weight was not recorded for 4/19/26 and 4/21/26 and he was unsure of the reason. LPN #3 identified it would have been his responsibility to ensure Resident #1's weights were obtained and documented every day per the physician's order and it was an oversight. Interview and review of the clinical record with the RN Supervisor (RN #3) on 5/7/26 at 11:40 AM identified he was unsure of the reason Resident #1's weights were not obtained and documented on 4/19/26, 4/21/26, 4/27/26 and 5/3/26 (4 out of 12 opportunities) and stated if a weight was not obtained or the resident refused a weight there should have been a nursing note in the clinical record with a reason and there was not. RN #3 indicated it would have been the responsibility of the charge nurse to ensure Resident #1's weights were obtained and documented every day per the physician's order and he was unsure why it was not done. Interview and review of the clinical record with the DNS on 5/7/26 at 3:30 PM identified Resident #1 should have been weighed every day per the physician's order and she was unsure why it was not done. The DNS indicated it would have been the responsibility of the charge nurse in collaboration with the Nurse Aide (NA) to ensure weights were obtained and documented. Review of the clinical record with the DNS failed to identify nursing progress notes for 4/19/26, 4/21/26, 4/27/26 or 5/3/26 that explained why Resident #1's weight was not obtained on those days. Interview and review of the clinical record with PA #1 on 5/8/26 at 1:10 PM identified Resident #1 had the potential for fluid overload and weights should have been obtained every other day per the physician's order. PA #1 indicated it would have been the responsibility of the nursing staff to ensure the residents' weights were obtained and documented and she was unsure why that was not done. Additionally, PA #1 stated if Resident #1's weight was not obtained there should have been a reason why documented in the clinical record by the charge nurse. Review of the facility policy, Weight Policy and Procedure, dated 10/2023, directed weights will be monthly unless physician's orders or the residents condition warrants more frequency as determined by the Interdisciplinary Team. If a resident refuses weighing or circumstances prevent weighing the resident the reason should be documented in the resident's medical record, and an attempt should be made to weigh the resident at another time. 2. Resident #7 diagnoses included diabetes, non-pressure chronic ulcer of the right lower leg, and peripheral vascular disease (PVD). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was cognitively intact, used a wheelchair, was independent with eating, and was dependent with bed mobility and bed/chair transfers. The MDS assessment further identified Resident #7 was at risk for developing pressure ulcers, had a diabetic foot ulcer, had a pressure reducing device for bed, and application of dressings to the feet. The MDS further indicated there was no turning/repositioning program in place for Resident #7 as this item was not checked off as applicable. The Resident Care Plan (RCP) dated 4/4/26 identified Resident #7 had the potential for skin breakdown related to decreased mobility. Interventions included ensuring Resident #7's legs and feet were not rubbing against any part of the bed or bed frame, and offload heels when in bed as the resident tolerates. The RCP further identified Resident #7 had PVD with interventions that included elevating his/her legs when sitting or sleeping and monitoring for signs and symptoms of skin problems. A physician order dated 4/6/26 and 5/4/26 directed to offload heels every shift as tolerated. Review of the clinical record identified a photo dated 5/5/26 which indicated a diabetic ulcer to the right lateral foot just below the 5th toe. Observation of Resident #7 on 5/8/26 at 6:30 AM identified Resident #7 was lying supine in bed on an air mattress which was set at 360 pounds (lbs.) and with his/her legs and foot at the same level as the body. Additionally, no pillow or offloading device was observed in the room or surrounding visible surfaces adjacent to Resident #7's bed. Observation of Resident #7 on 5/8/26 at 7:30 AM and at 7:35 AM with Licensed Practical Nurse (LPN) #7 identified Resident #7 was lying supine in bed with an air mattress in place set at 360 pounds (lbs.) and noted Resident #7's right heel (Resident #7 has only 1 foot) was directly resting on the mattress. LPN #7 indicated Resident #7's heel should be offloaded in bed to prevent his/her foot from resting directly on the mattress. LPN #7 indicated Resident #7 was able to move his/her own foot as needed to offload it, but was unaware there was not a pillow or offloading device in the bed for Resident #7 to use to offload their heel during his shift. LPN #7 identified that he had not offloaded Resident #7's heels himself during the shift, and the Nurse Aide had not told him Resident #7 refused a pillow this shift. LPN #7 further identified Resident #7 liked his/her air mattress to be firm so the setting was at 360 lbs. even though his/her weight was 263.2 lbs. Subsequent to surveyor inquiry, on 5/8/26 at 7:45 AM, LPN #7 obtained a pillow from a location outside of Resident #7's room. As LPN #7 lifted the sheet to place the pillow under Resident #7's leg, Resident #7's right lateral foot was noted to be positioned directly on the air mattress and LPN #7 placed the pillow under Resident #7's R lower leg to offload the foot and heel. Interview with Registered Nurse (RN) #1 on 5/11/26 at 8:30 AM identified Resident #7 should have his/her heel offloaded at all times when in bed due to presence of a wound on the side of his/her foot. She identified that Resident #7 was very cooperative with offloading his/her foot because he/she wanted the wound to heal. Interview with the DNS on 5/11/26 at 2:30 PM identified that Resident #7's heel should be offloaded at all times when in bed even though the wording of the order said to offload heels every shift as tolerated. Review of the Pressure Injury Prevention Management Program policy directed, in part, risk factors included decreased functional ability and medical condition compromising tissue-blood supply (PVD). The policy directed to reposition when in bed per the RCP, use of positioning devices such as pillows or foam to prevent direct contact of bony prominences. Review of the Guidelines for Use of Support Surfaces policy directed, in part, a support surface (air mattress) does not replace the need to turn and reposition and/or to offload heels based on resident risk factors. 3. Resident #17 was admitted to the facility in November of 2018 with diagnoses that included hemiparesis (weakness) on left side following stroke, visuospatial (inability to cognitively judge space/distance) deficit, dementia with behavioral disturbances and thrombocytopenia (low platelet count/causes bleeding and bruising). The Resident Care Plan (RCP) dated 4/6/26 identified a concern related thrombocytopenia with interventions to monitor signs and symptoms of bleeding and monitor vital signs and notify MD of significant abnormalities. In addition, Resident #17's RCP identified visuospatial deficit as the resident bumps into walls and objects when in the wheelchair with interventions that included to ensure glasses were on when out of bed and in the wheelchair and ensure resident had enough space and cueing and redirection as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was severely cognitively impaired and was totally dependent on staff for all activities of daily living. Physician orders dated 4/27/26 directed to apply Tubi Grip (elastic tubular bandage for compression and/or skin protection) to both arms and legs at all times, remove for care and skin check once a shift for fragile skin. The physician orders further directed to check the resident's skin for purpura and ecchymosis (bruising) every evening and notify the supervisor of any new areas. Observations on 5/5/26 at 10:00 AM noted Resident #17 lying in bed, wearing a short-sleeved hospital gown with Tubi Grips on his/her bilateral arms. The Tubi Grips were rolled down to just above the wrists and stretched out (not providing any compression or coverage to Resident #17's arms). Observation and interview on 5/6/26 at ll:55 AM with Licensed Practical Nurse (LPN) #1 (Infection Control Nurse) noted Resident #17 lying in bed, wearing a short-sleeved hospital gown. The Tubi Grip sleeves were rolled down near the resident's wrists and stretched out (not providing any coverage to Resident #17's arms). LPN #1 stated that she was not sure why Resident #17 was wearing Tubi Grip to his/her arms, but she assumed it was to protect the skin on his/her arms. LPN #1 indicated that the Tubi Grip to both arms was ineffective in providing skin protection and needed either better fitting Tubi Grip or another product might be better in providing protection. Interview and observation on 5/6/26 at 12:30 PM with LPN #10 (Resident #17's primary nurse on the 7:00 AM to 3:00 PM shift) indicated that the Tubi Grips were ill fitting because they were loose, stretched out and at the elbow, and needed to be replaced. LPN #10 stated that she had not applied the Tubi Grips to Resident #17's arms in the morning (AM) on 5/6/26 and that they were already in place. Furthermore, it was noted that the Tubi Grips were heavily soiled with a dry, brown substance on the end of Tubi Grip near Resident #17's right wrist. Subsequent to surveyor inquiry, a physician's order was put in place to check Tubi Grip sleeves for cleanliness and replace if soiled. In addition, LPN #10 replaced the Tubi Grip sleeves to Resident #17's bilateral arms on 5/6/26. Observation of the new Tubi Grips identified they were clean and were no longer sliding down/stretched out on Resident #17's arms. Interview with Nurse Aide (NA) #3 on 5/7/26 at 2:55 PM indicated that on 5/6/26 when providing AM care to Resident #17, Resident #17 had one Tubi Grip on, and one was removed. NA #3 indicated that Resident #17 was so skinny and tiny that the Tubi [NAME] sleeves just fell right down his/her arm. In addition, NA #3 indicated that Resident #17 drinks chocolate shakes and that was probably what caused his/her Tubi Grip sleeves to be soiled. Interview and review of the Tubi Grip supplies with the Central Supply Clerk (CSC) on 5/8/26 at 8:05 AM indicated that she orders the Tubi Grip sleeves and they come in a variety of sizes. The CSC was aware that Resident #17 uses Tubi Grip as the nurses ask her to bring them to the unit. She indicated that they just ask for the smallest size that is available. A review of the inventory revealed Tubi Grip size B the smallest size in the facility that measured 2 1/2 inches by 11 yards. The CSC indicated that she started working for the facility in October 2024 as the CSC and has not ordered size B since she started. A review with the customer service supply vendor and the online ordering system on 5/11/26 at 1:15 PM revealed that a size A Tubi Grip was available that was pediatric/infant size that measured 1 1/2 inches by 11 yards. The CSC indicated that she would need corporate approval to order this item as it was blocked out as it was not part of the facility formulary. Interview with the DNS on 5/11/26 at 3:45 PM indicated that she had found a smaller size of Tubi Grip for Resident #17 online and had ordered it after measuring his/her arms for fit. Although requested, the facility did not have a Tubi Grip policy available.

Based on observations, interviews, review of the clinical record, and facility policy for the only resident (Resident #66) reviewed for respiratory care, the facility failed to ensure a safe environment for a resident on oxygen therapy by allowing a petroleum-based product (lip balm) on the lips without a physician's order, staff oversight, or self-administration assessment. The findings include: Resident #66 was admitted to the facility in November 2024 with diagnoses that included respiratory failure, emphysema, and pneumonia. Physician's orders dated 4/11/26 directed to administer oxygen at 0.5 liters as needed via nasal cannula to maintain a pulse oximetry (estimates blood oxygen saturation/Sp02) above 90%. The Resident Care Plan (RCP) dated 4/21/26 identified pneumonia as a concern with interventions that included providing antibiotic therapy as ordered by the physician, encourage fluid intake, antinausea medication as ordered, vital signs once a shift, notify the physician of significant abnormalities, monitor and document breath sounds, rate, rhythm, and the use of any accessory muscles.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and required set-up assistance with activities of daily living (ADLS). The MDS did not identify the use of oxygen.Observation and interview of Resident #66 on 5/5/26 at 11:05 AM identified Resident #66 was lying in bed, oxygen via nasal cannula was not in place in Resident #66's nares, the nasal cannula tubing was on the bed and flowing at 2 liters/minute. Resident #66 stated that he/she had just removed the tubing from his/her nose and did not turn off the oxygen concentrator. Resident #66 stated that he/she had been using oxygen when needed for about month related to having pneumonia and being in the hospital. Additionally, it was noted that Resident #66 had 2 petroleum-based lip balms on the over bed table and within resident reach. Resident #66 stated that he/she used petroleum-based lip balm every night after supper, has had the lip balms for a long time and could not recall if he/she had purchased it or if someone had purchased it for him/her. Resident #66 indicated that he/she applied the petroleum-based lip balm after supper as his/her lips were dry. Resident #66 indicated that he/she had been periodically using oxygen at night and applied it before he/she went to sleep or sometime during the night. Resident #66 indicated that he/she had applied the petroleum-based lip balm last night after dinner and put his/her oxygen on sometime last night. Resident #66 indicated that he/she did not apply lip balm and oxygen simultaneously but used the petroleum-based lip balm every night and put his/her oxygen on sometime later in the evening. Furthermore, Resident #66 was unaware of any safety concerns regarding the use of a petroleum-based product with the use of oxygen.Interview with Licensed Practical Nurse (LPN) #2 on 5/5/26 at 11:15 AM identified that he was not aware of any safety concerns regarding the use of oxygen and petroleum-based lip balms or any other petroleum -based products. LPN #2 could not recall if Resident #66 was wearing oxygen when he went into the room earlier to administer Resident #66's medications. In addition, LPN #2 was not aware Resident #66 had 2 petroleum-based lip balms on the over bed table. Subsequent to surveyor inquiry, LPN #2 removed the lip balms from Resident #66's over bed table and placed them in the medication cart. Interview and review of the clinical record with Registered Nurse (RN) #1 at 12:50 PM indicated that she was aware that petroleum-based products could not be used on the face for anyone who utilized oxygen but was not aware that Resident #66 was using petroleum-based lip balm with oxygen until 5/5/26 when it was brought to her attention by LPN #2 after surveyor's observation. Interview and observation with Nurse Aide (NA) #1 on 5/5/26 at 12:55 PM (who was Resident #66's primary NA on 7:00 AM to 3:00 PM shift and on 5/5/26) indicated that she went into Resident #66's room at approximately 7:35 AM on 5/5/26, Resident #66 was utilizing oxygen and that Resident #66 routinely used oxygen in the morning. NA #1 did not notice petroleum-based lip balm on the over bed table, did not recall receiving education on safety concerns regarding petroleum-based products on the face with oxygen use and was not aware that it could be a fire hazard. Interview with LPN #2 on 5/5/26 at 12:35 PM indicated that he had never received education by the facility regarding safety concerns using petroleum-based products on the face with oxygen use.Interview with NA #3 on 5/5/26 at 1:50 PM indicated that she was not aware that petroleum-based products were a fire hazard for residents that utilized oxygen.Interview with the Oxygen Vendor Manager from the oxygen supplier on 5/5/26 at 1:55 PM indicated that use of petroleum-based products with oxygen was considered a safety and fire hazard. He indicated that it was the facility's responsibility to provide education on the safety guidelines for oxygen and that oxygen policies were developed by the facilities that were specific. The Oxygen Vendor Manager indicated that the oxygen company's policy on oxygen use was a general/broad policy that did not address the use of hazardous products with oxygen.Interview with the Director of Nursing (DNS) and the Corporate Regional Director on 5/5/26 at 2:00 PM revealed that they were aware that the use of oxygen and petroleum-based products was a fire hazard. The DNS indicated that she was not aware of any education or audits that were conducted by the facility. Review of the facility Oxygen Therapy Safety Guidelines followed by the facility from the American Association for Respiratory Care (AARC) (not dated) directed, in part, oxygen is not flammable, but it supports and accelerates combustion. Petroleum (oil based) products ignite in an oxygen enriched environment creating a serious fire hazard. Petroleum-based lubricants should not be used on lips or around nasal cannula. Avoid products containing Petroleum, Petroleum Jelly, Mineral oil, Paraffin, Paraffin liquid and [NAME] Soft Paraffin. The above deficiency resulted in the finding of Immediate Jeopardy (IJ). After observations made on 5/5/26, the facility Administrator was provided with the IJ template on 5/5/26 at 3:47 PM and submitted a removal plan which was approved by the State Agency on 5/6/26.The Removal Plan noted in part, the petroleum based lip balms were immediately removed from Resident #66's room, all residents oxygen orders verified for usage, all residents using oxygen were visually audited to ensure no petroleum-based products were present and if products were found, were immediately removed and non-petroleum based products were provided that could be used on the face. Additionally, education was provided to all nursing staff including agency prior to the start of shift, residents, and residents' representatives regarding the contraindication of using petroleum-based products on the face including the list of products that are safety hazard with oxygen. The facility implemented audits 3 times a week on each unit to ensure no petroleum-based products were in the room of residents receiving oxygen.Observations on 5/6/26 identified the facility implemented the removal plan and the IJ was removed.

Based on observations, interviews, review of clinical record and facility policy for the only resident (Resident #66) reviewed for respiratory care, the facility failed to ensure there was a physician's order in place for the use of oxygen. The findings include: Resident #66 was admitted to the facility in November 2024 with diagnoses that included respiratory failure, emphysema, and pneumonia. Physician orders dated 4/11/26 through 4/13/26 directed to administer oxygen at 0.5 liters as needed via nasal cannula to maintain a pulse oximetry (estimates blood oxygen saturation/Sp02) above 90%. On 4/13/26 physician orders were changed to administer oxygen 0.5 liters via nasal cannula as needed to maintain a Sp02 above 92% and discontinued on 4/20/26.A review of the Physician Assistant (PA) progress notes dated 4/13/26 and 4/14/26 indicated that Resident # 66 was receiving 2 to 3 liters of oxygen via nasal cannula which did not match the physician's orders that were in place at that time as order was for oxygen at 0.5 liters via nasal cannula as needed.The Resident Care Plan (RCP) dated 4/21/26 identified pneumonia as a concern with interventions that included antibiotic therapy as ordered by the physician, encourage fluid intake, antinausea medication as ordered, vital signs once a shift and notify physician of significant abnormalities, monitor and document breath sounds, rate, rhythm, and the use of any accessory muscles.The 5-day Minimum Data Set (MDS) dated [DATE] identified that Resident #66 was cognitively intact and required set-up assistance with activities of daily living (ADLS). The MDS did not identify the use of oxygen.Observation and interview with Resident #66 on 5/5/26 at 11:05 AM identified that Resident #66 was lying in bed with oxygen running at 2 liters; however, the nasal cannula tubing was on the bed and not in his/her nose at the time. Resident #66 stated that he/she had just removed the tubing from his/her nose but did not turn off the oxygen. Resident #66 stated that he/she has been using oxygen when needed for about month related to having pneumonia and being in the hospital. A review of Resident #66's physician's orders and care plan on 5/5/26 at 11:12 AM identified that Resident #66 did not have a current order for oxygen. Interview with Licensed Practical Nurse (LPN) #2 on 5/5/26 at 11:15 AM identified that he could not recall if Resident #66 was wearing oxygen when he went into the room earlier to give Resident #66's medications but stated that Resident #66 wore oxygen as needed since a pneumonia diagnosis sometime in April 2026. A second review of Resident #66's physician's orders on 5/5/26 at 11:30 AM identified that a physician's order for oxygen use at 2 to 3 liters via nasal cannula as needed was put into place on 5/5/26 at 11:18 AM and Registered Nurse (RN) #1 updated the care plan to include the use of oxygen as needed.Interview and review of the clinical record with RN #1 at 12:50 PM indicated that she had updated Residet #66's physician's orders and care plan for oxygen use as LPN #2 had just informed her that Resident #66 was using oxygen and did not have a current physician order. RN #1 indicated that Resident #66 should have had a current physician order for the as needed oxygen use and it should have been in Resident #66's care plan prior to 5/5/26 as Resident #66 has been using oxygen periodically since pneumonia diagnoses on 4/8/26 and his/her hospitalization from 4/18/26 through 4/21/26 for a stroke. A review of the physician's orders and care plan with RN #1 identified that she had updated the physician's orders and care plan for oxygen use on 5/5/26 at 11:18 AM and stated that she could not explain why Resident #66 did not have physician's orders for oxygen. RN#1 indicated that it was the responsibility of nursing to ensure physician's orders were in place for any resident using oxygen and care plan is updated.Interview with Nurse Aide (NA) #1 on 5/5/26 at 12:55 PM who was Resident #66's primary NA on 7:00 AM to 3:00 PM shift and his/her NA on 5/5/26 indicated that she went into Resident #66's room around 7:35 AM on 5/5/26 and that time Resident #66 was wearing oxygen and that Resident #66 routinely used oxygen in the morning. A review of the Oxygen Therapy policy (not dated), directed, in part, the policy instructs how to treat hypoxemia, decrease work of breathing, and decrease myocardial workflow in patients receiving supplemental oxygen. A physician's order will be in place. The order should include liter flow and type of oxygen delivery device.

Based on observations, interviews, review of clinical record and facility policy for the only sampled resident (Resident #66) reviewed for respiratory care, the facility failed to ensure medications were not left at the bedside. The findings include: Resident #66 was admitted to the facility in November 2024 with diagnoses that included respiratory failure, emphysema, and pneumonia. Physician orders dated 4/1/26 directed to administer Trelegy Ellipta (dry powder respiratory inhaler used for asthma) inhaler 100-62.5-25 MCG/ACT (micrograms/actuation-one puff) once a day related to emphysema.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 was cognitively intact and required set-up assistance with activities of daily living (ADLs). The Resident Care Plan (RCP) dated 4/30/26 identified emphysema as a concern with interventions that included giving aerosol or bronchodilators as ordered, identify shortness of breath while lying flat, elevate the head of the bed (45 degree angle) to promote optimal respiratory status, monitor for any signs and symptoms of a respiratory infection and for acute respiratory insufficiency.Observation on 5/5/26 at 11:05 AM noted Resident #66 had Trelogy Ellipta inhaler on the over bed table that contained 4 remaining doses in the inhaler. Resident #66 stated she was not aware the inhaler was on the over bed table and the nurses usually administer the inhaler. Interview, observation and review of the clinical record with Licensed Practical Nurse (LPN) #2 on 5/5/26 at 11:20 AM identified that the inhaler was at the bedside with 4 doses remaining. LPN #2 stated that he just opened a new inhaler that morning as there was not one in the medication cart that was already in use. LPN #2 stated that he believed Resident #66 received the inhaler 2 times a day and it must have been left there from the previous night. A review of physician's orders with LPN #2 noted that the Trelogy inhaler was once to be administered one a day at 9:30 AM. LPN #2 stated that Resident #66 did not have an order to self-administer the inhaler; therefore, the inhaler should not be left at the bedside, and it was the responsibility of nursing to ensure medications were not left at the bedside. Subsequent to surveyor inquiry, LPN #2 removed Resident #66's inhaler from the bedside and stored it in the medication cart.Interview and review of the clinical record with Registered Nurse (RN) #1 on 5/5/26 at 12:50 PM identified that Resident #66 did not have a physician's order to self-administer the inhaler nor was there a self-administration assessment completed for the Trelogy inhaler. RN #1indicated that Resident #66's inhaler should not have been left at the bedside, that the facility policy was that medications were to be locked in the medication cart and it was the responsibility of the nurse to ensure that medications were not left at the bedside.A review of the Medication Storage Policy dated 9/2024 directed, in part, that medications are to be locked and stored in medication cart and/or medication storage room (medication room).

Based on review of the clinical record, facility policy and interviews for 1 of 6 residents (Resident #70) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to submit a new referral for a resident with a new diagnosis psychiatric diagnoses. The findings include: Resident #70 had diagnoses that included atrial fibrillation, depression, and obstructive sleep apnea (OSA). A Notice of Level of Care Determination dated 4/6/21 identified Resident #70 was approved long term for nursing facility placement. The PASRR identified no further Level I screening was required unless Resident #70 was suspected of having a serious mental illness or an intellectual or developmental disability.A Psychiatric Evaluation and Consultation Advanced Practice Registered Nurse (APRN) progress note dated 5/16/25 identified Resident #70 was seen for mood evaluation and medication management and the chart was reviewed for current psychiatric diagnoses. The note identified diagnoses of depressive episodes, anxiety disorder, psychophysiologic insomnia, and psychosis not due to a substance or known physiological condition. The note further identified all of these diagnoses were chronic and stable. Additionally, the note identified for the psychosis diagnosis, Resident #70 continued with chronic visual hallucinations which he/she knew were not real, and it was recommended to monitor for worsening symptoms.Post admission diagnoses of anxiety, psychophysiologic insomnia, and psychosis not due to a known physiological condition were identified added into the electronic medical record (EMR) diagnoses section on 8/17/25.The quarterly MDS assessment dated [DATE] identified Resident #70 was cognitively intact, independent with eating, required substantial/maximal assistance with bed mobility, and did not attempt transfers due to medical condition or safety concern. The MDS further identified Resident #70 had an active diagnosis of depression. The MDS further identified Resident #70 had active psychiatric/mood disorder diagnoses of depression with an additional active diagnosis of psychophysiologic insomnia.Review of the clinical record failed to identify a new Level I screen had been submitted by the facility after the addition of the diagnoses of anxiety, psychophysiologic insomnia, and psychosis not due to a known physiological condition after completion of the Level of Care Determination dated 4/6/21 which did not include these diagnoses.Interview with the Director of Social Services, Social Worker (SW) #1, on 5/6/26 at 3:05 PM identified she identified residents with newly evident or possible serious mental illness after admission by reviewing the initial PASRR when the residents were admitted and then waiting for the MDS nurses to update the diagnoses. She identified that she was responsible for submitting the referrals for PASRR screenings and that the psychiatric APRN/MD would email the social service department any changes in psychiatric diagnoses or treatment. She was unable to identify the reason she had not been notified the PASSR contracted agency of Resident #70's psychiatric diagnoses and indicated that psychosis wasn't listed in the list she used but when submitting a referral there was an option to use Other to add in a diagnosis such as psychosis. She further identified that Resident #70 should have had a referral for a new Level I screen submitted after identification of the new psychiatric diagnosis.Subsequent to surveyor inquiry, a review of a Notice of PASRR Level I Screen Outcome dated 5/7/26 identified Resident #70's PASRR Level I determination indicated a referral for an onsite Level II visit for the suspected or confirmed PASRR condition of mental health disability. The PASRR outcome explanation indicated the Level I screen revealed Resident #70 may have a serious mental illness or intellectual disability and must have a Level II PASRR evaluation.Subsequent to surveyor inquiry, interview with SW #1 on 5/8/26 at 1:55 PM identified a referral had been submitted for Resident #70 and she was awaiting their onsite visit.Although requested, a facility policy for PASRR was not provided. (Facility does not have a policy).Per federal regulation PASRR screening evaluates all residents for serious mental illness and/or intellectual disability and ensures residents are in the most appropriate setting for their needs and that they receive the services they need.

Based on a review of personnel files, facility policy, and interviews for 4 of 10 Nurse Aide (NA) employee files reviewed (NA #7, NA #8, NA #9, and NA #10), the facility failed to ensure yearly performance reviews were completed timely. The findings include: 1.NA #7's date of hire was 4/28/22. A performance review was completed on 7/15/24 and 5/7/26, but a yearly review was not completed for 2025.2.NA #8's date of hire was 3/28/22. A performance review was completed 5/9/24 and 5/7/26, but a yearly review was not completed for 2025. 3.NA #9's date of hire was 9/18/19. A performance review was completed on 9/8/20 and 5/12/26 but failed to identify a yearly review was completed for the years 2021, 2022, 2023, 2024 or 2025.4.NA #10's date of hire was 4/5/11. A performance review was completed on 7/15/24 and 4/22/26 but a yearly review was not completed for 2025. Interview with NA #10 on 5/12/26 at 1:30 PM identified that he had never spoken with a supervisor about his performance review but was instead left a message with the performance review results. NA #10 could not identify whether he had a performance review in the prior year (2025) but did recall that it had never been completed over the phone before.Interview with the DNS on 5/12/26 at 2:05 PM indicated that NA performance reviews were typically conducted by the ADNS or by the NA's unit supervisor for the previous year. The DNS stated that performance reviews were expected to be completed every 12 months. If an employee was unavailable to complete the performance review in person, it may be conducted over the phone as long as there was direct dialogue or acknowledgment from the employee. However, the DNS clarified that a performance review would not be considered complete if the supervisor was unable to reach the employee and only left a message. The DNS also noted that the performance evaluations reviewed were the most current and stated that no additional reviews were available.Interview with the ADNS on 5/12/26 at 2:20 PM identified that she was unable to reach NA #10 by phone for the performance evaluation and was unable to complete it in person because NA #10 worked evening shifts and arrived at the facility around 3:00 PM, near the end of the ADNS's workday. The ADNS identified that NA #10 had been at work at the facility since the attempted performance review by phone on 4/22/26. The ADNS explained that she left a message for NA #10 with the performance review results and informed him that if he had any questions, the performance review would be filed with Human Resources and available to him at any time if needed. Although requested, a facility policy for performance evaluations was not provided. However, an undated portion of the employee handbook related to performance evaluations was provided and identified that performance evaluations should be conducted every 12 months.

Based on observation, taste test, and interviews, the facility failed to ensure food was palatable. The findings include: Interview with Resident #14 on 5/5/26 at 11:38 AM identified the food needed more variety.Interview with Resident #2 on 5/6/26 at 9:55 AM identified the food is a disaster, it is cheap and has no flavor. Resident #2 further identified he/she ordered food to be delivered whenever he/she had extra money because the food was not good and didn't want to eat it but had no other choice because, you have to eat to live.Observation and tasting of the meal test tray provided by the dietary department for the lunch meal on 5/7/26 at 12:15 PM identified the meal consisted of a Salisbury steak (a frozen meat patty) with gravy, mashed potatoes, and cut broccoli with 2 half slices of orange for garnish. The meal was served on a white ceramic plate covered with a pink insulted cover and was at an appropriate temperature upon tasting the food. The broccoli was overcooked and mushy and consisted of almost all stems with only 1 floret. The mashed potatoes were bland, thick and slightly sticky feeling on the tongue. The meat patty had a processed flavor that was not appealing, but the gravy was flavorful. The dessert was fruit salad which was canned and mushy with only a mild flavor.Interview with the Director of Dietary on 5/7/26 at 12:30 PM identified he was aware that residents had concerns related to food and that he was responsible for addressing those concerns. He identified that he deferred to what the Director of Recreation suggested for follow-up on resident food concerns. He indicated that the meet pattie served today was a pre-made frozen pattie.Interview with the Interim Director of Dietary on 5/8/26 at 12:50 PM identified that she did not know why the Director of Dietary ordered pre-made frozen meat patties. She indicated that they did not have a good flavor and were actually more expensive than buying ground meat and making meat patties by hand. She indicated that she would not be ordering those anymore and would be making several changes to the food order going forward. She identified broccoli should not be mushy and almost all stems. She indicated that the resident's enjoyment in what they eat was very important to her, and she was disappointed in the way the current food program was being managed. Review of the Food Preparation and Production policy directed, in part, food is prepared and produced by methods which maintain the nutritive value, palatability (flavor), and appearance of the food. The policy directed that attractiveness refers to the appearance of the food when it is served to the resident, and palatability was the taste or flavor of the food. The policy directed to taste the finished product for acceptability and adjust as needed.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to ensure the charge nurse notified the supervisor when a medication was not available for administration. The findings include:Resident #1's diagnoses included epilepsy, anoxic brain injury and meningioma (brain tumor). The Resident Care Plan dated 11/10/25 identified Resident #1 had a history of seizure disorder. Interventions directed to give seizure medication as ordered, seizure precautions, monitor for adverse drug reaction and side effects, monitor for seizure activity. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had short-and-long term memory recall deficits, was dependent on staff to perform activities of daily living and received anticonvulsant medication. A physician's order dated 1/15/26 directed to administer Brivaracetam oral tablet (a medication used to treat seizure disorder) 100 milligrams (mg) tablet by mouth two (2) times a day for seizures. The Controlled Substance Disposition Record dated 1/15/26 identified the facility had received twenty (20) tablets of Brivaracetam 100 mg from the pharmacy and on 1/20/26 at 8:00 AM there were ten (10) tablets remaining. The nurse's note dated 1/20/26 at 8:29 PM identified the Brivaracetam was not available to administer to Resident #1. The nurse's note failed to reflect documentation the nursing supervisor, provider and pharmacy were contacted regarding the Brivaracetam not being available. The nurse's note dated 1/21/26 at 3:18AM identified Resident #1 had seizure activity lasting two (2) minute, the provider was notified, and Resident #1 returned to baseline. The provider's note dated 1/21/26 at 2:03 AM identified Resident #1 was seen via telemedicine post two (2) minute seizure activity, Resident #1 will remain at the facility, and the primary care provider will follow up in the morning of 1/21/26. The nurse's note dated 1/21/26 identified Resident #1 was transferred to the hospital at 11:34 AM for sudden onset of right extremity paralysis. The hospital Discharge summary dated [DATE] identified Resident #1 was admitted on [DATE] for altered mental and initially was evaluated for a stroke, however neurology felt the event was a breakthrough seizure. The summary indicated Resident #1 was discharged with the following recommendations: increase the dose of antiseizure medication oxcarbazepine from 300 mg twice a day to 400 mg twice a day and the Brivaracetam dose will remain 100 mg twice a day. The hospital bloodwork results dated 1/21/26 identified the Brivaracetam level was 2.1 (normal level range 0.2-2.0) and the oxcarbazepine was 7.9 (normal range 3.0-35.0). The provider's note dated 1/23/26 identified Resident #1 was re-admitted to the facility. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 1/27/26 at 11:55 AM identified on 1/20/26 she could not find Resident #1's Brivaracetam in the medication cart for the scheduled 8:30 PM dose. LPN #1 explained the facility policy was when a medication was not available, the charge nurse was to notify the nursing supervisor who could then contact the provider for further instructions. LPN #1 identified although she did contact the supervisor during the shift, she did not inform the supervisor about Resident #1 missing the evening dose of Brivaracetam and stated she should have informed the supervisor. Interview with the 3-11PM nursing supervisor, Registered Nurse (RN) #1, on 1/27/26 at 12:14 PM identified on 1/20/26 LPN #1 did not report to her Resident #1 missed the scheduled evening dose of Brivaracetam. Interview with RN #2 on 1/27/26 at 12:57 PM identified on 1/21/26 after Resident #1 was sent to the hospital for seizure activity and stroke-like symptoms, she reviewed Resident #1's clinical record and found that on 1/20/26 LPN #1 did not report to the supervisor that she did not have the Brivaracetam for the evening dose. RN #2 indicated the facility policy was if a medication was not administered or not available, the charge nurse was to inform the supervisor so that the supervisor could contact the pharmacy and provider to get further instructions. Interview and clinical record review with the Director of Nursing (DON) on 1/27/26 at 1:07 PM identified on 1/21/26 she was notified Resident #1 had missed his/her 8:30 PM scheduled dose of Brivaracetam on 1/20/26. The DON indicated the nurse's note dated 1/20/26 failed to reflect documentation the supervisor and/or provider were notified. The DON identified facility policy directs if a medication was unavailable for the regular scheduled dose, the charge nurse was to notify the supervisor who can then notify the provider and pharmacy. The DON identified LPN #1 stated she spoke with the supervisor about another issue but failed to inform her of the missed dose of Brivaracetam on 1/20/26. Review of the clinical policy titled Medication Pass Policy, last revised 9/23/24, directed, in part that medications are administered safely and timely per the physician's order. Review of the facility policy titled Unavailable Medication Policy, last revised 10/2024, directed, in part if a medication is unavailable for any reason, the facility shall act promptly to notify the pharmacy and the appropriate practitioners to obtain a new medication supply order. The facility identified the deficient practice and developed an immediate action plan on January 21, 2026:Education was initiated for licensed nursing staff on the fiver rights of medication administration, high alert medications such as anticoagulants, insulin and opioids and physician notification.Random weekly audits will be conducted on medication pass audits to be completed weekly by supervisors.Random audits of medication omissions will be conducted weekly for four (4) weeks, then every month for three (3) months or until substantial compliance is achieved.Audit results will be reviewed monthly at QAPI (Quality Assurance Performance Improvement) meeting.Results will be reviewed at the next QAPI meeting.Completion date: January 26, 2026

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for changes made in their medication regimen, the facility failed to review, reconcile, and transcribe physician orders when the resident returned from a consulting physician's appointment. The findings include: Resident #2's diagnoses included neurofibromatosis (tumors affecting the brain, spinal cord, and nerves), elevated blood pressure, and pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place, time, and situation. The hospital Discharge summary dated [DATE] directed to administer (a medication for nerve pain) Gabapentin 300 milligrams (mg) capsule, one (1) capsule three (3) times a day and (a corticosteroid medication) Dexamethasone 4mg every eight (8) hours. Review of the Medication Administration Record (MAR) identified the medications from the hospital discharge summary were reconciled and transcribed onto the MAR. The consultation form dated 4/2/25 identified a physician's order for Gabapentin 300mg two (2) times a day and Gabapentin 600mg once a day in the evening and to continue the Dexamethasone 4mg every eight (8) hours, will begin to slow wean in two (2) weeks once the Koselugo, a medication to treat neurofibromatosis, is restarted. Review of the Medication Administration Record (MAR) from 4/2/25 through 4/23/25 failed to reflect documentation that the consulting physician's orders were transcribed onto the MAR. The consultation form dated 4/23/25 identified a physician's order to increase the Gabapentin to 600 mg three (3) times a day, to slow wean the steroid Dexamethasone from 4mg to 2mg every eight (8) hours for two (2) weeks, and to apply a Lidoderm patch 5% place one (1) patch over twelve (12) hours onto the skin every twenty-four (24) hours, remove and discard patch within twelve (12) hours. Review of the April and May 2025 Medication Administration Records (MAR) failed to reflect that the changes in medications made by the consulting physician had been reviewed, reconciled, and transcribed onto the MAR. Interview with the Director of Nursing (DON) on 5/19/25 at 9:30 AM identified that when a resident returns from an appointment with physician orders, the orders are reviewed and reconciled by the Advanced Practice Registered Nurse, and then the supervisor, charge nurse, or unit manager transcribes the orders into the Electronic Health record. The DON indicated if a resident returns without a consultation form, it is the responsibility of the charge nurse, supervisor, or unit manager to call the provider's office to verify if any changes were made to the care plan. The DON stated that she was not aware that orders had not been reconciled and transcribed until notified by the hospital and an investigation was conducted. Interview with the consulting physician, an Oncologist (MD #1), on 5/21/25 at 1:30 PM identified Resident #2 was seen in his office on 4/23/25. MD #1 indicated he made changes to the medication regimen and dictated the changes into the consultation note. MD #1 identified the facility did not send a consultation form, so he offered to print a copy of the consultation with the medication changes to send back to the facility, but the staff person who accompanied Resident #2 said the facility would get the orders off the computer and a paper copy was not necessary. In a follow-up interview on 5/22/25 at 9:45 AM the DON could not explain why orders placed on the consultation forms dated 4/2/25 and 4/23/25 were not reviewed, reconciled, and transcribed. The DON identified she could not explain why the staff person did not bring back a copy of the orders, but the supervisor, charge nurse, or unit manager should have followed up and called the physician's office to inquire about orders. Review of the Transcription policy dated 1/2/24 identified that Orders can be written in the electronic health record or obtained over the phone, secured messaging system, verbally, and/or from discharge and transfer paperwork from the hospital, physicians' office visit, or the consultant's recommendations, and transcribed by the Registered Nurse, Licensed Practical Nurse, or Unit Manger. Review of facility documentation identified the facility implemented an action plan: *The licensed staff were educated on receiving accurately transcribing new orders from consultation sheet after appointment and updating the resident/responsible party should medication not be available to start as ordered. *Audits will be conducted on residents with outside provider consults to ensure accuracy of new recommendations/orders over the last thirty (30) days. *The director of Nursing will audit residents with outside appointments twice weekly for accuracy of new recommendations/orders from consults times four (4) weeks then monthly times three (3) or until substantial compliance is achieved. *Audits will be reviewed at monthly Quality Assurance meetings. Based on review of facility documentation, past non-compliance was identified on 5/9/25.

Based on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for a change of condition, the facility failed to ensure the resident was evaluated upon return from a hospitalization. The findings included: Resident #1 was admitted to the facility in November of 2023 with diagnoses of transient ischemic attacks and cerebral infarction, alcoholic cirrhosis of the liver, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and was independent with toileting, dressing, bed mobility, and transfers. Review of the RCP dated 2/26/25 identified Resident #1 was on anticoagulant therapy related to a cerebral vascular accident with patent foramen ovale. Interventions directed to monitor/document/report as needed adverse reactions of anticoagulant therapy, including lethargy, loss of appetite, and sudden changes in mental status. A nursing note dated 4/7/25 at 5:15 PM identified Resident #1 returned to the facility following a hospitalization. The Therapy-Rehab/Activities of Daily Living Recommendation from Therapy to Nursing document identified Resident #1 required substantial assistance with toileting, dressing, bed mobility, and transfers. Review of provider notes identified Resident #1 was not evaluated by a provider, post hospitalization, until 4/12/25 (five days after Resident #1 was readmitted to the facility). Interview with the Director of Nursing on 5/5/25 at 2:50 PM identified the facility follows the Public Health Code for residents being admitted (as well as readmitted ) to the facility, which directs residents to be evaluated by a physician within forty-eight (48) hours of admission to the facility. The DNS further indicated readmissions following a hospitalization could be evaluated by either a physician or advanced practice registered nurse (APRN) and was unable to identify why Resident #1 was not evaluated by either until 4/12/25. Review of the Public Health Code directs a comprehensive medical history and medical examination shall be completed for each patient within forty-eight (48) hours of admission.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from sexual abuse. The findings include: 1. Resident #1 was admitted with diagnoses including malignant neoplasm of the brain, epilepsy with seizures, cognitive communication deficit and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of two (2) indicative of severely impaired cognition and was dependent on staff for bed mobility and transfers. The Resident Care Plan (RCP) dated 12/26/24 identified that the resident had impaired cognition related to a brain mass with interventions that included to cue, orient, and supervise as needed. 2. Resident #2 was admitted with diagnoses including dementia with behavioral disturbances, anxiety disorder, sepsis and chronic kidney disease. The Admission assessment dated [DATE] identified that Resident #2 was alert and oriented to person and required supervision for ambulation. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 12/24/24 identified Resident #2 was seen and assessed as a new referral to the facility, stating he/she was a poor historian, had poor immediate and remote memory and no concerns with mood or behaviors were reported by nursing or Resident #2. The note identified that no behaviors were noted during the evaluation, the resident had no history of psychotropic medication use and the resident was found not to be considered a danger to self or others. A nurse's note dated 12/27/24 at 6:47 AM identified that at approximately 4:40 AM Resident #2 was observed coming out of another resident's room. Licensed Practical Nurse (LPN) #1 instructed Nurse Aide (NA) #1 to check on the other resident and to then assist Resident #2 back to bed. LPN #1 was then called by NA # 1 to Resident #2's room and informed by NA #1 that she observed Resident #2 touching Resident #1 ' s genitalia.The note identified that LPN #1 then escorted the resident out of the room and seated Resident #2 in front of the nurse's station and RN #1 (11:00 PM to 7:00 AM nursing supervisor) was notified. Review of facility Reportable Event (RE) identified that at 4:45 AM on 12/27/24, Resident #2 was observed by NA #1 standing over Resident #1 (roommate) with his/her hands touching Resident #1's genitalia. Resident #1's brief was noted to be open at the time of the incident. Resident #1 was noted by staff to be teary and identified that Resident #2 had touched him/her inappropriately. NA #1 immediately brought Resident #2 to his/her side of the room and yelled for assistance from LPN #1, who was out in the hallway. LPN #1 came into the room and assessed the situation and directed for Registered Nurse (RN) #1 to be called. Resident #1 was assessed by RN #1 and did not to not have any injuries. Resident #2 was immediately placed on a one-to-one observation and kept out of the room for the remainder of the shift. Resident #1 was placed on every fifteen (15) minute checks for his/her safety and comfort and The RE reported that both resident's were seen by psychiatric services and Resident #2 had a room change to a private room and has remained on one-to-one observation since the 12/27/24 incident. A psychiatric Licensed Professional Counselor (LPC) note dated 12/27/24 at 10:12 AM identified Resident #2 was seen per request of the facility following an incident with the roommate (Resident #1) earlier that morning. It identified that the resident was unable to recall the year and the day, and a Brief Mental Interview for Mental Status (BIMS) was conducted reporting a seven (7) indicative of severely impaired cognition. The note reported that Resident #2 had no recollection of the event and had been relocated to a separate room. Review of a psychiatric evaluation note dated 12/30/24 for Resident #1 identified that the resident was seen because of a resident to resident incident. When asked about the incident Resident #1 became teary eyed, however, indicated that he/she did not want to discuss it any further. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 12/31/24 identified that Resident #2 was seen for evaluation in his/her room, alongside a NA, as resident remained on one-to-one observation per facility protocol. The resident was noted to be confused, display poor recent and remote memory, poor insight and requiring consistent redirection. Recommendations included starting Risperidone (antipsychotic medication) 0.5 milligrams (mg) twice daily as well as remaining on one-to-one observation and providing redirection and supportive care. Additionally, the note identified that an Abnormal Involuntary Movement Scale (AIMS) was completed. Interview with NA #1 on 1/15/25 at 10:14 AM identified that just prior to 5:00 AM on 12/27/24, LPN #1 and herself witnessed Resident #2 walking out of another resident's room and then into his/her room, stating she had never seen the resident wander before, so she went to check on the resident and see what Resident #2 had been doing in the room. She reported that when she entered the room, the resident was resting with his/her eyes closed and the blankets covering the resident were smooth and untouched, so she exited the room and went into Resident #2's room to check on him/her. She identified that when she entered, Resident #1 was wearing a johnny with the sheets uncovered, his/her brief was opened, and Resident #2 was standing over Resident #1 touching his/her genitalia. NA #1 reported that she immediately walked Resident #2 to his/her side of the room, and he/she stated that he/she was trying to help Resident #1. NA #1 reported that she yelled for LPN #1 who came right away to witness how Resident #1 was left. She reported that Resident #1 was teary and nodded yes when asked by LPN #1 if Resident #2 touched him/her inappropriately. She identified that LPN #1 and herself escorted Resident #2 to the nurse's station and RN #1 (nursing supervisor) was notified. She reported that Resident #2 remained at the nursing station for the remainder of the shift, accompanied by NA #2 and other staff while they did their charting. Interview with LPN #1 on 1/15/25 at 10:47 AM identified on 12/27/24 a little before 5:00 AM she was in the hall going to check on another resident when she observed Resident #2 coming out of the room across the hall from his/her room, so she directed NA #1 to go check on the resident. She reported that NA #1 came back to her and reported that nothing appeared disturbed, and the resident was sleeping so she was going to check on Resident #2. LPN #1 identified that a few minutes later, she heard NA #1 yelling for her from Resident #2's room and when she entered, NA #1 was standing next to Resident #2 who was already back in his/her bed and Resident #1 was laying in his/her bed with the sheet down and the brief pushed over, and his/her genitalia was exposed. NA #1 reported to her that she observed Resident #2 standing over Resident #1 touching his/her genitalia. LPN #1 identified that she asked Resident #1 if Resident #2 had touched him/her inappropriately and he/she had tears in their eyes and nodded his/her head yes. She reported that she then escorted Resident #2 to the nurse's station and notified RN #1 (nursing supervisor) of the incident. She reported that Resident #2 was placed on a one-to-one and remained at the nurse's station for the remainder of the shift. LPN #1 identified that she never observed the resident wandering prior to or following the incident on 12/27/24. Interview with RN #1 on 1/15/25 at 11:08 AM identified that when LPN #1 notified her of the incident on 12/27/24, she ensured resident was immediately placed on a one-to-one observation, reporting that Resident #2 sat at the nurse's station surrounded by staff until they were able to set up a new room for the resident. She identified that the resident was not left alone at any point, stating she called the ADNS who came in to assist with staffing and paperwork. She reported that staff also did frequent checks on Resident #1 to ensure his/her safety following the incident identifying that he/she had been crying and visibly upset. RN #1 reported that she does frequent rounds on the 11:00 PM to 7:00 AM shift and stated that she had never witnessed Resident #2 wandering and no staff had ever reported any wandering behaviors to her prior to the 12/27/24 incident. Interview with the DNS and ADNS on 1/15/24 at 1:39 PM identified that they had never observed or been alerted by staff that Resident #2 had been wandering in and out of other residents' rooms prior to the 12/27/24 incident. They identified that although the resident had a change in condition and has not been ambulating recently due to a gout flare up, there are no current plans to discontinue the one-to-one staff observation of Resident #2. They identified that the resident is still being followed closely by psych services and the family was hopeful that the confusion would clear, and the resident could be discharged home, but that the confusion has not yet subsided so the future is unclear if he/she may become long-term. Additionally, they reported that they initiated an immediate Plan of Correction to include a Quality Assurance and Performance Improvement (QAPI), staff education on wandering, abuse, close observation monitoring and resident behavior audits subsequent to the event. Review of the Abuse policy dated 01/2023 directed, in part, that each resident has the right to be free from abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Staff training should include appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, what constitutes abuse, that abuse allegations require immediate action and how to identify residents who have the potential for becoming victims of abuse. The facility will continue to provide individualized care plans that identify risk factors of residents as well as plans for protecting their rights. After the incident occurs the interdisciplinary team will update the person-centered care plan with appropriate interventions.

Based on clinical record reviews, reviews of facility documentation and facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who was an active smoker, the facility failed to develop a baseline care plan within forty-eight (48) hours after admission to address the facility smoking policy. The findings include: Resident #1's diagnoses included chronic obstructive pulmonary disease with exacerbation, acute respiratory failure with hypercapnia, and anxiety disorder. The hospital inter-agency referral report dated 12/6/24 identified Resident #1 was a current smoker. A discharge medication order directed Nicotine seven (7) milligram transdermal patch, apply one (1) patch on the upper body or upper outer arm daily for two (2) weeks and oxygen at two (2) liters per minute. The nursing admission assessment dated [DATE] at 10:23 PM identified Resident #1 was oriented to person, place, time, and situation, was independent with bed mobility, required supervision or touching assistance of one (1) staff with transferring. The assessment indicated Resident #1 was on oxygen at two (2) liters per minute, was an active smoker and the last time Resident #1 smoked a cigarette was on 12/6/24. The nursing note dated 12/6/24 at 11:28 PM identified Resident #1 arrived at the facility with multiple medications and one (1) cigarette, which was placed in the nurses' cart locked box and Resident #1 was educated on the facility's non-smoking policy. The physician's note dated 12/7/24 at 10:27 AM indicated Resident #1 was evaluated following admission to the facility and had cigarette nicotine dependence without complication. The note directed to continue the Nicotine seven (7) milligrams transdermal patch daily and for smoking cessation counseling. The Facility Reported Incident form dated 12/10/24 identified upon entering the room at 5:20 AM the Nursing Supervisor found smoking Resident #1 while on oxygen. The note indicated Resident #1 had smoking materials in his/her possession and relinquished a lighter. Interview and review of the Resident Care Plan with the Director of Nursing (DON) on 12/23/24 at 1:40 PM identified there was no care plan with interventions that addressed Resident #1 being an active smoker until 12/10/24. The DON indicated on admission, the nurse was responsible for completion of the initial assessment, and if the admission occurred during an off shift or weekend, a basic care plan was completed following review of the initial admission assessment and then the interdisciplinary team was responsible for creating a more comprehensive care plan within a few days following admission once the admission was reviewed. The DON identified it was the expectation to have a Resident Care Plan for smoking developed prior to the incident on 12/10/24. Review of the Baseline/Comprehensive Person Centered Care Plan policy dated 3/2023 directed, in part, a baseline care plan must be developed within 48 hours of admission and include at least a minimum of healthcare information necessary to provide the proper care for the resident, establish initials goals, and orders from the Healthcare Provider, dietary, therapy, social services and PASARR if applicable, and upon admission the interdisciplinary team completed respective assessments, identified function disabilities and high-risk factors requiring intervention for potential improvement or prevention.

Based on review of the clinical record, facility documentation, and facility policy for 12 of 20 residents, (Residents #3, 10, 13, 24, 32, 45, 49, 56, 80, 103, 104, and 105) whose clinical records lacked documentation that they had received their evening medications on 6/3/24 after the charge nurse left the facility and did not report off, the facility failed to ensure the resident representatives were notified, and for 1 of 2 residents (Resident #66) reviewed for non-pressure wounds, the facility failed to notify the physician or APRN/Family Nurse Practitioner (FNP-BC) when the resident's wound deteriorated on 10/7/24, and subsequently, 2 days later, when FNP-BC #1 did wound rounds on 10/9/24 and found the wound significantly deteriorated, the resident was sent to the hospital for treatment, and for 2 of 3 residents (Resident #4 and 9) reviewed for infection, the facility failed to ensure the resident representatives were notified when the residents had a change that required new medications related to covid-19, and for 1 of 3 residents (Resident #45) reviewed for hospitalization s, the facility failed to ensure that the physician was notified when the resident's blood sugars were outside the parameters. The findings include: 1. Resident #3 was admitted to the facility in July 2021 with diagnoses that included type 2 diabetes mellitus and depressive episodes. Review of the June 2024 monthly physician's orders directed to administer the following medications: Rivastigmine Tartrate 4.5 mg twice daily at 9:30 AM and 9:30 PM. Lantus Solution 100 unit/ml injection 17 units at bedtime (8:30 PM). Risperdal 0.5 mg at bedtime (9:30 PM). Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Lantus Solution due at 8:30 PM or Rivastigmine Tartrate and Risperdal due at 9:30 PM had been administered. 2. Resident #10 was admitted to the facility in November 2020 with diagnoses that included chronic pain syndrome, spinal stenosis, and hypertension. Review of the June 2024 physician's orders directed to administer the following medications: Baclofen 20mg three times daily at 9:30 AM, 5:30 PM, and 9:30 PM. Metoprolol Tartrate 50 mg twice daily at 9:30 AM and 6:30 PM. Meclizine HCL 50 mg twice daily at 6:00 AM and 6:00 PM. Tizanidine HCL 2 mg every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Baclofen due at 5:30 PM, Metoprolol due at 6:30 PM, Meclizine due at 6:00 PM, or Tizanidine due at 6:00 PM had been administered. 3. Resident #13 was admitted to the facility in November 2021 with a dementia diagnoses. Review of the June 2024 physician's orders directed to administer the following medications: Namenda 10 mg at bedtime at 8:30 PM. Trazadone HCL 50 mg at bedtime at 9:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Namenda due at 8:30 PM or Trazadone due at 9:30 PM had been administered. 4. Resident #24 was admitted to the facility in November 2021 with diagnoses that included COPD and Parkinson's Disease. Review of the June 2024 physician's orders directed to administer the following medications: Symbicort Inhalation Aerosol 80 - 4.5mcg/act twice daily at 8:30 AM and 5:30 PM. Sinemet 25 - 100 mg twice daily at 8:30 AM and 5:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Symbicort due at 5:30 PM or Sinemet due at 5:30 PM had been administered. 5. Resident #32 was admitted to the facility in October 2021 with diagnoses that included BPH with lower urinary tract symptoms and type 2 diabetes mellitus. Review of the June 2024 physician's orders directed to administer the following medications: Finasteride 5 mg daily at 5:00 PM. Humalog Injection Solution (Insulin Lispro) 100 unit/ml inject per sliding scale before meals and at bedtime at 8:00 AM, 11:30 AM, 4:00 PM, and 9:00 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Finasteride due at 5:00 PM or Insulin Lispro due at 4:00 PM had been administered. 6. Resident #45 was admitted to the facility in December 2020 with diagnoses that included pulmonary embolism, hyperlipidemia, and hypertension. Review of the June 2024 physician's orders directed to administer the following medications: Lipitor 40 mg daily at 5:00 PM. Senna 8.6mg at bedtime at 9:30 PM. Xalatan Ophthalmic Solution at bedtime at 9:30 PM. Carvedilol 3.125 mg every 12 hours at 8:30 AM and 8:30 PM. Eliquis 2.5 mg every 12 hours at 8:30 AM and 8:30 PM. Miralax 17 gm twice daily at 8:30 AM and 8:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Lipitor due at 5:00 PM, Senna due at 9:30 PM, Xalatan Solution due at 9:30 PM, Carvedilol due at 8:30 PM, Eliquis due at 8:30 PM, or Miralax due at 8:30 PM had been administered. 7. Resident #49 was admitted to the facility in January 2024 with diagnoses that included Charcot's Arthropathy and type 2 diabetes mellitus with foot ulcer. Review of the June 2024 physician's orders directed to administer the following medication: Keflex 4 mg four times daily at 1200 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Keflex due at 6:00 PM had been administered. 8. Resident #56 was admitted to the facility in September 2022 with diagnoses that included heart failure and hypertension. Review of the June 2024 physician's orders directed to administer the following medications: Atorvastatin Calcium 20mg at bedtime at 8:30 PM. Calcium 600 mg 8in the evening at 8:00 PM. Doxazosin Mesylate 4 mg at bedtime at 8:30 PM. Entresto 97 - 103 mg every 12 hours at 8:30 AM and 8:30 PM. Hydrocortisone 10 mg twice daily at 8:30 AM and 8:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Atorvastatin Calcium due at 8:30 PM, Doxazosin Mesylate due at 8:30 PM, Entresto due at 8:30 PM, or Hydrocortisone due at 8:30 PM had been administered. 9. Resident #80 was admitted to the facility in December 2023 with diagnoses that included herpes viral infection, hyperlipidemia, and typed 2 diabetes mellitus. Review of the June 2024 physician's orders directed to administer the following medications: Crestor 5 mg daily at 5:00 PM. Acyclovir 400 mg every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Insulin Lispro per sliding scale before meals at 7:30 AM, 11:30 AM, and 4:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Crestor due at 5:00 PM, Acyclovir due at 6:00 PM, or the Insulin Lispro due at 4:30 PM had been administered. 10. Resident #103 was admitted to the facility in January 2024 with diagnoses that included orthostatic hypotension and repeated falls. Review of the June 2024 physician's orders directed to administer the following medication: Midodrine 10 mg before meals at 8:00 AM, 11:30 AM, and 4:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Midodrine due at 4:30 PM had been administered. 11. Resident #104 was admitted to the facility in December 2019 with diagnoses that included alcoholic cirrhosis and mild protein-calorie malnutrition. Review of the June 2024 physician's orders directed to administer the following medications: Spironolactone 50 mg twice daily at 8:30 AM and 5:30 PM. Ensure Plus three times daily at 9:30 AM, 1:30 PM, and 5:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Spironolactone due at 5:30 PM or Ensure Plus due at 5:30 PM had been administered. 12. Resident #105 was admitted to the facility in December 2023 with diagnoses that included hypertension, hyperlipidemia, and BPH. Review of the June 2024 physician's orders directed to administer the following medications: Atorvastatin Calcium 40 mg daily at 5:00 PM. Finasteride 5 mg daily at 5:00 PM. Calcium Carbonate 600 mg twice daily at 8:30 AM and 5:30 PM. Furosemide 40 mg twice daily at 8:30 AM and 5:30 PM. Carvedilol 6.25 mg twice daily at 8:30 AM and 5:30 PM. Pantoprazole Sodium 40 mg twice daily at 8:30 AM and 5:30 PM. Gabapentin 600 mg three times daily at 9:30 AM, 1:30 PM, and 5:30 PM. Review of the June 2024 MAR failed to reflect documentation to show that on 6/3/24, the Atorvastatin Calcium due at 5:00 PM, Finasteride due at 5:00 PM, Calcium Carbonate due at 5:30 PM, Carvedilol due at 5:30 PM, Pantoprazole due at 5:30 PM, or the Gabapentin due at 5:30 PM had been administered. Review of the reportable event forms dated 6/3/24 and the clinical records failed to reflect that the resident representatives for Residents #3, 10, 13, 24, 32, 45, 49, 56, 80, 103, 104, and 105 were made aware that the facility could not determine if the evening medications had been administered after the charge nurse left the facility during her shift. The Change of Condition Notification policy directs the facility to inform the resident, consult with the resident's health care provider, and if known notify the resident's legal representative or family member when there is: an incident involving the resident which may result in injury or requires medical treatment, a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly, and a decision to transfer or discharge the resident from the facility. 13. Resident #66 was readmitted to the facility in July 2024 with diagnoses that included uncontrolled type 2 diabetes, severe PVD, chronic kidney disease, history of right foot cellulitis with osteomyelitis, status post transmetatarsal amputation, and Charcot foot. A wound evaluation by Family Nurse Practitioner - Board Certified (FNP-BC #1) dated 9/11/24 identified the wound on the right plantar metatarsal head (first identified 8/14/24) was stable and measured 2.4cm by 2.5cm by 0.2c with 50% new granulation tissue. Recommendations included to cleanse with normal saline, apply Calcium Alginate with silver to base of wound, and secure with ABD pad and rolled gauze daily and as needed. Review of the clinical record indicated that FNP-BC #1 evaluated the wound on 9/18/24 and 9/25/24 and the wound was stable with 100% granulation tissue. A wound evaluation by FNP-BC #1 dated 10/2/24 identified the wound was worsening, had a mild odor post cleansing, had 50% slough and moderate amount of serous drainage. Recommendations included a treatment change. Cleanse with Dakin's 1/4 strength, apply iodosorb, adaptic and Calcium Alginate with silver to base of wound, and secure with ABD pad and rolled gauze daily and as needed. Although the wound on the right plantar metatarsal head had worsened on 10/2/24 and required the treatment to be changed, review of the clinical record failed to reflect that an RN assessment of the wound had been done between 10/3/24 - 10/8/24. A wound evaluation by FNP-BC #1 dated 10/9/24 identified the wound had deteriorated, was malodorous post cleansing, had 50% slough, periwound had severe maceration that measured 5.0cm by 12.0cm, erythema, warmth and a moderate amount of serous exudate. Further, the right leg had increased edema, and the resident appeared to have discomfort at the wound. Recommendation to send the resident to the hospital. Interview with LPN #9 on 10/23/24 at 3:54 PM identified she was the charge nurse for Resident #66 on Friday 10/5/24, Monday 10/7/24, Tuesday 10/8/24 and Wednesday 10/9/24. LPN #9 identified that when she worked on Friday 10/5/24, Resident #66's right plantar wound was at baseline, however, when she came in on Monday 10/7/24, after being off for the weekend, she noted that the wound had deteriorated, had increased drainage and a boggy and soggy area that was new. LPN #9 identified she reported the change in wound status to RN #8 and LPN #8 and brought them both into the resident's room and showed them the wound. LPN #9 indicated that RN #8 and LPN #8 changed the dressing to the resident's right plantar wound on 10/7/24 and again on 10/8/24. LPN #9 identified that on 10/9/24 FNP-BC #1 came in and identified the wound was worse and sent the resident to the hospital. Interview with RN #8 on 10/24/24 at 12:25 PM identified she was on orientation (hired as the wound nurse) and was being trained by LPN #8 on Monday 10/7/24 and Tuesday 10/8/24. RN #8 identified she and LPN #9 were notified by the charge nurse, LPN #9, on Monday 10/7/24 that Resident #66's wound was worse, and they went in and looked at the wound. RN #8 indicated the wound was slighted macerated, and wet and boggy. RN #8 told LPN #9 to call FNP-BC #1 and report the change. RN #8 indicated that she did not notify FNP-BC #1 or write a note regarding the worsening of the residents wound because she was on orientation and thought that LPN #9 had done it. RN #8 also thought that there was a new order to change the dressing to the right plantar wound twice daily because of the drainage, but after review of the record, RN #8 identified that there was no change to the frequency of the dressing change or documentation that the physician or FNP-BC #1 had been notified. After further review of the clinical record, RN #8 identified there was no documentation of an RN assessment of the wound on 10/7/24 or 10/8/24 after LPN #9 reported the wound had deteriorated. Interview with FNP-BC #1 on 10/23/24 at 2:41 PM identified the residents wound deteriorated significantly between 10/2/24 - 10/9/24. The wound was noted to have a large area of maceration, increased drainage and the resident's right leg was edematous. FNP-BC #1 indicated she was worried about the wound and spoke to the attending physician and to the resident. FNP-BC #1 identified she explained to Resident #66 that it was best for him/her to be evaluated in the hospital due to the deterioration. FNP-BC #1 identified she had not been notified of the change in the wound on 10/7/24 or 10/8/24 and observed the change when she came in on 10/9/24 to do weekly wound rounds. FNP-BC #1 identified she should have been notified of the change when it was identified and that had she been made aware of the change sooner, she could have increased the dressing change frequency to 2 or 3 times daily, get blood work or send the resident to the hospital for an evaluation. Although requested, an interview with LPN #8 was not obtained. The Change of Condition Notification policy directs the facility to inform the resident, consult with the resident's health care provider, and if known notify the resident's legal representative or family member when there is: an incident involving the resident which may result in injury or requires medical treatment, a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly, and a decision to transfer or discharge the resident from the facility. 14. Resident #4 was admitted to the facility in June 2021 with diagnoses that included multiple sclerosis, quadriplegia, and dysphagia. The annual MDS dated [DATE] identified Resident #4 had moderately impaired cognition, was always incontinent of bowel, utilized a urinary catheter for bladder and was fully dependent on staff to assist with eating, bathing, and toileting. The care plan dated 7/9/24 identified Resident #4 had impaired decision making. Interventions included to use task segmentation to support short term memory deficits and break tasks into one step at a time. Review of the facility Covid line list identified Resident #28 (Resident #4's roommate) began to have symptoms and subsequently tested positive for covid-19 on 10/18/24 Review of the clinical record identified the facility initiated Covid antigen testing on Resident #4 due to the covid-19 exposure on 10/19/24. During an initial tour of the facility on 10/21/24 beginning at 8:02 AM, observation identified Resident #4, and Resident #28 residing in the same room. A sign posted outside of residents' door identified Droplet/Contact Precautions. Interview with Person #2 on 10/21/24 at 10:26 AM identified he/she has had ongoing concerns and conveyed the concerns to the facility administration regarding the lack of notification when changes are noted in Resident #4 condition including treatments, hospitalization s, and procedures. Person #2 also identified that she was not aware of any covid-19 outbreaks at the facility and had not been notified of any outbreak issues with Covid at all during 2024. An APRN note dated 10/21/24 at 10:46 AM identified Resident #4 had exam finding that included a congested cough. The note further identified Resident #4 had close exposure to Covid 19 and was undergoing current testing. The note further identified Resident #4 had tested negative despite a cough, and that Robitussin as needed was ordered for 10 days. Review of the clinical record failed to identify any documentation related to notification to Person #2 regarding Resident #4 having exposure to Covid 19 due to an outbreak in the facility, that the exposure required testing, or that Resident #4 had developed a cough that required treatment. Interview with RN #5 (Corporate Clinical Infection Preventionist) on 10/22/24 at 2:39 PM identified the facility utilized a mass notification system to notify family and resident representatives of Covid outbreaks in the facility, which included over 400 contacts. RN #5 identified a mass notification went out following the initial outbreak on 10/15/24, and most recently on 10/21/24. RN #5 identified she believed the notification was sufficient as it included information about testing and interventions related to all residents of the facility. Review of the documents provided by RN #5 titled Covid Updates identified the facility provided generalized Covid 19 update information on 10/15 and 10/21/24 and identified the facility would be testing exposed resident's on Day 1, Day 3, and Day 5. The documents provided included a page of multiple phone numbers and emails, which included Person # 2's email address, however the documentation provided did not identify any confirmation related to message delivery, what message was delivered, confirmation of receipt by the resident's family or resident representatives and did not provide any specifics related to individual residents or exposures. Interview with LPN #4 (infection preventionist) on 10/22/24 at 3:17 PM identified that she did not provide any notification to Person #2 regarding Resident #4's Covid exposure which required testing. Subsequent to survey inquiry, the clinical record identified a note dated 10/22/24 at 3:32 by LPN #4 that identified she contacted Person #2 via phone and notified him/her of the Covid outbreak in the facility, exposure, and current testing. The facility policy on change of condition directed that the facility would inform the resident, attending physician, and resident representative when there was a change of condition. The policy directed this included a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment) and that the licensed nurse per state regulations would conduct a complete physical/mental evaluation and document the findings in the clinical record. The policy further directed that the licensed nurse would contact the attending physician and resident representative regarding the change of condition, repeated attempts would be made until successful, and all attempts would be documented with date and time. 15. Resident #9 was admitted to the facility in July 2021with diagnoses that included dementia, renal insufficiency, depression, and heart failure. The quarterly MDS dated [DATE] identified Resident #9 had severely impaired cognition and required total assistance with personal hygiene, dressing, toileting, and transfers. Additionally, Resident #9 was taking antipsychotic, antidepressant, hypoglycemia, and diuretic medications daily. A physician's order dated 10/18/24 directed to administer Claritin 10 mg (antihistamine) one tablet daily for 7 days and Pataday 0.2% (antihistamine) eye drops instill one eye drop to each eye once a day for 14 days for allergic conjunctivitis. a. Review of the clinical record including progress notes dated 10/10/24 to 10/23/24 failed to reflect the resident representative was notified of the new order for Claritin 10 mg and Pataday 0.2% eye drops Interview with Person #4 on 10/23/24 at 9:08 AM indicated that he/she had reported on Friday on 10/18/24 about 5:00 PM to LPN #9 that Resident #9's eyes were red, swollen and tender. Person #4 had requested to LPN #9 that a provider see the resident's eyes. Person #4 indicated while he/she visited Resident #9 on Sunday 10/20/24 he/she had not heard anything back from nursing if anyone had looked at the resident's eyes or if a provider was notified. Person #4 indicated he/she had spoken with LPN #1 who never answered the questions. Person #4 indicated that LPN #1 was not aware if anything was done with the Resident #9's eyes. Person #1 indicated that as of today she was not aware if a provider had seen Resident #9's eyes and if anything was ordered for the eyes. Interview with APRN #2 on 10/24/24 at 1:30 PM indicated that she had seen Resident #9 on Friday on 10/18/24 because there was a note in her communication book that Resident #9 needed to be seen for his/her eyes. APRN #2 indicated that no one from nursing had called her to update her. APRN #2 indicated that she had seen Resident #9 on 10/18/24 and his/her eyes were red, swollen, and crusty. APRN #2 indicated that she diagnosed Resident #9 with allergy conjunctivitis and ordered Claritin and eye drops. APRN #2 indicated that nursing was responsible to call the resident representative with any new medication orders or any changes in medication orders. Interview with the DNS on 10/23/24 at 8:10 AM indicated that her expectation was if there was a change in condition or any new medications ordered that the resident representative would be notified, and documentation of that notification would be in the clinical record. After review of the clinical record, the DNS indicated that the clinical record lacked documentation that the resident representative had been updated on the new orders for Claritin and Pataday. Interview with LPN #1 on 10/23/24 at 10:15 AM indicated that she does remember speaking with Person #4 on Sunday 10/20/24 and Person #4 had questioned if anyone had looked at Resident #9's eyes on Friday 10/18/24 because he/she had reported that Resident #9's eyes were red, swollen, and sore. LPN #1 indicated that she had intended to look at the clinical record but did not. LPN #1 indicated that while she worked on 10/20/24 she did observe Resident #9's eyes, and they were red and slightly swollen, but she assumed that Resident #9 had rubbed them due to the covid-19 infection and forgot to tell the RN supervisor about the eyes. b. The care plan dated 10/15/24 identified Resident #9 had received the Covid-19 vaccine in September 2022. Interventions included to update the resident representative with any changes. The monthly physician orders for October 2024 (original date was 8/11/23) directed to obtain Rapid Antigen Covid-19 nasal swab testing as needed and record results as positive or negative documentative narrative in progress note as needed. The progress note written by LPN #1 on 10/20/24 at 1:45 PM identified Resident #9 had a cough, runny nose, and a temperature of 100.1. LPN #1 performed the Covid-19 test, and it was positive. Resident #9 was placed on transmission-based precautions. A physician's order dated 10/20/24 directed to give cough syrup 10 ml by mouth every 6 hours as needed for cough for 7 days. Additionally, to isolate for positive Covid-19 every shift for infection control measures for 10 days. Review of the progress notes dated 10/20/24 to 10/23/24 failed to reflect the resident representative was notified of the positive Covid-19 test or the new order for cough syrup. The care plan dated 10/20/24 identified Resident #9 was confirmed Covid-19 positive. Interventions directed to use transmission-based precautions, monitor oxygen saturation levels, notify and update physician and resident representative as needed. The APRN progress note written by APRN #2 dated 10/21/24 at 1:23 PM identified she was seeing Resident #9 today for Covid-19 infection. Resident #9 was had tested positive for Covid-19 over the weekend. Resident #9 reports sore throat resolved at this time but complains of nasal congestion and cough. Resident #9 has complaints of eye discomfort currently. Plan for new covid-19 infection to continue cough syrup as needed and continue acetaminophen as needed. Interview with the DNS on 10/23/24 at 8:18 AM indicated that her expectation was that either the supervisor or charge nurse can make the call to the resident representative that day to update on the new diagnosis of covid-19 and any new physician orders. The DNS indicated that the resident representative must be notified of any changes in condition such as a new diagnosis of covid-19, any new medications, or any medication changes right away and that notification must be documented in the clinical record. After clinical record review, the DNS indicated that there was not a progress note identifying that the resident representative was notified. Interview with LPN #1 on 10/23/24 at 8:41 AM indicated that on 10/20/24 Person #4 was visiting Resident #9 and brought to LPN #1's attention that Resident #9 was not feeling well and was tired. LPN #1 indicated that she had noted Resident #9's eyes were red and swollen and he/she was rubbing them. LPN #1 indicated there was a standing physician order to perform the covid-19 test. LPN #9 indicated that she decided to do the covid-19 test and it was positive, so she notified the RN supervisor via phone and called Person #4 via phone to inform Resident #9 had just tested positive for covid-19. LPN #1 indicated that she was not aware of the new physician order for cough syrup and did not call Person #4 to update him/her of the new physician order. Interview with Person #4 on 10/23/24 at 9:08 AM indicated that when he/she had visited Resident #9 on Sunday 10/20/24 he/she noticed Resident #9 was not feeling well and notified LPN #1. Person #4 indicated that LPN #1 had called him/her after the visit to informed him/her that Resident #9 had just tested positive with covid-19 and that the provider would be contacted. Person #1 indicated that no one called after that to inform him/her if the provider was contacted and had ordered any medications. Interview and clinical record review with the DNS on 10/23/24 failed to provide documentation that Person #4 was updated when the APRN wrote orders for the resident to receive cough syrup due to new onset covid-19. Review of the Change of Condition Notification identified the facility will inform the resident, residents' provider, and resident representative when there is a change of condition. The purpose is to ensure the residents change of condition or the start of a new medication was reported to the resident representative. The physician and resident representative notification must be documented in the electronic medical record. 46040 16. Resident #2 was admitted to the facility in March 2022 with diagnoses that included quadriplegia, aphasia, and weakness. The physician's orders dated 5/12/24 directed to administer Lovenox (an anticoagulant) injection 40 mg subcutaneously daily to prevent deep vein thrombosis. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was frequently incontinent of bowel, required a urinary catheter for bladder, and was dependent on staff to assist with eating, dressing, and transfers. The care plan dated 8/21/24 identified Resident #2 had a urinary catheter. Interventions included to monitor for blood and sediment. The care plan also identified Resident #2 required medication that increases the time it takes for the blood to clot. Interventions included to monitor for signs of bleeding in the urine, bowel movements, and bruising. A nurse's note dated 9/15/24 at 1:52 PM by LPN #7 identified that Resident #2 had an episode of genital bleeding with clots noted in his/her undergarment. The note identified Resident #2's urinary catheter was draining clear yellow fluid, and that Resident #2 was seen by the APRN and new orders for labs were placed. A change of condition follow up note dated 9/16/24 at 8:36 AM by LPN #6 identified Resident #2's urinary catheter was not draining after 2 attempts to flush. The note further identified 2 attempts to replace the catheter were also unsuccessful and that the ADNS was notified. Review of the clinical record failed to identify any documentation related notification to the physician or resident representative following the complications with Resident #2's urinary catheter and subsequent removal on 9/16/24. Interview with the ADNS on 10/24/24 at 11:45 AM identified she was aware that Resident #2 had the bleeding episode on 9/15/24, and issues with the urinary catheter on 9/16/24. The ADNS identified she was notified by LPN #6 that Resident #2's urinary catheter was removed and was unable to be replaced, and that Resident #2 was able to void freely. The ADNS identified that while she was aware of the prior bleeding episode and was notified by LPN #6 regarding the catheter issue, she did not make any notes or assess Resident #2 following the notification. The ADNS identified she believed there was communication with the APRN since a provider was in the facility daily but that she should have notified the APRN, completed an assessment on Resident #2, and ensured that Resident #2's resident representative was notified. The facility policy on change of condition directed that the facility would inform the resident, attending physician, and resident representative when there was a change of condition. The policy directed this included a need to alter treatment significantly (i.e a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment) and that the licensed nurse per state regulations would conduct a complete physical/mental evaluation and document the findings in the clinical record. The policy further directed that the licensed nurse would contact the attending physician and resident representative regarding the change of condition, repeated attempts would be made until successful, and all attempts would be documented with date and time. 17. Resident #45 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes, chronic kidney disease (Stage 4 severe) and morbid obesity. The quarterly MDS dated [DATE] identified Resident #45 had moderately impaired cognition, was always incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing and dressing. The care plan dated 6/14/24 identified Resident #45 had a history of insulin dependent diabetes but no longer required medication. Interventions included to monitor for signs/symptoms of hyperglycemia, hypoglycemia, and administer insulin per MD order. Review of the clinical record identified Resident #45 was hospitalized from 7/3/24 - 7/9/24 due to abnormal lab values. A hospital W-10 report dated 7/9/24 identified Resident #45 had a diagnosis of acute kidney injury. The report also identified that while hospitalized , Resident #45 had elevated blood glucose levels and a hemoglobin A1C (a lab test that measures an average blood glucose level over a 3-month period) was high at 8.6 % (normal lab value 4.0-5.6%). Resident #45

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2)residents reviewed for medication administration,(Resident #2) the facility failed to administer medication in accordance with facility policy resulting in a significant medication error with subsequent hospitalization . The findings include: Resident #2 was admitted to the facility with diagnoses that included Congestive Heart Failure, Diabetes Mellitus Type II, hypothyroidism, hypertension, Atrial Fibrillation and dementia. The care plan dated 3/24/23 identified Resident #2 had impaired thought processes related to dementia with interventions that included to administer medications as ordered, use the resident's preferred name, identify yourself at each interaction and reduce any distractions. The quarterly Minimum Data Set, dated dated dated [DATE] identified Resident #2 had moderately impaired cognition and was an extensive assist of one staff for bed mobility and transfers. A Nursing note dated 5/19/23 at 12:05 PM identified a that medication error had occurred, Resident #2 was assessed by the nurse, neurological signs were within normal limits, vitals were stable, no signs or symptoms of cardiac or respiratory distress and no allergic reaction from medications were identified. APRN #1 was updated, Resident #2 was placed out of bed to his/her wheelchair with no signs of lethargy or drowsiness, frequent monitoring was performed at that time. Review of Resident #2's Accident & Incident report dated 5/19/23 at 10:08 AM identified RN #1 administered the following medications to Resident #2 in error ( these medications were prescribed to Resident #3, Resident #2's roommate) Gabapentin 600 milligrams (mg) (an anticonvulsant), Baclofen 10 mg (a muscle relaxant), Metformin 500 mg (an antidiabetic), Tizanidine 2 mg (a muscle relaxant), Carvedilol 25 mg (a beta blocker given for high blood pressure), Amlodipine 10 mg (a calcium channel blocker given for high blood pressure), Amitiza 24 micrograms (a drug that treats constipation), Calcium Carbonate-vitamin D 500-200 mg (a vitamin), Duloxetine 30 mg (an antidepressant), Sertraline 50 mg three tablets (an antidepressant), and Losartan 50 mg two tablets (a medication given for high blood pressure) in error. A physician's order dated 5/19/23 directed vital sign monitoring for two days: every hour times four hours then every four hours for two days. Review of Resident #2's neurological observation record identified Resident #2's vital signs were taken at 10:10 AM, 10:25 AM, 10:40 AM, 10:55 AM, 11:25 AM, 11:55 AM and 12:55 PM and were within normal limits. A Situation, Background,Assessment , and Recommendation form (SBAR) dated 5/19/23 at 1:00 PM identified that Resident #2 was outdoors at a picnic, and he/she suddenly became lethargic with a blood pressure of 78/30 (normal range 90/60 - 120/80), ad an oxygen saturation of 81% with oxygen applied via oxygen mask (normal range 95%-100%). A nurse's note dated 5/19/23 at 4:20 PM written by RN #1 identified that at 12:45 PM Resident #2 was brought in from outside picnic feeling weak and dizzy, APRN #1 was notified, and Resident #2 was transferred to the hospital. The emergency room summary dated 5/19/23 identified Resident #2 received 650 ml of fluids on the way to the hospital, and upon arrival was lethargic, hypotensive, and was diagnosed with an acute kidney injury (when the kidneys suddenly can't filter waste from the blood). Interview with RN #1 on 6/6/23 at 12:50 PM identified she had just finished orientation and 5/19/23 was her first day administering medications independently. She identified that facility policy on medication administration directs to check the resident's name bracelet, picture on computer, and ask what their name and date of birth is, and to use two identifiers before administering medications to residents. She identified at 10:16 AM she prepared Resident #3's medications outside of the resident's room and went into the room with Resident #3's medications. She questioned Resident #2 are you --- (Resident #3's name), Resident #2 said yes. She identified she did not check Resident #2's name bracelet and gave Resident #2 Resident #3's medications. She identified she exited the room and went to the medication cart where she saw Resident #3's picture, and realized that she had given Resident #2, Resident #3's medications. Interview with APRN #1 on 6/6/23 at 1:15 PM identified she was notified that Resident #2 received the wrong medications and initially ordered to monitor in house with frequent vital signs, however, Resident #2 became bradycardic (a slow heart rate) and since he/she was given cardiac medications not prescribed to him/her, she sent Resident #2 to the hospital for further cardiac monitoring. Interview with the DNS on 6/7/23 at 4:30 PM identified prior the medication administration resident should be identified using two identifiers for example, speak to the resident, look at the picture in Medication Administration Record, and look at the name band. She identified there should be a triple check prior to administration, which RN #1 did not do. She further identified staff should not rely on the response of a cognitively impairment resident. Interview with the Regional DNS on 6/6/23 at 11:00 AM identified that RN #1 was immediately taken off the floor, RN #1's preceptor provided teaching and an in-service was provided to RN #1 on medication administration policy. RN #1 was placed back on orientation until further goals are met and medication compliance training completed again successfully. RN #1 will perform a competency with the pharmacy and/or staff education. Review of the medication administration and documentation policy directed in part, to review the physician's orders and compare against the medication administration record, and to identify the resident before administering medications. This can be accompanied by checking the identification band and/or checking the photograph attached to the administration record, asking the resident their name, or asking another staff member to identify the resident. It further directed to assure the 5 rights; compare the medication name, strength, route, dosage schedule on the medication administration record against the prescription label, always check three times prior to administration of medication.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for two of four sampled residents (Residents #11 and #60) reviewed for hospitalization , the facility failed to ensure the residents were free of significant medication errors related to critical medications not being administered for significant amounts of time which resulted in the residents experiencing a change in condition that required re-hospitalization . The failures resulted in a finding of Immediate Jeopardy. The findings include: 1. Resident #11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment dated [DATE] identified Resident #11 had intact cognition, required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and dressing. The assessment further identified the resident required total assistance for transfers. The assessment further identified that the resident's weight was 251 pounds. The hospital (acute) discharge summary dated 6/10/22 identified Resident #11 was admitted to the hospital from the skilled nursing facility on 6/3/22 for COVID-19 related acute respiratory failure with [CONDITION(S)] and hypercarbia, pulmonary [CONDITION(S)] secondary to acute kidney injury, chronic kidney disease stage 4, acute decompensated diastolic heart failure, and [CONDITION(S)]/flutter with worsened [CONDITION(S)]. The summary further identified Resident #11 underwent intermittent [CONDITION(S)] then demonstrated renal recovery and [CONDITION(S)] was discontinued. The summary noted Nephrology recommended Resident #11 start [MEDICATION(S)](diuretic) 80 mg daily and Cardiology recommended titration of [MEDICATION(S)] (used to decrease blood pressure which allows the amount of blood and oxygen to increase to the heart). In addition, the summary contained orders that directed to provide [MEDICATION(S)] 80 mg daily, [MEDICATION(S)] [MEDICATION(S)] 50 mg immediate release two times daily and [MEDICATION(S)] (used to treat restless leg syndrome) 0.25 mg three times daily. A nurses note dated 6/10/22 at 8:58 PM identified Resident #11 arrived at the facility and the W-10 medication orders (from the hospital) were reviewed and verified with the APRN. The admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's progress note dated 6/12/22 identified Resident #11 was on medications that included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. The Resident Care Plan dated 6/13/22 identified Resident #11 had altered respiratory status with interventions that included, monitor, document and report abnormal breathing patterns to the physician. Review of the electronic medical record identified that the first weight recorded for Resident #11 following readmission to the facility was on 6/15/22 (252.2 lbs.). The other weights were dated 7/1/22 (249.4), 7/4/22 (248.6) and 7/20/22 (252.0). The nurse's note dated 7/21/22 at 6:57 AM identified Resident #11 complained of chest pain and shortness of breath with a noted oxygen saturation level of 72% (normal range is between 95% to 100%). and a heart rate of 125-130 (average is 74-77). The note further identified that two liters of oxygen was applied, and the oxygen saturation level increased to 90%. The APRN recommended; monitor and if the chest pain continued to send the resident to the emergency room (hospital) for evaluation. A nursing supervisor's note dated 7/21/22 at 7:17 AM identified Resident #11 complained of chest discomfort, was alert and oriented, speaking without difficulty and lungs sounds clear on auscultation. The note further noted that the APRN was called and that the resident did not want to go the hospital at that time. The nurse's note dated 7/21/22 at 8:24 AM identified that a nurse's aide reported that Resident #11 was having difficulty breathing, upon assessment it was noted that the resident was on 3 liters of oxygen and his/her oxygen saturation level was 93% (normal range is between 95% to 100%). The note further identified that Resident #11 was repositioned in bed but continued to complain of difficulty breathing, he/she agreed to go to the hospital, 911 was called and the resident was transferred to the hospital emergency department to be evaluated. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It further failed to reflect the resident was monitored on an ongoing basis for weight changes and intake and output. The hospital discharge summary dated 8/1/22 identified Resident #11 was admitted to the hospital on 7/21/22 for the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary noted that the resident identified that he/she had experienced shortness of breath and chest pressure over the past four days but denied any other signs and symptoms. The hospital treatment course included the administration of IV [MEDICATION(S)] at 160 mg twice daily with the resident noted as losing approximately 9 pounds resulting in a discharge weight of 239 lbs. In addition, the summary noted that the cause of the resident's heart failure included not being administered the ordered diuretics at the skilled nursing facility. Additionally, the summary noted that during the hospital stay the resident also underwent aflutter ablation (a procedure to create scar tissue within an upper chamber of the heart in order to block the electrical signals that cause a fluttering heartbeat). Resident #11 was discharged back to the facility on [DATE] (the resident was hospitalized for eleven days) with new medication orders that included, [MEDICATION(S)] (diuretic) 2 mg two times daily, and [MEDICATION(S)] [MEDICATION(S)] XL 100 mg daily. Interview on 8/2/22 at 1:14 PM with the Medical Director who was also Resident #11's primary care provider at the facility identified that it was very important to follow the medication regimen prescribed by the hospital and to monitor the resident's response to the medications. He identified that he saw Resident #11 earlier that day and read her discharge summary and realized that the hospital indicated that he/she had not received his/her [MEDICATION(S)] which had contributed to Resident #11's congestive heart failure and fluid overload. He further identified that it was the supervising nurse and the APRN's responsibility to review the hospital prescribed medications and transcribe them into the electronic medical record (which would also generate the MAR). In addition, he noted that if the APRN identified issues or errors, then she should provide him (physician) with an update for him to review the discrepancies identified. He identified that no issues were identified with Resident #11's medication prescribed by the hospital and the failure to transcribe the ordered medications into the electronic medical record system must have been an error. Interview on 8/2/22 at 1:35 PM with RN #5 identified that the process for reviewing and ordering the hospital discharge medications involved confirming the medications orders with the APRN and once reviewed and confirmed with the APRN, the orders are then entered into the resident's electronic medical record. She further identified that she always double checked herself to ensure the medications were transcribed from the hospital discharge medication summary and it must have been an error if the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/2/22 at 2:45 PM with the DNS identified that she was unaware that the medications were not transcribed to Resident #11's electronic medical record resulting in 42 days of missed medication (42 doses of [MEDICATION(S)] 80 mg, 83 doses of [MEDICATION(S)] 50 MG, and 122 doses of [MEDICATION(S)]) and the medication error had not been addressed to date. Review of the facility's medication reconciliation policy identified that upon admission or readmission to the facility, the resident's hospital discharge medications are reviewed, and the orders are entered into the electronic medical record as physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #60's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital (acute care) discharge summary dated 6/22/22 identified Resident #60 was admitted for the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course identified the resident was diuresed with a net amount of eight liters. It noted the resident was maintaining an oxygen saturation of 95% on room air and an echocardiogram showed left ventricular ejection fraction of 55% (normal range: 54% to 74%). The summary further identified medications that were to be continued upon discharge and admission to the skilled nursing facility. They included, [MEDICATION(S)] (diuretic) 40 mg by mouth daily, Sevelamer ([MEDICATION(S)] binder) 800 mg by mouth three times per day, [MEDICATION(S)] (used to treat heartburn/indigestion) 1300 MG by mouth twice per day and [MEDICATION(S)] (Vitamin B-12) 1000 mcg by mouth daily. Review of the admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The resident care plan dated 6/24/22 identified Resident #60 had an altered cardiovascular status with interventions that included give all cardiac medications as ordered by the physician, monitor and document side effects and monitor blood pressure and notify the physician of any abnormal readings. The care plan further identified Resident #60 was on diuretic therapy with an intervention to administer diuretic medications as ordered by the physician and to monitor for side effects and effectiveness of the medication every shift, monitor dose and report pertinent lab results to physician. In addition, the care plan noted the resident had chronic kidney disease with interventions that included, if resident has decreased urinary output, increased confusion, fever, changes in usual mental status, or poor skin turgor, the resident may be dehydrated and if the resident has vomiting diarrhea, nausea, itching, swelling of legs, feet, face or hands, shortness of breath, pain in the back or side or appetite loss, these symptoms may indicate kidney failure. The admission MDS assessment dated [DATE] identified Resident #60 was cognitively intact, required extensive of two staff for mobility, dressing, toilet use and personal hygiene, required total assistance with transfers, did not ambulate, and utilized a wheelchair. The assessment further identified Resident #60 weighed 423 pounds and it was unknown whether or not the resident had gained or lost weight in the previous six months. The assessment also noted that the resident had not received a diuretic since being admitted to the facility (6/22/22). The nurse's note dated 6/30/22 at 11:00 PM identified Resident #60 was schedule for a chest x-ray on 7/1/22 related to congestion and oxygen desaturation (low oxygen level). The nurse's note dated 7/1/22 at 10:37 PM identified Resident #60's chest x-ray indicated moderate cardiomegaly and mild congestive heart failure. The note further identified that the APRN directed for the resident to be sent to the hospital for evaluation. The nurse's note dated 7/2/22 at 4:05 AM identified Resident #60 was admitted to the hospital for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluid volume excess in the intravascular compartment occurs due to an increase in total body sodium content and a consequent increase in extracellular body water. Treatment typically includes administration of diuretic medication and a limited intake of water, fluids, sodium, and salt). Review of Resident #60's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated 7/11/22 identified Resident #60 was admitted to the hospital for the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course included the administration of IV [MEDICATION(S)] (500 mg) intravenous three times per day and then the resident was transitioned to [MEDICATION(S)] 80 mg daily. During the hospital stay, the resident lost a total of 48 lbs. The resident's weight at discharge was 365.52 lbs. In addition, the summary noted that although the reason was unknown, the resident had not received the ordered [MEDICATION(S)] which may explain the episode of heart failure. Resident #60 underwent the placement of a right heart catherization (RHC) with cardioMEMS (a device implanted to monitor pulmonary artery pressure to identify worsening heart failure). The summary identified physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Pharmacist #1 on 7/27/22 at 1:00 PM identified that the facility's nurses transcribe (enter the physician ordered medications into the electronic medical record) the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Pharmacist #1 identified that that the missed doses of [MEDICATION(S)] and Sevelamer could have contributed to Resident #60's heart failure. Interview with APRN #1 on 7/27/22 at 1:38 PM identified that the process for reviewing the admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APRN #1 further identified that she rarely changes the medication orders identified in the discharge summary from the hospital unless there is a discrepancy. Interview with RN #2 (infection control nurse) on 7/27/22 at 1:45 PM identified that the process when admitting or readmitting a resident to the facility from the hospital involved reviewing the hospital discharge medications with the physician or the APRN and documenting on the discharge summary any changes made to the original orders. RN #2 further noted that he had performed the review of the medications when Resident #60 was admitted to the facility on [DATE]. He identified that he was in training at the time for the supervisor role and he missed transcribing the [MEDICATION(S)], Sevelamer, [MEDICATION(S)] and Vitamin B-12 into the electronic medical record. Interview with MD #1 on 7/27/22 at 2:00 PM identified that when he is admitting a resident to the facility, he typically imports the medication list from the hospital database, which he acknowledged may not be up to date. He noted that he reads the discharge summary but does not review the discharge medications again after they have been reviewed with the APRN or the physician unless changes need to be made to the existing orders. MD #1 acknowledged that he was unaware that the [MEDICATION(S)] and Sevelamer were never transcribed when the resident was admitted on [DATE] and noted that the missed doses of [MEDICATION(S)] contributed to Resident #60 experiencing a significant change in condition with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with APRN #3 on 7/28/22 at 12:20PM, she said that she was responsible for verifying the medication list received from the acute care facility discharge instructions. The facility nurse was responsible for making sure that all medications from acute care facility discharge instructions were transcribed into the physician orders. Subsequent to surveyor inquiry to Resident #60's [MEDICATION(S)], sevelamer, [MEDICATION(S)] and vitamin B-12 medications, the facility nurse should transcribe all approved medications from acute care facility discharge instructions into the physician order. Interview with RN #4 on 7/28/22 at 1:30 PM identified that she described the same process for reviewing and transcribing the medications orders into the electronic medical record. She further noted that while on duty at the facility, she received a call from the hospital physician during the time Resident #60 was a patient and the physician asked her to convey the resident's medication orders while at the facility. She further noted that she had confirmed to the hospital physician that Resident #60 had not been administered [MEDICATION(S)] from the time of admission 6/22/22 to 7/1/22 when the resident was sent to the hospital. In addition, RN #4 did not convey the call to the APRN, Physician or the DNS. Interview with the DNS on 7/28/22 at 2:00 PM identified that she was unaware of the transcription error involving Resident #60. She noted that the facility did not have a system in place to double check new orders and/or to double check admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent to the interview with the DNS, the facility submitted a Reportable Event Report to the State Survey Agency detailing the medication errors for Resident #60. Review of the facility's medication reconciliation policy identified that upon admission or readmission to the facility, the resident's hospital discharge medications are reviewed, and the orders are entered into the electronic medical record as physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure critical medications were administered to Resident #60 as ordered for a period of nine days resulting in the omission of a total of 63 doses of the combined omitted medications of [MEDICATION(S)], Sevelamer and [MEDICATION(S)], and Vitamin B-12 culminating in the resident being hospitalized for fluid overload and congestive heart failure. These failures resulted in a finding of Immediate Jeopardy. A review of the facility's corrective action plan on 8/3/22 identified that the facility would educate all licensed staff on the new admission process for transcription of medication orders into the resident's electronic medical record. It further noted that once the orders were transcribed by the charge nurse, the nursing supervisor would audit the transcribed orders, then the 11:00 PM to 7:00 AM nursing supervisor would perform an additional audit of the orders followed by a third check performed by the ADNS. The plan further noted that daily audits of all admissions and readmissions would be conducted for a period of four weeks.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews the facility failed to ensure for two of four newly admitted residents (Resident #11 and Resident #60), that hospital discharge medications were accurately reconciled, transcribed and communicated with each resident's facility physician to ensure orders for necessary medications were obtained and administered to provide for each resident's healthcare needs. These facility failures resulted in serious health issues and rehospitalization s for both residents. the facility failed to ensure that medications were administered as ordered by the physician which resulted in the resident's requiring re-hospitalization . The findings include: 1. Resident #11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment dated [DATE] identified Resident #11 had intact cognition, required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and dressing. The assessment further identified the resident required total assistance for transfers. The assessment further identified that the resident's weight was 251 pounds. The hospital (acute) discharge summary dated 6/10/22 identified Resident #11 was admitted to the hospital from the skilled nursing facility on 6/3/22 for COVID-19 related acute respiratory failure with [CONDITION(S)] and hypercarbia, pulmonary [CONDITION(S)] secondary to acute kidney injury, chronic kidney disease stage 4, acute decompensated diastolic heart failure, and [CONDITION(S)]/flutter with worsened [CONDITION(S)]. The summary further identified Resident #11 underwent intermittent [CONDITION(S)] then demonstrated renal recovery and [CONDITION(S)] was discontinued. The summary noted Nephrology recommended Resident #11 start [MEDICATION(S)](diuretic) 80 mg daily and Cardiology recommended titration of [MEDICATION(S)] (used to decrease blood pressure which allows the amount of blood and oxygen to increase to the heart). In addition, the summary contained orders that directed to provide [MEDICATION(S)] 80 mg daily, [MEDICATION(S)] [MEDICATION(S)] 50 mg immediate release two times daily and [MEDICATION(S)] (used to treat restless leg syndrome) 0.25 mg three times daily. A nurses note dated 6/10/22 at 8:58 PM identified Resident #11 arrived at the facility and the W-10 medication orders (from the hospital) were reviewed and verified with the APRN. The admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's progress note dated 6/12/22 identified Resident #11 was on medications that included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. The Resident Care Plan dated 6/13/22 identified Resident #11 had altered respiratory status with interventions that included, monitor, document and report abnormal breathing patterns to the physician. Review of the electronic medical record identified that the first weight recorded for Resident #11 following readmission to the facility was on 6/15/22 (252.2 lbs.). The other weights were dated 7/1/22 (249.4), 7/4/22 (248.6) and 7/20/22 (252.0). The nurse's note dated 7/21/22 at 6:57 AM identified Resident #11 complained of chest pain and shortness of breath with a noted oxygen saturation level of 72% (normal range is between 95% to 100%). and a heart rate of 125-130 (average is 74-77). The note further identified that two liters of oxygen was applied, and the oxygen saturation level increased to 90%. The APRN recommended; monitor and if the chest pain continued to send the resident to the emergency room (hospital) for evaluation. A nursing supervisor's note dated 7/21/22 at 7:17 AM identified Resident #11 complained of chest discomfort, was alert and oriented, speaking without difficulty and lungs sounds clear on auscultation. The note further noted that the APRN was called and that the resident did not want to go the hospital at that time. The nurse's note dated 7/21/22 at 8:24 AM identified that a nurse's aide reported that Resident #11 was having difficulty breathing, upon assessment it was noted that the resident was on 3 liters of oxygen and his/her oxygen saturation level was 93% (normal range is between 95% to 100%). The note further identified that Resident #11 was repositioned in bed but continued to complain of difficulty breathing, he/she agreed to go to the hospital, 911 was called and the resident was transferred to the hospital emergency department to be evaluated. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It further failed to reflect the resident was monitored on an ongoing basis for weight changes and intake and output. The hospital discharge summary dated 8/1/22 identified Resident #11 was admitted to the hospital on 7/21/22 for the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary noted that the resident identified that he/she had experienced shortness of breath and chest pressure over the past four days but denied any other signs and symptoms. The hospital treatment course included the administration of IV [MEDICATION(S)] at 160 mg twice daily with the resident noted as losing approximately 9 pounds resulting in a discharge weight of 239 lbs. In addition, the summary noted that the cause of the resident's heart failure included not being administered the ordered diuretics at the skilled nursing facility. Additionally, the summary noted that during the hospital stay the resident also underwent aflutter ablation (a procedure to create scar tissue within an upper chamber of the heart in order to block the electrical signals that cause a fluttering heartbeat). Resident #11 was discharged back to the facility on [DATE] (the resident was hospitalized for eleven days) with new medication orders that included, [MEDICATION(S)] (diuretic) 2 mg two times daily, and [MEDICATION(S)] [MEDICATION(S)] XL 100 mg daily. Interview on 8/2/22 at 1:14 PM with the Medical Director who was also Resident #11's primary care provider at the facility identified that it was very important to follow the medication regimen prescribed by the hospital and to monitor the resident's response to the medications. He identified that he saw Resident #11 earlier that day and read her discharge summary and realized that the hospital indicated that he/she had not received his/her [MEDICATION(S)] which had contributed to Resident #11's congestive heart failure and fluid overload. He further identified that it was the supervising nurse and the APRN's responsibility to review the hospital prescribed medications and transcribe them into the electronic medical record (which would also generate the MAR). In addition, he noted that if the APRN identified issues or errors, then she should provide him (physician) with an update for him to review the discrepancies identified. He identified that no issues were identified with Resident #11's medication prescribed by the hospital and the failure to transcribe the ordered medications into the electronic medical record system must have been an error. Interview on 8/2/22 at 1:35 PM with RN #5 identified that the process for reviewing and ordering the hospital discharge medications involved confirming the medications orders with the APRN and once reviewed and confirmed with the APRN, the orders are then entered into the resident's electronic medical record. She further identified that she always double checked herself to ensure the medications were transcribed from the hospital discharge medication summary and it must have been an error if the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/2/22 at 2:45 PM with the DNS identified that she was unaware that the medications were not transcribed to Resident #11's electronic medical record resulting in 42 days of missed medication (42 doses of [MEDICATION(S)] 80 mg, 83 doses of [MEDICATION(S)] 50 MG, and 122 doses of [MEDICATION(S)]) and the medication error had not been addressed to date. Review of the facility's medication reconciliation policy identified that upon admission or readmission to the facility, the resident's hospital discharge medications are reviewed, and the orders are entered into the electronic medical record as physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #60's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital (acute care) discharge summary dated 6/22/22 identified Resident #60 was admitted for the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course identified the resident was diuresed with a net amount of eight liters. It noted the resident was maintaining an oxygen saturation of 95% on room air and an echocardiogram showed left ventricular ejection fraction of 55% (normal range: 54% to 74%). The summary further identified medications that were to be continued upon discharge and admission to the skilled nursing facility. They included, [MEDICATION(S)] (diuretic) 40 mg by mouth daily, Sevelamer ([MEDICATION(S)] binder) 800 mg by mouth three times per day, [MEDICATION(S)] (used to treat heartburn/indigestion) 1300 MG by mouth twice per day and [MEDICATION(S)] (Vitamin B-12) 1000 mcg by mouth daily. Review of the admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The resident care plan dated 6/24/22 identified Resident #60 had an altered cardiovascular status with interventions that included give all cardiac medications as ordered by the physician, monitor and document side effects and monitor blood pressure and notify the physician of any abnormal readings. The care plan further identified Resident #60 was on diuretic therapy with an intervention to administer diuretic medications as ordered by the physician and to monitor for side effects and effectiveness of the medication every shift, monitor dose and report pertinent lab results to physician. In addition, the care plan noted the resident had chronic kidney disease with interventions that included, if resident has decreased urinary output, increased confusion, fever, changes in usual mental status, or poor skin turgor, the resident may be dehydrated and if the resident has vomiting diarrhea, nausea, itching, swelling of legs, feet, face or hands, shortness of breath, pain in the back or side or appetite loss, these symptoms may indicate kidney failure. The admission MDS assessment dated [DATE] identified Resident #60 was cognitively intact, required extensive of two staff for mobility, dressing, toilet use and personal hygiene, required total assistance with transfers, did not ambulate, and utilized a wheelchair. The assessment further identified Resident #60 weighed 423 pounds and it was unknown whether or not the resident had gained or lost weight in the previous six months. The assessment also noted that the resident had not received a diuretic since being admitted to the facility (6/22/22). The nurse's note dated 6/30/22 at 11:00 PM identified Resident #60 was schedule for a chest x-ray on 7/1/22 related to congestion and oxygen desaturation (low oxygen level). The nurse's note dated 7/1/22 at 10:37 PM identified Resident #60's chest x-ray indicated moderate cardiomegaly and mild congestive heart failure. The note further identified that the APRN directed for the resident to be sent to the hospital for evaluation. The nurse's note dated 7/2/22 at 4:05 AM identified Resident #60 was admitted to the hospital for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluid volume excess in the intravascular compartment occurs due to an increase in total body sodium content and a consequent increase in extracellular body water. Treatment typically includes administration of diuretic medication and a limited intake of water, fluids, sodium, and salt). Review of Resident #60's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated 7/11/22 identified Resident #60 was admitted to the hospital for the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course included the administration of IV [MEDICATION(S)] (500 mg) intravenous three times per day and then the resident was transitioned to [MEDICATION(S)] 80 mg daily. During the hospital stay, the resident lost a total of 48 lbs. The resident's weight at discharge was 365.52 lbs. In addition, the summary noted that although the reason was unknown, the resident had not received the ordered [MEDICATION(S)] which may explain the episode of heart failure. Resident #60 underwent the placement of a right heart catherization (RHC) with cardioMEMS (a device implanted to monitor pulmonary artery pressure to identify worsening heart failure). The summary identified physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Pharmacist #1 on 7/27/22 at 1:00 PM identified that the facility's nurses transcribe (enter the physician ordered medications into the electronic medical record) the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Pharmacist #1 identified that that the missed doses of [MEDICATION(S)] and Sevelamer could have contributed to Resident #60's heart failure. Interview with APRN #1 on 7/27/22 at 1:38 PM identified that the process for reviewing the admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APRN #1 further identified that she rarely changes the medication orders identified in the discharge summary from the hospital unless there is a discrepancy. Interview with RN #2 (infection control nurse) on 7/27/22 at 1:45 PM identified that the process when admitting or readmitting a resident to the facility from the hospital involved reviewing the hospital discharge medications with the physician or the APRN and documenting on the discharge summary any changes made to the original orders. RN #2 further noted that he had performed the review of the medications when Resident #60 was admitted to the facility on [DATE]. He identified that he was in training at the time for the supervisor role and he missed transcribing the [MEDICATION(S)], Sevelamer, [MEDICATION(S)] and Vitamin B-12 into the electronic medical record. Interview with MD #1 on 7/27/22 at 2:00 PM identified that when he is admitting a resident to the facility, he typically imports the medication list from the hospital database, which he acknowledged may not be up to date. He noted that he reads the discharge summary but does not review the discharge medications again after they have been reviewed with the APRN or the physician unless changes need to be made to the existing orders. MD #1 acknowledged that he was unaware that the [MEDICATION(S)] and Sevelamer were never transcribed when the resident was admitted on [DATE] and noted that the missed doses of [MEDICATION(S)] contributed to Resident #60 experiencing a significant change in condition with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with APRN #3 on 7/28/22 at 12:20PM, she said that she was responsible for verifying the medication list received from the acute care facility discharge instructions. The facility nurse was responsible for making sure that all medications from acute care facility discharge instructions were transcribed into the physician orders. Subsequent to surveyor inquiry to Resident #60's [MEDICATION(S)], sevelamer, [MEDICATION(S)] and vitamin B-12 medications, the facility nurse should transcribe all approved medications from acute care facility discharge instructions into the physician order. Interview with RN #4 on 7/28/22 at 1:30 PM identified that she described the same process for reviewing and transcribing the medications orders into the electronic medical record. She further noted that while on duty at the facility, she received a call from the hospital physician during the time Resident #60 was a patient and the physician asked her to convey the resident's medication orders while at the facility. She further noted that she had confirmed to the hospital physician that Resident #60 had not been administered [MEDICATION(S)] from the time of admission 6/22/22 to 7/1/22 when the resident was sent to the hospital. In addition, RN #4 did not convey the call to the APRN, Physician or the DNS. Interview with the DNS on 7/28/22 at 2:00 PM identified that she was unaware of the transcription error involving Resident #60. She noted that the facility did not have a system in place to double check new orders and/or to double check admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent to the interview with the DNS, the facility submitted a Reportable Event Report to the State Survey Agency detailing the medication errors for Resident #60. Review of the facility's medication reconciliation policy identified that upon admission or readmission to the facility, the resident's hospital discharge medications are reviewed, and the orders are entered into the electronic medical record as physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure critical medications were administered to Resident #60 as ordered for a period of nine days resulting in the omission of a total of 63 doses of the combined omitted medications of [MEDICATION(S)], Sevelamer and [MEDICATION(S)], and Vitamin B-12 culminating in the resident being hospitalized for fluid overload and congestive heart failure.

Based on review of the clinical record, facility documentation, facility policy and interviews for one of three residents (Resident #1) who were reviewed for laboratory services, the facility failed to report critical laboratory values in a timely manner, and for one of three residents (Resident #1) reviewed for medication administration, the facility failed to administer medications according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] identified Resident #1 was cognitively intact and required the assistance of one staff with Activities of Daily Living (ADL's) and was independent with eating. The Admission Care Plan dated 5/24/22 identified neutropenic precautions and depression. Interventions included to administer medications as directed, obtain laboratory work as ordered, and report to the physician. A. Review of the laboratory bloodwork results sheet dated 6/6/22 indicated that Resident #1 had labs drawn on 6/6/22 at 2:29 PM. Critical laboratory values identified a hematocrit of 6.7 (12.5-16.0), a Platelet count of 3 (150-450), and that the critical value labs had been called to the facility and reported to LPN #2 on 6/6/22 at 8:22 PM. A review of the Hospital Discharge Summary dated 6/17/22 at 1:16 PM identified that Resident #1 was admitted to the hospital on 6/7/22 with a headache, was noted to have bilateral subdural hematomas, a platelet count of 1, and was subsequently admitted to the Neurological Intensive Care Unit. A review of LPN #1's nurse's note dated 6/6/22 at 9:39 AM identified that Resident #1 told LPN #1 that s/he had a bloody nose and requested that APRN #2 be contacted for orders. APRN #2 directed a STAT (immediate) complete blood count, the lab was contacted, and they informed LPN #1 that the scheduled phlebotomist for the facility was not immediately available due to a call out. The lab indicated that although the bloodwork would be drawn, they were unable to indicate a time of arrival for the phlebotomist. (Lab work was drawn five hours after the initial order was obtained. Review of APRN #1's note dated 6/6/22 identified that she had seen Resident #1 on 6/6/22 at 11:40 AM, STAT bloodwork had been ordered by APRN #2 and that Resident #1 should continue to be closely monitored. APRN #1's note did not indicate that she had been informed of the delay in obtaining STAT bloodwork. Review of the LPN #1's nurse's note dated 6/6/22 at 3:45 PM indicated that APRN #2 should be called with laboratory results and that although an infusion was scheduled for 6/7/22, depending on the laboratory work, Resident #1 may be required to go for an infusion today (6/6/22). The on-coming nurse, LPN #2, was made aware. Interview with APRN #1 on 6/21/22 at 1:35 PM identified that the expectation was for the lab to have a four hour turnaround time for STAT testing. APRN #1 indicated that APRN #2 should have been notified and given the option to send Resident #1 to an alternate facility due to a delay in the availability of a phlebotomist. Although according to the lab documentation that critical lab values had been reported to LPN #2 on 6/6/22 at 8:22 PM, APRN #1 identified that she had not been notified of the results until she received the information via a text message on 6/7/22 at 6:56 AM when she was also informed that RN #1 had sent Resident #1 to the hospital. APRN #1 indicated that if she had been given the critical lab results when received by the facility on 6/6/22 at 8:22 PM, she would have immediately sent Resident #1 to the hospital. Interview with RN #2 on 6/21/22 at 1:59 PM identified that when she reported for duty on 6/6/22 for the evening shift, she did not recall being told by the off-going RN Supervisor or nurse during report, that Resident #1 had STAT bloodwork pending. RN #2 indicated that she should have been given the information and if she had, would have called the laboratory for updated information or results. Additionally, RN #2 indicated that she would have informed one of the APRN's, the on-coming RN night Supervisor (RN #1), and the DNS or ADNS of the unavailability of a phlebotomist. Interview with APRN #2 on 6/22/22 at 9:34 AM identified that the facility staff should have informed herself or APRN #1 that there was an inability to draw STAT lab work at the facility. APRN #2 indicated that if she had been told, she would have brought Resident #1 to an alternate location to draw the STAT lab work and an immediate transfusion could have been administered. APRN #2 indicated that a platelet count of 3 was a critical value and should have been reported immediately. After the facility received the critical lab value, Resident #1 should have been transported immediately for an emergency blood transfusion. APRN #2 indicated that Resident #1's nosebleed was not a big deal but was a problem if the finding was not acted upon and that the facility should have a process to ensure critical lab values are reported. APRN #2 identified that Resident #1 had an aggressive disease process with active [CONDITION(S)] and a dysfunctional coagulation system. Although Resident #1 had decreased platelets, s/he may still have had a subdural hematoma. Earlier intervention with additional platelets would have decreased the extent of the subdural hematoma but not prevented the occurrence. APRN #2 indicated she was unaware of the critical lab values until the following day, 6/7/22 after reporting to work, had read that Resident #1 had arrived at the Emergency Department and been admitted . Interview with LPN #2 on 6/22/22 at 3:38 PM identified she was Resident #1's evening charge nurse on 6/6/22. LPN #2 indicated that although the lab had called and reported the critical laboratory values to her on 6/6/22 around 9:00 PM or 10:00 PM per her recollection, she saw the faxed copy of the critical lab work, assumed the RN supervisor (RN #2) was already aware, and did not inform her of the call from the lab or of the critical lab values. Interview with the DNS on 6/22/22 at 11:23 AM identified that LPN#1 (day shift) should have notified the MD or APRN and the resident of the inability for the facility to obtain timely STAT bloodwork so they could have made a determination if alternative arrangements such as sending the resident out for bloodwork needed to be considered. Additionally, LPN #1 should have been aware labs were already drawn on her shift on 6/6/22 at 2:29 PM and should have notified the day supervisor of the status of the lab work so that subsequent supervisors (evenings and nights) could follow up to ensure STAT results were received. The DNS indicated that it would have been her expectation that LPN #2 to notify the evening Supervisor, RN #2 that she had received the critical lab values via phone, and that STAT lab values needed to be reported immediately. Although the DNS was not sure how long the policy allowed for notification of an urgent transfer to the hospital, she identified that waiting four hours was not acceptable. The initial physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the results were not reported to the facility until 8:22 PM, (six hours after being drawn and eleven hours after the initial STAT order. The APRN was notified of the critical lab work on 6/7/22 at 7:00 AM (four and one half (4.5) hours after Resident #1 was sent to the hospital and 21 hours after the initial order for STAT lab work was obtained). Review of the Diagnostic Services Policy identified, in part, that the facility has 24 hour, seven days per week access to services, emergency service requests should be label STAT to assure prompt action and that and that when test results are received by the center the physician shall be notified of the results. B. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview and clinical record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 indicated that she notified the Registered Nurse Supervisor, RN #1 that she did not have the medications. In an interview and clinical record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the resident and/or representative would need to be informed of the missing medication as well as the APRN or MD. In an interview with Pharmacist #1 on 6/21/22 at 12:17 PM she identified that the [MEDICATION(S)] order was received on 5/23/222 at 9:33 PM and a thirty day supply of the medication was delivered on 5/24/22 on the 11:00 PM to 7:00 AM shift. Pharmacist #1 further indicated that the pharmacy received the order for [MEDICATION(S)] on 5/31/22 at 7:05 PM and the medication was delivered on 6/1/22 at 2:13 AM and signed for by RN #1. Pharmacist #1 indicated that the facility, according to pharmacy records, should have had the medications available to administer to Resident #1. In an interview, clinical record review, and facility medication error documentation with the DNS on 6/21/22 at 11:23 AM, the clinical record failed to reflect documentation that Resident ##1 had received his/her medications as prescribed by the physician. The DNS indicated that this was a medication error and started a Reportable Event form. The DNS identified that if the medication was not administered the physician/APRN should have been notified. Subsequent to surveyor inquiry the APRN was notified. Review of the Medication Administration Policy directed, in part, that a medication error is a preventable event that may cause or lead to inappropriate medication use when in control of the health care professional.

Based on clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #5) who was reviewed for an allegation of exploitation on a social media site, the facility failed to ensure the resident was free from verbal and mental abuse. The findings include: Resident #5's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #5 had slurred speech and/or mumble words, difficulty communicating some words or finishing thoughts but was able to if prompted or given time, was oriented to person, place and time, required one (1) person supervision with positioning in the bed, ambulating in room, dressing and personal hygiene, and was independent with eating after set up assistance. The care plan revision dated 7/25/19 identified Resident #5 has a [MEDICAL CONDITION] disorder. Interventions directed a soft helmet to be worn when out of bed for [MEDICAL CONDITION] precautions. The Reportable Event Form dated 8/29/19 at 2:30 PM identified a nurse aide made fun of Resident #5 on snap chat and the family saw the photo and reported the incident to the facility. In a written statement dated 8/30/19 outlining the incident, the Administrator indicated at approximately 1:45 PM on 8/29/19, the receptionist informed her about a phone call the receptionist had received from Resident #5's family member. The family member reported that a staff member had uploaded a video of Resident #5 on a social media site. The statement identified the Administrator immediately went to Resident #5's room and found a 7AM-3PM nurse aide, Nurse Aide (NA) #4, sitting at the resident's bed side chair with her cell phone in her hands, at that time NA #4 was not videotaping or talking on the phone. When asked by the Administrator what she was doing, NA #4 replied she was conversing with Resident #5. The Administrator asked NA #4 how she was speaking with Resident #5 if the resident's was sitting with his/her back to her, to which NA #4 responded the resident had just turned around. The Administrator identified she questioned NA #4 if she was aware that no cell phones were allowed in resident care areas according to the facility's employee hand book and NA #4 responded, No, I was not aware. The statement indicated when the Administrator instructed NA #4 to leave the room because she needed to speak with NA #4 regarding the incident, NA #4 replied: I'm leaving, I'm going home, I quit. The Administrator's statement indicated when NA #4 was questioned prior to leaving the facility why would she videotape the resident and put him/her on snap chat, NA #4 stated she did not have a Snap Chat account and she did not post it. The investigation identified when the receptionist was walking down the hallway to inform the Administrator that Resident #5's family was in the main lobby and was about to enter Resident #5's room as NA #4 was coming out of the room, she heard NA #4 call the Administrator B _ _ _h. The investigation identified Resident #5's family member, Person #1, showed the video to the Administrator and Director of Nursing and the video identified NA #4 as the social media site user. The video showed Resident #5 seated in a wheelchair with a white helmet on his/her head, the resident was asking for a grilled cheese sandwich numerous times and the video's caption read All I want is a grilled cheese sandwich. The video was forwarded to the local authorities. During the investigation the facility found that NA #4 had attended a nursing staff meeting on 8/28/19, the day before the incident that included reminding staff personal cell phones were not allowed at the nurse's station and/or in resident care areas. Review of the clinical record from 8/29/19 through 8/31/19 identified Resident #5 was assessed by the Social Worker for three (3) days following the incident and the resident appeared to be in no distress and voiced no concerns. A psychological evaluation conducted on 9/4/19 identified that Resident #5 did not want to discuss the incident, he/she was anxious, and was becoming overwhelmed with the number of professional visitors questioning him/her about the 8/29/19 incident and this was impacting the resident's anxiety. In an interview review of the clinical record, review of facility documentation, and the videotape of Resident #5 on 9/9/19 at 9:15 AM with the Administrator identified she immediately went to the resident's room after the incident was reported and NA #4 was present in the resident's room with her cell phone on her lap. The Administrator indicated that if NA #4 had not quit, she would have been terminated. The Administrator stated that taking pictures and/or videos was demeaning and humiliating to a resident and constitutes abuse and subsequent to the incident staff were re-educated regarding cell phones and social media. In an interview with NA #4 on 9/9/19 at 11:40 AM she indicated that at first she denied to the Administrator videotaping and posting the video. NA #4 stated she did video tape Resident #5 and posted the video on a social media site. NA #4 identified she and Resident #5 were just fooling around and although someone else altered the video, she uploaded it. The Abuse Prohibition Policy identifies that it is the facility's responsibility to ensure that each resident has the right to be from abuse, mistreatment, neglect and misappropriation of his/her personal property. The policy indicates mental abuse includes humiliation, harassment, threats of punishment or deprivation and taking or using photographs or recordings of a resident and/or his/her personal space in any manner that would demean or humiliate a resident constitutes mental abuse regardless of the resident's cognitive ability or whether the resident consents. The policy directs that all staff are strictly forbidden from taking photos and videos of residents, doing so constitutes abuse and is grounds for immediate dismissal.

1. Based on clinical record review, review of facility policies and staff interviews for two of three residents reviewed for pain (R#1and R#2), the facility failed to ensure that the resident was reassessed and/or timely reassessed following pain medication administration. The findings include: a. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The pain assessment dated [DATE] identified that the Resident had intermittent abdominal and flank level 5 pain (scale of 1- 10 with 10 being the worst possible pain) daily. The plan of care dated 4/27/17 and 5/11/17 identified a concern with pain with interventions that included administering medications as ordered and assess effectiveness of medications and/or assess pain level 0-10 prior and post medication. Physician orders [REDACTED]. Review of the MAR (medication administration record) from 5/2/17 to 5/16/17 identified that the Resident received 40 doses of [MEDICATION NAME] 5mg and directed to reassess pain level 30 minutes after administration. The pain assessments dated 5/2/17 through 5/16/17 indicated that the Resident was never reassessed for pain within 30 minutes of pain medication administration, was reassessed 1 to 4 hours after the medication was administered and was reassessed to have continued pain on 24 occasions. Interview with the ADON (Assistant Director of Nurses) on 8/2/17 at 10:05 AM noted that the numeric score was used to assess pain, reassessment of pain was required 30 minutes following [MEDICATION NAME] administration and the assessment was not always completed. The facility pain management policy identified that the pain assessment will be performed every shift, recorded in the MAR indicated [REDACTED]. b. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment dated [DATE] identified that the Resident had occasional severe pain. Physician orders [REDACTED]. The plan of care dated 7/11/17 noted that the Resident had shoulder pain and interventions included to administer medications as ordered and assess pain level prior and post medication. The MAR indicated [REDACTED]. Although the pain assessment record identified that the Resident's pain was assessed every shift from 7/27/17 to 8/2/17, an assessment of the Resident's pain level prior to and after the medications were administered was not documented. Nursing narratives dated 7/27/17 to 8/1/17 lacked assessment regarding the Resident's pain level. Interview with the ADON on 8/3/17 at 10:45 AM indicated that there was a glitch in the electronic system and the system did not prompt nursing to enter a pre and post pain assessment with the [MEDICATION NAME] administration. 2. Based on clinical record review, review of facility policies and staff interviews for one of three residents reviewed for pain (R#1), the facility failed to ensure that the resident's pain was adequately managed. The finding includes: a. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The pain assessment dated [DATE] identified that the Resident had intermittent abdominal and flank level 5 pain (scale of 1- 10). The admission minimum data set assessment dated [DATE] indicated that the Resident had up to level 5 pain over the last 5 days and pain was almost constant (increase since admission). The plan of care dated 4/27/17 and 5/11/17 identified a concern of pain with interventions that included administering medications as ordered and assess effectiveness of medications and/or assess pain level 0-10 prior and post medication. Physician orders [REDACTED]. The APRN note dated 5/8/17 indicated that the Resident felt better the past two days with the administration of Tylenol and [MEDICATION NAME] for pain. Review of the pain assessment record from 5/10/17 to 5/16/17 identified that the Resident was assessed with [REDACTED]. A physician or APRN progress note was not documented from 5/9/17 to 5/13/17 to indicate an assessment and/or intervention for the Resident's increased pain. Although a progress note by APRN #2 dated 5/14/17 identified that the Resident had abdominal pain, the note incorrectly indicated that a urinalysis was pending, directed to continue with the [MEDICATION NAME] for pain and lacked new interventions for the Resident's increased pain. Interview with APRN #1 on 8/2/17 at 2:20 PM indicated that the Resident had pain, was lethargic and the Resident's Oncologist could have been consulted regarding the increased pain. Resident #1 was seen by the Oncologist on 5/16/17, the consult noted that the Resident had increased pain in the right upper abdomen and chest, was not on adequate pain control and was subsequently admitted to the hospital. The facility pain management policy identified a purpose to comprehensively assess pain and be able to manage the pain on an individual basis according to the needs of the individual resident. The Resident Bill of Rights policy identified a right to receive quality care and services with reasonable accommodation of individual needs and preferences. 3. Based on clinical record review and review of facility policies for one of three residents reviewed for pain (R#1), the facility failed to ensure that the plan of care for pain was followed when the resident complained of pain. The findings include: a. Resident #1 was admitted to the facility on [DATE]with [DIAGNOSES REDACTED]. The admission minimum data set assessment dated [DATE] indicated that the Resident had up to level 5 pain over the last 5 days and pain was almost constant (increase since admission). The plan of care dated 5/11/17 identified a problem with pain with interventions that included to administer medications as ordered and assess pain level 0-10 prior and post medication. Physician orders [REDACTED]. i- The pain assessment record dated 5/12/17 at 9:51 PM identified that the Resident had level 4 pain, [MEDICATION NAME] was administered and the Resident reported level 3 pain approximately 2 hours later at 11:54 AM. Although the Resident last received the Tylenol at 4:00 AM on 5/12/17, another dose was not administered at 11:54 PM with the continued complaint of pain. ii. The Resident was subsequently assessed for pain on 5/13/17 at 1:42 AM with a pain level of 3 and received [MEDICATION NAME] for pain. Although the Resident was assessed on 5/13/17 as having level 4 pain at 8:35 AM (almost 8 hours after the 1:42 AM dose of [MEDICATION NAME]), neither [MEDICATION NAME] or Tylenol was administered to the Resident. iii. The pain assessment and/or medication record dated 5/14/17 indicated that Resident #1 received [MEDICATION NAME] at 1:07 PM for level 4 pain, pain was relieved to a level 3 at 3:52 PM, and although the [MEDICATION NAME] did not completely eliminate the Resident's pain, Tylenol was administered instead of [MEDICATION NAME] at 5:02 PM when the Resident complained of level 7 pain. Resident #1 complained of level 3 pain at 6:30 PM and 6:40 PM, [MEDICATION NAME] could have been administered at this time, and was not administered until 11:52 PM (5 hours later) when the Resident pain level increased to level 7. iv. The pain assessment dated [DATE] at 12:14 AM indicated a pain level of 5 and although the resident could have received the Tylenol (last administered on 5/14/17 at 5:02 PM) , Tylenol was not administered as ordered. The Resident's pain was reported as level 8 on 5/15/17 at 4:44 AM and the [MEDICATION NAME] was administered. The pain assessment dated [DATE] at 8:45 AM identified a pain level of 5, [MEDICATION NAME] was administered and although the Resident reported continued level 5 pain two hours later and at 10:47 AM, Tylenol, although due, was not administered. Pain medication, [MEDICATION NAME], which could have been administered at 12:45 PM, was not administered to the Resident until 3:07 PM for a continued pain level of 5. The Facility pain management policy identified that residents have the right to appropriate assessment and control of their pain. The team nurse job description identified a duty to administer medications as ordered y the physicians or by required policy.

Based on clinical record review, review of facility policy and job descriptions, review of facility documentation, observations and interviews for one of three residents who required staff assistance for transfers (Residents #1), the facility failed to ensure that the resident was transferred in accordance with PT (physical therapy) recommendations. The finding includes: a. R#1's [DIAGNOSES REDACTED]. The annual minimum data set assessment dated [DATE] identified that the resident was cognitively intact (BIM =15), was total assistance of two staff for transfers and was unsteady with surface to surface transfers. Review of the PT (physical therapy) screen dated 3/9/17 directed moderate to maximum assistance of two with mechanical lift option for transfer. The NA care card further directed the assistance of two for transfer. Nursing narratives and/or the facility investigation dated 3/23/17 indicated that Resident #1 reported that NA #2 transferred Resident #1 from the W/C (wheelchair) to the bed independently at 4:30 PM on 3/23/17 and the resident sustained [REDACTED]. Although NA #2 was unable to be reached for interview on 5/16/17 and 5/17/17, facility documentation dated 3/28/17 noted that NA #2 informed the DON (Director of Nursing) that Resident #1 told him/her to wrap his her leg after the injury, not tell anyone and that it was Resident #1's right. Interview with NA #5 on 5/16/17 conflictingly noted that he/she helped NA #2 transfer Resident #1 in and out of bed on 3/23/17 before supper and saw a dressing on the Resident's leg and dried, red blood on the sheet. Interview with Resident #1 on 5/16/17 at 1:35 PM and/or 3:47 PM and review of Resident #1's statement dated 3/27/17 identified that the Resident maintained he/she was transferred unassisted by NA #2 to the bed before supper on 3/23/17 which caused injury to the right calf and was later sent to the ER. Resident #1 further identified that NA #2 tried to blame the day shift for his/her injury and lied about the incident. Interview with the DON on 5/16/17 indicated that he/she believed Resident #1's accounting of the incident and NA #2's employment was subsequently terminated by the facility. The facility NA job description identified a duty for rehabilitation nursing - to instruct patients in activities of daily living and provide assistance as needed. The Resident Bill of Rights identified a right to receive quality care and services with reasonable accommodation of individual needs.

Based on clinical record reviews, observation, review of facility documentation and staff interviews for one of three sampled residents at risk for pressure ulcer development (Resident # 192), the facility failed to ensure that a resident who entered the facility without a pressure ulcer does not develop a pressure ulcer unless his/her clinical condition indicate the pressure ulcer was unavoidable .The findings include: Resident # 192 [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] indicated a Braden score of 14 identifying the resident at moderate risk for developing pressure ulcers. Additionally, noted a surgical incision on left hip and intact skin. A Braden Score of 13-14 directs staff to place the resident on his/her side with a pillow/blanket at 30 degrees when lying on his/her side. The skin integrity care plan dated 1/17/16 identified interventions that included skin assessment per policy, directed to assess for the need for pressure relieving devices and to provide turning and repositioning every two hours. The nursing admission note dated 1/17/16 noted intact skin to bony prominence, directed staff to encourage Resident # 192 to turn and reposition self frequently for pressure re-distribution and to report pain of 10 on a scale of (1-10). An admission Minimum Data Set ((MDS) dated [DATE] identified the resident with a Brief Interview of Mental Status (BIMS) score of 15 identifying the resident with no cognitive impairment and noted two person physical assistance for transfer and bed mobility. Additionally, the assessment noted risk for developing pressure ulcers, intact skin, and directed staff to apply a pressure reducing device to the bed and an impairment of ROM to the lower extremity on one side. The Activities of Daily Living (ADL) sheets dated 1/17/16 through 2/8/16 identified Resident # 192 required extensive assistance of one or two people for bed mobility. Review of the ADL sheets, nurse's notes and Treatment Administration Record dated 1/17/16 through 2/8/16 failed to reflect that facility staff assisted and /or encouraged Resident # 192 to turn and reposition frequently for pressure re-distribution to prevent skin breakdown. The Treatment Administration Record dated 2/9/ 2016 directed to apply an air mattress to the resident's bed and a cushion to Resident # 192's wheelchair. The facility's Wound Care documentation dated 2/12/16 for 2/9/16 as a late entry indicated Resident # 192's left hip surgical incisions staples were removed and the resident was identified with a stage 2 pressure ulcer area on the buttock that measure 0.5 Centimeter (CM) by 0.5 CM with pink tissue. A new physician's orders [REDACTED]. The resident's skin remained intact over bony prominences and indicated Resident # 192 was evaluated by the Advanced Practice Registered Nurse (APRN). The Wound Care documentation dated 2/17/16 indicated the resident's left buttock stage 2 pressure ulcer was now an unstageable area that measured 1.0 CM by 1.0 CM with 80% pink tissue and 20 % yellow slough. On 2/19/16 surveyor requested to view Resident # 192 ' s Nurse Aide (NA) assignment sheets dated 1/17/16 through 2/8/16(the time frame prior to the resident developing a stage 2 pressure ulcer on 2/9/16) on the buttock area with RN # 1 and was informed the sheets were unavailable. Interview with Registered Nurse (RN) # 1 on 2/19/16 at 11:30 A.M.identified Resident # 192 was admitted to facility on 1/17/16 and at the time of admission to the facility, the resident did not have any open areas to the buttocks and/or coccyx. Further interview with RN# 1 at 1:45 P.M. indicated when she assessed the resident's buttock and noticed redness to the area she failed to implement turning and repositioning. RN # 1 also indicated she made a mistake by not implementing a turning and repositioning plan for Resident # 192 when the resident was identified with a red buttock. Interview with Nurse Aide (NA) #1 on 2/19/16 at 2:25 P.M. identified the Nurse Aide computerized charting system alerts nurse aides when to turn and reposition residents. During an interview with the Occupational Therapist (OT) # 1 on 2/19/16 at 1:00 P.M. identified on admission Resident # 192 had difficulty staying on his/her side secondary to pain due to a fracture and indicated the resident could only shift slightly in the bed. Review of the facility Pressure Ulcer Treatment Policy and Procedure directs staff to establish a written repositioning/turning per Medical Doctor (MD) and APRN orders, to encourage the patient to shift weight every 15 minutes while in the wheelchair and to use proper positioning and turning techniques.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to ensure that the use of enablers/side rails did not impede the resident from exiting the bed. The findings include: Resident #1 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] identified that Resident #1 had been admitted for epistaxis and had received Aspirin 81 milligram (mg), [MEDICATION NAME] 0.5 mg daily adjust per the [MEDICATION NAME] (PT) and International Ratio (INR). The summary indicated that Resident #1 wore a life vest, Cardioverter defibrillator, and that the INR on [DATE] was 3.32 (normal range 0XXX,[DATE].10). The Consent to Use Enablers dated [DATE] indicated that all beds were equipped with enablers to assist a resident with turning and moving in bed as needed. The enablers will improve, enhance or promote a resident ' s functional independence. The enabler may be easily released by the resident from inside the bed by applying light pressure on the lever and the attending physician has recommended the use of enablers. The consent was signed by Resident #1 on [DATE]. Although the consent explained the risks and benefits of using the enablers, the consent did not indicate the number of side rails that would be utilized for the resident. Review of the admission physician's orders [REDACTED]. The orders failed to reflect the use of enablers and/or the number that were to be implemented. The admission nursing assessment dated [DATE] identified Resident #1 was alert, oriented to person, place and time, had no history of falls, restraints were not utilized, was incontinent of bladder and utilized incontinent briefs, required one person extensive assistance with transfers in and/or out of bed, utilized a wheelchair and/or walker for mobility and the anticoagulation assessment identified the resident received [MEDICATION NAME], Aspirin and [MEDICATION NAME]. The fall risk assessment dated [DATE] identified Resident was a high risk for falls. The occupational therapy initial evaluation dated [DATE] identified that Resident #1 had presented looking somewhat tired, groggy and preferred to remain in bed due to feeling tired. The resident had difficulty following verbal commands, had decreased orientation to self and general time and declined the mobility assessment out of bed. The evaluation identified Resident #1 was educated on safety awareness, the use of the call bell for assistance out of bed, use of the rolling walker and the resident was left in bed with half rails. The [DATE] Medication Administration Record [REDACTED]. The nurse's note dated [DATE]/ at 3:08 AM stated charting for ,[DATE] 15 Resident with episodes of aggravation and calling out, needed frequent checks, incontinent of urine twice, life vest on at all times and resident remained in bed throughout the shift. The Reportable Event Form dated [DATE] at 2:00 AM identified Resident #1's roommate was woken up from a sound sleep and called for help stating Resident #1 had fallen. When staff entered the room Resident #1 was found on the floor near the end of the bed. Resident #1 was noted to keep saying ouch, a bump and skin tear were noted on the left side of the head, pupils were equal and reacting to light, vitals were blood pressure ,[DATE], pulse 90, respirations 21 oxygen saturation 96% on room air (on admission vital signs were blood pressure ,[DATE], pulse 78, respirations 18 and oxygen saturation 97%). The report indicated that Resident #1 climbed between the rails of the bed, losing his/her balance and fell against the wall hitting his/her head. 911 was activated and Resident #1 was transferred to the hospital for an evaluation. The hospital record dated [DATE] identified Resident #1 sustained an acute subdural hemorrhage along the falx, tentorium and overlying the right temporoparietal region, acute subarachnoid hemorrhage in the quadrigeminal cistern and sulcus along the right frontal lobe, a five (5) centimeter left temporal subgaleal hematoma without underlying osseous injury. In addition the resident sustained [REDACTED]. The hospital social work note dated [DATE] identified the plan was Resident #1 to return to the Rehab facility. The hospital Advanced Practice Registered Nurse's (APRN) note dated [DATE] at 7:48 PM Resident #1 became bradycardic, asystole and expired at 7:06 PM. The facility investigation in a written statement the ,[DATE]AM Nurse Aide (NA) identified Resident #1 was found on the floor to the right of the dresser with no clothing on except for the non-skid socks. The statement indicated it appeared Resident #1 hit his/her head since there was blood on the resident's head and floor and a bump on the side of the head. The nurse aide noted the bed was in the lowest position and the side rails were up. Interview with the ,[DATE]AM nurse aide, NA #2 on [DATE] at 1:00 PM identified she had checked on Resident #1 thirty (30) minutes before the fall. NA #2 stated that the resident was found on the floor, naked by the dresser, near the wall, all four (4) one-half side rails were up and the bed was in a low position. NA #2 indicated Resident #1 was non-compliant, determined to be independent and was not steady on his/her feet. In an interview with the two licensed charge nurses on duty [DATE], neither one could recall Resident #1. Interview with the Director of Nursing (DON) on [DATE] at 1:15 PM identified that with all four (4) half side rails up a resident was able to exit the bed and that all four (4) side rails when up was not considered a restraint. Review of the Consent to Use Enablers with the DON failed to reflect documentation that directed the number of side rails the resident had agreed to be utilized. The Enabler/Side rail policy identified that all beds are equipped with enablers to assist residents with turning and moving in bed as needed. These enablers will improve, enhance or promote a resident ' s functional independence. The enabler is easily released from inside the bed by light pressure on the lever. Resident, family, physician and case manager discuss the use of enablers at admission and consent form to use enablers is signed at this time. The policy failed to reflect clarification of the number of enablers that would be utilize, i.e. two, three, four, on the bed.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled resident (Resident #3) that were reviewed for pressure ulcers, the facility neglected to provide care and services for a resident who had an immobilizer on the right extremity to prevent the development of pressure areas which resulted in immediate jeopardy. The findings include: Resident #3 was admitted to the facility on [DATE] following a hospitalization for a right femoral neck fracture. The hospital discharge summary dated 11/12/14 directed partial weight bearing of the right lower extremity, maintain posterior and anterior total hip precautions, elevate the extremity above the heart intermittently throughout the day to minimize pain and swelling and to wear the right knee immobilizer while in bed at night. The physician's admission order dated 11/12/14 directed a right knee immobilizer while in bed at night. The orders did not direct when to remove the immobilizer and how often to assess the skin. Review of the Wound Care Notes dated 11/13/14 and 11/14/14 identified a right knee immobilizer was in place and the skin was intact. The Skin Assessment Documentation Form dated 11/17/14 identified that the right lower extremity immobilizer was removed, the skin was intact however the extremity was tender and warm to touch and positive Circulation, Movement and Sensation (CMS) were present. The note indicated to promote comfort ABD pads were applied between the skin and immobilizer. The Skin Assessment Documentation Form dated 11/21/14 identified the right leg immobilizer was removed. The skin was red, non-blanchable, and tender to touch and an ABD pad was applied for protection. Review of the clinical record from 11/12/14 through 11/21/14 failed to reflect documentation that a Medical Doctor (MD) and/or Advanced Practice Registered Nurse (APRN) were notified of the 11/17/14 and 11/21/14 assessments and/or that after the redness was identified the right leg was assessed daily until 11/25/14. The wound care note dated 11/25/14 at 5:22 PM identified an unstageable pressure ulcer measuring 4.5 centimeters (cm) by 2.0 cm with 100% slough to the right achilles related to the immobilizer. Review of the November 2014 Treatment Administration Record (TAR) and nurse's notes from 11/12/14 through 11/25/14 failed to reflect documentation that the right leg immobilizer had been removed and the skin was assessed daily. The orthopedic physician's consultation report dated 11/25/14 indicated that Resident #3 has sustained a pressure ulcer to the right lower leg caused by the immobilizer. The orthopedic physician's recommendations directed to discontinue the immobilizer. Interview and review of the clinical record with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/14/15 at 2:30 PM identified that when the resident was admitted on [DATE], the nurse failed to obtain clarification of the physician's orders. The ADON stated that when a resident has an immobilizer, the expectation is that the immobilizer be removed at least daily and the skin assessed for any breakdown and the assessment documented in the clinical record. Interview with Licensed Practical Nurse (LPN) #2 on 7/14/15 at 2:35 PM identified that when she cared for Resident #3 she had not removed the immobilizer and/or assessed the skin until 11/21/14, weekly skin assessment. LPN #2 stated that she noted the right achilles area was red and tender to touch, and the right heel was reddened and did not notify the wound nurse and/or physician. Interview with the wound nurse, Registered Nurse (RN) #2, on 7/15/15 at 2:30 PM identified that she was conducting the weekly skin assessment when she identified redness at the base of the right leg immobilizer. RN #2 stated she removed the immobilizer and noted an unstageable area to the right achilles. RN #2 identified that daily skin checks are to be completed and documented on residents with splints and/or an immobilizer. Interview with LPN #1 on 7/15/15 at 2:45 PM, she identified that the only time she opened the immobilizer was on 11/23/14. LPN #1 stated that she had opened the immobilizer to assess the leg and foot for [MEDICAL CONDITION], she did not remove the immobilizer and/or assess the skin. Interview with the orthopedic physician, MD #1, on 7/16/15 at 10:10 AM identified that Resident #3's pressure ulcer on the right achilles was avoidable and most likely caused from the edge of the immobilizer rubbing on the skin. MD #1 stated that the nursing staff should have removed the immobilizer and assessed the skin daily and on admission if the orders were not clear the facility should have called for clarification. Based on observations and interviews, the facility failed to ensure that the most recent federal survey results were readily accessible to residents and/or a notice of their availability was posted. The findings include: Observations of the front lobby on 7/20/15 at 8:05 AM identified that were no binders and/or signage of the recent federal survey results. Observations at 10:00 AM identified that the federal survey results were hanging off the top left corner a bulletin board near the elevator and one could not remove the survey results from the board. The area of the bulletin board the results were pinned to did not allow easy to access if seated in a wheelchair. Interview with the Assistant Administrator on 7/20/15 at 10:45 am identified that the survey results were in a file and subsequent to inquiry a binder was put together and the new location for the federal survey results was the main lobby.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #3) who utilized an immobilizer, the facility failed to monitor, assess and/or implement interventions to prevent skin breakdown which resulted in immediate jeopardy. The findings include: Resident #3 was admitted to the facility on [DATE] following a hospitalization for a right femoral neck fracture. The hospital discharge summary dated 11/12/14 directed Resident #3 to be partial weight bearing of the right lower extremity, maintain posterior and anterior total hip precautions, elevate the extremity above the heart intermittently throughout the day to minimize pain and swelling and to wear the right knee immobilizer while in bed at night. The physician's admission order dated 11/12/14 directed right knee immobilizer while in bed at night. The Nursing Admission assessment dated [DATE] identified that the resident had a right hip incision and skin tear. Review of the Wound Care Notes dated 11/13/14 and 11/14/14 identified a right knee immobilizer was in place and the skin was intact. The Minimum Data Set assessment dated [DATE] identified Resident #3 had no cognitive impairments, required extensive assistance with activities of daily living, functional limitations in range of motion, and had the presence of pressure ulcers and was at risk for further development. The admission resident care plan dated 11/17/14 identified skin integrity impairment. Interventions directed to monitor the skin and report changes, protect and off load the heels, and follow up appointment with the orthopedic surgeon and follow recommendations. The November 2014 Treatment Administration Record (TAR) identified the knee immobilizer while in bed at night at 9:00 PM but failed to reflect documentation of a time to remove the immobilizer. The Skin Assessment Documentation Form dated 11/17/14 identified that the right lower extremity immobilizer was removed, the skin was intact however the extremity was tender and warm to touch and positive Circulation, Movement and Sensation (CMS) were present. The note indicated to promote comfort ABD pads were applied between the skin and immobilizer. The assessment identified the right heel was reddened and a dry protective dressing was applied. The Skin Assessment Documentation Form dated 11/21/14 identified the right leg immobilizer was removed. The skin was red, non-blanchable, and tender to touch and an ABD pad was applied for protection. The assessment identified the right heel was red and a dry protective dressing was applied. Review of the clinical record from 11/17/14 through 11/21/14 failed to reflect documentation that a Medical Doctor (MD) and/or Advanced Practice Registered Nurse (APRN) were notified of the assessments and/or that interventions were implemented to relieve pressure. The wound care note dated 11/25/14 at 5:22 PM identified an unstageable pressure ulcer measuring 4.5 centimeters (cm) by 2.0 cm with 100% slough to the right achilles related to the immobilizer. A physician's orders [REDACTED]. Review of the MD/APRN progress notes from the time of admission 11/12/14 through 11/25/14 failed to reflect documentation that Resident #3's right leg had been assessed by the physician and/or APRN. The orthopedic physician's consultation report dated 11/25/14 indicated that Resident #3 has sustained a pressure ulcer to the right lower leg caused by the immobilizer. The orthopedic physician's recommendations directed to discontinue the immobilizer, maintain total hip precautions and weight bearing as tolerated. Subsequent to the development of the unstageable area on Resident #3's right lower extremity interventions were implemented. Review of the November 2014 Treatment Administration Record (TAR) identified to elevate the resident's bilateral lower extremities as much as possible. Interview with Licensed Practical Nurse (LPN) #2 on 7/14/15 at 2:35 PM identified that on 11/21/14 she conducted the weekly skin assessment. LPN #2 indicated she opened the immobilizer but did not take the immobilizer off. LPN #2 stated that the right achilles area was red and tender to touch, and the right heel was reddened. LPN #2 identified that she applied an ABD pad to keep the leg off the immobilizer and a dry protective dressing to the heel, but did not implement interventions to relieve pressure to the areas and/or report her findings because the areas were not open. Interview and review of the clinical record with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/14/15 at 2:30 PM identified that when the resident was admitted on [DATE], the nurse failed to obtain clarification of the physician's orders. Upon further review, the clinical record failed to reflect documentation of the removal of the right leg immobilizer, daily skin checks and interventions to relieve pressure from the leg and heel. The ADON stated that when a resident has an immobilizer, the expectation is that the immobilizer be removed at least daily and the skin assessed for any breakdown and the assessment documented in the clinical record. The DON indicated that the facility did not have a policy and procedure in place that directed care of a resident with an immobilizer. Interview with the wound nurse, Registered Nurse (RN) #2, on 7/15/15 at 2:30 PM identified that she was conducting the weekly skin assessment when she identified redness at the base of the right leg immobilizer. RN #2 stated she removed the immobilizer and noted an unstageable area to the right achilles. RN #2 identified that on 11/17/14 and 11/21/14 when the areas were first identified she should have been made aware so she could have assessed the area and implement interventions to relieve pressure. Interview with the orthopedic physician, MD #1, on 7/16/15 at 10:10 AM identified that Resident #3's pressure ulcer on the right achilles was avoidable and most likely caused from the edge of the immobilizer rubbing on the skin. MD #1 stated that the nursing staff should have removed the immobilizer and assessed the skin daily. MD #1 identified that on admission if the orders were not clear the facility should have called for clarification. MD #1 indicated that on 11/17/14 when the right achilles was first noted to be red, tender to touch and the heel red he should have been notified.

Based on clinical record reviews, review of facility documentation, and interviews for one of three sampled residents (Resident #4) reviewed for medication errors, the facility failed to administer medications as prescribed by the physician to the correct resident. The findings include: Resident #4's [DIAGNOSES REDACTED]. The five day Minimum Data Set assessment dated [DATE] identified that Resident #4 had no memory or cognitive impairments, required extensive assistance with activities of daily living, and received antipsychotic and antianxiety medications. The Reportable Event Form dated 7/1/14 at 9:40 PM identified that Registered Nurse (RN) #5 entered Resident #4 and Resident #13's room to administer medications. RN #5 heard Resident #13 in the bathroom and noted the resident was about to fall. RN #5 placed the medication cup down on Resident #4's overbed table to assist Resident #13. While RN #5 was assisting Resident #13, Resident #4 had taken the medication cup and consumed some of Resident #13's medications. The nurse's note dated 7/2/14 at 1:59 AM, charting for 7/1/14, identified that RN #5 entered Resident #4 and Resident #13's room to administer both residents their medications at approximately 9:40 PM. Upon entering the room RN #5 heard crying from the bathroom and when she looked into the bathroom it appeared Resident #13 was about to fall. RN #5 placed both medication cups down on Resident #4's over bed table and went to assist Resident #13 in the bathroom. The note indicated that while assisting Resident #13 back to bed, RN #5 observed Resident #4 holding a cup of medications and water. RN #5 immediately grabbed the pills out of Resident #4's hands, noted that some of the pills were missing and the medications Resident #13's medications. The physician was notified and directed to monitor Resident #4 and hold the [MEDICATION NAME]. Review of the nurse's notes from 7/2/14 at 1:59 AM through 7/2/15 identified that Resident #4 was arousable and vital signs were stable throughout the night. On 7/2/15 at 9:20 AM when the day shift charge nurse, RN #6, went to administer medication to Resident #4, the resident was noted to be in a deep sleep and unarousable. Vital signs identified the blood pressure was 93/32 (normal range 117/52-136/64), heart rate 78 (normal range in the 70's), respirations 13 and an oxygen saturation level of 88% on room air (normal 95-98%). The Advanced Practice Registered Nurse (APRN) was notified and ordered Intravenous (IV) fluids, 5% [MEDICATION NAME] with ½ Normal Saline, 200 cubic centimeter (cc) bolus and then run continuously at 75 cc per hour, two liters of oxygen to keep the oxygen saturation levels above 92%. The note identified that the resident's vital signs were checked every fifteen minutes. At 11:15 AM Resident #4 opened his/her eyes, was slightly responsive to mild stimuli, able to squeeze both hands and had no urine output. The APRN directed to obtain a bladder scan and if greater than 300 cc straight cath. At 12:00 PM the bladder scan indicated 379 cc, Resident #4 was straight cath for 300 cc of urine and the resident remained unarousable. At 12:50 PM the resident had no change in condition and subsequent to physician notification Resident #4 was transferred to the hospital. The APRN's progress note dated 7/2/15 identified that Resident #4 had ingested the roommate's medication, [MEDICATION NAME] 300 milligrams (mg), Klonopin 2 mg, [MEDICATION NAME] XR 50 mg and [MEDICATION NAME] ER 20 mg. The hospital discharge summary dated 7/3/14 identified Resident #4 was admitted overnight for mental status changes related to inadvertently ingesting the roommate's medications. Interview with RN #5 on 1/13/15 at 2:40 PM identified that she entered Resident #4 and Resident #13's room with both residents' medications. RN #5 indicated that Resident #13 had called to her from the bathroom. RN #5 stated she set both medication cups down on Resident #4's overbed table to assist Resident #13. RN #5 identified that after assisting Resident #13 back to bed, she turned and saw Resident #4 with a medication cup of in his/her hand. RN #5 stated she went over to Resident #4 took the cup of medications away from the resident and noted four or five medications were gone. RN #5 alerted the Nursing Supervisor and the physician was notified. RN #5 stated that she had poured and was going to administer both residents' medications at the same time because she was running behind and it was a busy night. Review of policy and procedure for Proper Administration and handling of Medications identified medications should never be left at the bedside and never leave medications unattended.

Based on observation, review of the clinical record, and staff interview for one of three sampled residents (Resident #447) who was reviewed for pressure ulcers, the facility failed to provide services according to the physician's orders [REDACTED]. The findings include: Resident #447 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] documented a pressure ulcer on the area of the coccyx/buttocks. No pressure ulcer stage or measurements were documented on the assessment. A wound care note dated 4/17/14 identified a stage III pressure ulcer that measured 1.5 by 2.0 by 0.2 with 100% slough. physician's orders [REDACTED]. The care plan dated 4/17/14 directed weekly wound documentation, turn and reposition every two hours, pressure relief device to bed and chair, and off load heels. Observation 4/21, 4/22, and 4/23/14 identified the resident had a two tone blue foam mattress and no air mattress was present. Interview and observation with the ADNS on 4/23/14 at 3:15PM, 7 days after the physician ordered the air mattress, identified the resident did not have an air mattress on the bed. The ADNS could not identify why it had not been placed. In a subsequent interview with the ADNS on 4/24/14 at 9:10AM it was identified that upon request, maintenance places the air mattress. Additionally, there was a new staff member who was unaware that the request for the air mattress needed to be placed into the maintenance book and it was not done. Upon request in the maintenance book, air mattresses will be placed within 24 hours. Subsequent to surveyor inquiry, the air mattress was applied. A wound care note dated 4/22/14 at 5:19 PM identified a stage III pressure ulcer on the sacrum that measured 3.0cm by 1.5cm by 0.1cm with 100% slough, the bilateral buttocks were denuded and measured; left buttock 6.0cm by 6.0cm and right buttock 2.6cm by 0.5cm with [MEDICATION NAME] tissue. Review of the Treatment Administration Record (TAR) dated 4/22/14 directed to cleanse the right and left buttock denuded area and apply [MEDICATION NAME] Alginate followed by Allevyn dressing every other day and as needed. A weekly skin assessment dated [DATE] identified a stage III pressure ulcer on the buttock. A wound note dated 4/24/14 identified three areas; 1. Right buttock stage III 2.5cm by 0.8cm by 0.1cm, (new). 2. Left sacrum (original area) stage III 4.5cm by 1.8cm by 0.1cm (deteriorated). 3. Left buttock stage III 1.2cm by 2cm by 0.1cm and another area that measured 2.5cm by 2.4cm by 0.1cm (new). Observation on 4/24/14 at 11:00AM identified the resident was seated in a recliner chair with a Geomatt chair cushion. Additionally, a chuck pad quadruple folded and a hoyer pad was between the resident's buttock and the Geomatt. Interview with the Quality Systems Coordinator, (manufacturer of the Geomatt cushion) on 4/24/14 12:10PM identified four layers would decrease the benefit of the pressure reduction significantly. Interview with the RN Manager at the [MEDICAL TREATMENT] center on 4/24/14 at 12:00PM identified they were unaware the resident had a pressure ulcer and the facility had not sent the resident with the Geomatt cushion when he/she came to [MEDICAL TREATMENT]. Additionally, the RN Manager stated that [MEDICAL TREATMENT] usually takes about 4 hours and the resident usually sits in a chair that is not pressure reducing.

Based on clinical record review and staff interview for one of three sampled residents reviewed for falls(Resident # 185), and/or for two of nine residents (Resident #530 and Resident #531) with smoking privileges, and/or for one of four nursing units(RC), the facility failed to ensure adequate supervision to prevent an accident for R#185 and /or failed to ensure adequate supervision and/or adequate communication to staff regarding the level of supervision required for smoking for R#530 and R#531 and/or for one of four nursing units the facility failed to maintain acceptable water temperatures. The findings include: 1. Resident # 185's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified intact cognition, required extensive assistance of 2 staff members for toilet use, not steady moving on and off toilet, only to stabilize with staff assistance, and as having a fall since admission. The resident care plan initiated 2/12/13 identified potential for falls related to unsteady gait. Interventions included falling star program, reminders regarding safety, encourage using call bell, monitoring for steadiness and balance, and place frequently used items within reach to avoid over reaching. The nurse's notes dated 2/18/13 at 3:45PM identified Resident # 185 was found on floor in the bathroom, the RN was made aware and a complete assessment was done. The resident was transferred to the hospital and admitted with a left femur fracture. Review of the facility documentation dated 2/18/13 at 3:45PM identified Resident # 185 was assisted to the bathroom and the nurse aide stepped outside of the room at which time the resident leaned forward to pick something up, lost his/her balance and fell off the toilet. Additionally, the documentation identified Resident #185 was non-compliant with safety education, exhibited a decrease in balance and did lose his/her balance occasionally. Interview and review of the clinical record on 5/22/13 at 11:00AM with Occupational Therapist #1 identified on 2/8/13 the initial occupational therapy evaluation noted Resident #185's sitting static was good, but on 2/15/13 the weekly progress note for occupational therapy identified the resident presented with decreased safety in the bathroom and decreased range of motion. Interview with NA # 1 on 5/22/13 at 2:10PM identified that he/she was walking by the residents ' room and observed Resident#185 ambulating independently in an unsteady manner and went into assist the resident to the bathroom. NA #1 identified he/she assisted the resident onto the toilet and went outside the bathroom to provide privacy and was standing on the other side of the bathroom door with it "cracked" open. Additionally, NA#1 identified Resident #185 was on the falling star program and should not have been left alone in bathroom. Interview with the RN Supervisor on 5/22/13 at 1:10PM identified Resident # 185 had a history of [REDACTED]. Interview with the DNS on 5/22/13 at 2:45PM identified that if the resident was unsteady walking around in the room, she would expect the resident not be left alone. 2. Resident #530 [DIAGNOSES REDACTED]. The physician orders [REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, was totally dependent on one staff member for locomotion off the unit and exhibited functional limitations of bilateral upper extremities. A care plan dated 5/17/13 identified smoking activity with interventions which included to review smoking policy with resident and family on admission, readmission and as needed. A smoking assessment dated [DATE] identified Resident #530 was able to smoke independently. Observation on 5/20/13 at 9:45AM with the MDS Coordinator identified Resident #530 smoking a cigarette in the designated smoking area with a family member and a portable oxygen tank attached to the wheelchair. Resident # 530 identified that although the oxygen tubing was in place, the oxygen was off during the smoking activity. Additionally, two other residents were in the smoking area. The MDS coordinator immediately removed the portable oxygen tank and placed it inside the building away from the smoking area. Interview with the MDS coordinator at the time, identified that the charge nurse may have not been aware that the family escorted Resident#530 outside to smoke and it is the facility policy to ensure that residents who smoke, remove oxygen prior to smoking and keep any portable oxygen tanks inside the facility during smoking activity. Interview with Registered Nurse #4(RN#4) on 5/20/13 at 10:05AM identified that although Resident #530 is independent with smoking, he/she rings for assistance to the designated area to smoke as he/she is not able to self-propel in the wheelchair and he/she was not aware that the resident left the nursing unit. 3. Resident#531's [DIAGNOSES REDACTED]. The smoking assessment dated [DATE] identified a safety risk while smoking at the facility despite absence of identified problems with compliance, cognitive and physical abilities. The smoking care plan dated 5/7/2013 identified interventions that included encourage smoking cessation, allow resident to smoke in designated area and review smoking policy with resident and family on admission , readmission and as needed. Observation on 5/20/13 at 8:30AM identified Resident #531 light a cigarette after taking the lighter out of his/her pocket in the smoking area. Clinical record review and interview with LPN#2 on 5/20/13 at 10:30AM identified Resident#531 was a supervised smoker that required staff to be with the resident while smoking. LPN#2 further identified that staff is made aware of the resident's smoking status and level of assistance required by a triangle symbol in the electronic record. Further interview identified that smoking materials for residents who required supervision while smoking were kept at the nurse's station by the charge nurse. A review of the facility smoking policy identified that a smoking assessment is completed by the admission nurse, on readmission and then quarterly for all residents who wish to smoke. Interview with the ADNS on 5/20/2013 at 2:00PM identified Resident #531 was now an independent smoker and the facility failed to complete a revised smoking assessment after 5/7/13 which accurately reflects the residents ability to smoke independently . 4. Observations on 5/22/13 at 10:00AM of the second floor with the Director of Maintenance identified a water temperature of 129 degrees in room 202 and the second floor dining room. Interview with the Director of Physical Plant at the time identified that water temperatures are monitored weekly, with the last temperatures being monitored on May 15th. Interview with the Assistant Administrator on 5/22/13 at 10:56AM identified a problem with the mixing valve over the past 15months and the valve had been replaced within the past two weeks. The Assistant Administrator identified that it would be the expectation that increased monitoring of water temperatures should have been initiated and documented to ensure the water temperatures were maintained at an acceptable level when the problem with the mixing valve was identified.

Based on clinical record review and staff interview for one of three sampled residents who was reviewed for accidents (R#380), the facility failed to provide the necessary supervision to prevent an elopement and/or for one of three resident reviewed for accidents (Resident #506), the facility failed to provide adequate supervision to prevent an accident and/or for one of three sampled residents identified as a smoker (Resident #508) the facility failed to provide adequate supervision during smoking to ensure the safety of the resident. The findings include: 1. Resident #380's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with intact cognition. A nurse's note dated 12/17/11 at 7:55 AM identified the resident as confused, agitated and wanted to leave the facility. The resident started packing and indicated he/she had called a taxi. Interview with LPN#1 on 5/1/12 at 1:50 PM identified the resident was very agitated on the morning of 12/17/11 and he/she said she was going to call a taxi and leave the building. LPN #1 reported the incident to RN#1 and the nurse aides on the unit and tried to keep an eye on the resident during medication administration. Interview with RN#1 on 5/1/12 at 1:25 PM identified that the resident had a history of [REDACTED]. Additionally, the morning of 12/17/11 the resident was agitated, confused and argumentative and although staff were aware that the resident verbalized he/she wanted to leave and called a taxi, there was no evidence that staff provided supervision to prevent an elopement. Review of the clinical record identified that by 9:00 AM, the resident was missing and the Missing Person Protocol was initiated. Interview with the DNS on 5/1/12 at 12:45 PM identified that although the facility has a policy on missing person, there is no facility policy on wandering and/or elopment prevention. 2. Resident #506's [DIAGNOSES REDACTED]. An interagency referral report (W-10) dated 4/19/12 identified the resident at a high risk for falls secondary to refusals of utilizing appropriate assistive device and decreased balance. A hospital discharge summary dated 4/19/12 further indicated the resident was at a high risk for falls due to chronic back pain. Fall risk assessment dated 4/19/12 identified a high risk for falls with a score of 13 ( score greater than 9 indicates high risk) with interventions that included to encourage the use of call bell and adaptive device as needed. An initial PT note dated 4/20/12 recommended to transfer the resident with minimum assist of two (sit to stand) and to ambulate the resident with a rolling walker with minimum assist of two. Further review of PT notes indicated that the resident's knees had a tendency to buckle due to weakness. OT note dated 4/21/12 indicated that the resident' s standing balance as fair to poor and required moderate assistance for toilet hygiene. A nurse's note dated 4/21/12 identified the resident was found on the floor in the bathroom. The resident indicated he/she tried to get up from the toilet and hit his/her head on the wall. Interview with NA#3 on 5/2/12 at 1:45 PM indicated that after assisting the resident to the bathroom, the resident requested privacy once seated on the toilet. NA#3 then indicated she closed the bathroom door and stood outside the door waiting for the resident to call. NA#3 indicated she heard a loud thump and then saw the resident on the floor. Review of the Accident/Incident report dated 4/21/12 identified the resident was transferred to the emergency room (ER) and sustained a fracture through the anterior arch of cervical vertebrae #1 (C1). Interview with the Rehabilitation Manager (PTM) and the ADNS on 5/02/12 at 2:00 PM indicated that it was a facility practice that once a resident is identified a fall risk, that resident cannot be left alone in the bathroom with visual contact maintained at all times. The PTM indicted that staff are provided with a "transfer board" at the start of each shift for reference. Interview with the ADNS on 5/02/12 at 8:45 AM and review of the transfer board printed out on 4/20/12 identified the resident required a minimum assist of one for transfers. The PTM indicated that the transfer board information was in error. Further review failed to identify the resident as a fall risk. Interview with the ADNS on 5/2/12 at 2:00 PM identified that the facility has three ways to identify a fall risk: by the transfer board, by a blue bracelet that is applied by the admitting nurse and by a blue star that is also placed by the door by the admitting nurse. The ADNS further indicated that although the transfer board did not indicate R#506 was a fall risk, other systems were in place to identify that the resident was such and therefore could not be left alone in the bathroom. 3. Review of the smoking assessment dated [DATE] identified R#508 as a smoker and "not smoking for seven weeks as per resident". A RCP dated 4/13/12 identified that resident smokes outside in designated area daily, with interventions that included, to explain rules of smoking and monitor for compliance. Observation on 5/2/2012 at 8:45 am identified R#508 in "designated smoking area", smoking unsupervised on patio. Interview with LPN #3 on 5/3/2012 at 9:15 AM indicated that he was aware that the resident smokes, and indicated that the resident did not smoke for six to seven weeks while hospitalized . Review of the facility's smoking policy indicates that a smoking assessment is completed by the admission nurse upon admitting the resident to the facility, on readmission, and then quarterly for all residents who wish to smoke.