Every finding on record at Mozaic Senior Life

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from physical restraints imposed for staff convenience. The findings include: Resident #1 had a diagnosis of Alzheimer's and insomnia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive assessment completed, had no behaviors, required maximal assistance with transfers and had no physical restraints. The Resident Care Plan (RCP) dated 3/4/26 identified a potential for falls, short/long term memory deficits, and alteration in activities of daily living (ADLs). Interventions directed to conduct frequent safety checks. Physician order dated 9/29/25 and last reviewed on 5/1/26 directed a seat belt alarm and to check function and placement every shift for Resident #1. Interview with the Rehabilitation Director on 5/20/26 at 9:13 AM identified Resident #1 was assessed to have an alarmed seat belt and was found the intervention was appropriate for the resident and that Resident #1's alarmed seat belt was self-releasing. Nursing note dated 4/23/26 at 12:27 AM identified Resident #1 was alert, confused and had no distress noted. Bed and chair alarm in place and functioning well, and Resident #1 was out of bed to wheelchair for safety. Facility email dated 4/22/26 at 4:19 PM from OT #1 addressed to the DNS indicated OT #1 observed Resident #1 this afternoon his/her self-releasing (seat) belt was tied. I did not see an aide or nurse nearby at the time to ask about it, so I wanted to bring it to your attention. I am not sure if it is broken or may need a new one. Resident #1 was currently on case load for positioning and OT #1 will let the therapist know. Facility reportable event dated 4/23/26 at 9:53 AM identified on 4/23/26 at approximately 8 AM, a message was received that Resident #1's seat belt had been tied in place on 4/22/26. Per the message, Resident #1 was seated in his/her wheelchair, and his/her alarmed seat belt was tied closed. Advanced Practice Registered Nurse (APRN) note dated 4/23/26 at 6:51 PM identified on 4/23/2026 Resident #1 was seen due to being found with his/her seat belt tied. Resident #1 had decreased safety awareness with multiple attempts to climb out of the wheelchair. Resident #1 examined no acute abdominal injury noted, and was at baseline cognition. Resident #1 was stable and currently in no acute distress. Reportable event summary dated 4/27/26 identified on 4/23/26 at approximately 8:00 AM an e-mail was received from OT #1 stating that Resident #1's alarmed seat belt was noted to be tied on 4/22/26 at approximately 3:45 PM. No injury was noted. Facility investigation determined that an alarmed seat belt, which the resident was able to release independently, was tied in a closed position between approximately 3:30 PM and 3:45 PM and through much of the evening shift. NA #1 was assigned to Resident #1 during the evening shift and reported that Resident #1 was very restless and repeatedly opening the alarmed seat belt, causing the alarm to sound. NA #1 stated that she tied the alarmed seat belt in an effort to maintain the resident's safety and prevent a potential fall with injury. Interview and documentation review with NA #1 on 5/18/26 at 12:35 PM identified she was assigned to provide care for Resident #1 on 4/22/26 during the 3 PM to 11PM shift. NA #1 stated Resident #1 was in his/her wheelchair at the start of her shift, and he/she kept trying to get out of the wheelchair. NA #1 stated she was busy and around 3:30 PM to 4 PM, she took disposable cleaning wipes and wrapped it around the Velcro part of the alarmed seat belt so he/she could not remove the seat belt. NA #1 further stated she took Resident #1 to the bathroom throughout the shift and put him/her back the wheelchair and re-tied the alarmed seat belt again after each toileting. NA #1 indicated she did this until 7 PM when she put Resident #1 back to bed, and stated she did not tie him/her down in the bed. NA #1 said tied the seat belt with the disposable cleaning wipes so the resident would not fall, and stated she knew that tying the alarmed seat belt would be considered a restraint. NA #1 stated she did not think it was a problem to tie the seat belt because she was doing it for safety reasons. NA #1 stated she did not tell the nurse or nursing supervisor that Resident #1 kept trying to get up and did not know she could contact the nursing supervisor. Interview with LPN #1 on 5/18/26 at 3:12 PM identified she was the charge nurse for Resident #1 on 4/22/26 on the 3 PM to 11 PM shift. LPN #1 stated she was not notified that Resident #1 was restless or trying to get up, and she did not recall seeing the alarmed seat belt tied. Interview with OT #1 on 5/19/26 at 9AM identified around 4 PM she observed Resident #1 with his/her seat belt alarm wrapped with what looked like a washcloth and she was not sure if the seat belt was broken. OT #1 stated there were no staff around and her manager had left for the day, so she decided to send an email to the Director of Nursing (DNS) to notify the DNS. OT #1 stated she did not check the seat belt alarm to make sure it was functional, and stated she probably should not have left Resident #1 with the seat belt tied. Interview with the Director of Nursing (DNS) on 5/19/26 at 9:30 AM identified when she came into work on 4/23/26, she saw the email from OT #1 that reported Resident #1's alarmed seat belt was found tied with something that looked like a cloth, but OT #1 was not sure if the seat belt was broken. Resident #1 was assessed by the APRN with no injuries were found and an investigation was started. NA #1 was assigned to Resident #1 on 4/22/26 on the 3 PM to 11 PM shift, and NA #1 stated she had tied the Velcro part of the alarmed seat belt with disposable washcloth around 3:45 PM to prevent Resident #1 from getting up. NA #1 stated she tied it for safety reasons which was to help prevent the resident from falling and NA #1 stated she had tied Resident #1's alarmed seat belt multiple times before. The DNS seat belts should not be tied to prevent a resident from getting up, and tying the seat belt would be considered a restraint. Review of facility Abuse Policy dated 5/23/2002 directed in part, abuse included willful unreasonable confinement.

Based on record review facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse or physical restraint use timely. The findings include: Resident #1 had a diagnosis of Alzheimer's and insomnia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive assessment completed, had no behaviors, required maximal assistance with transfers and had no physical restraints. The Resident Care Plan (RCP) dated 3/4/26 identified a potential for falls, short/long term memory deficits, and alteration in activities of daily living (ADLs). Interventions directed to conduct frequent safety checks. Physician order dated 9/29/25 and last reviewed on 5/1/26 directed a seat belt alarm and to check function and placement every shift for Resident #1. Interview with the Rehabilitation Director on 5/20/26 at 9:13 AM identified Resident #1 was assessed to have an alarmed seat belt and was found the intervention was appropriate for the resident and that Resident #1's alarmed seat belt was self-releasing. Facility email dated 4/22/26 at 4:19 PM from OT #1 addressed to the DNS indicated OT #1 observed Resident #1 in his/her wheelchair this afternoon his/her self-releasing (seat) belt was tied. I did not see an aide or nurse nearby at the time to ask about it, so I wanted to bring it to your attention. I am not sure if it is broken or may need a new one. Resident #1 was currently on case load for positioning and OT #1 will let the therapist know. Facility reportable event dated 4/23/26 at 9:53 AM identified on 4/23/26 at approximately 8 AM, a message was received that Resident #1's seat belt had been tied in place on 4/22/26. Per the message, Resident #1 was seated in his/her wheelchair, and his/her alarmed seat belt was tied closed. Interview and documentation review with NA #1 on 5/18/26 at 12:35 PM identified she was assigned to provide care for Resident #1 on 4/22/26 during the 3 PM to 11PM shift. NA #1 stated Resident #1 was in his/her wheelchair at the start of her shift, and he/she kept trying to get out of the wheelchair. NA #1 stated she was busy and around 3:30 PM to 4 PM, she took disposable cleaning wipes and wrapped it around the Velcro part of the alarmed seat belt so he/she could not remove the seat belt. NA #1 further stated she took Resident #1 to the bathroom throughout the shift and put him/her back the wheelchair and re-tied the alarmed seat belt again after each toileting. NA #1 indicated she did this until 7 PM when she put Resident #1 back to bed, and stated she did not tie him/her down in the bed. NA #1 said tied the seat belt with the disposable cleaning wipes so the resident would not fall, and stated she knew that tying the alarmed seat belt would be considered a restraint. NA #1 stated she did not think it was a problem to tie the seat belt because she was doing it for safety reasons. NA #1 stated she did not tell the nurse or nursing supervisor that Resident #1 kept trying to get up and did not know she could contact the nursing supervisor. Interview with LPN #1 on 5/18/26 at 3:12 PM identified she was the charge nurse for Resident #1 on 4/22/26 on the 3 PM to 11 PM shift. LPN #1 stated she was not notified that Resident #1 was restless or trying to get up, and she did not recall seeing the alarmed seat belt tied. Interview with OT #1 on 5/19/26 at 9AM identified around 4 PM she observed Resident #1 with his/her seat belt alarm wrapped with what looked like a washcloth and she was not sure if the seat belt was broken. OT #1 stated there were no staff around and her manager had left for the day, so she decided to send an email to the Director of Nursing (DNS) to notify the DNS. OT #1 stated she did not check the seat belt alarm to make sure it was functional, and stated she probably should not have left Resident #1 with the seat belt tied. Interview with the Director of Nursing (DNS) on 5/19/26 at 9:30 AM identified OT #1 did not try to call herself or the Administrator, or any other staff when she observed Resident #1's seat belt alarm tied. The DNS stated she did not know why OT #1 did not call or contact anyone, and stated the observation should have been reported immediately to ensure the seat belt was functional and safe for the resident. The DNS stated allegations of abuse, including use of restraints, are required to be reported immediately, and she was not notified until she received the email the next day, on 4/23/26 about 8 AM (approximately 16 hours after OT #1 made the observation). Review of facility Abuse Policy dated 5/23/2002 directed in part, abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment and if observed by staff, must be reported immediately to the Nursing Director.

Based on facility documentation review and staff interviews for one of thee residents (Resident #1) reviewed for abuse, the facility failed to conduct a complete and thorough investigation regarding an allegation of abuse, to include obtaining statements from all staff that worked the shift of the alleged incident. The findings include: Resident #1 had a diagnosis of Alzheimer's and insomnia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive assessment completed, had no behaviors, required maximal assistance with transfers and had no physical restraints. The Resident Care Plan (RCP) dated 3/4/26 identified a potential for falls, short/long term memory deficits, and alteration in activities of daily living (ADLs). Interventions directed to conduct frequent safety checks. Physician order dated 9/29/25 and last reviewed on 5/1/26 directed a seat belt alarm and to check function and placement every shift for Resident #1. Interview with the Rehabilitation Director on 5/20/26 at 9:13 AM identified Resident #1 was assessed to have an alarmed seat belt and was found the intervention was appropriate for the resident and that Resident #1's alarmed seat belt was self-releasing. Facility email dated 4/22/26 at 4:19 PM from OT #1 addressed to the DNS indicated OT #1 observed Resident #1 this afternoon his/her self-releasing (seat) belt was tied. I did not see an aide or nurse nearby at the time to ask about it, so I wanted to bring it to your attention. I am not sure if it is broken or may need a new one. Resident #1 was currently on case load for positioning and OT #1 will let the therapist know. Facility reportable event dated 4/23/26 at 9:53 AM identified on 4/23/26 at approximately 8 AM, a message was received that Resident #1's seat belt had been tied in place on 4/22/26. Per the message, Resident #1 was seated in his/her wheelchair, and his/her alarmed seat belt was tied closed. Reportable event summary dated 4/27/26 identified on 4/23/26 at approximately 8:00 AM an e-mail was received from OT #1 stating that Resident #1's alarmed seat belt was noted to be tied on 4/22/26 at approximately 3:45 PM. No injury was noted. Facility investigation determined that an alarmed seat belt, which the resident was able to release independently, was tied in a closed position between approximately 3:30 PM and 3:45 PM and through much of the evening shift. NA #1 was assigned to Resident #1 during the evening shift and reported that Resident #1 was very restless and repeatedly opening the alarmed seat belt, causing the alarm to sound. NA #1 stated that she tied the alarmed seat belt in an effort to maintain the resident's safety and prevent a potential fall with injury. Interview and documentation review with NA #1 on 5/18/26 at 12:35 PM identified she was assigned to provide care for Resident #1 on 4/22/26 during the 3 PM to 11PM shift. NA #1 stated Resident #1 was in his/her wheelchair at the start of her shift, and he/she kept trying to get out of the wheelchair. NA #1 stated she was busy and around 3:30 PM to 4 PM, she took disposable cleaning wipes and wrapped it around the Velcro part of the alarmed seat belt so he/she could not remove the seat belt. NA #1 further stated she took Resident #1 to the bathroom throughout the shift and put him/her back the wheelchair and re-tied the alarmed seat belt again after each toileting. NA #1 indicated she did this until 7 PM when she put Resident #1 back to bed, and stated she did not tie him/her down in the bed. NA #1 said tied the seat belt with the disposable cleaning wipes so the resident would not fall, and stated she knew that tying the alarmed seat belt would be considered a restraint. NA #1 stated she did not think it was a problem to tie the seat belt because she was doing it for safety reasons. NA #1 stated she did not tell the nurse or nursing supervisor that Resident #1 kept trying to get up and did not know she could contact the nursing supervisor. Review of facility staffing identified there were two (2) NAs (NA #1 and NA #3) and one (1) LPN (LPN #1) that worked on Resident #1's unit on 4/22/26 during the 3 PM to 11 PM shift, and there was one (1) free-float supervisor (RN #3). Review of facility reportable event investigation failed to identify staff from the 3 PM to 11 PM shift on 4/22/26 were interviewed regarding the incident. Review identified NA #1 was interviewed and staff that worked the shift prior were interviewed. Interviews were not obtained from the 3 PM to 11 PM shift staff, NA #3, LPN #1 and RN #3. Interview with the Director of Nursing on 5/19/26 at 9:30 AM identified she did not interview any staff members on the 3 PM to 11 PM shift that worked on 4/22/26. The DNS stated she should have interviewed all staff that worked the shift, but did she not think it was necessary at the time because NA #1 already admitted to doing it. Review of facility Abuse Policy dated 5/23/2002 directed in part, to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation.

Based on observations, interviews, review of facility documentation, and policy, the facility failed to maintain safe water temperatures and failed to monitor water temperatures in resident rooms/bathrooms to ensure residents were free from potential burns. The findings include:Resident #260's diagnoses included paroxysmal atrial fibrillation, chronic systolic (congestive) heart failure, and cardiomyopathy.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #260 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, and required partial/moderate assistance for personal hygiene, was independent for oral hygiene, transfers, and had the ability to walk 150 feet. The Resident Care Plan dated 9/4/25 identified Resident #260 was at risk for skin breakdown related to decrease in bed mobility, bowel and bladder incontinence. Interventions included incontinent care every 2 to 3 hours and scheduled skin checks. Observation on 9/22/2025 at 10:30 AM identified hot water temperatures exceeded 120 degrees Fahrenheit (F) in 25 out of 46 rooms observed. Water temperatures ranged from 120.2 degrees F to 148.5 degrees F.Observation and Interview on 9/22/2025 at 11:34 AM with Resident #260 identified his/her bathroom faucet water temperature was 121.6 degrees F. Resident #260 indicated that the water in his/her bathroom Is hot as anything!, that the water has been hot since he/she first admitted to the facility in February of 2024, and that it was especially difficult to regulate the temperature in the shower because it was so hot it took a while. Resident #260 further stated that he/she had told staff that the water was hot but didn't know if maintenance had been informed about the hot water temperature.Review of the facilities monthly domestic Hot Water Temperature Log from 8/1/2025 to 9/21/2025 identified that water temperatures were recorded high on 23 out of 52 days (greater than 120 degrees F) with no plan of correction documented or the implementation of measures to protect residents.Interview with the Maintenance Supervisor on 9/22/25 at 11:45 AM identified he checked the water temperature at the mixing valve in the boiler room daily during the morning and would record the temperatures in the log (3 different temps). For temperatures greater than 120 degrees F, he indicated he would adjust the mixing valve and watch the temperature decrease to under 120 degrees F. The Maintenance Supervisor indicated he would generally keep the temps around 118 F. According to the Hot Water Temperature Log indicating multiple temperatures above 120 degrees F for July, August, and September 2025 he failed to go into residents' rooms to check water temperatures and was unaware that he should have. Further, he identified that the facility would only check water temperatures in resident rooms for complaints of too hot or too cold water and he could not recall the last time he checked the water temperature in a resident's room.Interview and review of temperature documentation with the Director of Physical Plant and Administrator on 9/22/2025 at 2:38 PM identified the facility had taken temperatures in resident rooms previously identified by surveyors as above the requirement. After lowering the temperature at the mixing valves, the temperatures had returned to levels within the required range.Interview with the Director of Physical Plant and Maintenance Supervisor on 9/29/2025 at 10:38 AM identified that the water temperatures were checked daily at 3 mixing valves and not in resident care areas or rooms. The Maintenance Supervisor indicated that he thought that temperatures would be cooler in resident care areas/rooms after going through the mixing valves. The Maintenance Supervisor indicated that if the water temperatures were recorded above 120 degrees F, they would lower the temperature by a couple degrees and check the next day at the mixing valves. The Maintenance Supervisor stated the facility did not check the resident care area/rooms after a high temperature reading because the water system would need some time for the water temperatures to cool down.Interview with the Director of Physical Plant and Maintenance Supervisor on 9/29/2025 at 10:50 AM identified maintenance staff were responsible for taking water temperatures and should ensure the temperature was adjusted to the mixing valve by watching the monitor. The Maintenance Supervisor indicated weekend staff were not trained to make the adjustment, and the facility failed to perform adjustments to the mixing valve for elevated temperatures on 9/20/2025 and 9/21/2025 but should have. The Maintenance Supervisor identified he would be providing training for all of his staff so that adjustments could be made on the weekends. The Director of Physical Plant indicated temperatures were being taken at the mixing valve and despite elevated temperatures, as identified on the temperature logs for July, August, and September, there were no water temperatures taken in the resident areas or resident rooms. Further, he stated they had changed their Water Temperature Log form, would be documenting times temperatures were taken, and if any temperatures were over 118 degrees F, then water temperatures would be taken in resident areas/rooms.Review of the facilities operations and maintenance manual directed, in part, that mixing valves and/or anti-scald valves are necessary to reduce the final water temperature to no more than 120 degrees F in patient/resident areas to prevent scalding.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 4 sampled residents (Resident #245), reviewed for dining, the facility failed to ensure a dignified dining experience, and for 1 of 2 sampled residents (Resident #250) reviewed for urinary collection devices, the facility failed to maintain a urinary collection device for privacy. The findings include: 1. Resident #245's diagnoses included Alzheimer's disease, dementia, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #245 had a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment and required set up/clean up assistance with eating and partial/moderate assistance with transfers and bed mobility. The Dietary Change in Condition Nutrition assessment dated [DATE] identified Resident #245 fed him/herself and needed to be cued to eat with varied meal intakes ranging from 25% to 75%. The Resident Care Plan dated 7/17/25 identified Resident #245 was at risk for unintentional weight loss due to his/her hospice status. Interventions included assisting with meals as needed, monitor diet preferences, and offer substitutions of preferred foods. Review of the meal intake documentation amounts dated 8/25/25 through 9/25/25 indicated intakes varied from 0 to 100%. Observation and interview with Nurse Assistant (NA) #1 on 9/22/25 at 12:20 PM in the dining room identified Resident #245 sitting in a customized wheelchair, parallel to the corner of the kitchen counter with her/his back to the dining area. Ten residents were noted to be sitting at 2 long tables; one was being assisted by a NA. She indicated that Resident #245 was not sitting at the table with the rest of the residents because she had already tried to feed him/her and he/she refused. Additionally, she stated the reason for the separation was that Resident #245 was a puree consistency and would make a mess everywhere if seated at the table(with other residents). An observation on 9/22/25 at 12:31 PM during lunch, identified NA #1 sitting across from Resident #245 assisting him/her to eat. Resident #245 was not placed with other residents at the dining room tables while being assisted and was turned away (not facing) other residents who were still eating. An Observation on 9/24/25 at 12:03 PM during the lunch meal, identified Resident #245 sitting alone in the resident living room underneath the TV (not watching) facing residents in the dining room who were eating. Resident #245 remained in the living room watching other residents dine, did not have food, and was not being assisted. Observation on 9/25/25 at 9:32 AM identified Resident #245 awake, sitting alone in the resident living room, facing residents in the dining room who were eating breakfast. Interview with Licensed Practical Nurse (LPN) #1 on 9/25/25 at 12:15 PM identified Resident #245 did not dine with other residents because he/she needed to be fed to eat. Staff placed him/her alone, in the corner of the dining area while other residents dined and once the other residents had finished, he/she was assisted with his her/meal. LPN #1 indicated that Resident #245 was always placed away from the other residents because he/she did not always want to eat so we didn't want the other residents looking at her and feeling bad thinking that will be them someday, especially since they all used to eat together. Interview with the Director of Nursing (DNS) on 9/25/25 at 12:37 PM identified the facility policy directed the dining experience was all inclusive, and residents who didn't choose to eat in their rooms were served meals in the common kitchen area, and ate at a table, regardless of their diagnoses, mentation, or food consistency. Additionally, she identified that although some residents chose to eat at the kitchen counter, it was not acceptable to have a resident seated by the counter with her/his back facing the tables where other residents were dining. The DNS indicated it was undignified for Resident #245 to be excluded during a dining experience by being placed with their back facing the table where other residents were eating or by placing a resident who was not being served within view of other residents who were eating. The Dining Experience Policy revised 4/15/24, directed in part that all residents will have an enjoyable, dignified and safe dining experience, which includes food items being passed out in a timely manner to each Resident upon arrival of the meal. 2. Resident #250's diagnoses included retention of urine, urinary tract infection, and a pressure ulcer of the sacral region. A physician's order dated 9/3/25 directed to check Resident #250's urinary collection device and provide care every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #250 was cognitively intact and required substantial/maximal assistance for bed mobility, was dependent with toileting and transfers, and failed to indicate indwelling collection device use. The Resident Care Plan (RCP) dated 9/12/25 identified Resident #250 was admitted with an indwelling urinary collection device. Interventions included observing complications, report signs of infection, provide incontinent care, perform hand hygiene, and place on personal protective equipment when providing high contact care. Observations on 9/24/25 at 11:47 AM and 9/25/25 at 11:25 AM identified Resident #250 had his/her door open, was in bed, and the urinary collection bag containing urine was visible from the hall without the benefit of a privacy cover. Observation and interview with Nurse Aide (NA) #4 on 9/26/25 at 1:00 PM identified Resident #250 in his/her room, seated in a wheelchair, with the urinary collection device bag containing urine able to be viewed from the hallway. NA #4 indicated that it was her responsibility to ensure Resident #250's urinary collection bag was covered, but that she did not have a privacy cover available. Subsequent to surveyor inquiry, NA #4 placed a pillowcase over the collection bag and indicated that she would need to speak with her charge nurse about where to obtain a privacy cover. Observation and Interview with Licensed Practical Nurse (LPN) #4 on 9/26/25 at 1:05 PM identified Resident #250 seated in a wheelchair with the urinary collection device collection bag containing urine in view from the hallway. LPN #4 was unsure why Resident #250's urinary collection bag was not maintained for privacy, indicated the urinary collection device bag should always be covered, and that the NA was responsible. Subsequent to surveyor inquiry, LPN #4 instructed NA #4 that the pillowcase was inappropriate and that she would need to call and obtain a proper privacy cover for Resident #250's urinary collection device bag. Interview with the Director of Nursing Services (DNS) on 9/26/25 at 1:50 PM identified urinary collection device collection bags should always be covered for privacy, NA's were responsible to ensure urinary collection device bag covers, and that urinary collection device covers were in stock, so she was unable to explain the lack of a privacy cover for Resident #250 collection device bag. Review of facility policy, Urinary Collection device Care, dated 9/2005, directed urinary collection devices are cared for by all Nursing Personnel and to provide privacy. The Resident [NAME] of Rights directed, in part, that you have the right to be treated with respect, consideration and full recognition of your dignity and individuality.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #272) reviewed for dignity, the facility failed to meet the requirement to document and retain the resolution to a grievance following an orally expressed concern. The findings included:Resident #272 diagnoses included multiple sclerosis (MS), major depression, functional urinary incontinence and urinary tract infection (UTI). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #272's Brief Mental Status Interview score of 15 indicating intact cognition and was totally dependent on staff for incontinent care, dressing, bathing, and required maximum assistance of 2 staff members for bed mobility. The Resident Care Plan in effect from 9/5/25 through 9/22/25 failed to reflect any concerns with the 11:00 PM to 7:00 AM shift for the provision of incontinent care, answering of a call bell, or resolution to a concern. A physician's order dated 9/3/25 directed assistance from 2 staff members for bed mobility.An interview with Resident #272 on 9/22/25 at 2:30 PM identified that he/she had concerns with NA #11 who worked the 11:00 PM to 7:00 AM shift. He/she did not like the way NA #11 spoke to him/her and described it as demeaning and feeling like he/she was being reprimanded at times. NA #11 did not always answer the call bell timely or did not return timely after the call bell was answered. Resident #272 stated that it made him/her apprehensive to ring for incontinent care when NA #11 was working and that NA #11 provided his/her care alone. A meeting was requested and held with the Director of Nursing Services (DNS); however, the resident could not recall the date. Resident #272 stated they discussed his/her concerns regarding NA #11, and the outcome was that NA #11 could provide his/her care due to being the primary NA on the 11:00 PM to 7:00 AM shift. An interview with the DNS on 9/24/25 at 9:15 AM indicated that a meeting was requested by Resident #272 and held with NA #11 and herself, but she had failed to document the meeting. The DNS indicated that Resident #272 discussed the timeliness of answering the call bell and returning to the room for care after answering the call bell, but she did not recall any discussion regarding the way NA #11 spoke to Resident #272 other than NA #11 was loud. In retrospect, she indicated that she should have documented the meeting since it involved nursing care issues.Interview with NA #11 on 9/29/25 at 8:28 AM identified that she met with Resident #272 and the DNS, could not recall the date, and discussed concerns related to NA waiting for the call bell to be answered and receiving incontinent care. She indicated Resident #272 expressed that she talked too loudly making him/her feel as though he/she was being reprimanded. It was not her intention to reprimand Resident #272, and she may have spoken loudly at times to ensure Resident #272 could hear her. NA #11 stated she continued to provide care to Resident #272 on the 11:00 PM to 7:00 AM shift.Interview with the Administrator on 9/29/25 at 12:15 PM indicated that he was aware of the meeting that took place with Resident #272, the DNS, and NA #11 but was unsure of date. The Administrator stated he was unsure why there was no documentation related to the investigation and conclusion and that it was unintentionally overlooked.The Director of Post Acute Services verified on 9/30/25 at 1:26 PM that a meeting did take place with Resident #272, the DNS and NA #11 on 9/10/25 but there was no documentation related to the meeting. A review of the Grievance Policy dated 11/10/24 directed, in part, all complaints, problems and/or grievances will be investigated by social services/nursing in a timely manner. The facility will promote the grievance process throughout the organization. This includes notifying residents of their rights related to grievances as well as educating all those affected by potential grievances or concerns on the facility grievance process. The facility will strive for prompt resolution outcome for all grievances or complaints.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 sampled residents (Resident #272) reviewed for dignity, the facility failed to ensure 2 allegations of neglect occurring on 8/25/25 and 9/8/25, were reported to the State Agency (SA). The findings include:Resident #272 diagnoses included multiple sclerosis, major depression, functional urinary incontinence and Urinary Tract Infection (UTI). The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #272 was cognitively intact with a Brief Mental Status Interview (BIMS) score of 15 and was totally dependent on staff for incontinent care, dressing, bathing, and required maximum assistance of 2 staff for bed mobility. The Resident Care Plan dated 7/16/25 identified urinary incontinence with interventions that included incontinent care every 2 to 3 hours, apply barrier cream, perform skin assessments during daily care, nurses perform weekly skin assessments, and notify the physician for signs of a UTI.A nursing note written by Licensed Practical Nurse (LPN) #5 dated 8/25/25 at 1:07 PM identified Resident #272 reported to her that he/she had not been offered assistance and did not receive incontinent care on the previous 11:00 PM to 7:00 AM shift (8/24/25 into 8/25/25), and staff had not answered his/her call bell. Resident #272's responsible party was aware. The nursing supervisor Registered Nurse (RN) #4) was notified and went to speak with Resident #272 to address his/her concerns. A review of nursing documentation, from 8/23/25 through 8/27/25 failed to include written documentation by RN #4 of an assessment or any information for Resident #272's allegation of neglect. An interview and review of the clinical record with RN #4 on 9/26/25 at 2:15 PM identified that she was aware of the nurses note dated 8/25/25 written by LPN #5. When she saw Resident #272 the resident made his/her allegation of neglect known and indicated that his/her brief was wet. RN #4 stated that she made the ADNS aware but failed to document the concern or perform a skin assessment for incontinence skin damage, indicating a skin check was due to occur on a subsequent shift. Although RN #4 indicated it was a good practice to assess and document Resident #272's information based on the information given to her, she was unable to state the facility policy for documentation on allegations of neglect/Reportable Events.b. A nursing note dated 9/8/25 at 4:35 PM written by LPN #5 identified that Resident #272 expressed a concern that he/she did not receive incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. LPN #5 immediately notified the nursing supervisor of the concern. A physician's note signed 9/11/25 for a visit on 9/9/25 identified Resident #272 had a conflict with the third shift Nurse Aid (NA). Resident #272 did not ask for assistance for incontinent care when he/she had been incontinent, and the NA never went to check on him/her or offer to provide incontinent care. Resident #272 requested an extra absorbent pad on the bed to catch the overflow of urine and waited 12 hours between shifts for the provision of incontinent care. An interview with the Director of Nursing (DNS) on 9/25/25 at 11:00 AM identified that she was away on 8/25/25 when the allegation occurred and was never made aware, however, the allegation should have been brought to the attention of the Assistant Director of Nursing (ADNS). Additionally, she was aware of the allegation of neglect occurring on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. According to the facility abuse policy, reporting the allegations to the SA should have taken place per the facility policy, and that she and the ADNS were responsible for reporting requirements. An interview with the ADNS on 9/25/25 at 1:15 PM identified that she was aware of Resident #272's allegation made on 8/25/25 but could not locate any documentation related to the incident. The ADNS stated she recalled speaking to Resident #272 but could not provide any documentation as to whether the concerns were addressed or reported. The ADNS indicated that any allegation of neglect should be reported per the policy and was unable to explain why she had not completed a Reportable Event form or reported Resident #272's allegation of neglect to the State Agency. Interview with NA #11 on 9/29/25 at 8:28 AM indicated that she met with Resident #272 and the DNS but could not recall the date. Resident #272 had been concerned that he/she sometimes had to wait to have the call bell answered or when answered he/she had to wait for her to come back because she was attending to another resident. NA #11 stated the resident thought that she talked too loudly which made him/her feel as though he/she was being reprimanded. Further, she had always provided incontinent care to Resident #272 and had never failed to provide incontinent care when she was assigned to Resident #272.Interview with LPN #6 on 9/29/25 at 8:45AM identified that she was Resident #272's charge nurse on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. She was not made aware of any allegation by Resident #272 that he/she did not receive incontinent care. LPN #6 stated that Resident #272 did not want NA #11 to provide care to him/her and a NA from another unit needed to come over to the unit to help. Interview with RN #9 on 9/29/25 at 9:09 AM identified that she was the supervisor on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. RN #9 indicated that she did not recall any allegations of neglect reported by Resident #272 or staff that the facility failed to provide incontinent care to the resident.Interview with RN #6 on 9/29/25 at 9:50 AM indicated she was the RN supervisor on 9/8/25 on the 7:00 AM to 3:00 PM shift and had not received any reports of Resident #272 failing to receive incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. RN #6 indicated if she was made aware she would have initiated an investigation, interviewed and assessed Resident #272, contacted the NA and nurse that worked on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift, and reported the allegation to the DNS or ADNS. RN #6 indicated if Resident #272 had reported an allegation of neglect, the facility policy directed reporting to the State Agency. Interview and review of the clinical record with APRN #1 on 9/29/25 at 9:55 AM identified she was aware of the allegation of neglect for the failure to provide incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift as reported by Resident #272 during his/her visit on 9/8/25. APRN #1 stated she documented in her note and immediately reported the concern to the DNS. A review of APRN #1's note date 9/9/25 at 7:47 AM indicated that the resident had concerns related to overnight care, particularly being changed during the night, and that she informed both nursing staff and the DNS. Interview with the Administrator on 9/29/25 at 12:15 PM indicated that the 2 allegations of neglect should have been reported per the facility policy. The Administrator indicated that there were many concerns related to Resident #272 and somehow it just got overlooked. The Administrator indicated that it was his responsibility along with the DNS to ensure the Abuse policy for the reporting requirement was followed.A review of the Abuse Policy dated 5/1/24 directed, in part, that the alleged allegation will be reported to the Connecticut Department of Public Health immediately but no later than 2 hours.

Based on review of clinical records, facility documentation, facility policy, and interviews for 1 of 2 sampled residents (Resident #272) reviewed for dignity, the facility failed to ensure 2 allegations of neglect occurring on 8/25/25 and 9/8/25, were investigated. The findings include:Resident #272 diagnoses included multiple sclerosis, major depression, functional urinary incontinence and Urinary Tract Infection (UTI). The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #272 was cognitively intact with a Brief Mental Status Interview (BIMS) score of 15 and was totally dependent on staff for incontinent care, dressing, bathing, and required maximum assistance of 2 staff for bed mobility. The Resident Care Plan dated 7/16/25 identified urinary incontinence with interventions that included incontinent care every 2 to 3 hours, apply barrier cream, perform skin assessments during daily care, nurses perform weekly skin assessments, and notify the physician for signs of a UTI.A nursing note written by Licensed Practical Nurse (LPN) #5 dated 8/25/25 at 1:07 PM identified Resident #272 reported to her that he/she had not been offered assistance and did not receive incontinent care on the previous 11:00 PM to 7:00 AM shift (8/24/25 into 8/25/25), and staff had not answered his/her call bell. Resident #272's responsible party was aware. The nursing supervisor Registered Nurse (RN) #4) was notified and went to speak with Resident #272 to address his/her concerns. A review of nursing documentation, from 8/23/25 through 8/27/25 failed to include written documentation by RN #4 of an assessment or any information for Resident #272's allegation of neglect. An interview and review of the clinical record with RN #4 on 9/26/25 at 2:15 PM identified that she was aware of the nurses note dated 8/25/25 written by LPN #5. When she saw Resident #272 the resident made his/her allegation of neglect known and indicated that his/her brief was wet. RN #4 stated that she made the ADNS aware but failed to document the concern or perform a skin assessment for incontinence skin damage, indicating a skin check was due to occur on a subsequent shift. Although RN #4 indicated it was a good practice to assess and document Resident #272's information based on the information given to her, she was unable to state the facility policy for documentation on allegations of neglect/Reportable Events.b. A nursing note dated 9/8/25 at 4:35 PM written by LPN #5 identified that Resident #272 expressed a concern that he/she did not receive incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. LPN #5 immediately notified the nursing supervisor of the concern. A physician's note signed 9/11/25 for a visit on 9/9/25 identified Resident #272 had a conflict with the third shift Nurse Aid (NA). Resident #272 did not ask for assistance for incontinent care when he/she had been incontinent, and the NA never went to check on him/her or offer to provide incontinent care. Resident #272 requested an extra absorbent pad on the bed to catch the overflow of urine and waited 12 hours between shifts for the provision of incontinent care. An interview with the Director of Nursing (DNS) on 9/25/25 at 11:00 AM identified that she was away on 8/25/25 when the allegation occurred and was never made aware, however, the allegation should have been brought to the attention of the Assistant Director of Nursing (ADNS). Additionally, she was aware of the allegation of neglect occurring on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. According to the facility abuse policy, an investigation should have taken place per the facility policy, and that she and the ADNS were responsible for investigating allegations of neglect. An interview with the ADNS on 9/25/25 at 1:15 PM identified that she was aware of Resident #272's allegation made on 8/25/25 but could not locate any documentation related to the incident. The ADNS stated she recalled speaking to Resident #272 but could not provide any documentation as to whether the concerns were addressed or reported. The ADNS indicated that any allegation of neglect should be investigated per the policy and was unable to explain why she had not begun an investigation into Resident #272's allegation of neglect to the State Agency. Interview with NA #11 on 9/29/25 at 8:28 AM indicated that she met with Resident #272 and the DNS but could not recall the date. Resident #272 had been concerned that he/she sometimes had to wait to have the call bell answered or when answered he/she had to wait for her to come back because she was attending to another resident. NA #11 stated the resident thought that she talked too loudly which made him/her feel as though he/she was being reprimanded. Further, she had always provided incontinent care to Resident #272 and had never failed to provide incontinent care when she was assigned to Resident #272.Interview with LPN #6 on 9/29/25 at 8:45AM identified that she was Resident #272's charge nurse on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. She was not made aware of any allegation by Resident #272 that he/she did not receive incontinent care. LPN #6 stated that Resident #272 did not want NA #11 to provide care to him/her and a NA from another unit needed to come over to the unit to help. Interview with RN #9 on 9/29/25 at 9:09 AM identified that she was the supervisor on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. RN #9 indicated that she did not recall any allegations of neglect reported by Resident #272 or staff that the facility failed to provide incontinent care to the resident.Interview with RN #6 on 9/29/25 at 9:50 AM indicated she was the RN supervisor on 9/8/25 on the 7:00 AM to 3:00 PM shift and had not received any reports of Resident #272 failing to receive incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. RN #6 indicated if she was made aware she would have initiated an investigation, interviewed and assessed Resident #272, contacted the NA and nurse that worked on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift, and reported the allegation to the DNS or ADNS. RN #6 indicated if Resident #272 had reported an allegation of neglect, the facility policy directed conducting an investigation. Interview and review of the clinical record with APRN #1 on 9/29/25 at 9:55 AM identified she was aware of the allegation of neglect for the failure to provide incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift as reported by Resident #272 during his/her visit on 9/8/25. APRN #1 stated she documented in her note and immediately reported the concern to the DNS. A review of APRN #1's note date 9/9/25 at 7:47 AM indicated that the resident had concerns related to overnight care, particularly being changed during the night, and that she informed both nursing staff and the DNS. Interview with the Administrator on 9/29/25 at 12:15 PM indicated that the 2 allegations of neglect should have been investigated per the facility policy. The Administrator indicated that there were many concerns related to Resident #272 and somehow it just got overlooked. The Administrator indicated that it was his responsibility along with the DNS to ensure the Abuse policy for investigations was followed.A review of the Abuse Policy dated 5/1/24 directed, in part, that the allegations of neglect will be investigated.

Based on interviews, review of the clinical record, and policy for 1 of 5 residents (Resident #157) reviewed for nutrition, for the only sampled resident (Resident #259) reviewed for mood and behavior, and the only sampled resident (Resident #272) reviewed for care planning, the facility failed to follow the Resident Care Plan. The findings include: 1. Resident #157's diagnoses included Alzheimer's disease, depression, and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #157 was severely cognitively impaired, required substantial, maximal assistance for transfers, and bathing, was independent with eating, and weighed 111 pounds. The Resident Care Plan (RCP) in effect from 4/8/25 through 9/25/25 identified Resident #157 as at risk for unintended weight loss related to dementia and depression, due to variable intakes. Interventions included to record percentage of meals consumed, monitor weight as ordered, report significant changes in weight to the registered dietician, and physician, and provide the diet as ordered. Review of the vital sign reports identified Resident #157's weight on 4/1/25 was 110.8 pounds and on 9/22/25 Resident #157 weighed 97.4 pounds [a 13.4-pound (lb.) loss]. a. A physician's order dated 7/7/25 directed to give 4-ounces of nutritional shake and document the percent consumed daily. Review of the Medication Administration Record (MAR) dated 7/1/25 through 9/26/25 directed to administer a nutritional supplement daily at 2:00 PM but failed to include the physician order for documentation of the percentage of supplement taken by Resident #157. b. Review of the meal consumption amounts in the vital sign record identified from 5/15/25 to 9/25/25, 402 meals were served consisting of breakfast, lunch, and dinner over a 134 day period. The facility failed to document the percentage of meals Resident #157 ate 149 times. 2. Resident #259's diagnoses included Parkinson's disease, dementia, and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #259 was severely cognitively impaired and required substantial maximal assistance for transfers, personal and oral hygiene, was dependent for eating, and bathing, and weighed 139 pounds. The Resident Care Plan (RCP) dated 4/25/35 through 9/26/25 identified inadequate oral intake related to alterations in appetite secondary to covid 19. Interventions included to record percentage of meals consumed, provide diet as ordered, and assist with meals as needed. Review of meal consumption amounts in the vital sign record identified that from 4/23/25 through 9/26/25, a total of 471 meals consisting of breakfast, lunch, and dinner were served for a period of 157 days. Out of 471 meals, the facility failed to document the percentage of food Resident #157 ate 167 times. Interview with the Dietician Manager on 9/25/2025 at 11:04 AM identified, per the Resident Care Plan and standards of practice, every meal served to Resident #157 and Resident #259 should have had the percentage eaten recorded in the clinical record. Additionally, for Resident #157, according to the physician's order dated 7/7/25, the percentages of the nutritional shake intake should have been recorded on the Medication Administration Record but had not been. The Dietician Manager indicated that nursing staff were responsible for the documentation. Interview with the Director of Nursing Services (DNS) on 9/26/25 at 10:31 AM identified that that percentages of meal consumption were not being thoroughly documented and that the Nurse Aids (NA)were responsible. The DNS indicated that education was provided to the NAs regarding documentation of percentage of meal consumption to ensure the task was completed. Interview with NA #3 on 9/26/25 at 12:12 PM identified she was responsible for documenting meal consumption amounts after every meal. Although requested, a facility policy for NA documentation of meal consumption was not provided. 3. Resident #272 diagnosis included multiple sclerosis, major depression, functional urinary incontinence and urinary tract infection. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #272 had a Brief Mental Status Interview score of 15 and was cognitively intact. Resident #272 was totally dependent on staff for incontinent care, dressing, bathing and required maximum assistance of 2 staff for bed mobility. The Resident Care Plan dated in effect from 9/5/25 through 9/29/25 identified accusatory behaviors with interventions that included administering medications as ordered, follow-up with psychiatric services, and provide 2 staff with care due to behaviors. In addition, the Resident Care Plan directed that Resident #272 required 2 staff members to assist with bed mobility. Physician's order in effect from 9/5/25 through 9/29/25 directed the assistance of 2 staff members for bed mobility. Interview with Resident #272 on 9/25/25 at 10:15 AM identified that 2 staff members do not always provide care to him/her. Resident #272 indicated that this occurred on all 3 shifts and most of the time incontinent care and his/her bed bath were provided by 1 Nurse Aid (NA) in the room. Observations on 9/26/25 of NA #5 at 10:45 AM and 1:15 PM identified she provided Resident #272 with a full bed bath at 10:45 AM without the assistance of another staff member. NA #5 provided an incontinent check for Resident #272 at 1:15 PM without the benefit of another staff member. In an interview and review of Resident #272's Resident Care Card (directs NA how to provide care) with NA #5 on 9/26/25 at 1:25 PM she identified that according to the Resident Care Card; Resident #272 required 2 staff members for bed mobility and due to accusatory behaviors. NA #5 was unable to explain why she did not have another staff member assist her with Resident #272, but according to the Resident Care Card she should have. Interview and review of Resident #272's care plan with the Resident Care Coordinator (RN #3) on 9/26/25 at 1:30 PM identified that Resident #272 required 2 staff members for care related to accusatory behaviors and for bed mobility. RN #3 indicated that it was nursing's responsibility to ensure the plan of care was followed. RN #3 could not explain why staff did not follow Resident #272's plan of care as it was the policy of the facility to do so. Interview and review of facility documentation with Licensed Practical Nurse (LPN) #6, who worked the 11:00 to 7:00 AM shift, on 9/29/25 at 8:45 AM stated Resident #272 required the assistance of 1 staff member for his/her incontinent care and was unaware that Resident #272 was care planned for 2 staff members for care and accusatory behaviors. A review of the Comprehensive Care Plan Policy dated 5/14/25 directed, in part, that the care plan be implemented as a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The care plan process will be ongoing. Resident specific interventions will reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. Qualified staff who are responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on review of the clinical record, interviews, and facility policy for the only sampled resident (Resident #272) reviewed for resident care planning, the facility failed to ensure the Resident Care Plan was updated when there were allegations of neglect. The findings include:Resident #272 diagnoses included multiple sclerosis, major depression, functional urinary incontinence, and Urinary Tract Infection. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #272 had a Brief Mental Status Interview (BIMS) score of 15 indicating he/she was cognitively intact, and was totally dependent on staff for incontinent care, dressing, bathing, and required maximum assistance of 2 staff for bed mobility. The Resident Care Plan in effect from 7/16/25 through 9/26/25 and plan of care failed to reflect 2 allegations of neglect for the lack of incontinent care occurring on 8/24/25 and 9/7/25.A nursing note written by LPN #5 (who worked the 7:00 AM to 3:00 PM shift) dated 8/25/25 at 1:07 PM identified Resident #272 reported to her that he/she had not been offered assistance and did not receive incontinent care on the previous 11:00 PM to 7:00 AM shift (8/24/25 into 8/25/25), and staff had not answered his/her call bell. Resident #272's responsible party was aware. The nursing supervisor (RN #4) was notified and went to speak to Resident #272 to address his/her concerns. A nursing note dated 9/8/25 at 4:35 PM written by LPN #5 identified that Resident #272 expressed a concern that he/she did not receive incontinent care on 9/7/25 into 9/8/25 on the 11:00 PM to 7:00 AM shift. LPN #5 immediately notified the nursing supervisor of the concern. Interview and review of Resident #272's Resident Care Plan with Resident Care Coordinator (RN #3) on 9/26/25 at 1:30 PM identified that she was not made aware of any allegations of neglect or concerns related to incontinent care on 11:00 PM to 7:00 AM shift. RN #3 stated she would have updated the Resident Care Plan had she been made aware and that nursing or the social workers were also responsible to ensure the Resident Care Plan was updated when allegations of neglect occurred. RN #3 indicated the facility policy was to update the Resident Care Plan timely and was unable to explain why the other disciplines who were responsible had not completed the update for Resident #272's Resident Care Plan. The Comprehensive Care Plan Policy dated 5/14/25 directed, in part, that the care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed.

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #125) reviewed for accidents and hazards, the facility failed to follow physician's orders for a resident with a known behavioral issue. The findings include:Resident #125's diagnoses included Alzheimer's disease, anxiety, and epilepsy.A physician order in effect on 9/22/25 directed staff to follow the Resident Care Plan (RCP) as outlined.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #125 had a Brief Interview of Mental Status (BIMS) score of 0 indicating severely impaired cognition, exhibited verbal and physical symptoms directed towards others 4 to 6 days a week, and was dependent on staff for personal hygiene, dressing, and with chair/bed-to-chair transfers.The Resident Care Plan in effect on 9/22/25 identified Resident #125 was at risk for an activity of daily living problem due to the resident being observed throwing silverware across the table towards another resident. Interventions included Resident #125 was to be provided with plastic silverware from the dietary staff to prevent injuries.The Resident Care Card (NA care directive) in effect on 9/22/25 identified that plastic utensils were to be used at mealtimes for Resident #125.Observation on 9/22/25 at 11:57 AM identified Resident #125 was sitting in the dining room. He/she was in possession of a metal spoon and metal fork and using the metal spoon to eat ice cream.Observation and interview on 9/25/25 at 12:25 PM with Nurse Aide (NA) # 6, who was sitting at the dining room table with Resident #125, identified that Resident #125 was eating spaghetti with a metal fork and did not have plastic silverware. NA # 6 indicated that she was aware that he/she should be eating with plastic and not with metal silverware, stating that homemakers were responsible for setting the table with the correct type of silverware. NA #6 failed to remove his/her metal silverware after surveyor inquiry. Observation and interview on 9/25/2025 at 12:30 PM of Resident #125 with Homemaker #1 identified he/she was eating food with metal silverware. Homemaker #1 indicated she was the person who set the table for meal service, was aware Resident #125 needed plastic silverware because he/she had a history of throwing silverware at other residents and stated the resident must have reached across the table and taken another resident's silverware. Plastic silverware was not observed on Resident #125's table. The only 2 Residents dining at the table with Resident #125 were noted to have and be using metal silverware. Subsequent to surveyor inquiry, Homemaker #1 removed the residents metal silverware and provided Resident #125 with plastic silverware which had been obtained from behind the dining serving station. An interview with the Director of Nursing Services (DNS) on 9/26/2025 at 11:00 AM identified the expectation for staff was to follow all provider orders and the Resident Care Plan. Resident #125 had to use plastic silverware because he/she had a history of throwing silverware at other residents, and that the nurses, nurse aides, and homemakers were all responsible to ensure the correct silverware was provided and that Resident #125 should have been given plastic silverware.Review of the facility's Dining Experience policy failed to include distribution of adaptive equipment or special utensils for eating or setting tables in the Resident Dining Room.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #21) reviewed for pressure ulcers, the facility failed to complete a timely Registered Nurse (RN) assessment of a pressure ulcer, failed to clarify and follow a physician order for pressure ulcer treatment, and failed to ensure the appropriate air mattress pressure setting according to the Resident Care Plan (RCP). The findings include:Resident #21 had diagnoses that included Alzheimer's disease (dementia), pulmonary fibrosis, and heart failure.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, was at risk for developing pressure ulcers, used a wheelchair, and was dependent for bed mobility and transfers with no noted current pressure ulcers.The Resident Care Plan (RCP) dated 11/21/24 identified Resident #21 had a potential for alteration in skin integrity related to the need for staff assistance with positioning, and incontinence of bowel and bladder. Interventions included offload heels (remove pressure), and observe skin for signs/symptoms of redness, irritation, or breakdown weekly and with care, report irregularities to the nurse/physician.a. Licensed Practical Nurse (LPN) #9's progress note dated 11/29/24 at 8:24 AM identified an open area was observed on the right buttock which measured 5.0 centimeters (cm) length by 4.0 cm width by 0.1 cm depth (5.0 x 4.0 x 0.1 cm). The note identified the open area connected to a darkened area at the coccyx but did not indicate darkened area measurements. Barrier cream was applied for protection, and the Advanced Practice Registered Nurse (APRN) and responsible party were notified. The note failed to include notification of an in-house Registered Nurse (RN) Supervisor or the wound nurse.A physician order dated 11/30/24 directed to apply Zinc Oxide 20% to gluteal/sacral area every shift after care. Interview with LPN #7 on 9/25/25 at 2:15 PM identified that she was the nurse on 11/30/24 and was not on duty 11/29/24. LPN #7 indicated that she could not find a completed pressure ulcer packet from 11/29/24, and that was why she completed one on 11/30/24. Further, LPN#7 indicated that for any resident who developed a new pressure ulcer, the facility policy directed a pressure ulcer packet be completed as well as notification of the nursing supervisor, physician, family, and wound nurse. Interview and clinical record review with Wound Certified Registered Nurse, (RN) #2, on 9/25/25 at 3:05 PM identified when a new open area was found the policy required the nurse to complete a skin assessment, fill out a pressure ulcer packet, and give the information to the RN who would then write a nursing note and sign off the assessment as completed by the charge nurse. The clinical record failed to identify an RN assessment had been completed until 11/30/24 at 9:58 AM (24 hours after onset). The 11/30/24 assessment identified Resident #21 had a deep tissue pressure ulcer (localized tissue damage from prolonged pressure or shear) to the left gluteal/sacral area (a discrepancy from LPN #9's documentation of a right buttock open area). The area was noted to be 5.0 cm x 8.0 cm x less than 0.1 cm. and the tissue was characterized as an intact maroon discoloration.Interview with the Director of Nursing Services (DNS) on 9/29/25 at 10:50 AM indicated upon discovery of a new wound, the charge nurse was to fill out a pressure ulcer packet and document the findings in the clinical record. She identified if the wound nurse was not available at the time of discovery, the RN Supervisor should have been asked to assess Resident #21's wound and would have documented the assessment in a progress on 11/29/24 (the day of discovery). The DNS was unable to identify why facility staff had not ensured documentation of an assessment or a nurse's note by a Registered Nurse until 11/30/34.b. A physician order dated 9/18/25 directed treatment to the left gluteal wound as cleanse wound with normal saline or wound cleanser and pat dry, pack with MeSalt (used for absorption, cleansing, and healing) and cover with a dry clean dressing daily and as needed. Additionally, apply miconazole (antifungal) 2% cream, topically to the gluteal area daily, do not apply onto the gluteal wound. The order did not specify which area of the gluteal wound the medication was to be applied. Observation of Resident #21's wound care and interview with RN #2 and Physician #1 on 9/25/25 at 9:15 AM identified Physician #1 indicated a Stage 4 pressure ulcer that had a fungal rash to the peri-wound (periphery) caused by the wound drainage with a treatment order in place for miconazole cream to the affected area. RN #2 was observed to cleanse the wound on the left buttock, pack the open area with Mesalt, then applied a dry clean dressing covering the wound. RN #2 failed to apply miconazole to the peri-wound prior to placing the dry clean dressing and indicated that the girls would apply it later when performing incontinent care. RN #2 was unable to explain how the girls would apply the miconazole cream to Resident #21's peri-wound without removing the dressing.Observation and interview with RN #2 on 9/25/25 at 9:35 AM identified that the miconazole should have been applied to Resident #21's peri-wound prior to the application of the dry clean dressing and that the miconazole was in the clinical record as a separate order, not part of the MeSalt treatment order. RN #2 was unable to identify how the nurses would know to apply the miconazole during the dressing change. c. The Resident Care Plan (RCP) dated 7/17/25 identified Resident #21 had an alteration in skin integrity related to a left gluteal stage 4 pressure ulcer. Interventions included offloading (pressure relief), turn and position frequently, and check the placement and function of the group 2 low air loss mattress set to alternating therapy every shift.Review of the clinical record failed to identify a physician order for the placement and/or monitoring of the low air loss mattress for Resident #21.Periodic observations throughout the day of Resident #21 on 9/25/25 from 8:34 AM through 3:30 PM identified Resident #21 was lying on his/her back, in bed. The air mattress was observed to be functioning, and the lights indicated the low air loss mattress was set to static and firm (number 8 the highest setting). Interview with LPN #7 on 9/25/25 at 2:25 PM identified a resident with an air mattress in place should have an order in the clinical record for the nurse to sign off (indicating observed use). LPN #7 identified physician orders did not include resident specific settings for an air mattress and that when signing off the air mattress on the Treatment Administration Record, she was only signing that the mattress was in place and functioning (by pressing on and ensuring the bed frame could not be felt, bottoming out). She indicated it was not her responsibility to monitor specific settings. Interview with RN #2 on 9/25/25 at 3:05 PM identified air mattresses were put in place for residents who had a Stage 2 or greater pressure ulcer and that settings for air mattresses were not the same for all residents. RN #2 identified that the preferred setting for an air mattress was to the resident's comfort level and alternating, adding that as long as the air mattress wasn't bottoming out it was satisfactory. When he put air mattress orders into the clinical record, he would enter the order as group 2 low air loss mattress set to alternating therapy. RN #2 identified the facility owned their own air mattress, but there was more than one model which made it difficult to include the resident specific pump settings within the order so the nurses would not see the specific settings beyond alternating therapy. The responsibility for ensuring air mattress settings were correct was his, and there should not be air mattresses set to a static firm setting. RN #2 indicated if the resident was turned and positioned every 2 hours a static firm mattress setting on the air mattress wouldn't cause actual harm, it just wouldn't provide the optimal level of therapeutic benefit. Interview, record review and observation with RN #2 on 9/25/25 at 3:30 PM identified Resident #21 was lying in bed with the air mattress pump set on static and firm (setting at 8). RN #2 identified that the air mattress should not be set at the firmest setting, nor on static, and subsequently adjusted the settings to alternating and medium (setting at 5). He was unable to identify how settings became set to static and firm and was unable to identify how long the settings had been incorrect. RN #2 further identified there should be a physician order for a group 2 air mattress set to alternating therapy, but he was unable to identify why Resident #21's order was missing. RN #2 noted that alternating was part of the RCP. Interview with the Maintenance Supervisor on 9/29/25 at 10:20 AM identified he set up the air mattresses on the units after receiving a call from the nurse or a work order in the computer. He did not know what the mattresses were supposed to be set to, all mattresses he installed were set to medium, and the nurses were responsible for any adjustments.Interview with Director of Nursing Services (DNS) and RN #2 on 9/29/25 at 11:15 AM identified RN #2 did not routinely check air mattress settings after air the mattress was provided to a resident, unless the resident was obese. RN #2 identified he did not direct the settings for air mattresses to the Maintenance Department.Interview with Physician #1 on 9/29/25 at 11:58 AM identified Resident #21 had a stage 4 pressure ulcer which required placement of an air mattress to provide pressure relief and offloading of the wound. Physician #1 identified that if Resident #21's air mattress was set to firm and static, this could contribute to delayed healing as the standard of practice for air mattress settings was by the resident's weight, and that alternating pressure settings were the best for providing maximum pressure relief.Review of the Pressure Ulcer-Stage IV policy directed, in part, a skin inspection will be conducted each time a resident is bathed and when care is provided with special attention given to bony prominences, and the nurse should be notified of an observed changes in the skin (redness, rash, irritation, break in the skin). Further, a pressure relieving air mattress will be placed on the resident's bed and to avoid positioning the resident on the Stage IV ulcer site.Review of the Use of Support Surfaces policy directed, in part, that support services will be utilized in accordance with physician orders and manufacturer recommendations. The policy directed, for powered devices, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and/or inflation. The effectiveness of support surfaces will be monitored through ongoing assessment of the resident and/or wound such as lack of progression towards healing or changes in wound characteristics.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #228) reviewed for change in condition, the facility failed to prevent a significant (designation based on accepted clinical standards of practice without regard to the status of the resident) medication error for a resident with a transdermal narcotic medication. The findings include:Resident #228 had diagnoses that included progressive neuropathy, asthma, and chronic pain syndrome.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #228 was cognitively intact, required supervision or touching assistance with eating, and substantial/maximal assistance with bed mobility and transfers, and received opioid pain medication. The Resident Care Plan (RCP) dated 4/24/25 identified Resident #228 had a diagnosis of chronic pain. Interventions included to update the physician with new or increased pain, administer medications per current physician orders, and to observe and record any complaints of pain.A physician order signed 5/23/25 directed to check for fentanyl patch placement every shift. A physician order dated 5/30/25 directed for a fentanyl patch 25 micrograms/hour (mcg/hr.), apply 1 patch transdermally (to the skin) and a separate order for fentanyl patch 12.5 mcg/hr. provide a total dose of 37.5 mcg/hr. for chronic pain syndrome every 72 hours (3 days) and remove the old patch with each application.A nursing note by Licensed Practical Nurse (LPN) #8 on 6/8/25 at 4:54 PM identified a new fentanyl patch was placed to the left upper arm. The note failed to identify the dosage of the fentanyl patch and/or the number of fentanyl patches in place on the left upper arm.A nursing note dated 6/8/25 at 10:58 PM identified Resident #228 had a fentanyl patch in place to the left upper arm. A nursing note dated 6/9/25 at 7:53 AM identified a total of 75 mcg/hr. doses (double the dose of the physician order for 37.5 mcg/hr.), was removed from Resident #228 and the on-call Advanced Practice Registered Nurse (APRN) was notified. Resident #228's temperature was 97.5 (normal 97.8 degrees Fahrenheit to 99.1 degrees F.), respirations 18 (normal 12 to 18), heart rate 69 (normal 60 to 100) blood pressure was 109/64 (normal 90/60 to 120/80), and oxygen 94% (normal 95% to 100%) on room air. New physician orders were received for the correct application of a fentanyl patch (37.5 mcg/hr.), recheck the vital signs at 10:00 AM, and have Resident #228's APRN follow-up.A nursing note dated 6/9/25 at 8:23 AM identified the correct dose of fentanyl was applied to Resident #228 (1 fentanyl patch 25 mcg/hr. and 1 fentanyl patch 12.5 mcg/hr. patch) for a total of fentanyl patch 37.5 mcg/hr. to the right upper arm. Resident #228's APRN was in to see him/her with no new orders given, and a notification call was placed to the responsible party.A Reportable Event Form dated 6/9/25 identified at 7:20 AM on 6/9/25 (3) fentanyl 25 mcg/hr. patches were observed on Resident #228's left upper arm and that the order was for the application of fentanyl patches to equal 37.5 mcg/hr. patch every 72 hours. The on-call APRN was notified and a return call from the responsible party was pending.Vital signs obtained on 6/9/25 at 11:11 AM identified Resident #228's temperature was 98.2 F, respirations were 18, heart rate was 60, blood pressure was 114/71)Review of the Medication Administration Record (MAR) dated 6/8/25 identified LPN #8 signed off the order to check fentanyl patch placement. Both the fentanyl patch 25 micrograms/hour (mcg/hr.), and 12.5 mcg/hr. orders totaling 37.5 mcg./hr. had been signed off by LPN #8 as administered to Resident #228's on 6/8/25 and placed on the right upper arm, as well as the removal of the old patches from the left upper arm. A Record of Written Discussion dated 6/10/25 identified LPN #8 was provided written action for the failure to follow the 5 rights of administering medications. A written explanation by LPN #8 indicated she did not realize that she inadvertently placed 3 fentanyl 25 mcg/hr. (25 x 3 = 75 mcg/hr.) patches instead of 3 fentanyl 12.5 mcg/hr. (12.5 x 3 = 37.5 mcg/hr.) patches and would administer medications going forward using the 5 rights of medication administration. Interview with Director of Nursing Services (DNS) on 9/29/25 at 10:50 AM identified she had met with LPN #8 regarding the medication error and LPN #8 had inadvertently placed the wrong dosage of fentanyl patches on Resident #228. The DNS identified that she did not consider the error to be a significant medication error due to no harm had occurred and therefore there was no adverse outcome. Further, the DNS identified LPN #8 had received education.Interview with Pharmacy Regional Director on 9/29/25 at 12:48 PM identified after application of a fentanyl patch it took 12 to 24 hours for the level of medication in the blood to reach a level of efficacy. The Pharmacy Director identified that after a fentanyl patch was removed it took 20-27 hours for 50% of the medication to be eliminated further identified there was no maximum dosage for opioids. The significance of a narcotic medication error was patient specific, and she would not consider Resident #228's medication error as significant due to no adverse effect.Although attempted, an interview with LPN #8 was not obtained. Review of the Medication-Transdermal policy directed, in part, transdermal patches ordered by a physician are applied by a licensed nurse to alternate sites of patch application and the location recorded in the Medication Administration Record (MAR).Review of the Medication Administration policy directed, in part, to check the accuracy and completeness of each medication ordered in the MAR, to verify the resident's name, drug name, drug dosage, route of administration, and time of administration (5 Rights) by comparing the medication container with the MAR. The medication label is to be read 3 times before preparing the medication, narcotics should be compared to the MAR and medication container, and that labels should be read for a second time to ensure accuracy. According to the National Institute of Health, Fentanyl is a potent synthetic opioid similar to morphine, which produces analgesia but to a greater extent. This robust pharmacologic agent is typically 50 to 100 times more potent (than morphine).

Based on observations, interviews, and facility policy review, for 1 ([NAME] House) of 21 units within the facility failed to safely store medications and biologicals. The findings include:Observation on 9/22/25 at 9:38 AM identified the [NAME] House nurses' station/ medication room door unlocked and the door fully open. The charge nurse was observed at the end of the unit, with her medication cart, out of sight of the medication room door. Observation on 9/22/25 at 11:37 AM identified the [NAME] House nurses' station/ medication room door unlocked and open. The medication cart had been stored in the room and was noted to be unlocked and visible from the hallway. Two residents were self-propelling in their wheelchairs in the hallway, and one visitor was in the dining area outside of the nurse's station/medication room. No staff were visible in the area.Interview and observation with Licensed Practical Nurse (LPN) #2 on 9/22/25 at 11:46 AM identified the facility policy directed medication carts be locked when not in use. Additionally, she identified it was her responsibility to lock the medication cart, but she did not because she ran out in a hurry to help a Nursing Assistant (NA) in a resident's room. Subsequent to surveyor inquiry LPN #2 locked the medication cart and afterward closed and locked the nurse's station/medication room door when not occupied.Interview with the Director of Nurses (DNS) on 9/29/25 at 9:47 AM identified it was facility policy that medication carts and medication rooms were locked when nurses were not in view of the area. The DNS indicated that it was the responsibility of the nursing staff working on the unit to ensure medication carts and doors were kept locked.The Medication Storage Policy revised 5/29/25 directed in part that all medication housed on premises will be stored in the pharmacy and/or medication rooms according to manufacturer suggestions. Additionally, all drugs and biologicals will be stored in locked compartments, schedule II drugs and Schedule III, IV, and V medications are stored under double lock and key.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #21 and Resident #179) reviewed for pressure injury, the facility failed to perform hand hygiene and wound care under clean conditions and for 1 of 2 residents (Resident #250) reviewed for urinary collection devices, the facility failed to maintain appropriate infection control practices. The findings include:1. Resident #21 had diagnoses that included Alzheimer's disease (dementia), pulmonary fibrosis, and heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, had 1 unhealed Stage 4 pressure ulcer, and was dependent for bed mobility. The Resident Care Plan (RCP) dated 7/17/25 identified Resident #21 had an alteration in skin integrity related to a left gluteal Stage 4 pressure injury. Interventions included having the wound team follow the resident, ensure offloading (pressure reduction), perform frequent turning and positioning, and perform treatments per the physician orders. A physician order signed 9/18/25 directed treatment to the left gluteal wound, cleanse the wound with normal saline (NS) or wound cleanser (WC) and pat dry followed by packing the wound with Mesalt (dry normal saline wound dressing), followed by covering with a dry, clean dressing daily and as needed. A separate physician order dated 9/18/25 directed to apply miconazole nitrate 2% cream (antifungal cream) topically to gluteal area daily with additional instructions not to apply onto the gluteal wound. Observation of Resident #21's wound care and interview on 9/25/25 at 9:15 AM with RN #2 and Physician #1 identified RN #2 placed treatment supplies including wound cleanser, dressing package, gauze, and Mesalt package on top of Resident #21's bedside table without the benefit of cleansing the tabletop. After repositioning Resident #21, RN #2 removed the soiled dressing from Resident #21's left upper gluteal/coccyx area and folded it into his gloved hand. RN #2 then stepped aside to allow MD #1 to assess the wound. RN #2 removed his gloves with the soiled dressing and placed clean gloves without first performing hand hygiene. He proceeded to cleanse the wound with wound cleanser, and then placed the gauze, Mesalt, and dressing supplies on the bed next to Resident #21's buttocks. RN #2 sprayed the wound cleanser onto Resident #21's wound, wiped the wound with gauze, sprayed the wound again, and wiped the wound with a different area of the gauze. RN #2 then placed the soiled gauze down on the bed. Without changing his gloves and/or performing hand hygiene, he picked up the Mesalt and compressed one end into Resident #21's wound. He then placed a dry clean dressing over the Mesalt to cover the wound. RN #2 covered Resident #21 back up with his gloved hands, removed and discarded his gloves without hand hygiene, and subsequent to surveyor inquiry exited the room to obtain the miconazole. Continued observation of RN #2 identified he entered with the tube of miconazole and a new DCD and placing both on the bed next to Resident #21. The DCD he had placed earlier was removed and discarded. RN #2 then cleansed around the wound and changed gloves without performing hand hygiene. RN #2 applied the miconazole into his gloved hand and applied it to Resident #21 around the peri-wound extending onto the buttocks and placed a new dry clean dressing over the wound. Without removing his soiled gloves, he covered Resident #21 with a blanket and then removed his soiled gloves. Without performing hand hygiene, he picked up the wound cleanser and the tube of miconazole. RN #2 placed the wound cleanser on a small counter near the entry of the resident's room and walked out setting the tube of miconazole onto the top of the treatment cart and washed his hands with soap and water. The tube of miconazole was placed back into the treatment cart without the benefit of wiping it down with a disinfectant cloth or placing it inside a plastic bag. RN #2 then pushed the treatment cart down the hall to resume wound rounds with Physician #1. Interview with RN #2 on 9/25/25 at 3:05 PM identified that he should have sanitized the bedside table prior to placing treatment supplies onto it and should have performed hand hygiene after removing his soiled gloves during wound care, and after removing the old/soiled dressing prior to cleansing the wound. Additionally, RN #2 identified he should have cleansed the outside of the antifungal cream tube prior to placing it into the treatment cart and it should be a dedicated tube for Resident #21 since it was brought into the room. RN #2 identified that he had felt rushed while performing the wound care for Resident #21 during the wound rounds because Physician #1 was waiting for him to finish the wound rounds, and that made him feel pressured, so he rushed the treatment process which resulted in him not following proper infection prevention procedure. Subsequent to surveyor inquiry a physician order dated 9/25/25 directed treatment to left gluteal wound: Cleanse wound with NS or WC and pat dry followed by, apply miconazole 2% cream to peri-wound area followed by packing with Mesalt followed, by cover with a dry clean dressing daily and as needed. Review of the Infection Control-Hand Hygiene policy directed, in part, all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors, that hand hygiene could be done both by handwashing with soap and water or by using an alcohol based hand rub, and that hand hygiene would be performed according to accepted standards of practice after handling contaminated objects; before applying and after removing PPE, including gloves; before and after handling clean or soiled dressings; before performing resident care procedures; after handling items potentially contaminated with blood, body fluids, secretions, or excretions; and when, during resident care, moving from a contaminated body site to a clean body site. Further, if a task requires gloves, perform hand hygiene prior to donning (placing) gloves and immediately upon removal of gloves. 2. Resident #179 diagnoses included type 2 diabetes, rhabdomyolysis, and Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #179 had a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Additionally, the MDS identified Resident #179 was dependent on staff for hygiene, dressing, and transfers. The Resident Care Plan dated 9/23/25 identified Resident #179 was at risk of infection transmission due to an indwelling medical device, chronic wound or surgical incision. Interventions included hand hygiene and signage indicating personal protective equipment (PPE) use was required for high contact care. The physician's order dated 9/22/25 directed to perform treatment to the sacral wound every shift: apply topical Triad paste twice a day after care. The physician's order dated 9/23/25 directed Enhanced Barrier Precautions every shift for a wound. Observation of Resident #179's room on 9/25/25 at 10:52 AM identified an Enhanced Barrier Precautions sign posted outside the Resident #179's door. The sign directed that everyone was to clean their hands prior to entering, and after leaving the room. Additionally, the sign directed that gloves and a gown were to be applied for high contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, assisting with toileting, device care, and wound care. An observation of Licensed Practical Nurse (LPN) #2 and the Wound Nurse (RN) #2 on 9/25/25 at 10:54 identified gloves and a gown were placed on without the benefit of performing hand hygiene prior to entering Resident #179's room. LPN #2 was on the right side of the resident with a basin and cloth, while RN #2 was on left side assisting with Resident #179's positioning. LPN #2 removed Resident #179's brief and handed the soiled brief to RN #2 while she cleaned up the resident's peritoneal area. RN #2 disposed of the brief into the trash receptacle, removed and disposed of his soiled gloves and applied new gloves without the benefit of hand hygiene. LPN #2 removed her soiled gloves and applied clean gloves without the benefit of hand hygiene, she then sprayed the skin cleanser on a washcloth and cleaned Resident #179's wound, applied the Triad paste to a 4 centimeter (cm) by 4 cm gauze, dabbed it on the wound and applied a clean brief before repositioning the resident. LPN #2 and RN #2 removed their gloves and gowns and discarded them in the trash receptacle. Upon exiting the room RN #2 performed hand hygiene with the hand sanitizer outside the resident's room, while LPN #2 did not. Interview with LPN # 2 on 9/25/25 at 11:10 AM identified it was facility policy to perform hand hygiene before and after resident care, or when gloves were visibly soiled, as well as when putting on and taking off PPE and between glove changes. Additionally, LPN #2 identified although there was a mounted alcohol based hand rub dispenser outside Resident #179's room and a private bath in the room with soap and water, she did not perform hand hygiene prior to applying PPE, and between glove changes because she did not feel cleansing items were available in the room. LPN #2 was unable to explain why she did not follow the policy for performing hand hygiene prior to applying PPE. Interview with RN #2 on 9/25/25 at 11:16 AM identified it was facility policy to perform hand hygiene before and after care, before and after glove application, before and after putting on and taking off PPE and when hands were visibly soiled. Additionally, RN #2 identified that he should have performed hand hygiene when changing gloves but did not because there was no hand sanitizer in the room. RN #2 identified he performed hand hygiene prior to coming onto the unit and did not need to immediately before donning PPE. The Enhanced Barrier Precautions Policy dated 9/2/25 directed in part to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms and ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). The Hand Hygiene Policy dated 5/25/25 directed, in part, that all staff will perform hand hygiene procedures to prevent the spread of infection. Additionally, the use of gloves does not replace hand hygiene, and if the task requires gloves hand hygiene should be performed prior to donning gloves and immediately after removing gloves. 3. Resident #250's diagnoses include retention of urine, urinary tract infection, and pressure ulcer of the sacral region. A physician's order dated 9/3/25 directed to check Resident #250's urinary collection device and provide care every shift. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #250 was cognitively intact, required substantial/maximal assistance for bed mobility, and was dependent with toileting and transfers. The Resident Care Plan (RCP) dated 9/12/25 identified Resident #250 had bowel incontinence, had a chronic sacral wound, and an indwelling urinary collection device was in place. Interventions included observing complications, report signs of a Urinary Tract Infection (UTI), provide incontinent care, and place personal protective equipment when providing high contact care. Observation and interview with Nurse Aide (NA) #4 and LPN #4 on 9/26/25 at 1:00 PM identified Resident #250 seated in a wheelchair with the urinary collection device hung low under the wheelchair with the front bottom half of the drainage bag resting on the floor. Both LPN #4 and NA #4 indicated the collection bag should not have been resting on the floor. NA #4 and LPN #4 stated that it was NA #4's responsibility to ensure urinary collection bags were not on the floor and proceeded to instruct NA #4 to reposition the collection bag educating her to always suspend urinary collection devices so that there is no floor contact. Interview with the Director of Nursing Services on 9/26/25 at 1:50 PM identified Resident #250's urinary collection device collection bag should not have been resting on the floor and that it was the NA responsibility to ensure urinary collection devices are appropriately positioned off the floor. Review of facility policy, Urinary Collection device Care, dated 9/2005, directed urinary collection devices are cared for by all Nursing Personnel and to keep the drainage bag off the floor.

Based on clinical record review, facility documentation, and interviews for the only sampled resident (Resident#295) reviewed for hospitalization, the facility failed to provide the required notification of discharge/transfer to the State Ombudsman's Office. The findings include:Resident #295's was admitted with diagnosis including multiple fractures, diabetes, and small cell lung cancer.The admission Resident Care Plan dated 8/7/25 identified Resident #295 had hyperglycemia related to diabetes with interventions directed to monitor and record intake of food, monitor blood glucose per the physician's orders, and monitor for signs of hypoglycemia.The 5-day Minimum Data set (MDS) assessment dated [DATE] identified Resident #295 was cognitively intact, and required substantial, maximal assistance for bathing and toileting, and partial, moderate assistance for transfers.Review of the nursing note dated 8/10/25 at 4:11PM identified Resident #295 was observed with intermittent body tremors, non-verbal, eyes open, and could not follow commands. Resident #295's blood sugar was 32 and he/she was given Glucagon intramuscularly. The Advance Practice Registered Nurse was notified and directed Resident #295 be sent to the emergency room (ER) for evaluation and next of kin was notified.Review of the Nursing Progress Note dated 8/11/25 at 6:31AM identified Resident #295 was admitted to the hospital.Review of the Social Worker Progress note dated 8/11/25 at 2:40 PM identified Resident #295's family was educated on the bed hold policy which was declined and the family member indicated he/she was planning to retrieve Resident #295 belongings.An interview with Social Worker (SW) #2 on 9/26/2025 at 11:34 AM identified the ombudsman was not notified of Resident #295 transfer to the hospital on 8/10/25. Social Worker #2 stated that the facility policy to notify the ombudsman of a transfer did not include residents residing on the short term rehabilitation unit. SW #2 was not aware of the requirement to notify the ombudsman when a short-term rehabilitation resident was transferred to the hospital.Although a policy was requested for the notification of the ombudsman following resident transfer/discharge the facility failed to provide one.

Based on record review and interviews for one (1) of three (3) residents reviewed for medication errors (Resident #1), the facility failed to ensure the five rights of medication administration were followed, and subsequently, a resident was administered an excess of 26 units of the prescribed dose of Humalog insulin (a medication to lower blood glucose levels). The findings include: Resident #1 had diagnoses that included type 2 diabetes mellitus, heart failure, and hypertension. The physician's order dated 4/3/2025 directed to monitor blood sugars before meals and at bedtime and to administer 14 units of Humalog insulin 100 units/ml for blood sugar of 155 or less after meals, for a blood sugar of 155 or greater before meals, at 8:00 A.M., 12:00 P.M. and 5:00 P.M. hold insulin for a blood sugar of 90 or less. The admission [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was continent of bowel and bladder, independent with ADLs, and received insulin injections. The care plan dated 4/10/2025 identified Resident #1 had diabetes with interventions directing to assess signs of hypoglycemia or hyperglycemia, monitor blood glucose as ordered, diabetic foot checks, and administer insulin/oral glycemic agents as ordered. A vitals report dated 4/20/2025 at 8:03 A.M. identified RN #1 recorded Resident #1's blood sugar as 322. The facility accident and incident report dated 4/20/2025 identified that at 9:15 A.M. RN #1 administered 40 units of Humalog insulin to Resident #1; the order directed to administer 14 units before breakfast. RN #1 rechecked the blood sugar and notified RN #2 (supervisor) of the medication error. A nurse's note dated 4/20/2025 at 1:13 P.M. by the Assistant Director of Nurses (ADNS) identified at 12:30 P.M. APRN #1 was notified that Resident #1's current blood sugar was 199 and a new order was entered to notify APRN #1 prior to supper to determine if insulin will be needed. Review of the facility's summary dated 4/23/2025 identified on 4/20/2025 at approximately 9:15 A.M. RN #1 administered 40 units of Humalog Insulin and the order directed to administer 14 units of Humalog Insulin before meals. RN #1 reported she read 14 units, but inadvertently drew up 40 units, which she administered, and she realized the error and alerted the supervisor, APRN #1 and the family. RN #1 was provided education regarding the 5 rights and 3 checks for medication administration. Interview with RN #1 on 5/12/2025 at 10:35 A.M. identified on 4/20/2025 at approximately 8:00 A.M. Resident #1's blood sugar was checked and recorded as 322. RN #1 identified on 4/20/2025 she reviewed and verified physician's orders prior to administering Humalog insulin. RN #1 identified she knew that the physician's orders directed to administer 14 units of Humalog insulin prior to the breakfast meal for a blood sugar of 322. RN #1 identified when she was almost done administering the Humalog insulin injection, she realized she accidentally administered 40 units of Humalog insulin rather than 14 units per order. RN #1 indicated on 4/20/2025 she was flustered because earlier in the shift she was having difficulty logging into the computer, and then a fire alarm went off. Interview with the Director of Nurses (DNS) on 5/12/2025 at 10:59 A.M. identified RN #1 administered the wrong dose of Humalog insulin to Resident #1 on 4/20/2025 at approximately 9:00 A.M. The DNS identified the cause of the medication error on 4/20/2025 was caused by RN #1 feeling flustered. The DNS identified the 5 rights of medication administration (right resident, right medication, right dose, right time, and right route) should be followed by all nurses at all times. Although attempted, an interview with RN #2 was not obtained. According to Fundamentals of Nursing: 11th edition, Mosby, [NAME] and [NAME], 2022: To prevent medication errors nurses must follow the five rights of medication administration consistently every time medications are administered. The five rights of medication administration include the right medication, right dose, right resident, right route, and right time.

Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, (Resident #1), the facility failed to ensure a resident who is dependent on staff for transfers and all care remained free from significant injuries of unknown origin which included a left femur fracture (bone in upper thigh) and a right humerus (bone in upper arm) fracture. The findings include: Resident #1 had diagnoses that included Alzheimer's disease and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was non ambulatory, and was dependent on staff for mobility in the wheelchair. The care plan dated 12/30/24 identified Resident #1 demonstrates poor body alignment due to Alzheimer's disease with interventions that directed to assist resident in getting in and out of Tilt in Space wheelchair (TIS) (a specialized wheelchair that tilts the seat and back of the wheelchair simultaneously) and position the resident in TIS wheelchair with a head rest, foam cushion, elevating leg rests, calf wraps, arm rests, and lateral supports. A physician's order dated 1/16/2025 directed for transfers use a swing Hoyer lift for transfers and to provide the assistance of two (2) for bed mobility. A nurse's note dated 2/9/2025 at 3:24 P.M. written by Registered Nurse (RN) #2 (7:00 A.M.-3:00 P.M. shift supervisor), identified she was notified by Licensed Practical Nurse (LPN) #4 who observed a greenish light purplish bruise on Resident #1's right upper arm and Resident #1 screamed when the arm was slightly lifted. RN #2 identified Resident #1 had swelling and limited mobility. RN #2 notified the on-call MD and an order was obtained for a STAT (immediate) X-ray of the right arm. Review of Resident #1's right shoulder X-ray report dated 2/9/2025 at 11:57 P.M. identified a transverse fracture involving the neck of the humerus (a bone fracture where the break occurs perpendicular to the long axis to the bone) with minimal callus (early stages of healing) and mild displacement (broken bones are not in alignment). A nurse's note dated 2/10/2025 at 10:31 A.M. written by the Director of Nursing Services (DNS) identified, she assessed Resident #1 secondary to a report of swelling of the right upper arm and a bruise. The DNS identified that the resident had an X-ray that showed a transverse fracture involving the neck of the humerus with minimal callus and mild displacement. The DNS identified upon assessment Resident #1 was also noted with swelling to the left knee the APRN #1 was notified and the Resident #1 was transferred to the hospital. for evaluation. Review of the facility's accident and incident report dated 2/10/2025 identified that on 2/9/2025 at 8:50 A.M. resident was noted with an injury of unknown origin. The facility's incident report summary dated 2/14/2025 identified Resident #1 needs assistance with ADLs, is non-ambulatory, and transfers via a mechanical lift. On 2/9/2025, at approximately 8:50 A.M. during care the nurse aide noted a bruise on Resident #1's right upper arm the aide called the nurse who also noted the bruise along with swelling and pain to the right arm when arm was lifted. The physician was called and an order for an X-ray was obtained. The X-ray results were obtained and indicative of a transverse fracture involving the neck of the right humerus with minimal callus and mild displacement. The physician was notified, orders obtained to transfer Resident #1 to the emergency department. While in the hospital multiple X-rays were obtained, the left knee showed an obliquely displaced fracture of the distal femur with medial displacement (a fracture that occurs at an angle and the broken bones are not aligned). A thorough investigation was initiated and did not reveal a known or documented fall or injury. All statements prior to the day shift on 2/7/2025 revealed normal shifts with no increase in pain. The facility was unable to determine the exact cause of Resident #1's injuries. The hospital discharge summary dated 2/12/2025 identified Resident #1 presented to the hospital from the facility when staff noticed bruising and swelling to Resident #1's right upper extremity. Per documentation from the facility Resident #1 is bedbound and uses a Hoyer lift with no known falls or traumatic injuries. A trauma work-up further identified that the resident had a right displaced humeral neck fracture and a left displaced distal femur fracture. Interviews on 3/4/2025 and 3/5/2025 with Licensed Practical Nurse (LPN) #2, LPN #3, Nurse Aide (NA) #3 NA #4, NA #5, and NA #7 at various times who cared for the resident in the 72 hours prior to the injury being discovered, failed to identify any failed to identify any abnormalities to the lower and upper extremities, bruising, falls, accidents, behaviors, or incidents with the Hoyer lift prior to 2/9/2025. Interview with LPN #4 on 3/4/2025 at 1:35 P.M. identified on 2/9/2025 during the 7:00 A.M.-3:00 P.M. shift she was called to Resident #1's room by NA #2 who observed a bruise on Resident #1's right upper forearm. LPN #4 identified she observed a small red purple bruise on Resident #1's right upper forearm and when she lifted Resident #1's right arm the resident yelled out. LPN #4 LPN #4 indicated she notified RN #1, the on-call MD, and an order was obtained for an X-ray. Interview with RN #1 on 3/4/2025 at 1:55 P.M. identified on 2/9/2025 during the 3:00 P.M. to 11 :00 P.M. shift she observed a discoloration on Resident #1's right bicep and Resident #1 reported pain with movement of h/her right arm. RN #1 identified an X-ray was obtained of Resident #1's right upper extremity towards the end of her shift. RN #1 indicated prior to 2/9/2025 Resident #1 had no abnormalities to the lower extremities, bruising, falls, or accidents. Interview with the Director of Nursing Services (DNS) on 3/4/2025 at 12:00 P.M. identified on 2/9/2025 she was notified by RN #1 that Resident #1 had swelling to the right upper arm and a bruise was noted, the on-call provider was notified and an order for a STAT X-ray was obtained. The DNS identified on 2/10/2025 the facility received the results of Resident #1's X-ray that showed a transverse fracture involving the neck of the right humerus and Resident #1 was transferred to the hospital. The DNS identified while Resident #1 was in the hospital a second fracture was identified of the left femur and severe osteoporosis. The DNS identified that Resident #1 does not ambulate, is not able to self-propel in the wheelchair, requires assistance of two (2) staff with bed mobility, and two (2) staff for transfers using a Hoyer lift, and does not exhibit any behaviors. The DNS identified staff interviews indicated Resident #2 had no recent falls in the last 6-7 months. The DNS identified although a complete and thorough investigation was completed the DNS could not determine what caused Resident #1's right humerus fracture and left femur fracture. Interview with the Orthopedic Surgeon (OS) that treated Resident #1 in the hospital on 3/5/2025 at 11:30 A.M. identified on 2/10/2025 Resident #1 presented to the hospital from the facility for evaluation of a right transverse humerus fracture, and subsequently a left femur fracture was identified. The OS identified per the facility report Resident #1 was non-ambulatory, required use of a Hoyer lift, and had no falls, and even with severe osteoporosis routine movements and positioning it would not attribute to a right transverse humerus fracture or a left distal spiral fracture. MD #2 identified Resident #1's right humerus fracture was a transverse fracture which is caused by direct impact from trauma. MD #2 identified Resident #1's left femur fracture was a spiral fracture which is caused by a twisting motion during trauma. MD #2 identified he attributes Resident #1's humerus and femur fractures to some type of trauma, such as a fall. Although attempted interviews with RN #1 and NA #6 were not obtained. Review of the resident safe handling policy identified that is facility policy to ensure that residents are handeled safely to prevent or minimize risks for injury and provide a safe, secure and comfortable experience for the resident.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure physician's orders were transcribed and protocols for auditing physician's orders were followed. The findings include: Resident #1 has diagnoses that included Alzheimer's disease, dementia, and disorientation. The quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required set-up with eating. The care plan dated 3/19/24 identified Resident #1 at risk for unintended weight loss and malnutrition with interventions that directed to provide proper diet chopped with thin liquids and assist with meals as needed. A physician's order dated 4/5/24 directed to provide Resident #1 with a chopped diet with thin liquids. A nurse's note dated 5/26/24 at 1:45 P.M. written by LPN #1 identified Resident #1 was observed coughing while drinking thin liquids and on several occasions double swallowing and coughing to clear throat. LPN #1 indicated Resident #1's lungs were assessed with no abnormality. LPN #1 identified she changed Resident #1's liquid consistency from thin liquids to nectar and sent a request for a speech therapy screen. A Speech Therapy Pathology (SLP) evaluation and plan of treatment dated 5/27/24 at 4:21 P.M. identified Resident #1 was on a chopped diet with thin liquids and was downgraded by LPN #1 to nectar thick liquids due to coughing on thin liquids. SLP #1 identified Resident #1 requires skilled speech therapy services for dysphagia treatment to assess and evaluate the least restrictive oral intake and to analyze oral/pharyngeal function. A speech therapy physician's order form dated 5/27/24 directed Resident #1 to be a one-to-one (1:1) feed, maintain a chopped diet, nectar thick liquids, provide small portions, and place the resident on aspiration precautions. Review of the physician's orders for 5/26 and 5/27/24 failed to reflect the physician's orders for nectar thick liquids and one-to-one supervision. Review of the facility's accident and incident report dated 5/28/24 identified that at 10:19 A.M. Resident #1 was in the dining room and staff noted Resident #1 to be gasping and the beginning of circum-oral cyanosis (a blueish discoloration around the mouth). The Heimlich was performed by NA #1 and a piece of pancake was expelled. A thorough investigation was completed which identified the resident received the correct diet (chopped pancakes and nectar thick coffee). On 5/27/24 Resident #1 was seen by SLP #1 with orders to maintain chopped texture, nectar thick liquids, and provide 1:1 for feeding, however, the order was not transcribed from the ST order form into the physician's orders. Interview with LPN #1 on 6/28/24 at 11:00 AM identified that although she communicated to the nursing staff, she downgraded the resident's liquids to nectar thick on 5/26/24, she did not write a physician's order or document the change in the clinical record. Interview with SLP #1 on 6/28/24 at 10:10 A.M. identified LPN #1 requested speech therapy to screen Resident #1 due to coughing while drinking on 5/26/24. SLP #1 identified her recommendations were to continue Resident #1 on a chopped diet, continue with nectar thick liquids, and provide one to one with meals to encourage oral intake, not because SLP #1 had any safety concerns with Resident #1 ability to safely eat, but instead to encourage increased meal intake. SLP #1 identified that she completed the speech therapy physician's order form, then communicated with RN #4, and placed the flagged completed ST physician's order form in the resident's chart to be entered into the electronic health record by licensed staff. Interview with RN #4 on 6/28/24 at 5:00 P.M. identified SLP #1 evaluated Resident #1 on 5/27/24 and communicated to her that Resident #1 was to remain on a chopped diet with nectar thick liquids. RN #1 identified she is responsible for transcribing and implementing physician's orders including any physician's orders obtained by speech therapy. RN #1 indicated on 5/27/24 she believes SLP #1 did not place the flagged orders that needed to be transcribed into Resident #1's chart until after RN #4 completed her shift. Interview and clinical record review with DNS on 6/28/24 at 12:15 P.M. was unable to provide documentation to reflect that Resident #1's physician's orders dated 5/27/24 directing to provide a chopped diet, nectar thickened liquids, and a one-to-one supervision with meals were transcribed. The DNS identified the charge nurse is responsible for transcribing and implementing the ST physician's order form into the physician's orders in the electronic health record as soon as they are written. The DNS identified on 5/27/24 Resident #1's physician's orders were not transcribed by RN #4. The DNS identified her expectations are the charge nurse to transcribe the physician's orders when the order is obtained or written prior to the end of the shift. The DNS further identified that there is a 24-hour chart check audit protocol in place to ensure all orders written during the day are accurately transcribed, and that was not done either. Review of facility 24-hour check audit protocol identified that every night on the 11-7 shift a 24-hour check audit will be done on each medical record to ensure that all orders written in the last 24-hour period have been transcribed, checked, and noted. Although requested, a facility transcribing physician's orders policy was not provided.

Based on record review and staff interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure insulin was administered in accordance with physician orders resulting in Resident #1 receiving two (2) doses of insulin in error. Resident #1 subsequently became hypoglycemic (low blood sugar) requiring hospitalization . The failures resulted in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included Parkinson's disease, type 2 diabetes mellitus with long term use of insulin. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 2/22/2024 identified Resident #1 had diabetes mellitus. Interventions directed to monitor blood glucose, assess for signs of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), and to administer insulin/oral glycemic agents as ordered. Record review identified Resident #1 was discharged to the hospital on 2/22/2024 and was readmitted to the facility on [DATE] at 10:30 AM. Review of the Hospital Discharge Medication List dated 3/8/2024 identified physician orders for the following medications for diabetes management: a. Insulin Glargine (long-acting insulin), 34 units, at bedtime/sleep, for 9:00 PM. b. Insulin Lispro (fast-acting insulin), sliding scale (based on blood glucose result) at 7:30 AM, 11:30 AM, and 4:30 PM. Review of the clinical record identified physician orders were obtained upon readmission for Insulin Glargine (long-acting insulin) 34 units, at bedtime/sleep, for 9:00 PM, and for Insulin Lispro (fast-acting insulin) sliding scale (based on blood glucose result) at 7:30 AM, 11:30 AM, and 4:30 PM. RN #1 transcribed these orders onto the electronic medication administration record (eMAR). In addition, RN #1 transcribed the following insulin orders onto the eMAR in error (these orders were not listed as directed by a physician on the hospital discharge medication list and not listed as new orders from the facility attending physician): 1. Insulin Lispro 4 units at 4:45 PM, once a day. 2. Insulin Glargine 10 units at bedtime, for 10:00 PM if blood glucose level is greater than 120 (hold Glargine if blood glucose is less than 120). Review of the eMAR dated 3/8/2024 identified Resident #1's blood glucose was 287 at 4:30 PM and Resident #1 received the Insulin Lispro sliding scale coverage, 15 units, at 4:30 PM in accordance with the physician's orders. The eMAR further identified that Resident #1 received Insulin Lispro 4 units at 4:45 PM and Insulin Glargine 10 units at 10:00 PM as transcribed on the eMAR by RN #1 in error. The eMAR further identified that Resident #1 received Insulin Glargine 34 units at 8:00 PM as prescribed. A nursing note dated 3/9/2024 at 7:03 AM written by RN #3 identified Resident #1's blood glucose at 6 AM was 49 (normal 70-100 mg/dl) on the left hand, recheck on the right hand was 76 mg/dl, and the resident had no symptoms. The Supervisor was called, and Resident #1 was given 120 cubic centimeters (cc) of orange juice. The Supervisor arrived with insta-glucose, which was administered and repeat glucose level was 41 mg/dl. The MD was notified, and Resident #1 was transferred to the hospital at 6:55 AM for hypoglycemia. The Emergency Medical run sheet dated 3/9/2024 identified Resident #1's blood glucose level was 64 mg/dl at approximately 6:50 AM and Resident #1 was transferred to the hospital. The hospital Emergency Department record identified Resident #1's blood glucose at 7:32 AM was 25 mg/dl and at 7:44 AM was 24 mg/dl. The resident was admitted to the hospital with a diagnosis of hypoglycemia and cellulitis of the right great toe. A facility reportable event form and investigation dated 3/11/2024 at 4:00 PM identified on 3/8/2024 Insulin Lispro 4 units at 4:45 PM, and Insulin Glargine 10 units at 10 PM were administered in error. The form identified the insulin orders were entered in Resident #1's clinical record in error, and Resident #1 required transfer to the hospital. Interview with RN #1 on 4/1/2024 at 11:10 AM identified she entered the re-admission orders into the eMAR utilizing the hospital's W-10 medication list, verified the medication orders with the facility physician then transcribed the medications into the eMAR. RN #1 stated she mistakenly entered Insulin Lispro 4 units daily at 4:45 PM and Insulin Glargine 10 units daily at 10:00 PM into the eMAR and was unsure how the error occurred. Interview further identified the orders were not directed by the hospital discharge summary or by the facility attending physician. Interview with LPN #1 on 4/1/2024 at 2:05 PM identified on 3/8/2024, she administered Resident #1's medication as listed on the eMAR which included Lispro 4 units at 4:45 PM and documented she administered Glargine Insulin 10 units at 10:00 PM. LPN #1 stated although she documented she administered Glargine Insulin 10 units at 10:00 PM, she only administered 4 units as she believed this was the dose that should be administered. Further interview with LPN #1 stated subsequest to the administation of the two insulin dosages, she was informed Lispro 4 units at 4:45 PM and Glargine Insulin 10 units at 10:00 PM were transribed on the eMAR in error resulting in two medication errors. Interview with the Director of Nursing (DON) on 4/1/2024 at 12:05 PM identified that RN #1 transcribed Lispro 4 units and Glargine Insulin 10 units into the eMAR resulting in the medication error and LPN #1 did not follow the five (5) rights of medication administration when she administered Insulin Glargine, 4 units, to Resident #1 at 10 PM. The DON further stated a second check to verify that the orders were entered in the eMAR accurately should have been conducted by the 11 PM to 7 AM nurse, however, this was not completed. Interview with RN #3 on 4/2/2024 at 1:40 PM identified on 3/9/2024 it was her responsibility to conduct the second medical record review to verify accuracy of Resident #1's orders, however, she was not able to perform the check because she was busy reviewing the other resident charts for any new orders. RN #3 indicated she planned to review Resident #1's chart last, and she did not have time to do it before she checked Resident #1's glucose level. Interview with MD #1 on 4/2/2024 at 11 AM identified Resident #1's hypoglycemic event was likely related to the additional amount of insulin (Insulin Lispro and Insulin Glargine) he/she received in error on 3/8/2024. Review of the Medication Reconciliation Policy (undated) directed to reconcile medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than five (5) percent. Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his or her stay. Review of facility documentation dated 3/12/2024 identified the facility had initiated education to licensed staff regarding verifying physician orders, medication administration, transcription of orders, and the 11 PM to 7 AM nurse would perform a second check for accuracy. Additional focused education was provided for the nurses involved with the error. Chart audits were completed, and the incident was reviewed at a Quality Assurance meeting. On 4/5/2024, the facility educated staff that a second nurse would verify that physician orders were transcribed accurately prior to the administration of any medications for new admissions or readmissions. Immediate Jeopardy was identified as removed as of 4/5/2024.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #1) who were reviewed for accidents, the facility failed to ensure ambulatory assistance and supervision was provided for a resident who required assistance with ambulating who subsequently sustained a fall with significant injury. The findings include: Resident # 1's diagnoses included neurocognitive disorder with Lewy body dementia, atrial fibrillation, and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required supervision with bed mobility, transfers, ambulation on unit the with the use of a walker, required one person assist with toileting and had no recent falls. The Resident Care Plan dated [DATE] identified Resident #1 had an alteration in activity of daily living (ADL) function and a history of falls. Interventions directed to provide assist of one with ambulation with a rolling walker and provide frequent checks to the room for safety. Physician's orders dated [DATE] directed assist of one with the rolling walker. A nurse's note dated [DATE] at 6:42 AM at 4:20 AM Resident #1 was observed sitting on floor (of h/her room) facing the foot of bed with rollator walker in front of her. Resident #1 was crying and complaining of headache and pain all over, voluntarily moving all four extremities,and was non complaint with obtaining vital signs. Resident #1 was subsequently transferred to the emergency room for further evaluation. A facility Reported Event summary dated [DATE] identified staff responded to a thumping sound in Resident #1's room where s/he was observed sitting on the floor at the foot of the bed with the walker at h/her side. Resident #1 was very agitated, weepy, difficult to redirect and complaining of a headache with pain all over. Resident #1 was unable to state the cause of the fall and no apparent injury was observed. Resident #1 was last seen in the common area at 4:00 AM. S/he was uncooperative with vitals and pupil assessment. The Advanced Practice Registered Nurse (APRN) was contacted, and orders were obtained to send Resident #1 to emergency department (ED) for evaluation. Computed Tomography, CT scan (head) results dated [DATE] revealed an Interval acute/hyperacute left posterior parietal hematoma (bleeding) measuring up to 6 cm and underlying mass effect with a 3 mm left to right midline shift in the brain. Resident #1 subsequently expired at the hospital on [DATE]. The hospital Discharge Summary dated [DATE] identified Resident #1 was evaluated following a fall at the facility. A CT scan of the head identified acute/hyperacute left posterior parietal hematoma measuring up to 6 cm. The hemorrhage was non-surgical, and Resident #1 was not a candidate for external ventricular drain (EVD), a drain, a device used relieve elevated intracranial pressure when the normal flow of cerebrospinal fluid (CSF) inside the brain is obstructed. The situation was discussed with the responsible party who agreed to transition Resident #1 to comfort measures. Resident #1 was placed on hospice services and subsequently expired on [DATE]. An interview with Nurse Aide, NA #1 on [DATE] at 2:45 PM identified she was the assigned nurse aide on [DATE] overnight to [DATE] during the 11:00 PM to 7:00 AM shift. Resident #1 was up periodically during the night ambulating independently. NA #1 stated she last assisted with toileting at 3:00 AM and then assisted Resident #1 back to bed. Resident #1's bed alarm went off a few minutes after assisting Resident #1 back to bed. NA #1 checked Resident #1's room and observed Resident #1 standing by h/her bed stating s/he wanted to walk around then noted that Resident #1 was ambulating independently with h/her walker around the unit. NA #1 then heard a thump and went to check Resident #1's room where she observed Resident #1 on the floor next to the bed with the walker nearby, yelling in pain. NA #1 indicated Resident #1 required assistance of one when ambulating and on [DATE] Resident #1 was non-compliant with requests that NA#1 made to go back to bed and continued to ambulate independently on the unit, without assistance from NA#1. NA #1 stated she did not observe Resident #1 return to h/her room as there were bed alarms from other residents going off that she had to attend to. NA#1 further stated that it was well known Resident #1 would not allow staff assist when ambulating and although the resident was unable to be re-directed from independent ambulation, and she did not report to the nurse that the resident was ambulating independently and unable to be re-directed. An interview with Registered Nurse, RN #1 on [DATE] at 2:25 PM identified she was the assigned nurse on [DATE] overnight to [DATE] during the 11:00 PM to 7:00 AM shift. RN #1 indicated she had checked on Resident #1 periodically during the overnight shift while also working on an alternate unit. Resident #1 was up at intermittent times during the night and was observed ambulating independently on the unit with a rolling walker, which RN #1 believed was h/her baseline functional level, which is why she did not intervene. NA #1 did not report to her that the resident was unable to be re-directed. RN #1 was notified in the early morning on [DATE] that Resident #1 was observed on the floor in h/her room with the walker by h/her side. Resident #1 was agitated, complaining of pain, and subsequently transferred to the hospital. An interview with APRN #1 on [DATE] at 2:30 PM identified Resident #1 experienced multiple falls secondary to a diagnosis of Lewy body dementia, had poor safety awareness and was more difficult to redirect in the preceding month prior to the incident. APRN #1 indicated staff should have been providing assist of one when ambulating Resident #1 as ordered. An interview with the Director of Nursing on [DATE] at 3:30 PM identified she would expect staff to provide assistance of one with a rolling walker when ambulating Resident #1 for safety.

Based on record review and interviews for 1 of 3 residents (Resident #228) who was at risk of developing pressure ulcers, the facility failed to ensure measures were in place to prevent development of avoidable pressure ulcers. The findings include: Resident #228's diagnoses included fracture left patella (kneecap) with orthopedic repair, cerebral infarction, osteoporosis, hypokalemia, dementia, and anxiety. The Braden Scale for Prediction of Pressure Sore Risk dated 9/15/23 identified Resident #228 had potential problems related to friction and shearing. Further review identified the resident requires minimum assistance with movement. During a move, the skin probably slides to some extent, against sheets, chair, restraints, or other device. Maintains relatively good position in chair or bed most of the time but occasionally slides down. The resident was identified at risk for pressure ulcers and no interventions were identified. A physician's order dated 9/16/23 directed immobilizer to left lower extremity and weight bearing as tolerated, off-load heels every shift, skin assessment weekly on bath days, ted stockings from 8:00 AM to 8:00 PM and skin prep to bilateral heels twice a day for 14 days. The 5-day scheduled Minimum Data Set assessment dated [DATE] identified Resident #228 had no cognitive impairment, was at risk of developing pressure ulcers and required extensive assistance with bed mobility, transfer, locomotion, and personal hygiene. The Orthopedic office visit assessment on 9/29/23 identified Resident #228's left lower extremity incision over anterior knee was healing with staples in place. The staples were removed in the office and Steri-Strips were applied. There was no peri-incisional erythema or induration, there was no evidence of drainage, nontender to palpitation throughout, sensation was intact to light touch throughout all nerve distributions, tibial and doppler pulses were both positive with capillary refill less than 2 seconds to all toes. The resident transitioned from knee immobilizer to a hinged knee brace to be locked in full extension at all times for the next 2 weeks. In 2 weeks, the brace may be unlocked from 0-45 degree for therapy sessions only. At all other times locked strictly in full extension including sleep. The resident may shower in 2 days. Remove Steri-Strips in 1 week and the resident will be seen in the office for a clinical exam in 4 weeks. Review of the resident's clinical record from 9/29/23 to 10/3/23 failed to reflect left lower extremity skin assessment or skin protection under or near the hinged knee brace. On 10/4/23 during physical therapy treatment Physical Therapist (PTA #2) identified and documented hinged knee brace related left posterior lower leg pressure ulcer. The Physical Therapy Treatment Encounter Note dated 10/4/23 identified during adjustment of Resident #228's knee immobilizer, PTA #2 found pressure wound on posterior lower leg/heel, PTA #2 added padding underneath strap and reported findings to the nurse. In addition, distal left lower extremity also appeared more swollen and was warm to the touch which was also reported to the nurse. The nurse's notes dated 10/4/23 at 4:36 PM identified incision to knee with Steri-Strips in place, no drainage noted. Hinged brace to left lower extremity, resident to keep leg straight. Wound found to posterior left ankle underneath brace, foam dressing applied for protection. The wound nurse was notified, trace of edema noted to the left lower extremity, and the resident had no complaints of pain or discomfort. The Wound Assessment form dated 10/4/23 identified the resident with stage III pressure ulcer to left posterior lateral ankle, measuring 1.6 centimeter (cm) by 1.5 cm by 0.2 cm. Further review identified full thickness wound that extended to subcutaneous tissue without viable support structure noted. Etiology was likely a Medical Device Related Pressure Injury (MDRPI) from immobilizer, now stage III. The resident denied any pain, area was being offloaded and treatment in progress. The Physical Therapy Treatment Encounter Note dated 10/5/23 identified adjusted knee immobilizer and discussed with family talking to ortho about the brace due to it consistently loosening and getting out of place causing pressure on her/his wound. The wound care consult by Doctor of Osteopathy (DO #1) dated 10/5/23 identified the resident with stage III, medical device related pressure ulcer to left posterior lateral ankle, measuring 1.6 cm by 1.5 cm by 0.2 cm, with 30% thick adherent devitalized necrotic tissue and 70% granulation tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, blade was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 30 percent to 0 percent. Dressing treatment plan directed Calcium Alginate apply daily and off-load wound, reposition per facility protocol. Further review identified the resident with unstageable deep tissue injury with intact skin to left upper heel, measuring 4.2 cm by 1.1 cm and the depth was not measurable and there was no exudate. Dressing treatment plan directed to apply Betadine daily and off-load wound, reposition per facility protocol. The nurse's notes dated 10/6/23 at 9:08 AM identified the resident was seen by DO #1 on 10/5/23 during wound rounds and an additional wound was noted to the upper heel, likely MDRPI. The Resident Care Plan dated 10/6/23 (two days after stage III medical device related pressure ulcer to left posterior lateral ankle was identified and on the same date that deep tissue pressure injury to left upper heel was identified) identified Resident #228 at risk for skin breakdown related to decrease in bed mobility, needs assistance with toileting, bowel, and bladder incontinence. Interventions directed to assist with turning and repositioning every two hours and as needed, and schedule skin check, report to licensure nurse any new skin issues. The Wound Assessment form dated 10/6/23 identified the resident with deep tissue pressure injury to the left upper heel, measuring 4.2 cm by 1.1 cm by less than 0.1 cm. Further review identified that the resident was seen on wound rounds by the physician on 10/5/23 and additional wound was noted to the left upper heel, likely MDRPI from immobilizer, the skin was intact with a deep maroon appearance, now deep tissue pressure injury, treatment with Betadine daily, areas are being offloaded and the resident denied any pain. Interview and clinical record review with RN #5 on 10/18/23 at 9:44 AM identified until 9/29/23 Resident #228 had ice wrap under knee immobilizer on left lower extremity. On 9/29/23, during orthopedic office visit, the ice wrap and immobilizer were replaced with hinged knee brace with directions to keep it locked in full extension at all times for the next 2 weeks, including sleep. There were no directions to remove it for assessment, therefore the resident's skin was not assessed for integrity under or near the brace and the areas were not padded on left lower extremity until 10/4/23 when stage III pressure ulcer was discovered. Interview with DO #1 on 10/18/23 at 11:20 AM identified he carefully partially removed the hinged knee brace on 10/5/23 to assess the entire left leg, pad the brace and to apply dressing. At that time DO #1 identified a second pressure ulcer that was Deep Tissue Injury (DTI). DO #1 further identified although, there were no directions to remove the knee brace for assessment, it would be good to call the doctor and ask, there should be more communication with the doctor. With new interventions implemented both areas are improving. DO #1 stated that both pressure ulcers happened from friction and/or shear from the hinged knee brace. A person with a brace or any medical device is more likely to develop a pressure ulcer than a person without, that is why we must be extra protective of the skin. DO #1 identified those pressure ulcers could have possibly been prevented. Interview with MD #3 on 10/18/23 at 2:25 PM identified there was no visible skin injury to left lower leg under the immobilizer while the resident was in the office on 9/29/23. The resident's surgical incision was healing well. MD #3 stated there should be understanding for everyone, that for any brace in use, there should also be skin checks at least daily during the resident's rest, that is basic care, that should be standard of practice, and the brace should be opened, reapplied, and readjusted if needed. MD #3 further identified that order will be given to the facility to remove the hinged left knee brace to provide pressure ulcer care and to assess the resident's skin daily. Interview with MD #1 on 10/19/23at 9:32 AM identified the resident's brace should have been removed to assess the resident's skin under the brace at least every 48 hours, so maybe the skin injury would be identified at stage I and staff would put interventions in place to prevent developing any further. MD #1 further identified that it was expected of the facility to call the doctor for directions, therefore facility policy will be revised, and staff will be educated. Interview with DNS on 10/19/23 at 11:03 AM identified although requested, a facility policy on prevention of pressure ulcers due to brace/medical devices was not provided. The DNS further identified although the resident was at risk for developing pressure ulcers, the facility follows what the doctor wrote to keep the brace in place for two weeks at all times and failed to call the doctor to clarify those directions or to notify that the brace position needed to be adjusted at times. The DNS further identified staff could have checked the resident's skin on the left leg around the knee brace but not to remove the brace. Review of Post-op Knee brace instructions for use provided by the facility identified the healthcare professional should inform the patient about everything in this document that is required for safe use of this device. The patient should immediately contact a healthcare professional if any pain, skin irritation, or unusual reaction occurs with the use of the device. The instructions further directed a healthcare professional should adjust the device length to provide optimal knee stabilization. Upper hinge arms should extend no higher than 5 cm from groin level. Lower hinge arms should extend no lower than calf/Achilles tendon junction.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #2) who were reviewed for accidents, the facility failed to ensure the missing resident policy was immediately initiated, failed to ensure the resident was returned to the building once visualized by security staff and, failed to ensure exit doors alarms were functioning effectively for a resident who subsequently eloped to an unauthorized area outside the facility resulting in a finding of Immediate Jeopardy. The finding includes: Resident #2 had a diagnoses that included in part, dementia and aphasia (difficulty communicating). The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment, was sometimes understood, and required supervision with unassisted ambulation on and off the unit. The Resident Care Plan dated 7/26/23 identified Resident #2 utilized a wandering device with a history of wandering off the unit, was at risk for falls related to dementia with interventions that directed to provide cues and supervision, use of a wander guard (a bracelet worn to detect movement through an alarmed egress), to check placement of the wander guard each shift and functioning according to policy. A Physician's order dated 7/31/23 directed wander guard checks for placement every shift and weekly wander guard checks for function. A Nurse's note dated 9/2/23 at 10:00 PM written by Registered Nurse (RN) #6, identified Resident #2 was found by the security guard outside walking by him/herself at the back of the building. The Security Guard brought Resident #2 back to the unit. The nursing supervisor (RN #7) was notified. A facility Reported Event Summary dated 9/11/23 identified after a thorough investigation, it was concluded that Resident #2 went out a locked door on the unit, went down eight (8) flights of stairs and out the back of the building. The Resident was found on the facility sidewalk by the staff entrance by a staff member. The staff member alerted security who brought him/her up to the nursing unit, the resident was assessed, and no injuries were identified. Review of video surveillance dated 9/2/23 at 4:07 PM identified Resident #2 was first observed outside at the corner of the building wandering on the sidewalk around the perimeter of the building. At 4:20 PM video surveillance identified Resident #2 standing in the back of the facility when Security Guard #1 parked his car in space directly in front of Resident #2, exited the vehicle, and walked by the resident and entered the building without intervening and allowed Resident #2 to stay in the parking lot unsupervised. Video surveillance identified Resident #2 was approached by Housekeeper #1 and escorted back into the facility at 5:03 PM (approximately 1 hour after the resident was first visualized by video surveillance). A Door Report dated 9/2/23, for the secured key padded door located to the rear of Resident #2's unit identified a breech in the door at 2:45 PM lasting 2 minutes and 13 seconds (the door alarms if opened for more than 30 seconds). An interview with Nurse Aide (NA) #3 on 9/6/23 at 3:38 PM identified she was the assigned nurse aide on 9/2/23 during the 7:00 AM to 3:00 PM shift and had toileted Resident #2 sometime shortly before 3:00 PM and seated him/her in a chair at the edge of the dining room. An interview with NA #4 on 9/11/23 at 1:36 PM identified she was the assigned nurse aide for Resident #2 on 9/2/23 during the 3:00 PM to 11:00 PM shift. NA #4 reported to work shortly after 3:00 PM and noted that Resident #2 was not in the dining area but did not inquire as to his/her whereabouts. NA #4 proceeded with her rounds, and sometime after 4:00 PM (NA #4 was unsure of exact time) NA #4 returned to the dining area where she noticed Resident #2 was still not there. NA #3 and NA #4 notified the nurse, RN #6, and began looking for Resident #2 on the unit closer to 5:00 PM. NA #4 went off the unit with RN #6 to continue to look on neighboring units when she learned Resident #2 was returned to the unit by Security Guard #6. NA #4 indicated Dr. Hunt, the protocol for missing persons, was not initially activated when Resident #2 was first unaccounted for after 3:00 PM because NA #4 thought s/he was out with family or at an activity, therefore never inquired about his/her whereabouts. NA #4 did not hear any door alarms on the unit during her shift. An interview with RN #6 on 9/6/23 at 4:57 PM identified she was the assigned charge nurse on the unit on 9/2/23 during the 3:00 PM to 11:00 PM shift. RN #6 was alerted by NA #4 at approximately 4:30 PM that Resident #2 was missing, and she began assisting to locate him/her. While searching for Resident #2, s/he was returned to the unit around 5:00 PM by the security guard and it was not known how Resident #2 exited the unit. RN #6 did not activate the missing person protocol or inform the Nursing Supervisor, RN #7, of the incident after it occurred. RN #6 further identified that she did not hear any alarms sound on the unit. Interview with the security guard on 9/6/23 at 1:02 PM identified that although he saw Resident #2 on the sidewalk outside the building, he did not recognize him/her as a resident, so he did not intervene. The security guard further identified that he had not been educated of the residents in the facility that were at risk for elopement. Interview with the Senior [NAME] President (SVP) on 9/7/23 a 12:05 PM and 9/11/23 at 10:26 AM it would have been his expectation that staff initiate the missing person protocol to do an immediate search when the resident was initially noted to not be on the unit a little after 3:00 PM. The facility determined that the resident had somehow exited through the key padded door located on the unit that would alarm if the door is open for more than 30 seconds. Resident #2 went down eight flights of stairs and out a second locked door at the bottom of the stairs that was also supposed to alarm and notify security once opened, however, the battery on the door was not functioning and the door alarm did not sound or notify security of Resident #2's exit. A review of the Door alarm report dated 9/2/23 at 2:45 PM with the Senior [NAME] President identified the door was open for a total of 2 minutes and 13 seconds, however, no staff heard any alarms. The SVP identified that the facility did not have any systems or policies in place to check door function. Further, the security staff should know the residents who are at risk for eloping and should be able to identify those at risk and intervene if they are seen outside the facility. A review of the undated policy Dr. Hunt for missing persons directs that once a resident is determined not to be on a leave of absence, not on the unit or in the neighborhood, Dr. Hunt is to be initiated immediately where all staff are alerted and search for the resident.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication error, the facility failed to ensure staff verified the resident's identity prior to medication administration in accordance with standards of practice, which resulted in a significant medication error and a hospital admission due to low blood pressure. The failure resulted in the findings of Immediate Jeopardy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment. Review of the facility incident report dated 7/29/2022 identified at 10 AM, LPN #1 administered the wrong medications to Resident #1 (prescribed for another resident, Resident #2) and the physician was notified. The report further identified LPN #1 did not correctly identify Resident #1 prior to administration of the medications. Review of facility documentation identified Resident #1 received the following medications in error: [MEDICATION(S)] (a medication to treat high blood pressure) 10 milligrams (mg), [MEDICATION(S)] 300 mg (used to treat nerve disease and to help control certain kinds of seizures), [MEDICATION(S)] 100 mg (a medication to treat certain types of abnormal heartbeats), [MEDICATION(S)] 0.2 mg (used to treat high blood pressure), [MEDICATION(S)] 2.5 mg (used to treat or prevent blood clots), [MEDICATION(S)] 10 mg (a medication used to treat depression), [MEDICATION(S)] 300 mg (used to treat high blood pressure) and [MEDICATION(S)] 40 mg (a medication used to get rid of extra fluid). LPN #1 failed to confirm or verify Resident #1's identity prior to administering the medications, resulting in a significant medication error and Resident #1's admission to the hospital. The nurse's note dated 7/29/2022 identified that at 9:57 AM, Resident #1 was given morning medications not prescribed to her/him including several anti-hypertensives, an anticoagulant, an antidepressant, and an anticonvulsant. Resident #1 was sitting in her/his wheelchair and was watching television in the room. Resident #1 was alert, oriented, was informed of the medication error and denied pain, shortness of breath, dizziness, weakness, or drowsiness. Initial vital signs were stable with blood pressure 126/71, pulse rate 96, respiratory rate 20 and oxygen saturation level 94% on room air. The physician was notified and ordered close observation and every 15 minutes blood pressure and pulse checks were initiated. Nurse's notes dated 7/29/2022 at 10:57 PM identified at approximately 12:00 PM (two hours after the medication error), Resident #1's blood pressure began to decline and was fluctuating systolic (first number) from 61 to 87. Fluids were encouraged and Resident #1 was placed with his/her legs elevated above the heart. An EKG was ordered and showed prolonged QT waves (time the heart's electrical system takes to recharge between beats). Resident #1 continued to be alert, verbal and denied symptoms. 911 was called and staff remained with Resident #1. Resident #1 was seen by the Medical Director on the unit, paramedics arrived and started intravenous fluids. Resident #1 was transported to the hospital at approximately 2:00 PM (four hours after the medication error) and was admitted for [CONDITION(S)]. The Emergency Department (ED) physician note dated 7/29/2022 identified Resident #1 was transferred to the hospital after receiving the incorrect 10 AM medications. On arrival to the hospital, Resident #1 had appropriate mentation, was alert, and appeared tired. Emergency Medical Services (EMS) noted Resident #1 was initially hypotensive (low blood pressure) with initial blood pressure 60/48 and pulse 86. Treatment in the ED included [MEDICATION(S)] (used to treat abnormal cardiac function) and 1 liter of intravenous fluids. EKG showed [CONDITION(S)] (rapid heartbeat) and prolonged QRS interval (the time required for stimulus to travel across the heart ventricles), QTc (electrical measurement of the heart) prolonged at 552 (normal between 350 and 440). The note identified that Resident #1's blood pressure improved to 88/47. ED notes at 3:47 PM identified the ED staff was unable to obtain a manual blood pressure; Resident #1 was extremely lethargic and arousable with verbal stimuli, was started on an [MEDICATION(S)] drip (used to treat low blood pressure) and was transferred to the Medical Intensive Care Unit (MICU). The ED note further indicated critical care was required to treat or prevent imminent or life-threatening deterioration of circulatory failure. The hospital notes further indicated the clinical impression was [CONDITION(S)] due to drugs. Review of nurse's note dated 8/2/2022 at 1:43 PM identified Resident #1 was readmitted to the facility (Resident #1 was in the hospital for 7 days). Interview with LPN #1 on 8/15/22 at 1:04 PM identified she was a new Licensed Practical Nurse with no previous experience as an LPN. She indicated she was hired on 6/14/2022, had completed her facility orientation on 7/22/2022 (7 days prior to the medication error) and she was not familiar with the residents on the unit where she was working. LPN #1 indicated she had received an additional week of orientation because she did not feel comfortable to be independent (the extra week was completed, and she indicated she felt more comfortable. LPN #1 further identified that on 7/29/2022, she was running a little late with medication administration, trying to administer medications on time, was sidetracked. LPN #1 indicated she poured medications for Resident #1, and when pouring the medications, LPN #1 identified she did not look at the Medication Administration photo of Resident #1 (indicated she thought the photos did not look like the residents and was not aware she could enlarge the photos for better viewing). LPN #1 then entered Resident #1's room (private room) and called Resident #1 by his/her first name. She checked Resident #1's blood pressure and pulse and administered the medications that she had poured. LPN #1 returned to the medication cart and realized she had made an error; she identified the medications she administered to Resident #1 were the medications for Resident #2, and she immediately notified the nursing supervisor (RN #1). LPN #1 indicated she did not check Resident #1's identification (ID) bracelet or verify Resident #1's identity by use of the photo or with another staff member prior to administering the mediations. During an interview, clinical record review and facility documentation review with the DNS on 8/16/2022 at 11:50 AM, the DNS indicated LPN #1 did not follow the 5 rights of medication administration (right drug, right dose, right route, right patient, and the right time) and did not verify Resident #1's identity prior to administering the medications. LPN #1 administered medications to Resident #1 that were prescribed to another resident, which resulted in the need to transfer Resident #1 to the hospital, and subsequent admission to MICU due to a significant medication error. The DNS further indicated nurses must make sure they are administering medications to the right resident by verifying their identification. The DNS identified that although LPN #1 was provided orientation, and orientation ended on 7/22/2022, the DON was unable to explain why seven days later, LPN #1 did not verify Resident #1's identity prior to administrating medications. Please reference F760. Review of facility Medication Administration and General Guidelines Policy directed in part, to identify the Resident by using a picture on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further identified the 5 Rights of Medication Administration and procedural guidelines to support the accurate and safe administration of medications included: Right drug, Right Resident, Right dose, Right time, and Right route. Review of facility Admissions Policies directed in part in order to assure that each Resident receives medications and treatments prescribed for him/her and can be properly identified professional staff. The primary system of Resident identification is the Resident photograph and secondary systems include wrist identification (ID) bands and room door identification.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a medication error, the facility failed to ensure medications were administered to the right resident in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure resulted in the findings of Immediate Jeopardy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment. Review of the facility incident report dated 7/29/2022 identified at 10 AM, LPN #1 administered the wrong medications to Resident #1 (prescribed for another resident, Resident #2) and the physician was notified. The report further identified LPN #1 did not correctly identify Resident #1 prior to administration of the medications. Review of facility documentation identified Resident #1 received the following medications in error: [MEDICATION(S)] 10 milligrams (mg) (a medication to treat high blood pressure), [MEDICATION(S)] 300 mg (used to treat nerve disease and to help control certain kinds of seizures), [MEDICATION(S)] 100 mg (a medication to treat certain types of abnormal heartbeats), [MEDICATION(S)] 0.2 mg (used to treat high blood pressure), [MEDICATION(S)] 2.5 mg (used to treat or prevent blood clots), [MEDICATION(S)] 10 mg (a medication used to treat depression), [MEDICATION(S)] 300 mg (used to treat high blood pressure) and [MEDICATION(S)] 40 mg (a medication used to get rid of extra fluid). Review of the clinical record identified Resident #1 was allergic to [MEDICATION(S)], which was included in medications administered in error by LPN #1. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 7/29/2022 identified that at 9:57 AM, Resident #1 was given morning medications not prescribed to her/him including several anti-hypertensives, an anticoagulant, an antidepressant, and an anticonvulsant. Resident #1 was sitting in her/his wheelchair and was watching television in the room. Resident #1 was alert, oriented, was informed of the medication error and denied pain, shortness of breath, dizziness, weakness, or drowsiness. Initial vital signs were stable with blood pressure 126/71, pulse rate 96, respiratory rate 20 and oxygen saturation level 94% on room air. The physician was notified and ordered close observation and every 15 minutes blood pressure and pulse checks were initiated. Nurse's notes dated 7/29/2022 at 10:57 PM identified at approximately 12:00 PM (two hours after the medication error), Resident #1's blood pressure began to decline and was fluctuating systolic (first number) from 61 to 87. Fluids were encouraged and Resident #1 was placed with his/her legs elevated above the heart. An EKG was ordered and showed prolonged QT waves (time the heart's electrical system takes to recharge between beats). Resident #1 continued to be alert, verbal and denied symptoms. 911 was called and staff remained with Resident #1. Resident #1 was seen by the Medical Director on the unit, paramedics arrived and started intravenous fluids. Resident #1 was transported to the hospital at approximately 2:00 PM (four hours after the medication error) and was admitted for [CONDITION(S)]. The Emergency Department (ED) physician note dated 7/29/2022 identified Resident #1 was transferred to the hospital after receiving the incorrect 10 AM medications. On arrival to the hospital, Resident #1 had appropriate mentation, was alert, and appeared tired. Emergency Medical Services (EMS) noted Resident #1 was initially hypotensive (low blood pressure) with initial blood pressure 60/48 and pulse 86. Treatment in the ED included [MEDICATION(S)] (used to treat abnormal cardiac function) and 1 liter of intravenous fluids. EKG showed [CONDITION(S)] (rapid heartbeat) and prolonged QRS interval (the time required for stimulus to travel across the heart ventricles), QTc (electrical measurement of the heart) prolonged at 552 (normal between 350 and 440). The note identified that Resident #1's blood pressure improved to 88/47. ED notes at 3:47 PM identified the ED staff was unable to obtain a manual blood pressure; Resident #1 was extremely lethargic and arousable with verbal stimuli, was started on an [MEDICATION(S)] drip (used to treat low blood pressure) and was transferred to the Medical Intensive Care Unit (MICU). The ED note further indicated critical care was required to treat or prevent imminent or life-threatening deterioration of circulatory failure. The hospital notes further indicated the clinical impression was [CONDITION(S)] due to drugs. Hospital MICU note floor dated 7/31/2022 identified Resident #1 was started on [MEDICATION(S)] (a medication that can treat low blood pressure and heart failure) and was transferred to a regular floor, with stable blood pressure, and started on [MEDICATION(S)] (regulate blood pressure) and [MEDICATION(S)] (prevent blood clots) for [CONDITION(S)] with rapid ventricular response (irregular heartbeat). The hospital discharge summary dated 8/2/2022 identified the principal discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse's note dated 8/2/2022 at 1:43 PM identified Resident #1 was readmitted to the facility (Resident #1 was in the hospital for 7 days). Interview with LPN #1 on 8/15/22 at 1:04 PM identified she was a newly licensed practical nurse (had no previous experience as an LPN, had completed her facility orientation on 7/22/2022 (7 days prior to the medication error, and worked 4 shifts after her orientation had ended) and she was not familiar with the residents on the unit where she was working. LPN #1 indicated this was her first job as an LPN, she was hired on 6/14/2022 and had about a month of orientation. LPN #1 indicated she received an additional week of orientation and after the additional week, she felt comfortable to be independent administering medications. LPN #1 further identified on 7/29/2022, she was running a little late with medication administration, trying to administer medications on time, and was sidetracked. LPN #1 indicated prior to administering medications to Resident #1 she was upset because of a previous incident with Resident #3. LPN #3 identified that shortly before 10:00 AM she went into Resident #3's room and removed a [MEDICATION(S)] patch in error; the order was to check placement, not to remove the patch. Resident #3 had stopped her and told her that the [MEDICATION(S)] patch was just changed, should not be removed, and LPN #1 reapplied the patch. LPN #1 indicated she notified the nursing supervisor (RN #1). She then proceeded to the next room to administer medications to Resident #1, and when pouring the medications, LPN #1 identified she did not look at the Medication Administration photo of Resident #1 (indicated she thought the photos did not look like the residents and was not aware she could enlarge the photos for better viewing). LPN #1 then entered Resident #1's room (private room) and called Resident #1 by his/her first name. She checked Resident #1's blood pressure and pulse and administered the medications that she had poured. LPN #1 returned to the medication cart and realized she had made an error; she identified the medications she administered to Resident #1 were the medications ordered for Resident #2, and she immediately notified the nursing supervisor (RN #1). LPN #1 indicated she did not check Resident #1's identification (ID) bracelet or verify Resident #1's identity by use of the photo or with another staff member prior to administering the mediations and indicated she should have verified Resident #1's identity prior to administering the medication. LPN #1's failure to administer the right medications to the right resident, resulted in a significant medication error and resulted in Resident #1's hospital admission. During an interview, clinical record review and facility documentation review with the DNS on 8/16/2022 at 11:50 AM, the DNS indicated LPN #1 did not follow the 5 rights of medication administration (right drug, right resident, right dose, right time, and right route) and did not verify Resident #1's identity prior to administering the medications. LPN #1 administered medications to Resident #1 that were prescribed to another resident, which resulted in the need to transfer Resident #1 to the hospital, and subsequent admission to MICU due to a significant medication error. The DNS further indicated nurses must make sure they are administering medications to the right resident by verifying their identification. The DNS identified that although LPN #1 was provided orientation, and orientation ended on 7/22/2022, the DON was unable to explain why seven days later, LPN #1 did not verify Resident #1's identity prior to administrating medications. Interview with MD #1 on 8/15/2022 at 3:22 PM identified Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #1 indicated the medications Resident #1 received in error on 7/29/2022 may have caused the prolong QTc and blood pressure drop, and the very low blood pressure could have been a direct result of those medications, especially the [MEDICATION(S)] which may cause prolong QTc as well as a drop in the blood pressure. MD #1 further identified that Resident #1, if not treated, would have had difficulty sustaining life for long with his/her low blood pressure. MD #1 indicated due to the medication error, Resident #1 required a hospital admission, and transfer to the MICU for treatment because of the very low blood pressure. Review of facility Medication Administration and General Guidelines Policy directed in part, to identify the Resident by using picture on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further identified the 5 Rights of Medication Administration to ensure the accurate and safe administration of medications included: right drug, right Resident, right dose, right time, and right route.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for an accident, the facility failed to provide adequate supervision during care while the resident was in bed to prevent a fall out of the bed which resulted in an injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable decisions regarding tasks of daily living, required extensive two (2) person assistance with turning and repositioning while in bed, was dependent on two (2) staff for transfers in and/or out of the bed and chair, had functional limitation in range of motion on both sides of the upper and lower extremities. A physician's orders [REDACTED]. The Resident Care Plan dated [DATE] identified the resident had impaired ability to perform activities of daily living related to the [DIAGNOSES REDACTED]. The care plan identified the resident was prescribed an anticoagulant, Aspirin. Interventions directed to monitor for active signs of bleeding and to protect the resident from injury and trauma. The nurse's note dated [DATE] identified while applying protective dressings to Resident #1's coccyx, the resident rolled from a left side lying position onto the floor at the bedside. The note identified the resident was now lying on his/her right side, the left lower extremity was externally rotated, Resident #1's vital sign were stable, the resident was responsive and denied discomfort. The note indicated the Nursing Supervisor was notified and the Emergency Medical Services (EMS) was called to transfer the resident to the Emergency Department (ED) for evaluation. The note identified while waiting for EMS arrival the resident became lethargic, with mumbling, nonsensical speech, and occasional sonorous breathing was noted. The note indicated the resident was arousable, had requested to be transferred back to bed, Resident #1's blood pressure was ,[DATE], heart rate 98, respirations 20, and the oxygen saturation was 90% on room air. The Nursing Supervisor's late entry nurse's note for [DATE] identified the resident fell from the bed on [DATE] at 9:35 AM. The note indicated resident was found next to the bed leaning towards his/her right side with his/her back against the bed side table and the resident denied hitting his/her head but stated he/she hit the right side of his/her face on the bed, no visible signs of trauma to the head and/or face were noted. The note identified Resident #1 began to verbalize not feeling well, discomfort on the right side and visual disturbances, seeing floaters. The note indicated Resident #1 became lethargic, at 10:01 AM a repeat call was placed to EMS to change the transfer to a high priority, the EMS identified they were in the building and the resident was transferred to the ED at 10:15 AM. The nurse's notes failed to reflect documentation that a neurological assessment was conduct at the time of the fall and at the change in condition. The initial Emergency Department assessment dated [DATE] identified that after arrival Resident #1 was intubated, the pupils were fixed, no cranial nerve function was noted on exam, and the resident was coded multiple times. The note identified the initial assessment indicated a high spinal cord trauma and/or [MEDICAL CONDITION]. The x-ray report identified Resident #1 sustained an acute mild displaced fracture involving the right lesser trochanter and the proximal femoral diaphysis. The ED note identified due to the poor prognosis and following a discussion with the responsible party, the decision was made to withdraw care and the resident expired at 2:52 PM in the ED. The ED physician's note identified that the resident was not stable enough to take to the CT scan for trauma imaging to assess for a suspected intracranial injury and cervical spine injury. The note identified the case was discussed with the medical examiner and the medical examiner was made aware of the physician's concerns regarding the suspected injuries. The Medical Examiners autopsy report was not available at the time of this investigation. Interview and review of the clinical record and facility documentation on [DATE] at 10:45 AM with the 7AM-3PM charge nurse, Registered Nurse (RN) #1 who had conducted the dressing change on [DATE] identified the bed was positioned waist high for the treatment. RN #1 stated she pulled Resident #1 towards her with the use of a draw sheet, rolled the resident onto his/her left side, the left leg was positioned over the right leg, a pillow was placed between the resident and the upper quarter side rail and the resident held on to the side rail with the right arm. RN #1 stated at the completion of the dressing application, she turned away to dispose of the dressing wrappers and when she turned back toward the resident she observed the resident's feet falling off the bed followed by the legs. RN #1 indicated she attempted to prevent the resident from falling off the bed by grabbing on to the resident's clothing but was unable to stop the fall. RN #1 stated although the care plan directed the assistance of two persons for bed mobility, she had always repositioned the resident from one side to the other without having a second staff member to assist with positioning in accordance with the plan of care. Interview with the Occupational Therapist on [DATE] at 9:20 AM identified the last time Resident #1 was evaluated by therapy was on [DATE]. The [DATE] occupational therapy evaluation identified the resident's posture was asymmetrical, the lower extremity muscle tone was flaccid, gross motor coordination was impaired, and sensory processing was impaired. Interview with the primary care nurse aide, Nurse Aide (NA) #2, on [DATE] at 10:30 AM identified that she provided morning care to the resident on [DATE]. NA #1 stated Resident #1 was not able to move his/her legs and was totally dependent on staff for activities of daily living. NA #2 explained to prevent the resident from shifting weight and/or rolling during care she would pull the resident close to her, roll the resident on to his/her side, position the upper leg behind the bottom leg, and instruct the resident to hold onto a pillow, not the side rail. NA #2 stated while providing care when the resident was lying on a side, she would hold on to the resident's hip with one hand. NA #2 stated that although the care plan directed the assist of two for bed mobility, she always provided repositioning without assistance. Interview and review of the clinical record and facility documentation on [DATE] at 11:45 AM with Clinical Nursing Director #2 identified although the care plan directed an assist of two for bed mobility, the resident was able to assist with repositioning from side to side, the resident required the assist of two when being pulled up in the bed and in the past the resident refused the use of bolsters. Clinical Nursing Director #2 stated although a thorough investigation of the incident was conducted, the facility was unable to determine what caused Resident #1 to fall out of the bed. Subsequent to the incident, all residents who are not able to maintain a safe lying positions will be provided with bolsters and will be an assist of two for repositioning.

Based on clinical record review and staff interview, for one of three resident's reviewed for accidents (Resident #452), the facility failed to ensure the resident had access to his/her rolling walker resulting in a fall with injury. The findings include: 1. Resident #452's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated Resident #452 had moderately impaired cognition, and required extensive assist with one person for bed mobility, transfer, and walking. A resident care plan dated 9/8/16 identified a problem with falls and/or safety risk. The care plan indicated Resident #452 had fallen on 8/23/16 attempting to ambulate unassisted. Interventions included place the rolling walker in front of the resident when he/she is in the recliner, keep call light in reach, and instruct resident on safety measures. A physician's orders [REDACTED].#452 transfer with stand-by assist of one person and ambulate using the rolling walker and gait belt. The order further indicated to remind Resident #452 to stand close to the rolling walker. A review of a nurse's note dated 10/12/16 at 6:12 PM indicated Resident #452 was noted ambulating in the hallway of the household with his/her walker and no assistance. Resident #452 was assisted back to the household and educated to call for assistance. The note indicated after supper Resident #452 was again noted to get up from the dinner table without assistance and reaching for the walker. A nurse's note dated 10/24/16 indicated a physical therapy (PT) screen and PT schedule will be completed for ambulation and balance. A PT screen dated 10/24/16 indicated the resident was seen secondary to Resident #452 wanting to ambulate independently. Physical therapy services were to be done 1-3 times a week for strengthening and balance training to increase independence with ambulation. Physical therapy recommended Resident #452 continue with assist of one person with a rolling walker. A PT assessment summary dated 10/24/16 indicated Resident #452 had decreased lower extremity strength and decreased balance impairing the resident's ability to transfer and ambulate safely and independently. A nurse's note dated 10/28/16 at 7:03 PM indicted Resident #452 was found on the floor. Resident #452 complained of significant left femur/hip pain. The left leg was externally rotated and shortened. The Physician was notified and Resident #452 was sent to the emergency room for evaluation. Review of the Every 15 minute check form dated 10/28/16 indicated the last check of Resident #452 was at 6:00 PM. Review of a reportable event form and investigation dated 10/28/16 indicated Resident #452 was found on the floor. The resident's walker was by the TV stand. Resident #452 indicated he/she was walking without his/her walker to get the walker. The last time Resident #452 was seen was approximately 20 minutes prior to the fall. Resident #452 had been assisted into the recliner chair with the call bell, telephone, and chocolates within reach. Resident #452 was instructed to call for assist if needed. The investigation indicated Resident #452 was admitted to the hospital with [REDACTED]. The investigation indicated NA #1 did not leave the walker near the resident because there was limited space and he/she did not want Resident #452 to get up by him/herself. Resident #452 was noncompliant with calling for help and the assistive device was on the other side of the room. An interview on 5/9/17 at 2:47 PM with NA #1 indicated on 10/28/16 he/she brought Resident #453 from the dining room to his/her room. He/she assisted Resident #452 to the recliner and put his/her call bell, telephone, and candy within his/her reach. He/she did not put the walker within Resident #452's reach. Nurse aide #1 indicated he/she did not put the walker in the resident's reach because he/she was afraid he/she would trip over the walker. Nurse aide #1 indicated he/she had cared for Resident #452 many times before and this was the first time he/she did not put the walker within the resident's reach. The facility failed to ensure care plan interventions were in place to prevent an accident.

Based on clinical record reviews, review of facility investigations, and staff interviews for four of six residents in the survey sample reviewed for accidents and/or who sustained an injury, (Resident #99, 151 and 182, 448), the facility failed to provide the appropriate supervision and/or assistance during a transfer, and/or failed to ensure the resident's environment remained free of accident hazards and/or failed to revise the care plan for a resident with known behaviors resulting in an injury, and/or failed to ensure interventions to prevent/alert to fall dangers were initiated. The findings include: 1. Resident #182's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #182 had highly impaired vision, severe cognitive impairments, required extensive one person transfers in and/or out of the bed or chair, was non-ambulatory, the resident was four (4) feet nine (9) inches in height and weighed ninety-seven (97) pounds, the resident's balance during transitions and walking was not steady, the resident was only able to stabilize self with staff assistance and a wheelchair was utilized for mobility. The fall risk assessment dated [DATE] identified a score of 16, indicative of risk for injury. The Resident Care Plan dated 3/8/16 identified an inability to complete activities of daily living tasks independently, potential for falls and poor safety awareness. Interventions directed to stand pivot transfer with the assist of one and encourage safety precautions. The Reportable Event Form dated 4/11/16 at 4:50 AM identified NA #1 was assisting Resident #182 out of bed to go to the bathroom. After putting the resident's shoes on, NA #1 turned to reach for the wheelchair and Resident #182 fell forward onto the floor sustaining a laceration to the forehead and nose bleed. After RN assessment and physician notification, Resident #182 was transferred to the hospital for evaluation. Review of the clinical record identified Resident #182 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 8/3/16 at 1:10 PM, NA #1 identified on the morning of 4/11/16 at 4:50 AM, s/he woke Resident #182 to toilet him/her and after donning shoes, sat the resident on the side of the bed to transfer to the wheelchair. NA#1 identified the one-quarter side rails were up which the resident used to pull him/herself up. NA #1 stated s/he was positioned between the resident and the wheelchair, and upon turning and reaching to reposition the wheelchair next to him/her, Resident #182 fell forward onto the floor. In an interview on 8/3/16 at 2:25 PM, the DON identified based on NA #1's explanation, the facility determined NA #1 was positioned in front of the resident and when s/he turned to move the wheelchair closer to the bed, Resident #182 fell to the floor. Although the conclusion of the incident identified NA #1 was standing in front of Resident #182, the resident fell and sustained significant injuries. 2. Resident #99's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #99 had moderate cognitive impairments, required extensive one person assistance with transfers and limited one person assistance with ambulating, and utilized a walker and/or wheelchair for mobility. The RCP dated 7/7/16 identified decreased ability to perform transfers and ambulation, requiring an assist of one with the use of a gait belt and rolling walker. Interventions directed to practice transfer training with therapy staff and care givers with the rolling walker. The physical therapy note dated 7/8/16 identified that during therapeutic exercise, Resident #99 sustained a skin tear to the left anterior distal shin as the result of a wooden block tipping forward during the process of staff removing the block from under the resident's feet. The nurse's note dated 7/8/16 at 2:20 PM identified Resident #99 sustained a skin tear to the left shin while in therapy. The area was cleansed and two (2) steri-strips were applied. Interview with the physical therapist on 8/3/16 at 11:15 AM identified s/he was seeing the resident due to a recent fall and poor balance. The physical therapist stated that s/he had a student working and assisting with Resident #99's session. The physical therapist identified that as the student was removing the box from under the resident's feet, the box went forward hitting the resident's left shin. The physical therapist stated although the student was under direct supervision, s/he turned away to do something and as s/he turned back she saw the box hitting the resident's shin. 3. Resident # 151's [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] identified the resident with moderately impaired cognition, requiring extensive assistance with ADL's and total dependence for transfers. The RCP dated 1/13/16 identified a risk for injury related to restless behaviors. Interventions directed the use of padded side rails while the resident is in bed, use multiple pads if the resident removes them and tape the pads to the side rails when needed for resident's safety. physician's orders [REDACTED]. A Reportable Event dated 1/28/16 identified a bruise was noted on the resident's left knee. The Injury Investigation identified the resident was restless, removes the side rail padding and puts legs through the side rails. Nurse ' s Notes dated 2/3/16 identified the resident's Seroquel 12.5 mg was discontinued. At 10:55 PM, the resident was noted chanting help me, help me while in bed. The resident was transferred into a wheelchair and brought to the nurse ' s station for safety. On 2/5/16 at 2:30 PM, the resident was restless and was found with her/his legs over the side rails. On 2/9/16 at 3:23 AM, the resident was restless and calling out and one on one observation was provided. Nurse ' s notes dated 2/9/16 at 9:27 PM identified the resident removed the side rail pads and was observed with his/her left leg through the rail. A bruise was noted on the resident's left knee. At 10:43 PM it was identified that there was swelling and discoloration down to the resident's knee. A mobile X-ray was obtained and the resident was transferred to the ED for evaluation. The resident returned from the ED on 2/10/16 at 8:40 AM. A Hospital Report dated 2/10/16 identified a distal third, mildly displaced angulated tibia/fibula fracture. Interview, review of the clinical record and the facility's investigation of the incident on 8/4/16 at 9:45 AM with RN#4 identified that the resident had been in a standard bed with full side rails to prevent falls. The side rails were padded due to a history of restlessness, and agitation with attempts to put her/his legs through the rails. RN#4 indicated that on 2/9/16, the resident was observed with the left leg through the side rails with the side rail pads on the floor next to the bed. After the incident and fracture, the resident was provided with a low bed and half side rails. Interview, review of the clinical record, review of facility documentation with RN#3 on 8/4/16 at 12:15 PM identified that restraint and/or side rail assessments were never completed prior to the use of full side rails. RN#3 indicated that the resident's family had requested the use of the side rails. Additionally, although the facility was aware of the resident's ability to remove the side rail pads, the care plan was not revised to include different interventions to ensure the resident's safety. 4. Resident #448's [DIAGNOSES REDACTED].#448 had memory deficits, functional impairment to a lower extremity and was a fall risk. The fall risk assessment form dated 12/31/15 identified a score of 14 which is indicative for being at risk for injury. The resident care plan dated 1/4/16 identified the resident was a fall and safety risk. Interventions directed to keep the call bell within reach, encourage use of the call bell, use of mobility alarm and instruct resident on safety measures. The nurse's note dated 1/8/16 at 1:26 AM identified Resident #448 sustained a fall on 1/7/16 at 11:50 PM. The resident was found in his room lying on his/her back on the floor and was incontinent of urine. The resident was assessed by RN #1 with no apparent injuries and/or complaints of pain, neurological vital signs were initiated and Resident #448 was positioned by the nurse's station due to poor safety awareness and for continued monitoring. The nurse's note dated 1/8/16 at 11:13 AM identified Resident #448 complained of left hip pain, subsequent to physician notification an order directed to obtain a left hip x-ray. Results of the left hip x-ray were reported to the physician at 11:00 AM and Resident #448 was transferred to the hospital. The Reportable Event Form dated 1/7/16 identified Resident #448 was found on the floor in his/her room at 11:50 PM by RN #1. The facility investigation identified the resident was noted to be incontinent with his//her underwear down around the feet, the resident was confused and the bed alarm disconnected. The statement written by RN #1 identified the alarm did not sound and was found to be unplugged. In an interview on 8/3/16 at 11:00 AM, the DON identified all staff should check the bed alarm every shift and documentation should be entered in the clinical record. In an interview on 8/3/16 at 12:45 PM, RN #1 identified she found Resident #448 on the floor in his/ her room. RN #1 stated it is the responsibility for all staff to check the function of a bed alarm and at the time of the fall, Resident #448's bed alarm was noted to have been disconnected. In an interview on 8/4/16 at 10:10 AM, NA #2 could not recall specifics of the incident but identified bed alarms are checked with the outgoing nurse aide at the beginning of the shift. NA #2 stated bed alarms could easily be disconnected if the resident was restless or trying to get out of bed.

Based on clinical record reviews, staff interviews, review of facility documentation, and review of facility policy and procedure for two of six residents in the survey sample reviewed for accidents (R # 19, R #33), the facility failed to supervise the resident during care to prevent an injury and/or transfer the resident in a safe manner in accordance with the plan of care and/or assess the resident immediately following an injury. The findings include: 1. Resident #19's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident had moderately impaired cognition, required extensive assistance with ADL's including two person assistance with bed mobility and transfers,was not steady and only able to stabilize with staff assistance when moving from a seated to standing position and/or on and off the toilet. A RCP dated 12/5/2014 identified the resident was at risk for falls related to CVA. Interventions directed stand pivot transfers with the assistance of two. A nurse's note dated 12/7/14 identified that at 2:00 PM, the resident was found on the floor in the bathroom leaning against the bathroom wall on his/her right side. The right leg appeared edematous and shortened. The resident complained of pain when moving and constant moaning was noted. The Physician was notified and the resident was transferred to the emergency room for evaluation. A hospital discharge summary dated 12/9/14 indicated R #19 was diagnosed with [REDACTED]. A closed reduction was performed in the emergency room and the resident was admitted to a medical unit. The resident returned to the facility on [DATE] with a right leg immobilizer in place. An interview on 7/9/15 at 11:15 AM and review of a therapy evaluation dated 12/4/14 with PT #1 identified that the nursing department referred R # 19 to therapy due to a noticed decline in transfers and function. The assessment identified that the resident was unable to perform at a prior level of functioning secondary to a decrease in strength, decreased balance, decreased safety awareness and decreased cognition. Physical therapist # 1 indicated that it was not safe to leave the resident unattended in the bathroom. An interview on 7/9/15 10:45 AM with NA #3 indicated he/she helped NA# 2 transfer R #19 to the toilet. He/she indicated half of the staff were on break at the time of the incident. The resident was left on the toilet and instructed to use the call light when done. Nurse aide # 3 indicated he/she left the resident to assist other residents on the unit. An interview on 7/9/15 at 10:45 AM with NA #2 indicated R # 19 was left alone in the bathroom for privacy. While assisting another resident on the unit, he/she heard R # 19 call out for help. Nurse aide #2 found R #19 on the floor in the bathroom and called the nurse. A review of the clinical record and interview on 7/9/15 at 10:45 AM with RN # 3 identified that although the resident was a fall risk related to a history of falls, had poor safety awareness, balance deficits and/or impaired cognition, NA # 2 and NA # 3 left R #19 unsupervised in the bathroom while they assisted other residents. Review of NA # 2's employee filed noted he/she received a Disciplinary Discussion for failure to follow proper facility protocol for leaving a resident unsupervised in the bathroom. 2. Resident # 33's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident had no cognitive impairment, no behaviors were exhibited, required extensive assist of two staff members for bed mobility, and was totally dependent for transfers. A resident care plan dated 12/14/14 identified a problem with ADL's. Interventions included a swing lift with two staff members to assist to/from bed and to/from wheelchair. A nurse aide care card directed the use of a mechanical swing hoyer lift with the assistance of two staff members for transfers. Review of nurse's notes dated 1/27/15 at 8:50 PM documented that while NA #1 was repositioning R #33 in the wheelchair, R #33 sustained a 14 CM laceration to the right lower leg. The physician was notified and directed to send the resident to the emergency room for evaluation. Resident # 33 returned to the facility with 27 sutures to the right leg. The facility investigation noted a handwritten statement by NA#1 dated 1/28/15 that indicated that when he/she went to pull up the resident in the chair, it looked like the resident's leg was stuck under the chair. NA #1 documented that the resident made him/her believe (by noise) that he/she was in pain and when NA#1 pulled back the chair, he/she saw blood and called the nurse. Further review of the investigation noted that prior to notifying the nurse of the incident and/or injury, NA #1 transferred R #33 from the wheelchair to the bed (alone and without the benefit of the mechanical lift). The resident was observed in the bed when the nurse arrived with a 14 cm laceration. An interview on 7/7/15 at 2:50 PM with NA #1 indicated a completely different chain of events on the evening of 1/27/15 at 8:00 PM that did not match his/her written statement obtained at the time of the incident. NA #1 indicated that he/she found the resident (who is immobile) in the room with blood on the floor and immediately placed his/her arms underneath R #33's arms and transferred the resident to bed without utilizing the mechanical lift and/or obtaining assistance from a staff member. NA#1 indicated he/she did not notify the nurse until after the resident was transferred back to bed. An interview on 7/7/15 at 3:10 PM with RN #2 indicated when he/she was notified that R #33's had sustained a skin tear, he/she immediately went to assess the wound. When he/she arrived in the room, R #33 was in bed and the right leg had been wrapped with a dressing. An interview on 7/9/15 at 8:30 AM with the DNS indicated NA #1 received a final disciplinary warning related to transferring R #33 when a change in condition was noted and/or before being assessed by a nurse, and/or for not following the resident care plan related for transfers with a mechanical lift.

Based on clinical record reviews, observations, review of facility policy and interviews for one of two residents (Resident #235) reviewed for smoking, the facility failed to secure smoking materials to prevent potential accident and/or for one of three sampled residents who utilized wheelchairs withough leg rests (R#207), the facility failed to provide adequate supervision to prevent a fall from the wheelchair during transportation by a staff member. The findings include: 1. Resident #207 had [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] noted the resident scored twelve. A care plan last updated on 3/13/13 identified that R #207 was at risk for falls with interventions that included to encourage safety precautions and to supervise the resident with transfers. The MDS significant change assessment dated [DATE] identified that R #207 was cognitively intact with no behaviors, required two persons for bed mobility and transfer and one person for locomotion off the unit, used a wheel chair as a mobility device, and had falls in the previous month and previous two to six months with no fractures. The care plan dated 5/3/13 identified that R #207 demonstrated poor body alignment due to osteoporosis. Interventions included assisting the resident in and out of the Customized Wheelchair (CWC), and to follow the twenty-four (24) hour positioning plan for positioning the resident in the CWC. A CWC Annual Interdisciplinary Review dated 5/13/13 identified the resident had a new CWC but had difficulty propelling him/her self greater than ten (10) feet with upper extremities on small wheels. A Reportable Event investigation dated 6/10/13 at 1:55 PM identified that R #207 was being transported by a staff member to the Main dining room when the resident's legs got caught on the floor and he/she fell forward. As a result of the fall, R #207 sustained a 1.5 inch laceration above the right eye, a 3.0 cm ecchymosis of the right elbow, and right hip and back pain. Review of the care plan dated 6/10/13 addressed that R #207 had potential for falls. Interventions included application of the legs rests to the wheelchair and reinforce the need for legs rests with each transfer. 2. Resident #235's [DIAGNOSES REDACTED].#235 was cognitively intact and was independent for transfers and ambulation. A smoking assessment dated [DATE] identified the resident was safe to smoke independently. The care plan dated 6/13/13 identified the resident could smoke independently. Interventions included that resident would receive a lighter in the morning and return it on the 3-11 shift. Physician orders [REDACTED].#235 on 7-3 and ask for the lighter back on 3-11. Interview and observation on 8/7/13 at 2:15 PM with RN #3 identified a lighter sitting on Resident #235's dresser behind a book in a room shared with a resident on oxygen. RN#3 identified that Resident #235 is supposed to keep the lighter with him/her at all times so that other residents are kept safe. RN#3 further identified that the lighter should not have been there and should have been with Resident #235. Interview and review of facility policy on 8/8/13 at 10:45 AM with the DNS identified that the lighter which was observed was not the lighter that was signed out on the morning of 8/7/13, but was an extra lighter that Resident #235 had in his/her possession. The facility policy directed that Resident's lighters and matches must be kept at the nurse's station.