Every finding on record at New Haven Center for Nursing & Rehabilitation LLC

Based on clinical record reviews, review of facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) who were admitted for short term rehabilitation, the facility failed to implement and document an ongoing discharge plan for a resident to ensure a safe and effective transition back into the community. The findings include:Resident #1's diagnoses included bacteremia, intraspinal abscess and granuloma, and anxiety disorder. The admission history and physical summary dated 11/24/25 identified Resident #1 had unstable housing, was admitted to the long-term care facility for short term rehabilitation following hospital discharge on [DATE]. The social service admission note dated 11/28/25 at 11:23 AM identified Resident #1 was seen for admission to the facility. The note indicted prior to hospitalization in November 2025 Resident #1 was living at a friend's house, discharge plans were discussed and Resident #1 reported he/she would go back to the friend's house if no other housing options were available. The note identified a referral would be made to Money Follows the Person for housing reports and social service would provide support. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was alert and oriented to person, place, and time and the overall goal established was for discharge back into the community. The Resident Care Plan dated 12/15/25 identified Resident #1 was admitted for short-term rehabilitation and would be safely discharged back into the community. Interventions included the social worker will utilize community resources to ensure a safe discharge, the social worker will prepare the resident and family for discharge back into the community, the interdisciplinary care plan team will work together to discharge resident at the appropriate time, the social worker and resident's insurance company will work together to provide resident with all of the equipment and services that will be needed, and the social worker will involve the resident and family in the discharge planning process. The Level of Care Screen completed by Maximus dated 12/22/26 identified Resident #1's level of care was reviewed on 12/21/26, the approved length of stay was sixty (60) days effective 12/23/25, and the end date was 2/21/26. The rationale identified based on the submitted information received, short term care was appropriate for sixty (60) days and the long-term care facility should continue to assist with discharge planning for appropriate community and support services. The supportive care psychological services progress note dated 1/13/26 identified Resident #1 was seen to assist Resident #1 in managing anxiety related to potential early discharge and interpersonal conflict while residing in the nursing facility. The plan was to continue to address the discharge-related anxiety. The Advanced Practice Registered Nurse progress note dated 1/15/26 at 12:00 PM indicated Resident #1 completed the course of intravenous (IV) antibiotics, remained stable with no new reported symptoms, and Resident #1 was preparing for discharge to home later in the week, pending final coordination. The Transition of Care/Discharge Summary document dated 1/15/26 identified Resident #1 had an anticipated discharge date for 1/16/26 and the identified discharge location was back into the community. Review of the social service notes from the initial admission note dated 11/28/25 through 1/15/26 failed to reflect documentation social service had been working with Resident #1 regarding discharge back into the community. Interview with Social Worker #1 on 2/18/26 at 10:30 AM identified she was the person responsible for documenting discharge planning in the resident's record. Social Worker #1 identified the interdisciplinary team discussed discharge planning for Resident #1 the week of 1/16/26 and determined Resident #1 was appropriate for discharge. Social Worker #1 identified she then met with Resident #1 during that week to discuss the anticipated discharge on [DATE]. Social Worker #1 identified it was indicated Resident #1 needed housing resources and she encouraged Resident #1 to call family and friends, as well as provided 211 as a resource for Resident #1 to call. Social Worker #1 identified Resident #1 was to discharge back to the community although there was no identified set location for Resident #1 to discharge to upon being medically cleared and an anticipated discharge date of 1/16/26 set. Review of the clinical record with Social Worker #1 on 2/18/26 at 10:30 AM failed to reflect documentation of the interdisciplinary team's collaboration, referrals and resources provided for post-discharge needs, failed to reflect documentation of discharge readiness and Resident #1's participation in the discharge planning process. Social Worker #1 indicated she did document the discharge planning process in the electronic system under progress notes, however there must have been a glitch in the system because the notes were not in the record. Social Worker #1 identified facility policy was for documentation related to discharge planning to be completed and remain part of the clinical record. Interview with Resident #1 on 2/18/26 at 12:00 PM identified he/she was told by the facility he/she was ready for discharge on a Monday in January and asked if he/she was able to be discharged by that Friday. Resident #1 identified he/she needed to secure housing, was informed by Social Worker #1 if he/she was unable to find housing, then he/she could call 211 for assistance. Resident #1 identified he/she felt there was no ongoing assistance from the facility to secure housing upon discharge and no discussion on aftercare. Review of the facility Discharge Planning policy dated 1/1/25 directed, in part, discharge planning beings at admission and continued until the resident leaves the facility, and during stay (ongoing) the interdisciplinary team will review discharge progress weekly for short stay residents, update care plan as condition changes, and document progress notes regarding discharge readiness. It was further indicated a discharge meeting occurred for short term residents within 72 hours and weekly, and documentation must include participants, readiness for discharge, services arranged, and teaching provided.

Based on observations, review of facility documentation, and interviews for two (2) of three (3) sampled residents (Residents #1 and #4) who were reviewed for functioning call lights, the facility failed to ensure the call light indicator illuminated above the room door in the hallway when activated. The findings include: During a tour of the third floor on 2/17/25 at 2:40 PM, observations identified when Resident #4 activated the call bell while the surveyor was present, the visual indicator light outside the room above the door did not illuminate. Resident #4 indicated his/her call bell often did not work properly and facility staff had just come a day ago to fix it. Observations on 2/17/26 at 2:41 PM identified when Resident #1's call bell was activated, the call light indicator did not illuminate outside the room above the door. Observations and interview with the charge nurse, Licensed Practical Nurse (LPN) #1, on 2/17/26 at 2:43 PM identified when the call bell for Resident #4 was pressed, the call light indicator did not illuminate above the room door. LPN #1 identified although the indicator light was not illuminated above the door, the audible signal and visual light at the nurses' station was activated, which allowed staff to determine what wing a call bell light was activated so it was considered functional. Interview with the Director of Nursing (DON) on 2/17/26 at 3:30 PM identified the expectation was for the call light indicator above a room door to illuminate when activated and the call bell had been pressed. The DON identified she would inform maintenance to look into it. Interview with the Administrator on 2/18/26 at 10:15 AM identified although routine environmental rounds and testing of the call bell system were conducted, there was no specific timeframe for how often the rounds and testing were conducted. Although requested, no documentation on routine environmental rounds and testing of the call bell system was provided. Review of the facility maintenance log from December 2025 through February through 2026 failed to identify documentation of repair requests for Residents #1 and #4. Review of the facility Call Bell policy dated 1/1/24 directed staff will be made aware of the call bell being activated by the buzzer ringing at the nurses' station and the light above the room being lit and identified if a call bell is found to be defective a hand bell will be provided.

Based on clinical record reviews, review of facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) who were admitted for short term rehabilitation, the facility failed to implement and document an ongoing discharge plan for a resident to ensure a safe and effective transition back into the community. The findings include:Resident #1's diagnoses included bacteremia, intraspinal abscess and granuloma, and anxiety disorder. The admission history and physical summary dated 11/24/25 identified Resident #1 had unstable housing, was admitted to the long-term care facility for short term rehabilitation following hospital discharge on [DATE]. The social service admission note dated 11/28/25 at 11:23 AM identified Resident #1 was seen for admission to the facility. The note indicted prior to hospitalization in November 2025 Resident #1 was living at a friend's house, discharge plans were discussed and Resident #1 reported he/she would go back to the friend's house if no other housing options were available. The note identified a referral would be made to Money Follows the Person for housing reports and social service would provide support. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was alert and oriented to person, place, and time and the overall goal established was for discharge back into the community. The Resident Care Plan dated 12/15/25 identified Resident #1 was admitted for short-term rehabilitation and would be safely discharged back into the community. Interventions included the social worker will utilize community resources to ensure a safe discharge, the social worker will prepare the resident and family for discharge back into the community, the interdisciplinary care plan team will work together to discharge resident at the appropriate time, the social worker and resident's insurance company will work together to provide resident with all of the equipment and services that will be needed, and the social worker will involve the resident and family in the discharge planning process. The Level of Care Screen completed by Maximus dated 12/22/26 identified Resident #1's level of care was reviewed on 12/21/26, the approved length of stay was sixty (60) days effective 12/23/25, and the end date was 2/21/26. The rationale identified based on the submitted information received, short term care was appropriate for sixty (60) days and the long-term care facility should continue to assist with discharge planning for appropriate community and support services. The supportive care psychological services progress note dated 1/13/26 identified Resident #1 was seen to assist Resident #1 in managing anxiety related to potential early discharge and interpersonal conflict while residing in the nursing facility. The plan was to continue to address the discharge-related anxiety. The Advanced Practice Registered Nurse progress note dated 1/15/26 at 12:00 PM indicated Resident #1 completed the course of intravenous (IV) antibiotics, remained stable with no new reported symptoms, and Resident #1 was preparing for discharge to home later in the week, pending final coordination. The Transition of Care/Discharge Summary document dated 1/15/26 identified Resident #1 had an anticipated discharge date for 1/16/26 and the identified discharge location was back into the community. Review of the social service notes from the initial admission note dated 11/28/25 through 1/15/26 failed to reflect documentation social service had been working with Resident #1 regarding discharge back into the community. Interview with Social Worker #1 on 2/18/26 at 10:30 AM identified she was the person responsible for documenting discharge planning in the resident's record. Social Worker #1 identified the interdisciplinary team discussed discharge planning for Resident #1 the week of 1/16/26 and determined Resident #1 was appropriate for discharge. Social Worker #1 identified she then met with Resident #1 during that week to discuss the anticipated discharge on [DATE]. Social Worker #1 identified it was indicated Resident #1 needed housing resources and she encouraged Resident #1 to call family and friends, as well as provided 211 as a resource for Resident #1 to call. Social Worker #1 identified Resident #1 was to discharge back to the community although there was no identified set location for Resident #1 to discharge to upon being medically cleared and an anticipated discharge date of 1/16/26 set. Review of the clinical record with Social Worker #1 on 2/18/26 at 10:30 AM failed to reflect documentation of the interdisciplinary team's collaboration, referrals and resources provided for post-discharge needs, failed to reflect documentation of discharge readiness and Resident #1's participation in the discharge planning process. Social Worker #1 indicated she did document the discharge planning process in the electronic system under progress notes, however there must have been a glitch in the system because the notes were not in the record. Social Worker #1 identified facility policy was for documentation related to discharge planning to be completed and remain part of the clinical record. Interview with Resident #1 on 2/18/26 at 12:00 PM identified he/she was told by the facility he/she was ready for discharge on a Monday in January and asked if he/she was able to be discharged by that Friday. Resident #1 identified he/she needed to secure housing, was informed by Social Worker #1 if he/she was unable to find housing, then he/she could call 211 for assistance. Resident #1 identified he/she felt there was no ongoing assistance from the facility to secure housing upon discharge and no discussion on aftercare. Review of the facility Discharge Planning policy dated 1/1/25 directed, in part, discharge planning beings at admission and continued until the resident leaves the facility, and during stay (ongoing) the interdisciplinary team will review discharge progress weekly for short stay residents, update care plan as condition changes, and document progress notes regarding discharge readiness. It was further indicated a discharge meeting occurred for short term residents within 72 hours and weekly, and documentation must include participants, readiness for discharge, services arranged, and teaching provided.

Based on review of clinical records, interviews, and review of facility documents and policies for one of three residents (Resident #1) reviewed for accidents, the facility failed obtain a hospital discharge summary timely after a resident's readmission, and for one sampled resident (Resident #1) reviewed for leave of absence, the facility failed to ensure staff acted timely when a resident did not return as expected from a Leave of Absence, and failed to ensure staff were provided with a current facility policy that directed steps to follow when a resident did not return timely from a leave of absence. The findings include: Resident #1 had diagnoses that included cerebral infarction, chronic obstructive pulmonary disease, and adjustment disorder. Record review identified Person #1 was noted as Resident #1's responsible party. Hospital Discharge summary dated [DATE] identified Resident #1 reported use of Marijuana. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of eleven (11), indicating the resident had moderate cognitive impairment, and required set-up assistance with personal hygiene and supervision with transfers and ambulation. Physician order dated 8/13/2025 directed Leave of Absence (LOA) with rollator (walker). The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #1 was at risk for pain and had a potential for altered thought processes and difficulty adjusting to situations. Interventions directed to administer medications as ordered, and evaluation of the effectiveness of current psychotropic medications. 1. Review of the facility Reportable Event form dated 9/1/2025 at 8:00 AM identified Resident #1 had fallen earlier during the night, hit his/her head, and reported a 9/10 level of pain to his/her head, neck, and elbow. Resident #1 was transferred to the hospital for further evaluation. Review of RN #1's nursing note dated 9/1/2025 at 4:01 PM identified Resident #1 had returned from the hospital at 3:50 PM without paperwork and he/she was in stable condition. Record review failed to identify the hospital discharge paperwork was obtained after Resident #1's readmission to the facility on 9/1/2025 (14 days prior to record review). Interview with RN #2 on 9/9/2025 at 2:11 PM identified she was the nursing supervisor on 9/1/2025 during the 7 AM to 3 PM shift, when Resident #1 returned from the hospital. RN #2 stated she was aware that Resident #1 had returned from the hospital without hospital discharge paperwork and stated it was the responsibility of the 3 PM to 11 PM shift to follow up and obtain the missing hospital discharge summary. Interview and record review with the Director of Nursing Services (DNS) on 9/9/2025 at 1:07 PM identified the facility identified Resident #1 was sent to the hospital on the morning of 9/1/2025 after a fall with reported pain to his/her head, neck, and elbow, and he/she returned on the same day. Resident #1 returned without any hospital discharge paperwork to indicate what occurred at the hospital or if there were any new diagnoses or new treatments required. The DNS was unable to provide documentation that the facility obtained the discharge summary paperwork from the hospital and stated the facility policy was to review the hospital discharge summary upon readmission to the facility. The DNS stated it was the responsibility of the nursing supervisor to request the discharge summary if it was not sent with the resident. RN #1 was the supervisor who readmitted Resident #1 on 9/1/2025 and she should have requested the information from the hospital. The DNS stated the facility did not have Resident #1's discharge summary from his/her 9/1/2025 hospital visit, so it was not reviewed after Resident #1 was readmitted and she did not know why. Interview and record review with RN #1 on 9/9/2025 at 9:32 AM identified she was the supervisor when Resident #1 was readmitted from the hospital without the discharge summary. RN #1 stated she did not call the hospital to request Resident #1's discharge summary. RN #1 further indicated facility policy was to call the hospital and request the discharge paperwork if not returned with the resident. Interview failed to identify why RN #1 did not obtain the hospital discharge summary. Review of the facility Accident and Incident Policy dated 7/1/2025 directed in part, all hospital discharge paperwork must be reviewed within twenty-four (24) hours of the patient's return to the facility. 2. Review of a Leave of Absence Notification form dated 9/8/2025 identified Resident #1 left the faciity on an LOA at 10:30 AM and indicated on the form that he/she planned to return at 6:00 PM the same day. Review of the nursing note dated 9/8/2025 at 8:56 PM (2 hours and 56 minutes after the expected return time) identified Resident #1 was still out on LOA. The note further indicated Resident #1 was responsible for him/herself, and that the supervisor was aware. Nursing note dated 9/9/2025 at 12:00 AM identified a call was placed to Resident #1's emergency contact/Person #1, to inquire about the resident's whereabouts, and reached a recording that indicated Person #1's phone was out of service. Nursing note dated 9/9/2025 at 3:50 AM identified Resident #1 was returned to the facility (nine (9) hours and fifty (50) minutes after his/her expected time of return) by a Good Samaritan and was alert and verbal. Resident #1 stated he/she had back and knee pain and was informed he/she would need to go to the hospital to be assessed, and Resident #1 agreed. Interview with the Director of Nursing Services (DNS) on 9/9/2025 at 10:18 AM identified Resident #1 signed out of the facility at 10:30 AM on 9/8/2025 with the understanding that he/she was to return to the facility by 6:00 PM that evening. Although the DNS stated staff had called Resident #1's responsible party and two (2) local hospitals in an attempt to verify Resident #1's whereabouts, the DNS was unable to provide documentation of the calls. The DNS stated the staff did not notify her when Resident #1 did not return to the facility as scheduled; when she arrived at work on 9/9/2025 she was notified Resident #1 did not return to the facility as scheduled and had returned at 3:50 AM (9 hours and 50 minutes late). The DNS stated she and the Administrator should have been notified, and the local police and the resident's physician should have been notified that Resident #1 was missing, and staff did not know where he/she was. Interview failed to identify why notifications were not completed. Review of the facility Leave of Absence Policy dated 2/3/2025 (most recently dated policy), provided on 9/15/2025, directed in part, if a resident does not return to the facility within one (1) hour of the expected return time, the registered nurse supervisor would notify the Director of Nursing Services/Assistant Director of Nursing Services, the Nurse Practitioner/Medical Director, responsible party, and the Administrator. 3. Review of a one-page LOA policy dated 1/19/2018, provided on 9/9/2025, directed in part, if a resident cannot return as expected, the resident/responsible party should notify the facility as soon as possible. Subsequent to surveyor inquiry regarding if the facility had an LOA policy with a more recent date, resulted in receipt of multiple policies. On 9/15/2025 at 11:00 AM, copies of multiple facility Leave of Absence policies dated 1/19/2018, 3/23/2022, and 2/3/2025 were obtained and contained conflicting information directing a staff process to follow when a resident did not return timely from an LOA. On 9/15/2025, a Leave of Absence Policy dated 1/19/2018 was provided by the DNS. Page one (1) was a copy of the policy provided on 9/9/2025, along with two (2) additional pages titled Resident Return from Leave of Absence for Alert and Oriented Residents. The two (2) additional pages failed to indicate an effective date, approval date, and/or revision date. Review of the two (2) additional policy pages provided on 9/15/2025 identified an undated Policy: Resident Return from Leave of Absence (LOA) Alert and Oriented Residents, directed in part, if a resident returns later than 12 hours past the projected return, the facility will attempt a wellness check and notify the local police department and Department of Health. Review of the LOA policy dated 5/5/2021 and revised on 3/23/2022 directed in part, if a resident/responsible party does not contact the facility, the charge nurse will notify his/her supervisor immediately and attempt to contact the resident/responsible party. If the resident can not be located and he/she does not return by midnight, the LOA becomes unauthorized, the physician will be notified, and the LOA will be considered a discharge against medical advice (AMA). The facility will make a reasonable attempt to contact the resident/responsible party to advise him/her of the discharge. Review of the facility Leave of Absence Policy dated 2/3/2025 (most recently dated policy), provided on 9/15/2025, directed in part, if a resident does not return to the facility within one (1) hour of the expected return time, the registered nurse supervisor would notify the Director of Nursing Services/Assistant Director of Nursing Services, the Nurse Practitioner/Medical Director, responsible party, and the Administrator. Interview, facility documentation review and review of the multiple Leave of Absence policies with the DNS and Administrator on 9/15/2025 at 2:15 PM identified the two (2) additional pages titled Resident Return from Leave of Absence for Alert and Oriented Residents did not go with the Leave of Absence policy dated 1/19/2018 but was a separate, undated policy, and that the Leave of Absence policy dated 1/19/2018 was the most current and in use. The DNS stated the current policy that staff were directed to follow was the 1/19/2018 LOA policy and she had confirmed that with the Corporate Clinical Operations Manager. Interview failed to identify why the policy with the most current date was not the policy for staff to follow. Interview with RN #1 on 9/15/2025 at 2:28 PM identified paper copies of facility policies were no longer kept at the nursing stations as facility policies were maintained electronically and could be accessed at each nursing station when needed or requested. RN #1 provided a copy of the current Leave of Absence policy accessible electronically to all nursing staff from the on-line portal and identified it was dated 2/3/2025. Review of the LOA policy dated 2/3/2025, provided by RN #1 on 9/15/2025 from the electronic access available to nursing staff, directed in part, if a resident cannot return as expected, the resident/responsible party should notify the facility as soon as possible. If a resident does not return to the facility within one (1) hour of the expected return time, the RN supervisor will notify the DNS/ADNS, APRN/MD, responsible party and Administrator. If a resident remains absent for 24 hours beyond the expected return time without notifying the supervisor, the resident will be considered a discharge against medical advice. The RN supervisor will notify the DNS/ADNS, APRN/MD, responsible party and Administrator. Further review failed to identify the policy directed to notify the local police and the State Agency. Interview and record on 9/15/2025 at 2:15 PM with the DON and Administrator identified a LOA policy dated 2018 was provided on 9/9/2025. Two (2) additional pages (undated) were provided that directed if a resident was on LOA and returned later than 12 hours past the projected return time, to notify the police and State Agency. The DON stated the two (2) additional pages were sent to her from the Corporate Clinical Operations Manager and stated the three (3) pages do not go together. Further, the DON stated the policy dated 1/19/2018 is the policy that she was provided that directs staff what to do for an LOA when a resident does not return as expected, and staff have access to facility policies on the unit. The Administrator stated the 1/19/2018 Leave of Absence policy was the policy staff were directed to follow, and the Administrator confirmed that with the Corporate Clinical Operations Manager; the Administrator stated he received a text message from the Corporate Clinical Operations Manager confirming the current policy staff follow was the policy dated 1/19/2018. Interview failed to identify why the facility had numerous LOA policies and failed to identify why the DON and Administrator were directed that the current policy to follow was the 1/19/2018 policy when staff had electronic access to the policy dated 2/3/2025. Interview with the DON and Administrator on 9/15/2025 at 2:28 PM identified the facility should have one (1), most recently dated policy to clearly direct staff actions to take when a resident does not return from an LOA timely. Interview with the Medical Director/Physician #1 on 9/17/2025 at 1:28 PM identified he was not aware the facility had multiple Leave of Absence policies. The Medical Director further stated there should only be one policy that directs staff on what to do, and there should not be multiple or conflicting policies.

Based on review of clinical records, interviews, and review of facility documents and policies for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff notified the physician/medical director and facility administration timely when a resident failed to return to the facility as scheduled following a leave of absence, and for one of three residents reviewed for accidents, the facility failed to notify the provider that the resident's evening medications were missed. The findings included:Resident #1 had diagnoses that included cerebral infarction, chronic obstructive pulmonary disease, and adjustment disorder. Record review identified Person #1 was noted as Resident #1's responsible party. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had a Brief Mental Interview for Mental Status (BIMS) score of eleven (11), indicating the resident had moderate cognitive impairment, required set-up assistance with personal hygiene and supervision with transfers and ambulation. Physician order dated 8/13/2025 directed Leave of Absence (LOA) with rollator (walker). The Resident Care Plan (RCP) dated 8/28/2025 identified Resident #1 was at risk for pain and had a potential for altered thought processes and difficulty adjusting to situations. Interventions directed to administer medications as ordered, and evaluation of the effectiveness of current psychotropic medications. Review of a Leave of Absence Notification form dated 9/8/2025 identified Resident #1 left on a LOA at 10:30 AM and planned to return at 6:00 PM the same day. a. Review of the nursing note dated 9/8/2025 at 8:56 PM identified Resident #1 was still out on LOA. The note further indicated Resident #1 was responsible for him/herself, and that the supervisor was aware. Nursing note dated 9/9/2025 at 12:00 AM identified a call was placed to Resident #1's responsible party/Person #1, to inquire about the resident's whereabouts, and reached a recording that indicated Person #1's phone was out of service. Nursing note dated 9/9/2025 at 3:50 AM identified Resident #1 was returned to the facility (nine (9) hours and fifty (50) minutes after his/her expected time of return) by a Good Samaritan and was alert and verbal. Resident #1 was informed he/she would need to go to the hospital to be assessed, and Resident #1 agreed and stated he/she had back and knee pain as well. Interview with the Director of Nursing Services (DNS) on 9/9/2025 at 10:18 AM identified Resident #1 signed out of the facility at 10:30 AM on 9/8/2025 with the understanding that he/she was to return to the facility by 6:00 PM that evening. The DNS stated staff had called Resident #1's responsible party and two (2) local hospitals in an attempt to verify Resident #1's whereabouts. The DNS stated she was not notified by staff that Resident #1 did not return to the facility as scheduled; when she arrived to work on 9/9/2025 she was notified Resident #1 did not return to the facility as scheduled and had returned at 3:50 AM (9 hours and 50 minutes late). The DNS stated she and the Administrator should have been notified, and the local police and the resident's physician should have been notified that Resident #1 was missing, and staff did not know where he/she was. Interview failed to identify why notifications were not completed. Interview with Physician #1 on 9/17/2025 at 1:28 PM identified he would want to be notified if Resident #1 did not return timely from a LOA and that either he, the on-call physician, or Nurse Practitioner should be notified when a resident does not return timely from a leave of absence. Review of the Leave of Absence policy dated 2/3/2025 directed in part, if a resident does not return to the facility within one (1) hour of the expected return time, the registered nurse supervisor would notify the Director of Nursing Services/Assistant Director of Nursing Services, the Nurse Practitioner/Medical Director, responsible party, and the Administrator. b. Review of the Medication Administration Report (MAR) dated 9/8/2025 identified Resident #1 did not receive scheduled Furosemide (diuretic used to treat swelling) 40 milligrams at 9:00 PM, Gabapentin (used to treat pain) 800 milligrams at 9:00 PM, Quetiapine (Seroquel, antipsychotic used to treat mood) 50 milligrams at 7:00 PM, and Eliquis (anticoagulant/blood thinner) 5 milligrams, at 9:00 PM. Interview with LPN #1 on 9/15/2025 at 1:09 PM identified he/she failed to contact Resident #1's physician or APRN to notify them that Resident #1 missed scheduled medication. LPN #1 stated she did notify the charge nurse that the resident had missed his/her evening medications as he/she did not return from his/her LOA when scheduled to return. Interview with MD #1 on 9/10/2025 at 1:07 PM identified that although the facility provided him with resident updates during morning report, MD #1 stated he expected staff to notify him within one (1) to two (2) hours after a resident's medications were missed. MD #1 stated he, the on-call physician, or the Nurse Practitioner should be notified when a resident does not return timely from a leave of absence so that decisions could be made regarding any missed medications. Review of the Medication Administration policy directed staff to notify the provider, supervisor, Director of Nursing Services, or designee in the event of a medication administration error.

Based on review of clinical records, interviews, and review of facility documents and policies for one (1) of three (3) residents (Resident #1) reviewed for discharge, the facility failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer or discharge from the facility after a thirty-day discharge notice was given. The findings included: Resident #1 had diagnoses that included cerebral infarction, chronic obstructive pulmonary disease, and adjustment disorder. Record review identified Person #1 was noted as Resident #1's responsible party. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had a Brief Mental Interview for Mental Status (BIMS) score of eleven (11), indicating the resident had moderate cognitive impairment, required set-up assistance with personal hygiene and supervision with transfers and ambulation. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 was a short term stay admission. Interventions directed the Social Worker will utilize community resources to ensure a safe discharge, will prepare Resident #1 for discharge, the interdisciplinary care plan team will work together to discharge Resident #1 at the appropriate time, the Social Worker will, at the resident request, contact other facilities for a more appropriate placement, and will involve Resident #1 in the discharge planning Review of Resident #1's 30-Day Notice of discharge date d [DATE] identified a discharge was scheduled for [DATE] to a sister facility due to the resident being a danger to him/herself and others in the nursing facility. Review of Social Worker's note dated [DATE] at 10:48 AM identified Resident #1 was issued a thirty (30) day discharge notice (30-day notice) due to issues in complying with facility policies and that Resident #1 had refused to transfer to a sister facility. Review of the Social Worker's note dated [DATE] at 12:35 PM identified the resident was in agreement with the transfer. Interview with the Social Worker on [DATE] at 9:15 AM identified Resident #1 was given a 30-day discharge notice on [DATE] due to non-compliance with the facility smoking policy; Resident #1 would smoke in front of the building in the parking lot while awaiting transportation. The Social Worker stated the facility made a referral for transfer to a sister facility, but stated they were notified the resident's insurance would not pay for the stay at the alternate facility, and she was now unsure if the resident would be transferred. The Social Worker stated she had not done any additional planning for the discharge and was unsure where Resident #1 would go when the thirty (30) day notice expired on [DATE]. The Social Worker stated she had not talked with Resident #1 about his/her plans. Interview with the Director of Nursing Services (DNS) on [DATE] at 9:24 AM identified she was aware the 30-day discharge notice was given but was unsure as to the reason why. The DNS further stated residents with planned discharges and 30-day notice discharges were discussed during daily morning meeting and referred to a white board located in the conference room, however Resident #1's name was not included on the board. The DNS stated she was not aware if Resident #1 was appealing the discharge, and she was not aware if the Ombudsman was informed of the 30-day discharge notice. Interview with the Administrator on [DATE] at 9:24 AM identified he was new in the facility and was not aware a 30-day discharge notice was given. The Administrator stated he was not aware that Resident #1 was being transferred due to non-compliance with the smoking policy. Interview with the MDS Coordinator on [DATE] at 10:01AM identified Resident #1 would need to be removed from his HMO insurance plan for the sister facility to accept his/her transfer. The MDS Coordinator stated she had escalated the issue for coverage at another facility with the insurance company and had not received any updates regarding coverage. The MDS Coordinator stated she did not follow-up further regarding the insurance. Interview on [DATE] at 10:10 AM with the MDS Coordinator, Social Worker, and the Admissions Coordinator at the sister facility that Resident #1 was referred to for potential admission identified the Admissions Coordinator had not received a referral for a potential admission to the facility. The Social Worker the stated technically, a referral was not sent to the sister facility/. The Social Worker stated she had sent the other facility a notice because although Resident #1's insurance covered this facility it would not cover the new facility. The Social Worker then stated Resident #1 was covered by Medicaid insurance, and coverage should not be a problem. The Social Worker further stated she had not made any plans for a safe discharge (19 days after the notice was given) when the 30-day notice was due to expire on [DATE]. Interview with Resident #1 on [DATE] at 12:41 PM identified Resident #1 believed the facility was transferring him/her to another facility on [DATE]. Resident #1 stated the facility had not provided him/her with any additional details after he/she received the 30-day discharge notice on [DATE] (19 days prior).

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #14) reviewed for nutrition and who required aspiration precautions and supervision with meals, the facility failed to provide a chopped diet as ordered by the physician, failed to provide supervision with eating on 3 days (3 breakfast meals) of the survey, and failed to ensure required safe swallowing strategies were implemented to prevent the resident from choking. These failures resulted in Immediate Jeopardy. The findings include: Resident #14 was admitted to the facility in May 2021 with diagnoses that included dementia, dysphasia, and anxiety. The care plan dated 5/1/25 identified Resident #14 was at risk for aspiration with interventions that included a mechanically altered chopped diet with aspiration precautions and assist with meal intake. The annual MDS assessment dated [DATE] identified Resident #14 had severely impaired cognition and required supervision or touching assistance with staff providing verbal cues and/or touching and/or contact guard assistance for eating and was on a mechanically altered diet. The speech therapy Discharge summary dated [DATE] identified Resident #14 was seen for dysphasia and required the following swallow techniques; alternate solids with liquids to increase pharyngeal clearance, facilitate small bites and sips 1/2 to 1/3 teaspoon, facilitate body positioning to increase safety with intake and facilitate alternating bites with sips of liquids with distant supervision. Resident #14 is to receive a mechanically soft chopped diet using swallow strategies to facilitate safety and efficiency. Recommendations include using the following strategies or maneuverers during oral intake, lingual sweep and swallow, alternating solids and liquids with rate modification, upright posture during meals and upright posture for at least 30 minutes after meals. Resident and primary caregivers were trained in compensatory strategies and safe swallowing techniques to enable resident to safely consume highest level of intake. A physician's order dated 6/23/25 directed to provide a chopped diet with thin liquids. The APRN note dated 7/30/25 at 3:59 PM identified Resident #14 had intermittent generalized weakness and poor oral intake. Staff are to encourage nutritional supplements and assist with feeding. APRN reinforced with staff to assist Resident #14 with feeding and follow up with dietitian. The dietitian note dated 8/12/25 at 4:24 PM identified Resident #14 required a chopped diet and total feed. The dietitian noted on 7/10/25 Resident #14 triggered for a significant undesirable weight loss of 5.7% in a month. Resident #14 has a history of trending weight loss in the last 6 months. Boost supplements were increased to twice a day. Dietitian noted Resident #14 was at risk for malnutrition related to dementia, mechanically altered diet, and total feed. The physician's order dated 8/18/25 directed for a low sodium chopped diet with less than 6 ounces of animal protein per day. Observation on 8/24/25 at 9:06 AM identified Resident #14 was sitting upright in bed with a half-eaten breakfast tray in front of him/her on the overbed table. Resident #14 was holding a piece of a non-toasted whole bagel that had been cut in half and had some of the bagel in his/her mouth. There was a half-eaten hardboiled egg with bites out of it on the plate not cut up into pieces, and the other half of the bagel was in 1 piece on the plate. There were no staff in the room or supervising Resident #14 at the time. Resident #14's breakfast meal ticket dated 8/24/25 identified Resident #14 had aspiration precautions and was to receive 3 ounces of scrambled eggs and 2 slices of chopped French toast. Interview with the charge nurse on the unit, LPN #1, on 8/24/25 at 9:07 AM indicated Resident #14 was on a chopped diet and should not have been given the whole hard-boiled egg or the whole bagel that had been cut in half. LPN #1 indicated that Resident #14 was at risk for aspiration and was on aspiration precautions. LPN #1 indicated Resident #14 received the wrong consistency meal (a regular diet) and should have received a chopped diet. LPN #1 informed Resident #14 she would be removing the meal and indicated she would notify the director of the kitchen and have the correct meal sent. Interview with the Dietary Director (Interim) on 8/24/25 at 9:10 AM indicated that all residents should receive what is on their meal ticket. Dietary Director (Interim) reviewed Resident #14's meal ticket and compared what was delivered to Resident #14 and indicated that Resident #14 had received the wrong meal and that the meal ticket and the plate of food did not match. Dietary Director (Interim) indicated that the last person on the tray line in the kitchen was responsible to make sure the meal ticket and the meal matched on every tray before placing on the cart prior to delivery to the nursing unit. Dietary Director (Interim) indicated the nurse aide was responsible for reading the meal ticket and making sure it matched the items on the tray before bringing the tray to the resident. Interview with NA #1 on 8/24/25 at 2:05 PM indicated that she had given Resident #14 his/her breakfast tray this morning, a hard-boiled egg it its shell and a bagel. NA #1 indicated she had peeled the egg and cut it in half for Resident #14. NA #1 indicated she did not read the meal ticket or compare the meal ticket to the food on the plate to make sure it was the correct diet. NA #1 indicated she did not realize that Resident #14 was on a chopped diet or aspiration precautions and should not have received a regular diet for breakfast. NA #1 indicated that the kitchen was responsible to make sure the food on the tray was correct before sending it up to the nursing units. NA #1 indicated she has worked at the facility for more than 5 years and does not recall being educated on reading the meal tickets to ensure the diet consistency was correct. NA #1 indicated that her understanding of aspiration precautions was that staff were to ensure the residents sit upright for meals. NA #1 indicated that she was not aware if Resident #14 had to be supervised for meals. NA #1 indicated that Resident #14 always ate breakfast in bed and did not need supervision with eating before today. Interview with the DNS on 8/24/25 at 3:10 PM indicated the nurse aide was responsible to read the resident's care card to verify what diet the resident was on before distributing the meal tray so the resident receives the correct diet. Additionally, the DNS indicated the nurse aide was responsible to make sure the meal ticket and the items on the tray match before giving the tray to the resident. After reviewing the breakfast meal ticket for Resident #14, the DNS indicated Resident #14 was on a chopped diet with aspiration precautions. The DNS indicated Resident #14 should not have received a whole hard-boiled egg or a whole bagel sliced in half. The DNS indicated that aspiration precautions mean a resident must be upright 45 to 90 degrees when eating and chew slowly, and the food must be chopped up. The DNS indicated if the resident receives the wrong diet, he/she would be at risk of aspiration and choking where food goes into the lungs instead of going into the stomach. Interview with Dietary Director (Interim) on 8/24/2025 at 3:41 PM indicated the dietary aide on the tray line was responsible to make sure the meal ticket and the food items on the tray matched before the meal tray's leave the kitchen. Dietary Director (Interim) indicated he started education with the kitchen staff regarding making sure the meal tickets and the food items on the tray match. Observation on 8/25/25 at 8:50 AM identified Resident #14 was sitting upright in bed with his/her breakfast tray directly in front of him/her on the overbed table. Resident #14 was eating the cut-up pieces of pancake with syrup and off the plate with his/her fingers. There were no staff present for supervision or to assist Resident #14 with eating. Resident #14's breakfast meal ticket dated 8/25/25 identified aspiration precautions in capital letters at the top of the ticket, and the meal included 2 individual chopped pancakes and 1 chopped sausage patty. After surveyor inquiry, the speech evaluation dated 8/25/25 was completed and identified Resident #14 is currently on a chopped soft texture diet with thin liquids. Resident #14 has dysphasia with incomplete bolus formation, inadequate mastication and rotary chew pattern, lack of mastication, effortful mastication, excessive mastication time, oral residue, piecemeal chewing, poor attention to task and residue on tongue base. Resident #14's behavior was impacting safety with impulsive rate, poor safety monitoring skills, decreased safety awareness, uncontrolled talking while eating and reduced attention to task. To facilitate safety and efficiency it is recommended the resident use the following strategies and maneuvers during oral intake: lingual sweep and re-swallow, alternating liquids and solids, rate modification, and general swallowing techniques and upright during meals and upright at least 30 minutes after meals. Resident #14 chugged liquids and was unable to take small single sips with verbal and visual cues. Based on today's evaluation, continuation of a chopped texture diet is recommended. Encourage Resident #14 to have a slow rate of intake, upright posture during meals. Observation on 8/26/25 at 8:55 AM identified Resident #14 was lying in bed in the upright position eating the scrambled eggs with his/her fingers without staff present or supervision. The breakfast meal ticket for Resident #14 dated 8/26/25 identified 3 ounces scrambled eggs and 1 chopped up muffin. Interview with Dietitian #1 on 8/26/25 at 10:08 AM indicated that Resident #14 is on a chopped diet and should never have received a whole hard-boiled egg or a bagel. Interview with SLP #1 on 8/26/25 at 11:00 AM indicated when Resident #14 returned from the hospital she was asked to see the resident to do an evaluation for the diet. SLP #1 indicated she had Resident #14 on case load from 4/15/25 to 6/13/25 for dysphasia and to assess for the least restrictive diet. SLP #1 indicated Resident #14 is impulsive and eats too fast with food and requires cues to not eat fast and alternate a bite of food then a sip of liquid. SLP #1 indicated Resident #14 has mild to moderate residue diffuse food left after a bite of food in his/her mouth and pockets food in his/her cheeks. SLP #1 indicated Resident #14 needs the liquid sips to clear the food from the mouth before taking another bite. SLP #1 indicated Resident #14 needs cueing to stop talking while eating to prevent choking, the liquid to clear the food, and cueing to slow the rate he/she is eating. SLP #1 indicated after Resident #14 had ended therapy his/her chewing had improved but the resident still was eating too fast, was impulsive and needed cueing throughout the meal. SLP #1 explained that with a chopped diet, the food is chopped into pieces approximately a third to a half inch in size for all meats, vegetables, fruits, etc. SLP #1 indicated the kitchen is responsible to make sure that all food for a chopped diet is chopped prior to being sent to the unit. SLP #1 indicated Resident #14 puts food in his/her mouth quickly, has impaired cognition, and impaired reasoning which was why SLP #1 placed Resident #14 on aspiration precautions. SLP #1 indicated that when she recommends a mechanically altered diet, she verbally informs the nurse aides and charge nurses of the diet and safety strategies. SLP #1 indicated that she had informed the nursing staff that Resident #14 needed distant supervision for meals and to make sure Resident #14 is using strategies for aspiration precautions during the meal. SLP #1 indicated that staff need to make sure implement these measures when Resident #14 eats. SLP #1 indicated she was asked on 8/25/25 after surveyor inquiry to reevaluate Resident #14's aspiration precautions. SLP #1 indicated after evaluation there were no changes for Resident #14's diet or behaviors, he/she still needed a chopped diet, was still at risk for aspiration and needs to continue with the same aspiration precaution strategies. SLP #1 indicated when she recommends swallowing strategies and aspiration precautions, she verbally informs the nursing supervisor, and it would be the nursing supervisors responsibility to call the physician and get the orders to put the recommendations into place. SLP #1 indicated that Resident #14 should not have received a hard-boiled egg cut in half or a whole bagel cut in half. SLP #1 indicated that Resident #14 was at increased risk for aspiration with the bagel because a bagel is hard to chew and sticky and the resident eats at a fast rate and the bagel can adhere to the pharyngeal wall (inner lining of the throat) and could cause it to get stuck there. SLP #1 indicated that Resident #14 is on a chopped diet because the resident would take huge bites. SLP #1 indicated Resident #14 is at increased risk for aspiration with the hard-boiled egg due to impaired cognition and eating to fast. Interview with NA #14 on 8/27/25 at 2:22 PM indicated that the speech therapist verbally educates her when a resident needs aspiration precautions. NA #14 indicated that if a resident was on aspiration precautions that meant the resident should eat all meals in the dining room so staff cand keep an eye on the resident while eating. NA #14 indicated that the nurse aide goes back and forth from the hallway to the dining room to observe the residents while eating. NA #14 indicated she was not aware Resident #14 needed distant supervision or was on aspiration precautions. NA #14 indicated the care card only stated mechanically altered diet. NA #14 indicated that she does not know what mechanically altered means. NA #14 indicated that if Resident #14 was on aspiration precautions due to his/her confusion and was eating in his/her room she would have sat in the room to observe the resident eating or brought resident to the dining room. A physician order dated 8/27/25 at 6:25 PM identified Resident #14 to receive a chopped diet with less than 6 ounces of animal protein per day and a direct 1:1 feed. The nurses note dated 8/27/25 at 8:01 PM identified that Resident #14's lungs were assessed by an RN and noted to be clear to auscultation and without any distress. Oxygen saturation was 98% on room air. Resident #14 was able to talk and in no respiratory distress. Review of the Meal Type Policy and Procedure, undated, identified the purpose was to ensure accurate identification and delivery of prescribed and preferred meal types to all residents, thereby promoting safe, dignity, and compliance with physician's orders and resident choice. It is the policy that all meals served to residents must be clearly identified according to the physician orders, dietary restrictions, and resident preferences. Staff must utilize standardized labeling and cross-checks to prevent errors in meal service. The registered dietitian or dietary manager will update meal tickets accordingly. The meal tray identification for each meal ticket must include resident name, room number, diet type (regular, mechanically soft, cardiac, etc), allergen and texture alerts, beverages and for any special diet it must be clearly noted on the meal ticket. Texture-modified diets such as pureed, chopped, regular meal tickets must be checked by both dietary and nursing staff. Meal service and cross-checks the dietary staff prepares and verifies trays before leaving the kitchen, nursing staff receives tray and cross checks against the resident ticket before serving, direct care staff will confirm correct tray delivered to the resident at bedside or dining area. Staff training - all food service and nursing staff will receive annual training on therapeutic diets, meal identification (meal tickets and label), therapeutic and modified diets, resident rights to meal choice, and procedures for resolving discrepances. Random audits will be conducted by the dietary manager at least weekly to ensure accuracy of meal identification. Review of the Aspiration Precaution Policy dated 1/19/18 identified it was the policy to implement evidence-based aspiration precautions for all residents identified at risk for dysphasia or aspiration. This includes a multidisciplinary approach to ensure safe oral intake, appropriate supervision, and immediate intervention to mitigate risk and promote resident safety. To establish a consistent protocol to prevent aspiration events among at-risk residents, ensuring proper dietary modifications, positioning, and feeding techniques are incorporated into individualized care plans and implemented by staff. The nurse aide is responsible to follow positioning and feeding guidelines, observing signs of distress, and report promptly. The licensed nurse is responsible to implement and documenting in the care plan, notifying the provider of changes, and oversee feeding compliance. The SLP is responsible to assess swallowing function and providing written recommendations. Dietary is responsible to prepare and label meals in accordance with the diet order. Aspiration precautions procedures include verify the residents consistency on the meal ticket, ensure resident is sitting at 75 - 90 degree angle, clean residents mouth, feed slowly and do not rush resident, encourage small bites and sips of liquid, alternating solids with liquids, monitor for signs of distress (coughing, throat clearing, wet voice, etc.), avoid talking while chewing or swallowing, remain present and attentive during feeding, maintain upright position for at least 30 - 60 minutes after meal, inspect oral cavity for pocketing of food. During the survey it was determined that Immediate Jeopardy existed under S483.60(c)(3) Menus and nutritional adequacy. Menus must be followed.The Immediate Jeopardy began when observations on 8/24/25 at 9:06 AM identified Resident #14 alone in his/her room without supervision and had been provided and was eating a hardboiled egg and bagel, both cut in half. Subsequently, the investigation identified that the resident required aspiration precautions, swallowing strategies and a chopped diet. Further observations on 8/25/25 at 8:50 AM and 8/26/25 at 8:55 AM identified that although Resident #14 was provided the correct diet (chopped), the resident was observed alone in his/her room eating breakfast without supervision. On 8/27/25 at 5:55 PM the Administrator was notified that the failure to provide the correct diet (chopped) and supervision to Resident #14 on 8/24/25 at 9:06 AM with the ongoing failures to supervise the resident's meal intake on 8/25/25 at 8:50 AM and 8/26/25 at 8:55 AM constituted Immediate Jeopardy to the health and safety of the resident. The IJ Template was provided to the Administrator on 8/27/25 at 5:55 PM. The facility provided an Immediate Jeopardy removal plan on 8/27/25 at 8:00 PM that was accepted by the state agency. The IJ removal plan included the following. Immediate Actions Taken.Resident #14: Immediately removed all non-compliant food items from the tray and provided the correct physician-ordered diet (NAS chopped diet, thin liquids). Resident was placed under 1:1 supervision during all meals. RN assessed the resident. Physician and family were notified. No signs of aspiration were noted post-incident.Other residents on aspiration precautions: A rapid review was conducted on 8/27/25 of all residents with swallowing impairments or special diet orders. All diet orders were verified against current tray tickets and care plans. Corrections were made immediately for any discrepancies.Staff Re-Education: Nursing assistants, dietary aides, licensed nurses, Registered Dietitian, and speech therapy staff were immediately re-educated beginning 8/27/25 on: Reading and verifying meal tickets before tray delivery. Following physician orders and speech therapy recommendations for diet texture and supervision needs. Direct supervision protocols for residents on aspiration precautions.Systemic Changes Implemented.Tray Line Checks: Dietary Manager or designee will implement a checking system on the tray line to ensure meals match physician orders and diet tickets before trays leave the kitchen.Nursing Verification: Nursing staff will be required to confirm that trays match resident diet orders before serving.Communication Protocol: A formal handoff process is now required between Speech Therapy, Registered Dietitian, Nursing, and Dietary when aspiration precautions or swallowing and/or altered diet recommendations are made. All changes will be entered immediately into physician orders. Changes will be communicated electronically via email to SLP, RD, Nursing and Dietary. A paper communication form will be sent to the kitchen by the nurse with the confirmed changes. This communication form will be brought to the IDT for review to ensure accuracy and filed for reference and validation.Mandatory Education: All staff who deliver or assist with meals will undergo mandatory training on diet consistencies and aspiration precautions. Attendance logs will be maintained.Monitoring and Quality Assurance.Daily Meal Observation Audits: For the next 14 days, the DON or designee will conduct daily audits of meal service for all residents with aspiration precautions. Any non-compliance will result in immediate correction and staff re-education.Weekly IDT Review: The Interdisciplinary Team (IDT) will review all residents on aspiration precautions weekly to ensure orders are accurate, interventions are being followed, and supervision levels are consistent.Quarterly QA Reporting: Results of audits will be reported to the facility Quality Assurance & Performance Improvement (QAPI) Committee quarterly for ongoing monitoring and further corrective action as needed.Responsible party.The Director of Nursing (DON) will be the responsible party.Date of Compliance.The facility asserts that the immediate jeopardy was removed on 8/27/25, when all residents on aspiration precautions were verified for correct diet orders, supervision was implemented, and staff education initiated. The facility will remain in compliance ongoing.Based on observations and interviews by the survey team, the IJ was removed on 8/29/25.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Resident 12, 14, 23, 28, 51, 105, 137) the facility failed to provide adequate supervision to prevent accidents and failed to ensure the resident environment remained as free of accident hazards as is possible. For 2 of 7 residents (Resident #12 and 14) reviewed for nutrition and who required aspiration precautions, the facility failed to ensure adequate supervision during meals.For 2 of 12 residents (Resident #23 and 28), reviewed for accidents, the facility failed to ensure adequate supervision and follow smoking policies for residents with smoking violations. For 1 of 12 residents (Resident #51) reviewed for accidents, the facility failed to complete and document leave of absence (LOA) risk assessments prior to allowing the resident to go on an independent LOA, failed to ensure staff reviewed, and the resident understood and abided by the LOA protocols, failed to develop and implement interventions to keep the resident safe during LOA after the resident had several accidents, including sustaining a significant injury after falling out of the motorized wheelchair while intoxicated, and tested positive for substance use after being on an independent LOA, and exhibited ongoing unsafe behaviors of smoking in the street in front of the facility in the wheelchair.For 2 of 12 residents (Resident #51 and 105) reviewed for accidents, the facility failed to ensure smoking assessments were completed timely and when indicated, failed to ensure residents were not smoking unsupervised in unauthorized areas, failed to provide education related to smoking in areas adjacent to the facility property, failed to ensure that residents were free from contraband, and failed to address smoking violations and contraband violations per facility policy.For 1 resident (Resident #137) reviewed for closed record, the facility failed to develop appropriate strategies and ensure adequate supervision for a resident with a swallowing disorder who was known to access potentially unsafe food, who was found with whole nuts in their mouth, failed to examine root causes of how food was accessed and establish measures to prevent recurrence.Further, the facility failed to ensure an oxygen tank was stored securely away from residents, failed to ensure that the designated smoking area was free of hazards, and failed to ensure the smoking cart was supervised by facility staff when unlocked with smoking materials on the top and in the presence of residents. The findings include: 1. Resident #12 was admitted to the facility in November 2013 (readmission in January 2024) with diagnoses that included dementia, stroke affecting the left side, dysphasia, and abnormal weight loss. The Speech Therapy Discharge summary dated [DATE] identified Resident #12 was seen for skilled dysphasia therapy. Resident #12 needed to facilitate liquid delivery using small and controlled sips, facilitate small bites of 1/2 to 1/3 of a teaspoon for modification to bolus presentation, instruction in alternating a sip of liquid with a bite of food to increase pharyngeal clearance, and facilitate rate control during oral intake of food and liquids. Additionally, training was provided in the need for upright posture during meals and instruction in the use of upright posture for at least 30 minutes after meals. Resident #12 and care giver training in compensatory strategies, positioning maneuvers, safe swallow techniques and safety precautions to preserve current level of function and enable resident to safely consume highest level of intake with least amount of supervision. The Speech Evaluation and Plan of Treatment dated 11/27/23 identified Resident #12 had a recent decrease in oral intake and concerns for weight loss. Speech recommendations include close supervision for meals and continue with safe swallowing techniques and precautions. The speech therapy note dated 11/27/23 at 1:10 PM identified Resident #12 would benefit from being a total feed at this time. Resident #12 will continue a regular diet with thin liquids. A physician's order dated 4/7/25 directed to provide a regular diet, aspiration precautions, and total assistance with feeding. The care plan dated 6/23/25 identified Resident #12 was at increased risk for alterations in nutritional status due to diagnosis. Interventions included to provide a regular diet and monitor resident for difficulties with chewing, swallowing, and a need for a modified consistency requiring a speech evaluation. The dietitian note dated 7/8/25 at 1:16 PM identified Resident #12 was on a regular diet and required aspiration precautions and total feed. The annual MDS dated [DATE] identified Resident #12 had moderately impaired cognition, needs set-up and clean-up assistance for meals and has a therapeutic diet. The dietitian note dated 8/14/25 at 4:15 PM identified Resident #12 was on a regular diet and required total feed for meals.The dietitian note dated 8/21/25 at 3:40 PM identified he had met with the nurse aide because Resident #12 was requesting his/her food to be cut up because the resident is unable to independently cut up the food. The special instruction for chopped food is solely for residents' ease of eating, not convenience. Observation on 8/24/25 at 8:45 AM to 9:10 AM identified Resident #12 was in the dining room eating breakfast independently. A nurse aide was standing in the doorway with her back to Resident #12 looking into the hallway approximately 15 feet from the resident. There was one other resident in the dining room with his/her back towards Resident #12 at another table. At 8:46 AM the nurse aide exited the dining room and went down the hallway out of sight. Resident #12 continued feeding him/herself half a bagel with cream cheese. Resident #12 at 9:05 AM had completed eating most of the bagel but did not touch the bowl of hot cereal. At 9:08 AM the nurse aide entered the dining room and asked Resident #12 if he/she was done eating breakfast and removed the meal tray. Interview with NA #1 on 8/24/25 at 10:00 AM indicated Resident #12 eats independently and does not need supervision for meals. NA #1 indicated that sometimes Resident #12 will eat in the dining room and on other days will eat in bed for breakfast. Observation on 8/26/25 at 9:10 AM to 9:30 AM identified Resident #12 was lying in bed sitting in the upright position with the overbed table in front of him/her. On the table were 2 bowls of hot cereal, a cup of juice, and a cup of a hot beverage in front of the resident and within reach. Resident #12 had one bite missing from one bowl of hot cereal and no staff were present in the room. Interview with the DNS on 8/27/25 at 1:51 PM indicated that Resident #12 was on aspiration precautions and required a total feed per the physician's orders. The DNS indicated that the nurse aide should sit next to Resident #12 and assist the resident with every meal. The DNS indicated food should not be left in front of Resident #12 without someone present. After surveyor inquiry, the care plan dated 8/27/25 identified Resident #14 was at increased risk for alteration in nutritional status. Interventions included aspiration precautions in capital letters, regular diet and thin liquids, and a 1 to 1 feed.Interview with the DNS on 8/29/25 at 8:15 AM indicated that the physician's diet order, the care plan, and the nurse aid care card for the resident should all match. The DNS indicated the diet order, the assistance needed, if someone needed aspirations precautions, or any other special instructions would be a part of the physician's order. After reviewing the clinical record, the DNS identified there were 2 dietary physician orders for Resident #12. The DNS indicated there was one listed as a regular diet with aspiration precautions and a total feed, and a second order for self-feeding with set up. The DNS indicated the most recent physician order should be followed. The DNS indicated the order for aspiration precautions, and total feed was the most recent and the physician order for a setup should have been discontinued. After review of the nurse aide flow sheets, the DNS identified the day shift nurse aides were documenting Resident #12 was independent with meals, but Resident #12 should be fed. The DNS indicated she does not know why the nurse aides are documenting Resident #12 is independent eating meals.Interview with SLP #1 on 8/28/25 at 10:00 AM indicated Resident #12 was discharged from speech therapy on 11/27/23 and was made a total feed at that time with aspiration precautions. SLP #1 indicated she uses the term safety strategies interchangeable with aspiration precautions. Interview with OT #1 (Director of Rehab) on 8/28/25 at 10:05 AM indicated Resident #12 has required a total feed for a long time with the physician order as a 1 to 1 feed. OT #1 indicated Resident #12 became a 1 to 1 feed because of weight loss. OT #1 indicated there were 2 physician orders for diet but the OT order for diet for a set up for meals should have been discontinued when the total feed order was put into place. OT #1 indicated the physician order was fixed this morning after surveyor inquiry. Review of the Meal Type Policy and Procedure, undated, identified the purpose was to ensure accurate identification and delivery of prescribed and preferred meal types to all residents, thereby promoting safety, dignity, and compliance with physician's orders and resident choice. It is the policy that all meals served to residents must be clearly identified according to the physician orders, dietary restrictions, and resident preferences. Staff must utilize standardized labeling and cross-checks to prevent errors in meal service. The registered dietitian or dietary manager will update meal tickets accordingly. The meal tray identification for each meal ticket must include resident name, room number, diet type (regular, mechanically soft, cardiac, etc), allergen and texture alerts, beverages and for any special diet it must be clearly noted on the meal ticket. Texture-modified diets such as pureed, chopped, regular meal tickets must be checked by both dietary and nursing staff. Meal service and cross-checks the dietary staff prepares and verifies trays before leaving the kitchen, nursing staff receives tray and cross checks against the resident ticket before serving, direct care staff will confirm correct tray delivered to the resident at bedside or dining area. Staff training - all food service and nursing staff will receive annual training on therapeutic diets, meal identification (meal tickets and label), therapeutic and modified diets, resident rights to meal choice, and procedures for resolving discrepancies. Random audits will be conducted by the dietary manager at least weekly to ensure accuracy of meal identification. Review of the Aspiration Precaution Policy dated 1/19/18 identified it was the policy to implement evidence-based aspiration precautions for all residents identified at risk for dysphasia or aspiration. This includes a multidisciplinary approach to ensure safe oral intake, appropriate supervision, and immediate intervention to mitigate risk and promote resident safety. To establish a consistent protocol to prevent aspiration events among at-risk residents, ensuring proper dietary modifications, positioning, and feeding techniques are incorporated into individualized care plans and implemented by staff. The nurse aide was responsible to follow positioning and feeding guidelines, observing signs of distress, and report promptly. The licensed nurse was responsible to implement and documenting in the care plan, notifying the provider of changes, and oversee feeding compliance. The SLP was responsible to assess swallowing function and providing written recommendations. Dietary was responsible to prepare and labelling meals in accordance with the diet order. Aspiration precautions procedures include verify the residents consistency on the meal ticket, ensure resident is sitting at 75 - 90 degree angle, clean residents mouth, feed slowly and do not rush resident, encourage small bites and sips of liquid, alternating solids with liquids, monitor for signs of distress (coughing, throat clearing, wet voice, etc.), avoid talking while chewing or swallowing, remain present and attentive during feeding, maintain upright position for at least 30 - 60 minutes after meal, inspect oral cavity for pocketing of food. 2. Resident #14 was admitted to the facility in May 2021 with diagnoses that included dementia, dysphasia, and anxiety. The care plan dated 5/1/25 identified Resident #14 was at risk for aspiration with interventions that included a mechanically altered chopped diet with aspiration precautions and assist with meal intake. The annual MDS assessment dated [DATE] identified Resident #14 had severely impaired cognition and required supervision or touching assistance with staff providing verbal cues and/or touching and/or contact guard assistance for eating and was on a mechanically altered diet. The speech therapy Discharge summary dated [DATE] identified Resident #14 was seen for dysphasia and required the following swallow techniques; alternate solids with liquids to increase pharyngeal clearance, facilitate small bites and sips 1/2 to 1/3 teaspoon, facilitate body positioning to increase safety with intake and facilitate alternating bites with sips of liquids with distant supervision. Resident #14 is to receive a mechanically soft chopped diet using swallow strategies to facilitate safety and efficiency. Recommendations include using the following strategies or maneuverers during oral intake, lingual sweep and swallow, alternating solids and liquids with rate modification, upright posture during meals and upright posture for at least 30 minutes after meals. Resident and primary caregivers were trained in compensatory strategies and safe swallowing techniques to enable resident to safely consume highest level of intake. The APRN note dated 7/30/25 at 3:59 PM identified Resident #14 had intermittent generalized weakness and poor oral intake. Staff are to encourage nutritional supplements and assist with feeding. APRN reinforced with staff to assist Resident #14 with feeding and follow up with dietitian. The dietitian note dated 8/12/25 at 4:24 PM identified Resident #14 required a chopped diet and total feed. The physician's order dated 8/18/25 directed a low sodium chopped diet with less than 6 ounces of animal protein per day. Observation on 8/24/25 at 9:06 AM identified Resident #14 was sitting upright in bed with a half-eaten breakfast tray in front of him/her on the overbed table. Resident #14 was holding a piece of a non-toasted whole bagel that had been cut in half and had some of the bagel in his/her mouth. There was a half-eaten hardboiled egg with bites out of it on the plate not cut up into pieces, and the other half of the bagel was in 1 piece on the plate. There were no staff in the room or supervising Resident #14 at the time. Interview with the charge nurse on the unit, LPN #1, on 8/24/25 at 9:07 AM indicated Resident #14 was on a chopped diet and should not have been given the whole hard-boiled egg or the whole bagel that had been cut in half. LPN #1 indicated that Resident #14 was at risk for aspiration and was on aspiration precautions. LPN #1 indicated Resident #14 received the wrong consistency meal (a regular diet) and should have received a chopped diet. LPN #1 informed Resident #14 she would be removing the meal and indicated she would notify the director of the kitchen and have the correct meal sent. Interview with NA #1 on 8/24/25 at 2:05 PM indicated that she had given Resident #14 his/her breakfast tray this morning, a hard-boiled egg it its shell and a bagel. NA #1 indicated she did not realize that Resident #14 was on a chopped diet or aspiration precautions and should not have received a regular diet for breakfast. NA #1 indicated that her understanding of aspiration precautions was that staff were to ensure the residents sit upright for meals. NA #1 indicated that she was not aware if Resident #14 had to be supervised for meals. NA #1 indicated that Resident #14 always ate breakfast in bed and did not need supervision with eating before today. Interview with the DNS on 8/24/25 at 3:10 PM indicated the nurse aide was responsible to read the resident's care card to verify what diet the resident was on before distributing the meal tray so the resident receives the correct diet. Additionally, the DNS indicated the nurse aide was responsible to make sure the meal ticket and the items on the tray match before giving the tray to the resident. After reviewing the breakfast meal ticket for Resident #14, the DNS indicated Resident #14 was on a chopped diet with aspiration precautions. The DNS indicated Resident #14 should not have received a whole hard-boiled egg or a whole bagel sliced in half. The DNS indicated that aspiration precautions mean a resident must be upright 45 to 90 degrees when eating and chew slowly, and the food must be chopped up. The DNS indicated if the resident receives the wrong diet, he/she would be at risk of aspiration and choking where food goes into the lungs instead of going into the stomach. Observation on 8/25/25 at 8:50 AM identified Resident #14 was sitting upright in bed with his/her breakfast tray directly in front of him/her on the overbed table. Resident #14 was eating the cut-up pieces of pancake with syrup and off the plate with his/her fingers. There were no staff present for supervision or to assist Resident #14 with eating. Resident #14's breakfast meal ticket dated 8/25/25 identified aspiration precautions in capital letters at the top of the ticket. After surveyor inquiry, the speech evaluation dated 8/25/25 was completed and identified Resident #14 is currently on a chopped soft texture diet with thin liquids. Resident #14 has dysphasia with incomplete bolus formation, inadequate mastication and rotary chew pattern, lack of mastication, effortful mastication, excessive mastication time, oral residue, piecemeal chewing, poor attention to task and residue on tongue base. Resident #14's behavior was impacting safety with impulsive rate, poor safety monitoring skills, decreased safety awareness, uncontrolled talking while eating and reduced attention to task. To facilitate safety and efficiency it is recommended the resident use the following strategies and maneuvers during oral intake: lingual sweep and re-swallow, alternating liquids and solids, rate modification, and general swallowing techniques and upright during meals and upright at least 30 minutes after meals. Resident #14 chugged liquids and was unable to take small single sips with verbal and visual cues. Based on today's evaluation, continuation of a chopped texture diet is recommended. Encourage Resident #14 to have a slow rate of intake, upright posture during meals. Observation on 8/26/25 at 8:55 AM identified Resident #14 was lying in bed in the upright position eating the scrambled eggs with his/her fingers without staff present or supervision. Interview with SLP #1 on 8/26/25 at 11:00 AM indicated Resident #14 is impulsive and eats too fast with food and requires cues to not eat fast and alternate a bite of food then a sip of liquid. SLP #1 indicated Resident #14 has mild to moderate residue diffuse food left after a bite of food in his/her mouth and pockets food in his/her cheeks. SLP #1 indicated Resident #14 needs the liquid sips to clear the food from the mouth before taking another bite. SLP #1 indicated Resident #14 needs cueing to stop talking while eating to prevent choking, the liquid to clear the food, and cueing to slow the rate he/she is eating. SLP #1 indicated after Resident #14 had ended therapy his/her chewing had improved but the resident still was eating too fast, was impulsive and needed cueing throughout the meal. SLP #1 indicated Resident #14 puts food in his/her mouth quickly, has impaired cognition, and impaired reasoning which was why SLP #1 placed Resident #14 on aspiration precautions. SLP #1 indicated that when she recommends a mechanically altered diet, she verbally informs the nurse aides and charge nurses of the diet and safety strategies. SLP #1 indicated that she had informed the nursing staff that Resident #14 needed distant supervision for meals and to make sure Resident #14 is using strategies for aspiration precautions during the meal. SLP #1 indicated that staff need to make sure implement these measures when Resident #14 eats. SLP #1 indicated she was asked on 8/25/25 after surveyor inquiry to reevaluate Resident #14's aspiration precautions. SLP #1 indicated after evaluation there were no changes for Resident #14's diet or behaviors, he/she still needed a chopped diet, was still at risk for aspiration and needs to continue with the same aspiration precaution strategies. SLP #1 indicated when she recommends swallowing strategies and aspiration precautions, she verbally informs the nursing supervisor, and it would be the nursing supervisors responsibility to call the physician and get the orders to put the recommendations into place. SLP #1 indicated that Resident #14 was at increased risk for aspiration with the bagel because a bagel is hard to chew and sticky and the resident eats at a fast rate and the bagel can adhere to the pharyngeal wall (inner lining of the throat) and could cause it to get stuck there. SLP #1 indicated that Resident #14 is on a chopped diet because the resident would take huge bites. SLP #1 indicated Resident #14 is at increased risk for aspiration with the hard-boiled egg due to impaired cognition and eating to fast. Interview with NA #14 on 8/27/25 at 2:22 PM indicated that the speech therapist verbally educates her when a resident needs aspiration precautions. NA #14 indicated that if a resident was on aspiration precautions that meant the resident should eat all meals in the dining room so staff cand keep an eye on the resident while eating. NA #14 indicated that the nurse aide goes back and forth from the hallway to the dining room to observe the residents while eating. NA #14 indicated she was not aware Resident #14 needed distant supervision or was on aspiration precautions. NA #14 indicated the care card only stated mechanically altered diet. NA #14 indicated that she does not know what mechanically altered means. NA #14 indicated that if Resident #14 was on aspiration precautions due to his/her confusion and was eating in his/her room she would have sat in the room to observe the resident eating or brought resident to the dining room. A physician order dated 8/27/25 at 6:25 PM identified Resident #14 to receive a chopped diet with less than 6 ounces of animal protein per day and a direct 1:1 feed. Review of the Aspiration Precaution Policy dated 1/19/18 identified it was the policy to implement evidence-based aspiration precautions for all residents identified at risk for dysphasia or aspiration. This includes a multidisciplinary approach to ensure safe oral intake, appropriate supervision, and immediate intervention to mitigate risk and promote resident safety. To establish a consistent protocol to prevent aspiration events among at-risk residents, ensuring proper dietary modifications, positioning, and feeding techniques are incorporated into individualized care plans and implemented by staff. The nurse aide is responsible to follow positioning and feeding guidelines, observing signs of distress, and report promptly. The licensed nurse is responsible to implement and documenting in the care plan, notifying the provider of changes, and oversee feeding compliance. The SLP is responsible to assess swallowing function and providing written recommendations. Dietary is responsible to prepare and label meals in accordance with the diet order. Aspiration precautions procedures include verify the residents consistency on the meal ticket, ensure resident is sitting at 75 - 90 degree angle, clean residents mouth, feed slowly and do not rush resident, encourage small bites and sips of liquid, alternating solids with liquids, monitor for signs of distress (coughing, throat clearing, wet voice, etc.), avoid talking while chewing or swallowing, remain present and attentive during feeding, maintain upright position for at least 30 - 60 minutes after meal, inspect oral cavity for pocketing of food. 3. Resident #23 was re-admitted to the facility in April 2025 with diagnoses that included chronic obstructive pulmonary disease, and history of opioid use.A copy of the smoking policy dated 4/1/25, signed by Resident #23, identified smoking was only allowed outside in designated smoking areas. All residents must be supervised while smoking and smoking materials were to be secured by staff. Violations would be subject to a noninvasive room/person search and counseling.A Smoking Observation assessment dated [DATE] identified Resident #23 was safe to smoke on independent leave of absence (LOA).The MDS dated [DATE] identified Resident #23 had moderately impaired cognition and was independent with locomotion using a wheelchair/walker.The care plan dated 6/24/25 identified Resident #23 was a smoker and approved for independent LOA. Interventions included providing education on contraband and smoking policies.A physician's order dated 7/15/25 directed Resident #23 could be independent while on LOA with rollator.a. A Nurse's note dated 8/21/25 identified at 9:56 PM Resident #23 was found with an unknown substance in a box in his/her room. The APRN was notified, and a urine sample was requested.Subsequently, the corresponding care plan was revised noting contraband had been found in Resident #23's room with interventions that the resident submit to random room/person/container searches and may have restricted LOA.b. Observation on 8/26/25 at 2:45 PM identified Resident #23 was in a wheelchair in the front parking lot, actively smoking, with a cigarette pack visible in the shirt pocket. The area was without designated smoking signage, fire-safe disposal containers or appropriate fire control materials. Resident #23 declined to comment when asked about the smoking activity. The Administrator was immediately notified.A Resident Room Worksheet dated 8/26/25 identified Resident #23 was present during a room search with no documented findings of contraband.A Contraband Policy Violation Investigation dated 8/26/25 identified Resident #23 denied smoking but was on the premises with cigarettes, which was against facility policy. Interdisciplinary recommendations included no smoking materials while out on LOA and obtain consent for noninvasive searches.Interview with the Administrator on 8/27/25 at 11:32 AM identified Resident #23 had prior smoking violations and transfer to a sister facility was in progress.Review of the smoking policy directs smoking is allowed outside in designated smoking areas and at designated times. All residents must be supervised while smoking and at no time are residents allowed to have cigarettes and other smoking materials in their possession.Review of the Contraband policy directs violations of the contraband agreement may result in involuntary discharge including possession of controlled substances, cigarettes, cigars, pipes, e-cigarettes, vapes or other fire sources. 4. Resident #28 was admitted to the facility in August 2025 with diagnoses that included aftercare following surgery of the nervous system and chronic obstructive pulmonary disease (COPD).A Smoking Observation dated 8/1/25 identified Resident #28 was safe to smoke independently on leave of absence (LOA).A copy of the smoking policy dated 8/1/25, signed by Resident #28 identified smoking was only allowed outside in designated smoking areas and at designated times. All residents must be supervised while smoking and at no time are residents allowed to have cigarettes and other smoking materials in their possession.The care plan dated 8/1/25 identified Resident #28 was a smoker with interventions that included that Resident #28 would abide by the smoking policy and not possess any smoking materials in their room/on their person.The admission MDS dated [DATE] identified Resident #28 had moderately impaired cognition required supervision with ambulation using a walker.A physician's order dated 8/15/25 directed Resident #28 was independent while on LOA with rollator.A LOA Notification Form dated 8/27/25 identified Resident #28 was leaving the facility at 9:30 AM for a doctor's appointment.Observation on 8/27/25 at 10:07 AM identified Resident #28 was outside, on the premises, near the front entrance, smoking unsupervised. The area was without designated smoking signage, fire-safe disposal containers and appropriate fire control materials. When questioned Resident #28 responded that he/she was aggravated. The Administrator was immediately notified.Interview with the Administrator on 8/27/25 at 11:32 AM identified he met with Resident #28 and reminded the resident of the smoking policy. Resident #28 agreed to a room search upon return. The Administrator further identified that although smoking violations were subject to an emergency discharge notice for any violation, he indicated a notice had not been provided.A Notice of discharge date d 8/27/25 identified Resident #128 was to be discharged on 9/27/25 with a right to appeal. The notice was signed by the Administrator. It was noted Resident #28 refused to sign the notice at 10:16 AM, 1 hour and 16 minutes earlier.The Contraband Policy Violation Investigation dated 8/27/25 identified Resident #28 left the faciity on approved LOA, refused to sign the contraband policy, denied smoking and having contraband, stated he/she did not need to follow policies. Resident #28 did, however, agree to a room search which identified cigarettes that were removed.Review of the smoking policy directs smoking is allowed outside in designated smoking areas and at designated times. All residents must be supervised while smoking and at no time are residents allowed to have cigarettes and other smoking materials in their possession.Review of the Contraband policy directs violations of the contraband agreement may result in involuntary discharge including possession of controlled substances, cigarettes, cigars, pipes, e-cigarettes, vapes or other fire sources. 5. Resident #51 was admitted to the facility in May 2021 with diagnoses that included traumatic brain injury, alcoholic hepatitis, malignant neoplasm of the colon and left kidney, mild neurocognitive disorder with behavioral disturbance, hemiplegia and hemiparesis following a stroke affecting the right dominant side, and bipolar disorder. A Physician's order dated 8/21/24 identified Resident #51 may go out on pass independently (end date of 8/21/25). Review of the clinical record failed to reflect that a LOA risk assessment had been completed prior to the physician's order dated 8/21/24 that allowed the resident to go out on pass independently. The annual MDS dated [DATE] identified Resident #51 had moderately impaired cognition, was taking an anticoagulant and antiplatelet medication, and used a manual wheelchair with the ability to independently wheel at least 50 feet and make two turns and wheel at least 150 feet in a corridor or similar space. The care plan dated 5/21/25 identified Resident #51 was at risk for falls related to weakness and history of falls. Interventions included checking the wheelchair brakes and instructing the resident on proper use, toileting at regular intervals, and monitoring and reporting changes in mood, anxiety, sleep patterns, and behavior. The care plan further identified Resident #51 exhibited behaviors as evidenced by verbally/physically abusive, wandering, refusals of care, delusions, hallucinations, aggression, psychiatric conditions, and a history of risk of injury to self or others. Interventions included monitoring any changes in mood or behavior and reporting to the physician, providing the resident with the opportunity to express feelings through 1 to 1 and group visits, and using the resident's name and explaining the purpose upon approach. The care plan further identified Resident #51 had been approved for a LOA with responsible party. Interventions included completing an interdisciplinary team review for LOA, obtaining a physician's order for LOA, educating the resident on LOA and contraband policies and obtaining signatures. a. The[TRUNCATED]

Based on observation, review of facility policy, and interviews, the facility failed to ensure food items were labeled and dated in the kitchen and nourishment rooms and failed to ensure the walk-in freezer was defrosted. The findings include: 1. Tour of the kitchen with [NAME] #1 on 8/24/25 at 7:15 AM identified the following.Main walk-in refrigerator identified a 1/2 cut up cucumber without being covered, labeled, or dated, 1/2 an onion not covered, labeled, or dated, 3 heads of lettuce not covered labeled or dated with dripping liquid and wilted leaves and brown spots, 9 stalks of celery uncovered sitting on a metal tray not covered, labeled, or dated. The walk-in freezer identified 7 brown meat patties in a blue bag not closed with frost on them not labeled or dated. [NAME] #1 indicated they were Salisbury steaks. They were not in their original container. A blue bag not closed with visible frost on the chopped-up onions not labeled or dated, a clear bag with grey colored meat that was not labeled or dated. [NAME] #1 indicated they were pork chops. A blue bag not closed with breaded items inside not labeled or dated. [NAME] #1 indicated they were fish cakes. Twenty hamburgers in a clear plastic bag with frost covering them not labeled or dated, 18 chicken patties in a clear untied bag with freezer burn not labeled or dated. [NAME] #1 and the Dietary Director (Interim) on 8/24/25 at 7:20 AM discarded all the unlabeled and undated food items into the garbage. Interview with the Dietary Director (Interim) on 8/24/25 at 7:40 AM indicated the refrigerator items should have been covered, labeled, and dated. The Dietary Director (Interim) indicated the items that were prepared, used, or opened were to be discarded after 3 days. The Dietary Director (Interim) indicated the cooks, and dietary aides were responsible to check dates on all food items daily and discard outdated items after 3 days. The Dietary Director (Interim) indicated that the freezer items when removed from the original package were expected to be labeled and dated. 2. Tour of the walk-in freezer with the Dietary Director (Interim) on 8/24/25 at 7:35 AM identified large drips of ice from the fan in the back at the top wall to the top shelf with a half basketball size frozen block of ice. The fan on the right side had an ice drip frozen from the corner of the fan covering the corner of a box on the top shelf. There was a large frozen strip of ice on the right side in the middle of the wall from the top shelf going down to the bottom shelf. Interview with the Dietary Director (Interim) on 8/24/25 at 7:40 AM indicated he would defrost the freezer today.Observation on 8/25/25 at 1:00 PM identified the freezer had large forms of ice present inside the freezer.Observation on 8/26/25 at 10:00 AM identified the freezer continues to have the large forms of ice present in the freezer. Interview with Dietary Director (Interim) on 8/29/25 at 9:20 AM indicated on 8/27/25 he had cleaned the freezer. The Dietary Director (Interim) indicated that he did not have time before that to get the freezer defrosted and clean the freezer. 3. interview with the Dietary Director (Interim) on 8/25/25 at 11:00 AM indicated the dietary staff were responsible to check the nourishment refrigerators daily for expired foods, food or drinks not labeled with resident's name and items were dated. The Dietary Director (Interim) indicated any item not labeled or dated or past the 3 days from dated were to be discarded. The Dietary Director (Interim) indicated nursing was responsible to label and dating all items for residents prior to placing them in the nourishment refrigerator or freezer. 4. Observation and tour of 1 out of 3 nourishment refrigerators on 8/25/25 at 11:00 AM with the Dietary Director (Interim) in the nourishment room on second floor identified the following.The freezer had a 1/2 full 12-ounce water bottle not labeled or dated, 6 juice cups not labeled or dated and 5 individual ice pops not labeled or dated. The refrigerator had a half-used container of horseradish dip was not labeled but was dated as opened on 3/16/25 with an expiration date of 3/25/25. Dumpling bites expired 7/31/25, open box of sugar 16 ounces not labeled or dated. 7 cups of grape juice not labeled or dated, a kit kat chocolate bar with a manufacturer expiration date of 8/9/25, a chocolate bar 2/3's eaten not covered, labeled, or dated, 2 containers of food dated 8/14/25, a 1/2 eaten sandwich in a paper towel not labeled or dated. Further, the refrigerator contained Chinese yellow soup not labeled but dated 8/11/25, 2 containers of yogurt with expiration dates of 4/3/25, 1/2 pound of sliced ham use expired 8/21/25, 4- eight-ounce orange juice boxes with manufacturer expiration date of 8/9/25, 1 plastic container with a solid substance and the liquid had separated not labeled or dated, bacon horseradish dip manufacturer expiration date of 6/11/25, an open container of sliced ham not labeled but dated 8/16/25, deli sliced ham not labeled but dated 8/13/25, deli sliced ham not labeled but dated 8/18/25, 1/2 pound deli sliced cheese not labeled dated 8/12/25. The Dietary Director (Interim) discarded all the expired food items. Review of the Freezer and dry food Storage Policy identified to ensure all frozen and dry food items are stored in a safe, sanitary, and organized manner to prevent contamination, foodborne illness, and compliance with federal, state, and local regulations. Freezer storage all items must be labeled with product name, date received, date opened, and a use by or expiration date. Cover and seal all food items in freezer-safe containers or packaging. Discard any food with signs of freezer burn, torn packages, or exceeding safe storage time. Although requested a policy for labeling and dating refrigerated items and nourishment refrigerators were not provided.

Based on review of facility documentation, policy, and interviews for 5 of 5 nurse aides (NA #1, NA #6, NA #16, NA #17, and NA #18), the facility failed to ensure performance evaluations were completed, at least every 12 months. The findings include:Review of NA #1's personnel file identified that she was hired on 6/25/09 and failed to identify documentation that an annual performance evaluation was completed in the year of 2024 or to date, in 2025.Review of NA 18's personnel file identified that she was hired on 1/28/10 and failed to identify documentation that an annual performance evaluation was completed in the year of 2024 or to date, in 2025.Review of NA #17's personnel file identified that she was hired on 9/26/18 and failed to identify documentation that an annual performance evaluation was completed in the year of 2024 or to date, in 2025.Review of NA #6's personnel file identified that she was hired on 4/12/22 and failed to identify documentation that an annual performance evaluation was completed in the year of 2024 or to date, in 2025.Review of NA #16's personnel file identified that she was hired on 1/10/24 and failed to identify documentation that an annual performance evaluation was completed in the year of 2024 or to date, in 2025.Interview with the interim-DNS on 8/28/25 at 4:53 PM identified that she was unaware that the nurse aide annual performance evaluaitons were not completed in 2024 or to date in 2025, but she would expect them to have been completed annually.Interview with the Administrator on 8/29/25 at 10:00 AM identified that it was just brought to his attention that the 2024 performance evaluations were not completed for the nurse aide staff, and that no 2025 annual performance evaluations had been completed, yet. The Administrator indicated that he remembered a prior DNS completing the annual evaluations back in 2024, but he was unable to locate the documentation that they were completed. The Administrator further identified that he began conversations with the former DNS, back in March 2025, to start working on the annual performance evaluations, and the former DNS indicated that they were being completed; during the survey process he learned that they had not been completed. The Administrator identified that he would expect performance evaluations to be completed at 30, 60, and 90 days for new hires and annually thereafter.The Annual Staff Evaluation policy directs that formal performance evaluations for all staff members are conducted at least annually, and more frequently as needed. Evaluations will be used to assess job performance, recognize strengths, identify areas for improvement, and establish goals for the upcoming year. Performance evaluations are to be conducted annually, generally in the month of the employees hire date anniversary. Additional evaluations may be completed at the end of the probationary period, following a significant change in job duties, or when performance concerns arise. Direct supervisors or department heads are responsible for conducting evaluations of staff under their supervision, and evaluations must be reviewed and signed by the Administrator or designee to ensure consistency and fairness.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure consistent response and follow-up to Resident Council concerns according to facility policy. The findings include: Review of Resident Council minutes from 1/29/25 to 7/30/25 identified repeated concerns raised by residents regarding the following.Nurse aides using personal phones during work hours.Food quality issues, including cold meals, greasy or undercooked items, and meals served with reported allergens.Unmet food requests (e.g., butter, fruit, salt, and pepper).Incorrect meal tickets.The review identified there was no documented response from facility staff to concerns raised during the 2/26/25, 6/25/25, and 7/30/25 meetings, despite similar issues being previously reported. Additionally, the Food Service Director was not in attendance at the Resident Council meetings on 3/31/25, 5/28/25, 6/25/25, and 7/30/25, where food-related concerns were discussed. Interview with Resident #123 on 8/24/25 at 1:27 PM identified facility administration did not consistently follow up on Resident Council concerns. Interview with Resident #71 on 8/24/25 at 1:27 PM indicated facility administration did not consistently follow up on food-related concerns, there was no dedicated food committee, and the Food Service Director did not attend Resident Council meetings. Interview with the Director of Recreation on 8/25/25 at 10:02 AM identified she was responsible for facilitating Resident Council meetings and coordinating follow-up. Resident concerns were referred to appropriate departments using a 'Response Form' for review at the next meeting. The Director of Recreation indicated interdisciplinary follow-up was inconsistent, making it difficult to address concerns, and that the Administrator was aware. The Director of Recreation also noted the Food Service Director declined repeated invitations to attend the meetings. Interview with the Administrator on 8/26/25 at 10:25 AM identified he was aware Resident Council concerns were not being responded to consistently and that the Food Service Director was not attending monthly meetings. The Administrator further identified he would expect the Food Service Director to be in attendance monthly to address concerns related to food. Regardless, it was his responsibility to ensure monthly follow-up was unable to explain the ongoing breakdown to ensure consistent responses.Review of the facility's Resident Council policy directs accurate documentation of meetings, including concerns and recommendations, forwarding of concerns to the Administrator and department heads, written responses or updates to be provided at the next scheduled meeting.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #15, 18, 22, and 38) reviewed for covid vaccinations, the facility failed to offer and/or provide education on covid vaccinations. The findings include: During a review of the facility infection prevention program on 8/26/25 at 8:07 AM, a request was made to RN #1 (Infection Preventionist) to provide documentation for covid vaccinations or signed refusals with education for a list of 5 sampled residents (Resident #15, 18, 22, 38, and 60) for the last 12 months (8/2024 - 8/2025). Although requested, the facility failed to provide any documentation related to covid vaccinations or declinations for Resident #15, 18, 22, and 38. Interview with RN #1 on 8/27/25 at 8:10 AM identified that she did not have any mechanism for tracking vaccinations for residents of the facility. RN #1 identified she could not locate any tracking information in the IP that was provided to her when she took the position, and the only way she knew to track vaccinations to look up each individual resident in the electronic medical record to determine if they had been vaccinated. RN #1 identified she did not track any of the consents, declinations, or vaccines for any of the facility residents and was unaware of who needed vaccinations or who had refused them. The facility policy on COVID-19 vaccinations for residents directed that upon admission and readmission to the facility, residents would be assessed for eligibility to receive the most current recommended COVID-19 vaccination, and when indicated would be offered the vaccine within 14 days of admission to the facility, unless medically contraindicated or if the resident had already received the CDC's recommended dose. The policy further directed that residents who refused COVID-19 vaccinations would be reoffered the vaccine at each care plan meeting if applicable. The policy further directed that the facility would track consents, declinations, and vaccinations of all residents.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure ongoing review of antibiotic stewardship including tracking and monitoring of use for residents who required antibiotic treatment for infection. The findings include:During a review of the facility infection prevention program on 8/26/25 at 8:07 AM, a request was made to RN #1 (Infection Preventionist) to provide documentation including antibiotic use including criteria, tracking and monitoring for all residents who required antibiotic treatments in the last 12 months (8/2024 - 8/2025). Although requested, RN #1 was unable to provide documentation related to antibiotic surveillance or tracking. Interview with RN #1 on 8/27/25 at 8:10 AM identified that she had taken on the role of the IP nurse in February 2025 and since that time she had not completed any infection tracking, antibiotic use, or statistical information. RN #1 identified since she began in the IP role, she had attended 2 medical staff meetings but had not prepared or provided any statistical tracking or information related to infection rates or antibiotic use. RN #1 identified was the facility wound nurse, the staff development nurse, and infection prevention nurse, and had very minimal training for all the roles, and was basically learning on the job. RN #1 identified that prior to her becoming the IP nurse, there was no IP nurse for several months so there was no tracking done for that timeframe as well. RN #1 identified that there was no staff available to help her and she was doing the best she could. Interview on 8/27/25 at 8:00 AM with the DNS identified that she had been covering as the DNS for the last five weeks and had worked as the ADNS prior to that. The DNS identified that the facility did not have an IP nurse for several months prior to RN #1 taking over the role as there were issues filling the position. The DNS identified she had taken an infection preventionist certification at one point shortly after she started working at the facility in 8/2024 but never covered the infection prevention program.Interview with the Administrator on 8/28/25 at 11:10 AM identified that the facility did not have a designated IP nurse from August of 2024 until RN #1 began in the position in February 2025. The Administrator identified the facility had several issues with finding a qualified nurse to fill the role. The facility policy on the infection prevention and control program directed that the infection prevention and control program was coordinated and overseen by an Infection preventionist. The policy also directed the IP program included antibiotic stewardship which included culture reports, sensitivity data, and antibiotic usage reviews which would be included in surveillance activities and that antibiotic usage would be evaluated and practitioners. The policy further directed that the Infection Preventionist would gather data from nursing units and categorized each infection by body site and provide a uniform basis for comparison of infection rates then monthly rates would be plotted graphically or otherwise to compare trend comparisons.The facility policy on antibiotic stewardship directed that the facility would work to ensure safe and effective use of antibiotics and would actively seek to minimize the inappropriate use of antibiotics through ongoing assessment, education, and leadership activities as part of the facility infection prevention and control program. The policy further directed the facility medical director in conjunction with the infection preventionist, DNS, and pharmacy consultant, would assume the leadership roles in antibiotic stewardship. The facility would utilize the services of clinicians with specialized expertise in antibiotic prescribing as deemed clinically necessary. The policy further directed antibiotic stewardship activities would be coordinated through the pharmacy committee and infection control committee. The policy also directed antibiotic stewardship activities would include regular review of antibiotic utilization patterns and sensitivity patterns at committee meetings, use of antibiotics over time including quarterly, yearly, and past years, distribution of educational materials to staff on improving safe and effective use of antibiotics as well as materials on prevention of overprescribing on a regular basis in conjunction and coordination with annual in service training of nursing staff and other clinicians with clinical privileges.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that monitoring and tracking related to a GI outbreak was documented, failed to ensure ongoing infection surveillance tracking, and for 1 of 5 residents (Resident #86) reviewed for infection control, the facility failed to administer medications according to infection control standards and facility policy, and for 1 of 2 residents (Resident #90) reviewed for indwelling catheter, the facility failed to ensure the outlet valve of a supra pubic catheter collection bag was stored in a sanitary manner. The findings include: 1. A review of the state agency reportable event portal identified the facility reported 2 outbreaks since January 2024, one of which included a gastrointestinal outbreak (GI) in January 2025 that involved a total of 10 residents. Review of the documentation, provided by the former DNS, identified initially one resident developed nausea and vomiting on 1/4/25, with 5 additional residents experiencing the same symptoms along with diarrhea on 1/7/25, and 4 additional residents on 1/10/25. Further review of the documentation identified the residents were treated with an antiemetic, placed on isolation precautions until recovered, and that the outbreak was closed by the facility on 1/24/25.During a review of the facility infection prevention program as part of the recertification survey on 8/26/25 at 8:07 AM, a request was made to RN #1 (Infection Preventionist) to provide documentation related to all outbreaks for 2024 and 2025.Review of the outbreak documentation failed to include the GI outbreak that started on 1/4/25. Subsequent to surveyor inquiry on 8/27/25 at 7:30 AM, the DNS and RN #1 provided a line list which identified a total of 10 residents involved in a GI outbreak on the 1st floor unit beginning on 1/4/25 and ending 1/12/25. Review of the line list failed to reflect that the residents were placed on precautions or that testing was done to determine the cause. Interview with the DNS on 8/27/25 at 8:00 AM identified the line list provided was from the former DNS, but it was a basic list to try to keep track of the residents. The DNS identified since the facility did not have an IP nurse during that time, the staff did the best they could to track the outbreak. The DNS identified the residents were placed on contact precautions, but she could not identify when the precautions were placed. The DNS identified she remembered that the residents were all off precautions on 1/13/25 per the direction of the former DNS. Interview with RN #1 on 8/27/25 at 8:10 AM identified she vaguely remembered the outbreak after surveyor inquiry but was not the IP nurse at that time. RN #1 identified she was unsure who documented on the line list for the outbreak as it was in a shared drive for the facility but she believed the prior DNS completed it since the facility did not have an IP nurse during that time. 2. During a review of the facility infection prevention program as part of the recertification survey on 8/26/25 at 8:07 AM, a request was made to RN #1 (Infection Preventionist) to provide documentation including infection surveillance tracking for the last 12 months (8/2024 - 8/2025).Although requested, RN #1 was unable to provide any documentation related to infection surveillance tracking.Interview with RN #1 on 8/27/25 at 8:10 AM identified that she had taken on the role of the IP nurse in February 2025 and since that time she had not completed any infection tracking for residents of the facility. RN #1 identified that other than the facility list of MDROs, she did not track any infections, antibiotics, or statistical information related to infections and antibiotic use for facility residents. RN #1 identified she was the facility wound nurse, the staff development nurse, and infection prevention (IP) nurse, and had very minimal training for all the roles, and was basically learning on the job. RN #1 identified that prior to her becoming the IP nurse, there was no IP nurse for several months so there was no tracking done for that timeframe as well. RN #1 identified that there was no staff available to help her and she was doing the best she could. Interview on 8/27/25 at 8:00 AM with the DNS identified that she had been covering as the DNS for the last five weeks and had worked as the ADNS prior to that. The DNS identified that the facility did not have an IP nurse for several months prior to RN #1 taking over the role as there were issues filling the position. The DNS identified she had taken an infection preventionist certification at one point shortly after she started working at the facility in August 2024 but never covered the infection prevention program. Interview with the Administrator on 8/28/25 at 11:10 AM identified that the facility did not have a designated IP nurse from August of 2024 until RN #1 began in the position in February 2025. The Administrator identified the facility had several issues with finding a qualified nurse to fill the role. The facility policy on surveillance for infections directed that the infection preventionist would conduct ongoing surveillance of healthcare associated infections (HAIs) and other endemically significant infections that have had substantial impacts on potential resident outcomes and that may require transmission-based precautions or other preventative interventions. The policy further directed that surveillance of infections was used to identify both individual cases and trends of epidemiologically significant organisms and HAIs to guide the appropriate interventions and to prevent further infections. The policy further directed that infections to be included with routine surveillance included those with evidence of transmissibility and healthcare environment, clinically significant morbidity or mortality associated with the infection, and pathogens associated with serious outbreaks. The policy further directed that the charge nurse would notify the attending physician and the Infection Preventionist of a suspected infection. The policy also directed that the infection preventionist was responsible for gathering and interpreting surveillance data on infections. 3. Resident #86 was admitted to the facility in July 2024 with diagnoses that included anxiety and chronic pain. The care plan dated 6/12/25 identified Resident #86 has anxiety and chronic pain, with interventions that included to administer medications as ordered. The annual MDS dated [DATE] identified Resident #86 had intact cognition. Resident #86 is on a scheduled pain and as needed pain medication regime. Review of the August 2025 monthly physician's orders directed to administer the following medications.Alprazolam (antianxiety)1mg tablet at 6:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 9:00 PM.Tramadol (pain relief) 100 mg at 6:00 AM, 2:00 PM, and 10:00 PM.Sertraline 100mg (2 tablets) daily for major depressive disorder.Fluphenazine 10mg (antipsychotic) (2 tablets) three times daily. Observation on 8/28/25 at 1:26 PM identified LPN #14 was at the medication cart. LPN #14 picked up a medication cup and dropped the cup, which contained 2 pills, onto the floor. LPN #14 was observed to pick up the cup and the 2 pills off the floor and place them back into the medication cup and onto the top of the medication cart. Without the benefit of handwashing, LPN #14 removed a blister pack from the medication cart and popped 2 tablets into the medication cup containing the pills from the floor. LPN #14 opened the narcotic lock box, removed a blister pack, and popped 2 tablets into the medication cup containing the pills from the floor. Further, LPN #14 was also noted to intermittently use the laptop computer. Without the benefit of handwashing, LPN #14 proceeded to lock the medication cart and went down the hallway to Resident #86's room. LPN #14 offered the medications to Resident #86 and as LPN #14 was handing the medication cup to Resident #86, surveyor intervened and asked LPN #14 to step out of the room. The medications were not administered at that time. Interview with LPN #14 on 8/28/25 at 1:30 PM indicated that she was not going to throw any of the pills away and was going to administer all the pills to Resident #86. LPN #14 indicated repeatedly that she was not going to discard the medications that were on the floor because Resident #86 would not want her to discard any of his/her medications.Observation on 8/28/25 at 1:32 PM identified LPN #14 re-entered Resident #86's room and attempted to administer the pills in the medication cup that included the pills that had been on the floor. As LPN #14 extended her arm with the medication cup toward Resident #86, the resident extended his/her arm to take the pills. As the resident reached to take the medication cup, LPN #14 observed this surveyor standing in the doorway and she pulled the medication cup back and exited the room. Interview with LPN #14 on 8/28/25 at 1:33 PM indicated to this surveyor, (since you want me to discard the medication I will). Interview with the DNS on 8/28/25 at 1:45 PM indicated that if a nurse drops medication on the floor, the nurse is to discard the medication and get new medication. Interview with the DNS on 8/28/25 at 2:30 PM indicated that she had spoken with LPN #14 and who indicated she was going to give Resident #86 the medications she had dropped on the floor. The DNS indicated that LPN #14 should have discarded the medications immediately and obtained new medication. Review of the Infection Control for Dropped Medications Policy dated 1/19/18 identified medications that come in contact with the floor, unclean surfaces, or otherwise become contaminated are not considered appropriate for administration and must not be given to residents. The purpose is to prevent infection, cross-contamination, and ensure resident safety by establishing procedures for handling medications that are dropped on the floor or otherwise contaminated. 4. Resident #90 was admitted to the facility in January 2023 with diagnoses that included artificial openings of urinary tract status, neuromuscular dysfunction of the bladder, and urinary retention. A physician's order dated 6/1/25 directed for Resident #90's foley bag to be changed every month, special instructions: nurse must write date on the bag. The quarterly MDS dated [DATE] identified Resident #90 had severely impaired cognition, was dependent for personal and toileting hygiene, and had an indwelling catheter. The care plan dated 8/8/25 identified Resident #90 had a foley catheter related to impaired bladder functioning, urinary retention, and acute illness, with interventions that included irrigation or foley change as ordered/as needed and keep foley-bag below bladder level. The care plan identified Resident #90 required the application of Enhanced Barrier Precautions (EBP) during high contact resident care activities due to an indwelling medical device, with interventions that included gown and gloves to be worn with high contact with the affected source-urinary catheter. Observation on 8/24/25 at 7:20 AM with NA #2 identified the unsecured outlet valve to Resident #90's catheter collection bag was in contact with the floor. Interview with NA #2 on 8/24/25 at 7:20 AM identified that she had just begun her shift and had not yet rounded on Resident #90, but the external part of the catheter should not be touching the floor due to infection control, and that she would notify the nurse. Interview with LPN #4 on 8/24/25 at 7:40 AM identified that he had worked the night shift; when he last rounded on Resident #90 around 5:30 AM the drainage valve to the catheter collection bag was not touching the floor, and that the valve should not be in contact with the floor due to infection control problems. LPN #4 indicated that he would notify the nursing supervisor and ensure the collection bag was changed. Interview with LPN #2 on 8/24/25 at 10:35 AM identified that education was provided to the night shift nurse aide that no part of the catheter collection bag should be touching the ground and, and that LPN #4 had replaced the bag prior to the end of his shift. Observation of Resident #90's catheter collection bag on 8/24/25 at 10:40 AM identified a change date of 8/24/25 had been written on the bag. Interview with the interim DNS on 8/27/25 at 7:28 AM identified that the outlet valve of the catheter collection bag should not be in contact with the floor because it would be an infection control violation and that the nurse followed the procedure by changing the bag immediately. The interim DNS indicated that she would educate staff to ensure no part of a catheter collection bag should be in contact with the floor.The Urinary Catheterization policy directs a sterile, continuously closed drainage system should be maintained for indwelling and suprapubic catheter systems, if there are breaks in aseptic technique, disconnection of tubing, or leakage from the bag the drainage system should be replaced. Urine in drainage bags should be emptied at least once every shift using a container designated for that resident only, and care must be taken to keep the outlet valve from becoming contaminated. Catheter change indications may include mechanical dysfunction or blockage of the urinary catheter system and contamination of the closed system.

Based on review of the clinical record, facility documentation, facility policies, and interviews for the only sampled resident (Resident #45) reviewed for personal funds, the facility failed to protect the resident from misappropriate of resident funds. The findings include:Resident #45 was admitted to the facility in June 2021 with diagnoses that included major depressive disorder, paranoid personality disorder, and chronic pain.The quarterly MDS dated [DATE] identified Resident #45 had intact cognition and based on a brief interview for mental status and review of the medical record the resident had no acute change in mental status from baseline, no signs of inattention, disorganized thinking, or altered level of consciousness, had no hallucinations or delusions, and no physical, verbal, or wandering behaviors.The annual MDS dated [DATE] identified Resident #45 had intact cognition, was currently considered by the state level II PASRR process to have serious mental illness and based on a brief interview for mental status and review of the medical record he/she had no acute change in mental status from baseline, no signs of inattention, disorganized thinking, or altered level of consciousness, had no hallucinations or delusions, and no physical, verbal, or wandering behaviors.The care plan dated 6/9/25 identified Resident #45 preferred privacy and chose to remain in his/her room, with interventions that included therapeutic recreation (TR) staff providing the resident with a personal activity calendar and offering 1 to 1 visits from the activity cart. The care plan further identified Resident #45 exhibited behaviors as evidenced by pocketing medications in mouth, verbally/physically abusive, wandering, refusals of care, delusions, hallucinations, aggression, psychiatric conditions, and risk of injury to self or others. Interventions included reapproaching the resident at another time, providing the resident with the opportunity to express feelings through 1 to 1 and group visits, and using the resident's name and explaining the purpose upon approach.Interview with Resident #45 on 8/24/25 at 7:58 AM identified that the facility oversees his/her personal funds and he/she had not received a written financial statement in 2025.Interview with Resident #45 and the Director of Social Services (SW #1) on 8/26/25 at 1:25 PM identified that he/she just received his/her quarterly financial statement after not seeing his/her statements this year, and there were discrepancies identified. There were 3 withdrawals (2 withdrawals for $20 and 1 withdrawal for $10) that the resident indicated he/she did not recall authorizing. Resident #45 indicated that the last withdrawal he/she made from the account was in December 2024 or January 2025. Resident #45 further indicated that he/she notified the Business Office Manager of the discrepancies, and it was being worked on.Interview with the Business Office Manager on 8/26/25 at 2:00 PM identified that Resident #45 had notified her of the discrepancies in the quarterly financial statement and that the charges were not unauthorized by the resident. The Business Office Manager identified that she would pull the sign-out documentation for the withdrawals, as they had been filed away. The Business Office Manager indicated that residents would come to her or call her if they would like to make a withdrawal from their personal account, but she only works in the facility two days per week. In her absence residents could go to the Administrator, and the Recreation Director assisted. The Business Office Manager further indicated that she could not recall Resident #45 coming to her directly for a withdrawal from the personal funds, but that the Recreation Director sometimes assists residents with ordering food from outside the facility. Interview with the Recreation Director on 8/26/25 at 2:10 PM identified that Resident #45 preferred to stay in his/her room and chose not to participate in group activities. Resident #45 was very astute, and she would often engage the resident in different ways to ensure he/she felt part of things. The Recreation Director indicated that Resident #45 did not always like the food at the facility so there were a few times the resident asked about getting a pizza. The Recreation Director further indicated that she could not recall the last time she assisted Resident #45 with ordering a pizza or the details surrounding the pizza order, because she has a lot of residents that she deals with, but she would have gotten the money for the pizza from the Business Office Manager and could not recall who signed for the withdrawal.Review of the Resident Petty Cash document dated 4/18/25 with the Recreation Director on 8/27/25 at 9:25 AM identified that $10 was withdrawn from Resident #45's account for a bake sale.Review of the Resident Reimbursements document dated 5/2/25 with the Recreation Director on 8/27/25 at 9:25 AM identified that $20 was withdrawn from Resident #45's account.Review of the Resident Reimbursements document dated 5/5/25 with the Recreation Director on 8/27/25 at 9:25 AM identified that $20 was withdrawn from Resident #45's account.Interview with the Recreation Director on 8/27/25 at 9:25 AM identified that the withdrawal on 4/18/25 from Resident #45's personal account was for bake-sale items and that the withdrawals on 5/2/25 and 5/5/25 were for a pizza for Resident #45. Interview with Resident #45 on 8/27/25 at 9:35 AM identified that the Recreation Director worked very hard to please everyone at the facility and often times used her own money to treat the residents. Resident #45 indicated that he/she was under the impression that any baked good items that he/she had received were covered by the house or purchased with the Recreation Director's personal money, which was causing confusion because he/she was not aware that money had been withdrawn from his/her personal account for baked goods. Resident #45 identified that he/she did not know how to best answer this writer's questions but to read between the lines. Resident #45 received a piece of paper, yesterday, indicating that he/she had withdrawn $20 from his/her personal account on 5/2/25 and 5/5/25, but he/she had never authorized those withdrawals nor was he/she aware of those withdrawals. Resident #45 indicated he/she had authorized only 1 withdrawal, at the end of December 2024 or beginning of January 2025, which was sent directly to a family member. Resident #45 identified that he/she had ordered pizza twice; the first time he/she paid $20 for pizza and the second time he/she paid $22 for pizza using money from his/her own bank account at which point Resident #45 held up a small plastic bag containing cash that he/she kept on his/her person.The Administrator was notified on 8/27/25 at 9:47 AM of Resident #45's allegation of misappropriation and a facility investigation was initiated.Interview with the Administrator on 8/29/25 at 9:00 AM identified that he completed the investigation and was unable to substantiate the allegation of misappropriation as it was not willful misappropriation. The Administrator indicated the Recreation Director was not clear in her communication to Resident #45 that when pizza and bake sale items were purchased, the items were not provided by the facility and that money was going to be taken out of the resident's account. Interview with the Recreation Director on 8/29/25 at 9:15 AM identified that she prides herself on being honest, and that she tried very hard to create meaningful connections with all the residents at the facility, in unique ways. The Recreation Director indicated that she could not recall the conversation she had with Resident #45 regarding the purchase of bake sale items, but that she always tried to include the resident and would always try to ensure the resident felt included in activities and often times paid for resident items with her own money. The Recreation Director identified that on the day's pizza was purchased for Resident #45, NA #19 had approached her that Resident #45 wanted pizza. The Recreation Director indicated that NA #19 and the resident made a deal that if he/she would allow NA #19 to give him/her a shower and a shave they would buy pizza. The Recreation Director indicated that she then went to the Business Office Manager to get money for the pizza. The Recreation Director indicated she did not ask Resident #45 if he/she was aware that the money would be coming from his/her personal account; she was happy that he was included and participating in something. The Recreation Director further indicated that once she got the money from the Business Office Manager, she gave it to NA #19 to pay for the pizza upon delivery. The Recreation Director indicated she placed the order, herself, before leaving for the day to ensure it would be delivered for supper.Interview with Resident #45 on 8/29/25 at 9:30 AM identified that he/she still had some confusion about the bake-sale withdrawal because the details were a little foggy. Resident #45 further identified that a few months back he/she was talking about pizza with NA #19, and she told him/her that she would order it if he/she would like pizza for dinner. Resident #45 indicated that the pizza was not offered as an incentive for getting bathed or a shave and that he/she paid for the pizza with cash from the bag he/she kept with him/her. Resident #45 further indicated that he/she had only ordered pizza twice. The first time he/she gave $20 to NA #19 and the second time he/she gave $22 to NA #19. Resident #45 indicated that it was only two times he/she ordered pizza at the facility, this year, and both times he/she gave NA #19 cash, and neither time was it disclosed to him/her that money would be withdrawn from his/her facility account, and both times he/she gave cash directly to NA #19.Interview with the Business Office Manager on 8/29/25 at 9:51 AM identified that she was not aware that NA #19 had taken cash from Resident #45, nor did she provide Resident #45 with a receipt for the 5/2/25 and 5/5/25 withdrawals. The Business Office Manager indicated that subsequent to this incident she had already begun developing new procedures for cash withdrawals that included witnessed signatures and better documentation. The Business Office Manager further indicated that the facility would reimburse Resident #45 for withdrawals dated 4/18/25, 5/2/25, and 5/5/25.Interview with the Administrator on 8/29/25 at 10:05 AM identified that during his investigation of the alleged misappropriation it had not been disclosed to him that Resident #45 had given NA #19 cash for the pizza orders on 5/2/25 and 5/5/25. The Administrator indicated that a new investigation would be initiated. Review of the Daily Staffing Breakdown dated 5/2/25 identified NA #19 worked on Resident #45's unit from 3:00 PM - 11:00 PM.Review of the Daily Staffing Breakdown dated 5/5/25 identified NA #19 worked on Resident #45's unit from 3:00 PM - 11:00 PM.Although attempted, an interview with NA #19 was not obtained.The facility's Resident Abuse, Mistreatment, Neglect, Exploitation, Misappropriation of Resident Property, and Retaliation policy directs that residents are free from abuse, mistreatment, neglect exploitation, misappropriation of property, and retaliation. Misappropriation of resident property means intentional misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent.The facility's Quarterly Resident Statement policy directs that residents and/or their representatives have the right to request clarification of charges at any time.

Based on review of facility documentation, facility policies, and interviews for the only sampled resident (Resident #45) reviewed for personal funds, the facility failed to provide quarterly financial statements to the resident. The findings include:Resident #45 was admitted to the facility in June 2021 with diagnoses that included major depressive disorder, moderate protein-calorie malnutrition, and chronic pain.The annual MDS dated [DATE] identified Resident #45 had intact cognition.Interview with Resident #45 on 8/24/25 at 7:58 AM identified that the facility oversees his/her personal funds and he/she had not received a written financial statement in 2025.Interview with the Business Office Manager on 8/26/25 at 9:50 AM identified that she worked at the facility twice a week but was always accessible for staff and residents via telephone. The Business Office Manager indicated that Resident #45 was responsible for self and was most recently given a quarterly statement at the end of March/beginning of April 2025, but she did not have documentation to support that the quarterly statement had been provided to the resident. The Business Office Manager indicated that her process was to put the completed quarterly financial statements in the mailboxes of the residents that were responsible for self and someone from the recreation department would deliver the statements. The Business Office Manager identified that the facility changed fund management systems recently, and that due to that change, the quarterly statements for 4/1/25 through 6/30/25 were delayed and would be going out later that day (8/26/25). The Business Office Manager further identified that residents that were responsible for self were verbally notified of the system change and the potential delay in the delivery of their quarterly statements, however, no documentation of that notification was provided. A letter dated 5/1/25 was sent to families and conservators notifying them of the change in systems.Interview with the Administrator on 8/28/25 at 7:40 AM identified that residents should be receiving quarterly financial statements and first quarter statements should have gone out by the end of April. Additionally, residents would be welcome to obtain an account balance at any time. The Administrator indicated that he was aware that there was a fund management system change, and it went live a few weeks prior, which could have affected the second quarter statements, but he was not aware that the quarterly statements were going out late. The Administrator further indicated that the best practice would have been to provide a statement to each resident before the old system started to migrate to the new system of the final accounting information, and then a statement should have been provided again when the new system was up and running. The facility's Quarterly Resident Statement policy directs that the resident and/or their resident representative will be provided with written statements of all financial transactions related to the resident's account, at least once per quarter. These statements will detail charges, payments, credits, and the current account balance. Statement generation will be prepared at least quarterly (January, April, July, and October). Distribution of statements will be delivered to the resident, if the resident can understand financial documents, or the resident's responsible party, Power of Attorney, or other legal representative as designated in the admission agreement. Statements may be distributed via mailed hard copy, hand delivery during care plan meetings or upon request, or secured electronic transmission if consent has been obtained. The policy further directs that residents and/or their representatives have the right to request clarification of charges at any time.The Resident Rights policy directs that residents have the right to have the facility manage their personal funds, if it is authorized in writing, have the right to a quarterly accounting of funds, and be provided a separate statement about how the facility manages resident funds.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #59) reviewed for abuse, the facility failed to report an allegation of staff to resident verbal abuse to the state agency per established timeframes. The findings include:Resident #59 was admitted to the facility in 12/2023 with diagnoses that included allergies, unspecified asthma and diabetes mellitus.The quarterly MDS dated [DATE] identified Resident #59 was cognitively intact, independent with eating and independently mobile with the use of a wheelchair.The care plan dated 3/10/25 identified Resident #59 had the potential for alteration in nutrition with interventions that included accommodating resident's food preferences, observe allergies to pork, lactose intolerance and avoid serving pork, dairy, eggs, tomatoes and breaded foods.Interview with Resident #59 on 8/24/25 at 9:02 AM identified that [NAME] #2 had threatened him/her by saying (I am going to get you) after the resident had reported to the Administration repeated issues with receiving the wrong food items. The concern had been reported to the Administrator and Ombudsman without any follow-up.Interview with the Administrator on 8/25/25 at 7:15 AM identified there were past performance concerns related to food not being prepared according to preference denied that Resident #59 reported that [NAME] #2 had threatened him/her.Subsequent interview with Resident #59 on 8/25/25 at 8:40 AM identified the resident was in a meeting 6/24/25 at 1:07 PM which included the Administrator and the Ombudsman. Resident #59 raised concerns about receiving incorrect food items and reported during the meeting that [NAME] #2 had said to him/her (I am going to get you). Resident #59 further identified the Administrator said he would look into the issue but never got back to him/her.Subsequent interview with the Administrator on 8/25/25 at 10:30 AM identified that he could not recall Resident #59 reporting that [NAME] #2 had threatened him/her. The Administrator further identified any allegation of mistreatment or abuse should be reported immediately to the state agency.A review of the facility policy for Resident Abuse directed all residents are to be free from abuse, including verbally defined as any oral, written or gestured language used as a threat to harm. All allegations of abuse are to be reported to the Department of Public health within two hours of the allegation.

Based on observation, review of facility policy, and interviews for 1 of 5 residents (Resident #63) reviewed for dining, the facility failed to provide the resident a breakfast tray in a timely manner, resulting in the resident trying to obtain items from other resident's leftover trays. The findings include:Resident #63 was admitted to the facility in July 2025 with diagnoses that included anxiety disorder, specified depressive episodes, and orthopedic aftercare. The admission MDS dated [DATE] identified Resident #63 had intact cognition, was independent with eating, and required supervision or touch assist with ambulating 50 feet.The care plan dated 7/15/25 identified Resident #63 was at increased risk for alterations in nutritional status secondary to alcohol use, major depressive disorder, emphysema, prediabetes, hypocalcemia, and obstructive sleep apnea. Interventions included encouraging oral intake at meals and providing current diet: regular texture, thin liquids.Observation on 8/24/25 at 9:42 AM identified Resident #63 opened the door to the food truck containing dirty trays from the breakfast pass and rummaged through the breakfast trays. NA #3 told Resident #63 not to go through the old trays on the food truck and redirected him/her back to his/her room. NA #3 closed the food truck door.Observation on 8/24/24 at 9:46 AM identified Resident #63 re-entered the food truck containing dirty breakfast trays and removed a carton of milk and sugar; NA #3 told Resident #63 to return to his room and not to go through the truck. Resident #63 began yelling that his/her breakfast tray never came and he/she wanted sugar for his/her coffee.Interview with NA #3 at 8/24/25 at 9:46 AM identified that she observed Resident #63 remove milk and sugar from an old tray in the breakfast truck, and that she had told Resident #63 not to go through the old trays on the breakfast cart, but the resident didn't listen. NA #3 indicated that she had called the kitchen and notified them that Resident #63 had not received a breakfast tray yet.Interview with NA #4 on 8/24/25 at 9:47 AM identified that she had just delivered Resident #63's breakfast tray to his/her room at 9:40 AM; the kitchen had forgotten to send the residents breakfast tray.Interview with Resident #63 on 8/24/25 at 9:49 AM identified that he/she did not receive a breakfast tray and wanted a cup of coffee. Resident #63 indicated that he/she was tired of waiting, so he/she went into the dining room and poured a cup of coffee and then looked through the dirty cart to find milk and sugar on the leftover trays. Resident #63 further indicated that he/she was frustrated because when he/she did finally receive a breakfast tray it only contained one egg (2 eggs were ordered), a bagel with cream cheese, oatmeal, and grape juice. (There was no meal ticket on Resident #63's breakfast tray to confirm the order).Interview with the Administrator on 8/28/25 at 7:11 AM identified that it would be his expectation that the issue with Resident 63's food tray not being delivered in a timely manner would have been identified earlier by the nursing staff and that the kitchen would have been notified sooner. The Administrator indicated that the nurse aide that observed Resident #63 open the food truck with old breakfast trays should have asked him/her what he/she was looking for and gotten the milk and sugar the first time he/she began looking through the old breakfast trays.The Resident Rights policy directs that the facility will provide care and services in accordance with the Resident [NAME] of Rights; residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #130) reviewed for nutrition, the facility failed to ensure the resident received double portions per his/her request to receive double portions and per the physician order. The findings include:Resident #130 was admitted to the facility in June 2014 with diagnoses that included diabetes and malignant neoplasm of breasts. A physician's order dated 6/20/24 directed for a regular diet with double portions.The dietician note dated 3/18/25 at 1:50 PM identified Resident #130 requested to see the dietitian. Resident #130 complained he/she was still hungry after meals and requested increased portions. Resident #130 already receives double portions for meals and would recommend alternate foods on the meal tray. Resident #130 was agreeable to receive an egg salad sandwich at lunch and dinner. Kitchen updated.The dietitian quarterly assessment dated [DATE] identified Resident #130 is currently on a regular diet with double portions. Resident #130 is at risk for malnutrition related to breast cancer. Resident #130's weight 6 months ago was 295 lbs. on 10/2/24 and one month ago on 3/1/25 the resident weighed 206.4 lbs. Resident #130 is currently on double portions and the dietician will continue to monitor. The dietitian quarterly assessment dated [DATE] identified Resident #130 is currently on a regular diet with double portions. Resident #130 is at risk for malnutrition related to breast cancer. Resident #130 weight was 207 lbs. on 4/2/25 and 204 lbs. on 6/4/25. Weight is stable with no significant changes. The quarterly MDS dated [DATE] identified Resident #130 had intact cognition and was independent with eating. The care plan dated 7/31/25 identified Resident #130 was at risk for alterations in nutrition due to breast cancer, with interventions that included set up for meals, offer alternates, and provide diet per physician order. Interview with Resident #130 on 8/24/25 at 7:55 AM indicated that the portions of food at every meal are small. Resident #130 indicated that he/she was not trying to lose weight. Resident #130 indicated that no one offers snacks between meals or at bedtime and if you ask you won't get anything. Resident #130 indicated that he/she is still hungry after meals but does not get anything extra. Resident #130 indicated that he/she does not receive any sandwiches in addition to his/her meals. Resident #130 indicated that he/she had informed the nursing staff, dietary person, and the administrator that he/she was still hungry after eating a meal, but nothing changed.Observation on 8/24/25 at 8:55 AM identified Resident #130's meal included one hardboiled egg and 1 dry bagel cut in half.Resident #130's breakfast meal ticket dated 8/24/25 identified Resident #130 was to receive 2 hardboiled eggs and 2 bagels with cream cheese.Interview with NA #1 on 8/24/25 at 9:30 AM indicated that she had delivered Resident #130's breakfast tray. NA #1 indicated that there was one egg and 1 bagel on the tray. NA #1 indicated that she did not read the meal ticket and did not realize Resident #130 was supposed to receive 2 of each item per the meal ticket on the tray. NA #1 indicated that she did not inform the charge nurse or call the kitchen for the additional hard-boiled egg and bagel. Interview with the Director of Dietary (Interim) on 8/24/25 at 2:00 PM indicated that Resident #130 was only supposed to receive one egg and one bagel for a regular diet. The Director of Dietary (Interim) indicated he did not know why Resident #130's meal ticket said 2 eggs and 2 bagels. The Director of Dietary (Interim) indicated Resident #130 was not on double portions because the meal ticket did not identify double portions for Resident #130.Observation on 8/25/25 at 9:00 AM identified Resident #130 had his/her breakfast tray and received 2 pancakes and corn beef hash but did not receive double portions.Resident #130's breakfast meal ticket dated 8/25/25 identified Resident #130 was on a regular diet and received 4 pancakes with syrup and 4 ounces corn beef hash.Observation on 8/26/25 at 9:05 AM identified Resident #130 received a regular tray with scrambled eggs and 1 slice of toast cut in half and did not receive double portions.Resident #130's breakfast meal ticket dated 8/26/25 identified Resident #130 was on a regular diet and was to receive 1 cup cream of rice, 4 ounces scrambled eggs, and 2 individual muffins.Interview with the Director of Dietary (Interim) on 8/26/25 at 9:10 AM identified Resident #130 had received a regular portion and did not receive double portions. The Director of Dietary (Interim) indicated that he would investigate why Resident #130 had not received double portions for breakfast.Observation on 8/27/25 at 9:00 AM identified the meal tray had 2 slices of French toast cut in half and a sausage patty but did not receive double portions.Resident #130's breakfast meal ticket dated 8/27/25 identified Resident #130 was on a regular diet and was to have 4 slices of French toast and two sausage patties. Observation and interview with Resident #130 on 8/27/25 at 9:20 AM indicated that he/she still is not getting enough food on his/her tray for meals. Resident #130 indicated when dietary sends him/her a sandwich they cut it in half and count it as 2 sandwiches. Resident #130 indicates that when he/she should receive 2 slices of toast the dietary staff give one slice of toast cut in half and count it as 2 slices of toast.Interview with Dietitian #2 with Dietitian #1 present on 8/28/25 at 8:12 AM identified Resident #130 was supposed to be getting double portions for over a year, but Resident #130 has not received double portions per the physician's order. Dietitian #2 indicated that Resident #130 was on double portions per his/her request. Dietitian #2 indicated for example if Resident #130 was supposed to get 2 sandwiches the kitchen would take 1 sandwich and cut it in half and count it as 2 sandwiches even though it was only one. Dietitian #2 indicated that Resident #130 also wants a salad with Italian dressing for lunch and dinner every day. Dietitian #2 indicated he had informed the Director of Dietary (Interim) on 8/27/25 via email that Resident #130 should have been receiving double portions and the new request for salads.Dietitian #1 indicated there was a note in the electronic email system on 5/7/24 from the dietitian to the Director of Dietary that Resident #130 was to receive double portions for meals. Dietitian #1 indicated in the past there were paper slips that the dietitian would fill out to give to the Director of Dietary but now it is done via emails. Observation on 8/28/25 at 8:35 AM identified Resident #130 was sitting in the dining room at a table. SW # 1 brought Resident #130 his/her breakfast tray. Resident #130 received scrambled eggs and 1 slice of toast cut in half. Resident #130's breakfast meal ticket dated 8/28/25 indicated Resident #130 was to receive 4 ounces eggs and 2 slices of toast but did not identify double portions.Interview with the Director of Dietary (Interim) on 8/28/25 at 8:37 AM indicated that Resident #130 had received a regular portion of eggs and only 1 slice of toast not 2 as the meal ticket directed. The Director of Dietary (Interim) indicated that he would get Resident #130 another slice of toast. The Director of Dietary (Interim) indicated that Resident #130 was to receive a regular diet and did not know why his/her meal ticket said 2 slices when everyone else on a regular diet only received one slice of toast. The Director of Dietary (Interim) indicated that he did not receive any changes for Resident #130's meal from the dietitian yesterday or today regarding double portions. Interview with DA #1 with the Director of Dietary (Interim) present on 8/28/25 at 8:55 AM indicated that he was responsible for making sure the meal ticket matched the meal tray for the resident's breakfast trays this morning. Review of Resident #130's breakfast meal ticket with DA #1, he indicated he did not read the meal ticket this morning. DA #1 indicated Resident #130 had received a regular portion of scrambled eggs and one slice of toast instead of the double portions. DA #1 indicates that double portions are not on Resident #130's meal ticket, but he knows that is Resident #130 request when he speaks with him/her on the unit. Additionally, DA #1 indicated the Administrator has come to the kitchen and told the dietary staff to give Resident #130 double portions. Interview with DA #2 with the Director of Dietary (Interim) present on 8/28/25 at 9:57 AM indicated that he was aware that Resident #130 wants double portion because the Administrator came into the kitchen about 3 weeks ago and had informed the dietary staff to give Resident #130 double portions moving forward. DA #2 indicated the double portions were not on the meal ticket but the Administrator told them verbally to give Resident #130 double portions for meals. Interview with the Director of Dietary (Interim) on 8/28/25 at 9:00 AM indicated that the dietary staff were to follow what was on the meal tickets and it was DA #1's responsibility to read the meal ticket to make sure the tray was accurate before placing it on the cart to go upstairs. The Director of Dietary (Interim) indicated that the dietary staff nor the dietitian had informed him that Resident #130 was to receive double portions. The Director of Dietary (Interim) indicated he had reviewed the meal tracker and noted Resident #130 was to receive a regular diet not double portion. The Director of Dietary (Interim) indicated the prior director of dietary would receive the emails for changes that would need to be made to a resident meal ticket and would not update the meal tickets. The Director of Dietary (Interim) indicated he had found emails for resident preferences, aspiration precautions, double portions, and allergies that were not updated on the resident's meal tickets in the tracker system when he recently conducted an audit.Interview with the Administrator on 8/28/25 at 9:10 AM indicated Resident #130 has many times informed him that he/she was still hungry after eating a meal. The Administrator indicated he would go to the kitchen staff and the prior director of dietary and had requested Resident #130 receive double portions. The Administrator indicated the last time he had gone to the kitchen to request double portions for Resident #130 was about a month ago. The Administrator indicated that he had not informed the dietitian or nurses regarding Resident #130 requesting double portions.Review of the Resident Food Preferences Policy identified individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The dietitian or designee will identify a residents food preference. Dietitians or nursing staff will document the residents' food and potential eating preferences in the care plan. The food service department will offer a variety of foods at each scheduled meal with alternatives available, as well as snacks throughout the day and night.Review of the Resident Rights Policy dated 4/4/18 identified the resident has the right to be treated with consideration, respect and full recognition of your dignity and individuality. The residents have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #76) reviewed for pressure ulcer, the facility failed to ensure the resident representative was notified of a new wound. The findings include:Resident #76 was admitted to the facility in July 2023 with diagnoses that included polyneuropathy, bipolar, and diabetes. The care plan dated 4/28/25 identified Resident #76 was at risk for skin impairment related to decreased mobility, with interventions that included applying zinc oxide to coccyx area, encourage resident not to sit in the wheelchair for extended periods of time, perform weekly skin checks, and notify physician or APRN of any changes. The annual MDS dated [DATE] identified Resident #76 had moderately impaired cognition, was always incontinent of bowel and bladder and required maximum assistance with toileting, dressing, personal hygiene, turning side to side in bed, and transfers. Additionally, Resident #76 had a significant weight loss not prescribed by a physician of 5% or more in the last month or 10% or more in the last 6 months. Resident #76 was at risk for developing a pressure ulcer or injury. Resident #76 had a pressure-reducing device for the bed, nutrition or hydration intervention, and application of ointment other than the feet. The nurse's note written by LPN #7 dated 7/27/25 at 11:01 PM identified Resident #76 had a reddened area noted to the coccyx, resident was added to the skin rounding report, and the supervisor was notified. The nurse's note written by LPN #6 dated 8/10/25 at 2:15 PM identified that Resident #76 upon assessment was observed with a 0.5 cm by 1.0 cm open area at the top of the coccyx. Resident #76 expressed pain to the area. The nursing supervisor was made aware. The nurse's note written by RN #2 dated 8/10/25 at 6:47 PM identified earlier this morning she was notified Resident #76 had an open area on the sacrum. The area was measured, and a dry protective dressing was applied. The APRN was notified, and Resident #76 was placed in the skin rounding report for 8/11/25. A physician's order dated 8/11/25 directed to cleanse the coccyx with normal saline, pat dry, apply triad paste to peri wound, apply silver alginate to wound bed, and cover with dry clean protective dressing daily and as needed. The nurse's note written by RN #1 dated 8/13/25 at 7:59 PM identified Resident #76 had a stage 3 sacral wound measuring 0.4 cm by 0.3 cm by 0.2 cm with 100% granulated tissue with moderate serosanguineous drainage. Treatment is silver alginate to wound bed and zinc to peri wound with dry clean dressing daily and as needed. The APRN was updated. The wound physician note dated 8/13/25 identified he was asked to see Resident #76 for a sacral wound. The wound was classified as a stage 3 pressure ulcer measuring 0.4cm by 0.3 cm by 0.2 cm with moderate serosanguinous drainage. The nurse's note written by RN #1 dated 8/20/25 at 6:11 PM identified Resident #76 had a stage 3 sacral wound measuring 0.5 cm by 0.7 cm by 0.2 cm with 100% granulated tissue with moderate serosanguineous drainage. Treatment is silver alginate to wound bed and zinc to peri wound with dry clean dressing daily and as needed. The wound physician note dated 8/27/25 identified the sacral wound had been debrided of slough tissue with a curette on 8/20/25 and 8/27/25. Post debridement measurement is 0.6 cm by 0.6 cm by 0.4 cm. Debridement will be performed weekly as needed to remove devitalized tissue, decrease risk of infection, and expose viable tissue to promote wound healing. Resident #76 is still awaiting a low air loss mattress. Interview with RN #1 on 8/29/25 at 12:10 PM indicated when a nurse aide identifies a change in the resident's skin he or she must inform the charge nurse, and the charge nurse would inform the RN supervisor. RN #1 indicated the RN supervisor must perform an RN assessment on the new pressure ulcer or skin condition. RN #1 indicated the RN must notify the physician or APRN to receive a new treatment order for the new area on the skin that day. RN #1 indicated the RN must update the resident representative. RN #1 indicated that Resident #76 on 7/27/25 had a new open area to the coccyx and the resident representative (COP) was not notified. RN #1 indicated that she learned about the wound on Monday 8/11/25 and she evaluated the wound on 8/13/25. RN #1 indicated she assumed the resident representative had already been updated by the nurse either on 7/27/25 when area was first noted or on 8/10/25 when the RN assessment was done, and new treatment orders for the wound were obtained. After clinical record review, RN #1 indicated the resident representative (COP) was not updated on 7/27, 8/10, or 8/13/25 of the new ulcer he/she should have been updated.Interview with the DNS on 8/29/25 at 12:35 PM identified when Resident #76 developed an open area on the sacrum and a treatment was ordered; the charge nurse or RN supervisor was responsible to notify Resident #76' representative (COP). After clinical record review, the DNS indicated the resident representative (COP) had not been notified of the new pressure area or new treatment until 8/20/25, 11 days after its discovery. Review of the Change of Condition Policy identified it was to ensure that changes in residents' conditions are reported to the providers and families. The purpose is to ensure that all residents' change of condition is assessed and documented properly and is reported to the physician and family. All residents with the potential change of condition are identified in a timely manner. Any alteration in a resident's baseline indicates a potential change of condition. Any resident with a change of condition will receive timely and appropriate treatment. The RN will assess and determine if a change of condition has occurred. The RN will make the APRN or physician aware of a resident's current condition by in person notification or telephone call. Documentation will be noted in the residents' medical record and on the 24-hour report to ensure shift-to-shift communication. Repeated attempts will be made to reach the physician or the medical director and family until successful. The nurse will document the attempts noting the date and time. Review of the Skin and Wound Management Policy identified the nursing staff will assess and document an individual's risk factors for developing pressure ulcers. The nurse shall describe and document and report the following: a full assessment of a pressure sore including location, stage, length, width, depth, presence of exudate or necrotic tissue, a pain assessment, resident's mobility status, and current treatments including support surfaces. The physician will order pertinent treatments wound cleaning, dressings, and application of topical agents. Residents with pressure ulcers or other skin conditions will be seen and followed by the facility's wound physician.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for elopement, the facility failed to ensure that a resident who requires assistance and an assistive device with ambulation did not exit the facility without staff knowledge, resulting in the resident being found walking on the side of a roadway in the dark, nine (9) miles from the facility after he/she sustained a fall. These failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included opiate dependence, acute infective endocarditis (an infection and inflammation of the inner lining of the heart valves and chambers), bacteremia (bacteria in the bloodstream), osteomyelitis (infection in the bone), and neuropathy (weakness, numbness and pain from nerve damage). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of four (4) indicative of severely impaired cognition and required supervision assistance for transfers and ambulation. Additionally, the MDS identified that the resident had a history of falls and had Intravenous (IV) access and was receiving IV medications in the facility. Review of the admission Elopement Risk assessment dated [DATE] identified that Resident #1 was not at risk for elopement. The clinical record failed to identify Resident #1 had a Leave of Absence order (LOA). Review of the facility Reportable Event (RE) dated 10/16/24 identified that at 3:30 PM, it was reported that Resident #1, who was alert and oriented with forgetfulness and ambulated with a rolling walker, was seen outside walking down the street towards the bus stop. Staff then got in their cars and searched down the road where it had been reported that Resident #1 was observed walking. The RE reported that the resident was unable to be located so the facility then initiated their elopement protocol and notified the police. The resident was later found and sent to the hospital. Review of an Investigative police report dated 10/16/24 identified that the police department was called at 4:27 PM (54 minutes after the resident was noted to be missing by the facility and dispatched after a cognitively challenged resident was reported to be missing. The resident had last been seen at 3:13 PM after stating h/she was going to get a deck of cards. Review of Emergency Department (ED) note dated 10/16/24 identified that per Emergency Medical Services (EMS) Resident #1 reportedly walked between towns for four (4) hours. The resident was not dressed for the weather and was noted to be shivering. The resident reported he/she sustained a fall, striking his/her head at some point during the walk and was noted to have abrasions to his/her nose and tenderness along the nasal bone. The resident clearly confused, reported the year to be 1972. The resident was admitted to the hospital with a diagnosis of altered mental status. A nurse's note dated 10/22/24 at 1:28 PM identified that Resident #1 was readmitted to the facility at 12:00 PM. Interview and review of surveillance footage with the Administrator on 11/26/24 at 11:14 AM identified that NA #1left the facility through the main entrance. Two (2) people can be seen congregating at the front desk with the Receptionist and the Administrator is standing sideways in the center of the main entrance. Resident #1 is then seen walking directly behind the Administrator and exiting the main entrance. Interview with NA #1 on 11/25/24 at 11:54 AM identified that she always looks behind her when exiting the facility, and she never saw the resident exit the facility on 10/16/24. Interview with Resident #5 on 11/25/24 at 12:35 PM identified that he/she was setting up for the card activity on 10/16/24 when he/she noticed that one card was missing. Resident #5 reported that Resident #1 stated that he/she had a deck of cards and would go get them at his/her house and would be back in ten (10) minutes, identifying that he/she assumed that Resident #1 was referring to his/her room at the facility. Resident #5 identified that a few minutes later he/she saw Resident #1 outside through the window, walking down the hill. Resident #5 identified that he/she reported the sighting to the Recreation Assistant, who reported that she didn't think the resident was supposed to be outside and she left the room. Interview with the Recreation Assistant (RA) on 11/25/24 at 12:27 PM identified that she arrived at the second-floor dining room a little after 3:00 PM and Resident #5 reported to her that Resident #1 was outside on the front lawn. She reported that she then went to talk with the Receptionist at the front entrance and ask if Resident #1 had a LOA form. The Receptionist reported that Resident #1 did not have an LOA, so she (RA) went back upstairs to notify the Recreation Director that Resident #5 reported that Resident #1 was outside. Then her and the Recreation Director searched Resident #1's room and the third floor, they could not locate Resident #1 so they notified the Administrator. The RA identified that from the time it was reported that Resident #1 was outside to when the Administrator was notified was close to five (5) minutes, but stated she did not check the clock, and it was no longer than ten (10) minutes. Interview with the Recreation Director on 11/26/24 at 10:18 AM identified that when the Recreation Assistant reported to her that Resident #5 identified Resident #1 was outside, she immediately searched the resident's room and then notified the Nursing Supervisor (RN #2) that the resident could not be located and then went downstairs and notified the Administrator in person. She identified that within five (5) minutes of her notifying the Administrator, a code purple (missing resident) was called staff were outside searching for Resident #1. Interview with the Receptionist on 11/25/24 at 11:18 AM identified that residents must have a LOA form prior to leaving the building, the resident will present the LOA form and she will disengage the front door and let the resident out, she does not let any resident out that does not have a LOA form. The receptionist identified that the front entrance is the main entrance and exit for everyone and the area can become chaotic with people standing in the entrance asking her questions and her having to also answer the phone. She reported that the Recreation Assistant had come to her towards the beginning of the 3:00 PM to 11:00 PM shift on 10/16/24 and asked if Resident #1 had a LOA form, and she replied h/she did not. The receptionist did not recall the Recreation Assistant reporting to her that Resident #1 was outside, just that someone had said Resident #1 was outside. She reported that although the Administrator showed her the camera footage of Resident #1 walking out the front door shortly after a staff member on 10/16/24, she did not see the resident exit and stated that she had been talking with the Administrator and he must have been blocking her line of view where the resident was able to walk right behind him and exit the building. Interview with Police Officer (PO) #1 on 11/25/24 at 2:48 PM identified that he/she responded to the reported location of Resident #1 on 10/16/24 at 7:15 PM (sunset was at 6:07 PM) and found him/her at the intersection of two (2) main roads walking east in the bike lane. PO #1 identified that Resident #1 was disoriented and not aware of where he/she was, reporting that they had fallen and was noted with cuts on his/her nose and face. PO#1 reported that he/she brought the resident to a nearby parking lot and a few minutes later facility staff arrived on scene reporting that the resident had dementia and that they had been looking for him/her all afternoon. The resident was subsequently transferred to the ED. Interview with the DNS on 11/25/24 at 1:15 PM identified that Resident #1 was alert and oriented but should not have been able to leave the building unassisted, reporting that although he/she had the ability to ambulate, per physician's orders the resident should have had a rolling walker and been supervised by staff. The DNS identified that Resident #1 did not have a LOA order because the resident had a central line for IV antibiotics and a history of an opiate addiction. On 10/16/24 the Administrator reported to him that Resident #1 was spotted outside on the facility grounds, code purple was called and they both immediately went to search for the resident on foot identifying that when the resident could not be located, he got in his car and drove around the area. He identified that APRN #1 (off duty psychiatric APRN) called the facility and reported seeing the resident a few towns over while on her off-time. He reported that when he arrived at the location, the police were already on scene and transported the resident to the hospital. Interview with the Administrator on 11/26/24 at 9:59 AM identified that when viewing the camera surveillance from 10/16/24, NA #1 exited the front door and approximately thirty (30) seconds -while he (the Administrator) was near the front desk, Resident #1 was able to walk right behind him and out the door without the Receptionist or himself noticing. He identified that the front door had closed behind NA #1, at the time of the incident the locking mechanism would take 90 seconds to engage the lock of the door once the door was opened, so Resident #1 was able to exit the door before the lock was re-engaged. The Administrator identified that the Director of Recreation came to his office to notify him that she could not locate Resident #1 and had been seen outside He reported that he believed there was a ten (10) minute delay from when the Recreation Assistant was notified that Resident #1 was outside to when he was notified at around 3:30 PM, a code purple was called and the search for Resident #1 began. He identified that he expects the Receptionist to be able to monitor the front exit and multi-task with other tasks such as answering the phone. The Administrator further identified that the Assistant Director of Nursing Services called the police to report Resident #1 missing once he returned to the facility after searching on foot for Resident #1. He reported that ideally the police should have been contacted immediately, stating he was focused on finding the resident and that it did take too long to contact them. Interview with MD #1 (Medical Director) on 11/27/24 at 9:44 AM identified that it was his expectation that the facility notify the police immediately when it's identified that a resident is missing. Review of the Elopement policy dated 11/13/17 directed, in part, that upon admission all residents will be assessed by a registered nurse using the Elopement Observation on readmission, quarterly, annually and for any significant change in status and it will then be reviewed and care planned for by the interdisciplinary team. Should staff find that they cannot locate the resident, a Code Purple will be announced, and staff will immediately follow procedures for Code Purple. Review of the Code Purple procedure (undated) directed, in part, that for all missing residents a staff will page three times Code Purple identifying the unit and the resident's name. Staff will immediately search the interior of the facility including all shower rooms, bathrooms and staff areas. Staff members will be stationed at all exit doors to monitor for the resident while other staff members search the exterior of the facility. The police department will be contacted with the resident's information and facility staff members will be dispatched to begin a search of the community. Review of the Leave of Absence policy dated 9/16/18 directed, in part, that upon admission, residents that are mentally and physically capable may be given a physician's order for a therapeutic LOA if they are able to understand and follow all procedures involved with the LOA protocols. Any resident with intravenous (IV) access is not eligible for an LOA. Residents wishing to leave the building must notify their Charge Nurse and complete the form entitled, Release of Responsibility for Leave of Absence and complete the sign out log on their unit and at the security desk.

Based on review of the clinical record, facility documentation, facility policy and interviews, the facility failed to ensure sufficient staff (licensed nurses) on 7/2/22 during the 3:00 PM to 11:00 PM shift to provide care and services and to respond to each residents' needs on the 1st floor Birch & Cedar unit (21 residents). Further, when 1 licensed nurse was a no call, no show, the current licensed nurse who had worked on the unit for the 7:00 AM to 3:00 PM shift left without an oncoming nurse to take the unit. Subsequently, all 21 residents on the Birch & Cedar unit did not receive medications, treatments or monitoring on 7/2/22 between 3:00 PM - 7:00 PM, and several medications were omitted between 7:00 PM - 11:00 PM. Further, the RN Supervisor, (RN #1) left the facility at approximately 6:20 PM, without giving report and counting narcotics, and leaving the facility without an RN. This insufficient licensed nurse staffing resulted in a finding of Immediate Jeopardy. The findings include: Based on review of facility documentation and interview the following was identified: On Saturday 7/2/22, the scheduled 7:00 AM - 7:00 PM RN Supervisor called out. Per the on-call rotation, RN #2 was called to cover as 7:00 AM - 7:00 PM RN Supervisor. On 7/2/22 LPN #1 was assigned to the Birch & Cedar unit of the 1st floor for the 7:00 AM - 3:00 PM shift which had a census of 21. LPN #1 left the facility at 3:59 PM on 7/2/22. On 7/2/22 RN #1 was scheduled for the 7:00 PM - 7:00 AM shift as the free-floating RN Supervisor. Facility documentation indicated that on 7/2/22 the nurse scheduled on the Birch & Cedar unit (21 residents) for 3:00 PM - 11:00 PM was a no call no show. Although calls and blast texts for additional staff were attempted, no additional staff came to the facility during the 3:00 PM - 11:00 PM shift. Subsequently, the Birch & Cedar unit (21 residents) were without a licensed nurse from 3:00 PM - 7:00 PM, 4 hours, until RN #1 arrived at approximately 7:06 PM. Facility documentation identified that 21 of 21 residents on the Birch & Cedar unit did not receive their ordered evening shift medications, treatments and/or monitoring between 3:00PM - 7:00 PM, and some additional medications were omitted during the 7:00 PM - 11:00 PM shift. Medications omitted included Insulin, antiseizure, 2 doses of IV antibiotics, antipsychotics, anticoagulants, antihypertensives, and an anti-rejection medication. Additionally, 3 residents with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, one resident with a wound did not have the dressing changed, and one resident who had a medication ordered to be administered once monthly for [CONDITION(S)], missed that monthly dose. Review of a signed statement dated 7/4/22 by RN #1 (RN Supervisor 7:00 PM - 7:00 AM) identified that when she arrived at the facility on 7/2/22 for her 7:00 PM - 7:00 AM shift, she was informed that there was a staffing issue, and that the 7:00 AM - 7:00 PM RN Supervisor had left and there was no RN Supervisor in the building. Further that there was no nurse on the Birch & Cedar unit. Interview with Resident #20 on 7/20/22 at 11:31 AM indicated that he/she recalled an incident when he/she did not get Insulin. Additionally, Resident #20 indicated he/she requested the Insulin and was told by the nurse that she would be back, but the nurse never came back. Resident #20 could not recall the exact date that this happened. Interview with RN #2 (RN Supervisor 7:00 AM - 7:00 PM shift) on 7/20/22 at 12:56 PM indicated that there was only 1 nurse working on the 1st floor (46 residents), when there should have been 2, (1 for each unit). Additionally, RN #2 identified that due to the workload (2 admissions and 2 falls), RN #2 indicated she went to the first floor after change of shift to let them know she was involved in other things, but she was unable to get back down to the unit to administer medications. Interview with RN #1 (RN supervisor 7:00 PM - 7:00 AM shift) on 7/20/22 at 1:07 PM identified that when she arrived at the facility on 7/2/22, she went to the 1st floor, Birch & Cedar unit and took the unit for medication administration along with LPN #4. Additionally, RN #1 indicated that she did not give any medications that were due between 4:00 PM - 5:00 PM due to them being overdue and not scheduled during her shift. Interview with the DNS on 7/21/22 at 10:45 AM indicated that the free-floating supervisor (RN #2) on the 7:00 AM - 7:00 PM shift as well as the scheduler did make attempts to replace the staff member that was a no call/no show. Additionally, the DNS indicated that RN #2 informed her via a text message that she was overwhelmed and not feeling good, but she did not tell the DNS that medications had not been given on the Birch & Cedar unit. The DNS further indicated that she directed the RN supervisor (RN #2) to hang in there as it was close to the end of her shift. Interview with Scheduler #1 on 7/21/22 at 10:52 AM identified that RN #2 did reach out to her to let her know that there was a no call/no show on 7/2/22 for 3:00 PM - 11:00 PM, but that it wasn't until approximately 6:00 PM. Additionally, Scheduler #1 indicated that RN #2 did inform her that she attempted to replace the staff member via a blast text and calls to no avail. Scheduler #1 indicated that she also attempted to call and text staff members to fill in, but she either got a refusal or no answer back. Scheduler #1 indicated that she did inform the DNS, per protocol, that there was a no call/no show and she could not find a replacement. Review of the investigation/interviews conducted by RN #3 (Independent Nurse Consultant) dated 7/21/22 indicated for 7/2/22 3:00 PM - 11:00 PM one licensed staff was a no call/no show for the Birch & Cedar unit. RN #3 further indicated that RN #2 was the supervisor on duty on 7/2/22 from 7:00 AM - 7:00 PM. RN #3 conducted an interview with RN #2 on 7/20/22 at 6:30 PM along with the Administrator and the DNS. RN #2 stated that she did not pass the medications on the Birch & Cedar unit of the 1st floor because she had admissions and 2 fall incident reports to complete and she was overwhelmed. RN #2 stated that she did not convey to the DNS that she had not passed the medications on Birch & Cedar unit, she only told the DNS that she was overwhelmed. RN #2 also stated she told the oncoming supervisor (RN #1) that the medications had not been administered between 3:00 PM - 7:00 PM (this is in conflict with interviews that RN #2 had left without giving report and that RN #1 was not aware if medications had been administered between 3:00 PM - 7:00 PM). RN #2 stated she left the facility at 7:15 PM (this is in conflict with interviews that RN #2 left at approximately 6:20 PM). Additionally, RN #3 conducted an interview with RN #1 on 7/20/22. RN #1 stated that when she arrived at the facility at 7:00 PM, RN #2 was not there, and a licensed nurse greeted her at the door and informed her that there was no supervisor in the building. RN #1 indicated that she then went to the supervisor's office where she found the keys, but no report or narcotic count done. RN #1 stated at that time she and LPN #4 went to pass the 7:00 PM medications. RN #1 stated that she did not give the 5:00 PM medications because she did not know if RN #2 gave any medications or what she gave. RN #1 indicated she did attempt to call RN #2 3 times to ask if she gave any medications or what she gave, but RN #2 did not answer the phone. At that time RN #1 documented the medications as refused, to prevent another nurse from signing them off. Interview with RN #1, (the 7:00 PM - 7:00 AM RN Supervisor on 7/2/22) on 7/28/22 at 11:35 AM identified that when she arrived at the facility on 7/2/22 for her shift and was informed that there was no RN Supervisor in the building, she called the DNS to discuss the situation with her. RN #1 indicated that the DNS informed her that the previous RN Supervisor (RN #2) had gotten overwhelmed, but the DNS indicated she was not aware that RN #2 had left the building. Additionally, RN #1 indicated that she immediately went to the Birch & Cedar unit and started passing out medications and taking care of the resident's. When asked why she did not notify the DNS or the physician that the 21 residents may have missed their medications between 3:00 PM - 7:00 PM, RN #1 indicated that she had too many problems and had to prioritize to ensure resident needs were met. Interview with the DNS on 7/28/22 at 11:54 AM identified that on 7/2/22 she was told by the 7:00 PM - 7:00 AM RN supervisor (RN #1) that she (RN #1) had not received report from the previous RN supervisor (RN #2). Further RN #1 indicated to the DNS that she, (RN #1), would have to take the 1st floor Birch & Cedar unit. The DNS indicated that she did offer to come to the facility, but RN #1 declined stating by the time the DNS would arrive, she would have it handled. Additionally, the DNS indicated immediately following the call, she attempted to call other staff members to fill in the 3:00 PM - 11:00 PM shift but was unsuccessful. The DNS also indicated that she did talk with the scheduler (Scheduler #1) who also made calls to staff with no success. The DNS identified that when she spoke with the RN Supervisor for the 7:00 AM - 7:00 PM shift (RN #2), she was informed by RN #2 that there were admissions and falls that needed to be done. The DNS indicated at that time she instructed RN #2 to put in the MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS indicated that throughout the 3:00 PM - 7:00 PM shift, she called RN #1 to check on the situation at the facility. Interview with LPN #1 on 7/28/22 at 12:52 PM identified that on 7/2/22 at the end of her 7:00 AM - 3:00 PM shift, she called the nursing supervisor (RN #2) to let her know that her replacement staff had not come in yet. LPN #1 indicated she again called RN #2 and asked her to come to the unit to do the narcotic count with her and take report. LPN #1 indicated that RN #2 informed her that she was too busy to come to the unit and directed her to do the narcotic count with the other LPN on the first floor (LPN #3) and to give her report as well. LPN #1 indicated she gave the keys and a written report to RN #2 and left the facility. LPN #1 indicated that when no replacement staff comes in, it is the protocol to wait to leave the facility until another staff member comes to replace her. Additionally, LPN #1 indicated that she did leave the facility on 7/2/22 because she gave the keys and report to RN #2 and was under the impression that RN #2 was going to cover the unit until the next supervisor came in at 7:00 PM. Interview with RN #1 on 8/1/22 at 9:30 AM identified that when she arrived at the facility on 7/2/22 at 7:00 PM, she was told by a nurse aide who was the acting receptionist, that RN #2 was gone. RN #1 indicated that she did not get report from RN #2 and that she did attempt to call RN #2 several times, but RN #2 never answered her phone. RN #1 indicated she immediately went to the supervisor's office on the second floor and found keys on the desk and the door to the office ajar. RN #1 further indicated the keys found were the narcotic keys, the facility/supervisor keys and the 1st floor Birch & Cedar unit keys on the desk in the supervisor's office. The facility failed to ensure sufficient staff on the Birch & Cedar unit on 7/2/22 during the 3:00 PM - 7:00 PM shift to ensure the safe delivery of care according to professional standards. Subsequently, 21 of 21 residents on that unit did not receive medications, treatments and monitoring between 3:00 PM - 7:00 PM. Please cross reference F580, F658, F684 and F760.

Based on review of the clinical record, facility documentation, facility policy and interviews for 21 residents who reside on the Birch & Cedar unit (Resident #1 - 21) the facility failed to administer medications as prescribed, failed to notify the DNS and physician when medications were not administered, failed to complete assessments of the residents' condition after medications were omitted, failed to monitor residents who had significant medication omissions and failed to accurately document the medication omissions. Further, the facility failed to ensure licensed staff followed professional standards of practice including report to the oncoming and off going shifts, narcotic count and ensuring the security of the narcotic keys. These failures resulted in a finding of Immediate Jeopardy. The findings include: Based on review of facility documentation and interview the following was identified: On Saturday 7/2/22, the scheduled 7:00 AM - 7:00 PM RN Supervisor called out. Per the on call rotation, RN #2 was called in to cover as 7:00 AM - 7:00 PM RN Supervisor. On 7/2/22 at 3:00 PM, when the scheduled licensed nurse did not show up for his/her shift on the Birch & Cedar unit, the licensed nurse who was working 7/2/22 during the 7:00 AM - 3:00 PM shift on that unit, LPN #1, left the facility without an incoming replacement. Although the RN Supervisor working 7/2/22 between 7:00 AM - 7:00 PM, (RN #2), was aware that the 3:00 PM - 11:00 PM licensed nurse did not show up to cover the Birch & Cedar unit, and she (RN #2) was directed by the DNS to administer medications on the Birch & Cedar unit, RN #2 did not provide coverage of the Birch & Cedar unit, did not administer medications to the 21 residents on the unit, and did not report to the DNS, the physician or the oncoming RN Supervisor that medications and treatments had not been administered/completed between 3:00 PM - 7:00 PM on 7/2/22. Further, RN #2 placed her narcotic keys on the desk in the supervisor office and without giving report, without reporting to anyone that all 21 residents on the Birch & Cedar unit had missed their medications between 3:00 PM - 7:00 PM, and without counting the narcotics or handing the narcotic keys to a licensed nurse, she left the facility at approximately 6:20 PM. This left the facility without an RN in the building for approximately 46 minutes until the 7:00 PM - 7:00 AM RN Supervisor (RN #1) arrived. Subsequently, because LPN #1 left the unit on 7/2/22 at approximately 3:59 PM without coverage, and because RN #2 did not cover the unit or notify the DNS or any physician that the unit (21 residents) was not covered, the 21 residents on the Birch & Cedar unit did not receive any medications or treatments, including blood sugar monitoring and Insulin administration, between 3:00 PM to 7:00 PM on 7/2/22. Further, when the 7:00 PM - 7:00 AM RN Supervisor, (RN #1), arrived on 7/2/22 at approximately 7:06 PM, and she noted that the medications for the 21 residents on the Birch & Cedar unit had not been signed as administered, she failed to notify the DNS and the physician of the omissions, and failed to pass the information on in report. Further, she documented some of the missing medications erroneously as refused. The following day, 7/3/22 during the 7:00 AM - 3:00 PM shift, when the licensed nurse (LPN #1) began her shift, although the EMR alerted her to the missed medications the prior day (7/2/22), she documented all the missed medications for the 21 residents on Birch & Cedar unit as not administered and did not report the missed medications to the DNS or the attending physician's. Because the DNS and the physicians were not aware that all 21 residents had not received their ordered medications and treatments on 7/2/22 between 3:00 PM - 7:00 PM, the facility administration was not able to develop and implement corrective action to address the situation or to prevent a reoccurrence. Interview with RN #2 (RN Supervisor 7:00 AM - 7:00 PM shift) on 7/20/22 at 12:56 PM indicated that on 7/2/22 during 3:00 PM - 11:00 PM, there was only 1 nurse working on the 1st floor when there was supposed to be 2, 1 for each unit. Additionally, RN #2 identified that due to the workload (2 admissions and 2 falls), she was unable to get to the 1st floor to administer medications. Interview with RN #1 (RN supervisor 7:00 PM - 7:00 AM shift) on 7/20/22 at 1:07 PM identified that when she arrived at the facility, she went to the 1st floor, Birch & Cedar unit and took the unit for medication administration along with LPN #4. Additionally, RN #1 indicated that she did not give any medications that had been due between 4:00 PM - 5:00 PM because they were overdue and not due on her shift. RN #1 further indicated that she would not give the missed medication because she did not know if it had already been given. RN #1 identified that she documented some of the 3:00 PM - 7:00 PM medications as refused in the EMR because she had to put something in the system to move forward with the medication pass. RN #1 indicated although she attempted to get in touch with RN #2 to ascertain if the medications had been administered, she could not reach her. Interview with LPN #1 on 7/20/22 at 1:54 PM identified that on 7/3/22 when she came in for the 7:00 AM - 3:00 PM shift, and the medications from the previous night were flagging in the EMR as not administered, she documented not administered, not my shift to prevent the medications from repeatedly popping up and moved forward with the medication pass. Interview with the DNS on 7/21/22 at 10:45 AM indicated that the free-floating supervisor (RN #2) on the 7:00 AM - 7:00 PM shift, as well as the scheduler, did make attempts to replace the staff member that was a no call/no show. Additionally, the DNS indicated that RN #2 informed her via a text message that she was overwhelmed and not feeling good, but she did not tell the DNS that medications for the 21 residents on Birch & Cedar had not been administered. The DNS further indicated that she directed the RN supervisor (RN #2) to hang in there as it was close to the end of her shift. Review of the investigation/interviews conducted by RN #3 (Independent Nurse Consultant) dated 7/21/22 indicated there was 1 licensed nurse on the 1st floor who was a no call/no show for the 3:00 PM - 11:00 PM shift on 7/2/22. RN #2 was the supervisor on duty on 7/2/22 from 7:00 AM - 7:00 PM. RN #3 conducted an interview with RN #2 on 7/20/22 at 6:30 PM along with the Administrator and the DNS. RN #2 stated that she did not pass the medications on the Birch & Cedar unit of the 1st floor because she had admissions and 2 fall incident reports to complete and she was overwhelmed. RN #2 stated that she did not convey to the DNS that she didn't pass the medications and only told the DNS that she was overwhelmed. RN #2 also stated she told the oncoming supervisor (RN #1) that the medications had not been administered (this is in conflict with other interviews that indicate that RN #2 had left the facility at approximately 6:20 PM without giving report). RN #2 stated she left the facility at 7:15 PM (this is in conflict with other interviews that indicate that RN #2 had left the facility at approximately 6:20 PM). Additionally, RN #3 conducted an interview with RN #1 on 7/20/22. RN #1 stated that when she arrived at the facility at 7:00 PM, RN #2 was not there, and a licensed nurse greeted her at the door and informed her that there was no RN supervisor in the building. RN #1 indicated that she then went to the supervisor's office where she found the narcotic and supervisor keys, but no report or narcotic count done. RN #1 stated at that time she and LPN #4 went to pass the 7:00 PM medications on Birch & Cedar. RN #1 stated that she did not give the 5:00 PM medications because she did not know if RN #2 had given any medications or what she gave. RN #1 indicated she did attempt to call RN #2 several times to ask if she gave any medications or what she gave, but RN #2 did not answer the phone. At that time RN #1 documented some of the medications as refused, to prevent another nurse from signing them off. Review of the narcotic count sheet dated 7/2/22 identified that RN #2 did not sign in or off that the narcotic count was done. Interview with RN #1 on 7/28/22 at 11:35 AM identified that when she arrived at the facility and was informed that there was no supervisor there, she called the DNS. RN #1 stated that the DNS informed her that the previous RN supervisor (RN #2) had gotten overwhelmed but the DNS was not aware that she left the building. Additionally, RN #1 indicated that she immediately started passing out medications on the Birch & Cedar unit, taking care of the residents but because she prioritized, she did not notify the physician or the DNS that medications were omitted. Interview with the DNS on 7/28/22 at 11:54 AM identified that on 7/2/22 she was told by the 7:00 PM - 7:00 AM RN supervisor (RN #1) that she, (RN #1), had not received report from the previous RN supervisor (RN #2). Further RN #1 indicated to the DNS that she, (RN #1), would have to take the first floor Birch & Cedar unit because there was not a nurse there. The DNS indicated that she did offer to come to the facility, but RN #1 declined stating by the time the DNS would arrive, she would have it handled. Additionally, the DNS indicated immediately following the call, she attempted to call other staff members to fill in the 3:00 PM - 11:00 PM shift but was unsuccessful. The DNS also indicated that she did talk with the scheduler (Scheduler #1) who also made calls to staff with no success. The DNS identified that when she spoke with the RN Supervisor for the 7:00 AM - 7:00 PM shift (RN #2), she was informed by RN #2 that there were admissions and falls that needed to be done. The DNS indicated at that time she instructed RN #2 to put in the medication orders in for the admissions and to perform the RN assessments for the falls and the paperwork piece could be finished at a later time. The DNS indicated that throughout the 3:00 PM - 7:00 PM shift, she called RN #1 to check on the situation at the facility. Interview with LPN #1 on 7/28/22 at 12:52 PM identified that on 7/2/22 at the end of her 7:00 AM - 3:00 PM shift, she called the nursing supervisor (RN #2) to let her know that her replacement staff had not come in yet. She again called RN #2 after waiting for her replacement and asked her to come to the unit to do the narcotic count with her and take report. LPN #1 indicated that RN #2 informed her that she was too busy to come to the unit and directed her to do the narcotic count with the other LPN on the first floor (LPN #3) and to give her report as well. LPN #1 indicated she gave the keys and written report to RN #2 and left the facility. LPN #1 indicated that when no replacement staff comes in, it is the protocol to wait to leave the facility until another staff member comes to replace her. Additionally, LPN #1 indicated that she did leave the facility on 7/2/22 because she gave the keys and report to RN #2 and was under the impression that RN #2 was going to cover the unit until the next supervisor came in at 7:00 PM (RN #1). Interview with RN #1 on 8/1/22 at 9:30 AM identified that when she arrived at the facility on 7/2/22 at 7:00 PM, she was told by a nurse aide who was the acting receptionist, that RN #2 was gone. RN #1 indicated that she did not get report from RN #2 and that she did attempt to call RN #2 several times, but RN #2 never answered her phone. RN #1 indicated she immediately went to the supervisor's office on the 2nd floor and found keys on the desk and the door to the supervisor office ajar. Additionally, RN #1 indicated that due to the keys being present in the unlocked office, she did a narcotic count, on her own, without another staff member present, to ensure the narcotic count matched the narcotic sheets. RN #1 further indicated the keys found were the narcotic keys, the facility/supervisor keys and the 1st floor Birch & Cedar unit keys on the desk in the supervisor's office. Interview with the Medical Director, (MD #1) on 8/1/22 at 11:30 AM identified he had been informed by the facility on 7/20/22 that on 7/2/22 between 3:00 PM - 7:00 PM, 21 residents on Birch & Cedar did not receive their ordered medications/treatments. MD #1 indicated that staff should notify him immediately, as medication errors/omissions happen, as he needs to know what was omitted to determine if any significant medications were missed that he might need to do something about. MD #1 further indicated some medications may be ok to miss a dose, but other medications, for example Insulin or [MEDICATION(S)] may need additional monitoring or 1-time orders. Additionally, MD #1 indicated that outcomes that could have occurred due to the omitted doses depended upon the medication and some medications, for example, [CONDITION(S)] medication or blood pressure medication may not have a serious outcome, but missing a dose of an anticoagulant medication could be significant and may cause problems. Further, missing [CONDITION(S)] medications can easily result in behavior issues, and missing antiseizure medications can easily result in breakthrough seizures. MD #1 further indicated missing many medications may not affect the resident medically right away, but some medications are more critical and can have an effect medically. MD #1 indicated when resident's miss that many medications, it is important for him to be immediately made aware of what was missed to make any special changes. MD #1 further indicated that the expectation would be notification immediately when a medication is omitted with information such as the resident's name, the medication(s) that were missed, why they were missed and any follow up assessments that were done. MD #1 indicated that he would expect the nurse who omitted the medications to notify him when medications were missed, but if that nurse did not notify him, the next nurse coming on to the unit for the next shift or the next nurse who identified that medications were omitted should notify him when aware in order for him to decide what to do for the resident as it happens. Review of the controlled substance change of shift accountability log for the Birch & Cedar unit dated July 2022 identified on 7/2/22, there were no signatures by the incoming nurse for the 7:00 AM - 3:00 PM shift (LPN #1) or the outgoing nurse for the 3:00 PM - 11:00 PM shift (LPN #1). Review of the Medication Administration policy identified the goal is to provide a safe and effective medication framework to help eliminate any harm that could be caused at any level of the medication management process. Additionally, the policy directs in the event of a medication administration error, the licensed nurse will immediately provide care to the resident (if necessary) and notify the provider, supervisor, DNS, or designee. The event will be documented in the resident's chart, in the EMR, and an incident report (A&I) is to be completed and forwarded to the immediate supervisor of the licensed nurse who administered the medication. The incident will be reviewed and may be subject to disciplinary action if necessary, up to and including termination of employment. Review of the controlled substance policy directs nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DNS. Please cross reference F580, F684, F725 and F760.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 residents (Resident #7 and 8) reviewed for diabetic management, for Resident #7 the facility failed to have [MEDICATION(S)] (a medication to treat severely low blood sugar), readily available and to administer the [MEDICATION(S)] to Resident #7 to reverse a critically low blood sugar. Additionally, the licensed staff failed to follow standards of practice to treat the resident's [CONDITION(S)] and instead applied ice on the resident body which resulted in the resident becoming hypothermic with a body temperature of 90.9 F (normal body temperature ranges from 97.5°F to 98.9°F). These failures to properly treat Resident #7's [CONDITION(S)] with resulting hypothermia resulted in Immediate Jeopardy. For Resident #8, the facility failed to follow standards of practice when the resident's blood sugar was elevated, and for 4 residents (Residents #3, 4, 5 and 6) reviewed for medication administration, the facility failed to administer medications according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #7 was admitted to the facility on in [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] identified Resident #7 had intact cognition and was independent with eating with set up only and received insulin injections. physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . If blood sugar is less than 70, call MD. If blood sugar is 150 to 199 give 2 units. If blood sugar is 200 to 249 give 4 units. If blood sugar is 250 to 299 give 6 units. If blood sugar is 300 to 349 give 8 units. If blood sugar is 350 to 399 give 10 units. If blood sugar is greater than 400 call MD/APRN. physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated [DATE] indicated Resident #7 was at potential nutrition risk related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 6:30 AM Resident #7 had a blood sugar of 110 mg/dl (normal range is 70 - 100 mg/dl) and did not require insulin coverage, and at 8:00 AM the resident received 34 units of [MEDICATION(S)] Insulin. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #7 received [MEDICATION(S)] 500mg. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #7 had a blood sugar of 194 mg/dl. Resident #7 refused the sliding scale coverage of 2 units. Review of a Cubex (the Cubex System is an automated medication dispensing system) transaction dated [DATE] at 12:56 PM, the ADNS attempted to withdrawal [MEDICATION(S)] 1mg IM from the Cubex machine, but the medication was not able to be obtained. A nurse ' s note identified on [DATE] at approximately 1:15 PM Resident #7 was in bed, unresponsive with his/her eyes opened. The skin was cool and clammy, and the residents blood sugar level was noted to be 40 mg/dl (normal range is 70 - 100 mg/dl). The nursing supervisor was made aware, sugar was given under the resident ' s tongue, and a subsequent blood sugar level was noted to be lower at 33 mg/dl. A nurse ' s note dated [DATE] at 2:15 PM identified the ADNS who was also covering as the RN supervisor, was called to the resident ' s room. The note indicated Resident #7 had low blood sugar (40 mg/dl) around lunch time and was intermittently responsive, sweating with pale skin. One sugar pack was administered under the resident ' s tongue at that time and Resident #7 did swallow. Due to a technical malfunction, the [MEDICATION(S)] in the facility ' s Cubex machine was not able to be accessed. EMS arrived and subsequent to APRN notification, Resident #7 was transferred to the emergency room for an evaluation. A reportable event form dated [DATE] identified Resident #7 had a blood sugar of 40 mg/dl and the nurse attempted to obtain [MEDICATION(S)] from the Cubex machine, but the container would not open. In an effort to keep Resident #7 awake, the nurse placed ice packs on the resident. Upon arrival to the hospital, Resident #7 was noted to be hypothermic with a temperature of 90.9 F. The Administrator was updated, an investigation was immediately initiated including education provided to licensed staff. [MEDICATION(S)] immediately procured from pharmacy for all medication carts, and maintenance was immediately requested for the Cubex machine. Pharmacy representative to come and provide additional insulin education, and all diabetic resident ' s orders were audited, and additional order sets entered as needed. A written statement from the Independent Nurse Consultant (RN #1) dated [DATE] identified that at 1:30 PM she overheard the receptionist say 911 is coming. RN #1 indicated upon entering Resident #7 ' s room, the resident was non-responsive and there were 6 nurses standing around the resident ' s bed. LPN #9 reported the residents blood sugar was 34, there was no [MEDICATION(S)] available, and they had given Resident #7 several sugar packets. The residents lunch tray on the bedside table was untouched. RN #1 indicated Resident #7 had a bag of ice on each side of his/her body, LPN #10 was applying ice to the resident ' s chest, and another nurse was giving the resident a sternal rub. RN #1 educated the nurses at that time that ice, and sternal rub are not the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 indicated EMS arrived at 1:40 PM. At 2:00 PM following Resident #7 ' s departure, RN #1, the Administrator, and the ADNS went to the Cubex machine in the supervisor ' s office. The ADNS indicated the [MEDICATION(S)] IM was in the Cubie (cartridge/drawer). RN #1 and the ADNS attempted 3 times to open the Cubie without success, and the ADNS did not know how to override the Cubex machine. RN #1 indicated at 2:15 PM the pharmacy was called for [MEDICATION(S)] for each of the medication carts The hospital emergency room note dated [DATE] at 3:19 PM identified Resident #7 was found unresponsive at approximately 1:00 PM at the nursing home with a blood sugar of 30 mg/dl. Per EMS attendants, there was ice on Resident #7 to revive the resident. Resident #7 was found with low rectal temperature and placed on bear [NAME] (a convective temperature management system used in a hospital or surgery center to maintain a patient's core body temperature). The hospital admission note dated [DATE] at 5:02 PM identified Resident #7 was admitted for hypothermia and [CONDITION(S)]. Resident #7 was found to be hypoglycemic to 30 mg/dl at the nursing home. Resident was given [MEDICATION(S)] and 250 ml of Dextrose 10 fluids intravenously which his/her sugar improved to 80 mg/dl in the emergency room . In the emergency room , Resident #7 was found to be hypothermic to 90.9 Fahrenheit. A written statement from the ADNS dated [DATE] identified she was called to see Resident #7 who had low blood sugar and was on/off unresponsive around lunch time. Resident #7 was sweating with pale skin. The ADNS indicated LPN #9 informed her Resident #7 ' s blood sugar was 40 while LPN #10 went to go and get [MEDICATION(S)] IM. Sugar was given sublingually, and the resident was able to swallow. Blood sugar rechecked and was 33 mg/dl. The ADNS indicated she immediately went to the Cubex machine to get [MEDICATION(S)] IM for administration, and although she was able to open the Cubex drawer, she was unable to open dedicated [MEDICATION(S)] bin due to a malfunction. The ADNS indicated continuously attempting to get [MEDICATION(S)] IM from Cubex with no success. A written statement from LPN #9 dated [DATE] at 5:00 PM indicated at approximately 1:00 PM Resident #7 was incoherent and his/her eyes were opening and closing. LPN #9 checked the resident ' s blood sugar which was noted to be 40 mg/dl. NA #2 stayed with the resident, and a STAT was called. The staff were having a hard time getting the [MEDICATION(S)] out of the Cubex machine and there was none available on the medication carts. LPN #10 was trying to keep Resident #7 from passing out, so she put ice in a plastic bag around the resident. A written statement by LPN #10 dated [DATE] at 5:44 PM identified she heard LPN #9 yell to get [MEDICATION(S)]. LPN #10 went to go and get [MEDICATION(S)], and staff were having a hard time getting it. LPN #10 indicated Resident #7 was moaning and snoring and LPN #10 indicated she put ice on Resident #7 and performed a sternal rub to keep him/her awake and aroused. LPN #10 indicated she was trying to help the resident. Review of in-service by the ADNS and RN #2 dated [DATE] identified staff were educated on [CONDITION(S)]/[CONDITION(S)], insulin, blood sugar checks, diabetic resident must have snack at hour of sleep, not applying ice or perform sternal rub when a resident is hypoglycemic, emergency [CONDITION(S)] medication ([MEDICATION(S)] IM, [MEDICATION(S)] Gel, [MEDICATION(S)] tablet). Further the staff were educated on the Cubix machine by the pharmacy. The summary report dated [DATE] identified on [DATE] Resident #7 was transferred to the hospital after a period of unresponsiveness at the facility and was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility immediately initiated an investigation and established a timeline. During the investigation, it was determined that a malfunction of the Cubie in the Cubex machine prevented the ADNS from removing the [MEDICATION(S)]. The Cubie has been replaced and is functioning properly. The facility has also taken the following actions as part of a plan of correction related to this event: Charge nurse was provided with individual counseling, discipline, and education about the appropriate management of residents with [CONDITION(S)]. Charge nurse statement revealed that she applied the ice in an effort to keep the resident aroused in the absence of the [MEDICATION(S)]. The nurse was educated that ice application is not an appropriate intervention and she has documented understanding. Licensed staff were provided with education about change of condition, the appropriate management of residents with [CONDITION(S)] and use of the Cubex. [MEDICATION(S)] injectable and glucose tablets immediately ordered from the pharmacy and now available in each medication cart. Inventory of Cubex verified and licensed nurses re-educated on its use. Pharmacy representative to provide additional information about diabetes management. Audit completed of all diabetic residents to ensure appropriateness of orders in EMAR including emergency management interventions. Diabetic order set implemented in EMAR. Facility QAPI implemented to monitor compliance with this plan of correction. Interview with the ADNS on [DATE] at 1:57 PM identified she was the RN supervisor on [DATE] on the 7:00 AM - 3:00 PM shift and indicated LPN #9 called her around lunch about Resident #7 ' s blood sugar which was low at 40 mg/dl. When she arrived at Resident #7 ' s room she observed Resident #7 in bed and LPN #9 trying to stimulate the resident. The ADNS indicated the blood sugar was re-checked with another glucometer machine and the blood sugar result was 33 mg/dl. She indicated Resident #7 was alert, lethargic and attempting to open his/her eyes. The ADNS indicated she went to the supervisor ' s office to the Cubex machine md the drawer opened but the Cubie drawer malfunctioned and would not open to allow access to the IM [MEDICATION(S)] and she was unable to get it. The ADNS indicated she had another nurse attempt to open the Cubex machine, which was unsuccessful, so she directed all the nurses to check their medication carts for [MEDICATION(S)]. The ADNS indicated the facility did not have [MEDICATION(S)] gel or [MEDICATION(S)] IM available in any of the medication carts or in the medication rooms. The ADNS indicated she called the pharmacy account manager and called the pharmacy for STAT [MEDICATION(S)] IM and [MEDICATION(S)] Gel and indicated the pharmacy reported that the [MEDICATION(S)] Gel was on back order so she called another pharmacy. The ADNS indicated when the STAT [MEDICATION(S)] was delivered, she supplied each of the medication carts (6 medication carts) with one [MEDICATION(S)] IM, one [MEDICATION(S)] Gel, and one bottle of [MEDICATION(S)] tablets in a Ziploc bag. Interview with Social Worker #1 on [DATE] at 3:04 PM identified she does not remember the exact time, but it was around lunch time and she went to give Resident #7 his/her lunch tray and the resident was unresponsive in the bed. Social Worker #1 indicated she attempted to wake the resident up, but he/she would not wake up. Social worker #1 indicated she immediately went to get LPN #9 and then continued to pass out the lunch trays. Interview with LPN #9 on [DATE] at 3:25 PM identified at around lunch time Social Worker #1 reported Resident #7 could not be woken up. LPN #9 indicated she immediately went to the room and the resident was lying in the bed with his/her head at the foot of the bed. The resident tried to talk but could not and the skin was clammy to touch. LPN #9 indicated Resident #7 ' s blood sugar was 40 mg/dl and when she looked, the medication cart did not contain [MEDICATION(S)] IM so she asked LPN #10 to check her medication cart which also did not contain [MEDICATION(S)]. LPN #9 indicated LPN #10 ran to get the ADNS who came down and assessed Resident #7 who was in and out of responsiveness. At that point a STAT code was called and the ADNS went to the supervisor ' s office for [MEDICATION(S)] IM however, the Cubie would not open. LPN #9 indicated she had left the room to call EMS and was not in the room when ice was applied to Resident #7. Interview with NA #2 on [DATE] at 4:01 PM indicated Resident #7 told her that he/she had a little something for breakfast and she offered him/her a cold cereal. Interview with the Acting DNS on [DATE] at 4:18 PM indicated he was not in the facility when Resident #7 ' s blood sugar was 40 mg/dl and indicated that he was not aware that the medication carts did not have [MEDICATION(S)] IM. The Acting DNS indicated he came to the facility that evening and the ADNS notified him that the Cubex machine malfunction and she was unable to retrieve the [MEDICATION(S)] IM and the medication carts had no [MEDICATION(S)] IM or [MEDICATION(S)] Gel. The Acting DNS indicated that all the medication carts were supplied with one [MEDICATION(S)] IM, one [MEDICATION(S)] Gel, one bottle of [MEDICATION(S)] tablets and staff were educated on [CONDITION(S)]. Interview with NA #2 on [DATE] at 10:57 AM identified she had given Resident #7 cold cereal and he/she only ate a little bit. Although NA #2 documented the resident 100% of breakfast, the resident only ate a little bit of the breakfast and the little bit of the cold cereal. NA #2 indicated Resident #7 is a picky eater. Interview with LPN #10 on [DATE] at 11:18 AM identified she rechecked Resident #7 ' s blood sugar and it was 33 mg/dl, so she put the ice on the resident to keep him/her aroused and alert because the facility did not have any [MEDICATION(S)] IM. Interview with MD #1 on [DATE] at 8:44 AM identified he was not aware that the facility did not have [MEDICATION(S)] IM or [MEDICATION(S)] Gel available on each medication carts or that staff had put ice on Resident #7 in response to [CONDITION(S)]. MD #1 indicated the expectation is that every medication cart and the medication rooms should have [MEDICATION(S)] IM, and [MEDICATION(S)] Gel for emergencies. MD #1 indicated that the hypothermia was caused by staff placing ice on Resident #7. MD #1 indicated the staff should not have put ice on the resident. Interview with MD #2, (Endocrinology) on [DATE] at 1:39 PM identified he only saw Resident #7 once on [DATE] in the hospital. MD #2 indicated he documented that the hypothermia was caused by [CONDITION(S)] because was not aware that bags of ice had been applied to the resident during the hypoglycemic episode to arouse the resident. MD #2 indicated if he was aware that Resident #7 had ice applied to the body, he would have not documented in the note that [CONDITION(S)] can cause mental status changes and be associated with hypothermia as well. MD #2 indicated the reason for the hypothermia would have been because ice was applied to the resident during a hypoglycemic episode. Review of the facility blood glucose policy identified the purpose is to determine the amount of glucose (sugar) present in the blood and assist in the management of diabetes. Review of the facility medication administration policy identified to provide a safe and effective medication management framework to help eliminate any harm that could be caused at any level of the medication management process. To ensure that licensed facility staff will adhere to proper safety precautions in the administration of medications. Review of the insulin administration policy identified to provide guidelines for the safe administration of insulin to residents with diabetes. Documentation: How well the resident tolerated the procedure. Reporting: Notify your supervisor if the resident refuses the insulin injection. Notify the physician if the resident has sign and symptoms of [CONDITION(S)]/[CONDITION(S)] that are not resolved by following the facility protocol for [CONDITION(S)]/[CONDITION(S)] management. Review of the nursing care of the resident with diabetes policy identified diabetes is a disorder in which there is relative or absolute lack of insulin. Among other things, glucose (sugar) from food cannot be taken up by the cells, which results in elevated blood sugar ([CONDITION(S)]) and lack of energy for cellular function. Management of [CONDITION(S)]: For symptomatic (lethargic, drowsy) but responsive (conscious) residents with [CONDITION(S)] (<70 mg/dl or less than the physician-ordered parameter): If he/she is unable to swallow: 1) Immediately administer oral glucose paste to the [MEDICATION(S)] mucosa, intramuscular [MEDICATION(S)], or IV 50% dextrose, per facility protocol; 2) Recheck blood glucose in 15 minutes; and 3) Repeat protocol if indicated and recheck blood glucose in 15 minutes. Remain with the resident; monitor vital signs. For symptomatic and unresponsive residents with [CONDITION(S)] (<70 mg/dl or less than the physician-ordered parameter): Immediately administer oral glucose paste to the [MEDICATION(S)] mucosa, intramuscular [MEDICATION(S)], or IV 50% dextrose, per facility protocol and notify the physician for further orders; If resident remains unresponsive, call 911 (in accordance with resident ' s advance directives). Documentation should reflect the carefully assessed diabetic resident. The facility failed to ensure [MEDICATION(S)] was readily available to licensed staff on the units and in the medication carts for use in an emergency. The investigation found that there was one [MEDICATION(S)] IM in the facility, and it was located in a Cubex machine that malfunctioned and would not release the [MEDICATION(S)]. The facility failed to provide care according to professional standards when they gave Resident #7, who was unresponsive, sugar packets in his/her mouth and applied ice to the resident ' s body in an effort to awaken the unresponsive resident who became hypothermic with a body temperature of 90.9 F and required a bear [NAME] (a convective temperature management system used in a hospital or surgery center to maintain a patient's core body temperature) to bring his/her body temperature back to a normal range. These failures to properly treat Resident #7 ' s [CONDITION(S)] with resulting hypothermia resulted in Immediate Jeopardy. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated [DATE] identified the resident was at increased risk for alteration in nutritional status due to diabetes. The quarterly MDS dated [DATE] identified Resident #8 had moderately impaired cognition and required extensive assistance with personal hygiene. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #8 ' s blood sugar was documented at 559 mg/dl (normal range is 70 - 100 mg/dl). Review of the progress notes dated [DATE] - [DATE] failed to reflect that the physician, APRN or resident representative had been notified on [DATE] that Resident #8 ' s blood sugar at 6:00 AM was 559 mg/dl. Further, there was no documentation that Resident #8 had been assessed at that time due to the [CONDITION(S)]. Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #8 ' s blood sugar was documented at 528 mg/dl (normal range is 70 - 100 mg/dl). Review of the progress notes dated [DATE] at 6:40 AM identified Resident #8 ' s blood sugar was 528 mg/dl, the resident was alert and responsive with no signs and symptoms of [CONDITION(S)] and the physician was paged. Review of the progress notes dated [DATE] at 9:11 AM identified the ADNS notified the physician that Resident #8 ' s blood sugar was 528 mg/dl at 6:00 AM. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If blood sugar is less than 80 mg/dl, call the physician. If blood sugar is 200 mg/dl to 249 mg/dl, give 2 units. If blood sugar is 250 mg/dl to 300 mg/dl, give 4 units. If blood sugar is 301 mg/dl to 350 mg/dl, give 6 units. If blood sugar is 351mg/dl to 400 mg/dl, give 8 units. If blood sugar is greater than 400 mg/dl, give 10 units and call the physician. Further, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident responsible for self. Review of the [DATE] MAR failed to reflect that the order dated [DATE] at 9:11 AM for Insulin Sliding Scale coverage 3 times daily, and Insulin 28 units at hour of sleep had not been implemented at that time on [DATE] at 9:11 AM, and Resident #8 was without the benefit of Sliding Scale Insulin coverage for his/her blood sugar of 528 mg/dl at 6:00 AM. Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #8 ' s blood sugar was 489 mg/dl (this is in conflict with the blood sugar reading of high) and the resident received 10 units of Sliding Scale Insulin. Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (This is in addition to the 10 units Insulin that was given at 11:30 AM). Review of the [DATE] [DATE]/,d+[DATE] at 12:00 PM identified the resident ' s blood sugar was 587 mg/dl. Review of the nurse ' s note dated [DATE] at 12:44 PM identified Resident #8 ' s blood sugar registered high. Subsequently, the APRN was notified and ordered a one-time additional dose of [MEDICATION(S)] 10 units. Review of the [DATE] [DATE]/,d+[DATE] at 2:00 PM identified the resident ' s blood sugar was 487 mg/dl. Interview with MD #1 on [DATE] at 8:47 AM identified he was not aware Resident #8 ' s blood sugar on Sunday [DATE] at 6:00 AM was 559 mg/dl. MD #1 indicated he or the APRN should have been notified when the resident ' blood sugar was elevated. Additionally, MD #1 indicated he was aware of the resident ' s increase blood sugar on Monday [DATE] at 6:00 AM of 528 mg/dl and gave a new order to the ADNS for the Sliding Scale. MD #1 indicated that the sliding scale Insulin should have been administered immediately at the time of the order on [DATE] at 9:11 AM. Interview with LPN #13 on [DATE] at 11:38 AM identified she works on the 7:00 AM - 3:00 PM shift and indicated on [DATE] she received report from LPN #14 that Resident #8 ' s blood sugar was high, and the supervisor/(ADNS) was waiting for the physician to call back. LPN #13 indicated she received report that the ADNS had spoken to the physician and new order for a sliding scale was obtained, starting at 200 mg/dl and additional Insulin at 8:00 PM. LPN #13 indicated she was in the middle of passing out medication when the ADNS gave her the new orders for Insulin and she did not document the orders right away. LPN #13 indicated she was going to check Resident #8 ' s blood sugar at 11:30 AM when she does her rounds for blood sugar checks. LPN #13 indicated around 11:30 AM, RN #1 requested a blood sugar check on Resident #8 and the glucometer reading registered high. LPN #13 indicated she can't remember the details exactly what happened or why she documented that Resident #8 ' s blood sugar was 489 mg/dl at 11:30 AM. LPN #13 identified she administered 10 units of Sliding Scale Insulin coverage and notified the APRN at that time. LPN #13 indicated Resident #8 ' s blood sugar at 12:00 PM was 587 mg/dl and the APRN gave an order to administer an additional 10 units of Insulin coverage and recheck the blood sugar in 2 hours at 2:00 PM. At 2:00 PM Resident #8 ' s blood sugar was 487 mg/dl and was given additional coverage of 6 units of insulin. Interview and review of the clinical record with the ADNS on [DATE] at 12:45 PM identified she was the supervisor on duty on [DATE] from 7:00 PM - 7:00 AM, and the next morning ([DATE]). The ADNS indicated on [DATE] at 6:00 AM she was not notified that Resident #8 ' s blood sugar was 528 mg/dl. The ADNS indicated she ran a report on the computer between 7:00 AM and 8:00 AM and the report indicated Resident #8 ' s blood sugar was 528 mg/dl. The ADNS indicated she called the physician at that time and an assessment of Resident #8 for signs and symptoms of [CONDITION(S)] was completed. The ADNS indicated as she was leaving around 8:30 AM the physician returned the call and was updated on the elevated blood sugar. The ADNS indicated she wrote the new orders on a piece of paper and handed the paper to LPN #13 and gave LPN #13 a quick report. The ADNS indicated she also gave an update to the supervisor on duty. The ADNS indicated she documented her notes at 9:11 AM when she arrived at home. Interview with APRN #1 on [DATE] at 12:57 PM identified he was not aware that Resident #8 ' s blood sugar on [DATE] at 6:00 AM was 559 mg/dl. APRN #1 indicated he did not receive a phone call from RN #2 or LPN #12. Interview with LPN #14 on [DATE] at 10:27 AM identified she has been working at the facility through the agency for approximately one month. LPN #14 indicated on [DATE] Resident #8 ' s blood sugar at 6:00 AM was 528 mg/dl and Resident #8 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #14 indicated she was unable to document on Resident #8 because she was not trained or oriented on the computer system that the facility uses. LPN #4 indicated that she has not documented whenever she works at the facility. Interview with RN #2 on [DATE] at 12:01 PM identified LPN #12 did not report to him that Resident #8 had a blood sugar of 559 on [DATE] at 6:00 AM. RN #2 indicated the expectation of the facility is that the charge nurse is to notify the RN supervisor and the RN supervisor will assess the resident for signs and symptoms of [CONDITION(S)] and notify the MD or APRN. RN #2 indicated the charge nurse is responsible to notify the responsible party with any changes in condition during their shift. Interview with LPN #12 on [DATE] at 9:09 AM identified she is employed through the agency and her first day at the facility was on [DATE]. LPN #12 indicated she worked a double shift on the 3:00 PM - 11:00 PM shift and the 11:00 PM - 7:00 AM shift. LPN #12 indicated she cannot remember the residents on the unit and do not remember if any residents had increase blood sugar level. LPN #12 indicated that she did not notify the supervisor/MD/APRN or the responsible party regarding any increase blood sugar on [DATE] at 6:00 AM. LPN #12 indicated she did not document nurse's notes during her double shift and indicated the facility did not orient or train her on how to use the computer system. LPN #12 indicated she signed off when she administered medications. She indicated the facility said they were going to train her on the computer system, and they never did. LPN #12 indicated she received a phone call from the corporate staff at the facility regarding Resident #8 ' s blood sugar. LPN #12 indicated she told him that she does not know the residents by name. Review of the change of condition policy directed to ensure that changes in resident's conditions are reported to providers and families/emergency contacts in a timely fashion. To ensure that residents' changes of condition are assessed and documented properly. Documentation will be noted in the resident's medical record. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] identified Resident #3 had intact cognition, was independent with bed mobility, required assistance with transfers and personal hygiene, and walked independently. The corresponding care plan identified Resident #3 had a potential for symptoms of depression related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] controlled drug/receipt/record disposition form identified the last available dose of [MEDICATION(S)] was administered on [DATE] at 9:00 PM. Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation indicated the resident is asleep and does not want to be woken up. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility documentation identified Resident #3 ran out of the [MEDICATION(S)] 2mg on [DATE] at 9:00 PM and the pharmacy delivery sheet identified Resident #3 ' s [MEDICATION(S)] 2mg was delivered to the facility on [DATE] at 12:50 AM, 2 days later. Review of facility documentation identified that although the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the cubex emergency medication kit documentation failed to reflect that the [ME

Based on review of clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #9) reviewed for pressure ulcers, the facility failed to ensure the RN/IP assessed the area on admission and ongoing over the course of 4 weeks, including measurements, description, and reassessment, failed to ensure appropriate physician intervention and treatment changes, subsequently, the wound deteriorated to unstageable pressure ulcer without the knowledge of the IP or physician and was identified upon the residents admission to the hospital. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge tracking MDS dated [DATE] identified Resident #9 had an unplanned discharged to the hospital, return anticipated. Review of the resident census form identified Resident #9 was readmitted from the hospital to the facility on [DATE], over one month later. Review of the hospital discharge summary dated 3/6/22 at 2:06 PM identified Resident #9 was discharged back to the facility with a pressure injury to the left buttock stage II. The Braden Scale (pressure ulcer risk assessment) dated 3/6/22 at 5:57 PM identified Resident #9's sensory perception was completely limited, he/she was unresponsive to painful stimuli due to diminished level of consciousness or sedation, the resident's skin was constantly moist, he/she was bedfast with very limited mobility and required moderate to maximum assistance with moving. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the orders directed to cleanse the left buttocks wound with normal saline followed by foam dressing daily during the 3:00 PM - 11:00 PM shift. A nurse's note dated 3/6/22 at 6:49 PM identified Resident #9 returned to the facility at 4:06 PM via stretcher. A body audit was performed, and a small abrasion was noted to the left buttock. A dry clean dressing was applied. Review of the 1st floor resident shower schedule dated 3/6/22 identified Resident #9's room number was scheduled for a shower on Friday 3:00 PM - 11:00 PM. (not consistent with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident care card dated 3/7/22 identified Resident #9 showers with the assistance of 2 on Monday during the 7:00 AM - 3:00 PM shift. The care plan dated 3/7/22 identified Resident #9 requires assistance in all ADL's related to severe cognitive impairment and muscle weakness. Interventions included to transfer out of bed with the assistance of 2, bed mobility with the assistance of 2, assistance of 1 with toileting, and turn and reposition every 2 hours and as needed. A readmission nutrition assessment dated [DATE] at 11:42 AM identified Resident #9 had an abrasion to the left buttock. The care plans dated 3/7/22 - 3/17/22 failed to reflect documentation related to skin integrity. A wound physician's note dated 3/8/22 identified Resident #9 was seen in consultation for evaluation of wounds. Coccyx first evaluated on 3/8/22. Consult for Resident #9 with a reported open wound along the coccyx however, no wounds noted on evaluation today. The admission MDS dated [DATE] identified Resident #9 had severely impaired cognition, required total 2-person assistance with bed mobility, transfers, toilet use, and personal hygiene. Additionally, Resident #9 was always incontinent of urine and bowel, was at risk of developing pressure ulcers, had no pressure ulcers, had a pressure reducing device for bed, turning and repositioning program, application of nonsurgical dressings, and applications of ointments/medications. A nurse's note dated 3/24/22 at 10:50 PM identified Resident #9's skin was not intact. Skin condition: Wound condition #1 left buttock. Skin interventions: Pressure reducing device for bed. A nurse's note dated 3/25/22 at 10:23 PM identified Resident #9 skin was not intact. Skin conditions: Wound Left buttock. Skin interventions: Pressure ulcer/injury care. Review of the March 2022 TAR identified upon Resident #9's return 3/6/22, a treatment to the left buttock (cleanse left buttocks wound with normal saline followed by foam dressing daily) had been completed on 3/7/22 through 3/31/22 during the 3:00 PM - 11:00 PM shift. Review of the March 2022 TAR identified upon Resident #9's return 3/6/22, weekly skin checks on shower day (Mondays during the 7:00 AM - 3:00 PM shift). The TAR identified that staff documented that weekly skin checks had been completed on 3/7/22, 3/14/22, 3/21/22, and 3/28/22 during the 7:00 AM - 3:00 PM shift, however, there was no corresponding documentation in the clinical record to indicate what the residents skin looked like, if the area on the buttock was improved or deteriorated, or if skin breakdown existed. Review of the nurse's notes dated 3/6/22 through 4/5/22 identified inconsistencies in documentation. The nurse's notes dated 3/9/22, 3/10/22, 3/14/22, 3/16/22, 3/23/22, 3/25/22, 3/27/22, 3/29/22, 4/2/22 and 4/3/22 identified Resident #9's skin was intact, however, the nurse's notes dated 3/24/22, 3/25/22, and 3/29/22 identified Resident #9's skin was not intact and there was a wound to the left buttock. Documentation failed to reflect a description of the non-intact skin, where the non-intact skin was, or measurements/staging. Review of the April 2022 TAR identified a weekly skin check was performed on 4/4/22 during the 7:00 AM - 3:00 PM shift. Further, the TAR identified a treatment was completed on the left buttock wound, (normal saline followed by foam dressing) daily on 4/1, 4/2, 4/3, and 4/4/22, during the 3:00 PM - 11:00 PM shift. A nurse's note dated 4/5/22 at 1:48 PM identified Resident #9 was alert and responsive, the treatment was done as ordered to the left buttock, total care was provided, and the resident was repositioned. Further, Resident #9 was transported via stretcher at 11:10 AM to an appointment. A nurse's note dated 4/5/22 at 2:04 PM identified the ADNS received a phone call from the hospital that Resident #9 had been transferred to the hospital from the [CONDITION(S)] center. A nurse's note dated 4/5/22 at 10:19 PM identified Resident #9 was admitted to the hospital. Review of the hospital documentation dated 4/5/22 at 8:00 PM identified pressure injury present on hospital admission. Right medial gluteal and left lateral sacrum unstageable. Left lateral sacrum and right medial gluteal/coccyx cleanse with Dakin's solution (a dilute solution of sodium hypochlorite and other stabilizing ingredients, used as an antiseptic to cleanse wounds to treat or prevent infection). Apply Dakin's soaked gauze to wound bases, cover with foam or ABD twice a day. Interview with LPN #9 on 4/11/22 at 11:17 AM identified she is the regular nurse assigned to Resident #9 on the 7:00 AM - 3:00 PM shift. LPN #9 indicated on admission she heard Resident #9 had an abrasion to the left buttock. LPN #9 indicated she was aware that Resident #9 had an open area on the left buttock because on 4/5/22 the nurse aide reported that the dressing on the left buttock was soiled and that was the first time she viewed Resident #9 ' s left buttock. LPN #9 indicated Resident #9 had an open area and a stage II to the left buttock, she indicated she provided treatment as ordered and the Resident #9 left for [CONDITION(S)]. LPN #9 indicated the treatment is done on the 3:00 PM - 11:00 PM shift. LPN #9 indicated she does not perform a skin check on Resident #9 because the resident ' s shower day is on Fridays on the 3:00 PM - 11:00 PM shift. Interview with LPN #2 on 4/12/22 at 1:25 PM identified she is the Infection Preventionist (IP) and the wound nurse. LPN #2 indicated she does wound rounds with the wound physician every week on Tuesdays. LPN #2 indicated she was not aware that Resident #9 had an open area to the left buttock. LPN #2 indicated she and the wound physician made round on 3/8/22 and Resident #9 had no open areas. LPN #2 indicated the facility staff did not notify her that Resident #9 had an open area. LPN #2 indicated the expectation is when the staff observe any open areas, they are responsible to notify her, and she would assess the resident and add the resident to the wound list for the wound physician to assess on his next visit to the facility. Interview with MD #1 on 4/13/22 at 8:50 AM identified he was not aware Resident #9 had an open area to the left buttock and indicated he had confirmed the re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the APRN on 4/14/22 at 10:48 AM identified he was not aware Resident #9 had an open area to the left buttock. The APRN indicated he does not treat the wounds at the facility because the facility has a wound physician. Interview with MD #3 (wound physician) on 4/18/22 at 12:03 PM identified he was not aware Resident #9 had a wound on the left buttock. MD #3 indicated on 3/8/22 he assessed Resident #9 for wounds to the coccyx and indicated Resident #9 ' s skin was intact and that is what he documented. MD #1 indicated the facility staff did not notify him that Resident #9 had an open area to the left buttock. MD #3 indicated his expectation is that the facility staff should have reported the open area to LPN #2, and she would have added the resident to the wound list. MD #3 indicated he does wound rounds every Tuesday. MD #3 indicated if the facility staff had received an order from the medical physician there is no way he would have known. Interview with LPN #15 on 4/18/22 at 12:22 PM identified he has been working at the facility for approximately 2 months through an agency on the 3:00 PM - 11:00 PM shift. LPN #15 indicated the last time he performed a treatment to Resident #9 ' s left buttock open area, the open area was a stage II. Interview with LPN #16 on 5/3/22 at 1:36 PM identified she was not aware Resident #9 had an open area to the left buttock. LPN #16 indicated regarding the weekly skin assessments on 3/14/22, 3/28/22, and 4/4/22 she did not perform a thorough skin check on Resident #9 because the resident was combative during the assessments. LPN #16 indicated she did the best she could and did not see a dressing or an open area to the resident skin. Interview with the Administrator on 5/3/22 at 3:59 PM identified the facility has no documentation to substantiate skin checks were performed weekly on shower days on Resident #9. The Administrator indicated after the issue with Resident #9 the facility has implemented the weekly skin assessment form. Interview with LPN #9 on 5/4/22 at 10:45 AM identified she does not recall filling out the skin note form on 3/16/22 at 3:45 PM and indicated Resident #9 ' s treatment is done on the 3:00 PM - 11:00 PM shift. LPN #9 indicated the first time she saw Resident #9 left buttock open area was on 4/5/22. Review of the weekly skin checks policy identified skin checks are completed by the nurse on shower days and placed in binders. Review of the skin and wound management policy identified the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs include but are not limited to: Impaired/decreased mobility and decreased functional ability; The presence of previously healed pressure ulcers/injuries. Exposure of skin to urinary and fecal incontinence; Co-morbid conditions, such as [CONDITION(S)]. Cognitive impairment. The facility failed to thoroughly assess the resident ' s skin over a 4 week period, according to professional standards, including weekly measurements and description of a pressure ulcer, failed to notify the IP and physician when the area developed and deteriorated, and failed to ensure appropriate treatments were implemented. The clinical record failed to reflect any description of the wound on the resident ' s right buttock. Subsequently, the wound deteriorated to unstageable pressure ulcer, without the knowledge of the IP or physician, and was identified upon the resident ' s admission to the hospital.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #3) reviewed for a medication error, the facility failed to ensure the resident was free from a significant medication error resulting in hospitalization . The findings include: Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Care Plan (RCP) dated 7/9/20 identified a history of substance abuse related to cocaine use. Interventions directed to administer medications as ordered by physician, encourage Narcotics Anonymous, and identify triggers for substance use. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had intact cognition, required limited assistance of one for ambulation, and had no behaviors. The facility incident report dated 7/18/20 at 9:00 AM identified that Resident #3 (who was receiving [MEDICATION(S)]) received another resident's Naltrexone 50 mg in error. The report identified that Resident #3 had opiate withdrawal symptoms and the APRN was notified. The facility Investigation included a statement from LPN #1 that indicted when he was administering Resident #3 his/her medications, he accidently popped a pill from another resident's medication card into Resident #3 medications. The nurse's progress note dated 7/18/20 at 10:26 AM identified that Resident #3 experienced symptoms of nausea, severe abdominal cramping, sensations of bugs crawling on his/her skin, and acute emotional distress since he/she received the incorrect medication (Naltrexone 50 mg). The nurse's note dated 7/18/20 at 12:58 PM identified the nursing supervisor assessment indicated Resident #3 had received his/her regular scheduled [MEDICATION(S)] prior to the medication error, and Resident #3 was visibly in distress, had diarrhea, was yelling that his/her insides were on fire and his/her skin was crawling. The APRN was notified and Resident #3 was transferred at 10:45 AM to the emergency room for evaluation. The nurse's note dated 7/18/20 at 2:22 PM identified Resident # 3 was alert and verbally responsive when his/her medications were administered at 9:21 AM. Thirty (30) minutes later, Resident #3 was heard yelling in his/her room and when staff approached, she/he reported she/he couldn't stop going to the bathroom. Resident #3 questioned what medications were given earlier. LPN #1 checked the medication cards in the cart and discovered there was a card of Naltrexone 50mg (ordered for another resident) which had been administered in error to Resident #3 at 9:21 AM. The Nursing Supervisor and APRN were notified, and Resident #3 was transferred to the emergency room for evaluation. The nurse's note date 7/19/20 at 12:50 AM noted Resident #3 was admitted to the hospital. The Hospital Discharge Summary dated 7/20/20 identified the hospital primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was restarted on [MEDICATION(S)]. Hospital treatment included [MEDICATION(S)] intramuscular (IM) injections, [MEDICATION(S)], Lorazepam IM, Intravenous (IV) fluids, [MEDICATION(S)] IV, and Lorazepam IV. The nurse's note dated 7/20/20 at 11:34 PM identified Resident #3 was readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The APRN note dated 7/21/20 at 3:44 PM identified Resident #3 was a readmission from the hospital after Resident #3 received was Naltrexone 50 mg that belonged to another resident and experienced diarrhea, skin crawling and was sent to emergency room . During an interview with LPN #1 on 5/6/21 at 12:20 PM, LPN #1 indicated that he administered Resident #3 the wrong medication. LPN #1 did not recall the name of the medication but reported that he had popped a medication out of the blister pack with all the other scheduled medications and gave them all to Resident #3. LPN #1 indicated the blister pack with the medication for another resident was in the same slot with all of Resident #3's medications in the medication cart. He indicated that maybe someone came to the medication cart to speak to me and he became distracted and made the error. During an interview with Pharmacist #1 on 5/6/21 at 12:45 PM, Pharmacist #1 indicated that [MEDICATION(S)] 120 mg daily was a significant dose and that Naltrexone would [MEDICATION(S)] the [MEDICATION(S)], which would cause a person to almost immediately go into withdrawal (the intended effect of Naltrexone is to turn off the effects of the [MEDICATION(S)]). He indicated Resident #3 would experience nausea, abdominal pain, vomiting, muscle pain, sweating, a sensation of bugs crawling on his/her skin, and that the symptoms were caused by the effect of the Naltrexone administration. Pharmacist #1 further indicated the primary symptoms affect the digestive and sensory system, but they could also affect the cardiac and respiratory systems. Although requested, a facility policy on Medication Administration was not provided. Review of the facility undated Medication Administration Errors Policy, identified in part, that a medication error occurs when a medication is administered without a valid order. Review of the undated facility policy, General Guidelines for the Administration of Medications, directed in part, that the nurse observes the five rights in administering each medication: the right resident, the right time, the right medication, the right dose, and the right method. The Policy further directed the nurse compares the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record reviews, observations, review of facility documentation and interviews for one of three sampled residents (Resident #4) who had a history of [REDACTED]. The finding includes: Resident #4's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no cognitive impairment and was independent with eating after staff set up. A physician's orders [REDACTED]. The physician order [REDACTED]. The Resident Care Plan dated 1/18/19 identified the resident was at risk for choking or aspiration with interventions to encourage a slow rate of intake, nursing to assist to cut food, and provide diet consistency as ordered. A review of the speech therapist evaluation dated 1/25/19 indicated that Resident #4 was referred to speech therapy to assess tolerance and safety with soft textured diet and nectar thick consistencies following witness of increased coughing. The evaluation also identified Resident #4 was impulsive and required consistent cueing to utilize safe swallow precautions of slow rate and to alternate liquids and solids. The nurse's note dated 2/1/19 at 2:41 PM indicated that at approximately 12:50 PM, Resident #4 was observed in distress and having respiratory difficulty and the [MEDICATION NAME] maneuver was initiated while the resident was seated in the wheelchair. The nurses' notes further indicated that a piece of sausage was removed from the resident's airway. The facility reportable event dated 2/1/19 indicated that while eating lunch in the dining room Resident #4 was noted to be in distress and multiple particles of food was observed in Resident #4's mouth which were removed. The resident was noted to be unresponsive and the [MEDICATION NAME] maneuver was initiated and more food particles were expelled. Resident #4 became alert, supplemental oxygen was applied, and the resident was transferred to an acute care hospital for evaluation. Review of the acute care hospital discharge summary dated 2/3/19 indicated that upon presentation to the emergency department, Resident #4 was afebrile and had an oxygen saturation of 100% on [MEDICAL CONDITION]. While in the emergency room Resident #4 received Solu-[MEDICATION NAME] 125 milligrams, Magnesium and [MEDICATION NAME] nebulizer treatments. Resident #4 was transferred to the medical intensive care unit (MICU) secondary to hypoxemic hypercarbic [MEDICAL CONDITION] where Resident#4 tolerated [MEDICAL CONDITION] well and arterial blood gas dramatically improved. Resident #4 was readmitted to the facility on [DATE] and was prescribed a puree diet. In an interview with the Director of Nursing (DON) on 3/21/19 at 12:45 PM, she indicated that on 2/1/19 Resident #4's noon meal included sausage and at that time, the resident's diet was soft and the meat should be ground, however, the sausage was cut and not ground. The DON further indicated that under the direction of the Food Service Director #2, the cook cut the sausage and did not ground as per the [NAME]land diet Manual which is utilized by the facility. In an interview with Cook #1 on 3/21/19 at 1:30 PM he indicated that several months prior to this incident, Dietary Supervisor #2 directed the kitchen staff that residents who required a soft diet, the meat should be chopped and not ground. Cook #1 identified that on 2/1/19, sausage (with casing) was served as part of the soft diet and was sliced and not ground and although this was a deviation from the [NAME]land diet manual, he followed direction from Dietary Supervisor #2. In an interview with NA#5 on 3/21/19 at 1:45 PM she indicated that on 2/1/19 she provided Resident #4 with the noon meal and the meat was chopped and not ground. In an interview with NA#7 on 3/21/19 at 2:43 PM she indicated that while collecting the meal trays in the dining room on 2/1/19, Resident #4 was noted to have difficulties breathing and she immediately notified the charge nurse. Interview with LPN#3 on 3/22/19 at 11:55 AM indicated that she was alerted that Resident #4 was having difficulty in the dining room on 2/1/19, noted the resident to be distressed and initiated the [MEDICATION NAME] maneuver. LPN #3 indicated that a piece of sausage came out during the [MEDICATION NAME] and the sausage was too big. Interview with the Speech Therapist (ST) on 3/26/19 at 3:00 PM indicated that bite size pieces should be cut to 1.8 millimeters (mm) in length and although she made recommendation for a soft diet, the kitchen staff should utilize facility specific guidelines regarding meat to determine if it should be ground or cut because each meat texture is different. The ST further stated that residents with puree diet should not have meat with casing but was unable to recall if a mechanical soft diet can have meat with casing. In an interview with APRN#1 on 3/27/19 at 11:15 AM she indicated that Resident#4's diet order was written based on the speech therapist assessment and evaluation. APRN#1 further indicated that it is the responsibility of the dietary staff to ensure that the correct consistency is provided to each resident per the dietary manual utilized by the facility. Review of the [NAME]land diet manual, which is the facility's approved diet manual, with Food Service Director #1 on 3/21/19 indicated that meat should be ground for a soft diet and gravy or sauce may be added to moisten. The facility failed to ensure that Resident #4 received the correct diet consistency which resulted in the resident choking, required the [MEDICATION NAME] maneuver, and was subsequently hospitalized . Review of facility documentation identified that a plan of correction was developed and implemented on 2/1/19 and included the following: -Nursing and Dietary staff were in-serviced regarding diet texture, identification of varied therapeutic diets, the diets consistencies and quality assurance of the tray line. -All residents with therapeutic diet orders were reviewed. -Audits were conducted on accuracy of diet consistency with no additional concerns identified. -A diet texture list has been posted in the kitchen and in the resident dining rooms. Review of the facility's documentation identified the facility was in compliance on (MONTH) 1, 2019.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #99) reviewed for accidents, and/or for 1 resident (Resident #20) reviewed for skin condition, the facility failed to notify the physician and/or APRN an acute fracture, and/or when the residents wound deteriorated. The findings include: 1. Resident #99's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #99 had severely impaired cognition, was independent with ADL's, and had no falls. The care plan dated 10/18/17 identified Resident #99 had the potential for falls, was at risk for behavioral issues, and had the potential for elopement. Nurses notes dated 12/21/17 indicated Resident #99 punched another resident in the neck, and when the other resident pushed Resident #99 away, Resident #99 fell and sustained a skin tear to the right elbow and complained of right shoulder pain. Examination identified complaints of pain of the right shoulder with limited range of motion and right elbow skin tear. Subsequent to APRN notification, x-rays of the right elbow/shoulder were ordered. Review of an x-ray report of the right shoulder dated 12/21/17 indicated no fracture or dislocation. Unremarkable right shoulder. Review of an x-ray report of the right elbow dated 12/21/17 identified a displaced [MEDICAL CONDITION]. Nurse's note dated 12/22/17 identified that Resident #99 was given Tylenol 650mg at 11:00 AM for complaints of right arm pain and the resident was encourage to rest the arm on a pillow while in bed. Review of an APRN note dated 12/22/17 identified Resident #99 had moderate, constant shoulder pain which radiates to the arm, and is aggravated by movement. The x-ray was negative for fracture, to start [MEDICATION NAME] to the right shoulder for 5 days. Review of a nurse's note dated 12/23/17 indicated that [MEDICAL CONDITION] and bruising persisted to the right arm, and Resident #99 had complaints of pain. Nurses note dated 12/25/17 identified Resident #99's right arm pain, bruising/swelling continues, and the resident was medicated for pain. A nurse's note and dated 12/27/17 identified Resident #99 had right lower arm/hand [MEDICAL CONDITION] with a moderate amount of discoloration. The arm was cool to touch, and staff were unable to palpate pulses. Subsequent to physician notification, Resident #99 was sent to the hospital for evaluation. Hospital documentation dated 12/27/17 identified Resident #99 had complaints of right elbow pain after an unwitnessed fall at the facility on 12/21/17. Resident #99 had and elbow x ray at the facility which was reportedly negative. Due to persistent swelling and bruising, the resident was sent for reevaluation. A right elbow x ray dated 12/27/17 identified an intra-articular and comminuted fracture (a break or splinter of the bone into more than two fragments) of the proximal ulna/olecranon. There is a complete [MEDICATION NAME] fracture through the olecranon with significant proximal displacement of the main proximal fracture prominent posterior fat pad. Resident #99 returned to the facility with a right upper extremity splint with recommendations that included elevation and non-weight bearing of the right upper extremity, and assistance with activities of daily living. Facility investigation conclusion, undated, identified on 12/21/17 Resident #99 was involved in a resident to resident altercation. On 12/22/17 the RN Supervisor, (RN #7) reported in morning report that the x ray completed was negative. On 12/27/17 Resident #99 was noted increased discoloration and [MEDICAL CONDITION] to the right hand. Subsequent to physician notification, Resident #99 was sent to the hospital. A hospital x ray identified a right olecranon fracture with significant displacement. Review of a statement by RN #7 dated 12/27/17 identified on 12/21/17 sometime after 9:45 PM he/she received Resident #99's right shoulder and right elbow x ray results. Later, between 10:00 PM - 11:00 PM he/she texted Resident #99's x ray results to an incorrect person. Although RN #7 indicated he/she did realize the mistake that night, he/she forgot to report the x ray results to the DNS due to overwhelming evening. Although facility documentation identified RN #7 notified the APRN about the right elbow fracture on 12/21/17, the documentation indicated that when the APRN was interviewed on 12/27/17, he/she was not aware a right elbow x ray had been ordered. Additionally, although RN #7 thought he/she had reported the x-ray results to the APRN via text on 12/21/17, he/she had sent the text to the admissions liaison in error. Review of facility documentation (morning report dated 12/22/17) indicated the x-ray for Resident #99 was negative. Review of the paper clinical record identified two hard copy results of the negative shoulder x ray, but the record lacked a hard copy of the right elbow x ray. Interview with the DNS on 8/3/18 at 10:00 AM indicated he/she was not employed at the facility on 12/21/17 and was not completely knowledgeable of the event. The DNS further indicated of the involved personnel, only the admission liaison and RN #7 were still employed at the facility. Interview with the Admission Liaison on 8/3/18 at 10:20 AM indicated he/she received the texts on 12/21/17, realized that the texts were not for him/her, and deleted them. Interview with RN #7 on 8/3/18 at 10:35 AM indicated he/she could not recall a (MONTH) (YEAR) event without reviewing the statements made, and was not available to review statements. Although requested, the facility does not have a policy specific to reporting of laboratory/radiologic reports. Review of the facility change of condition in a resident status policy indicates the facility shall promptly notify the resident, his/her attending physician and representative of changes in the resident's condition. The facility failed to report the residents elbow fracture on 12/21/17, which led to a delay in appropriate fracture treatment until 12/27/17, 6 days later, during which time, the resident experienced ongoing pain. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 5/16/18 identified Resident #20 had an abrasion to the abdominal area. Interventions directed to observe the abdominal area for signs of healing and infection, to provide treatment as ordered, and to update the physician with concerns and/or changes in condition. The care plan dated 6/18/18 identified Resident #20 was non-compliant and/or refused treatments at times. Interventions directed to encourage Resident #20 to follow the plan of care as directed by the physician. The quarterly MDS dated [DATE] identified Resident #20 had no cognitive impairment, was independent with bed mobility, transfers, walking in room and/or corridor, and/or locomotion on and/or off the unit. Additionally, the MDS identified Resident #20 was independent with dressing, eating, personal hygiene, and required limited assistance with toilet use, required application of nonsurgical dressing (with or without topical medication) other than to feet, and required application of ointments and/or medications other than to feet. A physician's orders [REDACTED]. Review of a wound consultation form dated 7/19/18 identified Resident #20 had 2 open areas on his/her ventral hernia. One wound on the proximal surface measured 0.4cm by 0.4cm with a pink wound bed, no odor, drainage or induration. The second wound present distally, near the center of the hernia, measured 0.3cm by 0.3cm. The wound bed was 100% pink without odor, drainage, or induration. Recommendations included to continue silver [MEDICATION NAME] cream as ordered. The nurse's note dated 7/27/18 at 2:40 PM treatments were completed as ordered to large abdominal mass with copious amounts of yellow tinted drainage that had soaked through 5 abdominal pads. The nurse's note dated 7/28/18 at 6:35 AM identified Resident #20 complained of pain to abdomen and penile area. Resident #20 requested and received pain medication for pain associated with abdomen at 12:00 AM. The nurse's note dated 7/28/18 at 7:40 AM and 9:54 PM identified Resident #20 received [MEDICATION NAME] 5mg for complaints of pain to umbilical hernia. The nurse's note dated 7/29/18 at 7:36 AM identified Resident #20 received [MEDICATION NAME] 5mg for complaints of pain to umbilical hernia. The nurse's note dated 7/30/18 identified Resident #20 was transferred to the hospital after he/she was noted to have a decline in condition. Resident #20's hernia wound had become very malodorous with increased drainage, and the resident was weaker and unable to care for him/herself. Review of an APRN progress note dated 7/30/18 identified Resident #20 was seen due to mal odorous smell from wound. Resident #20 was seen at the wound clinic last week with no new orders. Today Resident #20 complained of pain in the scrotal area, and green yellow drainage was oozing from the wound. The note identified that symptoms began 1 week ago. Local infection of the skin and subcutaneous tissue was identified and Resident #20 was sent to the emergency room for evaluation. Review of the (MONTH) (YEAR) TAR identified Resident #20 refused treatment to the umbilical hernia wound 7 out of 20 times from 7/11/18 through 7/30/18. Review of Resident #20's clinical record failed to identify that the physician and/or APRN was notified on 7/27/18 when the hernia wound was noted with copious amounts of yellow tinted drainage that soaked through 5 abdominal pads. Interview and review of the clinical record with LPN #1 on 8/3/18 at 9:50 AM identified that Resident #20 had an abdominal wound with a lot of slough that appeared like a honeycomb, with copious amount of yellow tinged drainage. Additionally, LPN #1 identified that he/she did not notify the physician and/or APRN of the copious amounts of yellow tinged drainage on 7/27/18. Interview with APRN #1 on 8/3/18 at 10:47 AM identified that he/she was not notified about the copious amounts of yellow tinted drainage on 7/27/18 that soaked through 5 abdominal pads. Review of facility change in condition in a resident status identified that the nurse supervisor and/or charge nurse will notify the resident's attending physician or on-call physician when there had been a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. The facility failed to notify the physician/APRN on 7/27/18 when Resident #20's hernia wound deteriorated and was observed with new copious amounts of yellow tinted drainage that had soaked through 5 abdominal pads.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #99) reviewed for change of condition, and/or for 1 resident (Resident #20) reviewed for skin conditions, and/or for 1 of 7 residents (Resident #94) reviewed for accidents, and/or for 1 of 5 residents (Resident #115), reviewed for unnecessary medications, and/or for 1 resident reviewed for specialized services (Resident #236) the facility failed ensure the residents highest practicable well-being when the facility failed to report a fracture to the physician/APRN, which led to a delay in appropriate treatment, and/or monitor a non-pressure skin condition and provide appropriate treatments, and/or complete neurological vital signs after unwitnessed falls, and/or failed to administer medication per physician order, and/or failed to ensure care and services were provided in accordance to professional standards. The findings included: 1. Resident #99's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #99 had severely impaired cognition, was independent with ADL's, and had no falls. The care plan dated 10/18/17 identified Resident #99 had the potential for falls, was at risk for behavioral issues, and had the potential for elopement. Nurses notes dated 12/21/17 indicated Resident #99 punched another resident in the neck, and when the other resident pushed Resident #99 away, Resident #99 fell and sustained a skin tear to the right elbow and complained of right shoulder pain. Examination identified complaints of pain of the right shoulder with limited range of motion and right elbow skin tear. Subsequent to APRN notification, x-rays of the right elbow/shoulder were ordered. Review of an x-ray report of the right shoulder dated 12/21/17 indicated no fracture or dislocation. Unremarkable right shoulder. Review of an x-ray report of the right elbow dated 12/21/17 identified a displaced [MEDICAL CONDITION]. Nurse's note dated 12/22/17 identified that Resident #99 was given Tylenol 650mg at 11:00 AM for complaints of right arm pain and the resident was encourage to rest the arm on a pillow while in bed. Review of an APRN note dated 12/22/17 identified Resident #99 had moderate, constant shoulder pain which radiates to the arm, and is aggravated by movement. The x-ray was negative for fracture, to start [MEDICATION NAME] to the right shoulder for 5 days. Review of a nurse's note dated 12/23/17 indicated that [MEDICAL CONDITION] and bruising persisted to the right arm, and Resident #99 had complaints of pain. Nurses note dated 12/25/17 identified Resident #99's right arm pain, bruising/swelling continues, and the resident was medicated for pain. A nurse's note and dated 12/27/17 identified Resident #99 had right lower arm/hand [MEDICAL CONDITION] with a moderate amount of discoloration. The arm was cool to touch, and staff were unable to palpate pulses. Subsequent to physician notification, Resident #99 was sent to the hospital for evaluation. Hospital documentation dated 12/27/17 identified Resident #99 had complaints of right elbow pain after an unwitnessed fall at the facility on 12/21/17. Resident #99 had and elbow x ray at the facility which was reportedly negative. Due to persistent swelling and bruising, the resident was sent for reevaluation. A right elbow x ray dated 12/27/17 identified an intra-articular and comminuted fracture (a break or splinter of the bone into more than two fragments) of the proximal ulna/olecranon. There is a complete [MEDICATION NAME] fracture through the olecranon with significant proximal displacement of the main proximal fracture prominent posterior fat pad. Resident #99 returned to the facility with a right upper extremity splint with recommendations that included elevation and non-weight bearing of the right upper extremity, and assistance with activities of daily living. Facility investigation conclusion, undated, identified on 12/21/17 Resident #99 was involved in a resident to resident altercation. On 12/22/17 the RN Supervisor, (RN #7) reported in morning report that the x ray completed was negative. On 12/27/17 Resident #99 was noted increased discoloration and [MEDICAL CONDITION] to the right hand. Subsequent to physician notification, Resident #99 was sent to the hospital. A hospital x ray identified a right olecranon fracture with significant displacement. Review of a statement by RN #7 dated 12/27/17 identified on 12/21/17 sometime after 9:45 PM he/she received Resident #99's right shoulder and right elbow x ray results. Later, between 10:00 PM - 11:00 PM he/she texted Resident #99's x ray results to an incorrect person. Although RN #7 indicated he/she did realize the mistake that night, he/she forgot to report the x ray results to the DNS due to overwhelming evening. Although facility documentation identified RN #7 notified the APRN about the right elbow fracture on 12/21/17, the documentation indicated that when the APRN was interviewed on 12/27/17, he/she was not aware a right elbow x ray had been ordered. Additionally, although RN #7 thought he/she had reported the x-ray results to the APRN via text on 12/21/17, he/she had sent the text to the admissions liaison in error. Review of facility documentation (morning report dated 12/22/17) indicated the x-ray for Resident #99 was negative. Review of the paper clinical record identified two hard copy results of the negative shoulder x ray, but the record lacked a hard copy of the right elbow x ray. Interview with the DNS on 8/3/18 at 10:00 AM indicated he/she was not employed at the facility on 12/21/17 and was not completely knowledgeable of the event. The DNS further indicated of the involved personnel, only the admission liaison and RN #7 were still employed at the facility. Interview with the Admission Liaison on 8/3/18 at 10:20 AM indicated he/she received the texts on 12/21/17, realized that the texts were not for him/her, and deleted them. Interview with RN #7 on 8/3/18 at 10:35 AM indicated he/she could not recall a (MONTH) (YEAR) event without reviewing the statements made, and was not available to review statements. Although requested, the facility does not have a policy specific to reporting of laboratory/radiologic reports. Review of the facility change of condition in a resident status policy indicates the facility shall promptly notify the resident, his/her attending physician and representative of changes in the resident's condition. The facility failed to ensure Resident #99's highest practicable well-being when they failed to report the residents elbow fracture on 12/21/17, which led to a delay in appropriate fracture treatment until 12/27/17, 6 days later, during which time, the resident experienced ongoing pain. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 5/4/18 identified Resident #20 had an abrasion to the right lower extremity. Interventions directed to observe the right lower leg abrasion for signs of infection and healing, and complete treatment as ordered by physician. The care plan dated 5/16/18 identified Resident #20 had abrasion to abdominal area. Interventions directed to observe the abdominal area for signs of healing and infection, to provide treatments as ordered, and to update physician with concerns and/or changes in condition. The care plan dated 6/18/18 identified Resident #20 was non-compliant and/or refused treatments at times. Interventions directed to encourage Resident #20 to follow his/her plan of care as directed by the physician. The quarterly MDS dated [DATE] identified Resident #20 had no cognitive impairment, and was independent with bed mobility, transfers, walking, dressing, and personal hygiene. Review of a weekly non-pressure ulcer record dated 6/28/18 identified Resident #20 had a facility acquired wound to the top of the abdominal hernia that measured 4.5cm by 6.8cm. A physician's orders [REDACTED]. Review of a wound consultation dated 7/19/18 identified Resident #20 had 2 open areas on his/her ventral hernia. One wound on the proximal surface measured 0.4cm by 0.4cm with a pink wound bed, no odor, drainage or induration. The second wound present distally, near the center of the hernia, measured 0.3cm by 0.3cm. The wound bed was 100% pink without odor, drainage, or induration. Recommendations included to continue silver [MEDICATION NAME] cream as ordered. Additionally, the consultation indicated Resident #20 also had a venous wound present on the lateral left lower extremity that measured 8.0cm by 4.5cm, with a wound bed that had yellow non-malodorous exudate present. The nurse's note dated 7/27/18 at 2:40 PM identified a large abdominal mass with copious amounts of yellow tinged drainage that had soaked through 5 abdominal pads. The nurse's note dated 7/30/18 at 3:13 PM identified that Resident #20 was transferred to emergency department at 2:10 PM due to increased mal odorous drainage from the hernia wound. The care plan dated 7/30/18 identified Resident #20 had an open area to left tibia. Interventions directed to observe the left leg area for signs and symptoms of healing and infection, and provide treatments as ordered. Review of an APRN progress note dated 7/30/18 identified Resident #20 was seen due to mal odorous smell from a wound. Resident #20 was seen at the wound clinic last week with no new orders. Today Resident #20 complained of pain in the scrotal area, and green yellow drainage was oozing from the wound. The note identified that symptoms began 1 week ago. Local infection of the skin and subcutaneous tissue was identified and Resident #20 was sent to the emergency room for evaluation. Review of Resident #20's clinical record failed to reflect the residents wounds were monitored weekly. Interview and review of the clinical record with RN #8 on 8/2/18 at 1:07 PM identified that wounds in the facility were monitored by the wound physician on weekly basis, and he/she was directed to stop documenting wound characteristics, and go by the wound physician's documentation. RN #8 was unaware of the facility policy regarding non-pressure wound documentation and/or monitoring. Interview and clinical record review with DNS on 8/3/18 at 12:45 PM identified that Resident #20 was last seen by wound physician on 5/17/18, over 2 months ago, and was no longer being followed because the resident frequently refused treatment. The facility failed to ensure Resident #20's highest practicable well-being when they failed to complete weekly wound monitoring of the residents wounds, and/or failed to notify the physician/APRN for 3 days between 7/27/18 - 7/30/18 when Resident #20's hernia wound deteriorated and was observed with new copious amounts of yellow tinted drainage that had soaked through 5 abdominal pads. 3. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial admission care plan dated 5/30/18 identified Resident #94 had a history of [REDACTED]. physician's orders [REDACTED].#94's be non-ambulatory, transfer with a mechanical lift with assistance of 2 staff, and half side rails up as enabler/for positioning. Medications included [MEDICATION NAME] 5,000 units subcutaneously every 8 hours. Review of the facility's reportable event documentation identified that Resident #94 had 6 falls since admission (5/30/18): The admission MDS dated [DATE] identified Resident #94 had severely impaired cognition and required total assistance of 2 staff with all activities of daily living. Facility documentation identified on 6/1/18 at 5:00 PM Resident #94 had an unwitnessed fall, and was found lying face down on floor with an abrasion to left side of frontal skull. The neurological evaluation flowsheet identified incomplete documentation with 4 of the 22 required assessments missing. Facility documentation identified on 6/7/18 at 3:40 PM identified Resident #94 was found on the floor by maintenance staff. The neurological evaluation flowsheet identified incomplete documentation with 7 of the 22 required assessments missing. Facility documentation identified on 6/8/18 at 5:45 PM Resident #94 was found by staff lying on floor on his/her right side. The neurological evaluation flowsheet identified incomplete documentation with 3 of the 22 required assessments missing. Facility documentation identified on 6/10/18 at 7:55 AM the Resident #99 was found lying on the mat on floor at side of his/her bed. The neurological evaluation flowsheet and/or post- accident and incident assessment form could not be found. Facility documentation identified on 7/14/18 at 5:55 AM staff found resident crawling on floor. resident sustained [REDACTED]. The neurological evaluation flowsheet identified incomplete documentation with 6 of the 22 required assessments missing. Facility documentation identified on 7/26/18 at 4:00 PM Resident #99 slipped out of wheelchair with no injury. The neurological evaluation flowsheet identified incomplete documentation with 7 of the 22 required assessments missing. Interview with the DNS on 8/3/18 at 8:45 AM identified that the charge nurses were responsible to complete the required neurological assessments and vital signs after an unwitnessed fall, or a fall with actual or suspected head injury. The DNS further identified it was his/her expectation that all nurses follow their fall policy, but could not explain why the neurologic assessments were not consistently done. Review of the facility's falls management policy identified that if the resident fall was unwitnessed, or if a head injury is suspected, neurological signs will be monitored. Review of the facility's neurological evaluation flowsheet identified that level of consciousness, pupil response, motor function, vital signs and observation are to be monitored every 15 minutes times 4, then every 30 minutes times 4, then every 2 hours times 4, then every 4 hours times 4, then ever shift times 6. 4. Resident #115 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The annual MDS dated [DATE] identified Resident #115 had intact cognition, and required total assistance with bed mobility, transfers and toilet use. The care plan dated 11/1/17 identified Resident #115 was at risk for socially inappropriate and/or disruptive behaviors such as yelling/screaming/crying and/or resistive to care. Interventions included to assess Resident #115's mood and affect regularly, provide psychiatry services as needed, administer medications as ordered by the physician and notify the physician of changes. Review of the (MONTH) (YEAR) MAR failed to reflect that [MEDICATION NAME] 50mg had been administered during the month of January, (YEAR). Review of a medication error report dated 1/17/18 identified that a transcription error had occurred, and Resident #115's order for [MEDICATION NAME] 50mg daily in the morning was discontinued in error during the (MONTH) (YEAR) kardex edit. Subsequently, Resident #115 did not receive the 9:00 AM scheduled dose of [MEDICATION NAME] 50mg during the month of (MONTH) (YEAR). Additionally, the report indicated the staff member who made the transcription error received education. Interview with LPN #4 on 8/3/18 2:56 PM identified the error had been brought to his/her attention. Interview with LPN #9 on 8/3/18 at 3:00 PM identified as he/she was reviewing the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's, he/she noticed that the [MEDICATION NAME] 50mg 9:00 AM dose was missing from the (MONTH) (YEAR) kardex. LPN #9 indicated the error must have occurred during Kardex flip night. 5. Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] identified Resident #236 was alert and oriented to person, place, time and situation, required assistance for care, had a stage I blister to left buttocks, regular respiratory rate without cough and clear breath sounds. a. An admission care plan dated 4/25/18 identified interventions that included, follow facility skin care protocol, preventive measures in place, reposition as needed, treatment as ordered and report any new areas and/or changes to the physician and/or nurse. Nurse's notes dated 5/1/18 at 2:37 PM identified Resident #236 left the facility via a stretcher at approximately 10:40 AM and prior to being sent out to hospital the resident was observed as having a red rash to the right flank and right elbow area. Rash was reported to the APRN, but Resident #236 was not seen because he/she was sent to the hospital. Interview and review of the clinical record with LPN #4 on 8/1/18 at 12:58 PM indicated he/she saw Resident #236's rash for the first time on 5/1/18 while he/she was being transferred to the hospital. LPN #4 further indicated although he/she reported the rash to the APRN, the nurse practitioner was unable to exam Resident #236 due to the hospital transfer. Interview with NA #1 on 8/1/18 at 1:50 PM indicated he/she recalls Resident #236 having some redness on the side of his/her body as well as in the area of ostomy site. NA #1 further indicated he/she noticed the change in the resident's skin on or about 4/27/18, and had reported it to the LPN #2. Interview and review of the clinical record with LPN #2 on 8/2/18 at 8:05 AM indicated he/she was made aware of the changes to the resident's skin, but felt the resident's skin was more pink than red at the time it was reported. LPN #2 further indicated although he/she reported Resident #236's skin changes to the nursing supervisor, RN #1, the clinical record failed to reflect that changes to the resident's skin had occurred, and/or been reported. Interview and review of the clinical record with RN #1 on 8/2/18 at 9:40 AM indicated he/she was unable to recall the resident and/or the events regarding Resident #236' skin changes. Interview and review of the clinical record on 8/3/18 at 11:35 AM with the DNS indicated the nurse should report a change in the resident's condition to the nursing supervisor, and/or the physician and document the information on the 24 hour shift report and/or in the APRN's book. Interview and review of the clinical record with the APRN on 8/2/18 at 2:27 PM indicated he/she was made aware of the Resident #236's rash as he/she was being transferred to the hospital on [DATE]. The facility failed to ensure Resident #236's highest practicable well-being when staff failed to report a red rash on the residents right flank and right elbow area which was noted on 4/27/18 until 4 days later on 5/1/18, which delayed assessment and interventions to address the rash. b. Review of the admission care plan dated 4/25/18 identified interventions that included vital signs as ordered, and observe for signs and symptoms of respiratory and/or cardiac distress. An APRN progress notes dated 4/26/18 identified Resident #236 had a new left basilar pneumonia, suspicious for aspiration. Although the APRN progress note dated 4/26/18 identified Resident #236 had a new left basilar pneumonia, suspicious for aspiration, the clinical record lacked documentation of ongoing respiratory assessments between 4/26/18 - 4/30/18. Interview and review of the clinical record with RN #2 and the acting DNS on 8/1/18 at 2:59 PM indicated that with a [DIAGNOSES REDACTED]. saturation. Nurse's notes dated 5/1/18 at 2:37 PM identified Resident #236 was noted with an oxygen saturation of 57% (>95% normal range) on room air, and was breathing through an opened mouth. Oxygen was applied at 15 liters via non-rebreather (mask) and the oxygen saturations increased to 67% - 88%. Although a nebulizer treatment was administered, and the oxygen saturation improved to 97%, it dropped down to 88%, and EMS was initiated. Resident #236 was transferred to the emergency room for evaluation at approximately 10:40 AM. According to Mosby's Clinical Nursing Series, Respiratory Disorders, an assessment of a person with aspiration pneumonia would include obtaining vital signs and a complete respiratory status assessment. Vital signs would be obtained to assess for fever, tachypnea, and [MEDICAL CONDITION] The facility failed to ensure Resident #236's highest practicable well-being when staff failed to document ongoing respiratory assessments between 4/26/18 - 4/30/18 after the APRN documented the resident had a new left basilar pneumonia, suspicious for aspiration. Subsequently, Resident #236 was sent to the hospital after he/she exhibited respiratory distress and his/her oxygen saturation dropped. c. An admission nursing assessment dated [DATE] identified Resident #236 was alert and oriented to person, place, time and situation, required assistance with care and had an [MEDICAL CONDITION]. Interviews with LPN #1 on 8/1/18 at 12:58 PM, LPN #3 on 8/1/18 at 1:08 PM and LPN #2 on 8/2/18 at 8:05 AM indicated Resident #236's [MEDICAL CONDITION] would repeatedly become loose and dislodged and would leak all over the place. Review of the clinical record failed to reflect documentation regarding the [MEDICAL CONDITION] malfunction and/or if Resident #236 voiced concerns related to the leaking [MEDICAL CONDITION] and/or interventions to address the concerns. According to Clinical Nursing Skills, 9th Edition, (YEAR), Complete and accurate charting is essential to protect both the patient and the nurse. Since charting describes nursing interventions and their outcomes, other healthcare personnel can determine if subsequent treatments should be changed. Frequently a patient's reaction time is nearly as important as the reaction is itself; therefore accuracy of time observations becomes an integral part of the charting process. The facility failed to ensure Resident #236's highest practicable well-being when staff failed to utilize the recommended ostomy supplies and did not address the ongoing leaking of the ostomy.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 7 residents (Resident #11 and 70) reviewed for accidents, the facility failed to provide adequate supervision to prevent an accident and/or ensure the resident's environment remained free from accident hazards and/or falls with head injury, and/or for 1 of 19 residents (Resident #5) reviewed for smoking, the facility failed to provide assistive devices to prevent avoidable accidents during smoking and/or for 1 of 2 residents (Resident #386) reviewed for mood and behavior, the facility failed to provide adequate monitoring when the resident exhibited significant aggressive behaviors. The findings include: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 3/9/18 directed to transfer Resident #11 with assistance of 2 staff. The quarterly MDS dated [DATE] identified Resident #11 had severely impaired cognition, required total assistance with transfers and had no falls. The care plan dated 4/24/18 identified Resident #11 was at risk for falls related to impaired mobility and decreased safety awareness due to the stroke. Interventions directed to ambulate Resident #11 with a rolling walker and assistance of 2 staff. A nurse's note dated 7/29/18 at 12:44 PM identified Resident #11 was observed by staff with a golf ball size hematoma (a solid swelling of clotted blood within the tissues) over the left eye. Resident #11 stated he/she fell in the bathroom, hit his/her head, and got back to bed without the assistance of staff. Subsequent to physician notification, Resident #11 was sent to the emergency room for an evaluation. A reportable event form dated 7/29/18 at 12:50 PM identified Resident #11 was noted with a golf ball size hematoma above left eye. Review of a statement by LPN #10 dated 7/29/18 identified he/she administered medications and had a conversation with Resident #11 the morning of 7/29/18 while the resident was in bed, and at no time did the resident have any swelling on his/her face or lips. LPN #10 indicated the next time he/she saw Resident #11 was when he/she was called to the room after NA #11 had provided care and Resident #11 was up in the recliner chair. LPN #10 indicated at that time, Resident #11 was observed with a golf ball sized hematoma above the left eye and swelling to the lips with a scant amount of blood noted. Review of a statement by NA #11 dated 7/30/18 identified he/she brought Resident #11 his/her breakfast tray the morning of 7/29/18 and did not notice anything. Later, he/she transferred Resident #11 via stand pivot into the chair then onto the toilet. NA #11 identified he/she lifted Resident #11's face to wash it, and noticed a big knot on the forehead. A nurse's note dated 7/29/18 at 1:41 PM identified Resident #11 also had a swollen bottom lip with a scant amount of blood noted. The care plan dated 7/29/18 identified Resident #11 was noted with a hematoma over the left eye related to a fall. Interventions directed to transport Resident #11 to the emergency room for evaluation, observe the hematoma for signs of redness, swelling, pain/discomfort, and offer pain medication as needed. Facility documentation dated 8/1/18 identified NA #11 transferred Resident #11 with 1 staff member, however, the plan of care indicated the resident required 2, which caused the injury to the resident. Interview with the DNS on 8/2/18 at 11:17 AM identified NA #11 did not follow Resident #11's plan of care and transferred the resident without the assistance of 2 staff. The DNS indicated although Resident #11 reported he/she had fallen and gotten him/herself up, the resident has cognitive impairment, and would not be able to get up off the floor alone. The DNS indicated he/she does not believe Resident #11 fell because NA #11 would not be able to get Resident #11 off the floor alone. The DNS indicated he/she thinks something happened during the transfer with NA #11, and Resident #11 must have bumped his/her face and caused the hematoma. Interview with NA #11 on 8/2/18 3:13 PM identified he/she really does not know exactly how Resident #11 got the bump. NA #11 indicated when he/she went to wash the residents face around 11:00 AM, he/she noticed the lump on the head. At that time, NA #11 indicated they were in the bathroom, and he/she put the resident into the recliner and went to get the nurse. NA #11 reported to the nurse that Resident #11 stated he/she had fallen. NA #11 identified he/she did not have the nurse aide care card with him/her and did transfer the resident via stand pivot alone, because he/she thought the resident required only assistance of 1 staff. After NA #11 reviewed the care card, he/she noticed it directed Resident #11 to be assistance of 2 for transfers. Additionally, NA #11 indicated he/she did not use a gait belt during the transfer. The facility failed to ensure Resident #11 was transferred according to the plan of care, which led to the resident sustaining a golf ball sized hematoma above the left eye, and swelling to the lips. Additionally, Resident #11 required evaluation at the hospital. 2. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #70 had severely impaired cognition, required limited assistance with dressing and personal hygiene and was independent with eating. The care plan dated 6/6/18 identified Resident #70 included interventions to provide assistance with care as needed. Observation on 7/30/18 at 8:55 AM identified RN #4 removed a blue plastic disposable razor from Resident #70's nightstand drawer. Interview with LPN #6 on 8/1/18 at 1:45 PM noted that disposable razors are not to be kept in resident rooms. Interview with RN #4 on 8/2/18 at 11:45 AM noted RN #4 had removed a razor from Resident #70's nightstand. Review of the facility policy for shaving a patient identified that the razor is to be disposed of in a sharps container outside of resident's room. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/31/18 identified Resident #5 needed supervised smoking. Interventions directed to keep cigarettes and lighting material with the nursing staff, staff in-serviced on plan of care, and to remind resident about 1:1 basis of smoking policy. The smoking safety screen assessment dated [DATE] directed to provide Resident #5 with a smoking apron and supervision. The annual MDS dated [DATE] identified Resident #5 had intact cognition, required limited assistance with toileting and bed mobility, was independent with transfers, locomotion on unit, and eating. Observation on 7/30/18 9:45 AM during group smoking time identified Resident #5 seated in wheelchair, cigarette handed to resident by NA #5, and lit by NA #6. Resident #5 was observed without the benefit of a smoking apron for 8 minutes. At 9:53 AM, NA #5 reviewed a care card and placed a smoking apron on Resident #5. Resident #5 was noted to have closed eyes. Interview with NA #5 on 7/30/18 at 9:45 AM identified Resident #5 should have had the smoking apron put on at the beginning of smoking. NA #5 identified he/she was not aware that the Resident #5 needed the apron until after he/she checked the care card. NA #5 identified the reason for the apron was due to the fact that Resident #5 falls asleep while smoking. Review of facility smoking policy identified any need for assistive devices to safely allow residents to smoke will be noted on the assessment and utilized during smoking times. Smoking care plans will be individualized for each resident. 4. Resident #386 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified Resident #386's had severely impaired cognition and was independent with transfers and walking. Additionally, the MDS identified Resident #386 had difficulty with focusing attention, was easily distractible most of the time, presence of fluctuating disorganized thinking, daily occurrence of other behavior symptoms not directed toward others, and received antipsychotic, antidepressant and antianxiety medications daily. A care plan dated 6/15/18 identified Resident #386 had impaired cognition due to dementia with the presence of behavior symptoms i.e., aggression, wandering and rummaging into other residents' rooms. Interventions included to administer medications as ordered, social service to provide supportive services as needed, use simple direct communication and verbal cues, psychiatry consult as needed, redirect and re-orient as needed and 1:1 monitoring as needed. Observation on 8/3/18 at 11:30 AM identified Resident #386 was in his/her room walking towards the bathroom in a slow but steady gait, partly stooped but could straighten self. Review of the clinical record identified that on 6/7/18 at 11:56 PM Resident #386 was observed going into other residents' rooms, pulling linens on vacant beds, and was hard to re-direct. Resident #386 then went into another resident's room and refused to leave. A second dose of [MEDICATION NAME] 1 mg was given without effect. Resident #386 was sent to the emergency room for evaluation, and returned via stretcher to the facility on [DATE] with no new orders. Nurse's note dated 6/11/18 identified Resident #386 required redirection because he/she continued to wander into other residents' rooms. Resident #386 was easily agitated and anxious at times, noted with visual hallucinations. Resident #386 was redirected and [MEDICATION NAME] 1mg administered. Nurse's note dated 6/12/18 identified Resident #386 continued to have auditory and visual hallucinations. Resident #386 continued to enter other residents' rooms. A nurses note dated 6/13/18 at 12:10 PM identified a call was placed to the psychiatrist for an onsite evaluation and necessity of a Physician Emergency Certificate (PEC) due to intermittent aggressive behavior and breaking roommates television. A nurse's note dated 6/13/18 at 3:29 PM identified Resident #386 required constant redirection out of other residents' rooms. No physical aggression noted. A nurse's note dated 6/13/18 at 4:45 PM identified Resident #386 broke the toilet tank top in the bathroom and sustained a small laceration on the left 4th digit. An assessment identified Resident #386 was labile, impulsive, disorganized, confused, disoriented and paranoid. The plan was to monitor, redirect and offer as needed medication. A nurse's note dated 6/14/18 at 10:51 AM identified Resident #386 was placed on a 1:1 observation due to concerns verbalized by other residents regarding his/her behavior. The note indicated the psychiatrist would be in today to evaluate for PEC. A nurse's note dated 6/15/18 at 11:26 AM identified that upon a safety check, Resident #386 had wandered into the room of a female resident, was standing over her bed removing her covers. The note indicated Resident #386 was placed on 1:1 observation. The record indicated that Resident #386 was sent to the hospital for a psychiatric evaluation on 6/15/18 at 11:55 AM. Hospital discharge summary dated 6/19/18 identified that Resident #386 was also sent to the hospital prior for similar problems and had an uneventful 3 day stay. The discharge summary further identified that Resident #386 was initially aggressive and paranoid but by day 4 was becoming cooperative but continued to be confused. Recommendations included to initiate [MEDICATION NAME] 5mg twice a day as needed for agitation, continue previous [MEDICATION NAME] orders, [MEDICATION NAME] 6mg at hour of sleep, and follow up with psychiatric services post discharge. Nurse's noted dated 6/23/18 identified that another resident reported that Resident #386 gave him/her a black eye. Resident #386 denied any altercation/aggression towards any other resident, and a 1:1 was initiated. Nurse's noted dated 6/24/18 identified that Resident #386 appeared to be talking and yelling to him/herself, trying to pick up items from the floor that were not there, undressed self and crawled on the floor. Resident #386 punched a nurse aide while he/she was attempting to redirect him/her. Subsequent to physician notification, Resident #386 was sent to the emergency room for evaluation. A nurse's note dated 6/24/18 identified Resident #386 was sent to the hospital for evaluation. The hospital discharge summary dated 7/6/18 identified Trazadone 50mg in the morning was added to decrease Resident #386's irritability related to confusion, and Trazadone 50mg at hour of sleep was added also to help with sleep. In addition, the discharge summary identified Resident #386 would be discharged to a different nursing facility with additional recommendations for psychiatry to evaluate upon return/admission to skilled nursing facility. Nurse's noted dated 7/8/18 identified Resident #386 was observed holding the roommate's right hand, and attempting to hit the roommate. The residents were separated and Resident #386 became verbally aggressive and physically threatening to the staff. The police and emergency medical personnel were called and brought Resident #386 to the emergency room for evaluation. Resident #386 re admitted on [DATE], however, the discharge summary was unavailable for review. Review of a psychological note dated 7/19/18 identified Resident #386 continued to be agitated and restless. Review of the clinical record however failed to reflect that an assessment/consultation was conducted by the Psychiatric APRN. Nurse's noted dated 7/24/18 identified Resident #386 had an unwitnessed altercation with his/her roommate. Resident #386 was observed standing over the roommate with a metal rod in his/her hand while the roommate was on the floor. The residents were separated and Resident #386 was sent to the emergency room at the direction of the physician. Interview with the DNS on 8/3/18 at 3:00 PM indicated the discharge plan to another facility fell through because of an unavailability of a potential beds. Resident #386 was readmitted back to the facility Clinical record review and interview with the Director of Social Services on 8/3/18 at 12:07 PM identified that psychological note dated 7/18/18 identified Resident 386 was delusional, agitated, pacing and irritable with recommendations to refer to the APRN for medication review and to teach deep breathing. Although the hospital discharge summary dated 7/6/18 recommended to obtain a psychiatric consultation upon readmission to the facility, review of the clinical record failed to reflect Resident #386 had been seen by the psychiatrist/psychiatric APRN since 6/23/18. Interview with the Director of Social Service, (DSS) on 8/3/18 at 12:07 PM indicated that although he/she read the recommendations after each visit, he/she could not explain why the psychiatric APRN has not evaluated Resident #386 after readmission and according to recommendations. The Director of Social Service further identified that the facility was unable to meet Resident #386's needs, however, review of the clinical record failed to provide documentation that discharge planning had been initiated other than a referral note on 7/18/18 at the request of a family member. Review of the Social Worker's general job description identified that the social worker will work with residents by identifying their psychosocial, mental and emotional needs along with providing developing, and/or aiding in the access of those services to meet those needs. Although on 6/14/18 at 10:51 AM Resident #386 was placed on a 1:1 observation due to other residents' concerns related to his/her behaviors, the facility failed to ensure adequate supervision when Resident #386 was found in a female resident's room standing over her bed and removing her covers. Although Resident #386 exhibited significant behaviors, including aggression and altercations with other residents, the facility failed to ensure adequate supervision on 7/24/18 when Resident #386 had an unwitnessed altercation with his/her roommate, and was observed standing over the roommate, (who was on the floor), with a metal rod in his/her hand.

Based on clinical record reviews, facility documentation and interviews for three of four sampled residents (Residents #17, #80, and #187) who were reviewed for wound care, the facility neglected to implement physician's orders [REDACTED]. The findings include: 1. Resident #17's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessments dated [DATE] and [DATE] identified severe cognitive impairment, non-ambulatory, limited assistance with bed mobility, total dependence on staff for personal hygiene and transfers, and without pressure, vascular and/or arterial ulcers. The Resident Care Plan (RCP) dated [DATE] identified a potential for skin integrity related to impaired mobility and diabetes. An interim care plan dated [DATE] identified the resident was noted with an area of dry eschar to the left great toe. Interventions included, report changes and/or concerns to the physician, to float the heels, incontinent care every two hours, treatment to left great toe area as ordered, and observe for signs of healing and signs of infection. Review of the Braden Scale identified on [DATE] the resident was a mild risk for the development of pressure ulcers. The nurse's note dated [DATE] at 2:40pm identified that an area of eschar was noted to the left great toe measuring 1.1 centimeter (cm) by 1.2 cm, a treatment was in place, and the physician was updated. A physician's orders [REDACTED]. Review of the July and [DATE] Treatment Administration Record (TAR) identified skin prep was applied to the resident's left lateral great toe until [DATE]. Review of the nurse's notes failed to reflect documentation of a re-evaluation assessment on [DATE] (when the treatment stopped) of the resident's left great toe. Review of nurse's notes dated from [DATE] (date when area first identified through [DATE]) identified only one entry on [DATE] at 3:00pm noting the treatment to the left great toe continued. The nurse's note dated [DATE] at 6:05pm identified the left great toe had an open area measuring 0.5 cm, was hardened and skin black in color. The note further identified that the area was first discovered on [DATE]. The Advanced Practice Registered Nurse (APRN) was notified and a treatment ordered to cleanse the left great toe with Normal Saline followed by Triple Antibiotic Ointment (TAO) twice a day, cover with a dry clean dressing and re-evaluate in 1 week. Additionally a podiatry consult was ordered and for the infection control nurse to evaluate the wound. Review of the weekly shower/weight sheets from check completed and documented. Review of the treatment kardex for [DATE] lacked documentation that the body audit was completed on [DATE]. Review of the clinical record and the facility weekly wound sheets from [DATE] until [DATE] failed to reflect documentation that the left great toe was monitored weekly. Although the [DATE] treatment kardex on [DATE], [DATE] and [DATE] identified negative for open areas, the clinical record lacked documentation that the left great toe's eschar was gone. Review of the clinical record identified on [DATE] the Wound APRN conducted an initial visit regarding the left great toe. The note identified a gangrene wound located on the left great toe. The size measured 1.5 cm by 0.2 cm, 100% of the wound bed had slough tissue, moderate amount of serosanguineous drainage and a mild odor. Additionally, the note identified the entire toe was dusky black in color and between the great toe and second toe a slit was noted. A physician's orders [REDACTED]. The orders directed to obtain a wound culture prior to the next dressing change and a podiatry consult. Review of the laboratory data dated [DATE] (six days after the physician's orders [REDACTED]. Review of the podiatry consult dated [DATE] identified the resident had long nails, nothing indicated on the picture of the left foot and noted the left foot was completely covered. Interview with Corporate Nurse #1 on [DATE] at 1:20pm identified that she spoke to the podiatrist's office and was told the podiatrist never removed the dressing to the left foot so he did not examine and/or assess the resident's foot. The nurse's note dated [DATE] at 12:30pm identified during the dressing change of the left great toe about 50 or more maggots were noted in the wound and on the dressing. Maggots were noted coming out of the resident's skin. The APRN was notified and the resident was transferred to the hospital. Review of the patient information sheet from the hospital dated [DATE] at 3:43pm identified the resident was admitted with a gangrenous left great toe with chronic wound, drainage and maggots. The resident's toe was amputated on [DATE]. Interview with the former wound nurse, Licensed Practical Nurse (LPN) # 1 on [DATE] at 11:15am identified that she knew at some point the resident had a scab or something on his/her toe but was unaware Resident #17 had any eschar area to the left great toe in July. LPN #1 stated that the nurses are to report any skin issues onto the 24 hour report sheets and wounds are discussed in morning report. LPN #1 further stated she must not have been at morning report when Resident #17's wound was discussed and she does not review the 24 hour report sheets if she misses morning report but hopes that staff would tell her of any new wounds. Interview with the Director of Nursing (DON) on [DATE] at 3:00pm identified that all wounds are to measured and assessed weekly, and when the treatment was expired or there was a change in the wound they were to be re-evaluated by the wound nurse. The DON stated the wound nurse was responsible to know when a treatment ends to ensure the re-evaluation was completed and determine if the wound had healed or a treatment needed to continue. Review of Resident #17's clinical record with the DON failed to identify the wound was assessed weekly from [DATE] through [DATE] and failed to reflect when the treatment ended on [DATE] that the wound had been re-evaluated. 2. Resident #80 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severe cognitive impairments and required extensive assistance of two for bed mobility and transfers. A nursing admission assessment dated [DATE] identified right foot gangrene and the resident was at high risk for skin breakdown. A physician's orders [REDACTED]. Review of the clinical record failed to identify documented skin assessments between [DATE] and [DATE]. A nurse's note dated [DATE] at 3:30 PM identified a right foot necrotic area with foul odor and redness around peri-wound, the area was warm to touch, and the supervisor and infection control nurse were updated. Review of the APRN #1 wound assessment note dated [DATE] identified dry gangrene of the right fore foot from distal phalanges to approximately mid-metatarsals, also including the heel and a small area of wetness between second toe and third toe with a mild odor. A subsequent wound assessment note by LPN # 2 dated [DATE] identified gangrene to the right foot with measurements: right dorsal 15cm x 7.5cm, right heel 5.0cm x 4.0cm and right plantar 12.0cm x 5.5cm. In an interview and clinical record review on [DATE] at 2:00 PM, the ADNS was unable to provide documentation that skin and/or wound assessments of the right foot gangrene were checked every shift for the months of August and [DATE]. The ADNS identified that he/she assisted with Resident #80's admission on [DATE], that the resident was known to him/her, and the right foot gangrene was a chronic condition that had been identified previously, therefore he/she did not do any measurements or document the characteristics of the area. Interview on [DATE] at 2:45 PM with the DNS identified a nursing assessment upon admission should include a full skin/body assessment of the resident, any findings should be document, the physician should be notified, and any physician order [REDACTED]. 3. Resident #187's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified severe cognitive impairment, total dependence on staff for activities of daily living, incontinent of bowel and bladder, and at risk for developing pressure ulcers. The RCP dated [DATE] identified potential for alteration in skin integrity related to impaired mobility with left sided paralysis. Interventions included side rails up in bed to enable turning and repositioning, out of bed to wheelchair four hours a day, and record and report changes to physician. An interim RCP dated [DATE] identified impaired skin integrity to the left buttocks area. Interventions included treatment as ordered, monitor wound for infection and/ or deterioration, monitor and document wound condition weekly, keep the physician updated, bedrest for one week, turn and reposition off back. A physician's orders [REDACTED]. The Braden scale assessment dated [DATE] identified the resident at mild risk for pressure sore development. Review of the clinical record with Corporate Nurse #2 on [DATE] at 10:00 am indicated that the weekly body audits were signed for as being completed for March and [DATE], however the clinical record lacked documentation of what the assessment identified. The nurse's note dated [DATE] at 11:45pm identified a new order for treatment to left buttocks was conducted and the supervisor was aware. The record lacked documentation of an assessment at that time. A physician's orders [REDACTED]. Review of the Non Pressure Ulcer Skin Condition Record dated [DATE] (date of onset [DATE]) identified a full thickness wound caused by trauma and measuring 12.5cm by 13 cm with serosanguineous drainage. Review of the APRN ' s progress note dated [DATE] identified the resident was evaluated for a new wound on the buttocks. The note identified the wound measured 12.5cm by 13cm, predominately the left buttocks but crosses over to the right side, 85% dark purple, 15% red superficial, a scant amount of serosanguineous drainage, no odor but pain with dressing change. Wound documentation dated [DATE] identified the wounds measured 10cm by 12.5cm, a moderate amount of sanguineous drainage, and the wound bed was 90% necrotic, no odor and to continue with current treatment. The APRN progress note dated [DATE] identified the buttocks wound measured 10cm by 12.5cm, 90% eschar, 10% red, moderate amount of sanguineous drainage, without odor. The wound was discussed with the physician and the bulky Xeroform dressing was continued to prevent sheering when repositioning the resident. The nurse's note dated [DATE] at 11:00pm identified a dressing change was done to the buttocks wound, a foul odor was noted with serosanguineous drainage. The clinical record and 24 hour report sheets lacked documentation that the Supervisor and/or the physician were made aware of the foul odor. The nurse's note dated [DATE] at 4:00pm identified foul odor from wound, MD made aware, continue to monitor. The nurse's note dated [DATE] at 11:00pm identified the foul odor with drainage continued. The nurse's note dated [DATE] at 12:00pm identified the wound was noted to be caving in, and small open area noted around wound area. The Supervisor was made aware, and the physician ordered for the resident to be seen by the plastic surgeon. The nurse's note dated [DATE] at 11:00pm noted the wound treatment to the buttocks was done and a foul smelling odor was noted. The nurse's notes dated [DATE] at 2:00pm identified the treatment was to be evaluated today, the Supervisor aware and stated to continue with current treatment until seen by the wound nurse. Further review of the nurse's notes lacked documentation of an assessment of the resident ' s wound, drainage, pain and/or odor until [DATE] when the resident was seen by the APRN Wound Nurse. The wound documentation dated [DATE] identified the wound measured 10cm by 12.5cm, a heavy amount of brown drainage, the wound bed with slough, granulation and necrotic, odor and the resident having pain. The APRN's progress note dated [DATE] identified the resident was seen related to worsening of the buttocks wound. The assessment noted increased wound odor, increased pain, 70% eschar, 20% yellow lifting slough and 10% red, and heavy brown drainage. The note further identified worsening wound with infection, concern [MEDICAL CONDITION]. The resident was sent to the hospital for an evaluation and Debridement of the wound. Interview with LPN #1 on [DATE] at 10:45am identified that when the wound was identified on Resident #187's buttocks a complete assessment should have been done. LPN #1 stated that she was made aware of the resident's wound with the foul odor and brown drainage when she did the dressing change on [DATE]. LPN #1 further stated that when the foul odor started (on [DATE]) she should have been made aware and nursing should have been documenting on the wound with each dressing change to see if any change has occurred to report to the physician. Additionally, LPN #1 stated that after Resident #187 was identified with the pressure wound a facility investigation was conducted related how he/she developed the wound and it was noted that residents with low air loss mattresses had extra pads and briefs under them which took away from the effects of the mattress. Interview with the DON on [DATE] at 3:00pm identified that when Resident #187's wound was first noted on [DATE] a full assessment should have been completed and documented in the clinical record. The DON stated that when the resident had a change in the wound (foul odor) the physician was to be notified at that time and the nurse was to document in the clinical record their assessment. The DON further stated that after Resident #187 developed the pressure ulcer a facility audit was conducted of those residents at risk for the development of wounds and during the audit an observation of Resident #187 identified two cloth pads and an incontinent brief were noted between the resident and the low air loss mattress. The DON stated that the extra pads under the resident defeated the purpose of the low air mattress causing shearing and friction during personal care and repositioning which can lead to skin breakdown. Interview with the DON on [DATE] at 3:00pm and review of Residents #17, #80, and #187's clinical record identified that that assessments, monitoring of residents wounds, and implementing interventions to avoid pressure and/or vascular ulcers were not completed according to facility policy. The DON further stated that when a resident does have a wound weekly monitoring is to be completed and when a change is noted the physician is to be updated and documented in the clinical record.

A Based on clinical record review, facility documentation and interviews for three of three sampled residents (Resident #17, #80 and #103) reviewed for wound care, the facility failed to ensure weekly monitoring of wounds and/ or ensure interventions were in place to prevent deterioration and/ or the development of wounds which resulted in immediate jeopardy. The findings include: 1. Resident #17's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessments dated [DATE] and [DATE] identified severe cognitive impairment, non-ambulatory, limited assistance with bed mobility, total dependence on staff for personal hygiene and transfers, and without pressure, vascular and/or arterial ulcers. The Resident Care Plan (RCP) dated [DATE] identified a potential for skin integrity related to impaired mobility and diabetes. An interim care plan dated [DATE] identified the resident was noted with an area of dry eschar to the left great toe. Interventions included, report changes and/or concerns to the physician, to float the heels, incontinent care every two hours, treatment to left great toe area as ordered, and observe for signs of healing and signs of infection. Review of the Braden Scale identified on [DATE] the resident was a mild risk for the development of pressure ulcers. The nurse's note dated [DATE] at 2:40pm identified that an area of eschar was noted to the left great toe measuring 1.1 centimeter (cm) by 1.2 cm, a treatment was in place, and the physician was updated. A physician's orders [REDACTED]. Review of the July and [DATE] Treatment Administration Record (TAR) identified skin prep was applied to the resident's left lateral great toe until [DATE]. Review of the nurse's notes failed to reflect documentation of a re-evaluation assessment on [DATE] (when the treatment stopped) of the resident's left great toe. Review of nurse's notes dated from [DATE] (date when area first identified through [DATE]) identified only one entry on [DATE] at 3:00pm noting the treatment to the left great toe continued. The nurse's note dated [DATE] at 6:05pm identified the left great toe had an open area measuring 0.5 cm, was hardened and skin black in color. The note further identified that the area was first discovered on [DATE]. The Advanced Practice Registered Nurse (APRN) was notified and a treatment ordered to cleanse the left great toe with Normal Saline followed by Triple Antibiotic Ointment (TAO) twice a day, cover with a dry clean dressing and re-evaluate in 1 week. Additionally a podiatry consult was ordered and for the infection control nurse to evaluate the wound. Review of the weekly shower/weight sheets from check completed and documented. Review of the treatment kardex for [DATE] lacked documentation that the body audit was completed on [DATE]. Review of the clinical record and the facility weekly wound sheets from [DATE] until [DATE] failed to reflect documentation that the left great toe was monitored weekly. Although the [DATE] treatment kardex on [DATE], [DATE] and [DATE] identified negative for open areas, the clinical record lacked documentation that the left great toe's eschar was gone. Review of the clinical record identified on [DATE] the Wound APRN conducted an initial visit regarding the left great toe. The note identified a gangrene wound located on the left great toe. The size measured 1.5 cm by 0.2 cm, 100% of the wound bed had slough tissue, moderate amount of serosanguineous drainage and a mild odor. Additionally, the note identified the entire toe was dusky black in color and between the great toe and second toe a slit was noted. A physician's orders [REDACTED]. The orders directed to obtain a wound culture prior to the next dressing change and a podiatry consult. Review of the laboratory data dated [DATE] (six days after the physician's orders [REDACTED]. Review of the podiatry consult dated [DATE] identified the resident had long nails, nothing indicated on the picture of the left foot and noted the left foot was completely covered. Interview with Corporate Nurse #1 on [DATE] at 1:20pm identified that she spoke to the podiatrist ' s office and was told the podiatrist never removed the dressing to the left foot so he did not examine and/or assess the resident's foot. The nurse's note dated [DATE] at 12:30pm identified during the dressing change of the left great toe about 50 or more maggots were noted in the wound and on the dressing. Maggots were noted coming out of the resident's skin. The APRN was notified and the resident was transferred to the hospital. Review of the patient information sheet from the hospital dated [DATE] at 3:43pm identified the resident was admitted with a gangrenous left great toe with chronic wound, drainage and maggots. The resident's toe was amputated on [DATE]. Interview with the former wound nurse, Licensed Practical Nurse (LPN) # 1 on [DATE] at 11:15am identified that she knew at some point the resident had a scab or something on his/her toe but was unaware Resident #17 had any eschar area to the left great toe in July. LPN #1 stated that the nurses are to report any skin issues onto the 24 hour report sheets and wounds are discussed in morning report. LPN #1 further stated she must not have been at morning report when Resident #17's wound was discussed and she does not review the 24 hour report sheets if she misses morning report but hopes that staff would tell her of any new wounds. Interview with the Director of Nursing (DON) on [DATE] at 3:00pm identified that all wounds are to measured and assessed weekly, and when the treatment was expired or there was a change in the wound they were to be re-evaluated by the wound nurse. The DON stated the wound nurse was responsible to know when a treatment ends to ensure the re-evaluation was completed and determine if the wound had healed or a treatment needed to continue. Review of Resident #17's clinical record with the DON failed to identify the wound was assessed weekly from [DATE] through [DATE] and failed to reflect when the treatment ended on [DATE] that the wound had been re-evaluated. 2. Resident #80 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's last quarterly Minimum (MDS) data set [DATE] identified that the resident had severe cognitive impairment and required extensive assistance of two for bed mobility and transfers. A nursing admission assessment dated [DATE] identified right foot gangrene and the resident was at high risk for skin breakdown. A physician's orders [REDACTED]. Review of the clinical record failed to identify documented skin assessments between [DATE] and [DATE]. A nurse's note dated [DATE] at 3:30 PM identified a right foot necrotic area with foul odor and redness around peri-wound, the area was warm to touch, and the supervisor and infection control nurse were updated. Review of the APRN # 1 wound assessment note dated [DATE] identified dry gangrene of the right fore foot from distal phalanges to approximately mid-metatarsals, also including the heel and a small area of wetness between second toe and third toe with a mild odor. A subsequent wound assessment note by the APRN #1 dated [DATE] identified gangrene to the right foot with measurements: right dorsal 15cm x 7.5cm, right heel 5.0cm x 4.0cm and right plantar 12.0x5.5cm. In an interview and clinical record review on [DATE] at 2:00 PM, the ADNS was unable to provide documentation that skin and/or wound assessments of the right foot gangrene were checked every shift for the months of August and [DATE]. The ADNS identified that he/she assisted with Resident #80's admission on [DATE], that the resident was known to him/her, and the right foot gangrene was a chronic condition that had been identified previously, therefore he/she did not do any measurements or document the characteristics of the area. Interview on [DATE] at 2:45 PM with the DNS identified a nursing assessment upon admission should include a full skin/body assessment of the resident, any findings should be document, the physician should be notified, and any physician order [REDACTED]. 3. Resident #103's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified severe cognitive impairment, total dependence on staff for bed mobility, transfers, personal hygiene, requiring a tube feed and at risk for developing pressure ulcers. The RCP dated [DATE] identified potential for alteration in skin integrity. Interventions directed to off load the heels. The Braden scale dated [DATE] identified the resident at high risk for skin breakdown. The nurse's note dated [DATE] identified a suspected deep tissue injury to the right heel. The clinical record failed to reflect documentation that an assessment of the area had been conducted. A physician's orders [REDACTED]. The Wound APRN Progress note dated [DATE] identified the resident was seen for a new deep tissue injury to the right heel. The area presented as flat stained area where blister likely was, fully reabsorbed and continue with skin prep. Review of the weekly wound sheet dated [DATE] identified a 2.0cm by 0.2cm facility acquired deep tissue injury. The weekly wound sheet dated [DATE] identified the area measuring 1.7 cm by 1.5cm, appearing as a hollow circle with dark discoloration on one half, foam heel lift boots ordered. Review of the [DATE] Treatment Administration Record (TAR) identified the resident's heels were floated while in bed. Further review noted the [DATE] TAR failed to reflect documentation to elevate the heels. Although the August, September and [DATE] TAR identified to apply a blue boot to the left foot for protection every shift, the TAR failed to reflect documentation to off load heels. Interview with LPN #2 on [DATE] at 1:30pm stated that the facility switched pharmacies in July and the order to off load heels while in bed did not get transferred over to the new order sheets. LPN #2 further stated that it did not get picked up on the monthly kardex audits either. Review of the clinical record at that time with LPN #2 failed to identify interventions in place to off load heels from [DATE] through [DATE] when the deep tissue injury was identified. Further review noted that when the deep tissue was identified foam heel lifts boots and a low air loss mattress was put into place. Interview with the DON on [DATE] at 2:00pm stated that the nurses should be checking the previous month's orders with the new order sheets to ensure all orders are transferred over to the next month. B. Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents ( Resident # 15) who utilized an anti-anxiety medication ( Resident # 15), the facility failed follow the resident's plan of care and /or for one sampled resident reviewed for altered respiratory status ( Resident # 59), the facility failed to ensure the resident received the necessary care and services regarding the resident's concerns of difficulty breathing and/or the decrease in his/her oxygen saturation level. The findings include: 1. Resident #15's [DIAGNOSES REDACTED]. A quarterly (MDS) minimum data assessment dated [DATE] identified moderate cognitive impairment (a BIMS score of 8) and limited assistance with most ADLs. The care plan dated [DATE] identified Resident #15 exhibits and/or at risk for distressed mood symptoms. Interventions included medication as ordered, monitor for changes in mood in behavior and report. Review of the laboratory refill order form identified Resident #15's [MEDICATION NAME] had been ordered on [DATE] (the sticker on medication card placed on order form) at 10AM. Review of a nurse's note dated [DATE] identified [MEDICATION NAME] was not available, the supervisor was made aware and the pharmacy had been contacted. At that time, the pharmacy informed the facility that a prescription script was required by the physician to refill the medication. The nurse's note identified the physician was to be updated. A physician order [REDACTED]. The physician orders [REDACTED]. Review of the Medication Administration Record (MAR) for the month of October noted on [DATE] the 9 am and 5pm dosages were circled and written N/A. On [DATE] the 9 am and 5pm dosages were signed as given, on [DATE] the 9 am dosage was circled and in place of the 5pm dosage initial, hold was written in. Interview and review of the clinical record, MAR and facility documentation (including the medication refill order form) with LPN #9 on [DATE] at 12:30pm identified he/ she had been instructed by the RN supervisor to borrow the medication from Resident # 46. Further stating the RN supervisor had informed LPN #9 to relay the message to the evening nurse that she/he should borrow the evening dosage until the medication was received from the pharmacy. Attempts to contact RN #2 were unsuccessful. A follow up interview with LPN # 9 on [DATE] at 1pm identified usual practice is not to borrow medications. However she/he did so because R #15's needed his/her scheduled anti-anxiety medication and that she/he had been directed by the RN # 2 supervisor because the [MEDICATION NAME] was unavailable in the emergency box. Interview with the Director of Nursing on [DATE] at 11:30am identified there was no supply of [MEDICATION NAME] in the emergency medication supply, as it not a medication regularly stored/kept 2. Resident #59 was admitted to the facility on [DATE] for antibiotic treatment and physical therapy following a hospitalization for [MEDICAL CONDITIONS] exacerbation. Additional [DIAGNOSES REDACTED].#59 was independent in decision making, was without memory problems, and required supervision to minimal assist with activities of daily living. physician's order [REDACTED].#59 was receiving Intravenous (IV) Therapy and IV [MEDICATION NAME]. Additionally Resident #59 was receiving [MEDICATION NAME], and [MEDICATION NAME] with an ongoing adjustment of the dosage. A nurse ' s note dated [DATE] identified that Resident #59 was ambulating independently and his/her oxygen saturation level at room air was 96%. A nurses note dated [DATE] at 1:30 PM identified that Resident #59 had increased anxiety with an oxygen saturation level of 98% with the resident receiving continuous oxygen. Resident #59 continued to ambulate independently and participated in smoking breaks. The note further reflected that Resident #59 identified that he/she was not feeling well and his/her oxygen saturation level was noted to be 91% and was noted to have bilateral wheezing. The APRN was notified and subsequently ordered a chest x-ray and lab work to be completed. A nurses note dated [DATE] at 11:00 PM identified that Resident #59 was noted with increased anxiety and complained that he/she could not breath. An 11:30 PM note identified that Resident #59 was experiencing increased anxiety and stated that he/she was going to die and did not want to die and wanted to go to the hospital. The resident was receiving 3 Liters of oxygen and his/her oxygen saturation level was between 77 and 82%. The note identified that while the nurse was calling the Director of Nursing and the APRN, Resident #59 called 911 for an ambulance without consulting with nursing supervisor. The Emergency Medical staff notified the nursing supervisor that the resident ' s oxygen saturation level was dropping and that he/she must go to the emergency department. Interview with the ADNS, who was the nursing supervisor on [DATE] to [DATE] identified that Resident #59 had complained of difficulty breathing, was anxious and restless, had delusions of paranoia, and was [MEDICAL CONDITION]. Resident #59 was trying to get staff to call 911 for her. The ADNS notified the APRN, however did not receive an order to transfer the resident to the hospital. Further interview identified that while the Resident #59 ' s oxygen saturation level was as low as 77%, the ADNS did not express an urgency to transfer the resident for further evaluation. The facility failed to ensure that Resident #59 received the necessary care and services regarding the resident's concerns of difficulty breathing and/or the decrease in his/her oxygen saturation level. C. Based on observations, interviews and review of the clinical record for one of five sampled residents (Resident #120) who required supervision during Leave of Absence (LOA), the facility failed to ensure the physician's orders [REDACTED].#2), the facility failed to ensure that medications were administered and not left at the resident's bedside in accordance with physician's orders [REDACTED]. 1. Resident #120's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #120 was cognitively intact with feelings of depression, was independent with transfers, had lower extremity impairment on both sides and utilized of a wheelchair for mobility. A physician's orders [REDACTED].#120 may have a Leave of Absence (LOA) with responsible party. The resident care plan dated [DATE] identified Resident #120 with behavioral symptoms related to being socially inappropriate and/or disruptive. Interventions directed to assess the patient s mood and affect and assess for environmental and situational factors that may contribute to patient's change in mood or affect. The resident care plan dated [DATE] identified Resident #120 left the faciity on LOA without signing out. The nurse's note dated [DATE] identified Resident #120 asked the Nursing Supervisor for car keys and was observed leaving the facility driving the car and another resident was a passenger. Interview with the Director of Nursing (DON) on [DATE] at 1:00 PM identified that she was aware Resident #120 was leaving the facility independently, however she was unaware that the physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:45 PM identified that he was unaware the physician's orders [REDACTED]. Review of facility policy directs that a physician's orders [REDACTED]. The order will indicate whether the resident needs to be accompanied by a responsible person. The resident will sign out and list the time the resident will return and sign the Leave of Absence Log. 2. Resident #2's [DIAGNOSES REDACTED]. Observations during a tour of the first floor in Resident #2's room at 6:55pm identified a medicine cup containing five (5) pills and the resident was not in the room. Review of the medication kardex and interview with LPN #13 identified that the medication cup contained [MEDICATION NAME], and [MEDICATION NAME]. LPN #13, at that time, identified that he was going to administer the pills to the resident but the resident left the room so he left the pills on the bedside stand. Interview with the Director of Nurses (DON) on [DATE] at 7:35pm identified that medications should not be left at the bedside. Based on clinical record review and interview, for 8 of 8 Residents reviewed for Opioid Treatment Therapy (Residents #14, 117, 121, 128, 146, 184, 190, and 191), the facility failed to ensure the resident received care and services to maintain their highest practicable physical, mental, and psychosocial well-being and /or for three of six residents reviewed for constipation . The findings include: 1. Resident #14 was admitted to the facility on [DATE] with a recent readmission date of [DATE] with [DIAGNOSES REDACTED]. A care plan dated [DATE] identified the problem that Resident #14 had a history of [REDACTED]. Interventions included several as needed interventions and that Resident #14 went to the [MEDICATION NAME] Clinic once a week. The care plan failed to reflect specific interventions addressing Resident #14 ' s substance abuse history and/or measures to assist in recovery. The MDS dated [DATE] identified that Resident #14 was independent with ADLs and had a BIMS score of 14, indicative of intact cognition. physician's order [REDACTED].#14 was to receive [MEDICATION NAME] 5mg/5ml oral solution 20mls (20mg) daily, and that the medication was provided by a [MEDICATION NAME] Maintenance Treatment Program (MMTP). Review of the Medication Administration Record identified that Resident #14 received the medication daily at the facility. A nurse ' s note dated [DATE] at 12:00 PM identified that staff was informed by the staff at the MMTP that Resident #14 was noted to wander off while at the program and was noted to be communicating with and engaging in an exchange of a package with an unidentified person. The note further identified that during a search upon return to the Nursing Home, Resident #14 was noted with smoking materials and a small white particle, which the resident would not reveal to staff. The note failed to reflect that Resident #14 was assessed further as to how he/she obtained the items. A nurse ' s note dated [DATE] at 1:50 pm identified that a search of Resident #14 ' s room was conducted and staff found one tablet of 25 mg of [MEDICATION NAME], partial tablets, two pieces of a straw that were two inches in length and cut at an angle, and 3 vials of a white powder substance. The note failed to reflect that Resident #14 was assessed further as to how he/she obtained the items. Review of the care plan identified one care plan dated [DATE] reflecting the [DATE] event, which was a care plan for Behavior with a goal that Resident #14 would have no further episodes of non-compliance with the smoking policy. A care plan dated [DATE] reflecting the [DATE] event was a care plan for Behavior with the goal that Resident #14 would have no further episodes of non-compliance with the smoking policy. The care plan failed to reflect specific interventions addressing Resident #14 ' s Substance Abuse concerns. A hospital discharge summary dated [DATE] identified that Resident #14 went to the hospital on [DATE] for an evaluation of his/her altered mental status. The summary identified that there was a concern that Resident #14 was abusing his/her medications or another substance which he/she may have obtained while on a visit to the MMTP. Review of the Social Services Notes failed to reflect any notation of Resident #14 ' s Substance Abuse history, that Resident #14 attended the MMTP on a weekly basis, the Hospital ' s concerns, and/or the events where Resident #14 was found with tablets and/or vials of a white powder substance. Interview with the MDS Coordinator RN#3 on [DATE] at 7:00am identified that when Resident #14 goes to MMTP a staff person accompanies him/her. Interview with LPN #7 at the same time identified that the facility does not have a formal communication method between the facility and the MMTP. Interview with RN #5 on [DATE] at 2:00 PM identified that she is one of the nurses that goes to the MMTP. She either rides with the resident in their transportation or meets the resident at the MMTP as there are several residents that she meets there. Further interview identified that there are occasions when the resident waits at the MMTP for the nurse from the facility to arrive before the resident receives his/her dose of [MEDICATION NAME]. RN #5 further identified that while she does communicate with the MMTP, there is not documentation of this communication or a formal communication method between the two facilities. Interview with the Medical Director on [DATE] at 10:00am identified that nursing staff had informed him of the substances found and that Resident #14 was a little off and may have taken something. He further identified that he did not feel that Resident #14 had taken anything and that the nursing staff may have been overreacting. The facility failed to ensure that Resident #14 was appropriately supervised when out of the building and/or failed to ensure there was a communication method between the nursing home and the MMTP. The facility failed to assess for Resident #14 ' s needs regarding his/her substance abuse and interventions addressing such, upon admission to the facility and/or following the events where Resident #14 was found with suspicious substances and/or displaying an altered mental status. 2. Resident #117 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] identified that Resident #117 was independent with ADLs and had a BIMS score of 15, which is indicative of intact cognition. physician's order [REDACTED].#117 may go on a LOA with a responsible party. Additionally the orders identified that Resident #117 was to receive [MEDICATION NAME] 10mg/1ml, 4.5mls once daily and this was obtained from a MMTP. Review of the October MAR identified that Resident #117 received this medication on a daily basis. Review of the clinical record failed to reflect a care plan related to the [MEDICATION NAME] therapy and/or a substance abuse history and/or interventions to address such. Additionally the record failed to reflect that Social Services had assessed for Resident #117 ' s needs regarding their addiction and/or implement measures to assist Resident #117 in the recovery process. Interview with the MDS Coordinator RN#3 on [DATE] at 7:00am identified that when a Resident goes to MMTP a staff nurse meets them there. Interview with LPN #7 at the same time identified that the facility does not have a formal communication method between the facility and the MMTP. Interview with RN #5 on [DATE] at 2:00 PM identified that she is one of the nurses that goes to the MMTP. She either rides with the resident in their transportation or meets the resident at the MMTP as there are several residents that she meets there. Further interview identified that there are occasions when the resident waits at the MMTP for the nurse from the facility to arrive before the resident receives his/her dose of [MEDICATION NAME]. RN #5 further identified that while she does communicate with the MMTP, there is not documentation of this communication or a formal communication method between the two facilities. The facility failed to ensure that Resident #117, who had a physician's order [REDACTED]. The facility failed to assess for Resident #117 ' s needs regarding his/her substance abuse and interventions addressing such, upon admission to the facility or throughout their stay at the nursing home. 3. Resident #121 was admitted to the facility on [DATE] with a readmission on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] identified that Resident #121 was independent with ADLs and had a BIMS score of 13, which is indicative of intact cognition. physician's order [REDACTED].#121 was to receive [MEDICATION NAME] 10mg/5ml solution, 50 mg once daily. Review of the October MAR identified that Resident #121 received this medication on a daily basis and that the medication was obtained from a MMTP. A care plan dated [DATE] identified the problem that Resident #121 had a history of [REDACTED]. Interventions included several as needed interventions and that the [MEDICATION NAME] was obtained from the MMTP. The care plan failed to reflect specific interventions addressing Resident #121 ' s substance abuse history and/or measures to assist in recovery. A review of the clinical record failed to reflect that Social Services had assessed for Resident #121 ' s needs regarding their addiction and/or implement measures to assist Resident #121 in the recovery process. Additionally, the clinical record failed to reflect that Resident #121 received behavioral health services from the nursing home. Interview with the MDS Coordinator RN#3 on [DATE] at 7:00am identified that when a Resident goes to MMTP a staff nurse meets them there. Interview with LPN #7 at the same time identified that the facility does not have a formal communication method between the facility and the MMTP. Interview with RN #5 on [DATE] at 2:00 pm identified that she is one of the nurses that goes to the MMTP. She either rides with the resident in their transportation or meets the resident at the MMTP as there are several residents that she meets there. Further interview identified that there are occasions when the resident waits at the MMTP for the nurse from the facility to arrive before the resident receives his/her dose of [MEDICATION NAME]. RN #5 further identified that while she does communicate with the MMTP, there is not documentation of this communication or a formal communication method between the two facilities. The facility failed to ensure there was a communication method between the nursing home and the MMTP. The facility failed to assess for Resident #121 ' s needs regarding his/her substance abuse and interventions addressing such, upon admission to the facility or throughout their stay at the nursing home. 4. Resident #128 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] identified that Resident #128 was independent with ADLs with supervision with personal hygiene and had a BIMS score of 9, which is indicative of moderately impaired cognition. physician's order [REDACTED].#128 may go on a LOA with a responsible party and was to receive [MEDICATION NAME] 60 mg once daily and the medication was obtained from the MMTP. Review of the October MAR identified that Resident #128 received this medication on a daily basis and that the medication was obtained from a MMTP. Review of the clinical record failed to reflect a care plan related to the [MEDICATION NAME] therapy and/or a substance abuse history and/or interventions to address such. Additionally, a review of the clinical record failed to reflect that Social Services had assessed for Resident #128 ' s needs regarding their addiction and/or implement measures to assist Resident #128 in the recovery process. Interview with the MDS Coordinator RN#3 on [DATE] at 7:00am identifie

Based on clinical record review, facility documentation and staff interview for one of three sampled residents identified with pressure ulcers (Resident #187), the facility failed to assess a wound when the area was identified, notify the physician when there was a change in the wound and document on the wound when a change of condition occurred which resulted in immediate jeopardy. The findings include: Resident #187's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified severe cognitive impairment, total dependence on staff for ADL's, incontinent of bowel and bladder, and at risk for developing pressure ulcers. The RCP dated 3/17/15 identified potential for alteration in skin integrity related to impaired mobility with left sided paralysis. Interventions included side rails up in bed to enable turning and repositioning, out of bed to wheelchair 4 hours a day, and record and report changes to the physician. An interim RCP dated 3/30/15 identified impaired skin integrity to the left buttocks area. Interventions included treatment as ordered, monitor wound for infection and/ or deterioration, monitor and document wound condition weekly, keep physician updated, bedrest for 1 week, and turn and reposition off back. Physician orders [REDACTED]. A Braden scale assessment dated [DATE] identified the resident at mild risk for pressure sore development. Review of the clinical record with Corporate Nurse # 2 on 10/15/15 at 10AM identified although weekly body audits were signed off as being completed for March and April 2015, the clinical record lacked documentation of what the assessment identified. Nurse's notes dated 3/27/15 at 11:45pm identified a new order for treatment to left buttocks done as ordered and the supervisor was aware. The record lacked documentation of an assessment at that time. Physician order [REDACTED]. Additionally, the resident was placed on bedrest for a week and to turn and reposition keeping the resident off the back. Review of the Non Pressure Ulcer Skin Condition Record dated 3/30/15 (date of onset 3/27/15) identified a full thickness wound caused by trauma and measuring 12.5cm by 13 cm with sero-sanguinous drainage. Review of APRN Progress Notes dated 3/30/15 identified resident was evaluated for a new wound on the buttocks. The note identified the wound measured 12.5cm by 13cm, predominately the left buttocks but crosses over to the right side, 85% dark purple, 15% red superficial, a scant amount of serosanguineous drainage, and no odor but pain with dressing change. Wound documentation dated 4/8/15 identified the wounds measured 10cm by 12.5cm, moderate amount of Sanguineous drainage, wound bed 90% necrotic, and with no odor and to continue with current treatment. Advanced Practice Nurse Practitioner (APRN) progress notes dated 4/8/15 identified the buttocks wound measured 10cm by 12.5cm, 90% eschar, 10% red, moderate amount of sanguineous drainage without odor. The wound was discussed with the physician and the bulky Xeroform dressing was continued to prevent sheering when repositioning the resident. Nurse's notes dated 4/9/15 at 11pm identified a dressing change was done to the buttocks wound and a foul odor was noted with Serosanguineous drainage. The clinical record and 24 hour report sheets lacked documentation that the Supervisor or physician was made aware of the foul odor. Nurse's notes dated 4/10/15 at 4pm identified a foul odor from wound, the physician was made aware, and would continue to monitor. Nurse's notes dated 4/10/15 at 11pm identified foul odor with drainage continues. Nurse's notes dated 4/11/15 at 12pm identified that the wound was noted to be caving in and a small open area was noted around wound area. The Supervisor was made aware, and the physician ordered for the resident to be seen by the plastic surgeon. Nurse's notes dated 4/11/15 at 11pm noted treatment done to buttocks foul smelling odor noted. Nurse's notes dated 4//12/15 at 2pm identified the resident ' s treatment was to be evaluated on 4/12/15, the Supervisor was aware and stated to continue with current treatment until seen by the wound nurse. Further review of the nurse's notes lacked documentation of an assessment of the resident's wound, drainage, pain and/ or odor until 4/15/15 when the resident was seen by the APRN Wound Nurse. Wound documentation dated 4/15/15 identified the wound measured 10cm by 12.5cm, a heavy amount of brown drainage, the wound bed with slough, granulation and necrotic tissue, odor, and the resident was having pain. An APRN Progress Note dated 4/15/15 identified the resident was seen related to worsening of the buttocks wound. The assessment noted increased wound odor, increased pain, 70% eschar, 20% yellow lifting slough and 10% red, and heavy brown drainage. The note further identified worsening wound with infection and a concern [MEDICAL CONDITION]. The resident was sent to the hospital for an evaluation and debridement of the wound. Interview with LPN #1 on 10/15/15 at 10:45AM stated that when the wound was identified on Resident #187's buttocks, a complete assessment should have been conducted. LPN #1 stated that she was made aware of the residents wound with the foul odor and brown drainage when she did the dressing change on 4/15/15. LPN #1 further stated that when the foul odor started (on 4/9/15) she should have been made aware and nursing should have been documenting on the wound with each dressing change to see if any change has occurred to report to the physician. Additionally, LPN #1 stated that after Resident #187 was identified with the pressure wound, a facility investigation was conducted related how he/she developed the wound. It was noted residents with low air loss mattresses had extra pads and briefs under them which took away from the effects of the mattress. Interview with the Director of Nurses (DON) on 10/15/15 at 3pm stated that when the wound was first identified on 3/27/15 a full assessment should have been completed and documented in the clinical record. The DON stated that when the resident has a change in the wound (foul odor) the physician is to be notified at that time and the nurse is to document their assessment in the clinical record. The DON further stated that after Resident #187 developed a pressure ulcer, an audit of the facility was conducted and under Resident #187, 2 cloth pads and a brief were identified. The DON stated that the extra pads under the resident defeated the purpose of the low air mattress causing shearing and friction during personal care and repositioning which can lead to skin breakdown. Based on observations, clinical record reviews and interviews for two of three residents reviewed for pressure ulcers (Resident #3 and Resident #73), the facility failed to provide care and services to promote healing and/or prevention of recurrence of a pressure ulcer. The findings include: 1. Resident #3's [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified moderate cognitive impairment, total dependence for bed mobility, toileting and personal hygiene, always incontinent of bowel and bladder and no current pressure ulcers. The Braden Scale assessment dated [DATE] (used to identify pressure ulcer risk) identified the resident was at moderate risk for pressure ulcer development. The care plan dated 10/12/15 identified impaired skin integrity secondary to a left inner buttock open area and dependence on staff for bed mobility and hygiene. Interventions included providing the treatment as ordered, turn and reposition the resident every two hours and provide incontinent care every two hours. The care plan dated 10/15/15 identified the area on the left inner thigh was resolved. The care plan dated 10/20/15 identified an open are on the left buttocks with interventions that included to monitor for signs and symptoms of infection and to provide the treatment as ordered. Constant observation of the resident on 10/21/15 from 5:00 AM through 8:00 AM (three (3) hours) identified the resident in bed positioned on his/her back. The head of the bed was elevated 45 degrees. During the three hours, the resident was not afforded repositioning and/or incontinent care from the staff. At 8:00 AM, the surveyor notified LPN #9 the charge nurse, NA #3 and RN #1, the nursing supervisor of the lack of care provided to the resident. Although notified, facility staff did not enter the room to provide care to the resident until 9:10 AM (total of four (4) hours). Observation of care at 9:10 AM identified the resident had an incontinent brief on and was lying on a soaker pad. The resident was incontinent of bowel and bladder and when care was provided the resident's buttocks and upper posterior thighs were noted to be red and with several demarcation lines in the skin of the posterior thighs. A dressing was on the left buttock which was lifting away from the skin. Interview with NA #3 at the time identified the resident was in bed positioned on his/her back when he/she came on duty at 7:00 AM. NA #3 indicated that position was according to the resident's position plan and repositioning was not provided. NA #3 indicated she/he did not check or provide incontinent care to the resident after coming on duty at 7:00 AM. NA #3 further indicated she/he did not provide care at 8:00 AM when notified by the surveyor, because she/he was in the middle of providing breakfast to other residents. NA #3 noted once breakfast was finished, care was provided to the resident. Interview with RN #1 on 10/21/15 at 9:30 AM indicated that although she/he was aware the resident was without care for three (3) hours, she/he did not follow up to ensure NA #3 provided care to the resident at 8:00 AM. RN #1 indicated she/he thought NA #3 went to provide the care when notified. 2. Resident #73's [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] identified moderate cognitive impairment, extensive assistance for bed mobility and personal hygiene, functional limitations of bilateral lower extremities and two (2) stage four (4) pressure ulcers. The care plan dated 8/5/15 identified alteration in skin integrity due to right and left ischium pressure ulcers. Interventions included allowing out of bed to the wheelchair for only two (2) hours a day, reposition every two (2) hours side to side, use of a Roho cushion in the wheelchair, weekly wound care by the wound APRN, and use of a low air loss mattress on the bed. The APRN Wound assessment dated [DATE] identified a 0.1 cm x 0.1 cm x 0.1 cm stage 4 pressure ulcer on the left ischium, a 0.1 cm x 0.5 cm x 0.1 cm stage 4 pressure ulcer on the right distal ischium, and a resolved stage 4 pressure ulcer on the right proximal ischium. Constant observations on 10/21/15 from 5:00 AM through 8:00 AM (3 hours) identified the resident in bed with the privacy curtain drawn and the door to the room shut. The resident was laying on his/her back and buttocks in the bed with a low air loss mattress on the bed. Throughout the entire observation, the facility staff did not enter the resident's room, provide repositioning and/or encouragement to reposition onto his/her side. At 8:00 AM, the surveyor notified LPN #9 the charge nurse, NA #6 and RN #1, the nursing supervisor of the lack of care provided to the resident. NA #6 went into the room and attempted to reposition the resident onto his/her side. Resident #73 declined and LPN #9 was notified. LPN #9 although notified of the resident's noncompliance with repositioning, did not speak to the resident to educate the resident on the consequences of not allowing repositioning with the presence of stage 4 pressure ulcers. Observations of care on 10/21/15 at 11:35 AM identified an area of scar tissue on the left proximal ischium that was identified by RN #1 at the time as a healed stage 4 pressure ulcer. The area was noted with two (2) open slit areas. Measurement of the areas conducted at the time by LPN #9 and documented in the nurse's notes for 10/21/15 identified a 3 cm x 0.5 cm x 0.25 cm open area under a skin fold and a 0.5 cm open linear slit in the skin. The wound bed was pink and no drainage was noted. The wound APRN was notified and a treatment was obtained. The APRN Wound assessment dated [DATE] identified a new area with a date of onset of 10/21/15. The area was a Stage 4 wound located on the right (the accurate side is on the left) distal (lateral) ischium. The wound is not painful. The size is 0.3 (length) x 0.3 (width) x 0.1 (depth). The wound bed is covered with 100% granulation tissue. There is scant serosanguinous drainage that has no odor. The new open area occurred on heavily scarred areas of previously healed stage 4 wounds, and thus can be considered recurrent. Interview with LPN #9 on 10/21/15 at 9:00 AM indicated she/he was conducting the medication pass when notified by NA #6 that the resident refused to reposition onto his/her side. LPN #9 indicated he/she did not speak to the resident to encourage repositioning or educate as to the risks associated with noncompliance because she/he was conducting the medication pass.

Based on clinical record reviews, review of facility documentation and interviews for one of six sampled residents (Resident #109) who required nutritional support via a feeding tube and was at risk for dehydration, the facility failed to ensure the resident received a sufficient amount of fluids. The findings include: Resident #109's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #109 had severe cognitive impairments, required total staff assistance with activities of daily living, received nutrition via a tube feeding, and the average fluid intake per day was 501 cubic centimeters (cc) per day or more. The Hydration assessment dated [DATE] identified Resident #109 was at risk for dehydration. The resident care plan dated 5/29/15 identified an alteration in nutrition related to the gastrostomy feeding secondary to a potential for aspiration. Interventions directed to administer tube feeding per the physician's orders [REDACTED]. The care plan also identified a potential for dehydration due to diuretic use. Interventions directed to assess skin turgor, oral mucosa membranes every day, document intake and output and notify the physician and family for any changes in condition. A physician's orders [REDACTED]. 50 cc of water after turning the feeding off and 50 cc before turning the feeding on again. Review of the laboratory data dated 6/26/15 identified Resident #109's Blood Urea Nitrogen (BUN) was 53 (reference range is 7-20 mg/dL) and the creatinine was 1.8 (reference range is 0.5-1.2 mg/dL). Bloodwork obtained on 6/17/15 identified a BUN of 25 and creatinine of 0.6. A physician's orders [REDACTED]. (Therefore the expected fluid intake over a twenty-four (24) hour period at a minimum would have been 2250 cc, plus the flushes between medications). Review of the Intake and Output (I&O) sheets dated 6/17/15 through 7/3/15 identified that 10 out of 17 shifts failed to reflect the administration of the ordered fluid intake over the twenty-four hour timeframe. Review of the I&O sheet dated 7/3/15 identified the intake was 560 ml. For 7/4/15 the intake was 2404 ml and for 7/5/15 there was documentation to reflect the intake for the 11-7 shift. The nurse's note dated 7/2/15 at 11:00 PM identified the [DEVICE] was dislodged at the change of shift. The nurse's note dated 7/3/15 at 6:30 AM identified the dislodgment of the [DEVICE]. The nurse's note dated 7/3/15 at 8:55 AM identified the covering physician was notified of the dislodged [DEVICE] and Resident #109 was transferred to the hospital for [DEVICE] replacement and returned that evening on 7/3/15 at approximately 7:00 PM, which now indicated that Resident #109 had been without fluids for approximately twenty (20) hours. The nurse's note dated 7/5/15 at 11:00 AM identified Resident #109 had an elevated temperature of 101.3, blood pressure of 102/58 (normal range 130's/70's), pulse rate of 92 (normal range 70-80's), respiration of 24 and an oxygen saturation of 78% at 2 Liters via nasal cannula. Subsequent to physician notification Resident #109 was transferred to the hospital and admitted with the [DIAGNOSES REDACTED]. The hospital history and physical dated 7/5/15 identified that when Resident #109 arrived at the Medical Intensive Care Unit the resident's blood pressure was 98/44 the BUN was 88 and creatinine was 2.8, and Resident #109 received four (4) liters of intravenous fluids. The hospital discharge summary dated 7/19/15 identified Resident #109's BUN was 30 and the creatinine 0.8. Review of facility policy identifies that residents will have access to adequate fluids for hydration and residents at risk for dehydration or needing acute re-hydration and that appropriate interventions are initiated timely.

Based on clinical record review, review of facility documentation, and interviews for two of five sampled residents reviewed for accidents (Resident #27 and # 73), the facility failed to follow the residents plan of care and /or for one sampled Resident # 55 who was conserved, the facility failed to provide the necessary supervision. The findings include: 1. Resident #27's [DIAGNOSES REDACTED]. The monthly physician order [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident with severely impaired cognition, had memory problems and that the resident required total dependence from the staff with ADLs. The RCP revised 4/15/13 identified potential for falls related to immobility and actual falls. Interventions included bed bolsters and floor mat on floor at bedside. In addition, RCP revised 4/15/13 identified self-care deficit and directed two ? side rails elevated. Review of facility Reportable Event Form dated 4/28/13 identified that on 4/28/13 at 11:30 A.M. NA #3 was providing morning care to Resident #27, the resident fell off the bed, hit his head on the floor. Further review indicated the resident sustained [REDACTED]. The resident was transferred to the hospital for an evaluation required three sutures to the left eyebrow prior to the return to the facility. Interview with NA #3 on 1/27/14 at 12:56 P.M. identified that although the resident was in bed and was moving around that morning; the bolsters, ? side rails, alarm and the pad on the floor were removed for out of bed transfer. The NA #3 stated that she/he turned around to get the Hoyer lift that was approximately a few steps away and the resident fell out of bed. Further interview with NA #3 identified that she/he made a mistake by taking the side bolsters, mat and the side rails off the resident's bed. Interview with DNS #1 on 1/27/14 at 2:00 P.M. indicated it is the NA responsibility to follow the resident's plan of care and keep the resident safe. Additionally, NA received a Disciplinary Action on 4/28/13 for not following the resident's plan of care. 2. Resident #73's [DIAGNOSES REDACTED]. An annual MDS dated [DATE] identified the resident as severely cognitively impaired and requiring extensive assistance of one staff member for bed mobility and dressing. The MDS further noted the resident required total care of two staff for transfers and toileting. The transfer the resident back to bed secondary to fatigue care plan dated 10/15/13 and the physician's orders [REDACTED]. The nurse's notes dated 11/26/13 at 9:40 P.M. identified Resident # 73 was found on the floor face down after the Hoyer straps broke while the resident was being transferred back to bed via Hoyer . The nurse's notes further identify that the resident was transferred to the hospital. The Hospital Discharge Summary dated 11/29/13 identified Resident # 73 was seen the emergency room secondary to a fall via Hoyer lift ( approximately 3-5 feet) and indicated that the resident was discharged back to the facility with a [DIAGNOSES REDACTED]. Additionally, a Cash/Jewitt Extension brace was ordered for when the resident was out of bed and that the treatment plan remained non-operative. An interview with DNS#1 on 1/28/14 at 10:16 A.M. identified that in November of 2013 the facility utilized different Hoyer pads. The DNS further identified that the Hoyer pads at that time had a weight limit of 450 pounds (the resident weighed 272 pounds in November 2014) and utilized a colored border to delineate the various sizes. The DNS further identified the sizes were based on the residents upper body width from shoulder to shoulder but residents were not assessed for the correct size to be utilized. The DNS further noted that when he/she inspected the Hoyer pad after the incident, the border color was faded and worn but no fraying was identified and therefore stated that she/ he was unable to determine which Hoyer pad was used at the time of the incident. The DNS further noted that the resident's weight was in his/her upper body and the Hoyer sling utilized was not wide enough in the shoulder width. Further interview with the DNS identified that during the investigation, NA#5 stated the right upper side of the Hoyer pad loops broke while the resident was suspended, followed by the right lower side ("under the immediate strain"), then lastly the left upper side broke. On 1/28/14 at 11:30 A.M. an interview with NA#7 identified that in November 2013, the facility used small, medium and large Hoyer pads that were differentiated by the color of the border. He/she further noted that it was based on the resident's shoulder width and the NA would select the size Hoyer pad based on observing the resident's upper size. Interview with NA#5 on 1/28/14 at 7:15P.M. identified that he/she was assigned to R#73 on 11/26/13. NA#5 further identified that he/she was transferring the resident with another NA from the wheelchair to bed via the Hoyer lift. NA#5 further noted that they connected the loops from the Hoyer sling to the lift, raised the resident from the wheelchair to transfer the resident back to bed when, the loops " gave way " and the resident fell to the floor. NA#5 also noted that she/he utilized the Hoyer sling that the resident was already sitting on from the morning to transfer the resident into the wheelchair. 3. Resident#55's [DIAGNOSES REDACTED].The quarterly MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, had memory problems and required total dependence from the staff with all ADLs. The RCP dated 12/13/13 for self care deficit related to total dependence on staff for ADLs included interventions: to establish a routine with the resident , to provide assistance with ADLs in which the resident can't perform, to give clear, simple verbal instructions and to provide safety measures. Then nurse's notes 12/22/13 recorded at 2:00 P.M. identified that Resident # 55 was found across the street( busy main street) from the facility. Additionally, noted that the licensed staff and a NA went to get Resident # 55 from across the street and brought the resident back to the facility. Additionally, the nurse's notes indicated that the resident sustained [REDACTED]. The Reportable Event dated 12/22/13 at 1:00 P.M. identified that the resident was seen out side of the facility across the street and that the resident was alert times two and was noted with confusion. The investigation on 12/22/13 noted that Resident # 55 was found on the curb with a broken wheelchair wheel. The report also noted that Resident # 55 showed no signs and symptoms of trauma after the incident. Interview with NA # 3 on 1/27/14 at 1:00 P.M. identified that while she/he and another NA were looking out the window, they saw Resident # 55 outside on the curb across the street from the facility at which time they notified the facility staff. Interview with RN # 3 on 1/27/14 at 1:30 P.M. identified that she/ he was unaware that Resident # 55 had left the building until she/ he was notified by a NA that Resident # 55 was outside and indicated that a NA and a housekeeping staff brought the resident back to the facility.

Based on clinical record review, review of facility documentation, and interviews for one of three sampled residents (Resident #27) reviewed for accidents, the facility failed to provide appropriate supervision to prevent an injury. The findings include: Resident #27's [DIAGNOSES REDACTED]. The quarterly Minimum Data assessment dated [DATE] identified that Resident #27 had severe cognitive impairment, difficulty with focusing, disorganized thinking, an altered level of consciousness required total one person assistance with bathing, was non ambulatory, and no history of falls. The care plan dated 11/22/12 identified a self-care deficit with activities of daily living. Interventions included establishing a routine, to provide safety measures, and assistance of two with showers. Review of the resident care card identified that Resident #27 was showered on Mondays, during the 11:00 PM to 7:00 AM shift with the assistance of two. The Reportable Event Form dated 1/14/13 at 3:30 AM identified that while seated in the shower chair Resident #27 had leaned forward resulting in a fall. An assessment identified a laceration with swelling to the left eyebrow and Resident #27 was transferred to the Emergency Department for treatment. Review of the hospital Inter-Agency Referral Report dated 1/13/12 identified Resident #27 had sustained a laceration to the left forehead region that required three sutures. The reportable event summary identified that at the time of the fall only one nurse aide was present in shower room. Interview with the Director of Nurses (DON) on 2/27/13 at 2:30 PM identified that two nurse aides should have been present when Resident #27 was showered. The DON stated NA #1 was no longer employed at the facility and attempts to contact NA #1 were unsuccessful.

Based on clinical record reviews, observations and interviews for one of one sampled resident who required continuous oxygen and/or bed alarm (R#59) and/or for two of five sampled residents who required GT feeding (R#97, R#147) and/or for one of one sampled resident on Continuous Ambulatory Peritoneal [MEDICAL TREATMENT] (R#110) and/or for one sampled resident that required pain medication (R#134) and/or for one of twenty-five residents reviewed during medication administration, (R#77), the facility failed to implement physician orders. The findings include: 1. a. Resident #59's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observation of the resident on 1/11/12 at 6:05 AM identified the resident in bed without the benefit of the oxygen. Interview with NA #4 on 1/11/12 at 6:05 AM, who was assigned to provide care on the 11 PM - 7 AM shift, identified that the resident always takes the oxygen off and is non-compliant with wearing the oxygen. Further observation identified that the nurse aide failed to notify the charge nurse that the resident was without oxygen for an undetermined amount of time. Subsequent to surveyor observation and inquiry, LPN #5 was notified and applied the oxygen as ordered. Review of the nurse aide assignment identified to apply oxygen via nasal cannula at 2L/min. Interview with RN#2 on 1/11/12 at 7:00 AM and review of the clinical record and care plan identified that the resident has no behavioral issues regarding the application of the oxygen and should have been receiving the oxygen continuously. b. A physician's orders [REDACTED]. Observation of the resident on 1/11/12 at 6:06 AM identified R#59 in bed without the benefit of the bed sensor plugged into the alarm. Further observation identified 2 alarm boxes under the resident's bed which were not attached to any pad sensor. Interview with NA#4, at the time identified she was unaware that the resident's alarm was not in place. Although the physician order [REDACTED]. Subsequent to surveyor inquiry, the bed alarm sensor was applied and functioned properly. 2. Resident #97's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident as severely cognitively impaired, required supervision with eating, required a feeding tube and was on a mechanically altered diet. Further assessment identified a weight of 133 lbs and no loss of 5% or more weight loss in last month, or 10% or more in the last 6 months. The assessment also identified that 25% of total calories were received through the tube feeding, and the average fluid intake, per day by tube feeding was 501 cc/day or less. A physician order [REDACTED]. Additionally, physician order [REDACTED]. A physician order [REDACTED]. Review of the Medication Administration Record (MAR) from July, 2011, through September 14, 2011 (76 days) identified that the facility failed to provide the resident with the 2 cans of [MEDICATION NAME] 1.2 scheduled for 5:00 PM and 9:00 PM, as ordered by the physician via [DEVICE]. Interview with the Dietician on 1/12/11 at 1:00 PM identified that on the annual review R# 97, who required tube feedings, had a 16% weight loss in three weeks and indicated that residents on tube feedings should not be losing that much weight. The Dietician indicated that she identified that the facility was not providing the house supplement on September 14, 2011, but was unaware that the tube feeding was not being given as ordered by the physician for 2.5 months. Interview and review of the clinical record, medication kardex and weight log/records with RN #3 identified that the facility failed to administer the proper amount of tube feeding as ordered by the physician for 2.5 months. Further interview identified that the facility weight policy indicates that all residents with [DEVICE] feedings will be weighed weekly and only subsequent to surveyor inquiry, was the omission of the proper amount of nutritional tube feeding identified. The physician was unavailable for interview. 3. Resident # 147's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as severely cognitively impaired, total dependence on staff for activities of daily living, and required tube feedings. A RCP dated 2/28/11 identified the resident at risk for dehydration related to enteral feeding. Interventions included to provide tube feeding and water flushes as ordered, monitor intake and output and monitor for symptoms of dehydration. A physician's orders [REDACTED]. Hold feeding for [MEDICATION NAME] administration between 1-3 AM and 9-11 AM. Additionally, the physician orders [REDACTED]. A nurse's note dated 4/16/11 on the 3 PM to 11 PM shift identified that the GT was clogged, several attempts to unclog were unsuccessful, and will retry. A nurse's note dated 4/17/11 at 11:25 AM failed to reflect that R# 147's physician was notified of the clogged GT since 4/16/11. At 3:00 PM, R#147 was transferred to the hospital, and medications were administered by mouth in applesauce. A nurse's note dated 4/17/11 at 12:25 AM identified R#147 returned to the facility with an IV in the left wrist. A physician's orders [REDACTED]. Review of the MAR for April, 2011 identified that on 4/16/11 at 7:00 PM, the [MEDICATION NAME] feeding, and the 4:00 PM and 8:00 PM flushes were not documented as administered. Further review noted that on 4/17/11 on the the 7 AM to 3 PM shift both the tube feeding and flushes were held, and on 4/18/11, on the 11:00 PM to 7:00 AM shift the tube feedings and water flushes were held due to a clogged GT. Additionally, review of the medication kardex identified that R # 147 ' s [MEDICATION NAME] 200 mg was held at 2:00 AM on 4/17/11 and again on 4/18/11 at 2:00 AM and 10:00 AM because of a clogged GT. Review of Intake and Output sheets dated 4/16/11 thru 4/18/11 noted R # 147 failed to receive any fluids orally and/or tube feeding, and/or [MEDICATION NAME] nutrition for 6 shifts. Additionally, the output lacked documentation for 3 shifts. Review of the hospital summary dated 4/17/11 identified that R # 147 was identified with a nonfunctional GT, was placed on IV fluids and transferred back to facility at which time a GT replacement will be completed. Review of R # 147's clinical record, 24-hour nursing reports, and interview with the DNS on 1/11/12 at 2:20 PM failed to reflect that the physician was notified of the clogged GT until 4/17/11, at which time the physician directed the transfer of the resident to the hospital to have the GT unclogged and/or provide the resident with IV hydration. Additionally, the DNS indicated that if a resident is not meeting fluid goals, they are identified on the 24-hour nursing report, the information is communicated to the next shifts and the physician is made aware. b. A physician's orders [REDACTED]. Observations on 1/09/12, 1/10/12, and 1/11/12 identified R # 147 lying in bed without benefit of the abdominal binder. The abdominal binder was observed on a chair in the resident's room. Observation and interview with LPN # 5 on 1/1/12 at 12:30 PM identified the abdominal binder on chair. LPN #5 indicated that although R#147 pulls the abdominal binder off, all the time, she had not reported the behavior to anyone, nor has any new interventions been implemented to prevent the resident from pulling at the tube. Review of R#147's clinical record with the Corporate Nurse on 1/12/12 at 12:10 PM identified that although the abdominal binder was being circled as not applied on the treatment cardex, nurses notes and/or the 24-hour nursing reports failed to reflect that the physician was notified and/or new interventions implemented to prevent the resident from pulling at the feeding tube. 4. Resident # 110's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the I&O with the Assistant Director of Nursing on 1/18/12 at 10:00 AM identified that on 17 of 31 days the fluid intake amount exceeded 1000 cc. Although the fluid restriction order was discontinued on 11/03/11, the ADNS identified that the fluid intake had exceeded the physician's orders [REDACTED]. 5. Resident #134's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident's cognition as reasonable and consistent, required independence with ADL's and experienced moderate pain. A physician's orders [REDACTED]. A RCP dated 1/4/12 indicated alteration in comfort related to back pain. Observation on 1/12/12 at 9:30 PM identified the resident exhibiting facial grimacing and reporting discomfort and pain. The resident also reported that the pain medication scheduled for 6 AM was given at 8 AM. Review of the MAR and the narcotic count sheet noted the medication was administered at 8 AM. Interview with RN#6 on 1/13/12 at 9:45 AM identified that she had gone to the resident's room to administer the medication but the resident was asleep. RN#6 indicated that she forgot to administer the medication later and remembered during the narcotics count. 6. Resident #77 ' s [DIAGNOSES REDACTED]. Observation of a medication pass on 1/ 3 /12 at 9:45 AM identified the administration of Calcium 500 milligrams (mg) with 400 mg of Vitamin D, one tablet by mouth. Review of physician orders [REDACTED]. Interview with LPN#3 on 1/3/12 at 11:00 AM identified that the Calcium 500 mg with 400 mg Vitamin D was given because it was crushable. Subsequent to surveyor inquiry, a new order was obtained from the physician to discontinue Oyster Calcium 500 plus 125 mg D and give house stock Calcium 500 mg and 400 mg of Vitamin D.

Based on clinical records review and interviews for one of five sampled residents reviewed for gastrointestinal tube feeding (R#97) the facility failed to implement physician's orders [REDACTED]. Resident #97's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident as severely cognitively impaired, required supervision with eating, required a feeding tube and was on a mechanically altered diet. Further assessment identified a weight of 133 lbs. and no loss of 5% or more weight loss in last month or 10% or more in the last 6 months. The assessment also identified that 25% of total calories was received through the tube feeding and the average fluid intake per day through tube feeding was 501 cc/day or less. A physician order [REDACTED]. Additionally, physician order [REDACTED]. A physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A RCP dated 6/30/11 identified the resident with a [DIAGNOSES REDACTED]. Interventions included to continue house supplement 120 ml, three times a day by mouth, protein supplement 30 ml, twice a day and [MEDICATION NAME] 1.2 calories, 240 ml twice a day via gastrostomy tube, secondary to poor oral intake at times. Review of the weight log/record identified that the resident's weekly weights were not documented on the 3rd and 4th week of August, 2011 and the 1st week of September 2011. The record identified the resident's weight on August 23rd as 130.7 lbs and on September 13th as 110.3 lbs ( a 23 lb weight loss). Although a physician order [REDACTED]. Additionally, review of the nutrition/dietary assessment dated [DATE] identified that R#97 was not receiving the house supplement as ordered from September 1 to September 14, 2011. A nutrition progress note dated 9/14/11 identified that during the annual review the Dietician identified a significant weight loss of 16%. Interview with the Dietician on 1/12/11 at 1:00 PM identified that on the annual review R# 97, who required tube feedings, had a 16% weight loss in three weeks and indicated that residents on tube feedings should not be losing that much weight. The Dietician indicated that she identified that the facility was not providing the house supplement on September 14, 2011, but was unaware that the tube feeding was not being given as ordered by the physician for 2.5 months. Interview and review of the clinical record, medication kardex and weight log/records with RN #3 identified that the facility failed to administer the proper amount of tube feeding as ordered by the physician for 2.5 months. Further interview identified that the facility weight policy indicates that all residents with [DEVICE] feedings will be weighed weekly and only subsequent to surveyor inquiry, was the omission of the proper amount of nutritional tube feeding identified.