Every finding on record at New London Sub-Acute and Nursing

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pain management, the facility failed to ensure Resident #1's pain and nonverbal signs of pain were timely recognized, assessed, treated, and reported to the licensed nurse and physician. Specifically, despite Resident #1 demonstrating increased difficulty with transfers, grimacing, and grabbing the right leg on 7/1/26 and 7/2/26, nursing staff failed to ensure the resident was assessed for pain and a change in condition. Additionally, after Resident #1 was identified with significant right leg bruising, swelling, shortening, external rotation, and severe pain with movement and palpation on 7/2/26, the licensed nurse failed to administer available as-needed pain medication as ordered and Resident #1 remained at the facility for approximately three (3) hours after the injury was initially identified before being transferred to the hospital. Resident #1 was subsequently diagnosed with an acute right comminuted intertrochanteric fracture requiring surgical repair. The findings include:Resident #1 was admitted to the facility in November of 2022 with diagnoses including dementia without behavioral disturbances, repeated falls, restlessness, agitation and anxiety disorder.A physician's order dated 7/4/25 directed to administer acetaminophen 325 milligrams (mg), give two (2) tablets by mouth every four (4) hours as needed for pain, general discomfort or a temperature greater than 101 degrees.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), required substantial assistance for bed mobility and was dependent on staff for transfers.The Resident Care Plan (RCP) dated 4/7/26 identified Resident #1 had the potential for pain. Interventions included anticipating the need for pain relief and responding immediately to any complaint of pain, monitoring/recording/reporting to the licensed nurse any signs and symptoms of non-verbal pain, monitoring/recording/reporting to the licensed nurse complaints of pain or requests for pain treatment and administering analgesia per orders.A nurse's note by RN #1 dated 6/23/26 at 3:57 PM identified she was called to Resident #1's room by the charge nurse (LPN #1) for an unwitnessed fall. Resident #1 was observed to be sitting on the floor with his/her back against the recliner with the wheelchair in front of him/her. Due to dementia, Resident #1 was unable to explain what happened to cause the fall but denied pain or injury. Resident #1 could move all extremities, range of motion was within normal limits to all four (4) extremities and skin was intact with no open areas.Review of nurse's notes dated 6/23/26 through 7/1/26 failed to identify skin abnormalities, pain or increased difficulty with transfers following the 6/23/26 unwitnessed fall.A Pain Evaluation by RN #2 on 7/2/26 at 8:00 PM identified Resident #1 reported ten (10) out of 10 severe pain. A staff assessment for pain was also conducted identifying Resident #1 displayed facial expressions indicating pain.A nurse's note by RN #2 dated 7/2/26 at 9:00 PM identified Resident #1's right inner thigh and right lower extremity were bruised and edematous (swollen). The right lower extremity appeared shortened and externally rotated (turned outwards, away from the middle of the body). The last identified fall was on 6/23/26 and no injuries were identified. Upon palpation and movement of the right extremity, Resident #1 exhibited severe pain. The Medical Director was notified, and an order was obtained to transfer Resident #1 to the Emergency Department (ED).A nurse's note by LPN #2 on 7/2/26 at 9:18 PM identified she was called to Resident #1's room following reports of bruising to Resident #1's right leg. Upon assessment, bruising was noted to Resident #1's right inner thigh, the right leg was edematous, painful with movement and palpation and the right leg appeared to be shortened. The nursing supervisor (RN #2) was notified and assessed Resident #1.Review of the July 2026 MAR identified Resident #1 did not receive any as-needed acetaminophen on 7/2/26 prior to transfer to the ED.The Prehospital Care Report (ambulance run sheet) dated 7/2/26 identified the facility notified dispatch at 9:24 PM that Resident #1 had a leg injury and they arrived at 9:27 PM. Resident #1's right leg was significantly swollen with external rotation, shortening, and bruising to the right inner thigh. Resident #1 was unable to move the right extremity and upon palpation of right hip and leg, Resident #1 showed signs of extreme pain and discomfort.Review of hospital documentation dated 7/2/26 identified a right femur x-ray was obtained and Resident #1 was found to have an acute right comminuted intertrochanteric fracture (a hip fracture where the upper part of the femur between the greater and lesser trochanters is broken into multiple fragments). Resident #1 underwent a right hip cephalomedullary nailing surgery (metal rod inserted down the center of the femur and anchored into the femoral head) on 7/3/26 and returned to the facility on 7/7/26.Interview with RN #2 on 8/3/26 at 11:56 AM identified on 7/2/26, LPN #2 notified him that Resident #1's right leg was swollen and bruised, though he could not recall the time of the notification. On assessment, RN #2 observed the right leg to be shortened and externally rotated, with pronounced purple bruising on the right inner thigh. Resident #1 grimaced and yelled with any movement and when the area was palpated. RN #2 contacted the Medical Director, sent photos of the right leg, and was directed to send Resident #1 to the ED for evaluation. He completed the transfer paperwork and notified Emergency Services. RN #2 stated that LPN #2 should have administered pain medication prior to the ED transfer.Interview and review of the statement with NA #7 on 8/3/26 at 1:28 PM identified she frequently cared for Resident #1 on the 7:00 AM to 3:00 PM shift. Resident #1 was often stiff, making it difficult to move the legs to visualize the inner legs and groin. On 7/1/26, Resident #1 was unusually difficult to transfer and grimaced with movement. She requested assistance from other NAs several times for transfers and incontinent care and reported the change in condition to LPN #6. On 7/2/26, Resident #1 again was difficult to transfer, grabbed the right leg, grimaced with movement, extended the legs, and slid down in the chair. She notified LPN #8, who assisted with transferring Resident #1 back to bed using a gait belt.Interview with LPN #8 on 8/3/26 at 1:40 PM identified on 7/2/26, NA #7 did not report pain. She added that if pain had been reported, she would have administered as needed acetaminophen.Interview with the Rehab Director on 8/3/26 at 2:11 PM identified Resident #1 was screened by therapy on 6/24/26 following the 6/23/26 fall. During the screen, an NA was observed transferring Resident #1 without difficulty, and he reported Resident #1 did not appear to be in pain at that time. The Rehab Director identified that if Resident #1 had shown pain during transfers, difficulty transferring, staff should have stopped, submitted a new therapy screen and notified him. If staff were unable to transfer Resident #1 safely, the transfer method should have been downgraded to a mechanical lift.Interview with LPN #6 on 8/3/26 at 3:03 PM identified when she administered morning medications on 7/1/26, Resident #1 was already up in the wheelchair, but did not observe any signs of pain. NA #7 never reported any increase in pain. LPN #6 indicated she would have medicated Resident #1 and notified the provider immediately if pain had been reported.Interview with the Interim DON on 8/3/26 at 3:14 PM identified a licensed nurse should have been notified to assess Resident #1 and immediately notify the provider when Resident #1 was noted to have pain with movement and increased difficulty transferring, as this represented a change in condition. The Interim DON also stated that Resident #1 should have received as needed acetaminophen when pain was identified, including on 7/2/26 when severe pain was noted upon discovery of the injury to Resident #1's right leg.Interview with the APRN on 8/3/26 at 3:20 PM identified Resident #1 should have been given as needed acetaminophen when experiencing moderate to severe pain. If the medication was ineffective, the provider should have been notified. The APRN stated that on 7/2/26, when Resident #1 was noted to be in severe pain, the as needed acetaminophen should have been administered prior to the ED transfer.Interview with LPN #2 on 8/3/26 at 3:30 PM identified on 7/2/26 after dinner at around 7:00 PM, NA #6 notified her that Resident #1 had bruising and swelling to the right leg. She went to Resident #1's room and the right leg was swollen and the whole right inner thigh was dark purple and discolored. Resident #1 appeared to be in pain and grimaced with any palpation to the area. Although she should have immediately medicated Resident #1 with as needed acetaminophen after observing the right leg injury and signs of pain, she was the only licensed nurse on the unit that night and did not think to do so.Interview with NA #6 on 8/4/26 at 10:14 AM identified on 7/2/26 when she arrived for her 3:00 PM shift, NA #7 reported she had put Resident #1 to bed because he/she was tired but stated NA #7 never reported that Resident #1 had been increasingly difficult to transfer or in pain. Around 3:30 PM she went to check on Resident #1, and he/she was agitated and refused care. She went back again just after 4:00 PM and Resident #1 still refused care. Around 5:00 PM Resident #1 would not eat so she notified LPN #2, who fed Resident #1 dinner. She approached Resident #1 again between 5:30 and 6:00 PM and Resident #1 allowed her to provide care. As she went to change Resident #1, she noticed the right leg was significantly bigger than the left leg, bruising to the right leg and the area was tender. She notified LPN #2. Resident #1 was sent to the ED around 9:00 PM (3 hours after the initial discovery).Review of the Pain Control / Management policy dated 7/2023 directed, in part, that staff are to complete pain assessments upon admission, quarterly, and as needed; assess and monitor residents who are displaying pain-including verbal and non verbal indicators-and medicate the resident as needed per MD orders. Assess a resident's pain level using a 0-10 pain scale, monitor effectiveness of pain treatment, adjusting therapy based on resident response, documenting scheduled and PRN pain medication administration, and evaluating pain in non verbal or cognitively impaired residents using observed behaviors such as facial grimacing, crying, restlessness, or decreased appetite.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for facility incidents, the facility failed to promptly assess and notify the provider of a significant change in condition, including increased pain with movement, difficulty transferring, and repeated sliding down in the wheelchair, resulting in a delay in evaluation and treatment of an acute right intertrochanteric femur fracture. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances, repeated falls, restlessness and agitation and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), and required substantial assistance for bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 4/7/26 identified Resident #1 was at risk for falls and had actual falls while in the facility and had the potential for alterations in skin integrity due to bowel and bladder incontinence, impaired mobility and cognitive deficits. Interventions included anticipating and meeting the resident's needs, monitoring skin during incontinent care and notifying charge nurse/supervisor of any signs and symptoms of skin breakdown/redness and performing weekly body evaluations and notifying the supervisor of any new skin issues. A nurse's note by RN #1 dated 6/23/26 at 3:57 PM identified she was called to Resident #1's room by the charge nurse (LPN #1) for an unwitnessed fall. Resident #1 was observed to be sitting on the floor with his/her back up against the recliner with the wheelchair in front of him/her. Due to dementia, Resident #1 was unable to explain what had happened to cause the fall but denied any pain or injury. Resident #1 could move all extremities, range of motion was within normal limits to all four (4) extremities and skin was intact with no open areas. Neurological vital signs were initiated, within normal limits and Resident #1 was assisted up into the wheelchair by staff. The APRN and Resident #1's representative were notified of the incident and no new orders were obtained. The RCP was updated to include Resident #1 to be sat in the common area while awake especially during the change of shift to ensure safety. Review of nurse's notes dated 6/23/26 through 7/1/26 failed to identify any skin abnormalities, pain or increased difficulty with transfers following the 6/23/26 unwitnessed fall. A Skin Evaluation by LPN #8 on 6/29/26 identified Resident #1's skin was intact and no new skin issues were identified. A nurse's note by RN #2 dated 7/2/26 at 9:00 PM identified on assessment of Resident #1, Resident #1's right inner thigh and right lower extremity were noted to be bruised and edematous (swollen). The right lower extremity appeared shortened and externally rotated (turned outwards, away from the middle of the body). The last identified fall was on 6/23/26 and no injuries were identified. Upon palpation (when touched) and movement of the right extremity, Resident #2 exhibited severe pain. The Medical Director was notified, and an order was obtained to transfer Resident #1 to the Emergency Department (ED). A nurse's note by LPN #2 on 7/2/26 at 9:18 PM identified she was called to Resident #1's room following reports of bruising to Resident #1's right leg. Upon assessment, bruising was noted to Resident #1's right inner thigh, the right leg was edematous, painful with movement and palpation and the right leg appeared to be shortened. The nursing supervisor (RN #2) was notified and assessed Resident #1. Review of hospital documentation dated 7/2/26 identified a right femur x-ray was obtained and Resident #1 was found to have an acute right comminuted intertrochanteric fracture (a hip fracture where the upper part of the femur between the greater and lesser trochanters is broken into multiple fragments). Resident #1 underwent a right hip cephalomedullary nailing surgery (metal rod inserted down the center of the femur and anchored into the femoral head) on 7/3/26 and returned to the facility on 7/7/26. Interview and review of the statement with NA #7 on 8/3/26 at 1:28 PM identified she frequently cared for Resident #1 on the 7:00 AM to 3:00 PM shift. Resident #1 was often stiff, making it difficult to move the legs to visualize the inner legs and groin. On 7/1/26, Resident #1 was unusually difficult to transfer and grimaced with movement. She requested assistance from other NAs several times for transfers and incontinent care and reported the change to LPN #6. On 7/2/26, Resident #1 again was difficult to transfer, grabbed the right leg, grimaced with movement, extended the legs, and slid down in the chair. She notified LPN #8, who assisted with transferring Resident #1 back to bed using a gait belt. NA #7 reported seeing no bruising or discoloration on either 7/1/26 or 7/2/26 and was unable to determine the source of the pain. Interview with LPN #8 on 8/3/26 at 1:40 PM identified she completed the weekly skin evaluation for Resident #1 on 6/29/26 and observed no bruising, discoloration, pain, or difficulty standing. On 7/2/26, NA #7 reported Resident #1 was sliding down in the wheelchair and was difficult to transfer, requesting assistance. LPN #8 stated NA #7 did not report pain. She identified that if pain had been reported, she would have administered PRN acetaminophen. Although she observed Resident #1 sliding down in the wheelchair and knew the resident required a one person assist, she did not feel the transfer was difficult and did not believe NA #7's concerns needed to be reported to the nursing supervisor, provider, or therapy. She stated this was the first time she observed the issue and did not think anything of it. Interview with LPN #6 on 8/3/26 at 3:03 PM identified Resident #1 frequently slid down in the wheelchair and required staff assistance to be repositioned. She recalled that on 7/1/26 Resident #1 was again observed sliding down, and she helped the Recreation Assistant reposition Resident #1. LPN #6 reported that when she administered morning medications on 7/1/26, Resident #1 was already up in the wheelchair, so she did not see Resident #1's skin and did not observe signs of pain. NA #7 never reported difficulty transferring Resident #1 or an increase in pain. LPN #6 indicated she would have medicated Resident #1 and notified the provider immediately if changes had been reported. Additionally, she never reported the ongoing issue of Resident #1 sliding down in the wheelchair to therapy or the provider because she believed they were already aware. Interview with the Interim DON on 8/3/26 at 3:14 PM identified a licensed nurse should have performed an assessment and the provider should have been notified immediately of the change in condition when Resident #1 was observed to be in pain upon movement, was having increased difficulty transferring and was sliding down in the wheelchair, A therapy screen should have been submitted to therapy and a therapist should have been notified of the change. Interview with the APRN on 8/3/26 at 3:20 PM identified she was working in the building on 7/1/26 and reported she was never notified Resident #1 was having difficulty transferring, sliding down in the wheelchair and was complaining of acute pain with movement, which would have been a change in condition for Resident #1. She reported a provider should have been notified immediately upon observation and the delay in notification caused a delay in care. Interview with NA #6 on 8/4/26 at 10:14 AM identified on 7/2/26 when she arrived for her 3:00 PM shift, NA #7 reported she assisted Resident #1 to bed because he/she was tired but NA #7 never reported Resident #1 had been increasingly difficult to transfer or in pain. Around 3:30 PM she went to check on Resident #1, and he/she was agitated and refused care. She went back again just after 4:00 PM and Resident #1 still refused care. Around 5:00 PM Resident #1 would not eat so she notified LPN #2, who fed him/her dinner. She approached Resident #1 again between 5:30 and 6:00 PM and Resident #1 allowed her to provide care. As she went to change Resident #1, she noticed the right leg was significantly bigger than the left leg and bruising to the right leg. She immediately notified LPN #2. Resident #1 was subsequently sent to the ED around 9:00 PM. Review of statement by NA #9 identified on 7/1/26 he was not assigned to Resident #1 but observed Resident #1 sliding out of the chair on the 7:00 AM to 3:00 PM shift. Review of statement by NA #8 identified on 7/2/26 she worked the 7:00 AM to 3:00 PM shift and she observed Resident #1 sliding down in the wheelchair many times during the shift. They had to reposition Resident #1 several times in the wheelchair. Although attempted, interviews with NA #8, NA #9 were not obtained. Review of the Change of Condition in a Resident Status policy dated June 2023 directed, in part, that the facility shall notify the resident, the attending physician, and the resident's representative of changes in the resident's medical or mental condition. Nursing staff are to promptly contact the physician when events such as accidents, injuries of unknown origin, medication reactions, significant changes in condition, abnormal labs, refusals of treatment, or the need for transfer occur. It further defines significant change as a decline or improvement that does not self resolve, affects multiple areas of health, or requires interdisciplinary review and care plan revision. The RN will assess the resident's change in condition and document their findings in the medical record.Interview with the Rehab Director on 8/3/26 at 2:11 PM identified Resident #1 was screened by therapy on 6/24/26 following the 6/23/26 fall. During the screen, an NA was observed transferring Resident #1 without difficulty, and Resident #1 did not appear to be in pain at that time. Resident #1's skin was not assessed. The Rehab Director identified that if Resident #1 had pain during transfers, difficulty transferring, or was sliding down in the wheelchair, staff should have submitted a new therapy screen and notified him. If staff were unable to transfer Resident #1 safely, the transfer method should have been downgraded to a mechanical lift. He reported he was unaware that Resident #1 had been sliding down in the wheelchair prior to the 7/2/26 incident.

Based on review of clinical records, facility documentation, policies, and staff interviews for one of three sampled residents (Resident #1) reviewed for accidents/incidents, the facility failed to ensure timely reporting of an injury of unknown origin to the State Agency within the required two (2) hour timeframe. The facility did not identify, classify, or report a serious injury of unknown origin for more than 72 hours after discovery, despite policies requiring immediate reporting of suspected abuse, neglect, or injuries of unknown origin. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances, repeated falls, restlessness and agitation and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), and required substantial assistance for bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 4/7/26 identified Resident #1 was at risk for falls and had actual falls while in the facility and had the potential for alterations in skin integrity due to bowel and bladder incontinence, impaired mobility and cognitive deficits. Interventions included anticipating and meeting the resident's needs, monitoring skin during incontinent care and notifying charge nurse/supervisor of any signs and symptoms of skin breakdown/redness and performing weekly body evaluations and notifying the supervisor of any new skin issues. A nurse's note by RN #1 dated 6/23/26 at 3:57 PM identified she was called to Resident #1's room by the charge nurse (LPN #1) for an unwitnessed fall. Resident #1 was observed sitting on the floor with his/her back against the recliner with the wheelchair in front of him/her. Due to dementia, Resident #1 was unable to explain what happened to cause the fall but denied any pain or injury. Resident #1 could move all extremities, range of motion was within normal limits to all four (4) extremities and skin was intact with no open areas. Review of nurse's notes dated 6/23/26 through 7/1/26 failed to identify any skin abnormalities, pain or increased difficulty with transfers following the 6/23/26 unwitnessed fall. A Skin Evaluation by LPN #8 on 6/29/26 identified Resident #1's skin was intact and no new skin issues were identified. A nurse's note by RN #2 dated 7/2/26 at 9:00 PM identified on assessment of Resident #1, the right inner thigh and right lower extremity were bruised and edematous (swollen). The right lower extremity appeared shortened and externally rotated (turned outwards, away from the middle of the body). The last identified fall was on 6/23/26 and no injuries were identified. Upon palpation (when touched) and movement of the right extremity, Resident #2 exhibited severe pain. The Medical Director was notified, and an order was obtained to transfer Resident #1 to the Emergency Department (ED). A nurse's note by LPN #2 on 7/2/26 at 9:18 PM identified she was called to Resident #1's room following reports of bruising to Resident #1's right leg. Upon assessment, bruising was noted to Resident #1's right inner thigh, the right leg was edematous, painful with movement and palpation and the right leg appeared to be shortened. The nursing supervisor (RN #2) was notified and assessed Resident #1. Review of hospital documentation dated 7/2/26 identified a right femur x-ray was obtained and Resident #1 was found to have an acute right comminuted intertrochanteric fracture (a hip fracture where the upper part of the femur between the greater and lesser trochanters is broken into multiple fragments). Resident #1 underwent a right hip cephalomedullary nailing surgery (metal rod inserted down the center of the femur and anchored into the femoral head) on 7/3/26 and returned to the facility on 7/7/26.A facility Reportable Event (RE) dated 7/3/26 identified at 11:00 AM Resident #1, who was confused and required staff assistance with Activities of Daily Living (ADLs), transfers and ambulation, was observed with bruising to the right inner thigh and pain was noted. The provider was notified and Resident #1 was sent to the ED for evaluation. The RE was classified as an injury of unknown origin.Review of the State Agency Reportable Events website verified that the State Agency was notified of the injury of unknown origin on 7/5/26 at 10:41 PM, greater than 72 hours after the injury was documented to have been discovered on 7/2/26.Interview with the Interim DON on 8/3/26 at 2:23 PM identified an injury of unknown origin should be classified as abuse/neglect and investigated accordingly. She reported although she was not serving as the DON at the time of the incident, the injury of unknown origin should have been reported to the State Agency within two (2) hours of the discovery.Review of the Abuse Reporting policy dated 6/2023 directed, in part, that all personnel promptly report any incident or suspected incident of resident abuse, neglect, injuries of unknown origin, misappropriation of resident property, or mistreatment. The facility does not condone abuse by anyone and mandates immediate reporting of alleged violations to the administrator or designee. Abuse and neglect incidents must be investigated promptly. Staff who observe or suspect abuse must immediately report the incident to the charge nurse, providing details including the resident's name, date/time, location, involved persons, witnesses, and type of abuse. The charge nurse must examine the resident in cases of physical or sexual abuse, document findings, and ensure evidence is preserved. The policy directed completion of a Reportable Event Form along with written statements from witnesses. Allegations of abuse must be reported within 2 hours; allegations of neglect, exploitation, mistreatment, or misappropriation resulting in serious bodily injury must also be reported within 2 hours. All materials must be provided to the administrator within 24 hours, and the facility must complete an investigation with findings submitted within five working days. All phases of the investigation must remain confidential, and any person aware of abuse or mistreatment is obligated to report it. Attempts to prevent reporting or alter reports are prohibited.Review of the Accident and Incident Investigation policy dated 6/2023 directed, in part, all accidents and incidents be promptly reported to a supervisor and documented, with appropriate leadership notified depending on the severity of the event. It requires staff to communicate factual descriptions of their observations, initiate specific investigation tools based on the type of event, and ensure state and federal reporting requirements are met within required timeframes. The policy states that the Administrator, Director of Nursing, or designee must review all accidents and incidents to confirm required documentation is completed, determine causative or contributing factors, make every effort to ascertain the cause, and identify and implement interventions to prevent further occurrences.

Based on review of the clinical record, facility documentation/policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents/incidents, the facility failed to ensure an injury of unknown origin sustained by Resident #1, a cognitively impaired resident who required staff assistance for transfers and mobility, was thoroughly investigated according to regulatory requirements and facility policy. The facility failed to obtain statements from all staff who had contact with the resident during the 72 hours prior to the discovery of the injury, failed to follow up on reported changes in the resident's condition provided by a NA (NA #7), and failed to identify or interview additional personnel who had direct contact with the resident. These failures resulted in an incomplete investigation related to an injury of unknown origin, contrary to the facility's Abuse Reporting and Accident and Incident Investigation policies. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbances, repeated falls, restlessness and agitation and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), and required substantial assistance for bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 4/7/26 identified Resident #1 was at risk for falls and had actual falls while in the facility and had the potential for alterations in skin integrity due to bowel and bladder incontinence, impaired mobility and cognitive deficits. Interventions included anticipating and meeting the resident's needs, monitoring skin during incontinent care and notifying charge nurse/supervisor of any signs and symptoms of skin breakdown/redness and performing weekly body evaluations and notifying the supervisor of any new skin issues. A nurse's note by RN #1 dated 6/23/26 at 3:57 PM identified she was called to Resident #1's room by the charge nurse (LPN #1) for an unwitnessed fall. Resident #1 was observed sitting on the floor with his/her back against the recliner with the wheelchair in front of him/her. Due to dementia, Resident #1 was unable to explain what happened to cause the fall but denied pain or injury. Resident #1 could move all extremities, range of motion was within normal limits to all four (4) extremities and skin was intact with no open areas. Review of nurse's notes dated 6/23/26 through 7/1/26 failed to identify any skin abnormalities, pain or increased difficulty with transfers following the 6/23/26 unwitnessed fall. A Skin Evaluation by LPN #8 on 6/29/26 identified Resident #1's skin was intact and no new skin issues were identified. A nurse's note by RN #2 dated 7/2/26 at 9:00 PM identified on assessment of Resident #1, the right inner thigh and right lower extremity were bruised and edematous (swollen). The right lower extremity appeared shortened and externally rotated (turned outwards, away from the middle of the body). The last identified fall was on 6/23/26 and no injuries were identified. Upon palpation (when touched) and movement of the right extremity, Resident #2 exhibited severe pain. The Medical Director was notified, and an order was obtained to transfer Resident #1 to the Emergency Department (ED). A nurse's note by LPN #2 on 7/2/26 at 9:18 PM identified she was called to Resident #1's room following reports of bruising to Resident #1's right leg. Upon assessment, bruising was noted to the right inner thigh, the right leg was edematous, painful with movement and palpation and the right leg appeared to be shortened. The nursing supervisor (RN #2) was notified and assessed Resident #1. Review of hospital documentation dated 7/2/26 identified a right femur x-ray was obtained and Resident #1 was found to have an acute right comminuted intertrochanteric fracture (a hip fracture where the upper part of the femur between the greater and lesser trochanters is broken into multiple fragments). Resident #1 underwent a right hip cephalomedullary nailing surgery (metal rod inserted down the center of the femur and anchored into the femoral head) on 7/3/26 and returned to the facility on 7/7/26.A facility Reportable Event (RE) dated 7/3/26 identified at 11:00 AM Resident #1, who was confused and required staff assistance with Activities of Daily Living (ADLs), transfers and ambulation, was observed with bruising to the right inner thigh and pain. The provider was notified and Resident #1 was sent to the ED for evaluation. The RE was classified as an injury of unknown origin.The RE 5-day summary dated 7/8/26 identified a 72-hour look back was completed and did not reflect any falls, skin concerns or pain.Review of the facility schedules dated 6/30/26, 7/1/26 and 7/2/26 identified RN #3, RN #4, RN #5, LPN #1, LPN #2, LPN #3, LPN #5, LPN #6, LPN #7, LPN #8, NA #1, NA #2, NA #3, NA #5, NA #6 and NA #7 had been assigned to work on Resident #1's unit.Interviews with staff on 8/3/26 identified Resident #1 resided on a memory care unit and the Director of Recreation, and the Recreation Aide had also been in close contact with Resident #1 in the days leading up to the 7/2/26 incident and had helped reposition Resident #1 in the wheelchair.Review of the facility Accident and Investigation / Incident (A & I) documents for Resident #1 failed to identify statements were obtained from RN #4, RN #5, LPN #1, LPN #3, LPN #5, LPN #6, NA #2, the Director of Recreation and the Recreation Aide.Review of NA #7's statement dated 7/6/26 identified she worked the 7:00 AM to 3:00 PM shift on 7/1/26 and 7/2/26. On 7/1/26, Resident #1 had trouble standing in the morning when transferring to the chair, so another NA assisted. After lunch, another NA was again required to stand Resident #1 to change him/her. On 7/2/26, she also required assistance from another NA to transfer Resident #1 and then later in the shift, Resident #1 had trouble sitting in the wheelchair without sliding down in the seat and required assistance to sit back up. After lunch, she again required assistance to change Resident #1 and transfer him/her back to bed. The statement reported that on both 7/1/26 and 7/2/26, she reported to the nurses Resident #1's difficulties and sliding down in the chair. The facility failed to obtain a follow-up statement with NA #7 inquiring who the NAs were that assisted her with transferring Resident #1 or who she reported the difficulties with Resident #1's transfers and sliding down in the chair to.Review of the facility schedules and clinical documentation dated 7/1/26 and 7/2/26 identified LPN #6, LPN #7 and LPN #8 had been assigned to Resident #1 on the 7:00 AM to 3:00 PM shifts. Re-review of the facility A&I documents failed to identify a statement from LPN #6 to follow-up on NA #7's report. Interview with the Interim DON on 8/3/26 at 2:23 PM identified an injury of unknown origin should be classified as abuse/neglect and investigated accordingly. She reported statements or interviews should have been obtained from all staff who had contact with Resident #1 during the 72 hours preceding the reported injury. Any new or conflicting information identified through those interviews should have been promptly followed up by Administration. She was unable to provide documentation showing that these steps had been completed.Review of the Abuse Reporting policy dated 6/2023 directed, in part, that all personnel promptly report any incident or suspected incident of resident abuse, neglect, injuries of unknown origin, misappropriation of resident property, or mistreatment. Abuse and neglect incidents must be investigated promptly. Staff who observe or suspect abuse must immediately report the incident to the charge nurse, providing details including the resident's name, date/time, location, involved persons, witnesses, and type of abuse. The charge nurse must examine the resident in cases of physical or sexual abuse, document findings, and ensure evidence is preserved. The policy directed completion of a Reportable Event Form along with written statements from witnesses. Allegations of abuse must be reported within 2 hours; allegations of neglect, exploitation, mistreatment, or misappropriation resulting in serious bodily injury must also be reported within 2 hours. All materials must be provided to the administrator within 24 hours, and the facility must complete an investigation with findings submitted within five working days. Review of the Accident and Incident Investigation policy dated 6/2023 directed, in part, all accidents and incidents be promptly reported to a supervisor and documented, with appropriate leadership notified depending on the severity of the event. It requires staff to communicate factual descriptions of their observations, initiate specific investigation tools based on the type of event, and ensure state and federal reporting requirements are met within required timeframes. The policy states that the Administrator, Director of Nursing, or designee must review all accidents and incidents to confirm required documentation is completed, determine causative or contributing factors, make every effort to ascertain the cause, and identify and implement interventions to prevent further occurrences.

Based on review of the clinical record, facility documentation, facility policies, and staff interviews, for one (1) of three (3) sampled residents reviewed for abuse (Resident #8), the facility failed to protect a resident from abuse when staff failed to implement interventions for a roommate (Resident #7) with known, escalating aggressive and delusional behaviors, resulting in Immediate Jeopardy to resident health and safety. Specifically, despite documented behavioral episodes beginning on 4/3/26 - including agitation, yelling, paranoia, combativeness, and medication refusals - the facility failed to develop a behavior care plan or a care plan addressing medication refusals for Resident #7. On 4/15/26 and 4/16/26, staff failed to administer a prescribed PRN medication (trazodone 25 mg) for documented agitation and behavioral symptoms, failed to reattempt medication administration following refusal, and failed to implement alternative non-pharmacological interventions. On 4/16/26 at approximately 3:00 AM, following an episode in which Resident #7 refused food, threw food at staff, refused trazodone, and remained agitated and talking to him/herself, staff left Resident #7 unsupervised in a shared room with Resident #8 - a cognitively and physically impaired roommate with a Brief Interview for Mental Status (BIMS) score of 3 who was dependent on staff for transfers and had limited ability to protect him/herself. At approximately 3:30 AM, staff heard a loud noise, entered the room, and observed Resident #7 standing over Resident #8, holding a round hairbrush, yelling. Resident #8 was found with bruising to the left eye, face, and right hand, and his/her face was saturated with lotion. Resident #8 was subsequently transported to the emergency department, where imaging confirmed an acute subarachnoid hemorrhage (bleeding between the brain and the tissue covering it), new since a prior exam on 11/27/25. Resident #8's blood thinner (Eliquis) was held for two weeks due to the intracranial bleed. The facility's own Director of Nursing (DON) stated that if Resident #7 had been supervised, the incident could have been prevented. These failures resulted in the finding of Immediate Jeopardy. The findings include:1. Resident #8's diagnoses included dementia without behavioral disturbances, chronic pain, major depressive disorder and anxiety disorder.A physician's order dated 10/8/25 directed Resident #8 required an assist of two (2) stand pivot transfer and utilized a wheelchair for mobility.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance with bed mobility and was dependent on staff for transfers.The Resident Care Plan (RCP) dated 4/9/26 identified Resident #8 had impaired cognitive function or impaired thought processes related to dementia, a communication problem related to a cognitive deficit, was hard of hearing and had limited physical mobility related to a Cerebrovascular Accident (CVA). Interventions included anticipating and meeting needs, cueing, reorienting and supervising as needed and ensuring and providing a safe environment.2. Resident #7's diagnoses included metabolic encephalopathy (a change in brain function due to an underlying condition), dementia without behavioral disturbances, mild cognitive impairment, delusional disorder, anxiety disorder and major depressive disorder.The Nursing Evaluation dated 4/1/26 identified Resident #7 was admitted for a change in mental status, chronic decline and wandering. Resident #7 was alert and oriented to person, place and time and required extensive assistance for bed mobility, transfer and ambulation status was not determined at that time.A physician's order dated 4/2/26 directed Resident #7 was independent for mobility with no device on the secured memory unit.A physician's order dated 4/3/26 directed trazodone oral tablet 50 milligrams (mg), administer 25 mg by mouth every six (6) hours as needed for anxiety, restlessness or agitation.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #7 had impaired cognitive function related to dementia, utilized psychotropic medications related to anxiety, depression and dementia, resided on the secured memory unit and ambulated independently with no assistive device on the secured memory unit. Interventions included anticipating and meeting needs, keeping the routine consistent and try to provide consistent care givers to decrease confusion, cueing, reorienting and supervising as needed, administering medications as ordered and monitoring and documenting side effects and effectiveness.An Order Administration note by RN #3 dated 4/15/26 at 1:45 AM identified Resident #7 was paranoid, talking to him/herself loudly, ambulated the hallway and complained of being unable to sleep. Trazodone 25 mg was administered.An Order Administration note by RN #3 dated 4/15/26 at 4:06 AM identified the trazodone was effective in managing behavioral symptoms.A nurse's note by RN #4 dated 4/15/26 at 3:04 PM identified Resident #7 was paranoid, yelling and not easily redirected. Medications were taken after multiple attempts.A nurse's note by RN #3 on 4/16/26 at 3:49 AM identified at around 3:30 AM, Resident #7 became belligerent due to not being able to have breakfast, food and fluids were offered but Resident #7 refused to take any meal items that were offered. Resident #7 went back to bed, staff heard Resident #7 talking to him/herself and a few minutes later, a loud noise was heard, staff ran to the room and observed Resident #7 standing next to the roommates (Resident #8's) bed holding a round brush and yelling at him/her. The left side of Resident #8's hair was covered in lotion and Resident #8 had a red mark to the left side of the nose, bruising to the left eye and bruising to the right hand. The residents were immediately separated, one-to-one observation was initiated for Resident #7, Emergency Medical Services (EMS) was called, the provider was notified and the responsible parties were notified.Review of the April 2026 Medication Administration Record (MAR) failed to identify Resident #7 had been administered trazodone 25 mg for anxiety, restlessness or agitation per physician's order on 4/15/26 by RN #4 or on 4/16/26 by RN #3 prior to or following the documented behaviors.Review of the clinical record from 4/1/26 through 4/14/26 identified on 4/3/26 Resident #7 had increased agitation and yelling, refused medications and was unable to be directed. Resident #7 was found laying in a male resident's bed and multiple attempts were made to remove Resident #7 without success. There were multiple notations of Resident #7 refusing medications, weights, skin checks, vital signs, blood work and treatments as well as becoming agitated, confused, yelling, accusatory, paranoid, and combative with care.Review of the RCP for Resident #7 failed to identify a behavior care plan or a care plan related to refusals for Resident #7.Review of the Prehospital Care Report (ambulance run sheet) dated 4/16/26 identified EMS were dispatched to the facility on 4/16/26 at 3:50 AM, arrived on site at 4:00 AM and departed the facility at 4:19 AM. It was reported to them that staff found Resident #8's roommate (Resident #7) on top of him/her beating him/her in the face and head with a heavy hairbrush and Resident #8 did not know what happened but did know that he/she was injured. Resident #8 presented with severe bruising, swelling, discoloration, pain, and tenderness to his/her face, around the eyes, and on the forehead and staff reported Resident #8's roommate covered Resident #8 in lotion, which was found dripping out of Resident #8's ears.A psychiatric APRN note by APRN #2 on 4/16/26 identified she was asked to see Resident #7 following the alleged altercation with Resident #8. Resident #7 was calm but increasingly confused and Resident #7 explained someone broke into his/her room last night and he/she was fearful, reporting the person was his/her family member who molested him/her at a young age. The note identified Resident #7 was noted by staff to be calling Resident #8 a name with Resident #7's last name. Resident #7 was currently on one-to-one observation and showing signs of increased confusion and delusions and due to unpredictability of Resident #7's behaviors, recommended an inpatient psychiatric and medical evaluation and that the facility would facilitate the transfer. Resident #7 was calm and pleasant, was not a danger to him/herself or others but could become increasingly confused later in the afternoon/evenings and recommended continued one-to-one supervision until Resident #7 was transferred later in the day. A nurse's note by the DON on 4/16/26 at 1:03 PM identified Resident #7 was a planned pick-up at 7:30 PM for transfer to the inpatient psychiatric hospital and report was called in.Review of the hospital Emergency Department (ED) documentation dated 4/16/26 identified Resident #8 was seen following an assault and reported a contusion (soft tissue injury caused by blunt force trauma) to the right side of the head, contusion to the face and contusion to the right hand. Imaging dated 4/16/26 at 6:37 AM identified a small five (5) by six (6) millimeter peripheral hyper density in the right frontal region, new since prior exam on 11/27/25, consistent with an acute subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissue that covers and protects it). The documentation directed for Resident #8 not to take Eliquis (blood thinner) for two (2) weeks and to follow-up with the primary care provider.Review of the facility census on 4/20/26 identified Resident #7 remained hospitalized .Interview and observation of Resident #8 on 4/20/26 at 12:09 PM, identified purple and yellow bruising to the left side of the face and under the left eye, reddened discoloration under the right nostril, large bruising to both forearms and bruising to the right hand.Interview with NA # 12 on 4/21/26 at 9:07 AM identified on 4/16/26 she was providing care to Resident #8 around 6:00 PM, who had no visible bruising or injuries. Resident #7 was in the room talking to him/herself, yelling out and shrieking. She identified she could not redirect Resident #7 and RN #3 later came in, spoke with Resident #7 and pulled the curtain all the way around his/her bed and Resident #7 calmed down. NA #12 worked the 11:00 PM to 7:00 AM shift preceding and Resident #7 was out of bed, walking around and yelling out the door prior to the incident that occurred with Resident #8. She reported that at around 3:30 AM, she heard a loud noise and entered the room and Resident #7 was standing over Resident #8 with an object and Resident #8 was saturated with lotion and had multiple injuries, including a left black eye and reported it appeared Resident #8 had put his/her right arm up in defense, as it was starting to discolor. NA #12 identified Resident #8, was always seen smiling prior to the incident, appeared scared and fearful following the incident. She was directed by RN #3 to sit with and observe Resident #7 following the incident and Resident #7 reported thinking Resident #8 was a family member that hurt him/her as a child.Interview with NA # 11 on 4/21/26 at 9:41 AM identified she normally worked on the locked memory unit where both Residents #7 and #8 resided and she was assigned to Resident #7 the night of the incident. She identified since Resident #7 was admitted to the facility on [DATE], would intermittently talk to him/herself, scream, slam doors and wander the halls while awake. Prior to the incident, Resident #7 started yelling around 2:30 AM and was in and out of bed, She identified she last saw Resident #7 around 3:00 AM and at that time he/she had gone back to bed but was still talking to him/herself. NA #11 identified she went to care for other residents and around 3:30 AM heard yelling. When she went into the room, she observed Resident #7 standing next to Resident #8 and Resident #8 had bruising to his/her left eye and face, bruising to the right arm and his/her face was covered in lotion and reported Resident #8 appeared fearful of Resident #7. NA #11 identified looking back, Resident #7 probably should have been brought out of the room and into the common area so he/she could have been supervised. She identified staff would not have performed frequent checks on Resident #7 while in the room because Resident #7 continuously closed the room door.Interview with RN #3 on 4/21/26 at 8:26 AM identified on 4/15/26 she worked part of the 3:00 PM to 11:00 PM shift. Resident #7 was yelling and getting in and out of bed but Resident #7 seemed to calm down after she spoke with him/her and closed the curtain. She identified at around 2:00 AM, she heard Resident #7 talking to him/herself and yelling again so she went to speak with Resident #7 who was ordering breakfast into the call bell and started demanding a full hot breakfast and hot tea and then got out of bed and started walking around. She reported she left to try and gather some food for Resident #7 and when she returned Resident #7 refused the food and drinks she offered, threw the food back at her and became increasingly agitated. RN #3 reported she then attempted to give Resident #7 trazodone but he/she refused, and Resident #7 went back into the room and herself and NA #11 stood outside the door for a few minutes. Resident #7 seemed to calm down so they left the door ajar and went to care for other residents around 3:00 AM. RN #3 reported that at around 3:30 AM she heard yelling and went into Resident #7's room and saw him/her standing over Resident #8 with a round hairbrush in his/her hand and Resident #8 was noted with bruising to the left eye, face and right hand but Resident #7 would not explain what he/she had done. After calling EMS and the families, EMS refused to take Resident #7 because he/she appeared alert and oriented and refused to go, so Resident #7 remained in the building on a one-to-one until seen by a provider. At around 4:30 AM, Resident #7 was again yelling, slamming things in the room and trying to get out of the window. RN #3 identified she did not normally work on the locked memory unit. She identified she administered trazodone to Resident #7 the previous night when he/she started yelling which was effective. She could not explain why she did not immediately administer trazodone when Resident #7 began having behaviors around 6:00 PM on 4/15/26 or at 2:00 AM on 4/16/26. She reported she should have reapproached Resident #7 and reattempted to medicate him/her with the trazodone after the first refusal and identified she should not have left Resident #7 alone in the room with Resident #8 after Resident #7 was identified to be agitated. She thought Resident #7 calmed down but was still talking to him/herself and should have brought Resident #7 to the common area to be supervised by staff.Interview with APRN #2 (psychiatric APRN), on 4/20/26 at 2:15 PM identified she saw Resident #7 numerous times and made several medication adjustments. She did not receive clear staff reports regarding Resident #7's behaviors or incidents. The trazodone was ordered for anxiety, restlessness or agitation and if Resident #7 displayed those behaviors, staff should have offered the medication, documented on the behaviors and documented the effectiveness of the medication. She identified Resident #7 should have been supervised while the behaviors were occurring and ensured Resident #7 was completely calm and back to baseline after the aggressive behavior prior to allowing Resident #7 to go back to his/her room with Resident #8. Additionally, she identified Resident #7 was increasingly confused and not at baseline when she evaluated him/her on 4/16/26 and reported Resident #8 still appeared nervous when she saw him/her on 4/16/26.Interview with the Director of Rehab on 4/22/26 at 3:01 PM identified Resident #8 was an assist of two (2) stand pivot for transfers and utilized the wheelchair for mobility and Resident #8's ambulation level fluctuated but he/she required a rolling walker for ambulation with therapy. She identified she never saw Resident #8 get off the floor, had never evaluated Resident #8 for getting off the floor and was unsure of Resident #8's arm and leg strength to be able to push and pull him/herself up independently into a standing position but the resident was an assist of 2 for transfers. She reported she could not answer with certainty if it was possible for Resident #8 to have fallen out of bed and gotten him/herself up off the floor independently and back into bed independently within a half hour to have sustained a subarachnoid hemorrhage.Interview with the DON on 4/20/26 at 3:40 PM identified if a resident is ordered a medication by a psychiatric provider for anxiety, agitation or restlessness, staff should be attempting to administer the medication to the resident if behaviors occur so the resident's behaviors do not escalate out of control. She identified if a resident refuses a medication, other interventions should be implemented for safety, and the resident should be reapproached several times. She reported if a resident has behaviors, including aggression, staff should monitor the resident to ensure the resident is completely calmed down and have the resident sit in the common area so they can be supervised by several staff. She identified Resident #7 should not have been left in his/her room without frequent checks or supervision for a half hour following identified behaviors. She identified if Resident #7 was supervised the incident could have been prevented.Review of the Preventing Resident Abuse policy dated 6/2023 directed, in part, the abuse prevention/intervention program included: Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect and assessing residents with signs and symptoms of behavioral problems and developing and implementing care plans that can assist in resolving behavioral issues.Review of the Abuse Reporting policy dated 6/2023 directed, in part, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm of pain or mental anguish or deprivation by an individual. Physical abuse is defined as hitting, slapping, pinching, kicking, etc.Review of the Q15 minute and 1 to 1 policy dated 7/2023 directed, in part, that the policy establishes procedures for the observation of residents at risk of self harm, aggression, elopement, or severe confusion/agitation ensuring safety. 1:1 constant observation is when a staff member is assigned to a single resident, maintaining direct line-of-sight at all times including bathroom. Staff must not leave patient unless an in-person report is given. Q15 minute observation is physically checking and verifying the safety of a resident within every 15 minutes and documenting. Although requested, a facility policy for behavioral management was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of five (5) sampled residents (Resident #1 and #2) reviewed for accident hazards, the facility failed to ensure residents received altered texture diets consistent with physician's orders and International Dysphagia Diet Standardization Initiative (IDDSI) guidelines and were provided supervision during meals as required for residents with dysphagia, creating a choking hazard. Specifically, on 3/19/26 at approximately 1:00 PM, Resident #1, who had diagnoses of dementia and dysphagia who required supervision during meals and was ordered an IDDSI Level 6 diet, was served and consumed a peanut butter and jelly sandwich that was not ordered and not consistent with the prescribed diet. Resident #1 began choking, was observed to be red in the face and unable to breathe and required the Heimlich maneuver to be performed to expel the obstructing food. Upon further observation, Resident #1 was feeding him/herself in the dining room although following the choking incident, Resident #1 required one-to-one feeding assistance. The failures resulted in the finding of Immediate Jeopardy. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, oropharyngeal dysphagia (weakening of the throat muscles making it difficult to move food from the mouth into the throat and esophagus during swallowing) cerebrovascular disease (conditions that affect blood flow in the brain) and type II diabetes mellitus.A physician's order dated 7/4/25 directed a regular diet IDDSI 6 soft and bite sized texture, IDDSI 0 thin Liquids consistency. The orders directed Resident #1 to utilize a lip plate, built-up utensils, and required supervision with meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4), and required supervision assistance for eating and was dependent on staff for oral care, bed mobility and transfers. Resident #1 required a mechanically altered diet.The Resident Care Plan (RCP) dated 1/20/26 identified Resident #1 had impaired cognitive function or impaired thought processes related to dementia and had a potential swallowing problem related to a history of dysphagia and cerebral infarction (an ischemic stroke where the blood supply to part of the brain is blocked or reduced preventing brain tissue from getting oxygen and nutrients). Interventions included providing supervision with meals, diet to be followed as prescribed, instructing Resident #1 to eat in an upright position, to eat slowly, and to chew each bite thoroughly, monitoring/documenting/reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals and monitoring for shortness of breath, choking, labored respirations and lung congestion.A late entry nurse's note by RN #1 (the 7:00 AM to 3:00 PM nursing supervisor) dated 3/19/26 at 1:59 PM identified she was called to the dining room where Resident #1 was in the wheelchair eating lunch when he/she experienced a choking episode and the Heimlich maneuver was performed. Resident #1's lung sounds were clear but diminished bilaterally and vital signs were obtained to include a heart rate of 96, blood pressure of 151/95 and oxygen level of 95 percent (%) on room air. Resident #1 remained at the nurse's desk for further evaluation by APRN #1 and no new orders were obtained.A nurse's note by the DON on 3/19/26 at 2:06 PM identified she was called to assess Resident #1 following an incident of choking while in the dining room. The Speech Language Pathologist (SLP) was in the dining area and yelled out to LPN #1 who responded and performed the Heimlich maneuver. A speech evaluation was placed, the physician and Conservator were notified and vital signs were to be initiated and obtained every four (4) hours.Review of nurse's notes dated 3/19/26 for the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts failed to identify monitoring or assessments following the choking incident.A provider note by APRN #1 dated 3/20/26 identified Resident #1 had a choking episode on 3/19/26 requiring the Heimlich maneuver. APRN #1 directed a 2-view chest x-ray to evaluate for aspiration or consolidation and that staff would obtain vital signs every shift for 3 days and lab work would be obtained 3/23/26 to monitor for developing leukocytosis (elevated white blood cell count signifying an infection) or dehydration. Additionally, Resident #1's diet was downgraded to minced and moist and Resident #1 would be a one (1) to one (1) feed for meals.A physician's order dated 3/20/26 directed a regular diet, IDDSI 5 minced and moist texture, IDDSI 0 thin liquids consistency.A physician's order dated 3/20/26 directed Occupational Therapy Activities of Daily Living recommendation: 1:1 feed for meals.Review of the IDDSI guidance identified level 6 soft and bite sized texture included bite sized pieces no bigger than 1.5 centimeters (cm) by 1.5 cm pieces to reduce choking risks and should be able to be mashed or broken down with the pressure from a fork. No regular dry bread due to choking risks and to avoid sticky or gummy food including nut butters. Interview with the SLP on 4/13/26 at 11:45 AM identified Resident #1 had not been on her caseload at the time of the 3/19/26 incident, but reported residents who are on an altered texture diet for dysphagia and wish to have peanut butter and jelly sandwiches require an evaluation by a SLP to ensure safety. If approved, a physician's order should be entered to allow peanut butter and jelly sandwiches per exception, and the sandwich should be cut into 1.5 cm by 1.5 cm pieces. She identified that on 3/19/26, she was evaluating another resident in the dining room and had her back to Resident #1 when she heard loud banging on a table. She turned around, observed Resident #1 to be red in the face and it appeared Resident #1 was not breathing. She ran to the doorway of the dining room and alerted LPN #1, who was sitting at the nurse's station near the dining room entrance. The SLP reported LPN #1 immediately ran into the dining room, assessed Resident #1 and performed the Heimlich maneuver which dislodged a piece of food. The food and Resident #1's dentures launched out of his/her mouth. Following the incident, nursing downgraded the diet to puree, requested a speech evaluation, and she evaluated Resident #1 on 3/20/26. The evaluation identified Resident #1 was unable to self-feed due to cognition, required rate modification (slowing eating rate) had decreased safety awareness and the SLP recommended a downgrade to a level 5 minced and moist texture diet, which did not include peanut butter and jelly sandwiches. Resident #1 required one-to-one feeding assistance. The SLP identified the 3/19/26 choking incident could have been prevented if Resident #1's diet orders were followed. She reported she was not asked to supervise the dining room for the lunch meal on 3/19/26, she was only focused on the resident she was in the dining room to evaluate.Interview with LPN #1 on 4/13/26 at 11:14 AM identified on 3/19/26 she was at the nurse's station when the SLP ran to the dining room entrance and alerted her Resident #1 was choking. She reported she assessed Resident #1, who was clenching his/her teeth shut and she was unable to see food in Resident #1's mouth so she performed the Heimlich maneuver which required six (6) to seven (7) thrusts to dislodge the food. LPN #1 identified Resident #1 always received crustless, halved peanut butter and jelly sandwiches with meals and she was unaware there was no order for the sandwich or that it was not permitted on a level 6 texture diet. LPN #1 could not identify which NA was assigned to supervise lunch in the dining room or if there was an NA in the dining room to supervise lunch.Interview with RN #1 on 4/13/26 at 1:24 PM identified when she arrived on the unit on 3/19/26, Resident #1 was sitting upright in the wheelchair at the nurse's station. She reported Resident #1's eyes were red and watery, she assessed Resident #1 immediately and vital signs were normal, had no abnormal lung sounds and no further coughing was noted. She texted APRN #1 to report the incident, but APRN #1 did not respond. She did not contact the on-call provider or the Medical Director when she did not receive a response from APRN #1. RN #1 entered an order for vital signs every four (4) hours for three (3) days, downgraded Resident #1's diet to puree, entered a speech screen, and notified APRN #1 the following morning. She identified the subsequent licensed nurses should have monitored and documented assessments until Resident #1 was evaluated by APRN #1. She reported all staff interacting with residents on altered texture diets should be aware of what the diets include. She identified NA's are responsible for ensuring care is provided according to the residents plan of care and staff should have ensured Resident #1 was supervised for the lunch meal. RN #1 was unable to identify if there was an NA present in the dining room at the time of the choking incident.Interview with APRN #1 on 4/13/26 at 2:25 PM identified she was not scheduled to work on 3/19/26 and evaluated Resident #1 on 3/20/26. She reported Resident #1 should have been evaluated to eat peanut butter and jelly sandwiches prior to being served the sandwiches and identified a physician's order should have been in place allowing Resident #1 to have the peanut butter and jelly sandwiches only if it was deemed safe by the SLP. APRN #1 reported staff should follow diet orders and supervision orders prior to providing any resident with food or drinks. She identified that providing residents with food that is not authorized for a specific altered diet causes a choking risk. She reported RN #1 should have contacted the on-call provider or the Medical Director following the choking incident so a chest x-ray could have been ordered and obtained the same day to rule out aspiration.Review of the facility schedule dated 3/19/26 identified NA #1, NA #3, NA #4, NA #5, NA #10 and LPN #2 were also working on the south-east unit on the 7:00 AM to 3:00 PM shift on 3/19/26.Interviews with NA #1, NA #3, NA #4, NA #5, NA #10 and LPN #2 on 4/13/26 identified they were not assigned to the dining room for the lunch meal on 3/19/26 and did not witness Resident #1 choking around 1:00 PM. They identified at least one (1) NA is required to be present in the dining room at all times once meals are served to supervise residents and reported Resident #1 always received peanut butter and jelly sandwiches with meals for as long as they could remember and they were unaware a level 6 texture diet did not include peanut butter and jelly sandwiches or where guidance on IDDSI diets was posted. Additionally, NA #1 identified she often gave Resident #1 crustless peanut butter and jelly sandwiches for snacks because she thought Resident #1 could have them.Interview with the Rehab Director on 4/13/26 at 12:30 PM identified that per her records, Resident #1 was never evaluated by an SLP for an exception for peanut butter and jelly sandwiches. Residents on a modified diet that prohibits peanut butter should not be provided with a peanut butter and jelly sandwich unless first cleared by a SLP for an exception and then approved by the provider and an order entered. The Rehab Director identified the choking incident could have been prevented if staff followed the diet order.Observations of the dining room on 4/13/26 at 12:57 PM identified NA #2 and NA #3 present in the dining room for the lunch meal. Resident #1 was observed feeding him/herself, although a physician's order was in place directing Resident #1 receive one-to-one feeding assistance. Further, Resident #1's meal ticket did not indicate Resident #1 required one-to-one feeding assistance.Interview and observation with the Rehab Director on 4/13/26 at 1:00 PM identified NA #2 to be sitting in a chair beside Resident #1 in the dining room assisting Resident #1 with ice cream. Resident #1 was noted to have regular utensils and not built-up foam utensils in front of him/her. The Rehab Director identified following the 3/19/26 choking incident, Resident #1 required one-to-one feeding assistance so staff should have been feeding Resident #1 at all times. At 1:01 PM, NA #2 reported to the Rehab Director that Resident #1 was feeding him/herself.Interview with the Food Service Director (FSD) on 4/13/26 at 1:07 PM identified a level 6 soft and bite sized diet includes soft foods that are cut into 1.5 cm cubes and would not include peanut butter and jelly sandwiches. She reported Resident #1 was on a level 6 texture diet and his/her meal tickets included a peanut butter and jelly sandwich to be provided for each meal. She was unsure who approved the sandwich and was unable to locate a diet order slip directing dietary that Resident #1 had been approved to receive peanut butter and jelly sandwiches. Additionally, she identified all residents on modified diets would receive a crustless sandwich cut in half, reporting that they were never cut into 1.5 cm cubes or smaller.Interview with the Staffing Coordinator on 4/13/26 at 1:55 PM identified the 3/19/26 NA assignment sheet did not have any 7:00 AM to 3:00 PM staff assigned to supervise the dining room for the lunch meal. She identified that the nursing supervisors were responsible for assigning staff for their shift which was not consistently done. Review of Resident #1's Kardex on 4/13/26 identified Resident #1 was on a mechanically altered diet and required supervision for eating. (Not consistent with physician's order)Interview with the DON on 4/13/26 at 5:39 PM identified Resident #1 should have been provided with his/her diet per physician's orders, and staff should be aware of a residents diets, restrictions and ensuring meal tickets match the meal provided prior to serving a meal. She identified that following the incident, staff reported to her that Resident #1 always received peanut butter and jelly sandwiches with meals. She reported peanut butter and jelly sandwiches are outside of the level 6 texture and Resident #1 should have been evaluated by the SLP and an order should have been obtained prior to Resident #1 receiving a peanut butter and jelly sandwich. She reported residents who require supervision or one-to-one assistance should receive that level of care with all meals and the plan of care should be accurate. She identified two (2) NA's should be present in the dining room at all times once food is served. She was unable to identify if a NA was present when the choking incident occurred. The DON reported Resident #1 should not have been served peanut butter and jelly sandwiches and if Resident #1 had been provided with the correct diet and received supervision per physician's orders, the choking incident could have been avoided. Additionally, RN #1 should not have called APRN #1 on 3/19/26 following the incident, since she was not working and should have contacted the on-call provider or the Medical Director. She identified following any resident concern or change in condition, if a provider is contacted and they do not call back within ten (10) minutes, staff are to call back or contact a different provider and document accurately regarding provider notification.Interview with NA #8 on 4/14/26 at 9:55 AM identified she was assigned to the Pavilion unit on 3/19/26, did not see or have any contact with Resident #1 and was not assigned and did not go into the dining room on 3/19/26. 2. Resident #2's diagnoses included oropharyngeal dysphagia and cerebral infarction (an ischemic stroke where blood supply to part of the brain is blocked or reduced).A physician's order dated 7/4/25 directed a regular diet, IDDSI 6 soft and bite sized texture, IDDSI 3 moderately thick/ honey consistency and Resident #2 may have soft crustless sandwiches (tuna salad, egg salad, peanut butter and jelly) and required supervision with meals.A Stern Speech Therapy Screen by SLP #1 dated 7/31/25 identified Resident #2 was currently on a IDDSI 6 and honey thickened liquids diet, but she observed Resident #2 demonstrating overt signs and symptoms of aspiration with coughing after swallowing food. The screen identified a SLP evaluation for oropharyngeal swallow function was warranted.A physician's order dated 7/31/25 directed to provide Resident #2 a regular diet, IDDSI 5 minced and moist texture, IDDSI 3 moderately thick/honey consistency liquids.The SLP Discharge Summary for dates of service 7/31/25 through 10/24/25 and signed by SLP #1 on 10/27/25 identified Resident #2 met the highest practical level of function and refused to engage in speech therapy treatment or adhere to safe swallowing strategies that may have improved function. Diet recommendations were made for IDDSI 5 minced and moist texture, IDDSI 3 moderately thick/honey consistency liquids. The Discharge Summary did not identify Resident #2 was evaluated for peanut butter and jelly sandwiches or that Resident #2 was safe to consume peanut butter and jelly sandwiches.Physician's orders dated 9/11/25 and 1/6/26 directed Resident #2 may have crustless peanut butter and jelly sandwiches with every meal.Review of the clinical record from 10/25/25 through 4/13/26 failed to identify Resident #2 was evaluated by an SLP approving the crustless peanut butter and jelly sandwiches for Resident #2 after the 10/24/25 discharge.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), and required setup assistance for eating, partial assistance for bed mobility and was dependent on staff for oral hygiene and transfers. The MDS identified Resident #2 required a mechanically altered diet. The Resident Care Plan (RCP) dated 2/3/26 identified Resident #2 had impaired cognitive function and dysphagia. Interventions included cueing, reorienting and supervising as needed, providing setup assistance for feeding and an assist of one (1) as needed, providing a regular diet, IDDSI level 5 minced and moist texture; IDDSI 3 moderately thick/honey consistency liquids, providing a crustless peanut butter and jelly sandwich with each meal, taking aspiration precautions such as elevating the head of the bed, remaining in an upright position when eating.Observations of the dining room on 4/13/26 at 12:57 PM identified NA #2 and NA #3 present in the dining room for the lunch meal. Resident #2 was observed to have been served a halved, crustless peanut butter and jelly sandwich. NA #2 and NA #3 identified Resident #2 always received a crustless peanut butter and jelly sandwich with meals.Review of the IDDSI guidance identified level 5 minced and moist texture included foods that are soft and moist with no liquid leaking or dripping from the food, biting was not required, minimal chewing was required, lumps are to be 4 millimeter (mm) in size, lumps can be mashed with the tongue, no regular dry bread due to choking risks and to avoid textures that pose a choking risk for adults including sticky foods or nut butters.Interview with SLP #1 on 4/13/26 at 11:45 AM identified residents who are on altered texture diets who have been evaluated by an SLP and approved to be safe to consume peanut butter and jelly sandwiches should have a physician's order to allow the peanut butter and jelly sandwiches per exception and the sandwich should be cut up into pieces as specified by the IDDSI guidance.Observations on 4/14/26 at 12:38 PM, identified Resident #2 was served a quartered, crustless peanut butter and jelly sandwich.Review of physician's orders identified the 1/6/26 physician's order for the crustless peanut butter and jelly sandwich with every meal was discontinued on 4/14/26 following the lunch meal.Re-interview with SLP #1 on 4/20/26 at 12:56 PM identified after picking up Resident #2 for SLP services on 7/31/25, she trialed crustless peanut butter and jelly sandwiches but Resident #2 was not safe to consume the peanut butter and jelly sandwiches without one-to-one SLP observation. When she discharged Resident #2 on 10/24/25, she wrote a diet slip recommendation, which was submitted to nursing and identified Resident #2 should be placed on a IDDSI level 5 minced and moist texture; IDDSI 3 moderately thick/honey consistency liquids but did not mention that Resident #2 was permitted to consume crustless peanut butter and jelly sandwiches. She reported nursing should have ensured any physician's orders for crustless peanut butter and jelly sandwiches were discontinued and she did not know why physician's orders dated 9/11/25 and 1/6/26 directed crustless peanut butter and jelly sandwiches with every meal when she identified Resident #2 was not safe to consume the peanut butter and jelly sandwiches and had not indicated on the diet slip or to any staff that there was an approved exception for the peanut butter and jelly sandwiches.Interview with APRN #1 on 4/20/26 at 1:45 PM identified Resident #2 should have been served meals per SLP recommendations and if SLP #1 had not recommended Resident #2 was safe to receive crustless peanut butter and jelly sandwiches, an order should not have been entered by nursing. She identified she signed the 9/11/25 and 1/6/26 physician's orders directing Resident #2 to receive crustless peanut butter and jelly sandwiches with meals, but nursing had not discussed the order with her. APRN #1 identified she signed orders in bulk and assumed the order was approved by SLP #1.Interview with the DON on 4/20/26 at 9:26 AM identified she was unsure why orders were entered by nursing on 9/11/25 and 1/6/26 directing that Resident #2 may have crustless peanut butter and jelly sandwiches with every meal when it was not recommended by SLP #1 on the 10/24/25 discharge. She reported the 9/11/25 and 1/6/26 physician's orders should not have been entered, and Resident #2 should not have been receiving crustless peanut butter and jelly sandwiches with every meal.Review of the Modified Textures policy dated 1/25/26 directed, in part, residents will be provided foods which are the consistency that will be safe, tolerable and ordered by the physician and/or speech therapy. The diet texture is part of the diet ordered by the physician. Any texture ordered is provided according to the Diet Manual and transcribed onto the resident's diet card. Texture needs are regularly screened by the Speech Therapist. Revisions to the planned and menued modified texture diets can be made upon the request of the Speech Therapist or Dietician to accommodate individual needs. Modified textures may not be omitted on special occasions.Review of the Feeding Residents policy dated 6/2023 directed, in part, to ensure that the food listed on the dietary card are the foods on the tray.Although requested, a facility policy for staff supervision for meals in the dining room was not available prior to 4/13/26.Although requested, facility policies on diet consistency/texture exceptions for residents on modified texture diets, speech therapy recommendations and Nurse Aide Care Cards/Kardex were not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #8) reviewed for abuse, the facility failed to ensure a pain assessment was completed following injuries sustained from a resident to resident incident and failed to ensure Resident #8 was offered or administered as needed pain relief medication when the injuries were identified prior to hospital transfer. The findings include:Resident #8's diagnoses included dementia without behavioral disturbances, chronic pain, major depressive disorder and anxiety disorder. A physician's order dated 10/8/25 directed Resident #8 required an assist of two (2) stand pivot transfer and utilized a wheelchair for mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 4/9/26 identified Resident #8 had the potential for pain due to osteoporosis (when bones become weak, thin and brittle) and chronic pain, had impaired cognitive function or impaired thought processes related to dementia, had a communication problem related to a cognitive deficit and hard of hearing and had limited physical mobility related to a Cerebrovascular Accident (CVA). Interventions included anticipating the resident's need for pain relief and responding immediately to any complaint of pain, administering analgesic medications as per orders, anticipating and meeting needs, cueing, reorienting and supervising as needed and ensuring and providing a safe environment. A nurse's note by RN #3 dated 4/16/26 at 4:04 AM identified at 3:30 AM Resident #8 was assaulted by his/her roommate (Resident #7). Resident #8 was awake, alert and nonverbal at baseline and had been covered in body lotion to the left side of his/her hair, had a red mark to the left side of the nose, bruising to the left eye and a bruise to the right hand. The note failed to identify Resident #8 was assessed for pain or offered pain relief medications. Review of the Pain Assessment Interview and Pain Evaluations failed to identify Resident #8 had been evaluated for pain following the 4/16/26 assault. Review of the April 2026 Medication Administration Record (MAR) for Resident #8 identified a physician's order dated 7/4/25 for acetaminophen 325 milligrams (mg), give two (2) tablets every four (4) hours as needed for pain but failed to identify that it had been administered on 4/16/26. Review of the Prehospital Care Report (ambulance run sheet) dated 4/16/26 identified Emergency Medical Services (EMS) were dispatched to the facility on 4/16/26 at 3:50 AM, arrived on site at the facility and to Resident #8 at 4:03 AM and departed the facility at 4:19 AM (leaving 49 minutes for the facility to medicate Resident #8 for pain relief). The report identified it was reported to them that staff found Resident #8's roommate (Resident #7) on top of him/her beating him/her in the face and head with a heavy hairbrush and Resident #8 did not know what happened, but knew he/she was injured in some way. Resident #8 presented with severe bruising, swelling, discoloration, pain, and tenderness to his/her face, around the eyes, and on the forehead and indicated staff reported that Resident #8's roommate also covered Resident #8 in lotion, which was found dripping out of Resident #8's ears. Review of the hospital Emergency Department (ED) document dated 4/16/26 identified Resident #8 was seen following an assault and reported a contusion (soft tissue injury caused by blunt force trauma) to the right side of the head, contusion to the face and contusion to the right hand. Imaging dated 4/16/26 at 6:37 AM identified a small five (5) by six (6) millimeter peripheral hyper density in the right frontal region, new since prior exam on 11/27/25, consistent with an acute subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissue that covers and protects it). The document directed for Resident #8 not to take Eliquis (blood thinner) for two (2) weeks and to follow-up with the primary care provider. Additionally, the documentation identified Resident #8 was administered acetaminophen 650 mg at 9:54 AM (over 6 hours after the injuries occurred). Interview with RN #3 on 4/21/26 at 8:26 AM identified she did not think to administer Resident #8 pain relief medication following the injuries. RN #3 reported she should have documented a full assessment including pain, as well as complete a pain evaluation following the change in condition but identified she was preoccupied with Resident #7.Interview with the DON on 4/22/26 at 11:55 AM identified RN #3 should have ensured Resident #8 was assessed for pain and that a full pain assessment was completed following the injuries on 4/16/26. She reported although the early morning was chaotic due to the incident, RN #3 should have ensured Resident #8 was cared for and that acetaminophen was offered or administered following the injuries prior to transport to the hospital.Review of the Pain Control and Management policy dated 7/2023 directed, in part, complete a pain assessment on admission quarterly and as needed to assess pain and interventions as needed, monitor effectiveness of pain treatment and with non-verbal residents and monitor for pain via behavioral changes, such as weepiness/crying, grimacing, decrease in appetite, agitation and/or restlessness. For the non-verbal/dementia pain rating scale, assess for facial grimacing/frowning, intermittent moaning, sighing, decrease in appetite, restlessness, crying and loss of appetite.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #8) reviewed for abuse, the facility failed to ensure the state agency was notified within two (2) hours of an abuse allegation. The findings include:1. Resident #8's diagnoses included dementia without behavioral disturbances, chronic pain, major depressive disorder and anxiety disorder.A physician's order dated 10/8/25 directed Resident #8 required an assist of two (2) stand pivot transfer and utilized a wheelchair for mobility.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 3), required substantial assistance with bed mobility and was dependent on staff for transfers.The Resident Care Plan (RCP) dated 4/9/26 identified Resident #8 had impaired cognitive function or impaired thought processes related to dementia, a communication problem related to a cognitive deficit, was hard of hearing and had limited physical mobility related to a Cerebrovascular Accident (CVA). Interventions included anticipating and meeting needs, cueing, reorienting and supervising as needed and ensuring and providing a safe environment. 2. Resident #7's diagnoses included metabolic encephalopathy (a change in brain function due to an underlying condition), dementia without behavioral disturbances, mild cognitive impairment, delusional disorder, anxiety disorder and major depressive disorder.The Nursing Evaluation dated 4/1/26 identified Resident #7 was admitted for a change in mental status, chronic decline and wandering. Resident #7 was alert and oriented to person, place and time and required extensive assistance for bed mobility, transfer and ambulation status was not determined at that time.A physician's order dated 4/2/26 directed Resident #7 was independent for mobility with no device on the secured memory unit.A physician's order dated 4/3/26 directed trazodone oral tablet 50 milligrams (mg), administer 25 mg by mouth every six (6) hours as needed for anxiety, restlessness or agitation.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #7 had impaired cognitive function related to dementia, utilized psychotropic medications related to anxiety, depression and dementia, resided on the secured memory unit and ambulated independently with no assistive device on the secured memory unit. Interventions included anticipating and meeting needs, keeping the routine consistent and try to provide consistent care givers to decrease confusion, cueing, reorienting and supervising as needed, administering medications as ordered and monitoring and documenting side effects and effectiveness.An Order Administration note by RN #3 dated 4/15/26 at 1:45 AM identified Resident #7 was paranoid, talking to him/herself loudly, ambulated the hallway and complained of being unable to sleep. Trazodone 25 mg was administered.An Order Administration note by RN #3 dated 4/15/26 at 4:06 AM identified the trazodone was effective in managing behavioral symptoms.A nurse's note by RN #4 dated 4/15/26 at 3:04 PM identified Resident #7 was paranoid, yelling and not easily redirected. Medications were taken after multiple attempts. A nurse's note by RN #3 on 4/16/26 at 3:49 AM identified at around 3:30 AM, Resident #7 became belligerent due to not being able to have breakfast, food and fluids were offered but Resident #7 refused to take any meal items that were offered. Resident #7 went back to bed, staff heard Resident #7 talking to him/herself and a few minutes later, a loud noise was heard, staff ran to the room and observed Resident #7 standing next to the roommates (Resident #8's) bed holding a round brush and yelling at him/her. The left side of Resident #8's hair was covered in lotion and Resident #8 had a red mark to the left side of the nose, bruising to the left eye and bruising to the right hand. The residents were immediately separated, one-to-one observation was initiated for Resident #7, Emergency Medical Services (EMS) was called, the provider was notified and the responsible parties were notified. A psychiatric APRN note by APRN #2 on 4/16/26 identified she was asked to see Resident #7 following the alleged altercation with Resident #8. Resident #7 was calm but increasingly confused and Resident #7 explained someone broke into his/her room last night and he/she was fearful, reporting the person was his/her family member who molested him/her at a young age. The note identified Resident #7 was noted by staff to be calling Resident #8 a name with Resident #7's last name. Resident #7 was currently on one-to-one observation and showing signs of increased confusion and delusions and due to unpredictability of Resident #7's behaviors, recommended an inpatient psychiatric and medical evaluation and that the facility would facilitate the transfer. Resident #7 was calm and pleasant, was not a danger to him/herself or others but could become increasingly confused later in the afternoon/evenings and recommended continued one-to-one supervision until Resident #7 was transferred later in the day. A nurse's note by the DON on 4/16/26 at 1:03 PM identified Resident #7 was a planned pick-up at 7:30 PM for transfer to the inpatient psychiatric hospital and report was called in.Review of the hospital Emergency Department (ED) documentation dated 4/16/26 identified Resident #8 was seen following an assault and reported a contusion (soft tissue injury caused by blunt force trauma) to the right side of the head, contusion to the face and contusion to the right hand. Imaging dated 4/16/26 at 6:37 AM identified a small five (5) by six (6) millimeter peripheral hyper density in the right frontal region, new since prior exam on 11/27/25, consistent with an acute subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissue that covers and protects it). The documentation directed for Resident #8 not to take Eliquis (blood thinner) for two (2) weeks and to follow-up with the primary care provider. Review of the Connecticut Department of Public Health Facility Licensing and Investigations Section Reportable Event website on 4/20/26 identified the incident between Residents #7 and #8 occurred at 3:30 AM, the DON first knew about the incident at 5:00 AM but the incident was not reported until 6:41 AM (over 3 hours after the incident occurred).Interview with RN #3 on 4/21/26 at 8:26 AM identified she was aware the incident that occurred on 4/16/26 at 3:30 AM was required to be reported to the state agency and that she contacted the DON around 4:15 AM to notify her of the events that took place.Interview with the DON on 4/20/26 at 3:40 PM identified although RN #3 contacted her before 5:00 AM, she did not report the incident to the state agency until 6:41 and she should have ensured the incident was reported by 5:30 AM, within the two (2) hour timeframe.Review of the Abuse Reporting policy dated 6/2023 directed, in part, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm of pain or mental anguish or deprivation by an individual. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It identified report allegations involving abuse (physical, verbal, sexual, mental) no later than two (2) hours after the allegation is made.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of five (5) residents (Residents #1 and #2) reviewed for modified texture diets, the facility failed to ensure residents received prescribed diets per physician's orders and the diet manual per International Dysphagia Diet Standardization Initiative (IDDSI) guidelines and failed to ensure staff were competent in the IDDSI modified texture diets. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, oropharyngeal dysphagia (weakening of the throat muscles making it difficult to move food from the mouth into the throat and esophagus during swallowing) cerebrovascular disease (conditions that affect blood flow in the brain) and type II diabetes mellitus.A physician's order dated 7/4/25 directed a regular diet IDDSI 6 soft and bite sized texture, IDDSI 0 thin Liquids consistency. The orders directed Resident #1 to utilize a lip plate, built-up utensils, and required supervision with meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4), and required supervision assistance for eating and was dependent on staff for oral care, bed mobility and transfers. Resident #1 required a mechanically altered diet.The Resident Care Plan (RCP) dated 1/20/26 identified Resident #1 had impaired cognitive function or impaired thought processes related to dementia and had a potential swallowing problem related to a history of dysphagia and cerebral infarction (an ischemic stroke where the blood supply to part of the brain is blocked or reduced preventing brain tissue from getting oxygen and nutrients). Interventions included providing supervision with meals, diet to be followed as prescribed, instructing Resident #1 to eat in an upright position, to eat slowly, and to chew each bite thoroughly, monitoring/documenting/reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals and monitoring for shortness of breath, choking, labored respirations and lung congestion.A late entry nurse's note by RN #1 (the 7:00 AM to 3:00 PM nursing supervisor) dated 3/19/26 at 1:59 PM identified she was called to the dining room where Resident #1 was in the wheelchair eating lunch when he/she experienced a choking episode and the Heimlich maneuver was performed. Resident #1's lung sounds were clear but diminished bilaterally and vital signs were obtained to include a heart rate of 96, blood pressure of 151/95 and oxygen level of 95 percent (%) on room air. Resident #1 remained at the nurse's desk for further evaluation by APRN #1 and no new orders were obtained.A nurse's note by the DON on 3/19/26 at 2:06 PM identified she was called to assess Resident #1 following an incident of choking while in the dining room. The Speech Language Pathologist (SLP) was in the dining area and yelled out to LPN #1 who responded and performed the Heimlich maneuver. A speech evaluation was placed, the physician and Conservator were notified and vital signs were to be initiated and obtained every four (4) hours.A provider note by APRN #1 dated 3/20/26 identified Resident #1 had a choking episode on 3/19/26 requiring the Heimlich maneuver. APRN #1 directed a 2-view chest x-ray to evaluate for aspiration or consolidation and that staff would obtain vital signs every shift for 3 days and lab work would be obtained 3/23/26 to monitor for developing leukocytosis (elevated white blood cell count signifying an infection) or dehydration. Additionally, Resident #1's diet was downgraded to minced and moist and Resident #1 would be a one (1) to one (1) feed for meals. A physician's order dated 3/20/26 directed a regular diet, IDDSI 5 minced and moist texture, IDDSI 0 thin liquids consistency.A physician's order dated 3/20/26 directed Occupational Therapy Activities of Daily Living recommendation: 1:1 feed for meals.Review of the IDDSI guidance identified level 6 soft and bite sized texture included bite sized pieces no bigger than 1.5 centimeters (cm) by 1.5 cm pieces to reduce choking risks and should be able to be mashed or broken down with the pressure from a fork. No regular dry bread due to choking risks and to avoid sticky or gummy food including nut butters. Interview with the SLP on 4/13/26 at 11:45 AM identified Resident #1 had not been on her caseload at the time of the 3/19/26 incident, but reported residents who are on an altered texture diet for dysphagia and wish to have peanut butter and jelly sandwiches require an evaluation by a SLP to ensure safety. If approved, a physician's order should be entered to allow peanut butter and jelly sandwiches per exception, and the sandwich should be cut into 1.5 cm by 1.5 cm pieces. She identified that on 3/19/26, she was evaluating another resident in the dining room and had her back to Resident #1 when she heard loud banging on a table. She turned around, observed Resident #1 to be red in the face and it appeared Resident #1 was not breathing. She ran to the doorway of the dining room and alerted LPN #1, who was sitting at the nurse's station near the dining room entrance. The SLP reported LPN #1 immediately ran into the dining room, assessed Resident #1 and performed the Heimlich maneuver which dislodged a piece of food. The food and Resident #1's dentures launched out of his/her mouth. Following the incident, nursing downgraded the diet to puree, requested a speech evaluation, and she evaluated Resident #1 on 3/20/26. The evaluation identified Resident #1 was unable to self-feed due to cognition, required rate modification (slowing eating rate) had decreased safety awareness and the SLP recommended a downgrade to a level 5 minced and moist texture diet, which did not include peanut butter and jelly sandwiches. Resident #1 required one-to-one feeding assistance. The SLP identified the 3/19/26 choking incident could have been prevented if Resident #1's diet orders were followed. She reported she was not asked to supervise the dining room for the lunch meal on 3/19/26, she was only focused on the resident she was in the dining room to evaluate. Interview with LPN #1 on 4/13/26 at 11:14 AM identified on 3/19/26 she was at the nurse's station when the SLP ran to the dining room entrance and alerted her Resident #1 was choking. She reported she assessed Resident #1, who was clenching his/her teeth shut and she was unable to see food in Resident #1's mouth so she performed the Heimlich maneuver which required six (6) to seven (7) thrusts to dislodge the food. LPN #1 identified Resident #1 always received crustless, halved peanut butter and jelly sandwiches with meals and she was unaware there was no order for the sandwich or that it was not permitted on a level 6 texture diet. Interview with RN #1 on 4/13/26 at 1:24 PM identified when she arrived on the unit on 3/19/26, Resident #1 was sitting upright in the wheelchair at the nurse's station. She reported Resident #1's eyes were red and watery, she assessed Resident #1 immediately and vital signs were normal, had no abnormal lung sounds and no further coughing was noted. RN #1 entered an order for vital signs every four (4) hours for three (3) days, downgraded Resident #1's diet to puree, entered a speech screen. She reported all staff interacting with residents on altered texture diets should be aware of what each diet includes.Interview with APRN #1 on 4/13/26 at 2:25 PM identified she was not scheduled to work on 3/19/26 and evaluated Resident #1 on 3/20/26. She reported Resident #1 should have been evaluated to eat peanut butter and jelly sandwiches prior to being served the sandwiches and identified a physician's order should have been in place allowing Resident #1 to have the peanut butter and jelly sandwiches only if it was deemed safe by the SLP. APRN #1 reported staff should follow diet orders and supervision orders prior to providing any resident with food or drinks. She identified that providing residents with food that is not authorized for a specific altered diet causes a choking risk. Review of the facility schedule dated 3/19/26 identified NA #1, NA #3, NA #4, NA #5, NA #10 and LPN #2 were also working on the south-east unit on the 7:00 AM to 3:00 PM shift on 3/19/26.Interviews with NA #1, NA #3, NA #4, NA #5, NA #10 and LPN #2 on 4/13/26 identified they were not assigned to the dining room for the lunch meal on 3/19/26 and did not witness Resident #1 choking around 1:00 PM. They identified at least one (1) NA is required to be present in the dining room at all times once meals are served to supervise residents and reported Resident #1 always received peanut butter and jelly sandwiches with meals for as long as they could remember and they were unaware a level 6 texture diet did not include peanut butter and jelly sandwiches or where guidance on IDDSI diets was posted. Additionally, NA #1 identified she often gave Resident #1 crustless peanut butter and jelly sandwiches for snacks because she thought Resident #1 could have them.Interview with the Rehab Director on 4/13/26 at 12:30 PM identified that per her records, Resident #1 was never evaluated by an SLP for an exception for peanut butter and jelly sandwiches. Residents on a modified diet that prohibits peanut butter should not be provided with a peanut butter and jelly sandwich unless first cleared by a SLP for an exception and then approved by the provider and an order entered. The Rehab Director identified the choking incident could have been prevented if staff followed the diet order.Interview with the Food Service Director (FSD) on 4/13/26 at 1:07 PM identified a level 6 soft and bite sized diet includes soft foods that are cut into 1.5 cm cubes and would not include peanut butter and jelly sandwiches. She reported Resident #1 was on a level 6 texture diet and his/her meal tickets included a peanut butter and jelly sandwich to be provided for each meal. She was unsure who approved the sandwich and was unable to locate a diet order slip directing dietary that Resident #1 had been approved to receive peanut butter and jelly sandwiches. Additionally, she identified all residents on modified diets would receive a crustless sandwich cut in half, reporting that they were never cut into 1.5 cm cubes or smaller. Interview with the DON on 4/13/26 at 5:39 PM identified Resident #1 should have been provided with his/her diet per physician's orders, and staff should be aware of a residents diets, restrictions and ensuring meal tickets match the meal provided prior to serving a meal. She identified that following the incident, staff reported to her that Resident #1 always received peanut butter and jelly sandwiches with meals. She reported peanut butter and jelly sandwiches are outside of the level 6 texture and Resident #1 should have been evaluated by the SLP and an order should have been obtained prior to Resident #1 receiving a peanut butter and jelly sandwich. The DON reported Resident #1 should not have been served peanut butter and jelly sandwiches and if Resident #1 had been provided with the correct diet and received supervision per physician's orders, the choking incident could have been avoided. 2. Resident #2's diagnoses included oropharyngeal dysphagia and cerebral infarction (an ischemic stroke where blood supply to part of the brain is blocked or reduced).A physician's order dated 7/4/25 directed a regular diet, IDDSI 6 soft and bite sized texture, IDDSI 3 moderately thick/ honey consistency and Resident #2 may have soft crustless sandwiches (tuna salad, egg salad, peanut butter and jelly) and required supervision with meals.A Stern Speech Therapy Screen by SLP #1 dated 7/31/25 identified Resident #2 was currently on a IDDSI 6 and honey thickened liquids diet, but she observed Resident #2 demonstrating overt signs and symptoms of aspiration with coughing after swallowing food. The screen identified a SLP evaluation for oropharyngeal swallow function was warranted.A physician's order dated 7/31/25 directed to provide Resident #2 a regular diet, IDDSI 5 minced and moist texture, IDDSI 3 moderately thick/honey consistency liquids. The SLP Discharge Summary for dates of service 7/31/25 through 10/24/25 and signed by SLP #1 on 10/27/25 identified Resident #2 met the highest practical level of function and refused to engage in speech therapy treatment or adhere to safe swallowing strategies that may have improved function. Diet recommendations were made for IDDSI 5 minced and moist texture, IDDSI 3 moderately thick/honey consistency liquids. The Discharge Summary did not identify Resident #2 was evaluated for peanut butter and jelly sandwiches or that Resident #2 was safe to consume peanut butter and jelly sandwiches.Physician's orders dated 9/11/25 and 1/6/26 directed Resident #2 may have crustless peanut butter and jelly sandwiches with every meal.Review of the clinical record from 10/25/26 through 4/13/26 failed to identify Resident #2 was evaluated by an SLP approving the crustless peanut butter and jelly sandwiches for Resident #2 after the 10/24/25 discharge. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), and required setup assistance for eating, partial assistance for bed mobility and was dependent on staff for oral hygiene and transfers. The MDS identified Resident #2 required a mechanically altered diet. The Resident Care Plan (RCP) dated 2/3/26 identified Resident #2 had impaired cognitive function and dysphagia. Interventions included cueing, reorienting and supervising as needed, providing setup assistance for feeding and an assist of one (1) as needed, providing a regular diet, IDDSI level 5 minced and moist texture; IDDSI 3 moderately thick/honey consistency liquids, providing a crustless peanut butter and jelly sandwich with each meal, taking aspiration precautions such as elevating the head of the bed, remaining in an upright position when eating. Observations of the dining room on 4/13/26 at 12:57 PM identified NA #2 and NA #3 present in the dining room for the lunch meal. Resident #2 was observed to have been served a halved, crustless peanut butter and jelly sandwich. NA #2 and NA #3 identified Resident #2 always received a crustless peanut butter and jelly sandwich with meals.Review of the IDDSI guidance identified level 5 minced and moist texture included foods that are soft and moist with no liquid leaking or dripping from the food, biting was not required, minimal chewing was required, lumps are to be 4 millimeter (mm) in size, lumps can be mashed with the tongue, no regular dry bread due to choking risks and to avoid textures that pose a choking risk for adults including sticky foods or nut butters.Interview with SLP #1 on 4/13/26 at 11:45 AM identified residents who are on altered texture diets who have been evaluated by an SLP and approved to be safe to consume peanut butter and jelly sandwiches should have a physician's order to allow the peanut butter and jelly sandwiches per exception and the sandwich should be cut up into pieces as specified by the IDDSI guidance.Observations on 4/14/26 at 12:38 PM, identified Resident #2 was served a quartered, crustless peanut butter and jelly sandwich.Review of physician's orders identified the 1/6/26 physician's order for the crustless peanut butter and jelly sandwich with every meal was discontinued on 4/14/26 following the lunch meal. Re-interview with SLP #1 on 4/20/26 at 12:56 PM identified after picking up Resident #2 for SLP services on 7/31/25, she trialed crustless peanut butter and jelly sandwiches but Resident #2 was not safe to consume the peanut butter and jelly sandwiches without one-to-one SLP observation. When she discharged Resident #2 on 10/24/25, she wrote a diet slip recommendation, which was submitted to nursing and identified Resident #2 should be placed on a IDDSI level 5 minced and moist texture; IDDSI 3 moderately thick/honey consistency liquids but did not mention that Resident #2 was permitted to consume crustless peanut butter and jelly sandwiches. She reported nursing should have ensured any physician's orders for crustless peanut butter and jelly sandwiches were discontinued and she did not know why physician's orders dated 9/11/25 and 1/6/26 directed crustless peanut butter and jelly sandwiches with every meal when she identified Resident #2 was not safe to consume the peanut butter and jelly sandwiches and had not indicated on the diet slip or to any staff that there was an approved exception for the peanut butter and jelly sandwiches. Interview with APRN #1 on 4/20/26 at 1:45 PM identified Resident #2 should have been served meals per SLP recommendations and if SLP #1 had not recommended Resident #2 was safe to receive crustless peanut butter and jelly sandwiches, an order should not have been entered by nursing. She identified she signed the 9/11/25 and 1/6/26 physician's orders directing Resident #2 to receive crustless peanut butter and jelly sandwiches with meals, but nursing had not discussed the order with her. APRN #1 identified she signed orders in bulk and assumed the order was approved by SLP #1.Interview with the DON on 4/20/26 at 9:26 AM identified she was unsure why orders were entered by nursing on 9/11/25 and 1/6/26 directing that Resident #2 may have crustless peanut butter and jelly sandwiches with every meal when it was not recommended by SLP #1 on the 10/24/25 discharge. She reported the 9/11/25 and 1/6/26 physician's orders should not have been entered, and Resident #2 should not have been receiving crustless peanut butter and jelly sandwiches with every meal. Review of the Modified Textures policy dated 1/25/26 directed, in part, residents will be provided foods which are the consistency that will be safe, tolerable and ordered by the physician and/or speech therapy. The diet texture is part of the diet ordered by the physician. Any texture ordered is provided according to the Diet Manual and transcribed onto the resident's diet card. Texture needs are regularly screened by the Speech Therapist. Revisions to the planned and menued modified texture diets can be made upon the request of the Speech Therapist or Dietician to accommodate individual needs. Modified textures may not be omitted on special occasions.Review of the Feeding Residents policy dated 6/2023 directed, in part, to ensure that the food listed on the dietary card are the foods on the tray.Although requested, facility policies on diet texture/consistency exceptions for residents on modified texture diets, speech therapy recommendations and Nurse Aide Care Cars/Kardex were not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of eleven (11) sampled residents (Residents #11 and #12) reviewed for laboratory testing, the facility failed to ensure abnormal laboratory results were documented as reviewed with the provider and that a follow up assessment of the resident was completed by the nursing supervisor per policy. The findings include:1. Resident #11's diagnoses included end stage renal disease, dependence on renal dialysis and type II diabetes mellitus.The Nursing Evaluation assessment dated [DATE] identified Resident #11 was alert, oriented and appropriate and required limited assistance for bed mobility and extensive assistance for personal hygiene and transfers.The Resident Care Plan (RCP) dated 4/1/26 identified Resident #11 had type II diabetes mellitus and required hemodialysis (a treatment to filter waste and water from the blood as the kidneys did when they were healthy) for end stage renal disease. Interventions included monitoring lab work as ordered and reporting to the provider as needed.Review of lab work dated 4/6/26 identified Resident #11 had a critically high creatinine level (when kidneys are not properly clearing waste) of 4.24 (normal range of .70 to 1.5) that was reported to the facility on 4/6/26 at 5:40 PM and the lab work was reviewed by RN #1 on 4/7/26 at 9:00 AM.Review of nurse's notes from 4/6/26 through 4/7/26 failed to identify the critical creatinine level was reported to the provider on 4/6/26 when it was reported to the facility or on 4/7/26 when it was reviewed by RN #1 and failed to identify an RN supervisor assessed Resident #11.Review of a provider note dated 4/6/26 by APRN #1 which was signed at 6:13 PM failed to identify the critical creatinine level of 4.24 or that it was reported to her.The provider note dated 4/8/26 by APRN #1 identified the 4/6/26 lab work was reviewed, including the critical creatinine level (2-days later).2. Resident #12's diagnoses included heart failure, acute kidney failure and type II diabetes mellitus.The Nursing Evaluation assessment dated [DATE] identified Resident #12 was alert, oriented and appropriate and was dependent on staff for bed mobility, transfers and personal hygiene.The Resident Care Plan (RCP) dated 4/3/26 identified Resident #12 had the potential for fluid imbalance related to fluid restriction, diuretic therapy, congestive heart failure and bilateral lower extremity edema. Interventions included obtaining lab work, including Blood Urea Nitrogen (BUN) and creatinine per physicians order and notifying the physician or abnormal lab work.A. Review of lab work dated 4/6/26 identified Resident #12 had a critically high BUN level (indicating severe kidney dysfunction, profound dehydration or other acute conditions) of 73 (normal range of 10 to 24) that was reported to RN #8 on 4/6/26 at 3:08 PM and the lab work was reviewed by RN #1 on 4/8/26 at 10:41 AM.Review of nurse's notes failed to identify any notes on 4/6/26 and failed to identify the critical BUN level was reported to the provider on 4/6/26 when it was reported to the facility or on 4/8/26 when the lab work was reviewed by RN #1 and failed to identify an RN supervisor assessed Resident #12.Review of a provider note dated 4/6/26 by APRN #1 which was signed at 3:20 PM failed to identifiy the critical BUN level of 73 or that it was reported to her.The provider note dated 4/8/26 by APRN #1 identified the 4/6/26 lab work was reviewed, including the critical BUN level (2-days later).B. Review of lab work dated 4/9/26 identified Resident #12 had a critically high BUN level of 70 that was reported to the facility on 4/9/26 at 2:10 PM and the lab work was reviewed by RN #1 on 4/10/26 at 7:33 AM.Review of nurse's notes from 4/9/26 through 4/10/26 failed to identify the critical BUN level was reported to the provider on 4/9/26 when it was reported to the facility or on 4/10/26 when the lab work was reviewed by RN #1 and failed to identify an RN supervisor assessed Resident #12.Review of the provider note dated 4/10/26 by APRN #1 identified the critical BUN level of 70 (1-day later).C. Review of lab work dated 4/13/26 identified Resident #12 had a critically high BUN level of 80 that was reported to RN #7 on 4/13/26 at 1:55 PM and the lab work was reviewed by RN #1 on 4/14/26 at 4:52 AM.Review of nurse's notes from 4/13/26 through 4/14/26 failed to identify the critical BUN level was reported to the provider on 4/13/26 when it was reported to RN #7 or on 4/14/26 when the lab work was reviewed by RN #1 and failed to identify an RN supervisor assessed Resident #12.Review of provider note dated 4/13/26 by APRN #1 which was signed at 6:13 PM failed to identify the critical BUN level of 80 or that it was reported to her.Review of a provider note dated 4/14/26 by MD #1 mentioned the critical BUN level of 80 (1-day later).D. Review of lab work dated 4/16/26 identified Resident #12 had a critically high BUN level of 75 that was reported to RN #7 on 4/16/26 at 1:07 PM and the lab work was reviewed by RN #1 on 4/17/26 at 6:27 AM.Review of nurse's notes from 4/16/26 through 4/17/26 failed to identify the critical BUN level was reported to the provider on 4/16/26 when it was reported to RN #7 or on 4/17/26 when the lab work was reviewed by RN #1 and failed to identify an RN supervisor assessed Resident #12.Review of a provider note dated 4/17/26 by APRN #1 identified the critical BUN level of 75 (1-day later).Interview with RN #1 on 4/22/26 at 10:49 AM identified although she reviewed Resident #11 and #12's critical lab work results and was aware of the critical results and thought she reported them, she could not recall who she notified, at what time and if any new orders were obtained. She reported she was unaware that the policy directed that an RN assessment was to be performed by the RN Supervisor and reported along with the abnormal lab work results. RN #1 identified she should have ensured a provider was notified immediately of the critical values and should have written a note in both Resident #11 and #12's clinical record reporting who was notified, at what time and if there were any new orders. Additionally, RN #1 identified she could not recall RN #7 notifying her that she (RN #7) received calls regarding either Resident #11 or Resident #12's critical lab work results or that the lab work results were critical. She reported that she had been signing off lab work results as reviewed for all residents to clear them off her homepage and was not aware that the providers are the ones to review the lab work results under the results tab and that she should not have signed them off as reviewed. Further, she identified APRN #1 is off on Thursdays, and all critical and abnormal lab work results should have been reported to the Medical Director or the on-call provider (4/9/26 and 4/16/26).Interview with the Medical Director on 4/21/26 at 1:12 PM identified that a provider should be notified of abnormal lab work results by the RN receiving the critical lab work value results immediately after they are notified by the lab. He reported if a provider is notified and does not respond, or the abnormal results are received off hours, the on-call or himself should be notified and the RN should document the name of the provider notified, what time they were notified and if any new orders were obtained. He identified that although he was aware of critical lab work results for both Residents #11 and #12, he was unsure when exactly he was notified. Additionally, he identified no one should sign off the lab work of any resident as reviewed under the results tab except for a provider because the alert disappears and does not trigger for the provider to review.Interview with the DON on 4/21/26 at 11:35 AM identified RN #7 should have contacted a provider immediately upon receiving critical results from the lab for Resident #12 and RN #1 should have ensured a provider was notified if she was reviewing the critical lab work results for Residents #11 and #12. The DON identified both RN #7 and RN #1 should have ensured the provider notification for the critical lab work for Residents #11 and #12 was complete to include the provider notified, what time the provider was notified and if new orders were obtained. She reported she was unaware RN #1 had been signing off the lab work results as reviewed under the results tab and she was unsure who should be signing the lab work off as reviewed and was unsure what the abnormal lab work and physician's notification policies directed, stating she would have to review it.An interview with RN #7 was not obtained.Review of the Physician Notification of Abnormal Lab Values policy dated 7/2023 directed, in part, that it's the policy of the facility that the RN Supervisor will call all providers with any abnormal lab values. If a resident's lab values are abnormal it is the responsibility of the charge nurse to notify the RN supervisor on duty. It is then the RN Supervisor's responsibility to do a follow-up assessment and then report all changes to the provider.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #7) reviewed for behaviors, the facility failed to ensure behavioral symptoms were identified and managed to prevent escalation. Specifically, this failure included the failure to document ineffective interventions, reapproach and administer medication for anxiety, restlessness or agitation, and implement effective interventions for ongoing yelling, paranoia, agitation and wandering behaviors prior to an altercation with another resident. The findings include:Resident #7's diagnoses included metabolic encephalopathy (a change in brain function due to an underlying condition), dementia without behavioral disturbances, mild cognitive impairment, delusional disorder, anxiety disorder and major depressive disorder.The Nursing Evaluation dated 4/1/26 identified Resident #7 was admitted for a change in mental status, chronic decline and wandering. Resident #7 was alert and oriented to person, place and time and required extensive assistance for bed mobility, transfer and ambulation status was not determined at that time.A physician's order dated 4/3/26 directed trazodone oral tablet 50 milligrams (mg), administer 25 mg by mouth every six (6) hours as needed for anxiety, restlessness or agitation.The Resident Care Plan (RCP) dated 4/12/26 identified Resident #7 had impaired cognitive function related to dementia, utilized psychotropic medications related to anxiety, depression and dementia, resided on the secured memory unit and ambulated independently with no assistive device on the secured memory unit. Interventions included anticipating and meeting needs, keeping the routine consistent and try to provide consistent care givers to decrease confusion, cueing, reorienting and supervising as needed, administering medications as ordered and monitoring and documenting side effects and effectiveness. A nurse's note by RN #4 dated 4/15/26 at 3:04 PM identified Resident #7 was paranoid, yelling and was not easily redirected. Medications were taken after multiple attempts but failed to identify what interventions were initiated to deescalate Resident #7 or that the PRN trazodone was offered.A nurse's note by RN #3 on 4/16/26 at 3:49 AM identified at around 3:30 AM, Resident #7 became belligerent due to not being able to have breakfast, food and fluids were offered but Resident #7 refused to take any meal items that were offered. Resident #7 went back to bed, staff heard Resident #7 talking to him/herself and a few minutes later, a loud noise was heard, staff ran to the room and observed Resident #7 standing next to the roommates (Resident #8's) bed holding a round brush and yelling at him/her. The left side of Resident #8's hair was covered in lotion and Resident #8 had a red mark to the left side of the nose, bruising to the left eye and bruising to the right hand. The residents were immediately separated, one-to-one observation was initiated for Resident #7, Emergency Medical Services (EMS) was called, the provider was notified and the responsible parties were notified.Review of the April 2026 Medication Administration Record (MAR) failed to identify Resident #7 had been administered trazodone 25 mg for anxiety, restlessness or agitation per physician's order on 4/15/26 by RN #4 or on 4/16/26 by RN #3 prior to or following the documented behaviors.Review of the clinical record from 4/1/26 through 4/14/26 identified on 4/3/26 Resident #7 had increased agitation and yelling, refused medications and was unable to be directed. Resident #7 was found lying in a male resident's bed and multiple attempts were made to remove Resident #7 without success. There were multiple notations of Resident #7 refusing medications, weights, skin checks, vital signs, blood work and treatments as well as becoming agitated, confused, yelling, accusatory, paranoid, and combative with care.Review of the clinical record failed to identify a Resident Care Plan (RCP) for behaviors or refusal of care. Interview with APRN #2 (psychiatric APRN), on 4/20/26 at 2:15 PM identified she saw Resident #7 numerous times and made several medication adjustments. She did not receive clear staff reports regarding Resident #7's behaviors or incidents. The trazodone was ordered for anxiety, restlessness or agitation and if Resident #7 displayed those behaviors, staff should have offered the medication, documented on the behaviors and documented the effectiveness of the medication. Interview with the DON on 4/20/26 at 3:40 PM identified if a resident is ordered a medication by a psychiatric provider for anxiety, agitation or restlessness, staff should be attempting to administer the medication to the resident if behaviors occur, so the resident's behaviors do not escalate out of control. She identified if a resident refuses medication, other interventions should be implemented for safety, and the resident should be reapproached several times. Interview with RN #4 on 4/20/26 at 5:50 PM identified during her shift on 4/15/26 Resident #7 was in and out of bed, demanding and yelling about food. She reported it was her first time working on the unit and was unsure how to calm Resident #7 down, so she kept reapproaching him/her which took multiple attempts over hours to get Resident #7 to take ordered medications. RN #4 identified she did not think to check for medication available to calm him/her down but indicated she should have checked, and if she knew trazodone was available, she would have administered it to Resident #7.Interview with RN #3 on 4/21/26 at 8:26 AM identified on 4/15/26 she worked part of the 3:00 PM to 11:00 PM shift. Resident #7 was yelling and getting in and out of bed, but Resident #7 seemed to calm down after she spoke with him/her and closed the curtain. She identified at around 2:00 AM, she heard Resident #7 talking to him/herself and yelling again so she went to speak with Resident #7 who was ordering breakfast into the call bell and started demanding a full hot breakfast and hot tea and then got out of bed and started walking around. She reported she left to try and gather some food for Resident #7 and when she returned Resident #7 refused the food and drinks she offered, threw the food back at her and became increasingly agitated. RN #3 reported she then attempted to give Resident #7 trazodone, but he/she refused, and Resident #7 went back into the room and herself and NA #11 stood outside the door for a few minutes. Resident #7 seemed to calm down so they left the door ajar and went to care for other residents around 3:00 AM. RN #3 reported that at around 3:30 AM she heard yelling and went into Resident #7's room and saw him/her standing over Resident #8 with a round hairbrush in his/her hand and Resident #8 was noted with bruising to the left eye, face and right hand but Resident #7 would not explain what he/she had done. After calling EMS and the families, EMS refused to take Resident #7 because he/she appeared alert and oriented and refused to go, so Resident #7 remained in the building on a one-to-one until seen by a provider. At around 4:30 AM, Resident #7 was again yelling, slamming things in the room and trying to get out of the window. RN #3 identified she did not normally work on the locked memory unit. She identified she administered trazodone to Resident #7 the previous night when he/she started yelling which was effective. She could not explain why she did not immediately administer trazodone when Resident #7 began having behaviors around 6:00 PM on 4/15/26 or at 2:00 AM on 4/16/26. She reported she should have reapproached Resident #7 and reattempted to medicate him/her with the trazodone after the first refusal Interview with NA # 12 on 4/21/26 at 9:07 AM identified on 4/16/26 she was providing care to Resident #8 around 6:00 PM, who had no visible bruising or injuries. Resident #7 was in the room talking to him/herself, yelling out and shrieking. She identified she could not redirect Resident #7 and RN #3 later came in, spoke with Resident #7 and pulled the curtain all the way around his/her bed and Resident #7 calmed down. NA #12 worked the 11:00 PM to 7:00 AM shift preceding and Resident #7 was out of bed, walking around and yelling out the door prior to the incident that occurred with Resident #8. Interview with NA # 11 on 4/21/26 at 9:41 AM identified she normally worked on the locked memory unit where both Residents #7 and #8 resided and she was assigned to Resident #7 the night of the incident. She identified since Resident #7 was admitted to the facility on [DATE], and would intermittently talk to him/herself, scream, slam doors and wander the halls while awake. Prior to the incident, Resident #7 started yelling around 2:30 AM and was in and out of bed, she identified she last saw Resident #7 around 3:00 AM and at that time he/she had gone back to bed but was still talking to him/herself. NA #11 identified she went to care for other residents and around 3:30 AM heard yelling. When she went into the room, she observed Resident #7 standing next to Resident #8 and Resident #8 had bruising to his/her left eye and face, bruising to the right arm and his/her face was covered in lotion and reported Resident #8 appeared fearful of Resident #7.Review of the Medication Refusal Policy dated 7/2023 directed, in part, that for medication refusals, the nurse will explain to the resident the possible consequences of medication refusal, and for non-competent confused residents, the nurse will go back and offer the medication again within an hour. The nursing supervisor will notify the MD once 3 consecutive doses of any medication is refused, will document the conversation with the MD in the clinical record and the nurse will properly document the medication refusal on the resident's electronic medical record.Although requested, a facility policy for behavioral management was not provided.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for modified texture diets, the facility failed to revise the Resident Care Plan (RCP) to identify physician-ordered one-to-one feeding assistance following a choking incident resulting in Resident #1 not being provided one-to-one feeding assistance for meals per physician's order and for one (1) of three (3) residents (Resident #7) reviewed for behaviors, the facility failed to develop an RCP for ongoing behaviors, agitation, and repeated care refusals. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, oropharyngeal dysphagia (weakening of the throat muscles making it difficult to move food from the mouth into the throat and esophagus during swallowing) cerebrovascular disease (conditions that affect blood flow in the brain) and type II diabetes mellitus.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4), and required supervision assistance for eating and was dependent on staff for oral care, bed mobility and transfers. Resident #1 required a mechanically altered diet.The Resident Care Plan (RCP) dated 1/20/26 identified Resident #1 had impaired cognitive function or impaired thought processes related to dementia and had a potential swallowing problem related to a history of dysphagia and cerebral infarction (an ischemic stroke where the blood supply to part of the brain is blocked or reduced preventing brain tissue from getting oxygen and nutrients). Interventions included providing supervision with meals, diet to be followed as prescribed, instructing Resident #1 to eat in an upright position, to eat slowly, and to chew each bite thoroughly, monitoring/documenting/reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals and monitoring for shortness of breath, choking, labored respirations and lung congestion.A late entry nurse's note by RN #1 (the 7:00 AM to 3:00 PM nursing supervisor) dated 3/19/26 at 1:59 PM identified she was called to the dining room where Resident #1 was in the wheelchair eating lunch when he/she experienced a choking episode and the Heimlich maneuver was performed. Resident #1's lung sounds were clear but diminished bilaterally and vital signs were obtained to include a heart rate of 96, blood pressure of 151/95 and oxygen level of 95 percent (%) on room air. Resident #1 remained at the nurse's desk for further evaluation by APRN #1 and no new orders were obtained.A nurse's note by the DON on 3/19/26 at 2:06 PM identified she was called to assess Resident #1 following an incident of choking while in the dining room. The Speech Language Pathologist (SLP) was in the dining area and yelled out to LPN #1 who responded and performed the Heimlich maneuver. A speech evaluation was placed, the physician and Conservator were notified and vital signs were to be initiated and obtained every four (4) hours.A provider note by APRN #1 dated 3/20/26 identified Resident #1 had a choking episode on 3/19/26 requiring the Heimlich maneuver. APRN #1 directed a 2-view chest x-ray to evaluate for aspiration or consolidation and that staff would obtain vital signs every shift for 3 days and lab work would be obtained 3/23/26 to monitor for developing leukocytosis (elevated white blood cell count signifying an infection) or dehydration. Additionally, Resident #1's diet was downgraded to minced and moist and Resident #1 would be a one (1) to one (1) feed for meals.A physician's order dated 3/20/26 directed Occupational Therapy Activities of Daily Living recommendation: 1:1 feed for meals. Interview with the SLP on 4/13/26 at 11:45 AM identified Resident #1 had not been on her caseload at the time of the 3/19/26 choking incident, but following the incident, nursing downgraded the diet to puree, requested a speech evaluation, and she evaluated Resident #1 on 3/20/26. The evaluation identified Resident #1 was unable to self-feed due to cognition, required rate modification (slowing eating rate) had decreased safety awareness and the SLP recommended a downgrade to a level 5 minced and moist texture diet, which did not include peanut butter and jelly sandwiches. Resident #1 required one-to-one feeding assistance.Observations of the dining room on 4/13/26 at 12:57 PM identified NA #2 and NA #3 present in the dining room for the lunch meal. Resident #1 was observed feeding him/herself, although a physician's order was in place directing Resident #1 receive one-to-one feeding assistance. Further, Resident #1's meal ticket did not indicate Resident #1 required one-to-one feeding assistance.Interview and observation with the Rehab Director on 4/13/26 at 1:00 PM identified NA #2 to be sitting in a chair beside Resident #1 in the dining room assisting Resident #1 with ice cream. Resident #1 was noted to have regular utensils and not built-up foam utensils in front of him/her. The Rehab Director identified following the 3/19/26 choking incident, Resident #1 required one-to-one feeding assistance so staff should have been feeding Resident #1 at all times. At 1:01 PM, NA #2 reported to the Rehab Director that Resident #1 was feeding him/herself. Review of Resident #1's Kardex on 4/13/26 identified Resident #1 was on a mechanically altered diet and required supervision for eating. (Not consistent with physician's order)Interview with the DON on 4/20/26 at 9:26 AM identified the charge nurse or nursing supervisor should have updated the RCP immediately upon notification by SLP #1 that Resident #1 would require one-to-one feeding assistance effective 3/20/26. The DON reported she was unaware that the RCP and Kardex did not accurately identify the supervision status for feeding, but identified the physician's order, RCP and Kardex should have all matched so Resident #1 was supervised appropriately for meals.Interview with the MDS nurse, LPN #3 on 4/20/26 at 2:24 PM identified nursing or the interdisciplinary team (IDT) that is initially aware of a resident change is responsible for updating the RCP for an intervention that needs to be updated immediately, such as a resident requiring increased supervision for meals, behaviors or refusals of care. She reported nursing or the IDT would been responsible for updating the RCP and Kardex to identify the change or would have been responsible for notifying her immediately to do so, which they did not. She identified had the Care Plan for Resident #1 been updated immediately following the physician's order for Resident #1 to be a one-to-one feed and ensured it displayed on the Kardex, NA staff would have been able to see the changes on the Kardex and provided the necessary one-to one assistance for meals.2. Resident #7's diagnoses included metabolic encephalopathy (a change in brain function due to an underlying condition), dementia without behavioral disturbances, mild cognitive impairment, delusional disorder, anxiety disorder and major depressive disorder.The Nursing Evaluation dated 4/1/26 identified Resident #7 was admitted for a change in mental status, chronic decline and wandering. Resident #7 was alert and oriented to person, place and time and required extensive assistance for bed mobility, transfer and ambulation status was not determined at that time. An Order Administration note dated 4/3/26 at 9:29 AM identified Resident #7 refused the fluticasone nasal suspension 50 micrograms (mcg) per actuation (spray), 2 sprays in both nostrils once daily for seasonal allergies.Order Administration notes dated 4/3/26 at 3:02 PM and 3:05 PM identified Resident #7 refused the weekly body evaluation and the weekly weight as well as triamcinolone cream 1 percent (%) that was to be applied to affected areas every evening shift for contact dermatitis (inflammation of the skin).A nurse's note by RN #1 dated 4/3/26 at 7:01 PM identified Resident #7 had increased agitation and yelling, unable to administer evening or as needed medications or redirect Resident #7. Resident #7 was found lying in a male resident's bed and multiple attempts by staff to remove Resident #7 were unsuccessful. The family was notified and recommendations on how to handle Resident #7 were requested. With help from a NA, RN #1 was able to remove Resident #7 from the bed. Attempts were made to reorient Resident #7 to his/her personal space and belongings but Resident #7 continued to be irate and difficult. A nurse's note by LPN #4 dated 4/3/26 at 8:00 PM identified Resident #7 continued to refuse 8:00 PM medications. Resident #7 was educated on the risk and benefit and Resident #7 continued to refuse so the nursing supervisor was notified.A nurse's note by LPN #5 dated 4/4/26 at 2:53 PM identified Resident #7 became agitated with staff and refused to go to his/her room.An Order administration note dated 4/4/26 at 7:39 PM identified Resident #7 refused to have vital signs obtained.An Order Administration note dated 4/4/26 at 11:05 PM identified Resident #7 refused triamcinolone cream 1 percent (%) that was to be applied to affected areas every evening shift for contact dermatitis.A nurse's note by LPN #5 dated 4/5/26 at 12:37 PM identified Resident #7 became agitated with staff and refused to go to his/her room.A nurse's note by LPN #5 dated 4/6/26 at 3:00 PM identified Resident #7 refused lab work and that it was rescheduled.An Order Administration note dated 4/6/26 at 9:21 PM identified Resident #7 refused vital signs three (3) times.An Order Administration note dated 4/8/26 at 7:35 PM identified Resident #7 refused ketoconazole cream 2% that was to be applied to affected areas topically every evening shift for tinea corporis (superficial fungal infection of the skin).An Order Administration note dated 4/8/26 at 7:56 PM identified Resident #7 refused triamcinolone cream 1 percent (%) that was to be applied to affected areas every evening shift for contact dermatitis.A Skilled Nursing note by LPN #4 on 4/8/26 at 10:52 PM identified Resident #7 was alert but confused and agitated, yelling and refused evening care.An Order Administration note dated 4/9/26 at 8:08 PM identified Resident #7 refused triamcinolone cream 1 percent (%) that was to be applied to affected areas every evening shift for contact dermatitis.An Order Administration note dated 4/9/26 at 8:39 PM identified Resident #7 refused ketoconazole cream 2% that was to be applied to affected areas topically every evening shift for tinea corporis (superficial fungal infection of the skin).An Order Administration note dated 4/11/26 at 12:37 PM identified Resident #7 refused constulose 10 grams (gm) per 15 milliliter (mL) solution, give 30 mL for bowel management.A Skilled Nursing note by LPN #4 on 4/11/26 at 10:53 PM identified Resident #7 was alert but confused with increased agitation, was hard to redirect and took medications with a lot of encouragement.A nurse's note by RN #5 on 4/12/26 at 6:41 AM identified Resident #7 slept on and off throughout the night, crying and talking outload with increased paranoia, agitation and aggression towards staff. Resident #7 refused all medications and vital signs.A nurse's note by LPN #4 on 4/12/26 at 9:47 PM identified Resident #7 was alert but confused, paranoid, agitated, talking loudly to him/herself, however took all medications as ordered. An Order Administration note dated 4/13/26 at 4:50 AM identified Resident #7 refused to have vital signs taken and was paranoid and agitated.An Order Administration note dated 4/13/26 at 5:03 AM identified Resident #7 refused to take Synthroid 112 micrograms (mcg) tablet for hypothyroidism (underactive thyroid). A nurse's note by LPN #4 on 4/13/26 at 10:56 PM identified Resident #7 was alert but agitated and yelling loudly in the hallway. Resident #7 was redirected with a lot of encouragement.A Skilled Nursing note by LPN #4 on 4/14/26 at 10:07 PM identified Resident #7 was alert but confused, yelling, talking loudly to him/herself, tearful and anxious but took medications as ordered.A nurse's note by RN #3 dated 4/15/26 at 8:12 AM identified at the beginning of the shift Resident #7 was paranoid, talking to him/herself loudly, ambulated in the hallway and reported he/she was unable to sleep. It reported Resident #7 was medicated with as needed trazodone with good effect and he/she rested for the remainder of the night.A nurse's note by RN #4 dated 4/15/26 at 3:04 PM identified Resident #7 was paranoid, yelling and was not easily redirected. Medications were taken after multiple attempts.A nurse's note by RN #3 on 4/16/26 at 3:49 AM identified at around 3:30 AM, Resident #7 became belligerent due to not being able to have breakfast, food and fluids were offered but Resident #7 refused to take any meal items that were offered. Resident #7 went back to bed, staff heard Resident #7 talking to him/herself and a few minutes later, a loud noise was heard, staff ran to the room and observed Resident #7 standing next to the roommates (Resident #8's) bed holding a round brush and yelling at him/her. The left side of Resident #8's hair was covered in lotion and Resident #8 had a red mark to the left side of the nose, bruising to the left eye and bruising to the right hand.Review of the clinical record failed to identify a Resident Care Plan (RCP) for behaviors or refusal of care prior to the 4/16/26 incident. Interview with the DON on 4/20/26 at 9:26 AM identified nursing or the IDT should have identified the pattern of behaviors and refusals for Resident #7 from admission and initiated RCPs and interventions as soon as the behaviors were identified.Review of the Care Plans policy dated 6/2023 directed, in part, Resident Care Plans (RCP's) can be revised, as needed, at any time, on an interim basis. RCP's will include physical, cognitive and psycho-social problems and will address the residents' needs on an individualized basis.Review of the Resident Profiles policy dated 7/2023 directed, in part, that nursing staff must be aware of all of the residents' current needs for care to provide safe care. It is the responsibility of the nursing staff to check the resident profile on the computer system at the start of their shift and as needed throughout the shift for each resident they provide care for. This will ensure that nursing staff has the most up to date information regarding the residents' needs and abilities. The profile is accessible to all nursing staff through the POC or PCC accessible on the wall or desk units.Although requested, a facility policy for staff supervision for meals in the dining room was not available prior to 4/13/26.Although requested, a facility policy on therapy recommendations was not available.

Based on review of the clinical record, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #7) reviewed for accidents and incidents, the facility failed to ensure timely physician notification following significant changes in resident condition and behavioral incidents requiring medical and psychiatric evaluation. For Resident #1, the facility failed to notify the on-call provider or Medical Director following a choking incident requiring the Heimlich maneuver. For Resident #7, the facility failed to notify the provider regarding omitted medications, refusal of as needed medication, escalating behaviors and a behavioral incident involving Resident #7 entering and remaining in another resident's bed despite multiple unsuccessful staff redirection attempts. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, oropharyngeal dysphagia (weakening of the throat muscles making it difficult to move food from the mouth into the throat and esophagus during swallowing) cerebrovascular disease (conditions that affect blood flow in the brain) and type II diabetes mellitus.A physician's order dated 7/4/25 directed a regular diet IDDSI 6 soft and bite sized texture, IDDSI 0 thin Liquids consistency. The orders directed Resident #1 to utilize a lip plate, built-up utensils, and required supervision with meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4), and required supervision assistance for eating and was dependent on staff for oral care, bed mobility and transfers. Resident #1 required a mechanically altered diet.The Resident Care Plan (RCP) dated 1/20/26 identified Resident #1 had impaired cognitive function or impaired thought processes related to dementia and had a potential swallowing problem related to a history of dysphagia and cerebral infarction (an ischemic stroke where the blood supply to part of the brain is blocked or reduced preventing brain tissue from getting oxygen and nutrients). Interventions included providing supervision with meals, diet to be followed as prescribed, instructing Resident #1 to eat in an upright position, to eat slowly, and to chew each bite thoroughly, monitoring/documenting/reporting as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals and monitoring for shortness of breath, choking, labored respirations and lung congestion.A late entry nurse's note by RN #1 (the 7:00 AM to 3:00 PM nursing supervisor) dated 3/19/26 at 1:59 PM identified she was called to the dining room where Resident #1 was in the wheelchair eating lunch when he/she experienced a choking episode and the Heimlich maneuver was performed. Resident #1's lung sounds were clear but diminished bilaterally and vital signs were obtained to include a heart rate of 96, blood pressure of 151/95 and oxygen level of 95 percent (%) on room air. Resident #1 remained at the nurse's desk for further evaluation by APRN #1 and no new orders were obtained.A nurse's note by the DON on 3/19/26 at 2:06 PM identified she was called to assess Resident #1 following an incident of choking while in the dining room. The Speech Language Pathologist (SLP) was in the dining area and yelled out to LPN #1 who responded and performed the Heimlich maneuver. A speech evaluation was placed, the physician and Conservator were notified and vital signs were to be initiated and obtained every four (4) hours.A provider note by APRN #1 dated 3/20/26 identified Resident #1 had a choking episode on 3/19/26 requiring the Heimlich maneuver. APRN #1 directed a 2-view chest x-ray to evaluate for aspiration or consolidation and that staff would obtain vital signs every shift for 3 days and lab work would be obtained 3/23/26 to monitor for developing leukocytosis (elevated white blood cell count signifying an infection) or dehydration. Additionally, Resident #1's diet was downgraded to minced and moist and Resident #1 would be a one (1) to one (1) feed for meals.Interview with RN #1 on 4/13/26 at 1:24 PM identified when she arrived on the unit on 3/19/26, Resident #1 was sitting upright in the wheelchair at the nurse's station. She reported Resident #1's eyes were red and watery, she assessed Resident #1 immediately and vital signs were normal, had no abnormal lung sounds and no further coughing was noted. She texted APRN #1 to report the incident, but APRN #1 did not respond. She did not contact the on-call provider or the Medical Director when she did not receive a response from APRN #1. RN #1 entered an order for vital signs every four (4) hours for three (3) days, downgraded Resident #1's diet to puree, entered a speech screen, and notified APRN #1 the following morning.Interview with APRN #1 on 4/13/26 at 2:25 PM identified she was off on 3/19/26 and evaluated Resident #1 on 3/20/26 when she was back in the building. She reported RN #1 should have contacted the on-call provider or the Medical Director following the choking incident, as Resident #1 should have had a chest x-ray ordered and obtained the same day to ensure Resident #1 had not aspirated.Interview with APRN #1 on 4/13/26 at 2:25 PM identified she was not scheduled to work on 3/19/26 and evaluated Resident #1 on 3/20/26. She identified following any resident concern or change in condition, if a call is not returned by a provider within ten (10) minutes, the facility should contact different provider, and staff should document provider notification accurately. She reported RN #1 should have contacted the on-call provider or the Medical Director following the choking incident so a chest x-ray could have been ordered and obtained the same day to rule out aspiration.2. Resident #7's diagnoses included metabolic encephalopathy (a change in brain function due to an underlying condition), dementia without behavioral disturbances, mild cognitive impairment, delusional disorder, anxiety disorder and major depressive disorder.The Nursing Evaluation dated 4/1/26 identified Resident #7 was admitted for a change in mental status, chronic decline and wandering. Resident #7 was alert and oriented to person, place and time and required extensive assistance for bed mobility, transfer and ambulation status was not determined at that time.A physician's order dated 4/3/26 directed trazodone oral tablet 50 milligrams (mg), administer 25 mg by mouth every six (6) hours as needed for anxiety, restlessness or agitation.A nurse's note by RN #1 dated 4/3/26 at 7:01 PM identified Resident #7 had increased agitation and yelling, unable to administer evening or as needed medications or redirect Resident #7. Resident #7 was found lying in a male resident's bed and multiple attempts by staff to remove Resident #7 were unsuccessful. The family was notified and recommendations on how to handle Resident #7 were requested. With help from a NA, RN #1 was able to remove Resident #7 from the bed. Attempts were made to reorient Resident #7 to his/her personal space and belongings but Resident #7 continued to be irate and difficult. The note failed to identify a provider was notified of the missed medications or the escalation of behaviors.Review of the April 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) identified Resident #7 was not administered the 8:00 PM dose of pramipexole dihydrochloride tablet 0.5 milligrams (mg) for restless legs syndrome, the 8:00 PM dose of montelukast sodium tablet 10 mg for seasonal allergies, the 9:00 PM dose of memantine tablet 10 mg for dementia, topical triamcinolone acetonide cream 0.1 percent (%) to affected areas on the evening shift for allergic contact dermatitis (inflammation of the skin) or topical ketoconazole cream 2 % to affected areas for tinea corporis (superficial fungal infection of the skin).Review of the clinical record for 4/3/26 failed to identify a provider was notified of the missed medications, refusal of the as needed trazodone or the escalation of behaviors.Interview with RN #1 on 4/22/26 at 10:49 AM identified although she documented on 4/3/26 that Resident #7 was not administered medications, had an escalation in behaviors and was found in a male resident's bed and Resident #7 continued to be irate and difficult, she did not contact an on-call provider to report the behaviors.Interview with APRN #2 (psychiatric APRN), on 4/20/26 at 2:15 PM identified she was not made aware of the 4/3/26 incident with Resident #7 and nursing should have notified the on-call provider of the escalating behaviors and refusal of trazodone. She identified she was not aware Resident #3 was found in a male resident's bed on 4/3/26 despite evaluating Resident #7 several times after that date.Interview with the DON on 4/20/26 at 3:40 PM identified that an on-call provider should have been notified for any missed medications/refusal of medications, escalation in behaviors and behavioral incidents. She was unaware an on-call provider and psychiatric APRN were not notified of the 4/3/26 incident with Resident #7 wandering into a male resident's bed.Review of the Change of Condition in a resident status policy dated 6/2023 directed, in part, the nurse will notify the resident's attending physician or on-call physician when there has been an accident or incident involving the resident, a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. A significant change of condition is a decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan. The RN will assess the resident's change of condition and document their findings in the medical record. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.Review of the Charting and Documentation policy dated 6/2023 directed, in part, documentation of procedures and treatments will include care specific details, including: the assessment data and/or unusual findings obtained during the procedure/treatment and notification of family, physician or other staff, if indicated.Review of the Medication Refusal Policy dated 7/2023 directed, in part, that for medication refusals, the nurse will explain to the resident the possible consequences of medication refusal, and for non-competent confused residents, the nurse will go back and offer the medication again within an hour. The nursing supervisor will notify the MD once 3 consecutive doses of any medication is refused, will document the conversation with the MD in the clinical record and the nurse will properly document the medication refusal on the resident's electronic medical record.

Based on review of the clinical record, facility policy and interviews for six (6) of six (6) sampled residents (Residents #8, 13, 14, 15, 16 and 17) reviewed for comprehensive assessments, the facility failed to ensure the resident comprehensive assessments were completed within fourteen (14) days of the Assessment Reference Date (ARD) as required. The findings include:1. The admission Minimum Data Set (MDS) assessment for Resident #13 was noted to have an ARD of 3/18/26 and was due to be completed by 4/1/26. Review of the admission MDS dated [DATE] for Resident #13 identified it was completed on 4/6/26 (5-days late). 2. The quarterly MDS assessment for Resident #15 was noted to have an ARD date of 4/1/26 and was due to be completed by 4/15/26. Review of the quarterly MDS dated [DATE] for Resident #15 on 4/20/26 identified it had yet to be completed (5-days late). 3. The quarterly MDS assessment for Resident #8 was noted to have an ARD (final day of the resident's observation period) of 4/2/26 and was due to be completed by 4/16/26. Review of the quarterly MDS dated [DATE] for Resident #8 on 4/20/26 identified it had yet to be completed (4-days late). 4. The annual MDS assessment for Resident #14 was noted to have an ARD date of 4/4/26 and was due to be completed by 4/18/26. Review of the annual MDS dated [DATE] for Resident #14 on 4/20/26 identified it had yet to be completed (2-days late). 5. The quarterly MDS assessment for Resident #16 was noted to have an ARD date of 4/4/26 and was due to be completed on 4/18/26. Review of the quarterly MDS dated [DATE] for Resident #16 on 4/20/26 identified it had yet to be completed (2-days late). 6. The quarterly MDS assessment for Resident #17 was noted to have an ARD date of 4/4/26 and was due to be completed by 4/18/26. Review of the quarterly MDS dated [DATE] for Resident #17 on 4/20/26 identified it had yet to be completed (2-days late). Interview with the MDS nurse, LPN #3 on 4/20/26 at 2:44 PM identified admission, quarterly and annual MDS's are due within 14 days of the ARD date. She reported she failed to complete the MDS assessments for Residents #8, 13, 14, 15, 16 and 17 prior to going on vacation and when she returned they were past the 14-day ARD date. She identified she should have completed the MDS's prior to going on vacation or delegated them to the MDS Coordinator (RN #6). Interview with the DON on 4/20/26 at 3:40 PM identified each MDS should be completed within 14 days of the resident's ARD. She identified she was unaware that MDS's were not being completed timely and reported LPN #3 should have delegated the MDS's she was unable to complete on time/before her vacation to the MDS Coordinator. Review of the MDS policy dated 7/2023 directed, in part, that the policy of the facility is to complete the MDS on a new admission within 14 days and review it quarterly thereafter. A new MDS is done annually or with significant change in a residents condition. The MDS Coordinator is responsible for the timely completion of the MDS and for completing the physical/medical sections of the MDS. Other disciplines are responsible for conducting their assessments and completing the section specific to their department on the MDS. The MDS Coordinator will sign the MDS upon completion and review it for items triggered.

Based on review of the clinical record, facility documentation/policies, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the environment was free from accident hazards when a bathroom grab bar used for transfers dislodged from the wall, resulting in a fall and subsequent rib fractures. The findings include:Resident #1's diagnoses included history of falls, heart failure, and anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), was independent with care, transfers, and wheelchair use. The Resident Care Plan (RCP) dated 12/12/25 identified Resident #1 had limited physical mobility and was at risk of falls. Interventions included staff assistance with daily care as needed, provide urinal for use at night, call bell within reach, and use of non-skid socks.A Nurse's note by RN #2 (the 3:00 PM to 11:00 PM supervisor) dated 1/5/26 at 9:01 PM identified at 8:45 PM Resident #1 was using the grab bar in his/her bathroom to pull him/herself up from the wheelchair to transfer to the toilet when the grab bar dislodged from the wall and Resident #1 came back down to the wheelchair with his/her knees on the floor. There were no injuries, marks, or bruises. The Reportable Event form by the Director of Nursing (DON) dated 1/9/26 at 2:00 PM identified Resident #1 fell on 1/5/26 at 8:30 PM when the grab bar Resident #1 was using in the bathroom to transfer from the wheelchair to the toilet became dislodged from the wall. Resident #1 had no signs of injury and no significant complaints of pain until 1/9/26 at which time the Advanced Practice Registered Nurse (APRN) ordered a chest x-ray. The chest x-ray identified rib fractures to the left 5th to 7th rib.A nurse's note dated 1/9/26 at 2:20 PM identified a chest x-ray was performed on 1/9/26 which identified fifth (5th) to seventh (7th) rib fractures.A nurse's note dated 1/9/26 at 9:24 PM identified physician's orders directed Tramadol fifty (50) milligrams (mg) three (3) times a day for pain and Incentive Spirometer ten (10) breaths three (3) times per day. Interview with Resident #1 on 2/6/26 at 12:30 PM identified he/she was permitted to use the bathroom independently and to self-transfer to the toilet. Resident #1 identified that on 1/5/26 he/she grasped the bathroom grab bar when attempting to transfer from the wheelchair to the toilet and the grab bar dislodged from the wall. Resident #1 further identified falling to the floor with his/her head against the door. Resident #1 used the call bell to call for assistance, and two staff assisted Resident #1 off the floor. Resident #1 identified that a few days later, he/she experienced chest pain and an x-ray was performed and identified rib fractures. Interview with NA #2 (the 3:00 PM to 11:00 PM nurse aide) on 2/6/26 at 1:57 PM identified on 1/5/26 Resident #1 called for help using his/her call bell in the bathroom. Resident #1 was found positioned on his/her knees on the floor between the wheelchair and the toilet and the grab bar was observed on the floor. NA #1 called for a nurse and helped assist Resident #1 off the floor.Interview with the Administrator on 2/6/26 at 2:30 PM identified Maintenance conducted monthly environmental rounds of the facility, and an assigned resident room is assessed during those rounds, however checking the stability of grab bars was not part of those rounds prior to the incident on 1/5/26.Although attempted, a call was not returned by RN #2.Review of facility documentation identified that a Plan of Correction was initiated immediately:Grab bars in the entire facility were checked immediately and there were no additional findings. Staff training was completed and included random checks of grab bars during monthly environmental rounds of at least two (2) bathrooms per unit per month.Random audits of grab bars would be completed weekly for four (4) weeks, then monthly for three (3) months.Audits would be reviewed at the monthly QAPI meetings.The Administrator was responsible for the plan with a compliance date of 1/14/25.The plan of correction was reviewed on 2/6/26 during an on-site visit and the facility met all components for past non-compliance.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of five (5) sampled residents (Resident #2) reviewed for respiratory care, the facility failed to ensure Resident #2 who had a physician's order for oxygen was receiving oxygen as ordered. The findings include: Resident #2's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and history of pressure ulcers.The Physician's order dated 7/4/25 directed oxygen zero (0) to four (4) liters to maintain oxygen saturation above 92% due to hypoxia and to check oxygen saturations every shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) was unable to be conducted), was oxygen dependent, and was dependent with all care.The Resident Care Plan (RCP) dated 11/17/25 identified Resident #2 had an altered respiratory status due to COPD and a self-care deficit. Interventions directed staff administer medication as ordered, change oxygen and nebulizer tubing as ordered, monitor oxygen saturation as ordered, and when on portable oxygen check oxygen level of the portable tank every three (3) hours to ensure there was oxygen in the tank.Review of the Medication Administration Record (MAR) for January 2026 and February 2026 identified oxygen was administered to Resident #2 continuously and oxygen saturation rates were documented on each shift.Interview with Person #1 on 2/5/26 at 11:30 AM identified on several different occasions when visiting, Resident #2 was using oxygen supplied by a portable oxygen tank and there was no oxygen in the tank. Person #1 further identified the portable tanks that were not in use were often empty.Observation on 2/6/26 at 10:10 AM identified Resident #2 was lying in bed with the head of the bed elevated to approximately forty-five (45 ) and Resident #2's oxygen nasal canula was not in place and the oxygen concentrator was powered off. The oxygen tubing was observed on top of the dresser which was next to Resident #2's bed and out of Resident #2's reach, and the oxygen concentrator was next to the dresser and out of Resident #2's reach. Interview with NA #1 on 2/6/26 at 10:10 AM identified she fed Resident #2 breakfast at 8:45 AM and Resident #2's oxygen was on. NA #2 did not know how Resident #2's oxygen concentrator was powered off and identified it should have been on. Interview with LPN #1 on 2/6/26 at 10:15 AM identified she did not know why Resident #2's oxygen was off. LPN #1 checked Resident #2's oxygen saturation before re-applying the oxygen and the saturation was 90% (normal range: 95%-100%). LPN #1 identified she administered Resident #2's nebulizer treatment around 8:00 AM and Resident #2's oxygen was on at that time. She identified Resident #2's oxygen saturation was 95% prior to the nebulizer treatment and increased to 98% after the nebulizer treatment. LPN #1 further identified Resident #2 would not have been able to take his/her own oxygen nasal canula off or power off the oxygen concentrator and that the oxygen should not have been off.Interview with the Director of Nursing (DON) on 2/6/26 at 11:00 AM identified she saw Resident #2 when she did rounds around 6:30 AM and at that time, Resident 2's oxygen was on. The DON further identified that no one should have turned the oxygen off. Review of the facility policy on Oxygen use identified oxygen is administered per physician's orders.

Based on clinical record review, facility documentation/policy and interviews, for one (1) of five (5) sampled residents (Resident #2) reviewed for grievances, the facility failed to ensure complaints/concerns reported by a resident representative were documented in the grievance log, investigated, and resolved in writing in accordance with the facility's grievance policy. The findings include: Interview with Person #1 on 2/5/26 at 11:30 AM identified he/she reported multiple care complaints/concerns to Social Workers (SW) and the Administrator over a prolonged period of time and had not been aware of a grievance process. Once made aware that the facility had a grievance process, he/she sent multiple emails regarding complaints/concerns because he/she did not know how to file a grievance using the grievance form. Person #1 did not receive written resolution for any complaints/concerns reported to the facility and was not made aware of resolutions to the complaints/concerns. Person #1 was not satisfied with the lack of follow-through on the complaints/concerns reported.Interview with the Administrator on 2/6/26 at 11:00 AM identified Person #1 reported care complaints/concerns to her regarding Resident #2 and she addressed the complaints/concerns immediately. The Administrator identified that after addressing the complaints/concerns, she thought the complaints/concerns were resolved. The Administrator further identified it was the responsibility of the SW to log reported complaints/concerns in the grievance log and communicate the complaints/concerns to the appropriate staff members for resolution. The Administrator identified she did not treat the complaints/concerns reported as grievances, did not ensure they were entered in the grievance log, and did not investigate as directed in the facility grievance policy. The administrator did not follow up in writing with Person #1 on findings or applicable resolutions if indicated.Interview with the SW on 2/6/26 at 11:57 AM and review of email correspondence dated 11/24/25 between Person #1 and the SW identified Person #1 reported several complaints/concerns to the SW. The SW identified that she addressed the complaints/concerns immediately but she did not log the complaints/concerns as grievances, did not document the outcome of the conversation with Person #1, and did not follow the facility policy on Grievances.Interview with the Director of Social Services (DSS) on 2/6/26 at 12:10 PM and review of email correspondences dated 5/15/25, 5/16/25, 5/18/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 6/14/25, and 6/19/25 between Person #1 and the DSS identified Person #1 reported several complaints/concerns to the DSS. The DSS identified she either addressed the complaints/concerns immediately or forwarded them to the facility's former Administrator. The DSS identified she did not log the complaints/concerns as grievances, did not document the outcome of the conversation with Person #1, and did not follow the facility policy on Grievances. The facility Resident Rights Policy identified the resident had the right to have the facility respond to their grievance.The facility Grievance Policy identified persons residing at the facility, their families, and other interested parties are given fair and proper procedure to voice complaints, grievances, or suggestions. The policy further identified the Social Worker will document the complaint, actions taken, and resolution of the problem in the facility grievance log.

Based on clinical record review, facility documentation, facility policy, and interviews, for two (2) of five (5) sampled residents (Resident #1 and Resident #2) reviewed for a safe and sanitary environment, the facility failed to ensure Resident #1 received care in a safe environment when a bathroom grab bar detached from the wall during use, resulting in a fall and rib fractures, and failed to ensure Resident #2 was provided a sanitary sleeping environment when the resident's mattress had a urine odor. The findings include:a. Resident #1's diagnoses included history of falls, heart failure, and anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), was independent with care, transfers, and wheelchair use. The Resident Care Plan (RCP) dated 12/12/25 identified Resident #1 had limited physical mobility and was at risk of falls. Interventions included staff assistance with daily care as needed, provide urinal for use at night, call bell within reach, and use of non-skid socks.A Nurse's note by RN #2 (the 3:00 PM to 11:00 PM supervisor) dated 1/5/26 at 9:01 PM identified at 8:45 PM Resident #1 was using the grab bar in his/her bathroom to pull him/herself up from the wheelchair to transfer to the toilet when the grab bar dislodged from the wall and Resident #1 came back down to the wheelchair with his/her knees on the floor. There were no injuries, marks, or bruises. The Reportable Event form by the Director of Nursing (DON) dated 1/9/26 at 2:00 PM identified Resident #1 fell on 1/5/26 at 8:30 PM when the grab bar Resident #1 was using in the bathroom to transfer from the wheelchair to the toilet became dislodged from the wall. Resident #1 had no signs of injury and no significant complaints of pain until 1/9/26 at which time the Advanced Practice Registered Nurse (APRN) ordered a chest x-ray. The chest x-ray identified rib fractures to the left 5th to 7th rib.A nurse's note dated 1/9/26 at 2:20 PM identified a chest x-ray was performed on 1/9/26 which identified fifth (5th) to seventh (7th) rib fractures.A nurse's note dated 1/9/26 at 9:24 PM identified physician's orders directed Tramadol fifty (50) milligrams (mg) three (3) times a day for pain and Incentive Spirometer ten (10) breaths three (3) times per day. Interview with Resident #1 on 2/6/26 at 12:30 PM identified he/she was permitted to use the bathroom independently and to self-transfer to the toilet. Resident #1 identified that on 1/5/26 he/she grasped the bathroom grab bar when attempting to transfer from the wheelchair to the toilet and the grab bar dislodged from the wall. Resident #1 further identified falling to the floor with his/her head against the door. Resident #1 used the call bell to call for assistance, and two staff assisted Resident #1 off the floor. Resident #1 identified that a few days later, he/she experienced chest pain and an x-ray was performed and identified rib fractures. Interview with NA #2 (the 3:00 PM to 11:00 PM nurse aide) on 2/6/26 at 1:57 PM identified on 1/5/26 Resident #1 called for help using his/her call bell in the bathroom. Resident #1 was found positioned on his/her knees on the floor between the wheelchair and the toilet and the grab bar was observed on the floor. NA #1 called for a nurse and helped assist Resident #1 off the floor.Interview with the Administrator on 2/6/26 at 2:30 PM identified Maintenance conducted monthly environmental rounds of the facility, and an assigned resident room is assessed during those rounds, however checking the stability of grab bars was not part of those rounds prior to the incident on 1/5/26. b. Resident #2's diagnoses included Congestive Heart Failure, history of urinary tract infections, and history of pressure ulcers.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Status Mental (BIMS) was unable to be conducted), was dependent with all care and required the assistance of two (2) for transfers with a mechanical lift.The Resident Care Plan (RCP) dated 11/17/25 identified Resident #2 had a self-care deficit and was at risk for skin breakdown. Interventions directed staff to reposition the resident every two (2) hours, follow the orders to get the resident out of bed, check and change the resident during rounds and as needed for incontinence, and apply barrier cream after each change.Interview with Person #1 on 2/5/26 at 11:30 AM identified that at times when he/she visited Resident #2, Resident #2's mattress smelled of urine and he/she reported the mattress odor to the facility.Observation on 2/6/26 at 10:10 AM with RN #1 (7:00 AM-3:00 PM Supervisor) and NA #1 (7:00 AM-3:00 PM nurse aide) identified Resident #2 had been incontinent of urine. No odor was noted from Resident #2's brief upon assessment; however, when NA #1 lifted the mattress sheet, a strong urine odor was detected emanating from the mattress beneath the sheet.Interview with NA #1 on 2/6/26 at 10:10 AM identified housekeeping was responsible for washing residents' mattresses.Interview with the Administrator on 2/6/26 at 11:00 AM identified that any facility staff providing care were responsible for ensuring the resident's mattress was cleaned if it was soiled or had an odor.Although attempted, a call was not returned by RN #2Review of the facility Cleaning Checklist failed to identify a mattress cleaning schedule.Review of the facility Monthly Environmental Round Logs failed to identify checking grab bars for stability.

Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of seven (7) sampled residents (Residents #1, #2 and #6) who were reviewed for medication administration, the facility failed to ensure the residents received scheduled anti-anxiety medication, narcotic pain medication, or both for agitation and comfort as prescribed by the physician. The failures resulted in the finding of Immediate Jeopardy. The findings include:1. Resident #1's diagnoses included malignant neoplasm of the ovaries, schizoaffective disorder, anxiety, delusional disorders, restlessness and agitation and depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of zero (0) out of fifteen (15) indicating memory recall deficits. The Resident Care Plan dated 4/28/25 identified Resident #1 received hospice services for a diagnosis of ovarian cancer. Interventions directed to administer medications per the physician's orders. a. A physician's order dated 1/11/25 directed to administer morphine sulfate oral solution 100 milligrams (mg) in 5 milliliters (mL), give 40 mg sublingually (under the tongue) every four (4) hours for pain, to be given around the clock. Review of the June 2025 Medication Administration Record (MAR) identified the morphine sulfate was not administered from 6/5/25 at 8:00 AM through 6/9/25 at 12:00 PM therefore twenty-six (26) doses were omitted. Upon further review, doses were not administered on 6/25/25 at 8:00 PM and 6/26/25 at 8:00 AM. The nurse's electronic MAR (eMAR) notes dated 6/5/25 through 6/9/25 identified the morphine sulfate was not administered because the medication was not available and was on order. Both the nurse's note and eMAR note dated 6/8/25 identified Resident #1 was noted to be crying, moaning, and refused care and Tylenol (pain reliever) was administered. Review of the pain assessments from 6/7/25 to 6/9/25 identified pain levels of zero (0) through eight (8) on a scale of zero (0) to ten (10). b. A physician's order dated 6/26/25 directed to administer morphine sulfate oral solution 100 mg in 5 mL, give 1.5 mL sublingually every four (4) hours as needed for pain and start morphine sulfate Extended Release (ER) 60 mg tablet, give two (2) tablets (120 mg) by mouth every twelve (12) hours for pain. Review of the June and July 2025 MAR identified the morphine sulfate ER 120 mg was not administered from 6/26/25 12:00 PM when it was ordered until 7/4/25 when it was discontinued, Resident #1 had gone without the scheduled pain control, a total of sixteen (16) doses and the as needed morphine sulfate oral solution was not administered in it's place. Review of the pain assessments from 6/26/25 to 6/30/25 identified pain levels of zero (0) through five (5). The nurse's eMAR notes dated 6/26/25 through 7/4/25 identified the morphine sulfate ER 120 mg was not administered because the medication was on order and not available. Interview with Person #6 (pharmacy manager) on 8/20/25 at 8:40 AM identified on 6/2/25 when the pharmacy received a script for the morphine sulfate oral solution the quantity was not identified so they called the facility for clarification but never received follow-up. Person #6 reported the facility did not reach out for an update until 6/9/25 which by that time twenty-six (26) doses had been missed and the facility authorized the pharmacy to bill for 90 mL, three (3) bottles for a sixteen (16) day supply. Person #6 explained that on 6/26/25 when the morphine sulfate ER tablets were first ordered, the pharmacy called the facility for clarification because the script was dosed incorrectly, and the facility then never called back or communicated with them until 6/30/25 when the pharmacy informed the facility the dosage was on backorder and unavailable. Person #6 identified going without morphine from 6/26/25 through 7/1/25 could have caused increased discomfort, respiratory issues, pinpoint pupils, tremors, sweats, restlessness, nausea/vomiting and insomnia. Person #6 reported that the delay in the medication getting sent to the facility was due to the facility's lack in communication and not sending scripts prior to exhausting the supply. c. A physician's order dated 2/24/25 directed to administer lorazepam intensol oral concentrate 2 mg per mL, give 4 mg by mouth every four (4) hours for agitation and/or pain. Review of the MAR with associated eMAR notes from May through July 2025 identified the lorazepam was not administered ten (10) times in May 2025, thirteen (13) times in June 2025 and twenty-three (23) times in July 2025, as the medication was unavailable, on order or the resident was sleeping. The May 2025 MAR identified that from 4:00 PM on 5/22/25 through 4:00 AM on 5/24/25 there were ten (10) doses of lorazepam oral contrate not administered. Review of nurse's notes from 5/22/25 through 5/25/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. The June 2025 MAR identified that from 8:00 AM on 6/2/25 until 4:00 AM on 6/3/25 there were six (6) doses of lorazepam not administered, on 6/15/25 from 12:00 PM through 12:00 AM on 6/16/25 four (4) doses were not administered and on 6/18/25 through 6/19/25 there were four (4) doses not administered because the medication was on order. Review of the Controlled Drug Record dated 6/16/25 identified 150 mL (12.5 day supply) of lorazepam was delivered to and signed for by the facility on 6/16/25, so Resident #1 should have received the lorazepam on 6/18/25 and 6/19/25 as ordered. Review of nurse's notes from 6/1/25 through 6/20/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. Review of behavior monitoring from 5/1/25 through 8/1/25 with associated eMAR progress notes identified that on 6/8/25 at both 12:00 AM and 12:00 PM Resident #1 was noted to be crying and moaning. On 6/9/25 Resident #1 was noted to be anxious (last doses withheld/missed on 6/2/25 and 6/3/25). The July 2025 MAR identified that from 12:00 PM on 7/5/25 until 4:00 PM on 7/7/25 there were thirteen (13) doses of lorazepam not administered, and twelve (12) doses not administered from 4:00 PM on 7/26/25 until 4:00 PM on 7/28/25. Review of the nurse's notes from 7/4/25 through 7/29/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. Review of behavior monitoring from 5/1/25 through 8/1/25 with associated eMAR progress notes identified on 6/8/25 at both 12:00 AM and 12:00 PM Resident #1 was noted crying and moaning. On 6/9/25 Resident #1 was noted to be anxious (last doses withheld/missed on 6/2/25 and 6/3/25). Review of behavior monitoring on 7/1/25 at 4:00 AM Resident #1 was noted with behaviors, but no follow-up note was documented to explain what the behaviors observed were. On 7/7/25 at 11:43 PM Resident #1 was crying and calling out and on 7/8/25 at 1:31 PM Resident #1 was noted with increased anxiety (last doses withheld/missed 7/5/25 to 7/7/25). The Advanced Practice Registered Nurse (APRN) note dated 7/7/25 identified she had been notified on 7/7/25 that Resident #1's morphine sulfate ER tablets and lorazepam intensol oral concentrate had not arrived from either the facility's pharmacy or the hospice pharmacy and Resident #1 was withdrawing from both the morphine and lorazepam and Resident #1 stated he/she felt like they were crawling out of their skin. The note reported Resident #1 was staring up at the ceiling, grinding his/her teeth and was notably anxious. The note identified the APRN re-faxed the scripts to the pharmacy, directed to continue the morphine concentrate as needed, would start lorazepam 4 mg tablets every four (4) hours around the clock until the lorazepam concentrate was delivered, and order a fentanyl patch 50 micrograms (mcg) to be applied every seventy-two (72) hours until the morphine sulfate ER tablets were delivered to the facility. Review of physician's orders for July 2025 failed to identify the order for the lorazepam 4 mg tablets every four (4) hours around the clock was entered or initiated. The nurse's note dated 7/30/25 at 2:46 PM, after not receiving the lorazepam from 7/26/25 until 7/28/25, two (2) days twelve (12) doses, identified Resident #1 was combative, refusing medications and care and on 8/1/25 at 9:46 AM Resident #1 was calling out, yelling, and was noted to be paranoid. The APRN note dated 7/31/25 identified Resident #1 was agitated, refusing medications, attempting to hit others and actively hallucinating and hospice was concerned Resident #1 may require a psychiatric hospitalization. A hospice note dated 7/31/25 identified Resident #1 was irritable, hallucinating, refusing medications and meals and struck a nurse the previous day due to agitation. The note indicated if the facility was unable to manage Resident #1's behaviors with the current regimen they should follow-up with the medical director for the behaviors and Resident #1 may require transport to next level of care. Interview with Person #3 (facility pharmacy representative) on 8/15/25 at 2:07 PM and review of the May 2025 MAR identified Resident #1 missed doses of lorazepam from 4:00 PM on 5/22/25 through 4:00 AM on 5/24/25. Person #3 indicated she had no documentation identifying the facility contacted them from 5/20/25 through 5/22/25 for a refill but the pharmacy did receive a new script on 5/23/25 and the pharmacy delivered the lorazepam on 5/24/25 at 3:55 AM because the facility did not request a STAT delivery. Person #3 explained she was not aware until 8/15/25, that with the 5/23/25 refill order, the pharmacy staff incorrectly calculated the amount and supply and set the next refill date to be available in eighteen (18) days when it should have been eligible for a refill in seven and one half (7.5) days. Person #3 identified the facility called on 6/2/25 to inquire about the next delivery and the facility was told the script could not be refilled until 6/11/25 so the Assistant Director of Nursing ADON approved a fifteen (15) day supply to be billed to the facility, which was processed and delivered on 6/3/25, however, Resident #1 missed six (6) doses of lorazepam from 6/2/25 through 6/3/25. Interview with Person #2 (Hospice clinical manager) on 8/15/25 at 10:22 AM identified due to ongoing issues with the facility's pharmacy not delivering Resident #1's narcotics timely where Resident #1 was missing doses, they started utilizing their own pharmacy on 7/9/25 and started having their hospice nurse conduct narcotic count with a facility nurse several times weekly so that they (hospice) were aware when the counts were low. Person #2 was unable to identify why hospice was not aware that Resident #1 ran out of the lorazepam from 7/26/25 until 7/28/25. Person #2 explained there was a cycle where hospice would adjust Resident #1's medications, get Resident #1 stable, then the facility would run out of the medications again and Resident #1 would become anxious and display behaviors. Interview with APRN #1 on 8/15/25 at 1:56 PM identified that on 7/7/25 she was notified Resident #1 had not received the morphine and lorazepam for several days and although she wrote in the note dated 7/7/25 Resident #1 was withdrawing from both the morphine and lorazepam due to the supply being unavailable, she was going to order lorazepam 4 mg tablets every four (4) hours around the clock until the lorazepam concentrate was delivered. APRN #1 indicated she could not recall being notified from May 2025 through July 2025 that the facility would run out of Resident #1's supply of lorazepam. APRN #1 identified the licensed nurses should be notifying a provider for all missed doses of medication so that they can order an alternative until the supply is delivered. APRN #1 explained that Resident #1 missing the morphine and lorazepam doses could have contributed to the behaviors and discomfort Resident #1 was experiencing on 6/8/25, 6/9/25, 7/7/25 and 7/30/25 per the nurses' notes. Interview with Person #4 (Hospice Manager) on 8/18/25 at 11:08 AM identified the facility did not notify them until 7/28/25 that the supply of lorazepam was exhausted on 7/26/25, two (2) days later, and the facility requested a STAT delivery. The Hospice Manager explained although their nurse would do narcotic count with the facility's nurse twice a week, they did not start the count of the lorazepam until after the supply was delivered on 7/29/25. Interview with Person #5 (pharmacist) on 8/19/25 at 1:40 PM identified lorazepam intensol withdrawal symptoms can include increased anxiety, combativeness, agitation, hallucinations, nausea/vomiting, insomnia, tremors and seizures. Person #5 indicated the behaviors Resident #1 exhibited on 6/8/25, 6/9/25, 7/7/25, 7/8/25, 7/30/25 and 7/31/25 could have been related to withdrawal from the lorazepam, and for a resident on as high of a dose and frequency as Resident #1, he/she could have started withdrawing anywhere between one (1) and five (5) days depending on the resident. Interviews with charge nurses Licensed Practical Nurse (LPN) LPN #2, LPN #3, LPN #4, LPN #5, LPN #7, LPN #10, and LPN #11 identified they had been told by the facility prior, to August 2025 that they were not to call the pharmacy or the provider for medication issues, they were to notify the nursing supervisor on duty and the notifications were the supervisors responsibility. They stated they were not aware the provider had to be notified for each missed administration, with multiple staff stating another staff member communicated to them the pharmacy was notified and the supervisor was aware, so they took their word for it and did not notify the nursing supervisor that they still had not received a delivery and the medications continued to be omitted. Interviews with nursing supervisors, Registered Nurse (RN), RN #1 and RN #5 identified the charge nurses did not notify them consistently for all missed morphine and lorazepam doses between May and July 2025, stating if the charge nurses had informed them, they would have notified the pharmacy and provider. RN #1 and RN #5 reported when charge nurses did notify them, they did not always document in the clinical record when they had contacted the pharmacy or communicated with the provider. RN #5 stated she would not call the provider on the 11PM to 7AM shift for missed medication administration but would instead pass it on to the 7AM to 3PM shift to notify APRN #1. Interview with the Director of Nursing (DON) on 8/18/25 at 1:15 PM identified the facility should have never run out of the morphine or lorazepam, stating she was under the impression the hospice nurse was counting all of Resident #1's narcotic medications with the facility charge nurses twice weekly since Resident #1 was assigned to hospice's pharmacy early July 2025. The DON explained she had not observed the counts, and notes were not taken when the counts occurred. The DON identified the charge nurses should have been notifying the nursing supervisor at least twenty-four (24) hours prior to the medication being exhausted and requesting a refill, in case there were issues with the script. The DON identified that for all doses of medication not administered, the charge nurse was to call the pharmacy to inquire on when the medication would be delivered, then notify the nursing supervisor of the missed administration so the nursing supervisor can contact the provider, and the charge nurses should be following-up with the nursing supervisor and ask if any new orders were obtained. 2. Resident #6's diagnoses included chronic pain, osteoarthritis (degenerative joint disease where the tissues in the joints break down over time), kyphosis (excessive forward curve of the spine which can cause back pain and stiff muscles) and anxiety disorder. A physician's order dated 6/3/24 directed to administer hydrocodone/acetaminophen 5-325 mg tablet, give one (1) tablet every evening for pain. The annual Minimum Data Set assessment dated [DATE] identified Resident #6 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating Resident #6 was alert and oriented to person, place, and time. The Resident Care Plan dated 6/12/25 identified Resident #6 was at risk for pain related to osteoarthritis, osteoporosis (weak and brittle bones), chronic pain, headache syndrome and intestinal and rectal fistulas (abnormal connection between two parts inside the body that don't normally connect). Interventions directed to administer pain relief medications per the physician's order, to anticipate the resident's need for pain relief and respond immediately to any complaints of pain and to monitor and record characteristics of the pain. Review of the July 2025 MAR identified the hydrocodone/ acetaminophen was not administered 7/21/25 through 7/24/25, four (4) days and to see progress notes. The MAR identified pain assessments were completed every shift and no pain was noted from 7/21/25 through 7/24/25. The eMAR progress notes dated 7/21/25 through 7/24/25 identified the hydrocodone/ acetaminophen was not administered because it was not available and on order. Review of the Controlled Drug Record sheets identified the hydrocodone/acetaminophen had not been signed out from 7/21/25 through 7/24/25. Interview with LPN #2 on 8/18/25 at 9:48 AM identified that although she administered the last tablet of hydrocodone/acetaminophen to Resident #6 on 7/20/25 she could not recall if she had refilled the medication, contacted the pharmacy or notified the nursing supervisor. LPN #2 indicated she also did not administer the hydrocodone/acetaminophen on 7/21/25 through 7/23/25 because the medication was out of stock and not available, she did not notify the supervisor each day or call the pharmacy to inquire about the medication, explaining she did not have time to call the pharmacy and was unaware the nursing supervisor and provider had to be notified for each missed administration. Interview with Person #6 (Pharmacist Manager) on 8/20/25 at 8:40 AM identified they had no record the facility contacted them in July 2025 to inquire about a refill for Resident #6's hydrocodone/acetaminophen tablets. Person #6 reported the pharmacy received a new script on the afternoon of 7/24/25 and the facility received the hydrocodone/acetaminophen on 7/25/25. 3. Resident #2's diagnoses included dementia with behavioral and mood disturbances and anxiety disorder. The Resident Care Plan dated 7/30/25 identified that Resident #2 utilized psychotropic medications related to diagnoses of adjustment disorder, depression, anxiety, Alzheimer's dementia, delusional disorder and mood disorder. Interventions directed to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of three (3) out of fifteen (15) indicating poor memory recall. The psychiatric APRN note dated 8/5/25 identified she was asked to evaluate Resident #2 for mood and anxiety, Resident #2 could become angry with an explosive temper without provocation, hostile with staff members of color and combative with care, was confused and could not recall anything for longer than a few minutes so when Resident #2 becomes agitated it was best to walk away and reapproach after a few minutes. The note identified they would trial lorazepam three (3) times daily to see if it improves the behaviors. A physician's order dated 8/5/25 directed to administer lorazepam oral concentrate 2 mg per mL, give 0.5 mL by mouth three (3) times daily for anxiety/agitation/irritability. Review of the August 2025 MAR identified the lorazepam oral concentrate was not administered to Resident #2 on 8/5/25 at 12:00 PM or 4:00 PM, 8/6/25 at 8:00 AM, 8/7/25 at 4:00 PM or 8/8/25 at 8:00 AM and 12:00 PM. Review of the nurse's notes and eMAR notes dated 8/5/25 through 8/8/25 identified the lorazepam was either unavailable, Resident #2 refused the medication or the resident was sleeping. Interview with LPN #1 on 8/19/25 identified although she did not administer the lorazepam to Resident #2 on 8/5/25, 8/6/25 and 8/8/25 she was unaware she had to notify the nursing supervisor for all missed medication administrations and refusals so the nursing supervisor can notify the provider for possible alternative orders. Interview with the Person #6 (Pharmacist Manager) on 8/20/25 at 8:40 AM identified the pharmacy received the script on 8/5/25 at 5:30 PM for the lorazepam oral concentrate for Resident #2, reporting that it was not requested STAT (immediately) so it was sent on the 9:00 PM run and was signed for by the facility on 8/6/25 at 2:31 AM. Interview with the DON on 8/19/25 at 3:42 PM identified that she was not aware Resident #2 and Resident #6 did not receive the scheduled narcotics as ordered in July and August 2025. The DON indicated that the pharmacy and provider should have been contacted for all unavailable medications, medication refusals and missed administrations and this should be documented in the clinical record. The DON explained residents should be woken up for the scheduled narcotic medications. The DON identified the facility's emergency stock for lorazepam intensol oral concentrate, morphine sulfate oral solution and hydrocodone/acetaminophen tablets had been depleted prior to 6/17/25 and the supply was not refilled. Review of the Administration of Medications policy dated 7/2023 directed, in part, that medications are to be given at the time ordered or within 60 minutes before or after the time designated. Medication errors and adverse drug reactions shall be immediately reported to the attending physician, charted in the clinical records, and described in Medication Error Report, and incident report if necessary, which is submitted to the State Health Department. Review of the Medication Omission/Withholding policy dated 7/2023 directed, in part, that all medications are to be administered as prescribed by the attending physician unless in the nurses professional judgement the medication(s) should be omitted/withheld. If the nurse makes the decision to omit/withhold medication(s) the nurse will notify the supervisor who will notify the MD and document in the clinical record. Nurses notes are to include the date, specific time, and pertinent details. Review of the Medication Refusal Policy dated 7/2023 directed, in part, that for medication refusals, the nurse will explain to the resident the possible consequences of medication refusal, and for non-competent confused residents, the nurse will go back and offer the medication again within an hour. The nursing supervisor will notify the MD once 3 consecutive doses of any medication is refused, will document the conversation with the MD in the clinical record and the nurse will properly document the medication refusal on the resident's electronic medical record. Review of the Medication Re-Order Procedure dated 7/2023 directed, in part, that the 3-11 shift nurse is responsible for re-ordering routine medications on a regular basis to ensure that a resident is never without an appropriate available supply of prescribed medications. Medications should be reordered when an eleven (11) day supply remains.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of seven (7) sampled residents (Residents #1) reviewed for medication administration, the facility failed to follow up with the pharmacy services to ensure new medication orders were filled and standing orders were refilled prior to exhausting the supply. The findings include:Resident #1's diagnoses included malignant neoplasm of the ovaries, schizoaffective disorder, anxiety, delusional disorders, restlessness and agitation and depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of zero (0) out of fifteen (15) indicating memory recall deficits. The Resident Care Plan dated 4/28/25 identified Resident #1 received hospice services for a diagnosis of ovarian cancer. Interventions directed to administer medications per the physician's orders. A physician's order dated 6/26/25 directed to administer morphine sulfate oral solution 100 mg in 5 mL, give 1.5 mL sublingually every four (4) hours as needed for pain and start morphine sulfate Extended Release (ER) 60 mg tablet, give two (2) tablets (120 mg) by mouth every twelve (12) hours for pain. Review of the June and July 2025 MAR identified the morphine sulfate ER 120 mg was not administered from 6/26/25 12:00 PM when it was ordered through 7/4/25 when it was discontinued, Resident #1 had gone without the scheduled pain control, a total of sixteen (16) doses and the as needed morphine sulfate oral solution was not administered in it's place. The nurse's eMAR notes dated 6/26/25 through 7/4/25 identified the morphine sulfate ER 120 mg was not administered because the medication was on order and not available. Interview with Person #6 (pharmacy manager) on 8/20/25 at 8:40 AM identified on 6/2/25 when the pharmacy received a script for the morphine sulfate oral solution the quantity was not identified so they called the facility for clarification but never received follow-up. Person #6 reported the facility did not reach out for an update until 6/9/25 which by that time twenty-six (26) doses had been missed and the facility authorized the pharmacy to bill for 90 mL, three (3) bottles for a sixteen (16) day supply. Person #6 explained that on 6/26/25 when the morphine sulfate ER tablets were first ordered, the pharmacy called the facility for clarification because the script was dosed incorrectly, and the facility then never called back or communicated with them until 6/30/25 when the pharmacy informed the facility communicated the dosage was on backorder and unavailable. Person #6 reported the delay in the medication getting sent to the facility was due to the facility's lack in communication and not sending scripts prior to exhausting the supply. c. A physician's order dated 2/24/25 directed to administer lorazepam intensol oral concentrate 2 mg per mL, give 4 mg by mouth every four (4) hours for agitation and/or pain. The May 2025 MAR identified that from 4:00 PM on 5/22/25 through 4:00 AM on 5/24/25 ten (10) doses of lorazepam were not administered. Review of nurse's notes from 5/22/25 through 5/25/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. Interview with Person #3 (facility pharmacy representative) on 8/15/25 at 2:07 PM and review of the May 2025 MAR identified Resident #1 missed doses of lorazepam from 4:00 PM on 5/22/25 through 4:00 AM on 5/24/25. Person #3 indicated she had no documentation identifying the facility contacted them from 5/20/25 through 5/22/25 for a refill but the pharmacy did receive a new script on 5/23/25 and the pharmacy delivered the lorazepam on 5/24/25 at 3:55 AM because the facility did not request a STAT delivery. Person #3 explained she was not aware until 8/15/25, that with the 5/23/25 refill order, the pharmacy staff incorrectly calculated the amount and supply and set the next refill date to be available in eighteen (18) days when it should have been eligible for a refill in seven and one half (7.5) days. Person #3 identified the facility called on 6/2/25 to inquire about the next delivery and the facility was told the script could not be refilled until 6/11/25 so the Assistant Director of Nursing (ADON) approved a fifteen (15) day supply to be billed to the facility, which was processed and delivered on 6/3/25, however, Resident #1 missed six (6) doses of lorazepam from 6/2/25 through 6/3/25. Interview with the Director of Nursing (DON) on 8/18/25 at 1:15 PM identified the facility should not have run out of the morphine or lorazepam. The DON identified that for all doses of medication not administered, the charge nurse was to call the pharmacy to inquire on when the medication would be delivered, then notify the nursing supervisor of the missed administration so the nursing supervisor can contact the provider, and the charge nurses should be following-up with the nursing supervisor and ask if any new orders were obtained.

Based on review of the clinical record, facility documentation, facility policy and interviews for eleven (11) of thirteen (13) residents (Resident #1, 2, 4, 5, 6, 7, 8, 9, 12, 13 and 14) reviewed for medication administration, the facility failed to ensure that diabetic, cardiac, anti-seizure, pain and behavioral medications were administered timely per physician's orders. These failures resulted in a finding of Immediate Jeopardy. The findings include:1. Resident #1 's diagnoses included epilepsy, type 2 diabetes mellitus with foot ulcers, osteomyelitis (an infection in the bone) and atrial fibrillation (irregular heartbeat).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), required moderate assistance for eating, substantial assistance for bed mobility and was dependent on staff for transfers.The Resident Care Plan (RCP) dated 12/19/2024 identified Resident #1 had diabetes mellitus, pain related to left first and fifth toe amputations and had the potential for seizure activity related to the diagnosis of epilepsy. Interventions included administering medications as ordered by the provider and monitoring and documenting side effects and effectiveness.Review of the facility census identified Resident #1 resided on the East unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #1 was ordered to receive the following medications: 01/01/2025 at 9:00 PM: Keppra (anti-seizure medication) 750 milligrams (mg) (twice daily medication) which was not signed off as administered until 10:23 PM by LPN #1. 03/02/2025 gabapentin (used to treat nerve pain) (2) 100 mg capsules (three times daily medication) related to polyneuropathy (damage to peripheral nerves causing symptoms such as numbness, burning pain and weakness) and the 8:00 AM and 12:00 PM doses were signed off as administered together at 11:23 AM by LPN #1. 03/02/2025 at 9:00 AM: Keppra 750 mg (twice daily medication), metformin (medication used to treat diabetes mellitus) 1000 mg (twice daily medication) and lisinopril (medication used to treat high blood pressure) 5 mg which were not signed off as administered until 11:23 AM by LPN #1. 03/10/2025: gabapentin (2) 100 mg capsules (three times daily medication) and the 8:00 AM and 12:00 PM doses were signed off as administered together at 11:00 AM by LPN #1. 03/10/2025 at 9:00 AM: Keppra 750 mg (twice daily medication), metformin 1000 mg (twice daily medication) and lisinopril 5 mg, which were not signed off as administered until 11:00 AM by LPN #1. 04/22/2025 at 4:00 PM: gabapentin (2) 100 mg capsules (three times daily medication), Keppra 750 mg (twice daily medication) and metformin 1000 mg (twice daily medication) which were not signed off as administered until 10:48 PM by RN #2. 04/22/2025 at 4:30 PM: Insulin Lispro (short-acting insulin) 2 units subcutaneously (under the skin) was ordered before meals and was not signed off as administered until 6:17 PM by RN #2. 05/21/2025 at 5:00 PM: metformin 1000mg (twice daily medication) which was not signed off as administered until 10:34 PM by RN #2. 05/21/2025 at 8:00 PM: gabapentin (2) 100 mg capsules (three times daily medication), Keppra 750 mg (twice daily medication) and Tylenol (pain reliever) 975 mg (three times daily medication) which were not signed off as administered until 10:35 PM by RN #2. Review of nurse's notes from 01/01/2025 through 05/22/2025 failed to identify that the nursing supervisor or the provider were notified of the late medication administrations for Resident #1.2. Resident #2's diagnoses included dementia without behavioral disturbances, seizures, hypertension (high blood pressure) and neoplasm (cancer) to the bone, soft tissue and skin.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), required setup assistance for eating and substantial assistance for bed mobility and transfers.The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #2 was at risk for alteration in comfort related to intracranial (inside the skull) injuries. Interventions included administering pain medication per physician's orders.Review of the facility census identified Resident #2 resided on the East unit.Review of the Medication Administration Audit Report for January 2025 identified Resident #2 was ordered to receive the following medications: 01/17/2025 at 8:00 AM: gabapentin 300 mg (twice daily medication) for pain which was not signed off as administered until 9:10 AM by LPN #1. 01/19/2025 at 8:00 AM: gabapentin 300 mg (twice daily medication) which was not signed off as administered until 9:22 AM by LPN #1. 01/20/2025 at 8:00 AM: gabapentin 300 mg (twice daily medication) which was not signed off as administered until 9:51 AM by LPN #1. 1/23/2025 at 4:00 PM: gabapentin 300 mg (twice daily medication) which was not signed off as administered until 5:18 PM by LPN #1.Review of nurse's notes from 01/17/2025 through 01/24/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #2.3. Resident #4's diagnoses included heart failure, chronic pain and type II diabetes mellitus.The Resident Care Plan (RCP) dated 12/23/2024 identified Resident #4 had diabetes mellitus, chronic pain, altered cardiac status and an implanted cardiac defibrillator (an implanted device under the skin that corrects life threatening heart rhythms). Interventions included administering medications as ordered by the physician and monitoring and documenting side effects and effectiveness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.Review of the facility census identified Resident #4 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #4 was ordered to receive the following medications: 01/12/2025 at 4:00 PM: methocarbamol (used to relieve pain) (2) 500 mg tablets (twice daily medication) for muscle spasms, coreg (used to treat heart failure and high blood pressure) (2) 6.25 mg tablets (twice daily medication) and gabapentin 300 mg (three times daily medication) for chronic pain which were not signed off as administered until 5:55 PM by LPN #1. 01/12/2025 at 4:30 PM: Insulin Lispro 4 units prior to meals which was not signed off as administered until 5:55 PM by LPN #1. 03/10/2025 at 12:00 PM: gabapentin 300 mg (three times daily medication) and Insulin Lispro 4 units before meals which were not signed off as administered until 2:39 PM by LPN #1. 04/10/2025 at 4:00 PM: methocarbamol (2) 500 mg tablets (twice daily medication), coreg (2) 6.25 mg tablets (twice daily medication), gabapentin 300 mg (three times daily medication) and hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg (twice daily medication) for chronic pain syndrome which were not signed off as administered until 5:55 PM by LPN #1. 4/10/25 at 4:30 PM: Insulin Lispro 4 units prior to meals which was not signed off as administered until 6:31 PM by LPN #1. 05/17/2025 at 11:30 AM: Insulin Aspart (rapid acting insulin) 4 units which was not signed off as administered until 3:46 PM by LPN #1 05/17/2025 at 1:00 PM: gabapentin 300 mg (three times daily medication) which was not signed off as administered until 3:44 PM by LPN #1. 06/19/2025 at 4:00 PM: methocarbamol (2) 500 mg tablets (twice daily medication), coreg (2) 6.25 mg tablets (twice daily medication) and hydrocodone-acetaminophen 5-325 mg (twice daily medication) which were not signed off as administered until 8:18 PM by RN #2. Review of nurse's notes from 01/12/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #4.Interview with Resident #4 on 6/24/25 at 3:05 PM identified that when LPN #1 worked, he/she did not receive ordered medications until hours after they were ordered, at times, his/her blood sugar was not obtained and, at times, he/she did not receive medications at all, which caused increased pain. Resident #4 identified he/she reported the medication issues to the ADNS about three (3) weeks prior but LPN #1 continued to work on the unit. Interview with the ADNS on 6/24/25 at 3:11 PM identified Resident #4 reported the medication issues to her when she accompanied Resident #4 on an outpatient appointment, but she did not report the allegation to the DNS, or to the State Agency and did not investigate the allegation. The ADNS identified she was new to her position and was unaware of the requirements for an allegation of neglect. 4. Resident #5's diagnoses included cardiomyopathy (disease of heart muscle), atrial fibrillation (irregular heart rhythm), congestive heart failure and pain. The Resident Care Plan (RCP) dated 10/29/2024 identified Resident #5 was at risk for altered cardiac status, had a cardiac pacemaker/defibrillator (implanted devices under the skin that help to regulate the heart), was taking an anticoagulant (blood thinner) related to atrial fibrillation and had chronic pain. Interventions included administering medications as ordered.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.Review of the facility census identified Resident #5 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #5 was ordered to receive the following medications: 01/12/2025 at 4:00 PM: Eliquis (blood thinner) 5 mg (twice daily medication) for atrial fibrillation which was not signed off as administered until 6:11 PM by LPN #1. 04/17/2025 at 4:00 PM: Eliquis 5 mg (twice daily medication) which not signed off as administered until 10:44 PM by RN #2 04/17/2025 at 9:00 PM: Entresto (for congestive heart failure) 24-26 mg (twice daily medication), divalproex (anti-convulsant) 625 mg for mood disorder, risperidone (anti-psychotic) (2) 1 mg tablets and trazodone (for insomnia) 100 mg which were not signed off as administered until 11:01 PM by RN #2. 06/19/2025 at 4:00 PM: Eliquis 5 mg (twice daily medication) which was not signed off as administered until 10:19 PM by RN #2 06/19/2025 at 9:00 PM: Entresto 24-26 mg (twice daily medication), divalproex 625 mg, risperidone (2) 1 mg tablets and trazodone 100 mg which were not signed off as administered until 11:22 PM by RN #2. Review of nurse's notes from 01/12/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #5.Interview with Resident #5 on 06/25/2025 at 9:27 AM identified there was a day during the prior week that a Nurses Aid (NA) administered his/her medications at 10:30 PM. Resident #5 could not describe the NA, but insisted the staff member was an NA and not a nurse. 5. Resident #6's diagnoses included type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes), heart failure, tachycardia (rapid heart rate) and chronic pain syndrome.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.The Resident Care Plan (RCP) dated 10/31/2024 identified Resident #6 had diabetes mellitus, chronic pain syndrome and altered cardiovascular status. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness.Review of the facility census identified Resident #6 resided on both the East Unit and the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #6 was ordered to receive the following medications: 02/04/2025 at 3:00 PM: 1.5 tablets of trazodone 100 mg for agitation and poor sleep pattern which was not signed off as administered until 8:28 PM by LPN #1. 02/04/2025 at 4:00 PM: 2 capsules of gabapentin 300 mg (twice daily medication) for pain which was not signed off as administered until 8:27 PM by LPN #1. 02/04/2025 at 5:00 PM: bumex 1 mg (twice daily medication) for congestive heart failure which was not signed off as administered until 8:27 PM by LPN #1. 02/07/2025 at 3:00 PM: 1.5 tablets of trazodone 100 mg which was not signed off as administered until 8:42 PM by LPN #1. 02/07/2025 at 5:00 PM: bumex 1 mg (twice daily medication) which was not signed off as administered until 7:37 PM by LPN #1. 04/10/2025 at 8:00 AM: 2 capsules of gabapentin 300 mg (twice daily medication), Insulin Aspart 4 units with meals, metoprolol succinate (used to lower blood pressure and heart rate) 100 mg (twice daily medication) and bumex 1 mg (twice daily medication) which were not signed off as administered until 2:32 PM by LPN #1. 04/10/2025 at 12:00 PM: Insulin Aspart 4 units with meals which was not signed off as administered until 2:39 PM by LPN #1 (7 minutes after the 8:00 AM dose of Insulin Aspart was signed off as administered). 04/22/2025 at 4:00 PM: 2 capsules of gabapentin 300 mg (twice daily medication), metoprolol succinate 100 mg (twice daily medication) and bumex 1 mg (twice daily medication) which were not signed off as administered until 8:32 PM by RN #2. 06/19/2025 at 4:00 PM: metoprolol succinate 100 mg (twice daily medication) and bumex 1 mg (twice daily medication) which were not signed off as administered until 7:52 PM by RN #2. 06/19/2025 at 5:00 PM: 2 capsules of gabapentin 300 mg (twice daily medication) which was not signed off as administered until 7:54 PM by RN #2. Review of nurse's notes from 02/4/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #6.Interview with Resident #6 on 06/25/2025 at 9:11 AM identified that when LPN #1 worked, he/she consistently received medications late in the shift and receiving medications late caused him/her increased pain to the lower back and feet. Resident #6 identified his/her family member often visited in the evening and would leave the room to find LPN #1 to administer the medications.6. Resident #7 's diagnoses included muscle spasms of the back, neuropathy, chronic pain and congestive heart failure.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required setup assistance for eating and was dependent on staff for bed mobility and transfers.The Resident Care Plan (RCP) dated 01/11/2025 identified Resident #7 had chronic pain and altered cardiac function. Interventions included administering medications as ordered, anticipating the need for pain relief and responding immediately to complaints of pain.Review of the facility census identified Resident #7 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #7 was ordered to receive the following medications: 01/01/2025 at 8:00 AM: hydralazine 10 mg (three times daily medication) for hypertension (high blood pressure), 2 tablets gabapentin 600 mg (three times daily medication) for spinal stenosis (when the space inside the backbone is too small which can put pressure on the spinal cord and nerves) and baclofen 10 mg (three times daily medication) for muscle spasms which were not signed off as administered until 9:27 AM by LPN #1. 03/10/2025 at 12:00 PM: baclofen 10 mg (three times daily medication) and 2 tablets gabapentin 600 mg (three times daily medication) which were not signed off as administered until 2:28 PM by LPN #1 03/10/2025 at 1:00 PM: 2 tablets of hydralazine 10 mg (three times daily medication) and tramadol (used to treat pain) 50 mg (three times daily medication) for chronic pain syndrome which were not signed off as administered until 2:28 PM by LPN #1. 04/17/2025 at 9:00 PM: 2 tablets of gabapentin 600 mg (three times daily medication), doxazosin (used to treat high blood pressure) 4 mg, baclofen 10 mg (three times daily medication), tramadol 50 mg (three times daily medication) and 2 tablets of hydralazine (three times daily medication) which were not signed off as administered until 11:07 PM by RN #2. 05/17/2025 at 1:00 PM: baclofen 10 mg (three times daily medication), 2 tablets of gabapentin (three times daily medication), tramadol 50 mg (three times daily medication) and 2 tablets of hydralazine 10 mg (three times daily medication) which were not signed off as administered until 3:56 PM by LPN #1. 06/19/2025 at 9:00 PM: gabapentin 600 mg (three times daily medication), doxazosin 4 mg, baclofen 10 mg (three times daily medication), tramadol 50 mg (three times daily medication) and 2 tablets of hydralazine which were not signed off as administered until 11:11 PM by RN #2.Interview with Resident #7 on 06/25/2025 at 9:28 AM identified his/her medications were consistently administered late when LPN #1 and RN #2 worked, causing him/her increased pain and anxiety. Resident #7 indicated when he/she complained to the staff, he/she would eventually receive the medications but indicated he/she was worried about residents who could not self-advocate. Resident #7 identified that on 06/19/2025 at 10:00 PM he/she rang the call bell because he/she had not seen RN #2 since the start of the shift and both him/her and the roommate (Resident #5) had not yet received medications. Resident #7 identified a NA then administered a cup of pills to Resident #5 but he/she (Resident #7) received no medication that night. Resident #7 identified he/she wrote a complaint and gave it to staff to deliver to administration regarding the incident, but no one followed up with him/her regarding the complaint.Review of the letter dated 06/21/2025 from Resident #7 on 06/26/2025 identified, in part, that on the night of 06/19/2025, his/her nurse (RN #2) appeared to be absent and a NA brought Resident #5 (roommate) his/her medications at the end of the shift but he/she (Resident #7) did not receive any medications that night.Interview with the Administrator on 06/25/2025 at 10:48 AM identified there was a letter under his office door when he arrived to the facility on [DATE]. He identified he was unaware of who delivered the letter and that the facility was looking into it and indicated the DNS was given the letter for follow up.Interview with the DNS on 06/25/2025 at 10:53 AM identified she placed a call to RN #2 on 06/25/2025. She identified that RN #2 worked as an NA at the facility prior to becoming an RN and some residents still thought RN #2 was an NA. The DNS further identified she had not interviewed any other staff who worked during the evening/night shift on 06/19/2025. The DNS identified she reviewed the Medication Administration Record (MAR) for Residents #5 and #7 which identified medications were signed off as administered late on 06/19/2025 and that the provider should have been notified but was not. The DNS identified that the allegation from Resident #7 should have been reported to the Administrator or herself immediately rather than staff sliding a letter under the Administrator's office door and the allegation should have been reported to the State Agency, fully investigated and followed up on timely. 7. Resident #8's diagnoses included hypertension (high blood pressure), heart failure, atrial fibrillation (irregular heart rhythm), pain of the joints and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15).The Resident Care Plan (RCP) dated 11/18/2024 identified Resident #8 had altered cardiovascular status, was on anticoagulant therapy related to atrial fibrillation and had the potential for pain related to a wedge compression fracture, scoliosis, osteoporosis and lower extremity edema. Interventions included administering medications per physician's orders and monitoring for side effects and effectiveness every shift.Review of the facility census identified Resident #8 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #8 was ordered to receive the following medications: 01/24/2025 at 8:00 PM: metoprolol succinate 100 mg (twice daily medication) for hypertension which was not signed off as administered until 1/25/25 at 3:19 AM by RN #2 01/24/2025 at 9:00 PM: Eliquis 2.5 mg (twice daily medication) for atrial fibrillation and acetaminophen (2) 500 mg tablets for pain to the joints which were not signed off as administered until 1/25/25 at 3:20 AM by RN #2 . 02/17/2025 at 8:00 AM: metoprolol succinate 100 mg (twice daily medication) and Eliquis 2.5 mg (twice daily medication), which were not signed off as administered until 4:56 PM by LPN #1. 04/10/2025 at 8:00 AM: lisinopril (used to treat high blood pressure) 5 mg, Eliquis 2.5 mg (twice daily medication), metoprolol succinate 100 mg (twice daily medication) and trazodone 12.5 mg for anxiety which were not signed off as administered until 2:18 PM by LPN #1. 04/22/2025 at 8:00 PM: metoprolol succinate 100 mg (twice daily medication), acetaminophen (2) 500 mg tablets, and Eliquis 2.5 mg (twice daily medication), which were not signed off as administered until 9:57 PM by RN #2. 05/09/2025 at 8:00 AM: lisinopril 5 mg, Eliquis 2.5 mg (twice daily medication), metoprolol succinate 100 mg (twice daily medication) and trazodone 12.5 mg which were not signed off as administered until 10:27 AM by LPN #1. Review of nurse's notes from 01/24/2025 through 05/10/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #8.Interview with Resident #8 on 06/26/2025 at 2:06 PM identified that one night (could not recall the date) he/she did not receive evening medications until after 10:00 PM, he/she was worried and indicated that when he/she did not receive pain medications timely he/she could not sleep due to pain in the feet/toes. Resident #8 presented a notebook where he/she had written, LPN #1 comes too late at 9:30 PM to 10:00 PM referring to when he/she received medications when LPN #1 worked on the unit. 8. Resident #9's diagnoses included chronic pain, contracture of muscle of the right and left lower leg and polyneuropathy (damage or disease affecting the peripheral nerves outside the brain and spinal cord).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance for bed mobility and transfers and was independent with eating.The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #9 was at risk for pain related to arthritis, polyneuropathy and muscle contractures of the right lower extremity and the left lower extremity. Interventions included administering medication per physician's orders, anticipating the need for pain relief and responding immediately to any complaint of pain.Review of the facility census identified Resident #9 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #9 was ordered to receive the following medications: 01/11/2025 at 8:00 AM: baclofen 7.5 mg (twice daily medication) for cramps and spasms which was not signed off as administered until 9:43 AM by LPN #1. 01/12/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) which was not signed off as administered until 7:45 PM by LPN #1 01/12/2025 at 5:00 PM: acetaminophen (2) 325 mg tablets (twice daily medication) for pain which was not signed off as administered until 7:45 PM by LPN #1. 04/10/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not signed off as administered until 6:37 PM by LPN #1. 04/17/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not not signed off as administered until 4/18/25 at 12:37 AM by RN #2. 05/17/2025 at 8:00 AM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not signed off as administered until 10:18 AM by LPN #1. 06/19/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not signed off as administered until 7:16 PM by RN #2.Review of nurse's notes from 01/11/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #12.Although attempted, an interview with Resident #9 was not obtained.9. Resident #12's diagnoses included Alzheimer's disease and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), required setup assistance for eating and transfers and supervision assistance for ambulation.The Resident Care Plan (RCP) dated 05/22/2025 identified Resident #12 had chronic pain. Interventions included administering medications as ordered, anticipating the need for pain relief and responding immediately to any complaints of pain.Review of the facility census identified Resident #12 resided on the [NAME] unit.Review of the Medication Administration Audit Report for June 2025 identified Resident #12 was ordered to receive the following medications: 06/10/2025 at 5:00 PM: gabapentin 100 mg (three times daily medication) for chronic pain which was not signed off as administered until 6:33 PM by RN #2. 06/13/2025 at 5:00 PM: gabapentin 100 mg (three times daily medication) which was not signed off as administered until 8:43 PM by RN #2. 06/18/2025 at 5:00 PM: gabapentin 100 mg (three times daily medication) which was not signed off as administered until 7:31 PM by RN #2.Review of nurse's notes from 06/10/2025 through 06/19/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #12.10. Resident #13's diagnoses included Alzheimer's disease, hypertension (high blood pressure), major depressive disorder and central pain syndrome (consistent moderate to severe neuropathic pain).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 1) and required setup assistance for eating and transfers.The Resident Care Plan (RCP) dated 05/15/2025 identified Resident #13 was at risk for behaviors due to delirium (serious change in mental abilities that results in confusion and a lack of awareness of one's surroundings) and used antipsychotic medication for the treatment of major depressive disorder and anxiety disorder. Interventions included administering medications per physician's orders, observing for side effects and effectiveness each shift and reporting any negative signs and symptoms to the provider.Review of the facility census identified Resident #13 resided on the [NAME] unit.Review of the Medication Administration Audit Report for June 2025 identified Resident #13 was ordered to receive the following medications: 06/13/2025 at 5:00 PM: bupropion 150 mg daily for depression and 2 capsules of Depakote 125 mg daily for dementia with behavioral disturbances which were not signed off as administered until 7:18 PM by RN #2. 06/18/2025 at 5:00 PM: bupropion 150 mg daily and 2 capsules of Depakote 125 mg daily which were not signed off as administered until 7:42 PM by RN #2.Review of nurse's notes from 06/13/2025 through 06/19/2025 failed to identify that the nursing supervisor or the provider were notified of the late medication administrations for Resident #13.11. Resident #14's diagnoses included dementia with agitation and type 2 diabetes mellitus.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), required setup assistance for eating, supervision assistance for bed mobility and was independent with transfers and ambulation.The Resident Care Plan (RCP) dated 05/15/2025 identified Resident #14 had diabetes mellitus and utilized psychotropic medications related to adjustment disorder with anxiety, depressed mood and dementia. Interventions included administering medications as ordered by the physician and monitoring for side effects and effectiveness every shift.Review of the Medication Administration Audit Report for June 2025 identified Resident #14 was ordered to receive the following medications: 06/03/2025 at 4:00 PM: metformin 500 mg (twice daily medication) for diabetic management, Depakote 125 mg (twice daily medication) for behaviors and mood management and trazodone 25 mg (twice daily medication) for agitation which were not signed off as administered until 5:49 PM by LPN #1. 06/13/2025 at 4:00 PM: metformin 500 mg (twice daily medications), Depakote 125 mg (twice daily medication) and trazodone 25 mg (twice daily medication) which were not signed off as administered until 6:17 PM by RN #2. 06/18/2025 at 4:00 PM: metformin 500 mg (twice daily medication), Depakote 125 mg (twice daily medication) and trazodone 25 mg (twice daily medication) which were not signed off as administered until 8:03 PM by RN #2.Review of nurse's notes from 06/03/2025 through 06/19/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #14. Interview with LPN #1 on 06/24/2025 at 12:10 PM identified there were times that she administered medications late and further identified she documented as she administered medications. She identified a heavy medication pass on day and evening shifts on both the East and South units but indicated she was not aware she needed to notify the nursing supervisor and call the provider for medications that were more than one (1) hour late. Interview with RN #1 (nursing supervisor) on 06/24/2025 at 12:23 PM identified licensed nurses and NA's complained about LPN #1 not beginning the medication pass until two (2) hours prior to the end of the shift. RN #1 identified that the East and South unit medication passes were heavy and LPN #1 did not appear to administer medications to all her assigned residents as she was frequently off the floor and often difficult to find. She identified she spoke with both the previous DNS and current DNS several times regarding LPN #1, but to her knowledge, the concerns regarding LPN #1 were left unaddressed.Interview with LPN #3 on 06/24/2025 at 1:36 PM identified she worked first shift four (4) to five (5) days per week, and residents complained about not receiving medications or waiting until after 10:00 PM to receive medications, during the evening prior, when LPN #1 and RN #2 worked. LPN #3 identified she worked alongside LPN #1 during the day shift on weekends, LPN #1 worked on the East unit and she (LPN #3) worked on the South unit and residents on the East unit consistently rang their call bells asking where their medications were. She indicated LPN #1 did not communicate times she would leave the floor and that she (LPN #3) had a difficult time locating her. LPN #3 identified she reported the concerns and resident complaints to the DNS, but LPN #1 continued to work and be absent from the units while on shift.Interview with the DNS on 06/24/2025 at 2:01 PM identified RN #1, LPN #3 and LPN

Based on observations, review of the clinical records, facility documentation, facility policy and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure safe medication administration practices during the morning medication pass. These failures resulted in the finding of Immediate Jeopardy. Additionally, based on observations, interviews, review of the clinical record and facility policy for 1 of 3 sampled residents (Resident #52) reviewed for nutrition, the facility failed to conduct reweights according to the facility policy. The findings include: 1. a. Resident #3's diagnoses included severe protein calorie malnutrition, cerebral infarction, and anxiety disorder. A physician's order dated 12/18/24 directed to administer Clopidogrel Bisulfate (antiplatelet) 75 milligrams (mg) orally once a day, Escitalopram Oxalate (antidepressant) 20 mg orally one a day, Multivitamin (supplement) 1 tablet orally once a day, Vitamin B Complex (supplement) 1 capsule orally once a day, Vitamin C (supplement) 1 tablet orally once a day, Vitamin D (supplement) 1 tablet orally once a day. A physician's order dated 1/19/25 directed to administer Aspirin 81 milligrams (mg) chewable orally once a day. A physician's order dated 2/2/25 directed to administer Trazadone 50 mg (antidepressant) orally twice a day, a physician's order dated 3/16/25 directed to administer Bupropion HCL ER (antidepressant extended release) 150 mg orally twice a day. b. Resident #9 diagnosis included Alzheimer's dementia, diabetes, and congestive heart failure. A physician's order dated 8/6/24 directed to administer Memantine HCL (Anti-Alzheimer's) 5 mg orally1 tablet twice a day. A physician's order dated 8/7/24 directed to administer Aspirin 81 mg chewable orally once a day, Furosemide 20 mg (diuretic) 1 tablet orally once a day hold if systolic blood pressure is less than 100, Metformin HCL (antidiabetic) 500 mg 1 tablet orally once a day, Multivitamin 1 tablet orally once a day, Polysaccharide iron complex (supplement) 150 mg 1 capsule orally once a day, Toprol XL (extended release for high blood pressure) 25 mg 1 tablet orally once a day. A physician's order dated 8/9/24 directed Midodrine HCL (elevates blood pressure) 5 mg 1 tablet orally twice a day. A physician's order dated 2/21/25 directed to administer Tylenol extra strength 500 mg 2 tablets orally twice a day, c. Resident #12's diagnosis included Parkinson's disease, dementia and emphysema. A physician's order dated 6/3/24 directed to administer Amlodipine (lowers blood pressure) 2.5 mg 1 tablet orally once a day, Carb/Levo (Parkinson's) 25-100 mg 1 tablet orally three times a day, Polyethylene Glycol powder (constipation) 3350 1 tablet once a day, Rivastigmine dis (Alzheimer's/Parkinson's) 9.5/24 apply 1 patch once a day trans dermally, Alendronate (osteoporosis) 70 mg 1 tablet orally once a day, aspirin chewable 81 mg 1 tablet orally once a day, Calcium /D 600-400 mg (supplement) 1 tablet orally once a day, Memantine 5 mg 1 tablet orally once a day, Vitamin D 1000 international units (IU) 2 caps orally once a day, Acetaminophen (pain) 500 mg 2 tablets orally twice a day, Budes/[NAME] Aer( emphysema) 160-4.5 120 Inh 2 puffs orally twice a day, Celecoxib cp (anti-inflammatory) 100 mg 1 capsule twice a day, Entacapone (Parkinson's) 200 mg 1 tablet orally twice a day. d. Resident #18 diagnosis included Alzheimer's dementia, diabetes, and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 10 mg 1 tablet once a day, Aspirin low 81 mg 1 tablet orally once a day, Escitalopram 10 mg 1 tablet orally once a day, Hydrochlorothiazide (lowers blood pressure) tablet 25mg 1 tablet orally once a day, Losartan (lowers blood pressure) 50 mg 1 tablet orally once a day, Acetaminophen 500 mg tab orally twice a day, Metformin 1000 mg 1 tablet twice a day, Metoprolol Tar (lowers blood pressure) 50 mg 1 tab twice a day, A physician's order dated 10/29/24 directed to administer Potassium Chloride (elevates potassium) Liquid 20 milliequivalent/15 milliliter (meq/ml) 20 met orally twice a day. A physician's order dated 1/14/25 directed Lantus Solostar (antidiabetic) subcutaneous solutions pen injector 100 unit/ml inject 16 units subcutaneously once a day. A physician's order dated 3/6/25 directed to administer Atorvastatin Calcium (lowers cholesterol) 20 mg 1 tablet orally once a day. A physician's order dated 3/7/25 directed to administer Fenofibrate (lowers cholesterol) 145 mg 1 tablet once a day. e. Resident # 27 diagnosis included Dementia, Diabetes, and Epilepsy. A physician's order dated 5/30/24 directed to check blood sugars before meals and at bedtime. A physician's order dated 6/3/24 directed to administer Levetiracetam tabs (antiseizure) 500 mg give 1 tablet orally twice a day, Lisinopril ( lowers blood pressure) 5 mg give 1 tablet orally once a day, Metformin tab 1000mg give 1 tablet orally twice a day, Metoprolol Tar 25mg tablet give 0.5 tablet orally twice a day, Risperidone (antipsychotic) 2 mg tabs Give 1 tablet orally twice a day, Insulin lisp injection 100/ml inject per sliding scale if blood sugar is 150 - 199 give 2 units, 200-249 give 3 units, 250-299 give 4 units, 300-349 give 5 units, 350-399 give 6 units, grated than 399 give 8 units and call the physician subcutaneously before meals and at bedtime. A physician's order dated 7/15/24 directed to administer Gabapentin (antiseizure) capsule 300 mg give 1 capsule orally three times a day. A physician's order dated 7/23/24 directed to administer Depakote(antiseizure) oral tablet delayed release 250 mg give 2 tablets orally once a day. A physician's order dated 9/17/24 directed to administer oyster shell (supplement) oral tablet 500 mg give 1 tablet orally once a day. A physician's order dated 9/28/24 directed to administer Celexa (antidepressant) oral tablet 20 mg give 30 mg orally once a day. A physician's order dated 10/16/24 directed Celebrex (non-steroidal anti-inflammatory) oral capsule 100 mg give 1 capsule orally twice a day. A physician's order dated 10/24/24 directed to administer Oxycodone HCL (opioid pain reliever) tablet 5 mg, give 5 mg orally three times a day. A physician's order dated 11/5/24 directed to administer Amantadine (Parkinson's like symptoms) 100 mg caps give 2 capsules orally twice a day. A physician's order dated 11/6/24 directed to administer Cholecalciferol (supplement)oral capsule 1.25 mg give 1 capsule orally once a day every 7 days. A physician' order dated 1/15/25 directed to administer Xifaxan (treatment for high ammonia levels) 550 mg tabs give 1 tablet orally twice a day. f. Resident #31's diagnosis included heart failure, depression and dementia. A physician's order dated 7/4/24 directed to administer Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin (supplement) tablet 1000 micrograms (mcg) give 1 tablet orally once a day, Lipitor oral tablet 10 mg give 10 mg orally once a day, MiraLAX oral packet 17 grams (gm) give 1 packet orally once a day, Multiple vitamins with minerals give 1 tablet orally once a day, Senna (laxative) oral tablet give 8.6 mg orally once a day. A physician's order dated 7/11/24 directed to administer Ferrous sulfate (iron supplement) tablet 2 mg give 1 tablet orally once a day, Folic acid (supplement) oral tablet 1 mg give 1 tablet orally once a day. A physician's order dated 7/13/24 directed to administer Trelegy Ellipta (reduce bronchospasms in asthma/COPD) inhalation aerosol powder breath activated 200-62.5-25 mcg/act 1 puff inhale orally once a day. A physician's order dated 8/28/24 directed to administer Lubiprostone (constipation) oral capsule 24 mcg give 2 mcg orally twice a day. A physician's order dated 10/12/24 directed to administer Singulair (prevents asthma attacks) oral tablet 10mg give 1 tablet orally once a day. A physician's order dated 11/6/24 directed to administer Allegra allergy oral tablet give 180 mg orally once a day for allergies. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/20/25 directed to administer Prednisone (steroid) oral tablet 10 mg give 1 tablet orally once a day. A physician's order dated 2/3/25 directed to check blood glucose twice a day. A physician's order dated 2/13/25 directed to administer Lasix oral tablet 20 mg give 40 mg orally once a day. A physician's order dated 2/19/25 directed to check blood sugar before meals and at bedtime. A physician's order dated 2/23/25 directed to administer Gabapentin tab 600 mg give 1 tablet oral three times a day, Freestyle Libre 2 reader device apply 1 application trans dermally before meals and at bedtime. Novolog injection solution 100 unit/ml inject 4 units subcutaneously before meals and at bedtime, Novolog injection solution 100 unit/ml as per sliding scale if 150-199 give 4 units, 200-249 give 6 units, 250-299 give 8 units, 300-349 give 10 units, 350-399 give 12 units, 400-449 give 14 units, 450-499 give 16 units, 500 give 20 units and notify the provider before meals and at bedtime. A physician's order dated 2/24/25 directed to administer Metformin HCL oral tablet 500 mg Give 1 tablet orally twice a day. A physician's order dated 2/26/25 directed to administer Trazadone (antidepressant) HCL oral tablet 50 mg give 25 mg orally once a day. A physician's order dated 3/5/25 directed to administer Oxycodone HCL oral tablet 5 mg give 0.5 tablet orally twice a day. A physician's order dated 3/12/25 directed to administer Protonix (excessive stomach acid) oral tablet delayed release 40 mg give 1 tablet orally twice a day for 8 weeks. g. Resident # 33's diagnosis included dementia, congestive heart failure and Parkinson's disease. A physician's order dated 12/18/24 directed to administer Carb/Levo 25mg/100 tab give 2 tablets orally three times a day, Gabapentin 300 mg capsules give 1 capsule orally three times a day. A physician's order dated 12/28/24 directed to administer pantoprazole 40 mg tablets give 1 tablet orally twice a day. A physician's order dated 12/19/24 directed to administer Sertraline 100 mg tabs give 1 tablet orally once a day, aspirin low tab 8 mg give 1 tablet orally once a day, Clopidogrel tab 75 mg give 1 tablet orally once a day, Seroquel oral tablet 25 mg give 1 tablet orally once a day, A physician's order dated 1/28/25 directed to administer Amlodipine tab 10 mg Give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day, Carvedilol 6.25 mg tab give 2 tablets orally twice a day, A physician's order dated 1/30/25 directed to administer Lantus subcutaneous solution 100 units/ml inject 40 units subcutaneously once a day. A physician's order dated 2/13/25 directed to administer Primidone tab 50 mg Give 0.5 tablet orally twice a day. Trazadone 50 mg tabs give 25 mg orally twice a day. A physician's order dated 2/14/25 directed to administer Humalog Kwik pen subcutaneous solution 100units/ml inject 5 units subcutaneously before meals. A physician's order dated 2/28/25 directed to administer Isosorbide Mononitrate ER tablet extended release 24-hour 60 mg give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Insulin lisp injection 100/ml per sliding scales if blood sugar is 150-199 give 3 units if less than 70 notify the provider, 200-249 6 units, 250-299 9 units, 300-349 12 units 350-399 15 units, greater than 400 18 units and notify the physician before meals and at bedtime. A physician's order dated 3/24/25 directed to administer Hydralazine HCL 50 mg tablets give 1.5 tablets orally three times a day. h. Resident # 42's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 5 mg give 1 tablet orally once a day, fluticasone/vilanterol inhaler (steroid/bronchodilator for treatment of COPD) 100/25/60 1 puff inhale orally once a day, Divalproex (antiseizure) tab 250 mg DR give 250 mg orally twice a day, Guaifenesin (expectorant) tab 400 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tablet orally twice a day. A physician's order dated 8/13/24 directed to administer Tylenol extra strength oral tablet 500 mg give 1000mg orally twice a day. A physician's order dated 3/2025 directed to administer Escitalopram 5 mg tablet give 20 mg orally once a day, i. Resident # 45's diagnosis included dementia, diabetes and seizures. A physician's order dated 5/30/24 directed to monitor glucose with Freestyle Libre device check resting blood sugar before meals and at bedtime. A physician's order dated 1/18/25 directed to administer Aspirin low 81 mg give 1 tablet orally once a day, Calcium citrate tab 200 mg give 1 tablet orally once a day, Polyether glycol powder 3350 NF give 17(Gram) gm orally once a day, Primidone tab 50 mg give 1 tablet orally every 12 hours, Tab a vit tab give 1 tablet orally once a day, Tresiba Flex injection 100 unit inject 12 units subcutaneously once a day, Vitamin C 500 mg tabs give 1 tablet orally once a day, Lexapro oral tablet 5 mg give 1 tablet orally once a day, Novolog flex pen subcutaneous solution pen injector 100 unit/ml inject 4 units subcutaneously once a day, Tamsulosin 0.4 mg caps give 1 capsule orally twice a day. A physician's order dated 1/20/25 directed to administer Sodium Bicarbonate (antacid) oral tablet 650 mg give 1 tablet orally twice a day, Sodium chloride oral tablet 1 gm give 1 tablet orally twice a day. A physician's order dated 1/29/25 directed to administer Norvasc oral tablet 5 mg give 1 tablet orally once a day, Coreg oral tablet 12.5 mg give 12.5 mg orally twice a day hold for systolic blood pressure less than 100 or heart rate less than 55 and notify physician, Hydralazine HCL oral tablet give 15 mg orally three times a day. j. Resident #49's diagnosis included dementia, diabetes, and chronic kidney disease. A physician's order dated 8/22/24 directed to administer Tetrahydrozoline-dextran-polyethylene glycol povidone (eye irritation) eye drops instill 2 drops in left eye twice a day, Preparation H (hemorrhoid relief) rectal suppository insert 1 suppository rectally twice a day. A physician's order dated 8/23/24 directed to administer Citalopram Hydrobromide oral tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin tablet 1000mcg give 2 tablets orally once a day, Folic acid oral tablet 1 mg give 1 tablet orally once a day, Lidocaine HCL external patch 4 % apply to lower back topically once a day, Lisinopril oral tablet 2.5 mg give 1 tablet orally once a day hold for systolic blood pressure less than 90 or diastolic blood pressure less than 60 and notify the physician, Pravastatin sodium oral tablet 20 mg give 1 tablet orally once a day, PreserVision AREDS (supplement) 2 oral capsule with minerals give 1 tablet orally once a day, Vitamin D3 oral tablet 25 mcg give 1 tablet orally once a day. A physician's order dated 8/30/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally every Monday, Wednesday and Friday, Tylenol oral tablet 325 mg give 2 tablets twice a day. A physician's order dated 10/1/24 directed to administer Ferrous Sulfate oral tablet 325 mg give 325 mg orally one a day. A physician's order dated 2/6/25 directed to administer Eliquis oral tablet 5 mg give 1 tablet orally twice a day. k. Resident # 56's diagnosis included Alzheimer's disease, anxiety and depression. A physician's order dated 6/3/24 directed to administer Tab a Vite tab give 1 tablet orally once a day, l. Resident # 59's diagnosis included dementia, congestive heart failure and anxiety disorder. A physician's order dated 6/26/24 directed to administer Cyanocobalamin oral tablet 1000 mg give 1 tablet orally once a day, folic acid oral tablet 1 mg give 1 tablet orally once a day, Lactulose (laxative)oral solution 20 gm/30 ml give 30 ml orally once a day, MiraLAX oral packet 17 gm give 17 gm orally once a day, multivitamin oral tablet give 1 tablet orally once a day, Thiamine HCL oral tablet 100 mg give 1 tablet orally once a day. A physician's order dated 10/8/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 11/23/24 directed to administer Prozac (antidepressant) oral capsule 10 mg give 10 mg orally once a day. A physician's order dated 1/13/25 directed to administer Potassium chloride ER oral tablet 20 mEq give 1 tablet orally once a day. A physician's order dated 1/16/25 directed to administer Risperdal oral tablet 0.5 mg give 0.25 mg orally once a day. m. Resident #61's diagnosis included Diabetes, Dementia and Cerebral infarction. A physician's order dated 5/28/24 directed to administer Gabapentin cap 100 mg give 1 capsule twice a day, Metoprolol Tar tablet 50 mg give 1 tablet orally twice a day. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet once a day, Escitalopram 10 mg tabs give 1 tablet once a day, Ezetimibe (lowers cholesterol) tab 10 mg give 1 tab orally once a day, fluticasone vilanterol inhaler 200/25 60 inhaler 1 inhalation orally once a day, Oxybutynin tab 15 mg ER give 1 tablet orally once a day, Pantoprazole 40 mg tabs give 1 tablet orally once a day, Rosuvastatin (lowers lipids) tab 40 mg give 1 tablet orally once a day, Acidophilus (probiotic) oral capsule give 1 capsule orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Metformin tab 1000mg give 1 tablet orally twice a day. A physician's order dated 9/26/24 directed to administer Cholestyram (lowers cholesterol) powder 4 gm lite give 4 grams orally once a day. A physician's order dated 3/12/25 directed to administer Trulicity subcutaneous solution autoinjector 0.75 mg/0.5 ml inject 1 syringe subcutaneously once a day every Wednesday. Humalog Kwik pen subcutaneous solution pen injector 1unit/ml inject 2 units subcutaneously before meals. Fasting blood sugar check before meals and at bedtime. Humalog 100 units/ml Kwik pen 3ml inject as per sliding scale if blood sugar is 100-199 give 10 units call physician if glucose is less than 70, 200-400 give 15 units call physician if blood sugar is greater than 400 subcutaneously before meals and at bedtime. n. Resident #63's diagnosis included Alzheimer's dementia, diabetes, and cerebral infarction. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet orally once a day, Donepezil 10 mg tabs give 1 tablet orally once a day, Escitalopram 10gm tabs give 1 tablet orally once a day, Tab a Vite tab give 1 tablet once a day, Vitamin B1 tab 100mg give 2 tablets orally once a day, Midodrine tab 5 mg give 1 tablet orally twice a day, Reguloid (fiber) powder orange give 2 tablespoons orally twice a day. A physician's order dated 6/4/24 directed to administer Cholecalciferol oral tablet give 25 mcg orally once a day. A physician's order dated 8/20/24 directed to administer Acetaminophen oral tablet 325 mg give 2 tablets orally three times a day. A physician's order dated 12/6/24 directed to administer Tramadol HCL oral tablet 25 mg give 1 tablet orally twice a day. o. Resident #67's diagnosis included dementia, hypothyroidism, and chronic kidney disease. A Physician's order dated 6/3/24 directed to administer Allopurinol (gout) tab 100 mg give 1 tablet orally once a day, Amlodipine tab 10 mg give 1 tablet orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Hydralazine tab 25 mg give 1 tablet orally twice a day, Acetaminophen 500 mg tabs give 2 tablets orally three times a day. A physician's order dated 7/31/24 directed to administer Vitamin B12 oral tablet give 1000 mcg orally once a day. A physician's order dated 12/18/24 directed to administer Trazadone 50 mg tabs give 0.5 tablet orally twice a day. p. Resident # 68's diagnosis included Alzheimer's dementia, depression and hyperkalemia. A physician's order dated 6/3/24 directed to administer Vitamin D 1000 IU caps give 1 capsule orally once a day, Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day. A physician's order dated 11/2/24 directed to administer Trazadone HCL oral tablet 50 mg give 25 mg orally three times a day. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/18/25 directed to administer Aspirin EC tablet delayed release 81 mg give 1 tablet orally once a day. q. Resident # 69's diagnosis included dementia, psychotic disorder with delusions, and chronic kidney disorder. A physician's order dated 6/3/24 directed to administer Amlodipine tab 10 mg give 1 tablet orally once a day, Aspirin low 81 mg give 1 tablet orally once a day, Ondansetron (nausea and vomiting) tab 4 mg give 1 tablet orally once a day, Potassium chloride cap 10 mEq ER give 2 capsules once a day, Sertraline 100 mg tabs give 1 tablet orally once a day as part of 125 mg dose in am, Sertraline 25 mg tabs give 1 tablet once a day as part of 125 mg dose in am, Multivitamin with minerals oral tablet give 1 tablet orally once a day, Calcium carb 500 mg tab give 1 tablet orally twice a day, Vitamin C 500 mg tab give 2 tablets orally twice a day. r. Resident #72's diagnosis included dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Famotidine 10 mg tabs give 2 tablets orally once a day, Valsartan tab 160 mg give 1 tablet orally once a day, Vitamin D 3 50000 IU caps give 1 capsule orally once a day, Hydralazine tab 10 mg Give 1 tablet orally three times a day, A physician's order dated 6/20/24 directed to administer Aspirin tablet 81 mg give 1 tablet orally once a day. A physician's order dated 3/4/25 directed to administer Sodium Chloride oral tablet 1 gm give 1 tablet orally twice a day. s. Resident # 74's diagnosis included Alzheimer's dementia, hypokalemia, and hypothyroidism. A physician's order dated 6/3/24 directed to administer Escitalopram 10 mg tabs give 1 tablet orally once a day, Lisinopril 10 mg tabs give 1 tablet orally once a day, Memantine 5 mg tabs give 1 tablet orally twice a day. A physician's order dated 1/17/25 directed to administer Vitamin B 12 oral tablet 100 mcg give 1 tablet orally once a day. t. Resident # 78's diagnosis included Alzheimer's Dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Docusate sodium cap 100 mg give 1 capsule orally twice a day, Meloxicam tab 15 mg give 1 tablet orally once a day, Potassium chloride solution 10% give 15 ml orally once a day, Acetaminophen 500 mg tabs give 2 tablets orally twice a day, Genteal tear (dry eyes) solution instill 2 drops in left eye twice a day. A physician's order dated 7/16/24 directed to administer Lisinopril tablet 2.5 mg give 1 tablet orally once a day. A physician's order dated 1/24/25 directed to administer Multiple vitamins with minerals give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Combigan (glaucoma) 0.2-0.5% ophthalmic solution instill 1 drop in both eyes twice a day. u. Resident # 81's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 2.5 mg tabs give 1 tablet orally once a day, Atenolol 25 mg tabs give 0.5 tablet orally once a day, Memantine tab 10 mg give 1 tablet orally twice a day, Senna 8.6 mg tabs give 2 tablets orally once a day. v. Resident #92's diagnosis included Paranoid schizophrenia, hypokalemia and anxiety disorder. A physician's order dated 6/19/24 directed to administer Amlodipine besylate oral tablet 5 mg give 1 tablet orally once a day. A physician's order dated 7/27/24 directed to administer Oyster shell calcium oral tablet 500mg give 1 tablet orally once a day. A physician's order dated 12/4/24 directed to administer Trazadone HCL oral tablet 50 mg give 0.5 tablet orally twice a day. Observations on 3/26/25 at 10:30 AM, identified Licensed Practical Nurse (LPN) #6 was having difficulty accessing Point Click Care (PCC) the electronic medical record system (EMAR). LPN #6 was heard to state I can't get into these computers, I don't know what is wrong with these computers, I have not been able to get into PCC all morning. I hate these computers, I wish we just went back to paper. Interview with LPN #6 on 3/26/25 at 10:30AM identified she was unable to access PCC since the start of her shift at 7:00 AM. She stated she had tried 2 laptops and 2 desktop computers unsuccessfully. LPN #6 indicated she had administered medications to the 22 residents on her assignment, for the morning medication pass by memory, without the benefit of the use of a Medication Administration Record (MAR). (An MAR ensures the 5 rights of medication administration, right patient, right drug, right dose, right route, and right time). LPN #6 stated that she had failed to document any of the non-narcotic medications that she had administered by any alternate means of record keeping. LPN #6 was able to show a written record of each of the residents who received narcotics as narcotic medications required a signature in the narcotic book, on the proof of use sheet, that the medication had been signed out for a specific resident. Additionally, LPN #6 identified she had failed to notify a supervisor or the Assistant Director of Nursing (ADNS) when she was unable to access the EMAR or the software used for medication administration, PCC, because she wanted to get the medications passed and planned on documenting what she had given after the medication pass was completed. LPN #6 indicated that if any resident medications had changed, she would have expected the off-going nurse to communicate this verbally, during a nurse-to-nurse report, for the resident medications that changed . LPN #6 further indicated that it was not an appropriate practice to administer medications to residents without utilizing an MAR, and that the policy was to call a supervisor when locked out of the EMAR and PCC. Interview on 3/26/25 at 11:00 AM with the Assistant Director of Nursing Services (ADNS) identified that she was not made aware LPN #6 was unable to access the EMAR or PCC and had not received any communication from LPN #6 to reset her password. The ADNS stated that LPN #6 had passed medications to 22 residents without the benefit of an MAR and should have contacted the supervisor or herself to reset her password. The ADNS identified it was inappropriate and against the policy to administer medications without the benefit of utilizing the MAR to ensure the 5 rights of medication administration were performed. Further, the ADNS was unable to explain why LPN #6 would administer medications to 22 residents, by memory, without utilizing an MAR. Interview with the Corporate Regional Nurse, Registered Nurse (RN) #4 on 3/26/25 at 11:26 AM identified that the physician, Advanced Practice Registered Nurse (APRN), and responsible parties had been notified of LPN #6's inappropriate use of memory to administer medications to 22 residents without the benefit of utilizing an MAR. Interview with APRN #1 on 3/26/25 at 12:22 PM identified she was made aware that 22 residents were administered medications by LPN #6, by memory, without the benefit of an MAR, and that she had reviewed all of the medications ordered for the affected residents under her care. APRN #1 stated that for the residents who required blood sugar monitoring, she had ordered blood sugar checks immediately and to continue per the established schedule. All affected residents were to have vital sign checks every shift for 24 hours to monitor their health status. APRN #1 additionally ordered labs to be checked for the residents who were receiving sodium chloride tablets and that she was to be notified of any abnormalities. Interview with APRN #2 on 3/26/25 at 12:30 PM identified that she was made aware that 22 resident's medications were administered without the benefit of an MAR, by memory, by LPN #6. APRN #2 identified she had just observed all of the residents under her care, would review those resident medications, and would determine if further monitoring would be required. Additionally, APRN #2 identified that she would review the vital signs and blood sugars for her residents and leave orders to be notified for any abnormalities. Review of the policy Electronic Medication Administration Record (EMAR) revised 6/2023 directed the licensed nurse will read the physician order and complete the 5 checks, administer the medication as ordered and document the administration in the EMAR. Although requested, the facility failed to provide a policy for MAR utilization. 2. Resident #52 had a diagnosis that included dementia, anxiety, heart failure and chronic atrial fibrillation (an irregular and rapid heartrate resulting in poor blood flow). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required set up assistance for eating, maximum assistance for personal hygiene, and was dependent on toileting and supervision/touching assistance for bed mobility and transfers. The Resident Care Plan (RCP) dated 10/7/24 identified Resident #52 was at risk for alteration in cardiovascular status related to congestive heart failure (CHF) and atrial fibrillation (an irregular and rapid heartrate resulting in poor blood flow). Interventions included a diet consult as necessary, monitoring/documenting and reporting any changes in lung sounds on auscultation, edema, and changes in weight. A physician's order dated 10/21/24 directed to obtain weekly weights every Wednesday and notify the supervisor if the resident refused. Review of the Weights and Vitals Summary identified Resident #52's weights as: Date Weight (Lbs.) Discrepancy (Lbs.) 10/21/24 222.0 0 10/23/24 222.0 0 10/30/24 220.0 -2 11/6/24 220.8 +0.8 11/13/24 229.6 +8.8 11/18/24 228.6 -1 11/20/24 229.0 +1.6 11/27/24 230.0 +1 11/27/24 223.8 -6.2 12/4/24 223.2 -0.6 12/11/24 220.6 -2.6 12/18/24 228.0 +7.4 1/1/25 226.1 -2.1 1/8/25 225.2 -0.9 1/15/25 219.9 -5.3 1/22/25 226.0 +5.9 2/12/25 226.3 -0.3 2/19/25 226.8 +0.5 2/26/25 227.0 +0.2 3/5/25 207.3 19.7 (weight was struck out on 3/17/25 at 9:42 AM by the Dietician stating reweighed) 3/12/25 216.8 +9.5 3/13/25 212.4 -4.4 Review of Resident #52's clinical record from 10/21/24 through 3/17/25, identified no documentation for weight refusals within the progress notes or RCP. Interview and record review with LPN #8 on 3/20/25 at 2:30 PM, identified that NA's weigh residents and nurses document the weight in the computer. LPN #8 further stated that the dietician was responsible for monitoring resident weights, communicating weight changes to the provider, and directing reweights. LPN #8 indicated that residents with significant weight changes should be reweighed according to the facility policy and as directed by the dietician. LPN #8 identified that Resident #52 should have been reweighed on 11/13/24 when he/she gained 8.8 pounds (lbs.), on 12/18/24 with a weight increase of 7.4 lbs., on 1/15/25 with a weight decrease of 5.3 lbs., on 1/22/25 with a weight increase of 5.9 lbs., on 3/5/25 with a weight decrease of 19.7 lbs., and on 3/12/25 with a weight increase of 9.5 lbs. LPN #8 could not identify documentation for weight refusals within the progress notes or RCP. Interview and clinical record review with the DNS on 3/20/25 at 3:00 PM, identified that NA's weigh residents and nurses document weights. The DNS stated that the dietician was responsible [TRUNCATED]

Based on observations, review of the clinical records, facility documentation, facility policy, and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure the 5 Rights of medication administration, and professional standards of practice, were adhered to during the administration of medications. These failures resulted in the finding of Immediate Jeopardy. The findings include: 1. Resident #3's diagnoses included severe protein calorie malnutrition, cerebral infarction, and anxiety disorder. A physician's order dated 12/18/24 directed to administer Clopidogrel Bisulfate (antiplatelet) 75 milligrams (mg) orally once a day, Escitalopram Oxalate (antidepressant) 20 mg orally one a day, Multivitamin (supplement) 1 tablet orally once a day, Vitamin B Complex (supplement) 1 capsule orally once a day, Vitamin C (supplement) 1 tablet orally once a day, Vitamin D (supplement) 1 tablet orally once a day. A physician's order dated 1/19/25 directed to administer Aspirin 81 milligrams (mg) chewable orally once a day. A physician's order dated 2/2/25 directed to administer Trazadone 50 mg (antidepressant) orally twice a day, a physician's order dated 3/16/25 directed to administer Bupropion HCL ER (antidepressant extended release) 150 mg orally twice a day. 2. Resident #9 diagnosis included Alzheimer's dementia, diabetes, and congestive heart failure. A physician's order dated 8/6/24 directed to administer Memantine HCL (Anti-Alzheimer's) 5 mg orally1 tablet twice a day. A physician's order dated 8/7/24 directed to administer Aspirin 81 mg chewable orally once a day, Furosemide 20 mg (diuretic) 1 tablet orally once a day hold if systolic blood pressure is less than 100, Metformin HCL (antidiabetic) 500 mg 1 tablet orally once a day, Multivitamin 1 tablet orally once a day, Polysaccharide iron complex (supplement) 150 mg 1 capsule orally once a day, Toprol XL (extended release for high blood pressure) 25 mg 1 tablet orally once a day. A physician's order dated 8/9/24 directed Midodrine HCL (elevates blood pressure) 5 mg 1 tablet orally twice a day. A physician's order dated 2/21/25 directed to administer Tylenol extra strength 500 mg 2 tablets orally twice a day, 3. Resident #12's diagnosis included Parkinson's disease, dementia and emphysema. A physician's order dated 6/3/24 directed to administer Amlodipine (lowers blood pressure) 2.5 mg 1 tablet orally once a day, Carb/Levo (Parkinson's) 25-100 mg 1 tablet orally three times a day, Polyethylene Glycol powder (constipation) 3350 1 tablet once a day, Rivastigmine dis (Alzheimer's/Parkinson's) 9.5/24 apply 1 patch once a day trans dermally, Alendronate (osteoporosis) 70 mg 1 tablet orally once a day, aspirin chewable 81 mg 1 tablet orally once a day, Calcium /D 600-400 mg (supplement) 1 tablet orally once a day, Memantine 5 mg 1 tablet orally once a day, Vitamin D 1000 international units (IU) 2 caps orally once a day, Acetaminophen (pain) 500 mg 2 tablets orally twice a day, Budes/[NAME] Aer( emphysema) 160-4.5 120 Inh 2 puffs orally twice a day, Celecoxib cp (anti-inflammatory) 100 mg 1 capsule twice a day, Entacapone (Parkinson's) 200 mg 1 tablet orally twice a day. 4. Resident #18 diagnosis included Alzheimer's dementia, diabetes, and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 10 mg 1 tablet once a day, Aspirin low 81 mg 1 tablet orally once a day, Escitalopram 10 mg 1 tablet orally once a day, Hydrochlorothiazide (lowers blood pressure) tablet 25mg 1 tablet orally once a day, Losartan (lowers blood pressure) 50 mg 1 tablet orally once a day, Acetaminophen 500 mg tab orally twice a day, Metformin 1000 mg 1 tablet twice a day, Metoprolol Tar (lowers blood pressure) 50 mg 1 tab twice a day, A physician's order dated 10/29/24 directed to administer Potassium Chloride (elevates potassium) Liquid 20 milliequivalent/15 milliliter (mEq/ml) 20 met orally twice a day. A physician's order dated 1/14/25 directed Lantus Solostar (antidiabetic) subcutaneous solutions pen injector 100 unit/ml inject 16 units subcutaneously once a day. A physician's order dated 3/6/25 directed to administer Atorvastatin Calcium (lowers cholesterol) 20 mg 1 tablet orally once a day. A physician's order dated 3/7/25 directed to administer Fenofibrate (lowers cholesterol) 145 mg 1 tablet once a day. 5. Resident # 27 diagnosis included Dementia, Diabetes, and Epilepsy. A physician's order dated 5/30/24 directed to check blood sugars before meals and at bedtime. A physician's order dated 6/3/24 directed to administer Levetiracetam tabs (antiseizure) 500 mg give 1 tablet orally twice a day, Lisinopril ( lowers blood pressure) 5 mg give 1 tablet orally once a day, Metformin tab 1000mg give 1 tablet orally twice a day, Metoprolol Tar 25mg tablet give 0.5 tablet orally twice a day, Risperidone (antipsychotic) 2 mg tabs Give 1 tablet orally twice a day, Insulin lisp injection 100/ml inject per sliding scale if blood sugar is 150 - 199 give 2 units, 200-249 give 3 units, 250-299 give 4 units, 300-349 give 5 units, 350-399 give 6 units, grated than 399 give 8 units and call the physician subcutaneously before meals and at bedtime. A physician's order dated 7/15/24 directed to administer Gabapentin (antiseizure) capsule 300 mg give 1 capsule orally three times a day. A physician's order dated 7/23/24 directed to administer Depakote(antiseizure) oral tablet delayed release 250 mg give 2 tablets orally once a day. A physician's order dated 9/17/24 directed to administer oyster shell (supplement) oral tablet 500 mg give 1 tablet orally once a day. A physician's order dated 9/28/24 directed to administer Celexa (antidepressant) oral tablet 20 mg give 30 mg orally once a day. A physician's order dated 10/16/24 directed Celebrex (non-steroidal anti-inflammatory) oral capsule 100 mg give 1 capsule orally twice a day. A physician's order dated 10/24/24 directed to administer Oxycodone HCL (opioid pain reliever) tablet 5 mg, give 5 mg orally three times a day. A physician's order dated 11/5/24 directed to administer Amantadine (Parkinson's like symptoms) 100 mg caps give 2 capsules orally twice a day. A physician's order dated 11/6/24 directed to administer Cholecalciferol (supplement)oral capsule 1.25 mg give 1 capsule orally once a day every 7 days. A physician' order dated 1/15/25 directed to administer Xifaxan (treatment for high ammonia levels) 550 mg tabs give 1 tablet orally twice a day. 6. Resident #31's diagnosis included heart failure, depression and dementia. A physician's order dated 7/4/24 directed to administer Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin (supplement) tablet 1000 micrograms (mcg) give 1 tablet orally once a day, Lipitor oral tablet 10 mg give 10 mg orally once a day, MiraLAX oral packet 17 grams (gm) give 1 packet orally once a day, Multiple vitamins with minerals give 1 tablet orally once a day, Senna (laxative) oral tablet give 8.6 mg orally once a day. A physician's order dated 7/11/24 directed to administer Ferrous sulfate (iron supplement) tablet 2 mg give 1 tablet orally once a day, Folic acid (supplement) oral tablet 1 mg give 1 tablet orally once a day. A physician's order dated 7/13/24 directed to administer Trelegy Ellipta (reduce bronchospasms in asthma/COPD) inhalation aerosol powder breath activated 200-62.5-25 mcg/act 1 puff inhale orally once a day. A physician's order dated 8/28/24 directed to administer Lubiprostone (constipation) oral capsule 24 mcg give 2 mcg orally twice a day. A physician's order dated 10/12/24 directed to administer Singulair (prevents asthma attacks) oral tablet 10mg give 1 tablet orally once a day. A physician's order dated 11/6/24 directed to administer Allegra allergy oral tablet give 180 mg orally once a day for allergies. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/20/25 directed to administer Prednisone (steroid) oral tablet 10 mg give 1 tablet orally once a day. A physician's order dated 2/3/25 directed to check blood glucose twice a day. A physician's order dated 2/13/25 directed to administer Lasix oral tablet 20 mg give 40 mg orally once a day. A physician's order dated 2/19/25 directed to check blood sugar before meals and at bedtime. A physician's order dated 2/23/25 directed to administer Gabapentin tab 600 mg give 1 tablet oral three times a day, Freestyle Libre 2 reader device apply 1 application trans dermally before meals and at bedtime. Novolog injection solution 100 unit/ml inject 4 units subcutaneously before meals and at bedtime, Novolog injection solution 100 unit/ml as per sliding scale if 150-199 give 4 units, 200-249 give 6 units, 250-299 give 8 units, 300-349 give 10 units, 350-399 give 12 units, 400-449 give 14 units, 450-499 give 16 units, 500 give 20 units and notify the provider before meals and at bedtime. A physician's order dated 2/24/25 directed to administer Metformin HCL oral tablet 500 mg Give 1 tablet orally twice a day. A physician's order dated 2/26/25 directed to administer Trazadone (antidepressant) HCL oral tablet 50 mg give 25 mg orally once a day. A physician's order dated 3/5/25 directed to administer Oxycodone HCL oral tablet 5 mg give 0.5 tablet orally twice a day. A physician's order dated 3/12/25 directed to administer Protonix (excessive stomach acid) oral tablet delayed release 40 mg give 1 tablet orally twice a day for 8 weeks. 7. Resident # 33's diagnosis included dementia, congestive heart failure and Parkinson's disease. A physician's order dated 12/18/24 directed to administer Carb/Levo 25mg/100 tab give 2 tablets orally three times a day, Gabapentin 300 mg capsules give 1 capsule orally three times a day. A physician's order dated 12/28/24 directed to administer pantoprazole 40 mg tablets give 1 tablet orally twice a day. A physician's order dated 12/19/24 directed to administer Sertraline 100 mg tabs give 1 tablet orally once a day, aspirin low tab 8 mg give 1 tablet orally once a day, Clopidogrel tab 75 mg give 1 tablet orally once a day, Seroquel oral tablet 25 mg give 1 tablet orally once a day, A physician's order dated 1/28/25 directed to administer Amlodipine tab 10 mg Give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day, Carvedilol 6.25 mg tab give 2 tablets orally twice a day, A physician's order dated 1/30/25 directed to administer Lantus subcutaneous solution 100 units/ml inject 40 units subcutaneously once a day. A physician's order dated 2/13/25 directed to administer Primidone tab 50 mg Give 0.5 tablet orally twice a day. Trazadone 50 mg tabs give 25 mg orally twice a day. A physician's order dated 2/14/25 directed to administer Humalog Kwik pen subcutaneous solution 100units/ml inject 5 units subcutaneously before meals. A physician's order dated 2/28/25 directed to administer Isosorbide Mononitrate ER tablet extended release 24-hour 60 mg give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Insulin lisp injection 100/ml per sliding scales if blood sugar is 150-199 give 3 units if less than 70 notify the provider, 200-249 6 units, 250-299 9 units, 300-349 12 units 350-399 15 units, greater than 400 18 units and notify the physician before meals and at bedtime. A physician's order dated 3/24/25 directed to administer Hydralazine HCL 50 mg tablets give 1.5 tablets orally three times a day. 8. Resident # 42's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 5 mg give 1 tablet orally once a day, fluticasone/vilanterol inhaler (steroid/bronchodilator for treatment of COPD) 100/25/60 1 puff inhale orally once a day, Divalproex (antiseizure) tab 250 mg DR give 250 mg orally twice a day, Guaifenesin (expectorant) tab 400 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tablet orally twice a day. A physician's order dated 8/13/24 directed to administer Tylenol extra strength oral tablet 500 mg give 1000mg orally twice a day. A physician's order dated 3/2025 directed to administer Escitalopram 5 mg tablet give 20 mg orally once a day, 9. Resident # 45's diagnosis included dementia, diabetes and seizures. A physician's order dated 5/30/24 directed to monitor glucose with Freestyle Libre device check resting blood sugar before meals and at bedtime. A physician's order dated 1/18/25 directed to administer Aspirin low 81 mg give 1 tablet orally once a day, Calcium citrate tab 200 mg give 1 tablet orally once a day, Polyether glycol powder 3350 NF give 17(Gram) gm orally once a day, Primidone tab 50 mg give 1 tablet orally every 12 hours, Tab a vit tab give 1 tablet orally once a day, Tresiba Flex injection 100 unit inject 12 units subcutaneously once a day, Vitamin C 500 mg tabs give 1 tablet orally once a day, Lexapro oral tablet 5 mg give 1 tablet orally once a day, Novolog flex pen subcutaneous solution pen injector 100 unit/ml inject 4 units subcutaneously once a day, Tamsulosin 0.4 mg caps give 1 capsule orally twice a day. A physician's order dated 1/20/25 directed to administer Sodium Bicarbonate (antacid) oral tablet 650 mg give 1 tablet orally twice a day, Sodium chloride oral tablet 1 gm give 1 tablet orally twice a day. A physician's order dated 1/29/25 directed to administer Norvasc oral tablet 5 mg give 1 tablet orally once a day, Coreg oral tablet 12.5 mg give 12.5 mg orally twice a day hold for systolic blood pressure less than 100 or heart rate less than 55 and notify physician, Hydralazine HCL oral tablet give 15 mg orally three times a day. 10. Resident #49's diagnosis included dementia, diabetes, and chronic kidney disease. A physician's order dated 8/22/24 directed to administer Tetrahydrozoline-dextran-polyethylene glycol povidone (eye irritation) eye drops instill 2 drops in left eye twice a day, Preparation H (hemorrhoid relief) rectal suppository insert 1 suppository rectally twice a day. A physician's order dated 8/23/24 directed to administer Citalopram Hydrobromide oral tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin tablet 1000mcg give 2 tablets orally once a day, Folic acid oral tablet 1 mg give 1 tablet orally once a day, Lidocaine HCL external patch 4 % apply to lower back topically once a day, Lisinopril oral tablet 2.5 mg give 1 tablet orally once a day hold for systolic blood pressure less than 90 or diastolic blood pressure less than 60 and notify the physician, Pravastatin sodium oral tablet 20 mg give 1 tablet orally once a day, PreserVision AREDS (supplement) 2 oral capsule with minerals give 1 tablet orally once a day, Vitamin D3 oral tablet 25 mcg give 1 tablet orally once a day. A physician's order dated 8/30/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally every Monday, Wednesday and Friday, Tylenol oral tablet 325 mg give 2 tablets twice a day. A physician's order dated 10/1/24 directed to administer Ferrous Sulfate oral tablet 325 mg give 325 mg orally one a day. A physician's order dated 2/6/25 directed to administer Eliquis oral tablet 5 mg give 1 tablet orally twice a day. 11. Resident # 56's diagnosis included Alzheimer's disease, anxiety and depression. A physician's order dated 6/3/24 directed to administer Tab a Vite tab give 1 tablet orally once a day, 12. Resident # 59's diagnosis included dementia, congestive heart failure and anxiety disorder. A physician's order dated 6/26/24 directed to administer Cyanocobalamin oral tablet 1000 mg give 1 tablet orally once a day, folic acid oral tablet 1 mg give 1 tablet orally once a day, Lactulose (laxative)oral solution 20 gm/30 ml give 30 ml orally once a day, MiraLAX oral packet 17 gm give 17 gm orally once a day, multivitamin oral tablet give 1 tablet orally once a day, Thiamine HCL oral tablet 100 mg give 1 tablet orally once a day. A physician's order dated 10/8/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 11/23/24 directed to administer Prozac (antidepressant) oral capsule 10 mg give 10 mg orally once a day. A physician's order dated 1/13/25 directed to administer Potassium chloride ER oral tablet 20 mEq give 1 tablet orally once a day. A physician's order dated 1/16/25 directed to administer Risperdal oral tablet 0.5 mg give 0.25 mg orally once a day. 13. Resident #61's diagnosis included Diabetes, Dementia and Cerebral infarction. A physician's order dated 5/28/24 directed to administer Gabapentin cap 100 mg give 1 capsule twice a day, Metoprolol Tar tablet 50 mg give 1 tablet orally twice a day. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet once a day, Escitalopram 10 mg tabs give 1 tablet once a day, Ezetimibe (lowers cholesterol) tab 10 mg give 1 tab orally once a day, fluticasone vilanterol inhaler 200/25 60 inhaler 1 inhalation orally once a day, Oxybutynin tab 15 mg ER give 1 tablet orally once a day, Pantoprazole 40 mg tabs give 1 tablet orally once a day, Rosuvastatin (lowers lipids) tab 40 mg give 1 tablet orally once a day, Acidophilus (probiotic) oral capsule give 1 capsule orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Metformin tab 1000mg give 1 tablet orally twice a day. A physician's order dated 9/26/24 directed to administer Cholestyramine (lowers cholesterol) powder 4 gm lite give 4 grams orally once a day. A physician's order dated 3/12/25 directed to administer Trulicity subcutaneous solution autoinjector 0.75 mg/0.5 ml inject 1 syringe subcutaneously once a day every Wednesday. Humalog Kwik pen subcutaneous solution pen injector 1unit/ml inject 2 units subcutaneously before meals. Fasting blood sugar check before meals and at bedtime. Humalog 100 units/ml Kwik pen 3ml inject as per sliding scale if blood sugar is 100-199 give 10 units call physician if glucose is less than 70, 200-400 give 15 units call physician if blood sugar is greater than 400 subcutaneously before meals and at bedtime. 14. Resident #63's diagnosis included Alzheimer's dementia, diabetes, and cerebral infarction. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet orally once a day, Donepezil 10 mg tabs give 1 tablet orally once a day, Escitalopram 10gm tabs give 1 tablet orally once a day, Tab a Vite tab give 1 tablet once a day, Vitamin B1 tab 100mg give 2 tablets orally once a day, Midodrine tab 5 mg give 1 tablet orally twice a day, Reguloid (fiber) powder orange give 2 tablespoons orally twice a day. A physician's order dated 6/4/24 directed to administer Cholecalciferol oral tablet give 25 mcg orally once a day. A physician's order dated 8/20/24 directed to administer Acetaminophen oral tablet 325 mg give 2 tablets orally three times a day. A physician's order dated 12/6/24 directed to administer Tramadol HCL oral tablet 25 mg give 1 tablet orally twice a day. 15. Resident #67's diagnosis included dementia, hypothyroidism, and chronic kidney disease. A Physician's order dated 6/3/24 directed to administer Allopurinol (gout) tab 100 mg give 1 tablet orally once a day, Amlodipine tab 10 mg give 1 tablet orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Hydralazine tab 25 mg give 1 tablet orally twice a day, Acetaminophen 500 mg tabs give 2 tablets orally three times a day. A physician's order dated 7/31/24 directed to administer Vitamin B12 oral tablet give 1000 mcg orally once a day. A physician's order dated 12/18/24 directed to administer Trazadone 50 mg tabs give 0.5 tablet orally twice a day. 16. Resident # 68's diagnosis included Alzheimer's dementia, depression and hyperkalemia. A physician's order dated 6/3/24 directed to administer Vitamin D 1000 IU caps give 1 capsule orally once a day, Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day. A physician's order dated 11/2/24 directed to administer Trazadone HCL oral tablet 50 mg give 25 mg orally three times a day. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/18/25 directed to administer Aspirin EC tablet delayed release 81 mg give 1 tablet orally once a day. 17. Resident # 69's diagnosis included dementia, psychotic disorder with delusions, and chronic kidney disorder. A physician's order dated 6/3/24 directed to administer Amlodipine tab 10 mg give 1 tablet orally once a day, Aspirin low 81 mg give 1 tablet orally once a day, Ondansetron (nausea and vomiting) tab 4 mg give 1 tablet orally once a day, Potassium chloride cap 10 mEq ER give 2 capsules once a day, Sertraline 100 mg tabs give 1 tablet orally once a day as part of 125 mg dose in am, Sertraline 25 mg tabs give 1 tablet once a day as part of 125 mg dose in am, Multivitamin with minerals oral tablet give 1 tablet orally once a day, Calcium carb 500 mg tab give 1 tablet orally twice a day, Vitamin C 500 mg tab give 2 tablets orally twice a day. 18. Resident #72's diagnosis included dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Famotidine 10 mg tabs give 2 tablets orally once a day, Valsartan tab 160 mg give 1 tablet orally once a day, Vitamin D 3 50000 IU caps give 1 capsule orally once a day, Hydralazine tab 10 mg Give 1 tablet orally three times a day, A physician's order dated 6/20/24 directed to administer Aspirin tablet 81 mg give 1 tablet orally once a day. A physician's order dated 3/4/25 directed to administer Sodium Chloride oral tablet 1 gm give 1 tablet orally twice a day. 19. Resident # 74's diagnosis included Alzheimer's dementia, hypokalemia, and hypothyroidism. A physician's order dated 6/3/24 directed to administer Escitalopram 10 mg tabs give 1 tablet orally once a day, Lisinopril 10 mg tabs give 1 tablet orally once a day, Memantine 5 mg tabs give 1 tablet orally twice a day. A physician's order dated 1/17/25 directed to administer Vitamin B 12 oral tablet 100 mcg give 1 tablet orally once a day. 20. Resident # 78's diagnosis included Alzheimer's Dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Docusate sodium cap 100 mg give 1 capsule orally twice a day, Meloxicam tab 15 mg give 1 tablet orally once a day, Potassium chloride solution 10% give 15 ml orally once a day, Acetaminophen 500 mg tabs give 2 tablets orally twice a day, genteal tear (dry eyes) solution instill 2 drops in left eye twice a day. A physician's order dated 7/16/24 directed to administer Lisinopril tablet 2.5 mg give 1 tablet orally once a day. A physician's order dated 1/24/25 directed to administer Multiple vitamins with minerals give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Combigan (glaucoma) 0.2-0.5% ophthalmic solution instill 1 drop in both eyes twice a day. 21. Resident # 81's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 2.5 mg tabs give 1 tablet orally once a day, Atenolol 25 mg tabs give 0.5 tablet orally once a day, Memantine tab 10 mg give 1 tablet orally twice a day, Senna 8.6 mg tabs give 2 tablets orally once a day. 22. Resident #92's diagnosis included Paranoid schizophrenia, hypokalemia and anxiety disorder. A physician's order dated 6/19/24 directed to administer Amlodipine besylate oral tablet 5 mg give 1 tablet orally once a day. A physician's order dated 7/27/24 directed to administer Oyster shell calcium oral tablet 500mg give 1 tablet orally once a day. A physician's order dated 12/4/24 directed to administer Trazadone HCL oral tablet 50 mg give 0.5 tablet orally twice a day. Observations on 3/26/25 at 10:30 AM, identified Licensed Practical Nurse (LPN) #6 was having difficulty accessing Point Click Care (PCC) the electronic medical record system (EMAR). LPN #6 was heard to state I can't get into these computers, I don't know what is wrong with these computers, I have not been able to get into PCC all morning. I hate these computers, I wish we just went back to paper. Interview with LPN #6 on 3/26/25 at 10:30 AM identified she was unable to access PCC since the start of her shift at 7:00 AM. She stated she had tried 2 laptops and 2 desktop computers unsuccessfully. LPN #6 indicated she had administered medications to the 22 residents on her assignment, for the morning medication pass by memory, without the benefit of the use of a Medication Administration Record (MAR). (An MAR ensures the 5 rights of medication administration, right patient, right drug, right dose, right route, and right time). LPN #6 stated that she had failed to document any of the non-narcotic medications that she had administered by any alternate means of record keeping. LPN #6 was able to show a written record of each of the residents who received narcotics as narcotic medications required a signature in the narcotic book, on the proof of use sheet, that the medication had been signed out for a specific resident. Additionally, LPN #6 identified she had failed to notify a supervisor or the Assistant Director of Nursing (ADNS) when she was unable to access the EMAR or the software used for medication administration, PCC, because she wanted to get the medications passed and planned on documenting what she had given after the medication pass was completed. LPN #6 indicated that if any resident medications had changed since her last shift, she would have expected the off-going nurse to communicate this verbally, during a nurse-to-nurse report, for each of the residents who may have had changes. LPN # 6 further indicated that it was not an appropriate practice to administer medications to residents without utilizing an MAR, and that the policy was to call a supervisor when locked out of the EMAR and PCC. Interview on 3/26/25 at 11:00 AM with the Assistant Director of Nursing Services (ADNS) identified that she was not made aware LPN #6 was unable to access the EMAR or PCC and had not received any communication from LPN #6 to reset her password. The ADNS stated that LPN #6 had passed medications to 22 residents without the benefit of an MAR and should have contacted the supervisor or herself to reset her password. The ADNS identified it was inappropriate and against the policy to administer medications without the benefit of utilizing the MAR to ensure the 5 rights of medication administration were performed. The ADNS was unable to explain why LPN #6 would administer medications to 22 residents, by memory, without utilizing an MAR. Interview with the Corporate Regional Nurse, Registered Nurse (RN) #4 on 3/26/25 at 11:26 AM identified that the physician, Advanced Practice Registered Nurse (APRN), and responsible parties had been notified of LPN #6's inappropriate use of memory to administer medications to 22 residents, without the benefit of utilizing an MAR. Interview with APRN #1 on 3/26/25 at 12:22 PM identified she was made aware that 22 residents were administered medications by LPN #6, by memory, without the benefit of an MAR, and that she had reviewed all of the medications ordered for the affected residents under her care. APRN #1 stated that for the residents who required blood sugar monitoring, she had ordered blood sugar checks immediately and to continue per the established schedule. All affected residents were to have vital sign checks every shift for 24 hours to monitor their health status. APRN #1 additionally ordered labs to be checked for the residents who were receiving sodium chloride tablets and that she was to be notified of any abnormalities. Interview with APRN #2 on 3/26/25 at 12:30 PM identified that she was made aware that 22 resident's medications were administered without the benefit of an MAR, by memory, by LPN #6. APRN #2 identified she had just observed all of the residents under her care, would review those resident medications, and would determine if further monitoring would be required. Additionally, APRN #2 identified that she would review the vital signs and blood sugars for her residents and leave orders to be notified for any abnormalities. Review of the charting and documentation policy dated 6/2023 revised, in part, directed that documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations, medication administered, treatment or services performed. Review of the job description for a charge nurse, is that the LPN/RN is responsible for the overall operation and optimal quality of care for the residents on the assigned unit, follows all health, sanitary and infection control policies, and maintains established standards of practice set forth by the facility's administration and nursing policies and procedures. The direct supervisor is the RN supervisor. Qualifications included knowledge of nursing theory and practice including the administration of medications. According to the National Library of Medicine dated 9/4/23 Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 6 residents, (Resident #43) reviewed for abuse, the facility failed to thoroughly investigate an allegation of abuse, failed to remove the staff member from the schedule following the allegation, and once the allegation was substantiated by the State Agency again failed to remove the staff member from the schedule to ensure the residents were protected from abuse. These failures resulted in the finding of Immediate Jeopardy. The findings include: Resident #43's diagnoses included dementia, personality disorder, and hypertensive heart disease with heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions, and required maximal assistance for his/her toileting hygiene and chair to bed and bed to chair transfers. The MDS further indicated that Resident #43 did not reject evaluations of care including ADL assistance and was always incontinent of urine. The Resident Care Plan (RCP) in effect on 1/3/25 identified Resident #43 experienced frequent episodes of incontinence of bladder with an intervention of an assist of 2 with toileting upon request. The RCP further identified he/she had a behavior problem of making accusatory statements towards staff. Interventions included explaining all procedures to him/her before starting and allowing him/her to adjust to the changes, monitoring behavior episodes to determine the underlying cause, and documenting the behavior and potential cause. The Resident Care Card in effect on 1/3/25 identified Resident #43 was to have 2 staff members present at all times when in his/her room including when performing medication passes, answering call lights, and performing bathing and toileting tasks. An observation and interview with Resident #43 on 3/18/25 at 11:43 AM identified that he/she was sitting in the hallway in a wheelchair, hands flailing, crying, verbalizing he/she was upset regarding a financial matter. The resident verbalized, in the presence of Licensed Practical Nurse (LPN) #8, he/she had been hurt by staff on multiple occasions, most recently by LPN #7. The Director of Nursing Services (DNS) was called by LPN #8 to come to the resident's room regarding the allegation of abuse. An interview with Resident #43 on 3/18/25 at 11:51 AM was conducted in the presence of the DNS by the surveyor. Resident #43 alleged a few weeks prior, while he/she was trying to get into bed from his/her wheelchair, LPN #7 reached over the back of the wheelchair and pushed him/her onto the bed in a non-sexual manner. Resident #43 further identified that he/she was alone in the room with LPN #7 and started yelling for help, at which point LPN #7 grabbed the phone out of his/her hand and threw it across the room. It was noted by Resident #43, that Nurse Aide (NA) #7 entered the room and assisted him/her into bed in order to provide incontinence care. Resident #43 stated he/she experienced great humiliation over the event and continued to be afraid of LPN #7, noting LPN #7 continued to come into his/her room to provide care after the alleged incident of abuse. The DNS identified he was aware of the allegation of abuse and stated he had completed an investigation and reported the incident to the State Agency (SA). An interview and review of the abuse documentation with the DNS on 3/19/25 at 7:51 AM identified a Reportable Event (RE) form dated 1/3/25 indicating Resident #43 alleged LPN #7, with help from NA #7, picked up the resident threw him/her into bed. Actions taken indicated LPN #7 and NA #7 were off of the schedule until the investigation was completed and would no longer provide routine care. Review of the RE failed to identify that the allegation of mistreatment had been reported to the SA. Although requested, the DNS failed to provide documentation of a thorough investigation or any investigation whatsoever, except for a summary that he had created indicating what had transpired on 1/3/25. The summary of events was typewritten, noted to be undated, unsigned, and lacked the alleged staff member's name. The investigation provided lacked any staff interviews, staff statements, an interview with Resident #43, any resident interviews who may have witnessed or overheard the incident, or an interview with the staff member (LPN #7) against whom the allegation was made. The DNS indicated that the summary provided was created by him following his conclusion to the investigation into Resident #43's allegation of abuse dated 1/3/25. The DNS stated that he would have to look for the sworn and signed statements by the staff as he was unable to locate the information, and he would have to reach out to Information Technology (IT) to obtain the creation date of the investigation summary that was provided to the surveyor. Further, the RE indicated that the immediate action taken by the facility was that LPN #7 would no longer deliver care to Resident #43 unless it was in an emergency. The DNS stated that once the investigation had been completed, he had proven that the allegation of abuse was unfounded because Resident #43 had a history of allegations against staff, which were noted in the Resident Care Plan. The DNS was unable to further explain how he had reached his conclusion other than based on Resident #43's history of allegations. Additionally, the DNS identified that LPN #7 was allowed to return to providing care to Resident #43 upon the conclusion of the investigation. Interview with the DNS and Administrator on 3/19/25 at 9:45 AM identified the summary provided by the DNS to the surveyor had not been created following the conclusion of the investigation of mistreatment as previously stated. The DNS indicated that when he realized he had not submitted the RE to the SA, he had become nervous and wrote up the summary on 3/18/25 based on his memory of the events on 1/3/25. Further, the DNS indicated the nursing note written by LPN #7 on 1/5/25, which stated Resident #43 alleged to be thrown into bed, and not pushed, invalidated the allegation as the DNS deduced LPN #7 was not strong enough to throw the resident, adding this made all the difference in the outcome of his investigation. On 3/19/25 at 10:30 AM the DNS stated that he was unable to locate any of the sworn statements from the investigation he indicated was conducted following the abuse allegation on 1/3/25. Interview with NA #7 on 3/19/25 at 10:54 AM identified that she had no recollection of any incident that occurred on 1/3/25 and that the DNS had never asked her about the incident or to write a statement for the investigation. Following the interview with NA #7 the DNS informed the surveyor he would have NA #7 write a statement to replace the one he indicated was written at the time of the incident on 1/3/25 but he was unable to locate. An interview and review of nursing progress notes with LPN #7 on 3/19/25 at 4:26 PM identified that Resident #43 refused to be assisted with incontinence care when he worked on the second shift (7:00 PM to 10:45 PM) and remained wet. LPN #7 stated he worked on third shift (10:45 PM to 7:30 AM) and indicated that Resident #43 again declined to be assisted with incontinence care and that was when LPN #7 informed the resident that he/she had to be changed. LPN #7 stated that he would not be held responsible for the development of a urinary tract infection or [pressure] sore for Resident #43, so he provided the incontinence care despite Resident #43's objections. When NA #7 assisted putting the resident back to bed with LPN #7 they began to provide the incontinence care, and that is when Resident #43 began crying and yelling for help. LPN #7 remarked that was when he removed the phone from the resident's hand and told Resident #43 he/she could call for help when he was done. LPN #7 indicated he removed the phone because he could not reposition the resident if he/she was holding onto the phone. On the advice of the DNS, to protect himself, LPN #7 indicated he wrote a late progress note on 1/5/25 at 6:30 AM (2 days after the incident). Further, the progress note documented that the resident drew blood from LPN #7 in the process of LPN #7 transferring him/her back to the bed and that Resident #43 screamed, yelled, scratched, and hit staff during the incontinence care. LPN #7 indicated that Resident #43 was always crying about everything Boo Hoo Hoo this and Boo Hoo Hoo that and no one wanted to work with him/her because he/she cried about everything. LPN #7 stated that although he had subsequently spoken to the DNS about the incident, he was never asked by the DNS to write a statement. In a follow up interview with the DNS and Administrator on 3/20/25 at 8:36 AM the DNS indicated he had not yet begun an investigation into the allegation from 1/3/25, per the facility policy, and following the 3/18/25 interview with Resident #43 and the surveyor. The DNS stated the reason he had not done so was that he wanted to confirm with the surveyor first, but did not specify what he wanted to confirm. An interview and review of NA #7's newly written and undated statement with the DNS on 3/20/25 at 2:14 PM identified Resident #43 was fighting back and needed redirection multiple times during the 1/3/25 incident. The DNS reiterated that because Resident #43 was not thrown on the bed [was pushed], the abuse was unfounded. The DNS was informed by the surveyor that the abuse had been investigated and had been substantiated through the investigative process, by the surveyor. The DNS indicated that he would redo his investigation. According to punch in and punch out records, LPN #7 had punched in on 3/24/25 at 11:00 PM and punched out on 3/25/25 at 7:30 AM. A review of the staffing schedules identified that LPN #7 had been assigned to Resident #43's unit. Despite informing the DNS on 3/20/25 at 2:14 PM that the allegation of abuse had been substantiated by the surveyor, and LPN #7 had admitted to providing care to the resident against his/her will, LPN #7 was allowed to return to the facility, scheduled to work on Resident #43's unit, and worked in the facility on 3/24/25 on the 11:00 PM to 7:30 AM shift. An interview on 3/25/25 at 11:03 AM with the DNS identified that residents have the right to refuse care. He further identified if a resident refuses care, staff should document the refusal and reapproach later. The DNS identified that forcing a resident to receive care they had refused fell under the category of abuse. Although the DNS indicated to the surveyor that he would begin an investigation on 3/20/25, he stated that he still had not read LPN #7's progress indicating Resident #43 had drawn blood, although the DNS summary written 3/18/24 did identify blood was drawn during the resistance of care and he indicated he needed to investigate the 1/3/25 incident more thoroughly. Subsequent to surveyor inquiry, LPN #7 was removed from the staff schedule. A review of LPN #7's punch card identified LPN #7 had access to Resident #43 on 62 different shifts for the time period of 1/4/24 through 3/19/25, and again on 1/24/25. Review of the facility's Reportable Events Policy identified that a Class B event, (state classification) including a complaint of resident abuse, should be reported to the State Department of Public Health by the Administrator or DNS within the required time frame. An investigation will be conducted by the facility after the discovery of an allegation of abuse. The police are to be notified if an assault or suspected assault has occurred. Review of the facility's Abuse Reporting Policy identified when an allegation of abuse is reported, the facility administrator or his/her designee will notify the following persons of the incident: Department of Public Health; Ombudsman; Resident Representative; Law Enforcement Officials; and Primary Physician. Allegations of abuse must be reported no less than 2 hours after the allegation is made. A completed copy of the Reportable Event Form and written statements from witnesses must be provided to the Administrator within 24 hours of the occurrence of said incident.

Based on observation, interviews, clinical record reviews, facility documentation, and facility policy for 3 of 6 sampled residents, (Resident #43, Resident #42, and Resident #84) reviewed for abuse, for Resident #43, the facility failed to protect the residents' right to be free from physical abuse by staff, and for Resident #42 and Resident #84, the facility failed to protect the resident's right to be free from physical abuse by a resident. The findings include: 1. Resident #43's diagnoses included dementia, personality disorder, and hypertensive heart disease with heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions, and required maximal assistance for his/her toileting hygiene and chair to bed and bed to chair transfers. The MDS further indicated that Resident #43 did not reject evaluations of care including Activity of Daily Living assistance and was always incontinent of urine. The Resident Care Plan (RCP) in effect on 1/3/25 identified Resident #43 experienced frequent episodes of incontinence of bladder with an intervention of an assist of 2 with toileting upon request. The RCP further identified he/she had a behavior problem of making accusatory statements towards staff. Interventions included explaining all procedures to him/her before starting and allowing him/her to adjust to the changes, monitoring behavior episodes to determine the underlying cause, and documenting the behavior and potential cause. The Resident Care Card in effect on 1/3/25 identified Resident #43 was to have 2 staff members present at all times when in his/her room including when performing bathing and toileting tasks. An observation and interview with Resident #43 on 3/18/25 at 11:43 AM identified that he/she was sitting in the hallway in a wheelchair, hands flailing, crying, verbalizing he/she was upset regarding a financial matter. The resident verbalized, in the presence of Licensed Practical Nurse (LPN) #8, he/she had been hurt by staff on multiple occasions, most recently by LPN #7. The Director of Nursing Services (DNS) was called by LPN #8 to come to the resident's room regarding the allegation of abuse. An interview with Resident #43 on 3/18/25 at 11:51 AM was conducted by the surveyor in the presence of the DNS. Resident #43 alleged a few weeks prior, while he/she was trying to get into bed from his/her wheelchair, LPN #7 reached over the back of the wheelchair and pushed him/her onto the bed in a non-sexual manner. Resident #43 further identified that he/she was alone in the room with LPN #7 and started yelling for help, at which point LPN #7 grabbed the phone out of his/her hand and threw it across the room. It was noted by Resident #43, that Nurse Aide (NA) #7 entered the room and assisted him/her into bed in order to provide incontinence care. Resident #43 stated he/she experienced great humiliation over the event and continued to be afraid of LPN #7, noting LPN #7 continued to come into his/her room to provide care after the alleged incident of abuse. The DNS identified he was aware of the allegation of abuse and stated he had completed an investigation. An interview and review of abuse documentation with the DNS on 3/19/25 at 7:51 AM identified a Reportable Event (RE) form dated 1/3/25 indicating Resident #43 alleged LPN #7, with help from NA #7, picked up the resident threw him/her into bed. Actions taken indicated LPN #7 and NA #7 were off of the schedule until the investigation was completed and would no longer provide routine care to Resident #43. Although requested, the DNS failed to provide documentation of a thorough investigation or any investigation whatsoever, except for a summary that he had created describing what had transpired on 1/3/25. The summary of events was typewritten, noted to be undated, unsigned, and lacked the alleged staff members name. The investigation/summary provided lacked any staff interviews, staff statements, an interview with Resident #43, any resident interviews who may have witnessed or overheard the incident, or an interview with the staff member (LPN #7) against whom the allegation was made. The DNS indicated he would have to look for the completed investigation he had done and for the creation date of the summary provided. Other than a history of allegations by Resident #43 against staff, (noted in the resident's care plan), the DNS was unable to explain how he had reached a conclusion that the allegation was unsubstantiated, and LPN #7 was allowed to return to providing care to Resident #43 upon the conclusion of the investigation. In an interview with the DNS and Administrator on 3/19/25 at 9:45 AM the DNS identified the nursing note written by LPN #7 on 1/5/25 (2 days after the allegation), which stated Resident #43 alleged to be thrown into bed, and not pushed, invalidated the allegation. The DNS deduced LPN #7 was not strong enough to throw the resident, adding this made all the difference in the outcome of his investigation During a review of the facility abuse policy with the DNS, he stated that he had not needed to remove LPN #7 from the schedule as the LPN was not scheduled to work on 1/4/25 when he concluded his investigation. On 3/19/25 at 10:30 AM the DNS stated that he was unable to locate any of the sworn statements from the investigation following the abuse allegation on 1/3/25. An interview and review of nursing progress notes with LPN #7 on 3/19/25 at 4:26 PM identified that Resident #43 refused to be assisted with incontinence care when he worked on the second shift (7:00 PM to 10:45 PM) and remained wet. LPN #7 stated he worked on third shift (10:45 PM to 7:30 AM) and indicated that Resident #43 again declined to be assisted with incontinence care and that was when LPN #7 informed the resident that he/she had to be changed. LPN #7 stated that he would not be held responsible for the development of a urinary tract infection or (pressure) sore for Resident #43, so he provided the incontinence care despite Resident #43's objections. When NA #7 assisted putting the resident back to bed with LPN #7 they began to provide the incontinence care, and that was when Resident #43 began crying and yelling for help. LPN #7 remarked this was when he removed the phone from the resident's hand and told Resident #43 he/she could call for help when he was done. LPN #7 indicated he removed the phone because he could not reposition the resident if he/she was holding onto the phone. On the advice of the DNS, to protect himself, LPN #7 indicated he wrote a late progress note on 1/5/25 at 6:30 AM (2 days after the incident and when he worked on 1/4/25 into 1/5/25). Further the progress note documented that the resident drew blood from LPN #7 in the process of LPN #7 transferring him/her back to the bed and that Resident #43 screamed, yelled, scratched, and hit staff during the incontinence care. LPN #7 indicated that Resident #43 was always crying about everything Boo Hoo Hoo this and Boo Hoo Hoo that and no one wanted to work with him/her because he/she cried about everything. LPN #7 stated that although he had subsequently spoken to the DNS about the incident, he was never asked by the DNS to write a statement. In a follow up interview with the DNS and Administrator on 3/20/25 at 8:36 AM the DNS indicated he had not yet begun an investigation into the allegation from 1/3/25, per the facility policy, and following the 3/18/25 interview with Resident #43 and the surveyor. The DNS stated the reason he had not done so was that he wanted to confirm with the surveyor first, but did not specify what he wanted to confirm. An interview and review of NA #7's written and undated statement (created on 3/19/25 at the DNS request) with the DNS on 3/20/25 at 2:14 PM identified Resident #43 was fighting back and needed redirection multiple times during the 1/3/25 incident. The DNS reiterated that because Resident #43 was not thrown on the bed (was pushed), the abuse was unfounded. The DNS was informed by the surveyor that the abuse had been investigated and had been substantiated through the investigative process, by the surveyor. The DNS indicated that he would redo his investigation. According to punch in and punch out records, LPN #7 punched in on 3/24/25 at 11:00 PM and punched out on 3/25/25 at 7:30 AM. A review of the staffing schedules identified that LPN #7 had been assigned to Resident #43's unit. Despite informing the DNS on 3/20/25 at 2:14 PM that the allegation of abuse had been substantiated by the surveyor, and LPN #7 had admitted to providing care to the resident against his/her will, LPN #7 was allowed to return to the facility, scheduled to work on Resident #43's unit, and worked in the facility on 3/24/25 on the 11:00 PM to 7:30 AM shift. An interview on 3/25/25 at 11:03 AM with the DNS identified that residents have the right to refuse care. He further identified if a resident refused care, staff should document the refusal and reapproach later. The DNS identified that forcing a resident to receive care they had refused fell under the category of abuse. Although the DNS indicated to the surveyor that he would begin an investigation on 3/20/25, he stated that he still had not read LPN #7's progress note indicating Resident #43 had drawn blood (although the DNS summary written on 3/18/24 did identify LPN #7's blood was drawn) during the incident. The DNS stated he needed to investigate the 1/3/25 incident more thoroughly. Subsequent to surveyor inquiry, LPN #7 was removed from the staff schedule. A review of LPN #7's punch card identified LPN #7 had access to Resident #43 on 62 different shifts for the time period of 1/4/24 through 3/19/25, and again on 1/24/25. 2.a. Resident #42 had diagnoses that included dementia and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #42 had severe cognitive impairment with a Brief Interview of Mental Status BIMS of 0 and was independent with ambulation. The Resident Care Plan dated 10/23/24 identified Resident #42 had impaired thought processes, and an ADL deficit related to cognition. Interventions included to cue, orient and supervise as needed and provide supervision with ambulation. A nurse's note dated 11/23/24 at 7:07 PM identified Resident #42 was in the hallway when s/he attempted to prevent another resident (Resident #84) from pushing an item. During the interaction, Resident #84 became agitated and struck Resident #42 open handed on the right cheek. The residents were immediately separated and Resident #84 placed on 1:1 monitoring. The DNS, responsible party, physician and police were notified. Resident #42 had no complaints of pain, and no signs of bruising at the time of the incident. The Resident Care Plan was revised to include redirection away from situations that may cause conflict. b. Resident #84 had diagnoses that included dementia and delusional disorders. The annual MDS assessment dated [DATE] identified Resident #84 had moderately impaired cognition and was independent with bed mobility, transfers, and ambulation. The Resident Care Plan dated 10/7/24 identified Resident #84 had a history of inappropriate/disruptive behavioral symptoms evidenced by unprovoked aggression towards others. Interventions included anticipating needs and intervene as necessary to protect the rights of others. An unsigned Resident Monitoring Sheet dated 11/23/24 identified 6:15 PM through 6:30 PM Resident #84 was in the hall. A nurses note dated 11/23/24 at 7:09 PM identified Resident #84 was walking down the hall pushing an item. (Resident #42) attempted to stop him/her (from further movement) resulting in Resident #84 striking Resident #42 on the right cheek open handed. Resident #84 was placed on 1:1 supervision and returned to his/her room. The responsible party, physician. DNS, and police were notified. A facility Reported Event Summary dated 11/26/24 identified on 11/23/24 at approximately 6:30 PM, Resident #84 was pushing a wheelchair in the hallway. Resident #42 stepped in front (of resident #84) to prevent further movement. This upset Resident #84 who slapped Resident #42 with an open hand on the right side of his/her face. LPN #14 was passing medication in the hallway and observed the altercation but was unable to respond quickly enough to intervene. The residents were separated and immediately placed on a 1:1 sitter until details could be obtained and assessments by the RN supervisor completed. An assessment identified both residents at baseline with no injuries to Resident #42. Once details were sorted out, Resident #84 remained on a 1:1 sitter until cleared by the health provider. Resident #84's prescribed Trazadone (an antidepressant) was increased from 25 mg daily to 50 mg. Resident #84 was subsequently transported to an alternate (psychiatric) facility for evaluation and treatment on 11/25/24. An interview with LPN #14 on 3/24/25 at 11:49 AM identified she was the assigned nurse on 11/23/24 during the 3:00 PM to 11:00 PM shift. LPN #14 indicated while passing medications, she observed Resident #84 pushing a cart down the hall. Resident #42 attempted to stop Resident #84 from pushing the cart at which point, Resident #84 slapped Resident #42 open handed on the side of the face. In response, Resident #42 pushed Resident #84 into the wall. LPN #14 immediately intervened, separated the two residents and notified the nursing supervisor. An interview with the DNS on 3/24/25 at 1:30 PM identified Resident #84 was pushing an item down the hallway when Resident #42 attempted to stop him/her. Resident #84 slapped Resident #42 in the face. No injuries were noted as a result of the incident. The DNS further identified he was not aware Resident #42 had also pushed Resident #84 as this detail was not previously reported or documented in any written statements, though it should have been reported at the time of the incident. Attempts to interview RN #3, the assigned nursing supervisor were unsuccessful. A review of the facility policy for Abuse directs that the facility does not condone abuse by anyone including staff members and other residents. Further, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm of pain or mental anguish that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 50249 51182

Based on clinical record review, facility documentation, policies, and interviews, for one of four sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure Resident (R) #1's identity was verified prior to the administration of medications in accordance with facility policy. As a result, R #1 received his/her roommates medication and was subsequently hospitalized . The finding includes: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified R# 1 had severe cognitive impairment. The Resident Care Plan (RCP) dated 7/28/19 identified impaired cognition related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 10/20/19 at 10:10 AM identified that Registered Nurse (RN) #1, the shift supervisor, was notified by Licensed Practical Nurse (LPN) #1 that at 9:25 AM, R#1 was found unresponsive. While assessing R#1, LPN #2, who did the morning medication pass realized that she had administered the wrong medications to R#1. In error R#1 received his/her roommate's (R#2) morning medications which included [MEDICATION(S)] 0.5 mg (sedative), [MEDICATION(S)] 5 mg (antidepressant), and [MEDICATION(S)] 75 mg (antipsychotic). Emergency medical services (EMS) was notified. The resident's blood Pressure (BP) was 70/30 and pulse was 52 beat per minute. EMS assumed care and at 9:35 AM, R#1 was transferred to the emergency room (ER). Review of the record identified that a photo of Resident #1 was present as a form of identification. The Hospital Discharge Summary dated 10/27/19 identified R#1 did not demonstrate respiratory distress however due to his/her decreased level on consciousness and the abundance of medication R#1 received , the resident was intubated to protect his/her airway. R#1 was extubated the next day and discharged on [DATE] in stable condition to a long term care facility. The Facility Accident/Incident Report and investigation dated 10/21/19 identified LPN#2 who was on orientation, was administering medications with the oversight of LPN#1, the charge nurse. At approximately 8:30 AM, LPN#2 prepared R#2's medications (R#1's roommate). LPN #1 became distracted by another resident, turned her back to talk to the resident, and LPN#2 proceeded into the room and administered medications without LPN#1 present. LPN #2 failed to wait for LPN #1 to administer medications and LPN #1 failed to adequately supervise LPN #2 in the administration of medication in accordance with facility policy. Review of LPN#2's written statement dated 10/20/19 identified she poured R#2's medication, approached R#1, checked for a name band which the resident did not have, addressed R#1 with R#2's name and R#1 responded with a yes. LPN #2 then administered the medications. Interview, review of the clinical record and review of the facility policy on 10/31/19 at 10:00 AM with the Director of Nurses (DON) identified that LPN #2 was a new hire and was orienting on the unit with LPN #1. LPN #1 became distracted by another resident and failed to observe LPN#2 administer medications to R#1. Subsequent to the incident LPN#2's employment was terminated and all licensed staff were reeducated on medication administration while on orientation. All nurses were reeducated to check identification bands or photo identification before administering medications and not to administer medications if the resident does not have a form of identification. Interview, review of the clinical record and review of facility policy on 10/31/19 at 1:00 PM with LPN#1 identified that while orienting LPN#2 on medication administration she became distracted with another resident and failed to observe LPN#2 administer medications to R#1. Attempts to interview LPN#2 were unsuccessful. The Facility's Administration of Medications policy directed that during orientation of a medication pass, the orientee will not be left unsupervised during the medication pass. Residents identification will be verified with a name band or photo identification prior to the administration of each resident's medication.

Based on review of the clinical record, facility documentation, facility policy and staff interview for 1 of 3 residents, (Resident #28) reviewed for abuse, the facility failed to protect the resident from physical abuse by Resident #597. The findings include: Resident #28's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified Resident #28 had short and long term memory problems, moderately impaired cognition, exhibited verbal behavioral symptoms directed toward others, and required total assistance with all care. The care plan dated 7/7/18 identified Resident #28 at times shows socially disruptive behavioral symptoms by singing at the top of his/her lungs. Interventions included to administer medications as ordered, allow distance in seating other residents around the resident, avoid noise, over-stimulation, crowding other physically aggressive residents. Additionally remove any individuals who may be at risk related to resident's behavior. A nurse's note dated 9/8/18 at 4:38 AM identified Resident #28 was yelling at the top of his/her voice. [MEDICATION NAME] and Tylenol administered with no effect. Resident #28 was still yelling after 2 hours. A nurse's note dated 9/9/18 identified Resident #28 had occasional yelling. A nurse's note dated 9/11/18 identified Resident #28 continued with yelling fearfully this morning. A psychiatric evaluation was completed. A psychiatric evaluation dated 9/11/18 identified staff asked psychiatry to evaluate Resident #28 due to screaming and question of delusions. The evaluation identified Resident #28 has periods of increased yelling and the (as needed) pain medication and/or [MEDICATION NAME] is not effective. Recommendations included to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 0.25 mg as needed every 6 hours for anxiety, yelling, and fear for 14 days and re-evaluate. Review of nurse's notes dated 9/12, 9/13, 9/14, 9/15, 9/16, 9/17, 9/18, 9/19 and 9/20/18 identified Resident #28 had episodes of yelling, screaming, and screaming at the top of his/her voice. A nurse's note dated 9/21/18 at 2:10 PM identified Resident #28 had frequent episodes of yelling out, and was easily redirected with offered snacks. Resident #597 was re-admitted to the facility on [DATE] from a psychiatric admission (9/10/18-9/21/18) with [DIAGNOSES REDACTED]. The hospital discharge summary dated 9/21/18 identified Resident #597 was admitted via a Physician's Emergency Certificate (PEC) because he/she reportedly became agitated by another residents alarm and placed his/her hands around the resident's neck as though to strangle the resident. Resident #597's hands had to be forcibly removed. Resident #597 has had 2 prior psychiatric hospitalization s and was acutely agitated when he/she arrived to the unit on 9/10/18, and required IM [MEDICATION NAME]. A nurse's note dated 9/21/18 identified at 6:15 PM, staff heard Resident #28 yelling in his/her room. When staff responded, another resident (Resident #597) was standing over Resident #28 striking Resident #28 in the face while the resident was lying in bed. Additionally, Resident #597 was visibly upset and stated (yes I hit him/her). A reportable event form dated 9/21/18 identified Resident #28 was observed lying in bed while another resident was striking him/her in the face with his/her fists. Resident #28 sustained redness and slight purple color and swelling to the left cheek area. A witness statement by Staff #1 dated 9/21/18 identified Resident #597 came to the desk and stated (I hit that person that was yelling). The investigation dated 9/21/18 identified Resident #597 had been readmitted to the facility approximately an hour prior to this event on 9/21/18 from a psychiatric admission related to an altercation with another resident earlier in the month. Resident #597 was placed on a 1:1 observation and sent to the hospital for a psychiatric evaluation after the incident with Resident #28. Interview with NA #3 on 10/26/18 at 11:08 AM identified he/she heard a noise and witnessed Resident #597 punching Resident #28 in the face and yelling shut up shut up. Interview with the DNS on 10/26/18 at 1:43 PM identified on 9/6/18 Resident #597 wanted to hurt another resident because his/her alarm was ringing, in a common area. Resident #597 had never struck a resident prior to that incident and something different had been going on with the resident's behaviors. Lashing out was not a normal behavior for Resident #597. Review of the facility policy on abuse identified abuse will not be condoned by anyone, including staff members, other resident's, family members, legal guardians, sponsors, friends or other individuals. To assist the facility staff in recognizing incidents of abuse, the following definitions of abuse are provided: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm of pain or mental anguish or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Physical abuse is defined as hitting, slapping, pinching, kicking etc. it also includes controlling behavior through corporal punishment. Although Resident #597 was placed on every 15 minute observation by staff when he/she was re-admitted to the facility on [DATE] from a psychiatric hospitalization , the facility failed to protect Resident #28 from physical abuse, when due to Resident #28's behavior of yelling, Resident #597 went into the resident's room and repeatedly struck Resident #28 in the face with his/her fists which caused bruising and swelling of the left cheek. According to Appendix PP, F600 §483.12 Freedom from Abuse, Neglect, and Exploitation, the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who was at risk for elopement and resided on a secured unit, the facility failed to monitor and/or provide the appropriate supervision to prevent an elopement which resulted in immediate jeopardy. The findings include: Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The Admission Elopement assessment dated [DATE] Resident #1 was admitted on to a secured unit because for behavior management, dementia care, being identified as an a elopement risk and agitated behaviors. The assessment identified Resident #1 ambulated independently ad lib, had unsuccessful elopement attempts in the past, resisted being redirected, and verbalized statements of wanting to leave. A physician's order dated 2/10/16 directed to check the placement of the wanderguard bracelet on the left ankle every shift. The Resident Care Plan dated 2/12/16 identified the resident was at risk for wandering and/or elopement and was frequently noted to be exit seeking. Interventions directed to encourage involvement in recreational activities, ensure a name bracelet was on, placement on the secured dementia unit, to utilize the check in and check out log, and a wanderguard bracelet per the physician's order. Review of nurse's notes from 2/4/16 (time of admission) through 2/12/16 at 8:53 PM identified numerous notes of Resident #1 barricading himself/herself in the doorway to the emergency exits with his/her bags packed, stating he/she was being held against their will, pacing the hallways carrying personal belongings, asking when the bus was coming, attempting to pick the locks of exit doors, looking for car keys to leave, wandering around the unit, asking about going home, and telling staff to open the door and let him/her out. The 11-7AM Registered Nurse (RN) Supervisor's note dated 2/13/16 timed at 6:29 AM identified Resident #1 was ambulating in hallway with a jacket and blanket in his/her hands. At 6:00 AM Resident #1 was noted not to be in his/her bed. The secured unit was searched twice and then the remainder of the facility. A code Dr. Hunt was initiated and the police and Administrator were notified. The Reportable Event Form dated 2/13/16 at 6:00 AM identified when two Nurse Aides (NA), NA #1 and NA #2, were conducting 6:00 AM rounds they noticed Resident #1 was not in his/her bed and the last time the resident was seen was approximately at 11:30 PM when vital signs were taken and the wander guard was checked. The documentation identified the resident broke a window and exited from the facility through the gated courtyard. Upon further review, the documentation identified that the 11-7AM Registered Nurse (RN) Supervisor, RN #1, NA #1 and NA #2 stated that the last time they saw Resident #1 was around midnight and the resident was awake in the hallway saying he/she was ready to go home. The facility's investigation noted that Resident #1 was located at the local hospital by the police and the hospital identified Resident #1 had arrived at the hospital at approximately 2:30 AM. The investigation identified that staff failed to ensure the resident was present in the facility from 11:30 PM or 12:00 AM to 6:00 AM. Review of the facility's thirty (30) minute rounds documentation identified spot checks were signed off as being completed every thirty (30) minutes on all residents by both the licensed staff and nurse aides. Review of the hospital emergency room Report dated 2/13/16 identified Resident #1 came to the hospital initially with a report of frost bite to the hands, face and feet and the resident reported he/she thinks he/she had been hiking. The report noted that the resident was being admitted for altered mental status. Interview with NA #1 on 2/16/16 at 6:50 AM identified that when she came to work on 2/13/16 Resident #1 was in the hallway standing at the doors with his/her jacket wanting to leave. NA #1 stated that RN #1, the 11-7AM Nursing Supervisor brought the resident to his/her room and that was the last time she had seen Resident #1 that night. NA #1 identified during last rounds at approximately 6:00 AM, she and NA #2 were providing care to Resident #1's roommate and that was when they noticed Resident #1 was not in bed. NA #1 stated that they reported to RN #1 and began searching the unit. Interview with NA #2 on 2/16/16 at 7:00 AM identified that when she came to work on 2/13/16 Resident #1 was standing in hallway near the door with his/her jacket wanting to leave. NA #2 stated that RN #1 directed him/her back to his/her room and that was the last time she saw the resident that night. NA #2 identified that although she signed she had completed the every thirty (30) minute spot checks on all the residents, she did not actually look behind Resident #1's privacy curtain to see if the resident was in the room, she had just assumed Resident #1 was in bed. NA #2 stated that while doing last rounds with NA #1 at approximately 6:00 AM she noticed Resident #1 was not in bed and reported this to RN #1. NA #2 stated that she began searching the secured unit for Resident #1 but was unable to locate the resident. Interview with RN #1, the 11-7 shift RN Supervisor, on 2/16/16 at 10:40 AM identified when she started her shift Resident #1 was in the hallway holding onto his/her coat and blanket. RN #1 stated she brought the resident to his/her room, vital signs and checked the wanderguard for placement. RN #1 stated that around 6:00 AM, NA #1 and NA #2 reported they could not locate Resident #1 and immediately began searching the unit. RN #1 identified that after they searched the unit and could not find the resident they notified the rest of the facility and began searching the other units and outside. RN #1 stated that she did not page a Dr. Hunt in accordance with the facility policy and procedure because the unit was secured and the door alarms had not sounded. RN #1 indicated when conducting the thirty (30) minute spot checks the staff usually just stand at the door and look in to the room and do not visualize every resident every time. RN #1 stated that when a 7-3PM nurse aide told her another resident (Resident #2) was outside in the fenced in courtyard was when she discovered how Resident #1 was able to leave the facility. Interview with RN #2, the 7-3PM RN Supervisor, on 2/13/16 at 1:45 PM identified when he came on duty he saw the 11-7AM RN Supervisor and was told Resident # 1 was missing. RN #2 stated that he went to the secured unit looked into Resident #1's room and identified the resident's personal effects were gone. RN #2 stated that he gathered the staff and followed the facility's missing person policy and announced a Dr. Hunt. RN #1 identified he notified the police, the Director of Nursing (DON) and the Administrator of the situation. RN #2 stated that while the police were in the facility at approximately 7:30-8:00 AM the police were notified Resident #1 was found at the hospital. Interview with the DON on 2/13/16 at 1:55 PM identified she was notified of Resident #1's elopement 6:47 AM and came to the facility. The DON stated that the police were already at the facility and the building was searched. The DON stated while the police were at the facility the hospital reported to the police that Resident #1 was in the hospital emergency room . The DON indicated NA #1, NA #2 and RN #1 reported to her the last time they saw Resident #1 was around midnight. The DON stated the thirty (30) minute rounds are to be completed on every resident by visually seeing each resident to ensure the resident was ok. The DON identified they did not know how Resident #1 had exited the secured unit at first because the doors are alarmed and it was not until another resident (Resident #2) was noted to be standing outside in the fenced in courtyard and a window was noted to be open and the secure latch had been broken off. The DON stated the facility had started re-educating all staff after the incident to spot checking residents every two (2) hours and if a resident was unable to be located the charge nurse was to be notified and the facility's policy regarding a missing resident, Dr. Hunt, initiated. Interview with the Administrator on 2/13/16 at 1:55 PM identified they were not sure how Resident #1 had eloped until RN #1 told him another resident, Resident #2, was found outside in the courtyard and they discovered in Resident #2's room a window was off the track with the secure latch broken, footprints were noted in the snow, a chair was up against the fence and a piece at the top of the fence was broken off. Interview with NA #3 on 2/16/16 at 2:45 PM identified that he went into Resident #2's room and noted the room was cold, the outside temperature that night was noted to be below twenty (20) degrees. NA #3 stated that he realized the window was open and saw Resident #2 standing outside in the snowy courtyard. Review of the facility policy and procedure for Thirty (30) Minute Rounds directs staff to complete walking rounds throughout the unit every thirty (30) minutes and to spot check residents. Review of facility policy and procedure for Elopement Management identified when a resident is discovered missing a quick and thorough search of the unit is to be conducted and the Supervisor will page overhead a Dr. Hunt three (3) times and state which wing the resident is missing from. The policy states the Administration, police, and responsible party will be notified if the resident cannot be located. The Department of Public Health requested an action plan on 2/13/16 that included Supervisors were to be immediately inserviced concerning the expected protocols, and to be followed by all direct care staff. Prior to taking an assignment, all direct care staff were to be inserviced to include which residents were at risk for elopement, checking the wanderguard and identification bracelets, nursing rounds were to be completed every two (2) hours to account for all residents, if a discrepancy was identified the nursing supervisor was to be notified immediately and the Dr. Hunt protocol initiated in a timely fashion, and environmental awareness by unit staff should begin immediately i.e. a check of all egress the doors and windows are secured. The action plan identified the RN Supervisor was to be accountable the rounds were completed every two (2) hour and audits were to be conducted to ensure compliance.

Based on clinical record review, review of facility documentation, observations, and interviews for 2 of 6 sampled residents reviewed for pressure ulcers (R#5 and R#64) , the facility failed to implement measures to prevent the development of heel ulcers and/or implement new measures to treat heel ulcers once developed and promote healing. The findings include: 1. Resident # 5's [DIAGNOSES REDACTED]. Review of the Weekly Pressure Area Flow Record for the week of 12/15/14 identified a facility acquired (FA) (12/07/14) stage 2 to the left heel measuring 1.2 cm x 1.0 cm with preventative equipments identified as non powered pressure relief, positioning pillows/wedges and pressure relief cushion. Review of the Weekly Pressure Area Flow Record dated 12/22/14 identified the stage 2 left heel ulcer had deteriorated to stage 3 with measurements noted as 1.2 cm x 1.0 cm with preventative equipments identified as non powered pressure relief, positioning pillows/wedges and pressure relief cushion. The RCP dated 12/16/14 identified the resident with a pressure ulcer to left heel with interventions that included to administer vitamins and minerals per MD orders, apply dressing per MD order and assess pressure ulcer for stage, size, length, width and depth, presence of granulation tissue and epithelization. However, interventions failed to include heel offloading prior to the identification of a stage 2 ulcer on 12/07/14 or after evaluation and recommendations made by the Wound Care Specialist on 12/15/14 and 12/22/14 to offload heels. Review of the Wound Care Specialist Evalaution dated 12/15/14 identified that on 12/07/14 the resident was noted with a facility acquired stage 2 pressure ulcer on his/her left heel. Recommendations included to off load wound and reposition per facility policy. Further review of the wound care report dated 12/22/14 identified that the pressure ulcer on the left heel had progressed to a stage 3, with recommendations that included off load wound and reposition as per facility policy. Review of a Braden Scale dated 12/22/14 identified the resident a very high risk for skin breakdown. Review of the 12/14, 01/2015 and 02/2015 MAR's and Treatment Kardexes failed to reflect that the resident's heels were offloaded. Interview with the Infection Control Nurse/Wound Nurse ( ICN/WN) on 2/25/15 at 1:00 PM and review of the clinical record failed to reflect any documentation that the heels were off-loaded prior to and/or after the stage 2 was identified, or when the area deteriorated to a stage 3. The ICN/WN indicated that when the Wound Care Specialist makes recommendations the APRN reviews and signs the recommendations and writes orders. The ICN/WN further identified that the heels should have been off-loaded and could not identify why this was not done. 2. Resident #64's admission to the facility was on 10/15/14 with [DIAGNOSES REDACTED]. The Admission Clinical Documentation dated 10/15/14 and nursing narrative note indicated zero skin integrity issues on admission. A admission MDS assessment dated [DATE] identified R#64 as moderately cognitively impaired with signs/symptoms of [MEDICAL CONDITION] in behaviors of inattention and disorganized thinking, requiring extensive assistance with ADL's and no pressure ulcers. physician's orders [REDACTED]. Physician order [REDACTED]. The RCP dated 10/29/14 identified a potential for skin breakdown secondary to fragile skin related to immobilizer to right leg and decreased mobility. The care plan was updated on 11/18 and 12/30/14 to identify a new pressure ulcer of left heel and lateral aspect of the left foot. Interventions included to conduct a systematic skin inspection weekly, apply dressings per MD orders, foam boots to off load heels while in bed, assess pressure ulcer weekly and as needed (prn) by wound nurse, with preventative equipments identified as non powered pressure relief, positioning pillows/wedges and pressure relief cushion. Weekly systematic skin assessments completed on 10/22, 11/05, 11/19 and 11/26/14 identified the skin as intact and did not reflect the change in skin condition related to left foot pressure ulcers until 12/11/14. Wound Care Specialist Evaluation dated 11/24/14 identified an unstageable left heel wound measuring 4.8 cm x 2.6 cm and an unstageable left lateral foot measuring 2.3 cm x 2.0 cm with depth not measurable due to thick adherent black necrotic tissue (eschar) 100%. Weekly wound measurements indicated wound deterioration due to evolution of injury with measurements stable on 12/08/14. On 12/15/14 measurements of left heel 3.0 cm x 2.6 x not measurable cm, left lateral foot 2.3 cm x 2.0 cm x not measurable cm. 12/23/14 wounds remained stable. On 12/29/14 the left heel measured 2.2 cm x 1.4 cm x not measurable cm and the lateral foot was 1.9 x 1.6 x not measurable cm. On 1/05/15 the measurements remained stable. On 1/12/15 the wounds were surgically debrided measuring heel at 2.2 cm x 1.4 cm x 0.1 cm and the lateral foot wound at 1.7 cm x 1.5 cm x 0.3 cm. Wound deterioration was noted on 2/23/15 with left heel measuring 3.3 cm x 2.5 cm x 0.1 cm. The Wound Care specialist assessment dated [DATE] indicated wound deteriorated due to infection. Observation in the presence of LPN #1 on 2/25/15 at 2:15 PM identified the resident up out of bed in wheel chair without the benefit of wheel chair foot rest. Interview with the ICN/WN on 2/25/15 at 2:45 PM and observation identified the foam boots were not currently being utilized due to R#64's frequent refusals for foam boot use. At no time during resident observation on 2/25/15 with LPN #1 and/or with the ICN/WCN did the nurses offer or encourage the resident to offload his/her heels. Observation on 2/26/15 at 6:25 AM in the presence of the ADN'S identified R#64 lying in bed without the benefit of any heel offloading device. The ADN'S collected a new pillow from the linen cart and offered the pillow to the resident to offload his/her heels and the resident accepted. Interview with NA #2 on 2/26/15 at 6:45 AM indicated on 2/26/15 the resident was assisted for toilet service at 1:00 and 4:00 AM. Following resident 's return to bed the NA indicated a pillow was offered to the resident but the resident refused. In addition the NA#2 indicated h/she was unaware the resident had any specialized devices such as foam boots available for offloading. Clinical record review from 10/15/14 to 2/25/15 with RN #1 on 2/26/15 at 10:45 AM identified an assessment dated [DATE] indicating R#64's bilateral heels were noted to be pink in color and palpated as boggy. The nursing notes and treatment administration history indicated the resident was cooperative with care/treatment with the exception of 11/16/14, 1/30/15, 2/24 and 2/25/15. On 11/16 /14 at 1:48 AM the resident refused the foot cradle to bed. On 1/30/15 at 5:15 AM the resident refused vitals and heel treatment. On 2/24/15 at 9:28 PM the resident refused treatment to the lower extremity. Only one documented resident refusal from the treatment administration history was identified on 2/25/15 at 9:23 PM related to refusal for foam boots/heel offloading. Interview with the DNS on 2/26/15 at 11:00 AM and clinical record review failed to reflect any documentation of resident's refusal to wear foam boots or offload the heels prior to or following pressure ulcer development. The DNS indicated the typical course of action when a resident refuses care would be to document the refusal, report the refusal to the MD/responsible party as indicated, additional approaches would be attempted and the RCP would be updated. Furthermore the DNS could not identify additional interventions attempted and/or why the care plan did not reflect a history of resident refusals.

Based on clinical record review, facility documentation and interviews, for 2 of 6 sampled residents reviewed for accidents, (R#5, R#190) the facility failed to ensure resident equipment was stored properly and/or that the resident received care in accordance to the plan of care to prevent injury. The findings include: 1. Resident # 5's [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified the resident at risk for falls, had poor judgment and safety awareness and decreased muscular coordination. A resident care plan dated 12/23/14 identified that the resident at risk for falls related to cognitive limitations with interventions that included to ensure an uncluttered and safe environment. A reportable event (RE) form dated 2/18/15 identified the resident had a witnessed fall in the hallway and was bleeding from an open area on the left wrist. A nurse's note dated 2/18/15 at 11:35 AM identified that the resident was observed lying on the floor in the hallway in front of the bedroom with bleeding noted from the left wrist area. Upon further evaluation an open fracture was noted to h/her left arm and the resident was transferred to the hospital. Interview with LPN #1 on 2/26/15 at 2:00 PM identified that he/she was the nurse on duty when the fall took place. LPN #1 indicated that the resident asked for a drink and as they were talking the resident went into h/her room and tripped over the Hoyer. In a written statement obtained from NA#5 on 2/18/15 at 11:30 AM identified that NA#3 and NA#5 put the Hoyer next to the resident's bedroom while they went to check on another resident. Interview with NA #5 on 2/26/15 at 2:15 PM identified that he/she had been caring for R#5 the day of the fall. NA#5 indicated he/she had just finished transferring another resident via a Hoyer when R#5 asked for a drink. NA#5 indicated he/she then moved the Hoyer to the hallway near the wall because they were going to use it and when he/she returned R#5 had fallen over the Hoyer. Interview with NA#3 on 2/28/15 at 1:00 PM identified that he/she was helping NA#5 on the day of the fall, he/she stated that they had finished Hoyering a resident and moved the Hoyer to the end of the hall by the MDS office while NA#5 got R#5 a drink. Interview with the DNS on 2/28/15 at 1:30 PM identified that typically the facility would not store the Hoyer in the hallway but there were 14 Hoyer lifts on that unit. The DNS indicated that resident equipment should be put away after use. Review of the hospital discharge summary dated 2/21/15 identified the resident with a left distal radius and ulnar fracture with vascular laceration, R#5 was emergently taken to the operating room where an open reduction and internal fixation and a repair of the lacerated ulnar artery was performed. During recovery it was noted that R#5 was complaining of right wrist pain, an x-ray was performed and demonstrated a right wrist fracture and operative repair was advised and performed on 2/20/15. Subsequent to R#5's fall a new policy was developed and staff in-service education was provided proper storage of mechanical lift equipment. Review of facility policy identifies that the Hoyer should be stored when not in use. 2. Resident #190's [DIAGNOSES REDACTED]. Review of the resident's initial Minimum Data Set (MDS) assessment dated [DATE] identified the resident had severely impaired cognition, required extensive assistance of two staff with bed mobility and transfers, and extensive assistance of one staff person for personal hygiene, dressing and toileting. Review of a physician's orders [REDACTED]. Review of the resident's care plan dated 3/25/14 identified that the resident had cognitive loss with behavioral symptom with the potential for bruising, skin tears and abrasions secondary to impaired mobility, impaired cognition and poor safety awareness. The care plan directed staff to provide the assistance of two staff while the resident was in bed, turn and reposition the resident every two hours and toilet or provide incontinent care every two hours. Review of the resident's clinical record dated 5/21/14 identified that the resident's care plan was reviewed and the plan of care would be continued. A nurse's note dated 8/21/14 at 2:50 PM identified that the resident became combative during care and hit his/her head on the side rail and as a result, sustained a 1.5 centimeter laceration to the back of his/her head. The resident was transferred to the Emergency Department and required five (5) staples to close the laceration. Review of the resident's profile (care card/nurse's aide assignment sheet) identified that as of 3/25/14, two staff were required when providing care or repositioning the resident in bed. Interview with the Director of Nurses (DNS) on 2/25/15 at 11:15 AM and review of facility documentation dated 8/21/14 identified that on 8/21/14, NA#1 provided care to R#190 while the resident was in bed. The DNS identified that, although the resident's care plan and profile directed to utilize two staff when providing care to the resident when in bed, NA#1 provided care to the resident while he/she was in bed without the assistance of another staff person. The DNS identified that the resident became agitated during care and hit his/her head on the side rail of his/her bed. The DNS stated that NA#1 was terminated from the facility for not following the resident's plan of care. During an interview on 2/26/15 at 4:30 PM, NA#1 identified that on 8/21/14 at approximately 2:50 PM he provided incontinent care R#190 while the resident was in bed. NA#1 stated that when he was taking the resident's shirt off, the resident tilted backward and hit his/her head on the bedrail. NA#1 indicated that he checked the resident's head, felt a bump, observed some pink drainage and went to get the nurse. NA#1 stated that he was not aware that the resident required two staff to provide care to the resident in bed. NA#1 stated that he checked the resident's profile but he did not see that directive. Review of the facility's care plan policy with the Care Plan Coordinator on 2/25/15 identified in part, that the resident's care plan identifies the care and services that the resident needs and identifies the discipline responsible for providing the care required. The care plan coordinator identified that the Resident Profile is updated to include interventions from the resident's care plan and nurse aides are required to refer to each resident's profile when providing care to the resident.

Based on clinical record reviews, observations, review of facility documentation for four of six sampled residents reviewed for accidents (R#78, R#96, R#118, #40 ) the facility failed to provide follow through for PT evaluation/recommendations, failed to transfer the resident safely utilizing a mechanical lift, failed to contact the registered nurse prior to moving after the fall and/or failed to implement new and appropriate interventions to prevent further falls with injury and/or failed to provide adequate supervision to prevent a fall. The findings include: 1. Resident#78's [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] identified R#78 as cognitively impaired and totally dependent ADL's with one person physical assistance for locomotion on and off the unit. A Fall risk assessment dated [DATE] identified a fall risk score of 14, identifying the resident as a high risk for falls. Physician order [REDACTED]. A resident summary dated 7/13/12 indicated that R#78 was unable to propel the wheelchair and utilized pressure alarms in bed and wheelchair for safety. Review of facility A&I report dated 7/18/12 indicated that the resident leaned forward falling out of wheelchair while being wheeled to the feeding room by a nurses aide. Facility documentation also identified NA#1 as the only witness to incident. Nurse's note dated 7/19/12 indicated the resident return from the hospital with multiple lacerations and with a laceration to forehead closed with 10 sutures. Review of RN#4 statement dated 7/18/12 indicated she was called to assess the resident after a fall from wheelchair and resident was found lying on his/her left side on floor outside the feeding room. Interview with RN#4 on 3/28/13 at 10:15 AM indicated that she was in the nursing office at the time of the accident and she observed resident leaning forward and indicated that the incident happened very fast. RN#4 indicated that she noticed R#78 leaning forward and the nurse aide stop the wheelchair, however the resident was on the floor before the nurse aide could get to him/her. RN#4 also indicated she believed that R#78 was in a regular standard wheelchair with footrests. Review of NA#1 written statement dated 7/18/12 indicated that resident leaned forward and when she stopped the wheelchair the resident fell out of wheelchair and onto the floor. Interview with NA#1 on 3/28/13 at 10:30 AM, she indicated that R#78 was not utilizing the footrests at time of transfer, the resident placed his/her feet on the floor, the wheelchair stopped suddenly, and the resident fell from the wheelchair onto the floor. Interview with LPN#5 on 3/28/13 at 10:30 AM, indicated that the resident was not utilizing the footrest at the time of the incident and footrest were never utilized for R#78 while in wheelchair. LPN#5 further indicated that the supervisor was in the nursing office at the time of the incident and assisted with the resident after the fall. Interview with DNS on 3/28/13 at 1:30 PM identified that although R#78 had a physical therapy screen completed on 5/30/12 indicating use of straps or leg rests to improve positioning of legs, they were never utilized. The DNS indicated that straps and/or leg rest were only therapy reccommendations and not a physician order [REDACTED]. DNS further indicated that resident did not utilize footrest at time of fall and he/she just fell out of the wheelchair. The DNS was unable to indicate why therapy recommendations were not followed through by nursing staff and that the therapist who made the recommendations was not available for an interview. Interview with LPN#6 on 3/28/13 indicated that whenever a therapy screen is done recommedations are given to nursing staff and it is the responsibility of the nursing staff to then obtain a physician order. Review of the clinical record failed to reflect follow-up for PT recommendations for the use of foot rests. 2. Resident #96's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident as severely cognitively impairmed and required two person physical assistance for transfers and one person physical assistance for toilet use. The assessment also indicated that R#96 was not steady and only able to stablize balance with assistance of staff. A RCP dated 6/26/12 identified R#96 at risk for falls related to poor safety awareness. Interventions included pressure alarm at all times, provide call bell within reach while in room at all times, and staff will cue residents to safety awareness as needed. An Admission Fall assessment dated [DATE] indicated a score of 16, indicating a high risk for fall. A physician order [REDACTED]. A review of the facility A&I dated 6/30/12 indicated NA#2 left the resident on the toilet and was standing outside the bathroom door, she heard a loud thud and upon entering the bathroom R#96 was found on the floor. Review of a hospital summary dated 7/05/12 indicated the resident was hospitalized from [DATE] through 7/05/12 with a left hip fracture. Nurse's note dated 6/18/12 through 6/30/12 identified the resident as alert with confusion and a nurse's note dated 6/20/12 indicated the resident attempting to get out of bed. Interview with NA#2 on 3/27/13 at 2:25 PM identified that after assisting R#96 to the bathroom, she left the resident on toilet and closed the door about three-fourths of the way and stood outside the door. NA#2 indicated that the resident was unable to see her standing outside the door and she heard a loud thud and upon entering the bathroom resident was found on the floor. Interview with Person#1 on 3/28/13 at 12:30 PM she indicated the resident was confused and forgetful at times and indicated that the resident should not have been left alone in the bathroom without assistance on 6/30/12, the day of the incident. Review of A&I dated 11/16/12 indicated that R#96 was found sitting on the foot pedal of the wheelchair. Interventions included for the resident to be placed in a supervised area when out of bed. Review of A&I dated 12/08/12 identified that the resident was found lying on floor near the foot board secondary to resident having removed the seat belt. Interventions again included to encourage supervised area. A&I dated 3/27/13 indicated R#96 was found lying face down on bathroom floor, head against the bathroom door, a small bruise under left eye, and two skin tears to the right ankle and left shin were noted. Interview with the DNS on 3/28/13 at 1:20 PM identified that the RCP was updated to include to keep the resident in a supervised area when out of bed, therefore the resident should not be left in bathroom or in any room without supervision. Review of facility documentation and staff interviews indicated that although the resident had several falls with interventions to keep resident in supervised area, the facility failed to follow through with recommendation. 3. Resident #118's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified R#118 as severely cognitively impaired, exhibited behavioral symptoms not directed towards others, rejecting care, wandering, inattention and disorganized thinking, and had three falls within the last 90- days. In addition R#118 required maximum to total assistance with ADL's and the assistance of 1 for transfers and ambulation. A RCP dated 3/07/12 identified the resident a risk for falls related to poor safety awareness, fall history and fall risk score. Interventions included to provide the assistance of 2 with transfers, OOB to customized wheelchair in a supervised area at all times, ambulate with rehab only, beveled mattress to wheelchair, continue pressure alarm at all times, continue self-releasing seatbelt, check placement and function per protocol, resident also has clip belt to wheelchair, continue to monitor medication changes, provide low bed, and to monitor for signs and symptoms of discomfort. Intermittent observations on 3/27/13 from 9:30 AM to 11:30 AM identified the resident reclined in a geri-chair in the hallway, with a cervical collar in place. The resident was subsequently moved from the hallway into resident's room. Reportable Event (RE) dated 3/05/13 identified the resident fell from the bed resulting in a 1 ? " laceration to the occiput portion of head requiring 5 sutures. A RE dated 3/12/13 identified the resident fell from the bed resulting in an abrasion to the forehead and a laceration to the nose. A RE dated 3/16/13 at 5:00 PM identified the resident fell from the wheelchair with no injuries, and no new interventions at this time was noted on the RE. A RE dated 3/17/13 identified a fall from bed with a laceration to the back of the head and a 8.0 cm by10.0 cm lump to left forehead, the resident was transferred to the hospital and diagnosed with [REDACTED]. Subsequent to the 3/16/13 fall the resident fell OOB fracturing his/her cervical spine. Interview with RN#2 on 3/27/13 at 1:00 PM identified that although the facility usually implements new measures after every fall the RCP did not reflect any new interventions after the 3/16/13 fall. Interview with RN#5 on 3/28/13 at 9:15 AM identified a physician order [REDACTED]. Review of the clinical record identified a physician progress notes [REDACTED]. Review of the clinical record failed to reflect that the labs ordered by the physician on 3/16/13 were related to the fall. A physician's orders [REDACTED]. physician's orders [REDACTED]. 4. a. Resident #40's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified severely impaired cognition, short and long term memory deficits and requiring two person assist for transfers. The resident care plan dated 6/29/12 identified R#40 at risk for falls with approaches to utilize Hoyer lift for transfers. Review of the nurse's notes dated 8/16/12 at 2:00 PM identified R#40 had slipped through the Hoyer pad during transfer and fell to the floor, hitting his/her head on the leg of the Hoyer lift. R#40 sustained an abrasion to the back of the head. Nurse's notes dated 8/16/12 at 4:30 PM identified that R#40 had continued bleeding to the back of the head, was observed to have episodes of shaking and twitching and was transferred to an acute care hospital. The resident was treated for [REDACTED]. Interview with NA#10 on 3/27/13 at 10:15 AM identified that he/she was requested by the Occupational Therapist (OT) to transfer R#40 back to bed so the wheelchair could be serviced. The OT offered to assist with the transfer, and in the process, of transfer, the resident fell through the sling on to the floor. NA #10 identified that sling was not centered under the resident prior to the lift. Interview with the OT on 3/27/13 at 10:00 AM identified that he/she offered to assist but had not been oriented to Hoyer lift transfers. He/she had observed that the resident was not positioned correctly but the transfer occurred so quickly there was no time to prevent the fall. Interview with the Director of Rehabilitation on 3/27/13 at 12:45 PM identified that the therapists are not typically oriented to Hoyer lift transfers and OT #1 should not have assisted in the transfer as a second person unless oriented. Review of facility policy directed that two to three staff members (per order) are to be present at all times and to make sure the sling is centered under the resident prior to the lift. 4. b. Review of facility accident and investigative report dated 8/16/12 identified that after the fall OT#1 and NA#10 transfered the resident into bed from the floor prior to alerting the registered nurse. Interview with NA#10 (hired on 6/27/12) on 3/27/13 at 10:15 AM identified that he/she thought that the OT was a nurse and when the OT attempted to lift the resident after the fall and place into bed, NA#10 assisted. Interview with the OT on 3/27/13 at identified that he/she was not aware that nursing should be contacted prior to moving a resident after a fall. Interview with the Director of Rehabilitation on 3/27/13 at 12:45 PM identified that the therapists are not typically oriented to Hoyer lift transfers and OT #1 should not have assisted in the transfer as a second person unless oriented. Review of facility policy directed that after a fall, keep the resident in the position and call the registered nurse.

Based on clinical record review, review of facility documentation/investigations, observations and interviews for one of two residents with an injury of unknown origin (Resident #1), the facility failed to handle and assess the resident appropriately to prevent an injury, and/or for one of three sampled residents who were reviewed for range of motion (Resident #80), the facility failed to ensure the resident was free from accident hazards. The findings include; 1. Resident #1's [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was in a persistent vegetative state, required two person physical assistance for all ADL's including bed mobility and transfers and was non-ambulatory. Physician orders [REDACTED]. The Resident Care Plan dated 7/21/11 identified a risk for injury related to osteoporosis. Interventions included that the staff were to handle the resident gently and assess for pain, redness and swelling. Nurse's notes dated 8/19/11 identified that at 9:40 AM, the resident's left lower extremity was swollen with a one inch discrepancy in the length. When palpated, the resident would grimace in pain. Additionally a bruise was noted over the right eye that measured 4.0 by 1.5 cm. The Physician was notified, and an x-ray of the left hip and pelvis were ordered as well as pain medication. An x-ray Report dated 8/19/11 identified mild osteoarthritis of the left hip, an unremarkable pelvis, and no fracture. Further review of the nurse's notes failed to provide documentation of ongoing assessments of the resident's injury including range of motion assessments of the left extremity and/or neurological assessments to rule out a head injury. Although a nurse's note dated 8/22/11 at 1:45 PM identified left knee swelling and pain as evidenced by grimacing and moaning when palpated, ROM of the extremity was not conducted and/or the physician was not notified that the swelling had extended to the knee. The next nurse's note regarding the residents injury was not until 8/31/11 at 10:30 AM when they noted an increase in the swelling of the left upper and lower leg, including the knee. The physician was notified and directed an x-ray of the left knee and an ultrasound of the left lower extremity. Additionally, the physician ordered bedrest, an immobilizer to the left knee, continue to medicate for pain, and an orthopedic consult. The X-ray report dated 8/31/11 identified a comminuted fracture of the left distal femur. The resident was transferred to theER on [DATE] for evaluation. The Hospital Discharge Summary dated 9/4/11 identified a [DIAGNOSES REDACTED]. Additionally, although an investigation was conducted to determine the cause of the injury, the investigation failed to provide documentation and/or staff interviews regarding the last Hoyer transfer prior to identifying the injury on 8/19/12. Interview, review of the clinical record,and review of facility documentation on 2/16/12 at 2:00 PM and on 2/21/12 at 1:00 PM with the DNS failed to provide documentation that complete and ongoing assessments were conducted after the injury was identified. She noted that a "head to toe" assessment should be conducted at the time an injury is identified, including ROM and Neurological checks when there is a head injury. Interview on 2/21/12 at 11:30 AM with RN #2, who conducted the initial assessment of the injury, identified that ROM of the left leg had not been done at the time because she/he did not want to move the leg and cause more pain. Interview on 2/21/12 at 1:30 PM and review of the X-ray report dated 8/31/11 with Radiologist #1 identified "something had to have happened to cause the fracture", it was not spontaneous and/or pathological. 2. Resident #'80's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified short and long term memory problems, severely impaired cognition, required total assist with all care and had a limitation of range of motion to the upper and lower extremities. The care plan dated 12/27/11 identified the resident had contractures of the right hand related to decreased mobility and advanced dementia. Physician orders [REDACTED]. Intermittent observations on 2/13/12 and 2/14/12 identified the resident was without the benefit of the handroll in the right hand. Observation on 2/16/12 at 11:15 AM with LPN#1 identified the residents middle and ring finger nails were long and the fingers were noted to be tightly clenched into the hand. Observation on 2/16/12 at 11:20 AM with RN#1 identified that the residents nails of the middle and ring finger on the right hand had just been cut and the resident was bleeding from both fingers. Interview with LPN#1 on 2/16/12 at 12:30 PM identified that she did trim the residents fingernails and at that time she was unaware that she had cut the residents fingers. Review of a facility report dated 2/16/12 documented an "accidental skin tear" on right 4th finger while doing nail care.