Every finding on record at Pheasant Wood Center

Based on interview and record review, the facility failed to follow hypoglycemia protocols resulting in a resident becoming unresponsive and requiring intervention and hospitalization in 1 of 3 residents reviewed for hospitalizations in a final sample of 18 residents. (Resident identifier is #4). Findings include:Review on 7/15/26 of Resident #4's provider note dated 2/5/26 revealed that the evening prior, Resident #4 was hospitalized when he/she was found unresponsive with a blood glucose (BG) in low 50's [milligrams per deciliter (mg/dl)].Review on 7/15/26 of Resident #4's February 2026 Medication Administration Record (MAR) for 2/4/26 revealed the following physician orders: Insulin Lispro 100 unit/ml inject per sliding scale: if 1-150 [mg/dl]= [is equal to]0. Further review revealed blood glucose check at 8:00 a.m. was 67 and the Lispro insulin was held.Review on 7/15/26 of Resident #4's February 2026 MAR revealed Hypoglycemia Protocol Observe Sign/Symptoms of hypoglycemia as needed if blood glucose is less than 70mg/dl or ordered low parameter follow Hypoglycemia protocol., Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70, Pt arousable conscious and able to swallow Hold all diabetic medications until provider authorizes resumption. Remain with pt. [patient] Keep pt. in bed/chair for safety. Repeat blood glucose in 15 mins. The hypoglycemia protocol was not documented as completed on 2/4/26. Review on 7/15/26 of Resident #4's February 2026 MAR revealed his/her Insulin Glarigine 30 unit scheduled for 9:00 a.m. was administered at 10:46 a.m.Review on 7/15/26 of Resident #4's change in condition nurses note dated 2/4/26 revealed at routine blood glucose check resident found unarousable, pale and cool and clammy skin. BG=[equal to]53; unable to swallow so administered Glucagon as ordered for hypoglycemia ,70; after 10 minutes BG recheck at 54. Notified provider who ordered resident be sent out via EMS [Emergency Medical Services] to ED [Emergency Department]. Called 911 at 1645 [4:45 p.m.]. Then received new order to administer 2nd Glucagon shot; BG recheck 67 prior to arrival of EMS at 1655 [4:55 p.m.].Left via EMS at 1715 [5:15 p.m.]. Further review revealed no prior note for 2/4/26 regarding low blood glucose or actions taken, to include notifying provider or holding all insulins.Review on 7/16/26 of Resident #4's hospital Discharge summary dated [DATE] revealed Admitting diagnosis: 1. Diabetes mellitus type 2 with acute hypoglycemia.Hospital Course:.presented to the emergency department with hypoglycemia in the 50s and more confusion than his reported baseline.[pronoun omitted] was treated with IV dextrose.Blood sugars [blood glucose] at the lowest were 49.Interview on 7/16/26 at approximately 11:00 a.m. with Staff B (Director of Nursing) confirmed above findings.Interview on 7/16/2026 at approximately 9:30 a.m. with Staff H (Nurse Practitioner) confirmed above findings.

Based on interview and record review, the facility failed to document that the resident and/or the resident's representative was fully informed of the risk and benefits of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident identifiers are #1, # 2, #5, and #12).Findings include: Resident #1 Review on 7/16/26 of Resident #1's current physician's orders revealed the following orders: Duloxetine HCL (hydrochloride) Oral Capsule Delayed Release Sprinkle 30 mg (milligram). Give 1 capsule by mouth 2 times a day for depression, start date 6/12/26 (antidepressant). Quetiapine Fumarate Oral Tablet 100 mg. Give 1 tablet by mouth one time a day for OCD (obsessive compulsive disorder), delusional disorder, start date 2/17/26 (antipsychotic). Quetiapine Fumarate Oral Tablet 150 mg. Give 1 tablet by mouth two times a day for OCD, delusional disorder, start date 2/17/26 (antipsychotic). Review 7/16/26 of Resident #1's consent forms revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Resident #2 Review 7/16/26 of Resident #2's current physician's orders revealed the following orders: Sertraline HCI Oral Tablet 100 mg. Give 100 MG by mouth one time a day for depression, start date 12/27/25 (antidepressant). Aripiprazole Oral Tablet 5 mg. Give 1 tablet by mouth one time a day for bipolar with antipsych behavior, start date 4/24/26 (antipsychotic). Review 7/16/26 of Resident #2's consent forms revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Resident #12 Review on 7/16/26 of Resident #12's current physician's orders revealed the following orders: Seroquel Oral Tablet 25 mg. Give 1 tablet by mouth three times a day for adjustment disorder with anxiety, start date 1/7/26 (antipsychotic). Sertraline HCI Oral Tablet 100 mg. Give 100 mg by mouth one time a day for borderline personality disorder, start date 1/24/26 (antidepressant). Review 7/16/26 of Resident #12's consent forms revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Interview on 7/16/26 at approximately 2:00 p.m. with Staff G (Unit Manager) confirmed there was no documentation that Resident #1, #2, and #12 and/or the resident's representatives were fully informed of the risk and benefits of psychotropic medications prior to starting the medications. Resident #5 Review on 7/16/26 Of Resident #5's physician orders revealed the following order: Zoloft 25mg by mouth one time daily for depression/anxiety, dated 6/29/26. Review on 7/16/26 of Resident #5's progress notes, consents, psychiatric notes from June 2026 revealed that there was no consent or evidence of discussion with Resident #5 or the resident representative about the risks and benefits of Zoloft. Interview on 7/16/26 at approximately 1:00 p.m. with Staff C (2nd Floor Unit Manager) confirmed the above findings. Review on 7/16/26 of the facility's policy, Behaviors: Management of Symptoms, revised 9/15/25, revealed .7. When medication is ordered for behavioral symptoms: 7.1 Obtain consent .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment in the facility with a census of 84 residents. Findings include:Resident #51Observation on 7/15/26 at approximately 10:00 a.m. of Resident #51's room revealed the baseboard heater was missing approximately four inches of the heater cover in the middle and the edges were sharp. Further observation revealed the baseboard heater cover was dirty, with dried brown substances adhered to it.Interview on 7/16/26 with Staff C (Licensed Practical Nurse) at approximately 10:05 a.m. confirmed the above findings. Resident #60 and Resident #61Observation on 7/15/26 at approximately 10:05 a.m. of Resident #60 and #61's doorway revealed the transitional strip between the carpet in the hallway and flooring to the room was missing. Further observation revealed there was approximately 1/4 inch gap between the carpet and flooring. Interview on 7/15/26 with Staff C at approximately 10:08 a.m. confirmed the above findings. Resident #84 and #85Interview on 7/14/26 at approximately 10:10 a.m. with Resident #84 and Resident #85 revealed that they moved into the facility about a month ago and have not been able to open one side of their closet door. Further interview revealed that they have reported it several times to someone at the facility.Observation on 7/14/26 at approximately 10:10 a.m. of Resident #84 and Resident #85's closet door revealed that the closet door was off the track and unable to open on the left side.Interview on 7/15/26 with Staff C at approximately 10:10 a.m. confirmed the above findings.Review on 7/16/26 of the facility policy titled, Environmental Services Inspection, Dated 3/1/24, revealed . Centers/Communities will regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis . 2. All opportunities will be corrected immediately by environmental services personnel.Review on 7/16/26 of the facility policy titled, Cleaning and Disinfecting, Revision Date 5/1/25, revealed . Cleaning and disinfecting of frequently touched items and surfaces, patient/resident . care items and the environment . will be conducted routinely and based on risk of infection involved. 5.3 Multi-patient equipment must also be cleaned/disinfected between patients.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled according to professional standards on 1 of 2 medication carts observed. Findings include:Observation on 7/14/26 at approximately 8:05 a.m. of the 2S Medication Cart with Staff A (Registered Nurse) revealed:Resident #36's Fluticasone Salmeterol opened and labeled with an open date of 6/9/26.Resident #10's Ravicti 1.1 gms (grams)/ml (milliliter) opened with no date of opening and no open expiration date. Interview on 7/14/26 at approximately 8:05 a.m. with Staff A confirmed the above findings. Review on 7/14/26 of the manufacturer's instructions for Advair Diskus (Fluticasone Salmeterol), Revision Date 3/26, revealed: . Discard Advair DIskus 1 month after opening the foil pouch .Review on 7/14/26 of the manufacturer's instructions for Ravicti, Dated 2025, revealed: . Discard bottle 28 days after opening .Review on 7/14/26 of the facility policy titled, Medication Storage, 4.1 Dated 1/26, revealed: . 14. Outdated, . medications . are immediately removed from stock, .

Based on interview and record review, the facility failed to obtain radiology services as ordered by a physician for 1 of 3 residents reviewed for accident and hazards in a final sample of 18 residents. (Resident identifier is #12).Findings include:Review on 7/15/26 of Resident #12's medical record revealed an order for a 2-view x-ray of Resident #12's left hand/wrist for pain and swelling, dated 7/2/26.Review on 7/16/26 of Resident #12's provider note, dated 7/2/26, revealed the following: Patient had developed swelling to the left hand and nursing has been attempting to elevate, however, reports worsening of swelling. Concerns of pain vs resistance of touch as patient does pull back at times during care or when touched. [Family] in to visit who also report concern as patient was pulling back for them as well. Review further revealed Discussed with family plan to order x-ray to assess for any acute injury and starting scheduled Ibuprofen of which they are agreeable. Both ordered, floor nurse aware of plan.Interview on 7/15/2026 at 1:08 p.m. with Staff H (Nurse Practitioner) confirmed that he/she ordered the x-ray on 7/2/26 of Resident #12's wrist/hand to rule out an injury because the swelling had not subsided and both family and nursing reported pain. Interview further revealed that he/she was unable to locate the results of the x-ray in the medical record on 7/8/26 and notified Staff G (Unit Manager) to obtain the results from the imaging company. Interview on 7/15/2026 at 1:23 p.m. with Staff G revealed that he/she was unable to locate the x-ray results for Resident #12 and was unable to determine if the imaging was obtained for Resident #12Interview on 7/15/26 at 2:06 p.m. with Staff B (Director of Nursing) confirmed that the imaging of the wrist/hand was not obtained for Resident #12.Review on 7/16/26 at facility's policy, Diagnostic Tests, revised 3/1/24, revealed .1. Verify order for laboratory, diagnostic testing, and parameters for reporting. 2. Notify diagnostic service to arrange for test. 3. Obtain report of diagnostic test.

Based on observation, interview, and record review, the facility failed to establish a policy/procedure that followed accepted national standards to maintain infection control practices for 1 of 1 resident observed for wound care. (Resident identifier is #2.) Findings include: Review on 7/15/26 of Resident #2's July 2026 Treatment Administration Record revealed the following physician's order, dated 7/10/26: wash all open areas on bilateral feet (lateral feet, medial feet, ankles, medial left metatarsal) with normal saline, pat dry and apply Xeroform to wounds, cover with pads and secure with Kerlix. Observation on 7/15/26 at 2:23 p.m. of Staff G (Unit Manager) providing wound care to Resident #2 revealed that Staff G used clean scissors to cut the dirty dressing (dated 7/14/26) off Resident #2's right foot/ankle area. Staff G was observed using the scissors (without cleaning them) to cut 2 pieces of Xeroform (fine mesh absorbent gauze coated with a petrolatum blend containing bismuth tribromophenate) and apply them to 2 wounds to the right foot. Futher observation revealed Staff G use the same scissors to cut the dirty dressing (dated 7/14/26) off Resident #2's left foot/ankle and was then observed using the scissors (without cleaning them) to cut 4 pieces of Xeroform to apply to 4 wounds on the left foot. Interview on 7/15/26 at 3:03 p.m. with Staff G confirmed they did not clean the scissors after using them to cut the dirty dressing and before cutting the clean Xeroform. Interview on 7/15/26 at 3:17 p.m. with Staff I (Staff Development) confirmed that scissors should be cleaned before cutting clean wound care supplies. Review on 7/16/26 of the facility's policy titled Skin Integrity and Wound Management revised 9/15/25 revealed it did not address cleaning reusable equipment when moving from dirty to clean. Review on 7/16/26 of the facility's Clinical Competency Validation for Wound Dressing: Aseptic No-Touch revised 12/2021 revealed, .14. Open dressing(s) without contaminating . Interview on 7/16/26 at 9:30 a.m. with Staff B (Director of Nursing) revealed that the facility's policy/procedure did not indicate the scissors should be cleaned when moving from dirty to clean care. Review of the Centers for Disease Control (CDC) CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings retrieved from https://www.cdc.gov/infection-control/hcp/core-practices/ revealed, Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled . 2. Maintain separation between clean and soiled equipment to prevent cross contamination .

Based on observation, interview, and record review, the facility failed to maintain patient equipment for 1 out of 1 resident reviewed for respiratory care in a final sample of 18 residents. (Resident identifier is #51.) Findings include:Observation on 7/14/26 at approximately 10:00 a.m. of Resident #51's oxygen concentrator revealed approximately 1/8-inch of white debris and hair adhered to the external air filter.Observation on 7/15/26 at approximately 10:15 a.m. of Resident #51's oxygen concentrator revealed approximately 1/8-inch of white debris and hair adhered to the external air filter.Interview on 7/15/26 at approximately 10:15 a.m. with Staff C (Licensed Practical Nurse) confirmed the above findings.Review on 7/15/26 of Resident #51's July 2026's TAR (Treatment Administration Record) revealed the following physician's order:Clean external filter on oxygen concentrator every day shift every 7 days(s), Start date 6/15/26. Further review revealed that it was signed in the TAR as being completed on 7/13/26 by Staff D (Registered Nurse).Interview on 7/15/26 at approximately 10:20 a.m. with Staff D revealed that he/she had forgotten to clean the external air filter but had signed the TAR that the external air filter had been cleaned. Review on 7/16/26 of the [Brand Name Omitted] 10-Liter Oxygen Concentrator Service Manual revealed: . The air filter should be . cleaned as needed by the user or caregiver.Review on 7/16/26 of the facility policy titled, Procedure: Respiratory Equipment/Supply Cleaning/Disinfecting, revision date 7/15/21 revealed: . 1.8 In addition to surface cleaning and disinfecting, perform the following, . 1.8.4 Oxygen Concentrators: Rinse and dry the external filter weekly and PRN [as needed] when visibly dusty.

Based on interview and record review, the facility failed to ensure that the facility assessment included specific direct care staffing needs for each unit and each shift such as day, evening, and night.Findings include: Review on 7/15/26 9:45 a.m. of the facility assessment, dated 2026, revealed that the facility assessment contained daily staffing numbers by discipline for the entire facility. It did not include information on the direct care staffing levels needed for each unit or each shift such as day, evening, and night. Interview on 7/15/26 9:45 a.m. with Staff F (Administrator) confirmed the above findings.

Based on interview and record review it was determined that the facility failed to follow its grievance policy for grievances for 2 out of 5 residents reviewed for grievances (Resident Identifiers are #67 and #80). Finding include: Review on 6/12/25 of the facility's policy Grievance/Concern revised 10/15/24, revealed .3. Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern. Patients and/or patient representatives/families may complete a Grievance/Concern form and submit the completed form to a staff member .4. Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance Concern Log . 6. The department manager will: . 6.2 Investigate the grievance; 6.3 Take corrective action, if needed .6.5. Notify the person filing the grievance in a timely manner . Resident #67 Interview on 6/11/25 at 10:25 a.m. with Resident #67 revealed he/she had filed numerous grievances about waiting over an hour for his/her call bell light to be answered during the 3-11 shift. He/she indicated there had been no resolution. Review on 6/12/25 of the facility 2024/2025 grievance log revealed that there were no grievances from Resident #67 about call bell lights. Review on 6/12/23 of Resident #67's care plan note, dated 5/22/25, revealed that . [Pronoun omitted] has filed a couple of grievances and set up weekly check in meetings with the Unit Manager to discuss problems . Interview on 6/13/25 at 8:42 a.m. with Staff K (Unit Manager) revealed that Resident #67 had complained about an LNA (Licensed Nursing Assistant) who he/she felt had an attitude with him/her and waiting a long time for as needed pain medication. Interview further revealed that Staff K had not documented Resident #67's complaints on a grienvance/concern form. Resident #80 Interview on 6/11/25 at 10:15 a.m. with Resident #80 revealed that Resident #80 was admitted to the facility in 3/2025 and he/she had filed multiple grievances to staff since he/she was admitted . He/she stated that he/she waited for over 2 hours in a soiled brief a few weeks ago and that he/she had told an LNA the next day and no one had come to talk to him/her about it. Interview on 6/12/25 at 11:58 a.m. with Staff I (LNA) revealed that Resident #80 had complained approximately three weeks ago about sitting in a soiled brief for a long time. Staff I stated that he/she reported the grievance to Staff K. Review on 6/12/25 of the facility 2025 grievance log revealed that there was no grievances documented for Resident #80. Interview on 6/13/25 at approximately 1:30 p.m. with Staff E (Administrator) confirmed that the grievances from Resident #67 and Resident #80 were not forwarded to him/her and therefore there were no grievances documented on the grievance log for Resident #67 and Resident #80.

Based on record review and interview, it was determined that the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days for 1 of 1 residents reviewed for medication side effects in a final sample of 18 residents. (Resident identifier is #8.) Findings include: Review on 6/11/25 of Resident #8's June 2025 MAR (Medication Administration Record) revealed the following order: Lorazepam Oral Tablet 0.5 mg (milligrams) (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for increased anxiety, dated 5/9/25. The order had no stop date indicated. Review on 6/11/25 of Resident #8's May 2025 MAR (Medication Administration Record) revealed the following order: Lorazepam Oral Tablet 0.5 mg (milligrams) (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for increased anxiety, dated 5/9/25. The order had no stop date indicated. Further review revealed Resident #8 received 2 doses on 5/31/25. Interview on 6/12/25 at approximately 11:30 a.m. with Staff C (Director of Nursing) confirmed the above findings. Review on 6/12/25 of the facility policy titled, Medication Management, Dated 1/25 revealed: .Type of PRN (as needed) PRN orders for Psychotropic medications, excluding antipsychotics, Time Limitation 14 days, Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order .

Based on interview and record review, it was determined that the facility failed to ensure the physician was notified of a weight change for 2 of 2 residents reviewed for notification of changes in a final sample of 18 residents. (Resident identifiers are #85 and #143.) Findings include: Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 20212, Chapter 19, page 267 revealed the following Communication with other health providers needs to be timely, acurate, and relevant to the patient's clinical situation. Resident #85 Review on 6/11/25 of Resident #85's May 2025 Treatment Administration Record (TAR) revealed the following physicians order: CHF (Congestive Heart Failure) Daily Weight: Notify the provider if: gain >(greater than) 2 lbs (pounds) in 1 day, or 5 lb in a week, one time a day for 7 days, start date 5/28/25. Further review revealed that there was no documented weight obtained on 5/29/25. Review on 6/11/25 of Resident #85's June 2025 TAR (Treatment Administration Record) revealed the following physicians order: CHF Daily Weight: Notify the provider if: gain > 2 lbs in 1 day, or 5 lb in a week, one time a day for 7 days, start date 5/28/25. Further review revealed: June 1st weight was 193.2 lbs; June 2nd no weight obtained; June 3rd weight was 205 lbs (11.8 lb gain) Resident #143 Review on 6/11/25 of Resident #143's June 2025 TAR revealed the following physicians order: Daily weight CHF: Notify the provider if: gain >2 lbs in 1 day, or 5 lb in a week in the morning, Start Date 6/8/25. Further review revealed: June 8th no weight obtained; June 9th no weight obtained; June 10th no weight obtained; June 11th weight refused. Interview on 6/12/25 at approximately 12:45 p.m. with Staff C (Director of Nursing) confirmed that there was no documentation of the provider being notified of the above findings. Interview on 6/12/25 at approximately 1:00 p.m. with Staff D (Nurse Practitioner) confirmed that he/she was not notified of the above findings as ordered.

Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff, as determined by their facility assessment, to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents on the 2nd floor with a census of 47 residents. (Resident identifiers are #8, #33,#67, and #80 Findings include: Resident #33 Interview on 6/11/25 at approximately 8:45 a.m. with Resident #33 revealed he/she was concerned with not having enough staff at times for him/her to go to the bathroom. A lot of times, I end up wetting myself because it takes up to 30 minutes for them (the staff) to answer my call bell. This happens here all the time. Resident #8 Interview on 6/11/25 at approximately 9:00 a.m. with Resident #8 revealed he/she was concerned with not having enough staff at times for him/her to be able to go outside and smoke. Especially on the weekends when there is only 3 aides, sometimes I can't even get outside to smoke at times. Interview on 6/11/25 at approximately 9:10 a.m. with Staff F (Anonymous) revealed that he/she did not feel that there is enough staff to meet the residents needs on the 2nd floor, Residents are incontinent because we don't have enough staff to get to them in time. Further interview revealed that Resident #8 sometimes can not get outside to smoke because there is not enough staff. Interview on 6/11/25 at approximately 10:25 a.m. with Resident #67 revealed that call bell wait times were not answered timely on the 3-11 shift. He/she states that he/she uses oxygen continuously and he/she has had waited over an hour to be connected to his/her portable tank when he/she had wanted to leave his/her room in the afternoon or early evening to go to an activity or go outside for fresh air. Interview on 6/11/25 at approximately 10:15 a.m. with Resident #80 revealed that he/she had waited a long time for his/her call bell to be answered. He/she stated that it was worse on the 3-11 and 11-7 shift. He/she was unable to ambulate on his/her own when he/she was admitted . He/she stated that he/she had waited up to 2 hours in a dirty brief. Resident #80 stated that they waited over 30 minutes for help in the bathroom [ROOM NUMBER] nights ago. Review on 6/12/25 of Resident #80's care plan, initiated on 4/1/25, revealed that Resident #80 was incontinent of bowel with potential for improved control and management of bowel elimination. Further review under interventions included . Encourage resident to call for assistance if need to defecate before next schedule time .Provide assistance as needed . Review on 6/11/25 of the Resident Council Meeting Minutes, dated 4/29/25, revealed that .Sometime call-lights can take a while for staff to respond. This is inconsistent, and appears to be more prevalent on the weekends . Interview on 6/12/25 at approximately 10:23 a.m. with the Resident Council revealed that 7 residents in attendance who reside on the 2nd floor had concerns with call bells being answered timely. Residents stated that it was worse on the 3-11 shift or before 7:00 a.m. when there are only 2 Licensed Nursing Assistants (LNA) on the floor trying to get residents up for the day. One resident stated that they feel like residents were not able to attend activities due to not enough staff to help get them there especially in the late afternoon or early evening hours. Interview on 6/12/25 at approximately 7:00 a.m. with Staff N (Anonymous) revealed that residents have complained to him/her multiple times about waiting long for care. He/she stated that residents have been put to bed in their day clothes or left up for them to be to put to bed for the next shift. Interview further revealed that at times, residents may have to wait longer when there were only 2 LNA's scheduled and there was a resident that would need both LNA's for care. Interview on 6/13/25 at 9:47 a.m. with Staff M (Anonymous) revealed that residents were often not up out of bed or dressed and ready to get to activities. Staff M revealed that it happened more on the weekends and on the 2nd floor.

Based on record review, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 5 residents reviewed for choices in a final sample of 18 residents. (Resident identifier is #8.) Findings include: Interview on 6/11/25 at approximately 9:00 a.m. with Resident #8 revealed he/she was concerned with receiving the wrong dose of his/her pain medication recently. Review on 6/13/25 of Resident #8's April 2025 Medication Administration Record (MAR) revealed the following as needed (PRN) physician orders: Hydromorphone HCL (Hydrochloric Acid) Tablet 2 mg (milligrams), Give 0.5 tablet (1mg) by mouth every 6 hours as needed for breakthrough pain 8-10, Start Date 4/1/25. Further review revealed on 4/16/25 a dose was signed as being administered at 11:18 p.m Hydromorphone HCL Tablet 2 mg, Give 1 tablet by mouth every 4 hours as needed for pain 8-10 for 30 days, discontinued on 4/1/25. Review on 6/13/25 of Resident #8's Individual Patient's Narcotic Record for the above discontinued order revealed that 1 tablet [2 mg] was given on 4/16/25 at 8:30 p.m. Interview on 6/13/25 at approximately 9:45 a.m. with Staff C (Director of Nurses) confirmed the above findings. Review on 6/13/25 of Resident #8's May 2025 MAR revealed the following physician's orders: Hydromorphone HCL (Hydrochloric Acid) Tablet 2 mg (milligrams), Give 0.5 tablet (1 mg) by mouth two times a day for chronic pain, Start Date 4/1/25. Review on 6/13/25 of Resident #8's Individual Patient's Narcotic Record for Hydromorphone 2 mg revealed on 5/3/25 one 2 mg tablet was documented as being administered at 7:20 p.m. Interview on 6/13/25 at approximately 9:45 a.m. with Staff C confirmed that Resident #8 received the wrong dose of Hydromorphone on 5/3/25. June 2025 Review on 6/13/25 of Resident #8's June 2025 MAR revealed the following physician's orders: Hydromorphone HCL (Hydrochloric Acid) Tablet 2 mg (milligrams), Give 0.5 tablet (1 mg) by mouth two times a day for chronic pain, Start Date 4/1/25. Review on 6/13/25 of Resident #8's Individual Patient's Narcotic Record for Hydromorphone 2 mg revealed on 6/4/25 one 2 mg tablet of Hydromorphone was documented as being administered at 10:00 p.m. Interview on 6/13/25 at approximately 1:00 p.m. with Staff C confirmed that Resident #8 received the wrong dose of Hydromorphone on 6/4/25. Review on 6/13/25 of Resident #8's Individual Patient's Narcotic Record for Hydromorphone 2 mg 1/2 tablets, dated 4/3/25 revealed: The quantity indicated was the facility received 23 tablets. Further review revealed 2 nurses documented receiving 12 tablets. Interview on 6/13/25 at approximately 1:00 p.m. with Staff C confirmed that there was a discrepancy with the quantity received. Further interview revealed that he/she was unaware of the discrepancy. The facility did not follow their policy for notifying a supervisor of the discrepancy, did not complete a Controlled Drug Discrepancy Investigation Form, and did not initiate an investigation into the discrepancy. Review on 6/13/25 of the facility policy titled, NSG300 Controlled Drugs: Management of, Revision Date 1/31/25, revealed . The management of controlled substances-including the ordering, receipt, storage, administration, ongoing inventory, and destruction-is conducted under the direction and ultimate responsibility of the Administrator and Director of Nursing, and follows safe practice . Receipt: Controlled substances are received in separate containers with separate invoices. Licensed nursing staff must accept delivery and take responsibility for receipt of controlled substances Discrepancies noted at any step of the process will be reported to appropriate persons. If a discrepancy is noted, the nursing supervisor will be notified and immediately initiate investigation using the Controlled Drug Discrepancy investigation form .

Based on interview, observation and record review it was determined that the facility failed to follow currently accepted professional principles for labeling and/or storing drugs and biologicals in 2 of 3 medications carts observed. (Resident identifiers are #16 and #41.) Findings include: Observation on 6/11/25 at approximately 8:05 a.m. of the 2nd Floor Medication Cart revealed: One open bottle of Brimodine eye drops opened with no open date or open expiration date and no resident identifier; One box of Cipro ear drops for Resident #16 labeled with an expiration date of 6/6 stored in the medication cart with eye drops; and one open Breyna inhaler for Resident #41 with no open date or open expiration date. Interview on 6/11/25 at approximately 8:10 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Observation on 6/12/25 at approximately 7:00 a.m. of the Celtics Court Medication Cart revealed Resident #37's open Incruse Ellipta inhaler was not labeled with an open date or an open expiration date. Interview on 6/12/25 at approximately 7:00 a.m. with Staff B (Licensed Practical Nurse) confirmed the above finding. Review on 6/1/25 of the instructions for use for Incruse Ellipta, date 12/2023, revealed . Safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler . Review on 6/12/25 of the patient instructions for Breyna inhaler, revision date 9/2020, revealed . Throw away Breyna when the counter shows zero ('0) or 3 months after you take your Breyna inhaler out of its foil pouch, whichever comes first . Review on 6/12/25 of the Consumer Medicine Information for Brimodine, Dated May 2017, revealed . Storage . Discard the eye drops 4 weeks after opening . Review on 6/12/25 of the facility policy titled, 4.1 Storage of Medication, Dated 1/25, revealed . 4. Medications should be stored so that various routes of administration are separated 6. Eye medications are stored separately from ear medications . 14. Outdated, . are immediately removed from stock .

Based on interview and record review, it was determined that the facility failed to provide the resident and/or resident representative a Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 3 of 3 residents reviewed for beneficiary notices. (Resident identifiers are #69, #145 and #146.) Findings include: Resident #69 Review on 6/13/25 of Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #69's last covered day of Medicare Part A Services was on 6/4/25 with benefit days remaining. Resident #69 remained in the facility. The facility was unable to provide Resident #69's NOMNC and SNF ABN. Resident #145 Review on 6/13/25 of Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #145's last covered day of Medicare Part A Services was on 1/6/25 with benefit days remaining and Resident #145 was discharged home. The facility was unable to provide Resident #145's NOMNC. Resident #146 Review on 6/13/25 of Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #146's last covered day of Medicare Part A Services was on 2/6/25 with benefit days remaining and Resident #146 was discharged home. The facility was unable to provide Resident #146's NOMNC. Interview on 6/13/25 at approximately 8:15 a.m. with Staff E (Administrator) confirmed that he/she could not provide the above NOMNC or SNF ABN.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that dishes were sanitized according to manufacturer's instruction for food services safety in the main kitchen. Findings include: Interview on 6/25/24 at approximately 8:45 a.m. with Staff L (Dietary Manager) revealed that the facility utilized a high temperature dish machine to sanitize utensils and dishes. Observation and interview on 6/25/24 at approximately 8:45 a.m. during dishwashing in the kitchen revealed that Staff K (Dietary Aide) was washing food debris off dishes with water and lining them on a tray. The tray with dishes was then placed in the dish machine. During the rinse cycle, the rinse temperature was 170 degrees Fahrenheit (F). Staff K and Staff L (Dietary Aide) did not check the wash and rinse temperature gauge on the dish machine while it was running. After the rinse cycle, Staff L removed the tray with dishes from the dish machine and was going to store the dishes to air dry. Interview with Staff K confirmed the observation on the rinse cycle temperature. The tray went through the dish machine the second time and the rinse temperature was 175 degrees Fahrenheit. The tray with dishes went through the dish machine the third time and the rinse temperature was 180 degrees Fahrenheit. Observation and interview on 6/25/24 at approximately 2:19 p.m. during dishwashing in the kitchen with Staff K and Staff L revealed that a tray with dishes was placed in the dish machine and during the rinse cycle the rinse temperature was 176 degrees Fahrenheit. Staff K and Staff L did not check the wash and rinse temperature gauge while the dish machine was running. Staff L was going to store the dishes on the tray to air dry. Interview with Staff K confirmed the observation on the rinse cycle temperature. The tray with dishes went through the dish machine the second time and the rinse temperature was 178 degrees Fahrenheit and the third time the rinse temperature was 180 degrees Fahrenheit. Review on 6/25/24 of the FDA Food Code 2017, retrieved from:https://www.fda.gov/media/110822/download, revealed: .4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions .501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: .(2) For all other machines, 82oC (180oF) . Review on 6/25/24 of the ECOLAB XL-HT dish machine specification revealed .Operating temperatures sanitizing rinse (minimum) 180 F . Review on 6/25/24 of the facility's policy titled, Machine Warewashing and Sanitizing, effective date of 5/1/23, revealed: .The dishwasher is used for machine warewashing. High temperature or low temperature machines are acceptable for use. 1.1. For a high temperature machine, the wash cycle temperature ranges between 150-165 [degrees] F [Fahrenheit] the final rinse temperature is a minimum of 180 F or 165 F for a stationary, single temperature machine. 1.1.1 Manufacturer's specifications for temperatures are followed .If temperatures fall below the standard for either wash or final rinse, or the chemical sanitizer does not test at the appropriate concentration, The Director of Dining Services/Director of Culinary Services or Maintenance Department is notified immediately .If the issues cannot be corrected by facility staff, the chemical supply service representative is notified and warewashing is discontinued until the issues is corrected .

Based on interview, record review, and policy review, it was determined that the facility failed to act upon the Medication Regimen Review (MRR) recommendations for 1 of 5 residents reviewed for unnecessary medications in a final sample size of 23 residents (Resident Identifier #59). Findings include: Resident #59 Review on 6/27/24 of Resident #59's pharmacy consultation report dated 4/23/24 revealed that Resident #59 received an anticholinergic medication Benzotropine 0.5 milligram (mg) three times a day for prevention or treatment of extrapyramidal symptoms without evidence of a Gradual Dose Reduction (GDR). Pharmacy recommendation was to attempt a GDR of Benzotropine 0.5 mg to two times a day with the end goal of discontinuation. Further review of Resident #59's pharmacy consultation report revealed that the provider accepted the recommendation and to implement as written on 4/26/24. Review on 6/27/24 of Resident #59's active physician orders revealed that the Benzotropine 0.5mg medication order remained at three times a day instead of a GDR of two times a day as mentioned in the above pharmacy recommendation for Resident #59. Interview on 6/27/24 at approximately 9:00 a.m. with Staff A (Director of Nursing) confirmed the above findings for Resident #59. Review on 6/27/24 or the facility's policy titled, Medication Regimen Review, revision date of 6/1/24, revealed: .Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR .For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR .

Based on observation, interview and facility policy review, it was determined that the facility failed to have a secondary lock secured for a controlled medication in 1 of 2 medication rooms (Resident Identifier #76). Finding includes: Review on 6/25/24 of Resident #76 medical record revealed an order for Lorazepam 2 milligram (mg) 1/milliliter (ml), give 0.5 ml (1 mg) by mouth twice a day and as needed every 6 hours for anxiety. Observation on 6/25/24 at approximately 8:45 a.m. of the second floor medication room with Staff D (Licensed Practical Nurse) revealed the medication refrigerator was not locked with one 30 ml bottle of Lorazepam 2 mg/1 ml labeled with Resident #76's name inside. Interview on 6/25/24 at approximately 8:45 a.m. with Staff D confirmed the findings. Staff D indicated controlled substances should be double locked in the medication room. Interview on 6/25/24 at approximately 10:30 a.m. with Staff A (Director of Nursing) confirmed the above finding. Review of the facility policy titled, NSG300 Controlled Drugs: Management of, with a last revised date of 4/1/22, revealed: .All controlled substances are stored under double lock, separate from other medications .

Based on observation, interview, and record review, it was determined that the facility failed to maintain wheelchairs and tubefeeding pumps according to manufacturer's instructions for 3 of 5 residents reviewed for physical environment in a final sample of 23 residents (Resident Identifiers are #2, #3, and #65). Findings include: Resident #65 Observation on 6/25/24 at approximately 11:00 a.m. and 1:00 p.m. revealed that Resident #65 was in the common area sitting in a wheelchair with yellow dried liquid splatters that differed in sizes on the left wheel, left inner side panel, and left arm rest on the wheelchair. Further observation revealed that there was clumps of dried yellow food-like substance that differed in sizes on the left side of the chair cushion between Resident #65 and the left inner side panel of the wheelchair. Observation and interview on 6/26/24 at approximately 1:23 p.m. with Staff H (Unit Manager) confirmed the above findings of Resident #65's wheelchair conditions. Staff H stated that the wheelchairs were to be cleaned by nursing staff weekly on residents shower days. Interview on 6/26/24 at approximately 1:25 p.m. with Staff I (Licensed Nursing Assistant) revealed that he/she was not aware of a current schedule for cleaning wheelchairs for nursing staff to complete. Staff I stated that in the past there was a weekly cleaning schedule of wheelchairs on residents shower days. Review on 6/26/24 of the facility's third floor shower schedule protocol, updated date of 6/12/24, revealed that wheelchairs should be sprayed down and dried during shower times and that the 11-7 shift was to wash all wheelchairs and walkers for each shower that day if not done during shower days. Further review of the shower schedule protocol revealed that Resident #65's shower was scheduled for Tuesdays on 3-11 shift, which indicates that Resident #65's wheelchair should have been cleaned on 6/25/24. Review on 6/26/24 of Resident #65's wheelchair manufacturer's instruction revealed .Maintenance and Care .Clean your wheelchair. See the Cleaning schedule section in this manual for instructions .weekly .Cleaning .Axles, Wheels, Tires and Moving Parts: 1. Clean around the axles and wheels weekly with a damp rag .Painted Surfaces 1. Hand wash using a cloth and mild detergent 2. Dry using a clean cloth or allow wheelchair to air dry .Upholstery: 1. Hand wash using a cloth and mild detergent. 2. Allow upholstery to air dry .Plastic Components 1. Hand wash using a cloth and mild detergent .Sanitizing 1. Disinfect surfaces with over the counter disinfecting sanitizer of at least 70% [percent] alcohol wipes. Do not soak or allow pooling of cleaning solutions. 2. Allow sanitizer to remain on surface for at least 15 minutes and remove with aseptic cloth . 26364 Resident #3 Observation on 6/25/24 at approximately 9:00 a.m. revealed that Resident #3's wheelchair had built up dust and a dark substance on his/her wheelchair. Interview 6/25/24 at approximately 9:00 a.m. with Resident #3 revealed he/she had asked to have his/her wheelchair cleaned before and that the LNA had refused to do it .The LNA would only clean the seat. Interview on 6/27/24 at approximately 8:04 a.m. with Staff F (Infection Preventionist) confirmed the above findings. Review of the facility's policy on 6/27/24 titled, Second Floor Shower Schedule, updated 2/9/24 revealed: .Wheelchairs should be sprayed down and dried on shower time 11-7 shift: wash all wheelchairs/walkers for each shower that day if not done during shower. Easy to assess chairs during rounds . Review of the manufacturer's instruction Edition 1, dated 7/9/2020, for M3 Corpus user manual revealed: . 5. Maintenance .For the wheelchair to work well, it is important that you use it correctly and maintain it regularly. A well maintained wheelchair lasts longer and has lower of defects .5.2 Cleaning .Regular care and maintenance will prevent unnecessary wear and damage to your Permobile product .Maintenance and inspection schedule chart clean the wheelchair and upholstery weekly, check upholstery, seating, and postural supports for wear weekly . 50163 Resident #2 Observation on 6/25/24 at 8:40 a.m. of the second floor dining area revealed that Resident #2 was sleeping in a tilt-n-space wheelchair with tube feed running. Further observation revealed that Resident #2's tube feed kangaroo pump had dried off-white substance covering the top of the tube feed kangaroo pump and the screen. Observation on 6/26/24 at 1:50 p.m. of Resident #2's tube feed kangaroo pump revealed the pump had dried off-white substance covering the top of the tube feed kangaroo pump and the screen, as observed above. Interview on 6/26/24 at 2:05 p.m. with Staff E (Licensed Practical Nurse (LPN)) confirmed above findings. Observation and interview on 6/27/24 at 8:05 a.m. with Staff F (Infection Control) confirmed that Resident #2's tube feed kangaroo pump had dried off-white substance on top of the pump and dried brown substance in the grooves on the front of the pump and around the screen. Review on 6/27/24 of facility policy titled, IC201 Cleaning and Disinfecting with revision date of 5/1/24 revealed: .POLICY - Cleaning and disinfecting of frequently touched items and surfaces, patient/resident (hereinafter patient) care items and the environment, including common areas of the Center, will be conducted routinely and based on risk of infection involved PRACTICE STANDARDS- .3. Clean items of all foreign materials such as blood, feces, dust, or dirt before disinfecting. 4. Follow manufacturer's recommendations . Review on 6/27/24 of manufacturer's operating manual for Kangaroo Connect Enteral Feeding Pump with revision date of 11/2017, revealed: GENERAL CLEANING DIRECTIONS- Cleaning Frequency: It is recommended that the pump .be cleaned after each feeding set use for a minimum duration of 30 seconds, to prevent bacterial contamination of the pump .

Based on interview and record review, it was determined that the facility failed to ensure that the resident's Minimum Data Set (MDS) accurately reflected the resident's status for 3 of 23 residents reviewed for MDS in a final sample of 23 residents (Resident Identifiers are #22, #29 and #56). Findings include: Resident #22 Review on 6/26/24 of Resident #22's Quarterly MDS with an Assessment Reference Date (ARD) of 5/6/24 revealed under Section O, Special Treatments, Procedures, and Programs, that the resident was receiving chemotherapy, radiation, dialysis, hospice, isolation/quarantine for active infectious disease, and Intravenous (IV) therapy all while a resident. Review on 6/26/24 of Resident #22's medical record revealed no documentation that the resident was receiving the above coded treatments/services during the 5/6/24 Quarterly MDS timeframe. Interview on 6/26/24 at 1:45 p.m. with Staff A (Director of Nursing) confirmed Resident #22 did not receive the above special treatments during the above MDS timeframe and that the MDS had been coded in error. Resident #29 Review on 6/27/24 of Resident #29's Quarterly MDS with an ARD of 5/23/24 revealed under Section P, Restraints and Alarms, that Trunk Restraint was coded as being used less than daily when in a chair or out of bed. Interview on 6/27/24 at approximately 2:00 p.m. with Staff E (Licensed Practical Nurse (LPN)) revealed that Resident #29 had not used a restraint since his/her admission to the facility, including the above timeframe in May 2024. Interview on 6/27/24 at approximately 2:00 p.m. with Staff G (Assistant MDS Coordinator) confirmed that Resident #29's 5/23/24 Quarterly MDS was incorrectly coded for a restraint. 40522 Resident #56 Review on 6/26/24 of Resident #56's active physician's order revealed an order for Apixaban (anticoagulant) 2.5 milligram (mg) by mouth two times a day for atrial fibrillation with a start date of 1/2/24. Review on 6/26/24 of Resident #56's Quarterly MDS with an ARD of 5/9/24 revealed that under Section N, High-Risk Drug Classes: Uses and Indication, anticoagulant was not checked as is taking and/or indication noted. Review on 6/26/24 of Resident #56's May 2024 revealed that Resident #56 received Apixaban medication from 5/2/24 to 5/8/24 during the assessment timeframe for the 5/9/24 Quarterly MDS. Interview on 6/26/24 at 1:50 p.m. with Staff A confirmed the above findings. Interview with Staff A revealed that anticoagulant use and indication noted should have been coded as is taking and indication noted in the above mentioned MDS.

Based upon a review of a facility investigation, review of facility Guidelines For Managing A Fall, staff interview and resident record review the facility failed to ensure that their policies and procedures were implemented to prevent the transfer of a resident which resulted in this resident falling, being moved off the floor without first being assessed for injury and sustaining a fractured left hip(Resident identifier is #1). Findings include: According to a Facility Initial Report investigation of 9/29/13, Resident #1 was being transferred in a Hoyer lift from Resident #1's bed to his wheelchair by Staff A(LNA), instead of using two persons for the transfer as specified in Resident #1's care plan, when a "misaligned" strap gave way causing Resident #1 to fall out of the Hoyer lift onto the floor. In a 10/9/13 interview Staff B(Administrator) acknowledged that after Resident #1 fell to the floor Staff A, contrary to the facility Guidelines For Managing A Fall, moved Resident #1 from the floor by themself into his bed before Resident #1 was assessed for any injuries. The facility Guidelines For Managing A Fall specify that once a resident falls staff must "Call for licensed nurse to assess patient." According to the facility investigation; Resident #1, reported "generalized pain" when assessed by a licensed nurse in bed but "had full range of motion and was without visible signs or symptoms of injury." Resident #1, was subsequently transferred from the bed to his wheelchair. A "short time thereafter" Resident #1 " complained of significant pain in his left leg." Resident #1 was then taken to the hospital, according to the investigation, and determined to have had a fracture of his left hip.

Based on facility investigation form, interview and record review the facility failed to ensure that Resident was free of accident hazards as Resident fell from the mechanical lift and suffered a fractured hip which required surgical intervention. (Resident identifier is #1.) Findings include: According to a Facility Initial Report Investigation and Staff A's personal statement regarding the facility investigation, on 9/29/13 at 6:45 a.m. Resident #1 was being transferred solely by Staff A (LNA) from the bed to chair via a total lift. Resident #1 fell out of the total lift when the resident became poorly positioned on the hoyer pad which caused the total lift to become off balance and one of the hoyer pad loops disconnected from the total lift and the resident fell to the floor. Staff A assisted Resident #1 off the floor and back to bed where resident was later assessed by the nurse according to nurses note dated 9/29/13 and resident was later transported to the hospital where x-rays revealed a fractured hip requiring surgical intervention to repair. Staff A documented in Staff A's statement dated 9/30/13 that "The 6:00 am LNA for North called out and the 6:00 am LNA for South called in to be late. My nurse was on the North side so I hoyered resident by myself." Resident's care plan for transfers dated 2/24/2012 stated Resident is a 2 person transfer for all transfers. The facility's Policy and Procedures, effective date: 06/01/96 and revision date: 01/01/13 entitled, "Procedure: Total Lift: Use of" requires 2 persons to use the lift for transfers of residents. Interview on 10/9/13 with Staff B (Administrator) confirmed Staff A was educated at the time of hire on 12/2010, on 6/2013 and after this incident was re-educated 10/1/13 on the proper use of the total lift and the need for at least two staff members at all times when using any mechanical lift. Staff B stated Staff B did not know why Staff A did not perform transfer with a second LNA or why Staff A assisted the resident back to bed before a nursing assessment had been done.