Every finding on record at Pines at Bristol for Nursing & Rehabilitation, The

Based on clinical record review, facility documentation review, facility policy review and interviews for three of five residents (Residents #5, #6 and #7) reviewed for misappropriation, the facility failed to prevent the misappropriation of the residents' controlled narcotic medications. The findings include: Resident #5 was admitted with diagnoses that included lumbar intervertebral disc painful compression and stenosis (narrowing of the spinal canal) and heart failure. A nursing admission/readmission evaluation dated 1/4/2026 at 4:06 PM identified Resident #5 was alert and oriented to person, place, time and situation and needed moderate assistance for walking. An APRN note dated 1/4/2026 at 8:45 AM identified Resident #5 was hospitalized for intractable back pain and several falls at home. Resident #5 was diagnosed with a compression fracture of the lower back (lumbar or L5) and treated with a back brace and pain management. A physician order dated 1/4/2026 directed to administer Hydromorphone HCl (a narcotic pain medication) two (2) milligrams (mg) tablet by mouth every six hours (6) hours as needed. A Resident care plan (RCP) dated 1/5/2026 identified Resident #5 had pain. Interventions directed to administer pain medications as ordered. A physician order dated 1/6/2026 at 12:14 PM directed to discontinue use of Hydromorphone. A facility reportable event (RE) form dated 1/6/2026 at 3:15 PM identified an incidence of misappropriation; during controlled medication audit it was identified that a white original copy of the Controlled Substance Disposition Record (Proof of Use Sheet) was missing, and the associated blister card of 28 tablets of Hydromorphone 2 mg was missing from the medication lock box in the medication cart. LPN #3 was assigned as the unit charge nurse for Resident #5's unit on 1/6/2026 on the 7:00 AM to 3:00 PM shift. Notifications were completed to the Administrator, local law enforcement, state Consumer Protection Agency Drug Control Division (drug control) and the medical director. Interview and facility documentation review with the DON on 3/11/2026 at 9:10 AM identified two (2) nurses complete a shift-to-shift reconciliation (narcotic count) at the change of each shift. The shift process required a count of the narcotics in the medication lock box compared to the number of medication tablets listed as remaining on the Controlled Substance Disposition Record (Proof of Use Sheet). The process also included a count of the Proof of Use Sheets and required sign off by the off-going and on-coming nurse at shift change. The supervisor would be notified of any count discrepancy between the actual number of tablets in the lock box and the Proof of Use Sheet, so an investigation could be initiated immediately. On 1/6/2026 at 7:10 AM, a narcotic count reconciliation was completed on Resident #5's unit medication cart by LPN #3 and the off-going 11-7 AM nurse, LPN #4, and the reconciliation identified the count was correct. At 9:40 AM an audit was performed by the ADNS who verified that the count and Proof of Use Sheets were correct. At 3:05 PM on 1/6/2026, an audit was performed by the DON of the Proof of Use Sheets prior to the nurse-to-nurse end of shift narcotic count. The DON identified that the Proof of Use Sheet (#1514816) for Resident #5's Hydromorphone 2 mg (unused medication) blister packet with 28 tablets was not in controlled medication book, and she did not observe the blister pack with the Hydromorphone at that time (the box was locked). The DON then observed the shift change narcotic count at 3:15 PM completed by LPN #3 and the oncoming 3-11 PM nurse and they indicated the count was correct. The DON then checked the locked medication box after LPN #3 left the unit and identified the Hydromorphone 2 mg 28 tablets that should have been in the lock box (related to the missing Proof of Use sheet) was not in the box. LPN #3 was the only nurse who had the keys to access the narcotic book and the medications in the lock box on 1/6/2026 during the 7 AM to 3 PM shift, and she was also the nurse who noted the new physician order to discontinue the Hydromorphone. The DON concluded that LPN #3 had diverted Resident #5's Hydromorphone 2 mg blister pack. LPN #3 was an agency nurse, she notified the employer, and stated during a subsequent call with the agency she was notified the agency was unable to contact LPN #3. Interview with CT Drug Control Agent #1 on 3/11/2026 at 1:00 PM identified she had been in contact with the local police who identified that LPN #3 had no explanation for the 28 missing Hydromorphone 2 mg tablets. Drug Control Agent #1 stated attempts to contact LPN #3 were unsuccessful, and she concluded that LPN #3 must have diverted Resident #5's 28 tablets of Hydromorphone 2mg on 1/6/2026, 2. Resident #6 was admitted with diagnoses that included after care after joint replacement right hip and osteoarthritis. A nursing admission evaluation dated 12/18/2025 at 6:45 PM identified Resident #6 was alert and oriented to person, place, time and situation and needed moderate assistance for walking. An APRN note dated 12/19/2025 at 5:55 PM identified Resident #6 had a right hip replacement and had effective pain control with the current medication regimen. A physician order dated 12/18/2025 directed to administer Hydromorphone HCl give two (2) mg by mouth every four (4) hours as needed for moderate pain, and give four (4) mg tablet by mouth every four hours (4) hours as needed for severe pain (7- 10 out of 10 possible levels). A physician order dated 12/19/2025 directed to administer Hydromorphone HCl give two (2) mg by mouth every four (4) hours as needed for moderate pain (scale of 4 to6 out of 10 possible levels) for fourteen (14) days, hold for sedation or shortness of breath (sob) and report to provider. The order further directed to give four (4) mg tablet by mouth every four hours (4) hours as needed for severe pain (7- 10 out of 10 possible levels) for fourteen (14) days and hold for sedation or shortness of breath (sob) and report to provider. The RCP dated 12/22/2025 identified that Resident #6 had pain due to osteoarthritis and medical procedure. Interventions directed to administer medications as ordered. A facility reportable event (RE) dated 12/22/2025 at 1 PM identified an incident of misappropriation; during a narcotic audit it was identified that Resident #6's new blister pack of fifteen (15) Hydromorphone HCL (Dilaudid) 2 mg and the white disposition sheet were missing from the unit narcotics lock box. The MD, local police and the state drug control were notified, and an investigation was initiated. A facility RE summary dated 12/31/2025 identified Resident #6 had no adverse effects of the missing medication as there was an additional supply that was available for use as ordered. An audit of the entire facility controlled medications was completed and no other controlled medications were unaccounted for, and the State drug control completed an audit on 12/29/2025. The summary failed to identify how the medication was missing. Interview and facility documentation review on 3/11/2026 at 11:27 AM with the DON identified she completed the investigation regarding missing Hydromorphone for Resident #6. The Hydromorphone HCL 2 mg fifteen (15) tablets blister pack was received from the pharmacy on 12/19/2025. The audit completed on 12/22/2025 identified the Proof of Use Sheet was missing (#1494923) from the narcotic book, 3 days after the medication was delivered. The DON stated she compared staff assigned to that unit and narrowed the list to three (3) possible nurses, including one (1) nurse that was involved with a prior narcotic diversion, but she was unable to identify which nurse was involved. Review of a state Division of Consumer Protection, Drug Control Division report case number 2025-2550 dated 2/25/2026 identified the pharmacy delivered two (2) blister pack cards Hydromorphone, fifteen (15) tablets each card, to the facility on [DATE]. The order was confirmed on 12/19/2025 at 3:43 PM by LPN #3 who was scheduled on the 3 to11 PM shift on 12/19/2025, on Resident #6's unit, and LPN #3 had received the Hydromorphone delivered by the pharmacy. 3. Resident # 7 was admitted with diagnoses that included status post displaced fracture of the left femur and left hip replacement. A 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 (was alert and oriented), and had reported occasional pain in the past five (5) days. The RCP dated 11/28/2025 identified Resident #7 had pain related to the fracture with interventions that directed to evaluate the effectiveness of pain relief and respond immediately to complaints of pain. A physician order dated 12/2/2025 directed Oxycodone HCL (opioid medication for pain) 5 mg, give 1 tablet every 4 hours as needed for moderate hip pain and give 2 tablets by mouth for severe hip pain. A facility reportable event (RE) dated 12/11/2205 identified an incident of misappropriation; Resident #7's new blister pack of fifteen (15) tablets of Oxycodone 5 mg was missing from the narcotic lock box, and the matching white Proof of Use Sheet (#1366669) was missing. On 12/5/2025 the facility received two (2) blister packs of Oxycodone 5 mg, each blister pack contained 15 tablets, and only one (1) card of 15 tablets was present in the narcotic lock box - 15 tablets were missing. Review of the Medication Administration Record (MAR) identified no Oxycodone was administered and an investigation was initiated. A facility RE summary dated 12/21/2025 identified an house-wide controlled medication audit was completed, and no other controlled medications were unaccounted for. The summary failed to identify how the medication was missing. Interview and facility documentation review with the DON on 3/13/2026 at 10:26 AM identified she completed the investigation. The DON stated two (2) blister pack cards of 15 tablets of Oxycodone were delivered to the facility on [DATE]. An audit completed on 12/11/2025 identified the white Proof of Use Sheet #1366669 was missing from the unit controlled substance book, and the matching Oxycodone 5 mg, 15 tablet blister pack was missing. The DON suspected a diversion, and her investigation identified the white Proof of Use Sheet was not included in the narcotic count on 12/9/2025 at 11 PM (there were 13 sheets at 3 PM, and at 11 PM there were only 12 sheets in the book). Interview failed to identify how the Oxycodone was missing. Interview and documentation review with the DON on 3/13/2026 at 11:00 AM identified that LPN #3 was identified in each investigation above. The DON stated the facility had systems in place to attempt to prevent misappropriation of controlled medications, and she concluded that the missing narcotics for Resident #5, Resident #6 and Resident #7 were likely all taken by LPN #3. Although attempted, interviews with LPN #3 were not obtained during the survey. The facility Abuse Policy dated 12/2023 directed in part, that each resident has the right to be free from misappropriation of resident property. Misappropriation of Resident Property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to provide adequate supervision to a resident with dementia who required staff assistance, resulting in a fall with injury. The findings include:Resident #1 had diagnoses that included dementia, fall with fractured femur, stroke, anxiety, history of falls, and atrial fibrillation. A physician's order dated 4/7/20 directed to administer Apixaban (thin blood and prevents blood clots) 2.5 milligram (mg) twice a day and assistance of one with toileting and ambulation using a rolling walker. The Resident Care Plan (RCP) dated 6/3/20 identified Resident #1 was at high risk for falls due to stroke, limited mobility, incontinence, psychotropic medication use, seizure disorder, vision impairment, and dementia. Resident #1 had prior falls on 3/25/20, 3/30/20, and 6/26/20. Interventions included floor mats on both sides of the bed, assist resident with getting ready for bed after dinner, assist resident with putting clothes away, and ensure resident is in wheelchair on last rounds on the 7:00 AM to 3:00 PM shift. The Fall Risk Evaluation dated 6/26/20 at 8:39 AM identified Resident #1 was at high risk for falls due to confusion, need for assistance with elimination, recent fall, history of 1-2 falls in the last 6 months, history of fall with fracture within the last 6 months, 2 or more falls since admission to the facility, confined to a chair, loss of balance while standing, balance problem when walking, decrease in muscular coordination, and use of an assistive device. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderately impaired cognition, was frequently incontinent of bladder, occasionally incontinent of bowel, and required extensive assistance for transfers, toileting, and personal hygiene. The MDS further identified anticoagulants (blood thinner) were administered since admission. Facility Reportable Event dated 8/4/20 at 10:15 PM identified Resident #1 was found on floor next to the bed with an open area under the bottom lip, with complaints of pain to his/her head, right hip, and right leg. Resident #1 was transferred to the emergency room. NA #1's written statement dated 8/4/20 identified at 10:15 PM she toileted Resident #1 and needed to go get a brief. NA #1 identified she left Resident #1 alone because the other staff were busy with other residents, so she ran to get a brief. NA #1 identified when she returned to the room Resident #1 was lying on the floor next to his/her bed clinching a pair of underwear and bleeding from his/her mouth. NA #1 called for the nurse who called the supervisor. The nurse's note written by Registered Nurse (RN) #2 on 8/4/20 at 11:48 PM identified at 10:20 PM she was called to assess Resident #1 due to a fall upon arrival Resident #1 was observed on the floor face down bleeding from his/her lips. RN #2 indicated Resident #1 was awake and alert and responsive per his/her baseline. RN #2 identified the APRN was notified, new orders obtained to send Resident #1 to the hospital, 911 was called, and Resident #1 was transported to the hospital. Review of the facility summary of the investigation dated 8/5/20 written by RN #1 (prior Director of Nursing Services) identified Resident #1 was unable to explain what happened, NA #1 stated she left Resident #1 alone on the toilet when she went to get supplies and upon return Resident #1 was on the floor. The Emergency Discharge summary dated [DATE] at 3:52 AM identified Resident #1 presented with a lower lip laceration requiring Dermabond (topical skin adhesive) facial contusion, hematoma, loose upper teeth, and headache. A CT scan showed no acute findings. The nurse's note dated 8/5/20 at 4:35 AM identified Resident #1 returned from the emergency room status post mechanical fall and the lower lip laceration was treated. Resident #1 has a facial contusion, subluxation of tooth, ecchymosis and swelling to left lower lip, left chin below the lip, and a linear bruise below left inner eye. The APRN note dated 8/5/20 at 12:12 PM identified Resident #1 was seen for complaints of left hip pain, X-ray ordered. Resident #1 had a fall last night and hit his/her mouth and the left side of his/her face bleeding was unable to be controlled so Resident #1 was sent to emergency room for CT scan of the head. In the emergency room Dermabond was applied to the lip laceration. A physician order dated 8/5/20 directed to obtain an X-ray of the left hip. The nurse's note dated 8/5/20 at 2:27 PM identified Resident #1's X-ray results of the left hip showed a post op left hip hardware with anatomic alignment and osteopenia without fracture. The nurse's note written by RN #3 dated 8/8/20 at 4:13 PM identified Resident #1 was noted with fading bruising around his/her left orbital area, chin area down to neck, and part of the jaw. RN #3 indicated Resident #1 complained of mild pain but can chew his/her food and drink. The investigation form dated 8/10/20 completed by RN #1 (the Director of Nursing Services at the time of the incident on 8/4/2020) identified NA #1 placed Resident #1 on the toilet with a wheelchair present, NA #1 left the resident unattended on the toilet to obtain supplies. Upon return, NA #1 found Resident #1 on the floor between the bed and dresser with a bleeding lip. Resident #1 was transferred to the hospital and required Dermabond to the laceration on the lower lip. RN #1 identified Resident #1 should not have been left alone and staff should obtain supplies prior to providing care.Interview with the Certified Occupational Therapy Assistant (COTA) on 2/20/26 at 12:03 PM identified in August of 2020 therapy documented per the physician's order Resident #1 required the assistance of one for toileting. The COTA indicated staff would automatically know not to leave Resident #1 alone in the bathroom because when they wrote the physician order it automatically transfers onto Resident #1's care plan and the nurse aide care card. The COTA identified residents requiring assistance of one staff for toileting must have supervision and should not be left alone, especially with a diagnosis of dementia. The COTA identified Resident #1 had a diagnosis of dementia, was a high fall risk, required assistance for toileting and should not have left alone in the bathroom by NA #1. Interview with RN #1 (former Director of Nursing Services) on 2/20/26 at 1:02 PM identified she was the Director of Nursing Services on 8/4/20; however, she does not recall Resident #1's fall. RN #1 indicated if a resident was at risk for falls, with a diagnosis of dementia, and required assistance for all ADLs including toileting, the resident may have needed consistent supervision on the toilet, depending on the individual resident's needs. RN #1 indicated Resident #1 required supervision in the bathroom it should have been on the care plan. Interview with Licensed Practical Nurse (LPN) #1 on 2/20/26 at 1:45 PM identified on 8/4/20 he was the nurse assigned to Resident #1. LPN #1 identified that a nurse aide notified him that Resident #1 was on the floor, so he notified the supervisor. LPN #1 indicated Resident #1 would at times get up without calling for assistance. LPN #1 further indicated that NA #1 was aware Resident #1 should not be left alone in the bathroom. LPN #1 identified Resident #1 who had diagnosis of dementia and required the assistance of one should not have been left alone in the bathroom by NA #1. Interview with NA #1 on 2/20/26 at 2:04 PM identified on 8/4/20 she was assigned to care for Resident #1. NA #1 identified she was aware that Resident #1 had a habit of getting up unassisted, wandered at times, was at risk for falls, and should not be left alone in the bathroom. NA #1 identified on 8/4/20 she left Resident #1 alone in the bathroom because she needed supplies and no one was around to help. NA #1 further identified when she returned to the room Resident #1 was on the floor. Interview and clinical record review with the DNS on 2/20/26 at 3:00 PM identified she was not the DNS at the facility on 8/4/20 when Resident #1 experienced a fall. The DNS identified on 8/4/20, Resident #1 was toileted by NA #1, NA #1 left Resident #1 alone in the bathroom to retrieve supplies, and upon returning NA #1 found Resident #1 on the floor bleeding from his/her lip. The DNS identified NA #1 should not have left Resident #1 unattended in the bathroom. Review of the facility Fall Prevention Program Policy identified the purpose of the program is to reduce the incidence of falls in residents identified at high risk for falls. Participation in the program is determined by a residents Fall Risk Assessment Score, history of falls, and recommendations from the nursing staff. Residents at high risk for falls will have interventions initiated to prevent falls.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #59, 63, 72, 121, and 346), reviewed as part of the sufficient competent nurse staffing review, the facility failed to ensure that the physician and resident representatives were immediately notified when medication omissions/errors were identified. The findings include: 1. Resident #59 was admitted to the facility in September 2023 with diagnoses that included psychiatric disorder with delusions, dementia, and chronic obstructive pulmonary disease The care plan dated 8/23/24 identified Resident #59 required psychotropic medications. Interventions included to administer medications as ordered. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance with dressing, bathing and toileting. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Prednisone tablet 10 mg daily (for wheezing). Gemtesa tablet 75 mg (for incontinence). Cholecalciferol tablet 1000 units (for osteoporosis). 9:30 AM Aspirin 81 mg by mouth (for prophylaxis). Bupropion extended release tablet 150 mg by mouth (for dementia and mood disturbance). Cardizem CD extended release tablet 120 mg (for hypertension). Cyanocobalamin tablet 1000 mg (b 12 supplement). Donepezil tablet 10 mg (for dementia). Gemtesa tablet 75 mg (for incontinence). Hydrochlorothiazide tablet 12.5 mg (for hypertension). Sertraline tablet 50 mg (for depression). Trilegy Ellipta 200-62.5-25 MCG inhaler one puff (for COPD). Budesonide 0.5 mg/2 ml inhalation one puff (for COPD). Gabapentin capsule 300 mg (for polyneuropathy). Preservision AREDs vitamin 1 tablet (for macular degeneration). Refresh Tears solution two drops to each eye (for dry eye). Reglan tablet 5 mg (for slow colonic transition). A nurse's note dated 9/23/24 at 1:40 AM by RN #6 identified that Resident #59 missed doses of all morning medications and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of all morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #59 after the missed doses of all morning medications. 2. Resident #63 was admitted to the facility in January 2020 with diagnoses that included Alzheimer's dementia, dysphagia and hypertension. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with dressing, bathing and toileting. The care plan dated 8/22/24 identified Resident #63 had altered cardiovascular status due to hypertension. Interventions included to administer cardiac medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:30 AM Amlodipine tablet 5 mg (for hypertension). Soothe XP artificial tears one drop in both eyes (for dry eyes). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #63 missed a 9:30 AM dose of amlodipine and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Amlodipine. The clinical record failed to reflect documentation related to an assessment of Resident #63 after the missed dose of Amlodipine. 3. Resident #72 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's dementia, delusional disorder and adult failure to thrive. The annual MDS dated [DATE] identified Resident #72 had intact cognition, was always continent of bowel, occasionally incontinent of bladder, required supervision with bathing, and was independent with toileting and dressing. The care plan dated 9/9/24 identified Resident #72 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Ascorbic Acid tablet 500 mg (Vitamin C supplement). Polyethylene Glycol powder 17 GMS daily (for constipation). Cyclosporin emulsion 0.5% one drop to each eye (for inflammation). A nurse's note dated 9/23/24 at 1:42 AM by RN #6 identified that Resident #72 missed a 9:00 AM dose of Vitamin C and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Vitamin C. 4. Resident #121 was admitted to the facility on [DATE] with diagnoses that included pneumothorax, dementia, and hypertension. The admission MDS dated [DATE] identified Resident #121 had moderately impaired cognition, was occasionally incontinent of bowel and bladder and required partial staff assistance with dressing, bathing and toileting. The care plan dated 7/12/24 identified Resident #121 had a potential of untoward effects due to anticoagulant therapy. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Cozaar 25 mg tablet (for hypertension). Lidocaine 4% patch apply to lower back topically (for pain). Loratadine tablet 10 mg by mouth (for allergy symptoms). Metoprolol 24 hour extended release tablet 25 mg (for beta blocker). Sertraline tablet 50 mg half tablet (for anxiety). Vitamin D 5000 unit tablet (for supplement). Eliquis 2.5 mg tablet (for anticoagulation). Memantine tablet 5 mg (for psychotropic). 9:30 AM Preservision AREDs vitamin 1 tablet (for supplementation). 12:00 PM Tylenol table 650 mg (for pain). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #121 missed 9:00 AM doses of Eliquis, Loratadine, Losartan, Memantine, Metoprolol, Vitamin D and a 12:00 PM dose of Tylenol, and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of the morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #121 after the missed doses of morning medications. 5. Resident #346 was admitted to the facility in November 2018 with diagnoses that included Alzheimer's dementia, heart failure and hypertension. The quarterly MDS dated [DATE] identified Resident #346 had severely impaired cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with toileting and was dependent on staff to assist with dressing and bathing. The care plan dated 9/19/24 identified Resident #346 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). Refresh tears one drop in each eye (for dry eye). 1:00 PM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). A nurse's note dated 9/23/24 at 1:14 AM by RN #6 identified that Resident #346 missed a 9:00 AM dose of Lexapro on 9/22/24 and an APRN was notified. Review of the clinical record failed to identify an order for Lexapro for Resident #346. During a review of performance evaluations for facility nursing staff on 3/25/25, a review of LPN #3's personnel file identified multiple documents related additional training, verbal and written counseling, and disciplinary actions related to medication administration errors involving multiple residents in the facility. A review of the file identified (on the job training) dated 9/22/24 identified LPN #3 to her failure to administer morning medications to 5 residents. The training provided included that all medications must be administered for each medication pass and if a resident was unable to get their medication for any reason, then a supervisor must be notified. Review the documentation failed to identify the names of the 5 residents involved, any investigations regarding the incident, or the outcome of the investigation. Interview with the DNS on 3/25/25 at 3:00 PM identified that she did not investigate the medication errors for the 5 residents identified in LPN #3's personnel file documentation. The DNS identified that the facility used a prepackaged packet system that contained all the medications due on a specific time/date for each resident of the facility. The DNS identified that on 9/22/24 when RN #6 came on duty for the 7:00 PM - 7:00 AM shift, she discovered prepackaged morning medications for 5 residents that had been assigned to LPN #3 during the 7:00 AM - 3:00 PM shift were in the medication cart. The DNS identified that RN #6 notified her of what occurred, and she spoke with LPN #3 the following day on 9/23/24. The DNS identified that LPN #3 reported to her that for those 5 residents, LPN #3 identified to her that she opted to use individual blister packets of each medication that were due to administer morning medications for just those 5 residents. The DNS identified this as a sufficient explanation but was unable to identify why LPN #3 would have dispensed the medications for just those 5 residents from individual blister packets, when each resident had individual fully prepacked medications for each administration time. The DNS also identified that she did not look any further into any additional medications that were not prepackaged for the impacted residents, as LPN #3 signed off the medications on the MAR. Interview with the DNS on 3/25/25 at 4:30 PM identified that, following a request to provide documentation of the 5 residents affected by the errors, the DNS identified Resident #59, Resident #63, Resident #72, Resident #121, and Resident #346 as the residents impacted. Interview with RN #6 on 3/26/25 at 9:37 AM identified she was the RN supervisor on the 7:00 PM - 7: AM shift on 9/22/24 and during the shift, LPN #10 notified her that 5 of her residents' prepackaged morning medications were in the medication cart. RN #6 identified that she instructed LPN #10 to place a note for each resident in the APRN notification book related to the errors, and then RN #6 then went through the packages and made notes in each resident's chart. RN #6 identified that LPN #3 had worked a double shift (7:00 AM - 11:00 PM) on 9/22/24, and that once the errors were discovered, she completed the on the job training form and completed education and counseling with LPN #3 prior to her shift ending. RN #6 identified that LPN #3 was unable to identify why the residents' morning medication packets were in the cart, and did not provide any explanation to her related to use of blister packets instead of the pharmacy prepackaged medications. RN #6 identified that she only reviewed the medication packets and did not look any further into the errors. RN #6 identified that LPN #10 was assigned to the 5 residents at the time the errors were discovered, and she was unsure if LPN #10 completed any assessments on the residents. Although attempted, an interview with LPN #3, LPN #10 and MD #1 (Medical Director) were not obtained. The facility policy on accidents and incidents directed that occurrences would be investigated in a timely manner and preventative measures would be initiated and the Risk Management system (RMS) event would be used to document incidents including those involving medication errors. The policy further directed that staff would notify the nursing supervisor when an incident occurred, the licensed nurse or nursing supervisor would complete and document an evaluation of the resident's condition, including but not limited to vital signs, neurological status, and evaluation of pain. The policy also directed that the healthcare provider would be notified with a date and time of notification in the RMS and nurse's notes with any new orders or recommendations made by the provider. If the healthcare provider could not be reached in a timely manner, the Medical Director should be called. The policy also directed that the resident representative should be notified by the licensed nurse or designee in the RMS and nurse's notes, including any failed attempts. The facility policy on change of condition directed that the facility must inform the resident, consult with the resident's healthcare provider and notify the resident's legal representative or family member when an incident involving the resident may result in injury or require medical treatment, a significant change in the resident's physical, mental, or psychological status; or a need to alter treatment significantly. The policy further directed that the licensed nurse would conduct a complete physical/mental evaluation and document the findings in the medical record, including the resident's reaction to symptoms (i.e pain, anxiety, etc). The policy also directed the licensed nurse should notify the resident, attending physician, and family and/or resident representative of the change of condition, and that repeated attempts would be made until successful and would be documented. The facility policy on medication pass directed that the physician should be notified immediately for any high risk medications for change of condition not given including but not limited to cardiac medications, anticoagulants, and psychotropics.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 7 residents (Resident #59, 63, 68, 72, 85, 121 and 346), the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For 1 of 2 residents (Resident #59) reviewed for edema, the facility failed to follow the physician's order for compression stockings. For 2 of 2 residents (Resident #68 and 85) reviewed for edema, the facility failed to ensure the staff monitored the intake and output for a resident on a fluid restriction. For 5 residents (Residents #59, 63, 72, 121 and 346) the facility failed to ensure medications were administered per the physician's orders, and failed to ensure that following an identified medication administration error, a change of condition nursing assessment was completed. The findings include. 1. Resident #59 was admitted to the facility in July 2022 with diagnoses that included dementia, high blood pressure, and heart failure. The quarterly MDS dated [DATE] identified Resident #59 had moderately impaired cognition and required limited assistance for dressing and transfers with one staff member. The care plan dated 2/14/25 identified Resident #59 had altered cardiovascular status. Interventions included keeping legs elevated times 2 hours and notifying the physician of any change in condition. A physician's order dated 3/22/25 at 12:10 PM directed to apply compression socks in the morning and remove at bedtime. Observation on 3/23/25 at 10:40 AM identified Resident #59 was sitting dressed in his/her wheelchair wearing regular socks and slippers without the benefit of the compression socks. Observation on 3/24/25 at 11:00 AM identified Resident #59 was dressed and sitting in the wheelchair with regular socks on and slippers without the benefit of the compression socks. Observation on 3/25/25 at 11:30 AM identified Resident #59 was dressed and sitting in the wheelchair with regular socks on and slippers without the benefit of the compression socks. Observation on 3/25/25 at 2:40 PM identified Resident #59 was in the recreation room for bingo sitting in the wheelchair with regular socks on and slippers without the benefit of the compression socks. Interview with LPN #7 on 3/25/25 at 2:56 PM indicated that the nurses are responsible to put the compression socks on residents in the morning with morning care before a resident gets out of bed and the nurse must sign off on the TAR that the compression socks have been applied. LPN #7 indicated that she did not put the compression socks on Resident #59 this morning because she did not see an order for the compression socks. After clinical record review, LPN #7 indicated that although there is an order for compression socks, the compression socks are not listed on the TAR so LPN #7 indicated she was not aware. LPN #7 indicated that when transcribing the order from the physician, LPN #8 should have made sure it was added to the TAR and included specific times to apply and remove. Interview with APRN #1 on 3/25/25 at 3:10 PM identified Resident #59 had dependent edema in bilateral lower extremities and had poor circulation from sitting in a wheelchair. APRN #1 indicated that she had put the order for the compression socks in the EMR and the charge nurse is responsible to transcribe the order. APRN #1 indicated the nurses are responsible to follow the order and apply the compression socks every morning before the resident gets out of bed and if the resident had refused, the refusal should be documented, and she would have been notified. Interview with the DNS on 3/25/25 at 3:15 PM indicated the order for Resident #59 was for the white compression socks that are house stock and if not available the nurse can notify the pharmacy to send them. The DNS indicated APRN #1 had put in the order for the compression socks but did not trigger the order to display on the TAR to have the nurse sign off as applying the compression socks in the morning and the evening nurse to remove them. The DNS indicated that when LPN #8 confirmed the order he was responsible to check the order to make sure it was correct before signing off as transcribing/confirming the order. The DNS indicated that she would correct the order and make sure Resident #59 has a new pair of compression socks for tomorrow morning. Although requested, a facility policy for compression socks was not provided. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure (CHF) and cognitive communication deficit. A physician's order dated 3/3/25 directed to administer Torsemide (diuretic) 80 mg daily, and Cardizem LA extended release 120 mg daily. Additionally, maintain a fluid restriction of 1500 ml daily (breakfast 420cc, lunch240cc, 240ml dinner and evening, and 120 ml on nights) and daily weights for CHF. The care plan dated 3/13/25 identified Resident #68 has a 1500 ml per day fluid restriction. Interventions included giving 420 ml with breakfast, 240 ml with lunch, and 240 ml with dinner and nursing to give 480 ml. Resident #68 was non-compliant with fluid restrictions and diet. The quarterly MDS dated [DATE] identified Resident #68 had moderately impaired cognition, was always incontinent of bowel and bladder and required set up and clean up for eating, dressing and personal hygiene. Additionally, Resident #68 received diuretic medications. The nurse's aide care card failed to reflect the ordered fluid restriction. Review of the daily intake and output forms dated 3/19/25 to 3/22/25 identified 4 out of 4 days were not completed every shift and 24-hour totals were not calculated. Observation on 3/23/25 at 10:30 AM identified the resident was sitting in a recliner chair next to the bed with a large, insulated cup with a lid and straw drinking from it. Resident #68 indicated that the staff had filled it for him/her. Resident #68 indicated at that time that he/she was on a fluid restriction but does not know why and knows he/she does not follow it and drinks a lot more than he/she should. Interview with the DNS on 3/23/25 at 1:50 PM identified that Resident #68 was on a 1500 ml per day fluid restriction for CHF per physician's order. The DNS indicated that the charge nurse was responsible to ask the nurse's aide each shift what Resident #68' fluid intake was and document the total on the form. The DNS indicated that the intake and output is documented on paper, that are then scanned into the medical record and that staff do not document intake and output in the electronic medical record directly, only on paper. The DNS indicated that the 3:00 PM to 11:00 PM nurse was responsible to add the 24-hour total and if Resident #68 had gone over the restriction he/she is responsible for noting that in the APRN book. The DNS indicated that the charge nurse does not document notification to the APRN in the clinical record and only documents it in the APRN communication book on the unit if Resident #68 goes over the fluid restriction. After review of the clinical record, the DNS identified that the intake and output was not completed from 3/19/25 to 3/22/25. The DNS indicated that Resident #68 has a care plan for non-compliance with the fluid restriction and that the resident drinks more than he/she should. The DNS was not able to identify if Resident #68 was over or under the fluid restriction for the 4 days because the information was not completed. After surveyor inquiry, a physician order dated 3/24/25 at 8:16 AM transcribed by the ADNS directed the nurse to document Resident #68's fluid intake at end of each shift due to the fluid restriction. Interview with the Dietitian on 3/25/25 at 8:37 indicated that Resident #68 was on a 1500 ml per day fluid restriction for heart failure and edema. The Dietitian indicated that Resident #68 was not always compliant with the fluid restrictions and nursing was responsible to monitor the intake and output. The Dietitian indicated that it was important to monitor his/her fluid restriction because of the CHF and he/she could go into fluid overload if the fluid restriction is not followed. 3. Resident #85 was admitted to the facility in March 2024 with diagnoses that included chronic kidney disease, dysphasia, and hypertension. The quarterly MDS dated [DATE] identified Resident #85 had moderately impaired cognition, was occasionally incontinent of bladder and required maximum assistance for toileting, dressing, and personal hygiene. The care plan dated 12/26/24 identified Resident #85 had fluid overload or potential for fluid volume overload due to Chronic Kidney Disease (CKD) and hypertension. Interventions included setting the resident up for meals, and monitoring and document intake and output as per facility policy. Additionally, Resident #85 is on a 1500 ml per day fluid restriction 420 ml for breakfast, 240 ml for lunch, 240 ml for dinner, and 480 ml for nursing between dinner and evening and 120 ml during the night. Additionally, ensure all meals and fluid intake occur under staff supervision. A physician's order dated 2/14/25 directed a fluid restriction of 1500 ml per day with 420 ml for breakfast, 240 ml for lunch, 240 ml for dinner and 480 ml nursing between dinner and evening, and 120 ml for nights related to chronic kidney disease stage 3. Interview with the DNS on 3/23/25 at 2:00 PM identified that Resident #85 was on a 1500 ml per day fluid restriction for chronic kidney disease per the physician's order. The DNS indicated that the charge nurse was responsible for asking the nurse aides each shift what the resident's intake was and document the total on the form. The DNS indicated that the intake and output is documented on paper and then scanned into the medical record. The DNS indicated that they do not document the intake and output in the electronic medical, only on paper. The DNS indicated that the 3:00 PM to 11:00 PM nurse was responsible for adding the 24-hour total and if Resident #68 had gone over to write it in the APRN book for the APRN next visit. The DNS indicated that the charge nurse does not document the APRN notification in the clinical record and only documents it in the APRN communication book on the unit. Review of the clinical record identified that the intake and output was not completed from 3/19/25 to 3/22/25. The DNS was not able to identify if Resident #85 was over or under his/her fluid restriction for the last 4 days. After surveyor inquiry, a physician's order dated 3/24/25 at 8:19 AM created and transcribed by the ADNS directed the nurse to document Resident #85's fluid intake at end of each shift. The interview with Dietitian on 3/25/25 at 8:41 AM indicated Resident #85 was on a 1500 ml per day fluid restriction for chronic kidney disease. The Dietitian indicated that nursing was responsible to monitor and document the intake and output and notify her if Resident #85 was going over the fluid restriction. Review of the daily intake and output forms dated 3/19 to 3/22/25 identified 4 out of 4 days were not completed every shift and there were no 24-hour totals. Review of the Intake and Output Policy, revised in 3/2023, identified to accurately monitor, evaluate, and manage adequate hydration levels of those residents requiring fluid intake and output monitoring nursing personnel are responsible for documenting fluid intake and output totals in the EMR. The nurse's aide is responsible for documenting the total amounts of fluid taken with meals and those fluids taken between meals that have been provided by the nurse's aide. The nurse is responsible for documenting fluids given to the residents including tube feeding, IV, supplements, those given with medication pass, etc. the EMR will calculate the total fluid intake and output daily. This can be reviewed daily by accessing the look back report for each resident. The Licensed nurse will assess the total intake and output report requiring fluid intake monitoring to determine if the resident is meeting their hydration goals. Notify the healthcare provider of all fluid averages that fall below established fluid goals after 3 consecutive days. 4. Resident #59 was admitted to the facility in September 2023 with diagnoses that included psychiatric disorder with delusions, dementia, and chronic obstructive pulmonary disease The care plan dated 8/23/24 identified Resident #59 required psychotropic medications. Interventions included to administer medications as ordered. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance with dressing, bathing and toileting. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Prednisone tablet 10 mg daily (for wheezing). Gemtesa tablet 75 mg (for incontinence). Cholecalciferol tablet 1000 units (for osteoporosis). 9:30 AM Aspirin 81 mg by mouth (for prophylaxis). Bupropion extended release tablet 150 mg by mouth (for dementia and mood disturbance). Cardizem CD extended release tablet 120 mg (for hypertension). Cyanocobalamin tablet 1000 mg (b 12 supplement). Donepezil tablet 10 mg (for dementia). Gemtesa tablet 75 mg (for incontinence). Hydrochlorothiazide tablet 12.5 mg (for hypertension). Sertraline tablet 50 mg (for depression). Trilegy Ellipta 200-62.5-25 MCG inhaler one puff (for COPD). Budesonide 0.5 mg/2 ml inhalation one puff (for COPD). Gabapentin capsule 300 mg (for polyneuropathy). Preservision AREDs vitamin 1 tablet (for macular degeneration). Refresh Tears solution two drops to each eye (for dry eye). Reglan tablet 5 mg (for slow colonic transition). A nurse's note dated 9/23/24 at 1:40 AM by RN #6 identified that Resident #59 missed doses of all morning medications and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of all morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #59 after the missed doses of all morning medications. 5. Resident #63 was admitted to the facility in January 2020 with diagnoses that included Alzheimer's dementia, dysphagia and hypertension. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with dressing, bathing and toileting. The care plan dated 8/22/24 identified Resident #63 had altered cardiovascular status due to hypertension. Interventions included to administer cardiac medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:30 AM Amlodipine tablet 5 mg (for hypertension). Soothe XP artificial tears one drop in both eyes (for dry eyes). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #63 missed a 9:30 AM dose of amlodipine and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Amlodipine. The clinical record failed to reflect documentation related to an assessment of Resident #63 after the missed dose of Amlodipine. 6. Resident #72 was admitted to the facility in September 2021 with diagnoses that included Alzheimer's dementia, delusional disorder and adult failure to thrive. The annual MDS dated [DATE] identified Resident #72 had intact cognition, was always continent of bowel, occasionally incontinent of bladder, required supervision with bathing, and was independent with toileting and dressing. The care plan dated 9/9/24 identified Resident #72 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Ascorbic Acid tablet 500 mg (Vitamin C supplement). Polyethylene Glycol powder 17 GMS daily (for constipation). Cyclosporin emulsion 0.5% one drop to each eye (for inflammation). A nurse's note dated 9/23/24 at 1:42 AM by RN #6 identified that Resident #72 missed a 9:00 AM dose of Vitamin C and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed dose of Vitamin C. 7. Resident #121 was admitted to the facility on [DATE] with diagnoses that included pneumothorax, dementia, and hypertension. The admission MDS dated [DATE] identified Resident #121 had moderately impaired cognition, was occasionally incontinent of bowel and bladder and required partial staff assistance with dressing, bathing and toileting. The care plan dated 7/12/24 identified Resident #121 had a potential of untoward effects due to anticoagulant therapy. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Cozaar 25 mg tablet (for hypertension). Lidocaine 4% patch apply to lower back topically (for pain). Loratadine tablet 10 mg by mouth (for allergy symptoms). Metoprolol 24 hour extended release tablet 25 mg (for beta blocker). Sertraline tablet 50 mg half tablet (for anxiety). Vitamin D 5000 unit tablet (for supplement). Eliquis 2.5 mg tablet (for anticoagulation). Memantine tablet 5 mg (for psychotropic). 9:30 AM Preservision AREDs vitamin 1 tablet (for supplementation). 12:00 PM Tylenol table 650 mg (for pain). A nurse's note dated 9/23/24 at 1:44 AM by RN #6 identified that Resident #121 missed 9:00 AM doses of Eliquis, Loratadine, Losartan, Memantine, Metoprolol, Vitamin D and a 12:00 PM dose of Tylenol, and an APRN was notified. Further review of the clinical record failed to identify any other documentation related to the missed doses of the morning medications. The clinical record failed to reflect documentation related to an assessment of Resident #121 after the missed doses of morning medications. 8. Resident #346 was admitted to the facility in November 2018 with diagnoses that included Alzheimer's dementia, heart failure and hypertension. The quarterly MDS dated [DATE] identified Resident #346 had severely impaired cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with toileting and was dependent on staff to assist with dressing and bathing. The care plan dated 9/19/24 identified Resident #346 had impaired cognitive function due to dementia. Interventions included to administer medications as ordered. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning medications as administered as follows: 9:00 AM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). Refresh tears one drop in each eye (for dry eye). 1:00 PM Lorazepam oral concentrate 2 mg/ml - 1 ml by mouth (for anxiety and restlessness). A nurse's note dated 9/23/24 at 1:14 AM by RN #6 identified that Resident #346 missed a 9:00 AM dose of Lexapro on 9/22/24 and an APRN was notified. Review of the clinical record failed to identify an order for Lexapro for Resident #346. During a review of performance evaluations for facility nursing staff on 3/25/25, a review of LPN #3's personnel file identified multiple documents related additional training, verbal and written counseling, and disciplinary actions related to medication administration errors involving multiple residents in the facility. A review of the file identified (on the job training) dated 9/22/24 identified LPN #3 to her failure to administer morning medications to 5 residents. The training provided included that all medications must be administered for each medication pass and if a resident was unable to get their medication for any reason, then a supervisor must be notified. Review the documentation failed to identify the names of the 5 residents involved, any investigations regarding the incident, or the outcome of the investigation. Interview with the DNS on 3/25/25 at 3:00 PM identified that she did not investigate the medication errors for the 5 residents identified in LPN #3's personnel file documentation. The DNS identified that the facility used a prepackaged packet system that contained all the medications due on a specific time/date for each resident of the facility. The DNS identified that on 9/22/24 when RN #6 came on duty for the 7:00 PM - 7:00 AM shift, she discovered prepackaged morning medications for 5 residents that had been assigned to LPN #3 during the 7:00 AM - 3:00 PM shift were in the medication cart. The DNS identified that RN #6 notified her of what occurred, and she spoke with LPN #3 the following day on 9/23/24. The DNS identified that LPN #3 reported to her that for those 5 residents, LPN #3 identified to her that she opted to use individual blister packets of each medication that were due to administer morning medications for just those 5 residents. The DNS identified this as a sufficient explanation but was unable to identify why LPN #3 would have dispensed the medications for just those 5 residents from individual blister packets, when each resident had individual fully prepacked medications for each administration time. The DNS also identified that she did not look any further into any additional medications that were not prepackaged for the impacted residents, as LPN #3 signed off the medications on the MAR. Interview with the DNS on 3/25/25 at 4:30 PM identified that, following a request to provide documentation of the 5 residents affected by the errors, the DNS identified Resident #59, Resident #63, Resident #72, Resident #121, and Resident #346 as the residents impacted. Interview with RN #6 on 3/26/25 at 9:37 AM identified she was the RN supervisor on the 7:00 PM - 7: AM shift on 9/22/24 and during the shift, LPN #10 notified her that 5 of her residents' prepackaged morning medications were in the medication cart. RN #6 identified that she instructed LPN #10 to place a note for each resident in the APRN notification book related to the errors, and then RN #6 then went through the packages and made notes in each resident's chart. RN #6 identified that LPN #3 had worked a double shift (7:00 AM - 11:00 PM) on 9/22/24, and that once the errors were discovered, she completed the on the job training form and completed education and counseling with LPN #3 prior to her shift ending. RN #6 identified that LPN #3 was unable to identify why the residents' morning medication packets were in the cart, and did not provide any explanation to her related to use of blister packets instead of the pharmacy prepackaged medications. RN #6 identified that she only reviewed the medication packets and did not look any further into the errors. RN #6 identified that LPN #10 was assigned to the 5 residents at the time the errors were discovered, and she was unsure if LPN #10 completed any assessments on the residents. Although attempted, an interview with LPN #3, LPN #10 and MD #1 (Medical Director) were not obtained. The facility policy on accidents and incidents directed that occurrences would be investigated in a timely manner and preventative measures would be initiated and the Risk Management system (RMS) event would be used to document incidents including those involving medication errors. The policy further directed that staff would notify the nursing supervisor when an incident occurred, the licensed nurse or nursing supervisor would complete and document an evaluation of the resident's condition, including but not limited to vital signs, neurological status, and evaluation of pain. The policy also directed that the healthcare provider would be notified with a date and time of notification in the RMS and nurse's notes with any new orders or recommendations made by the provider. If the healthcare provider could not be reached in a timely manner, the Medical Director should be called. The policy also directed that the resident representative should be notified by the licensed nurse or designee in the RMS and nurse's notes, including any failed attempts. The facility policy on change of condition directed that the facility must inform the resident, consult with the resident's healthcare provider and notify the resident's legal representative or family member when an incident involving the resident may result in injury or require medical treatment, a significant change in the resident's physical, mental, or psychological status; or a need to alter treatment significantly. The policy further directed that the licensed nurse would conduct a complete physical/mental evaluation and document the findings in the medical record, including the resident's reaction to symptoms (i.e pain, anxiety, etc). The policy also directed the licensed nurse should notify the resident, attending physician, and family and/or resident representative of the change of condition, and that repeated attempts would be made until successful and would be documented. The facility policy on medication pass directed that the physician should be notified immediately for any high risk medications for change of condition not given including but not limited to cardiac medications, anticoagulants, and psychotropics. 46040 47457

Based on observation, review of the clinical record review, facility documentation, facility policy, and interviews, the facility failed to ensure all facility nursing staff were educated on the identifying mechanism for enhanced barrier precautions (EBP). The findings include: Observations on 3/23/25 at 11:37 AM of the 1st floor Passport unit identified multiple bright pink circular stickers placed on several exterior name plates for residents on the unit. No other information identifying what the pink stickers were for was observed. Interview with LPN #3 on 3/23/25 at 11:50 AM identified she was unsure what the pink circular stickers were for and identified that she thought they had been placed by the Infection Control Nurse, and had something to do with infections, but did not know anything else about the stickers. Interview with NA #4 on 3/23/25 at 11:51 AM identified she had seen the pink circular stickers on multiple resident entryways but had no idea what the stickers meant. Interview with NA #5 on 3/25/25 at 10:30 AM identified that the pink circular stickers were placed to identify if a resident needed to don PPE with wound care. NA #5 further identified that the stickers were also used for residents with colostomies. Interview with RN #1 (Staff Development Nurse) and RN #5 (Infection Prevention Nurse #2) on 3/25/25 at 1:04 PM identified that the pink circular stickers were implemented in March 2024 to identify residents who met the criteria for enhanced barrier precautions (EBP). RN #1 identified that the facility had multiple in-service education sessions for facility staff working in the facility at the time the sticker system was implemented, and that in addition, all newly hired staff were provided education on the sticker system as part of the new hire process. A review of facility in-service documentation related to the EBP sticker identification system identified education began on 3/27/24 and ended 4/7/24. Review of the in-service sign in logs failed to identify any documentation that LPN #3, NA #4, or NA # 5 were provided in-service education for the EBP sticker system. Further review of the in-service education sign in logs identified that 3 of 17 RNs, 9 of 27 LPNs, and 20 of 72 nurse aides in the facility had documented education on the EBP sticker system, including what EBP was, how the sticker system worked, and how EBP was implemented for an affected resident. A follow up interview with RN #1 on 3/25/25 at 4:25 PM identified that subsequent to surveyor inquiry she had begun auditing staff on the sticker system and had discovered that many staff were not aware of what the pink circular stickers were for, and advised she was now working on an education plan to reeducate the staff on the stickers, what enhanced barrier precautions were for, and how to implement them. The facility policy on enhanced barrier precautions (EBP) directed that residents would be on EBP to reduce the transmission of novel and MDROs when contact precautions did not apply when performing high risk resident care activities. The policy further identified that EBP was indicated for resident with pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous statis ulcers, central lines including hemodialysis catheters, urinary catheters, urinary catheters, feeding tubes, and tracheostomies. The policy also directed that high-risk care activities included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device, or wound care. The policy also identified that residents of the facility on EBP would have special precaution notes in their care profile and would be identified by a bright pink colored dot next to their name outside of their room door.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #340) reviewed for transmission-based precautions, the facility failed to ensure nursing staff adhered to appropriate infection control techniques for a resident on contact precautions. The findings include: Resident #340 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, history of falling, and dysphagia. The admission MDS dated [DATE] identified Resident #340 had moderately impaired cognition, was always continent of bowel, occasionally incontinent of bladder and required partial assistance from facility staff with dressing, bathing, and toileting. The care plan dated 3/22/25 identified Resident #340 had gastroenteritis. Interventions included standard plus enteric contact precautions. A physician's order dated 3/22/25 directed to collect stool sample for Clostridium Difficile (C. Diff) one time for diarrhea. Observation on 3/23/25 at 11:43 AM identified a sign located outside of Resident #340's room along with a PPE cart labeled Contact Enteric Precautions. Visitors cleanse hands with sanitizer upon entering room and wash with soap and water upon leaving room. Doctors and staff must gown and glove at the door. LPN #3 was observed to enter Resident #340's room without the use of hand sanitizer, gowning, or gloving to provide assistance as Resident #340 appeared unsteady on his/her feet. NA #4 was observed standing outside of the room, directly facing the resident's doorway, the precautions sign, and PPE cart, observing Resident #340 and LPN #3. At 11:45 AM, LPN #3 asked NA #4 to provide assistance to Resident #340. LPN #3 then exited Resident #340's room and used a wall mounted hand sanitizer for hand hygiene. NA #4 entered Resident #340's room without use of hand sanitizer, gowning or gloving, and provided Resident #340 assistance to bed and then exited the room at 11:47 AM. Interview with LPN #3 and NA #4 immediately following the observation identified that LPN #3 was aware that Resident #340 was on precautions due to GI symptoms but was unsure if the resident had been diagnosed with any specific organism. LPN #3 identified that she did not don PPE due to Resident #340's need for immediate assistance but she should have washed her hands prior to exiting the room. NA #4 identified that she did not she need PPE since LPN #3 did not put on PPE. NA #4 identified she was unsure if she should have washed her hands or used hand sanitizer on entering or exiting. A C-Diff toxin PCR lab report dated 3/23/25 at 3:59 PM identified Resident #340 was negative. Interview with RN #1 (Staff Development Nurse) and RN #5 (Infection Prevention Nurse #2) on 3/25/25 at 1:04 PM identified that the facility was in a current GI outbreak and that any resident with diarrhea and GI symptoms was placed on contact enteric precautions while determining the cause. RN #1 identified that the precautions included ensuring gloves and gowns were used when a resident with symptoms had a bowel movement and that all staff should perform hand hygiene after doffing gloves. RN #1 identified that education regarding outbreak control, along with hand hygiene and PPE audits had been ongoing since 12/2024, and all staff received infection prevention, hand hygiene and PPE donning and doffing education upon hire and annually. RN #1 and RN #5 identified that the level of PPE needed depended on the level of care a resident may require but that with bowel movements staff should always don gloves. Review of education documentation for LPN #3 dated 7/31/24 identified competencies were noted as passed and performed correctly related to hand hygiene and all skills met related to PPE donning and doffing. Review of education documentation for NA #4 dated 9/26/24 identified competencies were noted as passed and performed correctly related to hand hygiene and all skills met related to PPE donning and doffing. The facility policy on precautions to prevent Infection directed that contact precautions were to be implemented for any resident with the presence of acute diarrhea or C-diff infection and PPE should be used with any room entry. The policy further directed that PPE should include gloves and gown (don before room entry, doff before room exit) and entrance to the room should be restricted to medically necessary care. The policy directed for use of alcohol based hand sanitizers except with C-Diff. Review of the hand hygiene competency education form directed all staff to remember to always use soap and water for patients with C. Diff or Norovirus.

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure resident council funds, that were raised during fund raising events, had complete and accurate record keeping, and were in an interest-bearing account. The findings include: Review of the resident council meeting minutes identified the following. Minutes dated 9/11/23 identified starting 9/18/23 to 9/27/23 there would be a [NAME] to raise money for resident council. Minutes dated 11/13/23 identified the craft fair on 11/10/23 and 11/11/23 raised $1200. Minutes dated 2/5/24 identified someone donated an Afghan to be raffled off for Mother's Day. Minutes dated 3/11/24 identified residents had a tag sale on 4/26/24 and 4/27/24. The Director of Recreation informed the residents she would be using the proceeds from the raffles and tag sale to purchase cloths for the prom and other recreation items needed for the residents. Minutes dated 4/1/24 identified Director of Recreation informed residents the Easter [NAME] raised $250 and all proceeds from the raffles and tag sale would be used to purchase clothing for the prom in May. Minutes dated 9/10/24 identified there would be a craft show on 11/15/24 and 11/16/24 and the residents were making different crafts to sell. The Director of Recreation informed residents that recreation has money and asked for suggestions on how to use the money. The Recreation Assistant suggested an Elvis impersonator, pizza party, more entertainers, and more animal visits. Minutes dated 10/7/24 identified the Director of Recreation asked how residents wanted to spend money from the resident council fund but did not identify how much money was in the fund. The Director of Recreation suggested a game table and everyone liked the idea. The Director of Recreation indicated that the resident council funds would be used for a pizza party this month. The Director of Recreation asked residents about a visit from the Elvis impersonator and only a few residents showed interest. Minutes dated 11/11/24 identified a ping pong and air hockey table was purchased. Minutes dated 12/2/24 identified 2 residents were selling [NAME] tickets for a gift basket and there will be a sign-up sheet for residents to sell tickets. Review of the monthly recreation calendars dated 1/1/24 to 3/31/25 failed to reflect the fund-raising events. A resident council meeting held on 3/24/25 at 1:00 PM with Resident #22, 53, 60, 77, and 114 indicated they do fund raising for the resident council monthly. Residents #60 and 77 indicated they have repeatedly asked about having a treasurer for the raised funds and they were informed by the Director of Recreation they don't need a treasurer because they don't have an account, and she holds onto the money. Residents #60 and 77 indicated they had repeatedly asked the Director of Recreation after fundraisers each month how much profit they had made, and they are informed she does not know and was not able to tell them. Resident #60 and 77 indicated that they have asked how much money the resident council account has in its account and the Director of Recreation informs them she puts the resident council money with the recreation department money and does not know who has how much. Resident #22, 53, 60, 77, and 114 indicated they want to know how much money they have raised after every fund-raising event and how much the facility money is vs their money that the Director of Recreation has told them she doesn't know. Resident #22, 53, 60, 77, and 114 indicated they want their own bank account for resident council money and want to appoint a treasurer to keep track of it, so the resident council in their monthly meetings can state how much was made after sale events and how much is in the account, and they can decide how to spend the money and vote on it. The interview with Director of Recreation on 3/24/25 at 2:19 PM indicated the resident council sells tickets for 8 - 9 [NAME] baskets a year, has a tag sale every year in April, a craft and bake sale in November, and this summer will start selling candy bars. The Director of Recreation indicated that the residents from resident council have asked repeatedly how much money was raised after fund raising events and she informs them I don't know. The Director of Recreation indicated that she has not figured out how much was spent on fundraising events and how much the profit was made at each event for the last 3 years. The Director of Recreation identified she has money in her locked desk drawer that is resident council money. Director of Recreation indicated that the resident council wanted a pizza party approximately 3 times in the past 2 years, so she added the pizza as part of a recreation program and added it on her recreation calendar. The Director of Recreation indicated that she does not recall if it was voted on by the resident council for approval. The Director of Recreation indicates that she had used the resident council funds to buy an air hockey table for the recreation room and a white board used for playing word games during recreation activities. The Director of Recreation indicated that the residents had not voted on using their funds to purchase these items for the recreation room. The Director of Recreation indicated that she does not have any records of the resident council funds for the last 3 years and she does not report monthly or quarterly to the resident council how much money they have. The Director of Recreation indicated that she does not know how to set up a resident council fund bank account and how to bring a resident to the bank. The Director of Recreation indicated that she had not spoken with the Administrator about how to set up a council fund at a bank and that she was not able to inform/resident council each month what they had for funds in their account, or how much money they were making on the fundraising events. Interview with the Administrator on 3/24/25 at 2:41 PM indicated that the Director of Recreation was responsible for the resident council funds and notifying the residents in resident council what was made after each event. The Administrator indicated that the Director of Recreation had informed him what she had used the resident council funds for but was not aware that the resident council had not voted on it. The Administrator indicated that the Director of Recreation just informs him that she is using the resident council money to buy the monthly birthday cake (on the recreation calendars) for the residents, pizza, or Chinese food for the resident's, but he does not know who receives the food. The Administrator indicated that he was not aware that the residents were not being informed of how much they were making after sale/[NAME] events. The Administrator indicated that he was not informed that the residents had asked the Director of Recreation for an accounting for the resident council funds and that she had informed them that they did not need a treasurer when they wanted to appoint someone. The Administrator indicated that he thought the Director of Recreation was keeping track of the resident council funds separate from the recreation funds. The Administrator indicated that the resident council funds are for what the resident council wants to purchase or donate, not anything that recreation should be purchasing such as food or a white board that are for recreation activities and on the monthly recreation calendar. The Administrator indicated that the resident council funds should not be in a drawer and should be in an interest-bearing account and there should be a ledger of what money goes in and goes out. The Administrator indicated that he would open a separate account for the resident council funds. The interview with the Director of Recreation on 3/25/25 at 10:00 AM identified she was not able to give an accounting of how much residents had made monthly during the fundraising events or spent during 2023 and 2024. Review of the Resident Trust Fund identified the facility must maintain a separate and accurate accounting record of the resident trust fund. The fund cannot be comingled with any other account. Resident funds are managed and maintained in accordance with Federal and State Laws. The resident trust account must be reconciled monthly following the reconciliation of the bank statement. Quarterly a statement must be generated and sent to each resident and/or a responsible party. The statement is comprised of the individual resident account balance, deposits, and disbursements for the quarter and monthly interest allocations. Although requested, a facility policy for resident council funds was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #344) reviewed for dignity, the facility failed to ensure that the resident's medical information and care needs remained private. The findings include: Resident #344 was admitted to the facility on [DATE] with diagnoses that included sepsis, muscle weakness, and legal blindness. The care plan dated 3/21/25 identified Resident #344 had impaired visual function. Interventions included to tell the resident where items were being placed and to provide total feed assist with all meals. Observation on 3/23/25 at 11:00 AM identified a sign located on the exterior room door of Resident #344 and Resident #345 with the following: Resident is Legally Blind. Total Feed with meals. Keep items within reach. The sign also identified Resident #344's bed number. The 5 day MDS dated [DATE] identified Resident # 44 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with dressing, showers, and required supervision with meals. Observation on 3/24/25 at 6:58 AM identified that the sign previously observed on Resident #344's exterior door was removed. Further observation identified that an identical sign was located taped to Resident #344's wall, directly above the resident's bed. Review of the clinical record identified Resident #344 was transferred to the hospital on 3/24/25 at 6:36 PM for evaluation of abdominal pain and rectal bleeding. Observation and interview with the ADNS on 3/25/25 at 7:02 AM identified that she was not aware that there was a sign placed above the resident's bed identifying the resident's medical or care needs, and it would be investigated. The ADNS also identified that it would not be appropriate to place any kind of sign on an exterior door of a resident's room related to diagnoses or care needs. Interview with the ADNS on 3/25/25 at 1:52 PM identified she had a discussion with LPN #3 via phone and identified the sign was placed at Person #1's request. The ADNS also identified that LPN #3, Person #1 and Resident #344 was present for the discussion. Subsequent to surveyor inquiry, review of the clinical record identified a late entry note dated 3/20/25 at 2:31 PM, documented on 3/25/25 at 2:35 PM, by LPN #3 identified Person #1, Resident #344's resident representative, requested a sign be placed over Resident #344's bed stating that Resident #344 was blind and needed assistance with meals. Review of the facility nurse staffing schedules identified LPN #3 did not work on 3/20/25 or 3/25/25. Interview with Person #1 on 3/26/25 at 8:50 AM identified he/she was the emergency contact for Resident #344, but that Resident #344 was responsible for him/herself. Person #1 identified that he/she had spoken with a female staff member at the facility on 3/19/25 following Resident #344's admission to the facility to make sure that the nurse and other facility staff were aware that Resident #344 was blind and needed assistance. Person #1 identified he/she did not remember the nurse's name, but identified after speaking to staff member, the staff member identified she would place a sign above Resident #344's bed. Person #1 identified he/she did not discuss the sign with Resident #344 and was unaware if Resident #344 knew the sign was in place as Resident #344 was not present during the discussion. Person #1 also identified that he/she was unaware if the female staff member, or if any facility staff, notified or discussed the sign with Resident #344. Person #1 also identified he/she had not seen a sign on Resident #344's exterior door related to Resident #344's blindness or care needs, and that it would not be appropriate for a sign to be on the exterior door as Resident #344 had a roommate as well as other visitors walking through the halls. Although attempted, an interview with Resident #344 was not obtained. Although attempted, an interview with LPN #3 was not obtained. The facility policy on resident rights directed that all residents had the right to have privacy and confidentiality regarding all personal and health information kept by the facility pertaining to the resident. The facility notice of privacy practices directed that the facility's responsibilities to the resident included understanding that information about the resident and resident's health was private and personal, and by law the facility was required to maintain the privacy of the resident's protected health care information. The policy further directed that protected health care information included the resident's past, present or future physical or mental health or condition, the provision of health care provided to the resident, and date that could actually or reasonably identify the resident. The policy also directed that the resident had a right to know if the facility used or disclosed the resident's health information in a manner that was not legally permitted and compromised the resident's security or privacy.

Based on review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #59) reviewed for pre-admission screening and resident review (PASARR), the facility failed to refer the resident, who had a new mental health diagnosis, to the State-designated authority. The findings include: Resident #59 was admitted to the facility in July 2022 with diagnoses that included anxiety disorder and osteoporosis with a pathological fracture. Notice of PASARR Level 1 Screen outcome dated 7/13/22 identified Resident #59 had no mental health diagnosis known or suspected and no diagnosis of dementia. No Level 2 is required because no serious behavioral health conditions or intellectual/developmental disabilities exist. If changes occur or new information refutes these findings, a new screen must be submitted. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and had an active diagnosis of anxiety, depression, and dementia. The psychiatric APRN note dated 1/25/23 identified Resident #59 was receiving Aricept for dementia, Zoloft for depression, Seroquel for anxiety and agitation, and Xanax for anxiety. Resident #59 presents with paranoid delusions. Diagnosis of dementia with psychotic disturbances and psychotic disorder with delusions. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and had an active diagnosis of anxiety, depression, dementia, and psychotic disorder. The care plan dated 9/25/23 identified Resident #59 was receiving psychotropic medication Seroquel. Intervention was to administer psychotropic medications as ordered by the physician. Interview with the Administrator on 3/25/25 at 10:45 AM indicated that the social workers were responsible for reviewing and updating the State-designated authority for PASARR's as needed based on the resident. Interview with SW #1 on 3/25/25 at 1:03 PM indicated she is responsible to do a new level of care screen if a resident receives a new psychiatric diagnosis while at the facility. SW #1 identified when a resident comes in and the psychiatric APRN or physician gives the resident a new diagnosis they do not tell her, so she is not aware. SW #1 indicated that when Resident #59 received the diagnosis of psychotic disorder with delusions, a new level 1 should have been submitted. After surveyor inquiry, SW #1 on 3/26/25 at 1:00 PM identified that she had updated the State-designated authority with a new PASARR screening for a level of care change for Resident #59. Although requested, a facility policy for PASARR Level 1 and Level 2 was not provided.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 8 residents (Resident #112) reviewed for accidents, the facility failed to administer medications according to professional standards. The findings include: Resident #112 was admitted to the facility in October 2024 with diagnoses that included paroxysmal atrial fibrillation, dysphagia, and hypertension. The care plan dated 3/13/25 identified Resident #112 had a deficit in self-care function: activity intolerance. Interventions included set up/clean up assistance for eating/feeding and personal hygiene/oral care. The quarterly MDS dated [DATE] identified Resident #112 had intact cognition, required set-up or cleaning assistance with eating, had complaints of difficulty or pain with swallowing, and was on a mechanically altered diet while a resident. A physician's order dated 3/21/25 directed to administer the following medications. Apixaban 2.5mg, 1 tablet by mouth, twice daily for blood thinner related to paroxysmal atrial fibrillation. Ferrous sulfate 325mg (65 Fe), 1 tablet by mouth, twice daily for anemia. Miralax oral packet 17 gm by mouth, once daily for constipation, mix with 8 oz of water. Acetaminophen 325mg, 2 tablets by mouth, every 6 hours as needed for generalized discomfort. Multivitamin, 1 tablet by mouth, once daily for a supplement. Ascorbic acid 500mg, 1 tablet by mouth, once daily for wound healing. Metoprolol Tartrate 25mg, 1 tablet by mouth every 12 hours for hypertension. Enulose solution 10gm/15ml, give 30 ml by mouth, once daily for constipation. Observation and interview with Resident #112 on 3/23/25 at 8:00 AM identified a medication cup with 7 pills, a medication cup with a pale colored fluid, and a cup of a clear fluid on the resident's bedside table. Resident #112 indicated that he/she planned to take the medications once breakfast was served. Observation with LPN #5 on 3/23/25 at 8:03 AM identified that the medications left at Resident #112's bedside were not from her medication pass, as she had worked the night shift, but she would remove the medication from the bedside table and locate the day shift nurse. Interview with LPN #4 on 3/23/25 at 8:06 AM identified Resident #112 refused to take his/her medications this morning and wanted to wait until he/she had eaten breakfast. LPN #4 indicated that Resident #112 does not have an order to self-administer medications, and that she should have remained at the residents bedside until he/she took all of the medications or removed the medications and returned when the resident was ready to take the mediations. LPN #4 further indicated that the medications left at the bedside were from the morning medication pass: apixaban, iron (ferrous sulfate), miralax, Tylenol (acetaminophen), multivitamin, vitamin C (ascorbic acid), metoprolol, and lactulose (enulose). LPN #4 identified that she had just been in Resident #112's room to administer the medications, and they hadn't been left for more than a few minutes. LPN #4 further identified that the medications had been removed from the table, and she would administer the medications once breakfast had been served. Interview with the DNS on 3/25/25 at 2:24 PM identified that the expectation is that the nurse remains at the bedside with the resident until all of the medications are taken. The DNS indicated that Resident #112 likes to take his/her morning medications with breakfast and that his/her morning medication administration time has been adjusted to accommodate that request. The DNS further indicated that LPN #4 had been reeducated on not leaving medications at a resident's bedside. The facility's Medication Pass policy directs that residents are always observed until they have swallowed all medications that have been administered. Do not leave medications in the medication cup at the bedside or on the table.

Based on review of the clinical record, facility documentation, facility assessment, and interviews, the facility failed to ensure a licensed nurse had the competencies and education to administer IV therapy. The findings include: Resident #390 was admitted to the facility on [DATE] with diagnosis that included sepsis, bacteremia, and acute and subacute endocarditis. The admission nurse's note dated 3/22/25 at 5:51 PM identified that Resident #390 was admitted from an acute care facility with a diagnosis of sepsis and acute renal failure. Blood culture showed Group B (beta) strep (Streptococcus) bacteremia and probable endocarditis. A PICC (peripherally inserted central catheter) was placed, and IV (intravenous) antibiotics were ordered for 6 weeks. Physician's orders dated 3/22/25 directed to administer Ceftriaxone Sodium Solution Reconstituted (IV antibiotic) 1gram, use 2 grams intravenously, once daily for sepsis until 4/29/25, before breakfast, and to monitor IV PICC site for redness, swelling, drainage, and any signs of infection, every shift for prophylaxis. The care plan dated 3/22/25 identified Resident #390 was receiving intravenous therapy via a PICC line. Interventions included flushing the line before and after antibiotic administration and to monitor the site for placement and for signs and symptoms of infection, every shift. The care plan further identified the Resident #390 was on antibiotic therapy related to sepsis. Interventions included administering the antibiotic medications as ordered. The March 2025 MAR identified that on 3/22/25 during the 11:00 PM - 7:00 AM shift, LPN #9 monitored Resident #390's IV site for redness, swelling, drainage or signs of infection, and on 3/23/25 at 6:32 AM, LPN #9 administered Ceftriaxone Sodium Solution Reconstituted 1 GM, intravenously. Interview and review of facility documentation with the Regional Director of Clinical Operations and the Infection Preventionist (RN#4) on 3/24/25 at 9:33 AM failed to identify that LPN #9, hired on 1/8/22, had a certificate of completion for infusion therapy or competencies related IV therapy on file. RN #4 indicated that LPN #9 worked per diem and typically did not provide care to residents with IV lines. Review of the clinical record identified LPN #9 had signed off Resident #390's IV antibiotics as administered, on 3/23/25. The Regional Director of Clinical Operations indicated that she would look for LPN #9's certificate of completion for infusion therapy and competencies related to IV therapy. Subsequent to surveyor inquiry LPN #9's Infusion Services Certificate of Completion dated 1/24/22 was provided. The Regional Director of Clinical Operations indicated that LPN #9 provided the facility with her certificate that was obtained at another facility. Interview and clinical record review with the Staff Development Nurse (RN #1) on 3/26/25 at 7:18 AM identified that according to facility documentation, LPN #9 was not identified as IV certified, therefore she was not on RN #1's list of annual competency for IVs. RN #1 indicated that if LPN #9 had obtained her IV therapy certification and competency at a different facility, she would have also expected her to complete the annual 2023 and 2024 on-line education and IV competencies at this facility. RN #1 indicated that when LPN #9 saw that Resident #390 had an IV medication scheduled to be given during her shift, she notified the 11:00 PM - 7:00 AM RN Supervisor (RN #6) for assistance, because she had not worked with an IV during her time at this facility. RN #1 indicated that RN #6 assisted LPN #9 with administering Resident #390's IV antibiotics. Interview with the DNS on 3/26/25 at 9:13 AM identified that she would expect a nurse administering an IV medication to have an IV therapy certification on file and the required annual education and competencies completed, however she was told that RN #6 had assisted LPN #9 with setting up the medication and hung Resident #390's IV antibiotic because LPN #9 did not have an IV certification. Interview with RN #6 on 3/26/25 at 9:37 AM identified that she had assisted LPN #9 with setting up the IV pump and priming the tubing because LPN #9 told her that she had been working outside of this facility and needed a reminder. RN #6 indicated that she was not aware that LPN #9 had not been up to date with her IV competencies and that she did not have an IV certification on file. RN #6 further indicated that she verbally went through the motions of flushing the PICC line and connecting the IV tubing to the IV port, but she was not present at the bedside when LPN #9 flushed Resident #390's PICC or connected him/her to the IV antibiotics. Interview with LPN #9 on 3/26/25 at 1:49 PM identified that she was employed as a per diem nurse and worked at this facility once in a while. LPN #9 further identified that she had completed the IV therapy certification program while employed at a different facility and had sent this facility her IV therapy certification, earlier this week. LPN #9 indicated that she had not completed the annual IV education or competencies at this facility, and that she does not provide IV therapy at her other job, only at this facility. LPN #9 further indicated that she had called the RN Supervisor (RN #6) for assistance with setting up Resident #390's IV antibiotics. LPN #9 identified that hung Resident #390's IV medications, but she could not recall if RN #6 was with her at the bedside. The Facility Assessment directs that services are based on evaluation of the residents' needs and the following reflects the resources needed to provide care related to medications: awareness of any limitations of administering medications, administration of medications that residents need by route of oral, nasal, buccal, sublingual, topical, subcutaneous, intravenous (peripheral of central lines), intramuscular, inhaled, etc. Assessment and management of polypharmacy. Training/education and competencies after hire occur throughout the year on topics related to patient care and services. All employees must have certain competencies related to topics discussed on orientation. These would include areas such as infection control, disaster procedures, resident rights, grievance procedures, HIPPA, OSHA standards, abuse etc. Although many of these topics are customized to the employee's job/function. All staff have certain competencies that are required in order to perform their jobs in an acceptable manner to support our resident population as outlined in the assessment. The competencies are demonstrated on hire and are checked annually to ensure continued competency. The following are competencies that are demonstrated by staff as appropriate: medication administration including injectable, oral, subcutaneous, topical, anal, and buccal.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #59) reviewed for accidents, the facility failed to ensure every 15 minute checks were completed after an unwitnessed fall, per physician's order and per facility policy. The findings include: Resident #59 was admitted to the facility in July 2022 with diagnoses that included dementia, high blood pressure, history of falls, and heart failure. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and required maximum assistance with dressing, toileting, and personal hygiene. The care plan dated 10/7/24 identified Resident #59 was at risk for falls Interventions included to remind Resident #59 to call for assistance, neurological checks and fall assessments per facility protocol. A reportable event form dated 11/15/24 at 7:30 AM identified Resident #59 reported falling in the dining room causing a bruise and abrasion to the left flank area. Interventions included to complete every 15-minute checks for 3 days and pad the wheelchair arm rest. The care plan and nurse's aide care card dated 11/15/24 identified Resident #59 was on every 15-minute checks and pad wheelchair armrest. A physician's order dated 2/18/25 at 7:00 AM directed for every 15-minute checks every shift indefinitely. Review of the every 15-minute checks daily forms dated 2/16/25 to 3/23/25 identified the following forms were missing: 2/16, 2/17, 2/18, 2/23, and 3/9/25. The following every 15-minute checks daily forms had days that were incomplete or had a line through the shift; 2/20, 2/21, 2/22, 2/27, 2/28, 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/10, 3/11, 3/12, 3/15, 3/16, 3/17, 3/18, 3/19, 3/21, 3/22, 3/23, and 3/25/25. An interview with the DNS on 3/26/25 at 7:15 AM indicated if Resident #59 fell on [DATE], he/she would not have been able to get him/herself up off the floor without staff assistance. The DNS indicated that she concluded there was no fall, but the abrasion and bruise was from the arm rest of the wheelchair. The DNS indicated that for this incident the intervention was every 15-minute checks for 3 days and pad the wheelchair arm rest. The DNS indicated that the nurse aides were responsible to document every 15-minutes checks with their initials on the form in the space provided. After clinical record review, the DNS indicated the nurse implemented every 15-minute checks daily starting on 11/15/24 for 3 days but she was not able to locate the every 15-minute daily forms from 11/15/24 to 11/18/24. The interview with Medical Records Person #1 on 3/26/25 at 8:00 AM indicated that when she receives or collects every 15-minute forms completed or when not complete she gives them to the ADNS. Medical Records Person #1 indicated that the ADNS completes the forms and gives them back to her to scan into the residents EMR. After clinical record review, Medical Records Person #1 indicated that she had not seen the every 15-minute daily forms for 11/15/24 to 11/18/24. Interview with the DNS on 3/26/25 at 7:20 AM indicated that the expectation for completing the every 15 minute check form included to complete each box indicating the check had been done at that time. The DNS indicated staff should not draw a line straight down the form for the entire shift. The DNS indicated that she was aware that nurse aides were doing that and education had been provided in the past. The DNS indicated that she printed all every minute check forms from the EMR. The DNS indicated the resident fell on [DATE], however, the nurse started the every 15-minute checks intervention on 2/18/25. The DNS indicated that she would continue to look for the missing dates. Interview with Medical Records Person #1 on 3/26/25 at 8:00 AM indicated that when she receives every 15-minute check daily forms and they are not completed she gives them to the ADNS. Medical Records Person #1 indicated that the ADNS completes the forms and gives them back to her to scan into the residents EMR. Interview with ADNS on 3/26/25 at 10:00 AM indicated that every 15-minute check was implemented for the fall on 2/16/25 for Resident #59. The ADNS indicated the nurse's aide assigned to the resident were responsible to see the resident every 15 minutes for safety and sign the form and if the aide is on break the nurse or another nurse's aide can sign for that 15-minute time slot. The ADNS indicated that the unit secretary or Medical Records Person #1 collects the daily forms from the units and places them in her mailbox to audit. The ADNS indicates that if a form was not completed, she will call the nurse's aide assigned to the resident and ask them if they had done every 15-minute checks on the resident and then have them sign the form the next time they come into the facility. The ADNS indicated there was not a policy for the every 15-minute checks form. Interview with Medical Records Person #1 on 3/26/25 at 11:25 AM indicated that the ADNS had found every 15-minute daily checks in her office for 3/22/25 but it was not complete. Requested the additionally missing dates 2/16, 2/17, 2/18, 2/21, 2/23, 3/7/25. Interview with Medical Records Person #1 on 3/26/25 at 2:00 PM indicated she was not able to find every 15-minute check daily forms for 2/16, 2/17, 2/18, 2/23, and 3/9/25. Although requested, a facility policy for every 15-minute checks form was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #4) reviewed for a specialized treatment, the facility failed to ensure that staff consistently monitored and recorded fluid intake and output for a resident on fluid restriction. The findings included: Resident #4 was admitted to the facility in September 2024, with diagnoses that included chronic kidney disease stage 3, and diabetes. The December 2024 physician's order directed a 1500 ml fluid restrictions per day (breakfast 420 ml, lunch 240 ml, dinner 240 ml, nursing 480 ml between days and evenings, and 120 ml on nights). Review of the fluid intake monitoring record dated December 2024 identified staff failed to document the resident's intake 17 out of 93 occasions. Review of the fluid intake monitoring record dated January 2025 identified staff failed to document the resident's intake 34 out of 93 occasions. The care plan dated 2/12/25 identified the resident requires hemodialysis related to renal failure. Interventions included a 1500 ml fluid restrictions per day (breakfast 420 ml, lunch 240 ml, dinner 240 ml, nursing 480 ml between days and evenings, and 120 ml on nights). The quarterly MDS dated [DATE] identified Resident #4 had intact cognition and required setup or clean-up assistance with eating. Review of the fluid intake monitoring record dated February 2025 identified staff failed to document the resident's intake 63 out of 84 occasions. A nutritional evaluation dated 3/25/25 identified Resident #4 required a fluid restriction of 1500 ml. Review of the fluid intake monitoring record dated March 2025 identified staff failed to document the resident's intake 51 out of 78 occasions. Interview with the DNS on 3/26/25 at 6:33 AM identified she was not aware that staff were not following the physician's order for the fluid restriction or recording Resident #4's intake and output forms consistently and there were missing shifts and days of documentation. Interview with LPN #6 on 3/26/25 at 7:20 AM identified she was not aware that intake and output forms were not being consistently completed. LPN #6 indicated that the nursing staff fills out the intake monitoring on the fluid restriction record each shift, and then the form goes down to the ADNS. LPN #6 indicated prior to Sunday 3/23/25 the nursing staff were not able to document the resident intake and output into the computer. LPN #6 indicated on Sunday 3/23/25 at 4:50 PM the nursing staff received a text message from the DNS indicating staff could go into the computer under a certain task and enter the amount of fluid the resident consumed. Interview with NA #7 on 3/26/25 at 8:50 AM identified she records Resident #4's fluid intakes on the intake and output form when she is working. Interview with the Registered Nurse at the specialized treatment center on 3/26/25 at 8:55 AM identified the specialized treatment center was not informed by the facility that staff were not consistently monitoring to ensure the residents fluid restriction. Interview with the Dietitian at the specialized treatment center on 3/26/25 at 11:26 AM identified the facility had not informed her that staff were not monitoring the fluid restriction. The Dietitian indicated the nursing staff should be following the physician's order for 1500 ml fluid restriction in 24 hours. Interview with MD #2 on 3/28/25 at 10:20 AM identified he was not aware staff were not consistently monitoring and recording the resident's fluid intake. MD #2 indicated the nursing staff should be following the physician's order for 1500 ml fluid restriction a day. Although attempted, an interview with the facility Dietitian was not obtained. Review of the facility hemodialysis policy identified a resident who is admitted to the facility requiring hemodialysis, with their consent, will have their dialysis needs met. The Licensed Nurse will obtain the healthcare provider orders for hemodialysis which should include possible fluid restriction. Review of the facility intake and output policy identified the facility is to maintain accurate fluid intake and/or output monitoring. Nursing personnel are responsible for documenting fluid intake and/or output totals in the plan of care. The nurse aides are responsible for documenting the total amounts of fluids taken with meals and those fluids taken in between meals that have been provided by the nurse aides.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure that nurse aides had annual performance evaluations completed for 2024, The findings include: During a review of performance evaluations for facility nursing staff on 3/25/25, facility documentation failed to identify a 2024 performance evaluation completed for NA #6. A request was made on 3/25/25 at 10:00 AM to the HR Director to provide the 2024 performance evaluation for NA #6. Review of the provided performance evaluation for NA #6 on 3/25/25 at 10:52 AM identified NA #6 had not signed the evaluation, and the signature from the DNS on the evaluation was dated 10/30/25, 7 months in the future. Interview with the HR Director on 3/25/25 at 10:52 AM identified she observed the DNS sign the evaluation today, just prior to the DNS handing the evaluation to the HR Director. Interview with the DNS on 3/25/25 at 11:00 AM identified she was aware that there were facility nursing staff who did not have annual evaluations completed for 2024, but this was due to the staff working per diem or being out on leave, and she would attempt to complete the evaluations when the staff were in the building. The DNS also identified that while she did have NA #6's performance evaluation in her office, she had just forgotten to give the evaluation to the HR Director to place in NA #6's personnel file. The DNS identified that she also could not remember if she did the evaluation with NA #6 in person or over the phone. When asked, the DNS reiterated she signed the evaluation on 10/30/24 and not when the HR director asked for it prior to surveyor review. Interview with the Human Resources (HR) Director on 3/25/25 at 4 PM identified that performance evaluations for facility staff were to be done initially 90 days after hire, and then annually per the facility policy. The HR Director identified she would prepare the evaluations that were due for nursing staff, placed them into a folder labeled by year (i.e. 2024, 2025) and would then give the folder to the DNS to keep in her office. The HR director identified while she assisted the DNS by filling out the preliminary information on the evaluation including the staff member name, job title, hire date, and type of evaluation (initial or annual), it was the responsibility of the DNS to then complete the evaluation, review and sign with the staff member, and return the completed and signed evaluation to the HR Director to be placed in the staff member's personnel file. A request was then made to the HR Director to provide the 2024 evaluation folder for review. Further review of the 2024 performance evaluation folder for nursing staff identified a total of 6 additional nurse aides that did not have a performance evaluation completed for 2024. The facility employee handbook directed it was the policy of the facility to review the performance of each staff member at the end of the first 3 months of employment and every year thereafter, that the purpose of performance reviews was to assure the facility that the employee was properly placed in his/her current position. The handbook also directed that attendance, attitude, and job performance were among the most important factors considered in the performance evaluation. The handbook further directed it was the policy of the facility to review the performance of each staff member at the end of the first 3 months of employment and every year thereafter, the purpose of performance reviews was to assure the facility that the employee was properly placed in his/her current position. The handbook also directed that attendance, attitude, and job performance were among the most important factors considered in the performance evaluation.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident of two residents (Resident #1) reviewed for pressure wounds, the facility failed to ensure care was provide timely. The findings include: Record review identified Person #1 was Resident #1's emergency contact. Resident #1 was admitted with diagnoses that included status post stroke with decreased movement on the right side. A nursing admission evaluation dated 9/26/2024 identified Resident #1 was alert and oriented, was a very high risk for pressure ulcer development and had blanchable redness on the sacrum, coccyx and groin area, and was dependent for transfers and did not walk. Physician note dated 9/26/2024 identified Resident #1 was aphasic (difficulty speaking) and followed commands. The Resident Care Plan dated (RCP) dated 9/27/2024 identified Resident #1 was dependent for toileting, ADLs, and had a potential for skin breakdown. Interventions directed to turn and reposition every two (2) to three (3) as tolerated by the resident and skin checks with care. Record review identified Resident #1 received incontinent care at 10:09 AM on 10/1/2024. A nursing note dated 10/1/2024 at 1:30 PM identified Resident #1 was out to a medical appointment accompanied by a family member. A nursing note dated 10/1/2024 at 5:00 PM identified Resident #1 had returned from a medical appointment. A facility grievance form dated 10/1/2024 at 8:54 PM identified Person #1 complained that incontinent care was not provided in a timely manner. Resident #1 was out for an appointment and care was provided after supper. The form stated Resident #1 had developed a red bottom. Interview with NA #1 and review of her written statement on 10/22/2024 at 11:50 AM identified she worked 3 to 11 PM on 10/1/2024 and she was assigned to care for Resident #1. Resident #1 had returned from a medical appointment and was in his/her wheelchair when she fed Resident #1 around 5:30 PM. NA #1 stated she did not check Resident #1 for incontinence prior to feeding him/her and stated Resident #1 did not express any concerns when she fed him/her. NA #1 stated after feeding Resident #1, she left him/her in the wheelchair and proceeded to provide care for other residents on her assignment. NA #1 stated she did not return to check on Resident #1 until she entered Resident #1's room about 8 PM to provide care. NA #1 stated she had not provided any care for Resident #1 prior to 8 PM, and Person #1 voiced concerns about the resident's care and Person #1 left the room to speak with the RN #2/supervisor. NA #1 stated she should have check Resident #1 for incontinence when Resident #1 returned from the appointment, when she fed him/her, or at least every two (2) hours, and stated she did not provide the care because she was very busy that evening. Interview with RN #1 identified that he was the charge nurse on 10/1/2024 during the 3 to 11 PM shift. RN #1 stated about 7:30 PM, Person #1 expressed that Resident #1 was being ignored and requested care for Resident #1. RN #1 then directed NA #1 to provide care. Further RN #1 stated he assessed Resident #1's skin on 10/2/2024 and identified a moisture associated skin damage (MASD) area on the sacrum and coccyx area. Interview with RN #2, nursing supervisor, identified on 10/1/2024 about 8 or 8:30 PM, Person #1 came stated Resident #1 needed care and had been ignored since returning from an appointment earlier in the shift. RN #2 stated she went to Resident #1's room, observed NA #1 in the room and Resident #1 was in his/her wheelchair, dressed, appeared messy, leaning to the right with no visible soiling or wetness. She assisted NA #1 transfer Resident #1, provide incontinent care, noted Resident #1 was incontinence of a large bowel movement, and his/her clothing was not wet. RN #2 noted that his/her sacrum was reddened with intact skin, and she assisted NA #1 to shower Resident #1. RN #2 stated NA #1 should have checked Resident #1 for incontinence care upon return to the facility and then every two (2) to three (3) and she initiated the grievance in response to Person #1's concern. Interview with the DON on 10/22/2024 at 1:30 PM identified that she expected NA #1 to check Resident #1 for incontinence for when he/she returned from the appointment at 4:00 PM and then every two (2) to three (3) hours throughout the shift. The DON stated she did not know why NA #1 did not provide the care. Subsequent to the incident, the DON stated a physician order was entered for Resident #1 to provide every 2-hour incontinent care. Facility documentation review identified staff education and audits were initiated on 10/7/2024. Education included providing incontinent care timely, and prior to leaving and upon return from appointments. A QAPI meeting was held on 10/10/2024. Based on review of facility documentation, past non-compliance was identified as of 10/10/2024.

Based on clinical record review, facility documentation, facility policies and interviews for one sampled resident (Residents #1) who required staff assistance with dressing and was reviewed for an allegation of mistreatment, the facility failed to treat a resident in a dignified and respectful manner when providing care. The findings include: Resident #1's diagnoses included dementia with psychotic disturbance. The Resident Care Plan dated 7/10/23 identified Resident #1 had an activities of daily living self-care performance deficit related to weakness. Interventions directed limited two (2) person assistance with dressing. The admission Minimum Data Set assessment dated [DATE] identified Resident #1's hearing was adequate, Resident #1 did not use hearing aid, rarely or never made self-understood, rarely or never understood others, had some short- and long-term memory deficits, required extensive two (2) person assistance with dressing, and utilized a wheelchair for mobility. The Facility Reported Incident form dated 7/21/23 at 6:30 AM identified staff witnessed a nurse aide, Nurse Aide (NA) #1, yelling at Resident #1. NA #1 was noted to be frustrated because she had to get Resident #1 up early and Resident #1 was not helping him/herself, NA #1 stated you lift your foot up any other times, why can't you do it all of a sudden. As NA #1 was putting socks on Resident #1's feet, Resident #1 stated you are hurting me. NA #2 witnessed the incident, went and got the supervisor, and the supervisor sent NA #1 home pending an investigation. The nurse's note dated 7/21/23 at 6:36 AM identified at approximately 6:30 AM the Director of Nurses (DON) received a call from the nursing supervisor that NA #1 was witnessed by another staff member, NA #2, yelling at Resident #1 and using inappropriate language. The note indicated the facility abuse protocol was followed, and the police, family members, and Advanced Practice Registered Nurse (APRN) were notified. The note identified no new orders were obtained, a body audit was completed with no injuries, new bruises or skin tears noted, and Resident #1 denied any pain or discomfort. A follow up psychiatric progress note dated 7/24/23 identified Resident #1 was seen related to the allegation of verbal abuse, Resident #1 and a family member reported an aide yelled at Resident #1. Resident #1 and a family member denied any injuries and Resident #1 felt safe in the facility. The summary report dated 7/25/23 at 10:58 AM identified on 7/21/23 around 6:30 AM, NA #2 witnessed NA #1 yelling at Resident #1 to lift his/her foot as he/she had done prior. The summary indicated NA #1 resigned from the facility effective 7/24/23. Interview with the 11PM-7AM nurse aide, (NA) #1, on 8/7/23 at 11:40 AM identified Resident #1 kept getting up during the night wanting to use the bathroom and finally fell asleep around 4:00 AM. NA #1 indicated the charge nurse, Licensed Practical Nurse (LPN) #1, directed her to get Resident #1 up. NA #1 identified she questioned LPN #1 why he wanted her to get Resident #1 up, however LPN #1 kept insisting on getting Resident #1 up and she did not understand why. NA #1 indicated she was not frustrated with Resident #1 however she was frustrated with LPN #1. NA #1 identified she was speaking loud to Resident #1 because he/she was hard of hearing, and she was speaking to Resident #1 like she would speak to any resident who was hard of hearing. NA #1 denied using any inappropriate language while caring for Resident #1. Interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #1, on 8/7/23 at 12:35 PM identified he told NA #1 to get Resident #1 up and ready because he noticed Resident #1 getting up from the bed and Resident #1 was a fall risk. LPN #1 indicated he was in the hallway passing mediations to other residents and could hear NA #1 speaking loudly to Resident #1. LPN #1 identified the way NA #1 was speaking to Resident #1 was not appropriate, and it was harsh. LPN #1 indicated he overheard NA #1 say to Resident #1 you are not listening, you are frustrating me. LPN #1 identified he asked NA #2 to help NA#1 and after a while he noticed NA #2 leave Resident #1's room to get the nursing supervisor. Interview with the Director of Nurses (DON) on 8/7/23 at 1:00 PM identified Resident #1 was hard of hearing however was not to the point where Resident #1 needed a hearing aide. The DON indicated NA #1 spoke loudly to Resident #1 and did not give Resident #1 a chance to talk or react to what she was doing, NA #1 was rushing. The DON identified NA #1 if she was frustrated, she should have left the room and had NA #2 take care of Resident #1. Interview with NA #2 on 8/7/23 at 1:42 PM identified LPN #1 directed her to go and help NA #1 with Resident #1. NA #2 indicated NA #1 was very upset that she needed to get Resident #1 up in the morning. NA #2 identified when she walked into Resident #1's room he/she was in his/her bed naked with pants and brief up to his/her knees. NA #2 indicated as NA #1 was getting Resident #1 ready, NA #1 started yelling at Resident #1 why can't you lift your leg up, you were able to do it before and Resident #1 stated to NA #1 why are you yelling at me. Interview with the 11PM-7AM nursing supervisor, Registered Nurse (RN) #1, on 8/8/23 at 8:35 AM identified NA #2 came to her office and told her to go and listen to how NA #1 was speaking to Resident #1. RN #1 indicated she stood outside of Resident #1's door and heard NA#1 say to Resident #1 move your leg, you did it earlier, stop being lazy, stop being a baby in a very aggressive raised tone of voice. RN #1 identified she called NA #1 out to the hallway and told NA #1 the way she was speaking to Resident #1 was unacceptable. RN #1 indicated NA #1 started yelling at her, saying she did not like to work on this unit and continued to be loud. RN #1 identified at that point she told NA #1 she was suspended and to go home. The Resident's [NAME] of Rights directed residents have the right to be treated with consideration, respect and full recognition of the resident dignity and individuality. The residents had a right to receive quality care and services with reasonable accommodation of resident individual needs and preferences, except when resident health or safety or the health of safety of others would be endangered by such accommodation.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse. The findings include: Resident #1's diagnoses included Alzheimer's Disease, dementia with mood disturbance, persistent mood (affective) disorder, atrial fibrillation, hypertension, and Diabetes Mellitus. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The Resident Care Plan (RCP) dated 1/26/2023 identified a behavior problem related to dementia, anxiety, and mood disorder. Interventions directed to administer medications as ordered, monitor and document for side effects and effectiveness, and to approach/speak in a calm manner. A nursing note dated 2/21/2023 at 10:46 PM, written by RN #2, identified Resident #1 was assessed and found calm, cooperative with care, no change in mood or demeanor with skin intact and RN #3 was updated on assessment findings. A social service's note dated 2/22/23 at 3:56 PM identified Resident #1 was alert, significantly confused, quiet, remained at baseline for mood, and there were not changes in behaviors. Facility statement by RN #2 (supervisor) dated 2/21/2023 identified at 7:35 PM, NA #1 reported that she had gone into Resident #1's room and observed LPN #1 with his/her head in Resident #1's lap and that there was sexual activity. Additionally, the statement indicated NA #1 did not see any exposed body parts. The statement further identified when questioned further NA #1 was unable to elaborate on what exactly she observed stating LPN #1's head was obstructing a clear view and she did not say anything to LPN #1 and just walked out of the room. Additionally, the statement identified RN #2 informed the DNS/RN #3 regarding the allegation at 7:48 PM on 2/21/2023 and assessed Resident #1. Facility statement dated 2/22/2023 written by the DNS/RN #3 identified she was notified by RN #2 on 2/21/2023 at approximately 7:50 PM that NA #1 alleged LPN #1 was seen with her head in Resident #1's lap inappropriately. The statement further identified the DNS/RN #3 instructed RN #2 to assess Resident #1 and collect statements. Review of the facility accident and investigation report dated 3/2/2023 at 12:30 PM identified NA #1 reported that she walked into Resident #1's room on 2/21/2023 and witnessed LPN #1's head in Resident #1's lap. The report indicated NA #1 could not see any exposed body parts because the staff member's head was in the way. Additionally, the report identified RN #2 reported the incident to the DNS/RN #3 at that time. Review of the State Agency Reportable Events electronic tracking identified the allegation of staff to resident abuse was reported to the State Agency on 3/2/2023 at 2:26 PM, nine days after the event occurred. Although attempted, an interview the DNS/RN #3 was not obtained during survey. Interview with the Acting DNS and RN #1 (Director of Clinical Operations) on 3/6/2023 at 1:06 identified the Acting DNS was the ADNS in the facility prior to taking on the role of the Acting DNS. The Acting DNS and RN #1 indicated they became aware of the allegation on 3/2/2023 (9 days after the incident occurred), and identified the DNS/RN #3 had initiated an investigation but had not completed the investigation. Further, the State Agency was not notified of the incident/allegation until 3/2/2023. The Acting DNS and RN #1 further identified the facility policy was to report an allegation of abuse within a 2-hour time frame and the DNS/RN #3 did not report it timely, per the policy. The Acting DNS and RN #1 identified they did not know why RN #3 made the choice to not report the allegation, but that she should have reported it within the 2-hour time frame. The facility Abuse Policy and Procedure dated 1/2023 directed in part, the reporting timeline for all allegations is a 2-hour requirement to report to Department of Public Health and Local Law Enforcement. The policy directed the facility will notify Department of Public Health and local law enforcement immediately but no later than two hours after the allegation is made if the events that cause the allegation involve abuse.

Based on observation of the Dietary Department and staff interview, the facility failed to ensure a trash receptacle was covered and not in the proximity of clean utensils. On 1/31/23 at 11:55 AM, during a walk-through inspection of the Dietary Department with the Food Service Director (FSD) identified a large gray plastic trash receptacle was observed being stored and partially exposed from under the clean side of a 3 bay sink counter. The trash receptacle had a liner, was uncovered, and approximately 2/3 full of garbage. Above the trash receptacle were several clean serving utensils drying on the 3 bay sink counter. Interview at that time with the FSD indicated the utensils on the counter were clean and identified the trash container should have been covered and in its proper location which was on the soiled side of the 3 bay sink (not on the clean side of the sink). Additionally, she identified it was the responsibility of all kitchen staff to maintain sanitary conditions and that the Dietary Aides were primarily responsible to clean the kitchen equipment. Additionally, the FSD indicated she did not know who moved the trash receptacle to the clean side of the sink. Subsequent to surveyor inquiry the trash can was covered and moved at the time of the inspection to the soiled side of the 3 bay sink. She also identified she would remind staff concerning sanitary conditions and the proper location and covering of the trash container.

Based on observation, staff interview, review of the clinical record review and facility policy for 1 of 1 sampled residents (Resident #2) reviewed for receiving a hemolytic treatment, the facility failed to monitor intake totals for a resident who was exceeding a physician ordered fluid restriction. Resident #2's diagnoses included end stage renal disease, heart failure, diabetes and Alzheimer's disease. Physician orders dated 9/1/22 (through 2/2/23) directed a fluid restriction of 800 milliliters (ml) per day and hemodialysis 3 times per week at a dialysis center. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired and required one person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #2 was independent with eating after being set up and received dialysis. A Resident Care Plan dated 12/15/22 identified Resident #2 was at risk for a nutritional problem secondary to end stage renal disease, dementia, malnutrition, and hemodialysis. Interventions included to monitor intake and record every meal, Dietitian to evaluate and make diet change recommendations as needed, weekly weights and post dialysis weights. Intake and Output Report documentation identified in November 2022, Resident #2 exceeded the 800 ml fluid restriction 12 of 30 days, (for 12 days, total intake ranged from 920 ml to 1200 ml in a 24 hour period), in December 2022, Resident #2 exceeded the fluid restriction 9 of 31 days, (for 9 days, total intake ranged from 920 ml to 1320 ml in a 24 hour period). Additionally, in January 2023, Resident #2 exceeded the 800 ml fluid restriction 5 of 31 days (for 5 days, total intake ranged from 960 ml to 1320 ml in a 24 hour period). Communication log between the facility and the dialysis center dated 1/25/23 indicated Resident #2 had a weight gain between treatments over 4 times in the past month and to please evaluate fluid intake. On 2/1/23 at 10:03 AM interview with LPN #1 identified that the Nurse Aides record fluid intake but was unable to identify where the intake was documented. On 2/1/23 at 1:20 PM interview with the ADNS identified a system glitch and that the fluids consumed at meals was not accurate. Additionally, she indicated that it was unclear who was monitoring 24 hour intake totals and identified the facility doesn't follow a strict intake monitoring policy. She indicated residents are evaluated/assessed for edema, lung sounds and weight changes if they consistently exceed the fluid restriction, however the facility does not have a written policy for exceeding fluid intake. On 2/2/23 at 9:25 AM interview with the Dietitian identified that she was not aware that Resident #2 was exceeding his/her fluid intake restriction on several occasions. Additionally, she indicated she would begin to monitor fluid intake in the future. Facility policy on Intake and Output dated 9/28/22 identified the software documentation system calculates the total fluid intake and output daily and can be reviewed daily by assessing the look back report for each resident. Additionally, the policy indicated that the unit manager/supervisor will monitor fluid intake and/or output and report any concerns at morning meeting.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 89) reviewed for dental services, the facility failed to ensure an oral surgeon referral was arranged in a timely manner. The findings include: Resident #89 was admitted to the facility with diagnoses that included oropharyngeal phase dysphasia, dysphasia oral phase, and gastro-esophageal reflux disease. A Dentist progress note dated 10/17/21 at 7:09 PM identified x-rays were taken and identified Resident #89 was missing the following teeth #1, 4, 5, 7, 9, 10, 13, 14, 16, 19, 22, and 29 - 32. Additionally, coronal portions of teeth #3, 6, 8, 18, 20, 21, 26, and #28. Extensive decay on tooth #24. Removal is recommended. Referral to an oral surgeon may be necessary depending on which teeth become active. The quarterly MDS dated [DATE] identified Resident #89 had intact cognition, was on a mechanically altered diet and was a set up for meals. The Dental Consultation Request Form, in the facility dental communication book identified on 1/31/22 ( a year ago) a nurse placed Resident #89 on the dental list to be seen for evaluation for the rest of his/her teeth to be pulled out. A dental hygienist progress note dated 2/7/22 at 3:58 PM identified resident was seen at the request of nursing for evaluation to have the rest of resident's teeth removed. The resident reported that he/she wanted all his/her teeth pulled out because the sharp ones bother his/her lower lip. The resident pointed to remaining root tips #6 and #8 and noted those are the worst. Exam identified multiple fractured teeth and root tips present. Exam shows area on lower lip was slightly red at #26 and #27 and resident reported that was where it gets sore. A dental hygienist progress note dated 3/18/22 at 2:52 PM identified the resident's oral hygiene was poor with generalized heavy plaque deposits present. The resident reports that he/she wants all teeth taken out. Dentist was notified of today's findings. A dental note dated 4/29/22 identified Resident #89 needed a referral at his/her request for removal of all remaining teeth with an oral surgeon. Should resident decide to have dentures fabricated in the future please prep alveolar ridges for denture insertion. The care plan dated 12/8/22 identified a Resident #89 had a nutritional problem with broken and missing teeth. Interventions included to provide a mechanically soft high moisture diet with set up assistance by 1 staff. Interview with Resident #89 on 1/30/23 at 9:31 AM indicated he/she was missing his/her front teeth on top and has broken and missing front teeth on the bottom. Resident #89 indicated he/she bites the inside his/her mouth, tongue, and lip while eating and it hurts when this occurs. Resident #89 indicated he/she had informed SW #2 about 3 weeks ago that he/she wanted to see a dentist to remove all his/her teeth. Additionally, Resident #89 indicated he had told the nurses but could not recall who. Observation of Resident #89's mouth on 1/30/23 at 9:45 AM noted many missing and broken teeth. Interview with SW #2 on 1/30/23 at 1:03 PM indicated Resident #89 had not informed her that he/she wanted to see a dentist to have all teeth removed for dentures. SW #2 indicated if she was aware she would have informed nursing and made sure resident was added to the dental list. Interview with the ADNS on 1/30/23 at 1:15 PM indicated she was not aware that Resident #89 wanted to see the dentist to have all his/her teeth removed. Interview with the ADNS on 1/30/23 at 2:00 PM indicated nursing was aware Resident #89 wanted all his/her teeth removed and had last been seen by the hygienist on 12/19/22 and now has an oral surgeon appointment on 2/14/23 at 1:45 PM. The social worker note dated 1/30/23 at 4:24 PM noted Resident #89 had indicated he had requested to see a dentist in order to remove his/her remaining teeth that are causing some concern. SW #2 spoke with the ADNS who reported an appointment was made and wheel chair transportation was arranged. SW #2 educated resident to eat and drink with head of bed elevated to help prevent aspiration. An interview with NA #7 on 2/01/23 at 8:50 AM indicated Resident #89 a while ago had complained he/she wanted his/her teeth removed. NA #7 noted resident had seen the dentist, but she did not know if anything was done. NA #7 indicated it happened a while ago but could not indicated if it was weeks, months, or a year ago. An interview with Medical Records Person #1 on 2/01/23 at 9:08 AM indicated she does all the calling/scheduling for consents for dental. Medical Records Person #1 indicated she receives a phone call from the nurses if a resident needs to be added to the dental list and she has the dental consult book in her office. Medical Records Person #1 indicated when the dentist comes in, she looks at the list of who needs to be seen. Medical Records Person #1 indicated the dentist and hygienist's document directly into the resident's electronical medical record. Medical Records Person #1 indicated no one follows up to review the dentist or hygienist notes, she depends on them to verbally tell her if someone needs a referral or follow up appointment. Medical Records Person #1 indicated the dentist sometimes will go to the unit and tell the nurse. Interview with DMD #2 on 2/01/23 at 11:02 AM indicated Resident #89 was referred, including a letter dated 4/29/22 to an oral surgeon. DMD #2 indicated Hygienist #1 had notified Medical Records Person #1 and SW #2 the same day that there was a referral made for an oral surgeon and that the letter was with the dental x-rays under the miscellaneous folder in the electronic medical record. DMD #2 indicated her expectation was the arrangements would have been made within a week or 2 but the appointment may not have been for 6 to 8 weeks. DMD #2 indicated her expectation was the facility would have reach out to her and notify her if the facility was not able to make an appointment. DMD #2 indicated if the facility had a problem scheduling an appointment, she would have made some phone calls to get it done. DMD #2 indicated she was not notified that the Resident #89 never had the appointment made with the oral surgeon since 4/29/22. Interview with Hygienist #1 on 2/01/23 at 11:05 AM indicated on 4/29/22 when DMD #2 had written the referral for the oral surgeon, she remembered having a verbal conversation with Medical Records Person #1 and SW #2 the same day, and the x-rays were in the electronic medical record. Hygienist #1 indicated the floor nurses are aware of who they see but they do not provide a list of who was seen to anyone. Interview with Medical Records Person #1 on 2/1/23 at 11:31 AM she was not aware of the referral to the oral surgeon until after surveyor inquiry and identified if she was aware of a referral, she could get it booked the same day. Interview with SW #2 on 2/01/23 at 12:39 PM indicated that she recalls something regarding Resident #89's teeth but does not recall anyone coming to her to inform her regarding a referral for an oral surgeon. SW #2 indicated Resident #89 was is in discomfort and she was frustrated with the lack of communication. An interview with the DNS on 2/1/23 at 2:57 PM indicated sometimes the nurse would schedule the appointment or ask/notify Medical Records Person #1. The DNS indicated once Medical Records Person #1 was aware the appointment would be scheduled within a couple of days including the transportation. The DNS indicated the dentist does progress notes and for that day there was not a progress note, however, the dentist scanned in the referral letter. Interview and clinical record review with the DNS on 2/1/23 at 3:00 PM identified that there was a dental referral for an oral surgeon made on 4/29/22 and the appointment was not made until 1/30/23. Review of Dental Services Policy identified the facility is responsible to provide assistance for dental care upon resident's/resident's representative's request. The facility will also assist with providing transportation as needed. In the event there is a delay in obtaining a dental appointment, the facility will document the reason for the delay and what measures were in place to ensure that the resident was capable of eating and drinking adequately.

Based on review of the clinical record, facility documentation, facility policy and staff interviews for one (1) of five (5) residents reviewed for hospitalization (Resident #1), the facility failed to ensure treatment and care provided met resident care needs as evidenced by lack of ongoing monitoring and assessments of Resident #1's left lower extremity (LLE) after developing a [CONDITION(S)] (DVT) that progressed to no visualized blood flow in the extremity. Additionally, the facility failed to ensure the APRN ordered an International Normalized Ration (INR) blood test to ascertain a baseline level prior to ordering another anticoagulant and failed to communicate Resident #1's DVT treatment plan to the covering provider and facility nursing staff resulting in Resident #1 not receiving an anticoagulant for 2 days which resulted in the finding of Immediate Jeopardy. During the onsite visit the Immediate Jeopardy was verified as corrected when the facility implemented an immediate action plan to mitigate further risk to all residents. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility, personal hygiene and was dependent for transfers. A Resident Care Plan dated 7/31/21 identified Resident #1 had a problem with a DVT due to immobility and a [CONDITION(S)] with weakness. Interventions included to administer medications as ordered, monitoring for side effects and effectiveness, inspect legs and feet for skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish, red, warm along course if vein (superficial) and to monitor laboratory values to monitor/document effect of anticoagulant therapy. a. APRN #2's progress note dated 7/31/21 identified being called at home regarding Resident #1's LLE swelling, tenderness and ruddy discoloration behind the knee. APRN #2's note further identified Resident #1 with a history of CVAs and currently not on anticoagulation, a telehealth visit was conducted. A diagnostics report dated 7/31/21 at 2:42 PM identified that Resident #1 had a positive thrombus formation throughout the visualized venous circulation of the left lower extremity. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was diagnosed with a DVT on 7/31/21 and the clinical record failed to provide evidence of assessing Resident #1's legs and feet for skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish, red, warm along course of vein (superficial) as outlined in the RCP. A RN nurse's note dated 8/2/21 at 10:19 AM identified that Resident #1's LLE to the thigh area was discolored, tender to touch, bluish purple, weak pulses, and cold upon palpation, and the APRN was notified (this assessment differed from the 7/31/21 assessment, as it identified that there was an extension of the discoloration and the change in temperature of the limb). APRN #1's progress note dated 8/2/21 identified that Resident #1 reported a pain level of 6 (10 being the most severe level of pain) and noted that Resident #1 presented with LLE discoloration and pain, positive DVT by doppler with a history of [CONDITION(S)] and was on [MEDICATION(S)] twice a day to be changed to [MEDICATION(S)]. The APRN's physical exam identified that Resident #1's LLE had a bluish hue. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 experienced a significant change in the LLE on 8/2/21 and review of the clinical record failed to reflect monitoring or an assessment of Resident #1's left leg for circulation, movement and sensation from 8/3/21 to 8/8/21. A nurse's note dated 8/9/21 at 2:03 PM identified that Resident #1's LLE was with increased discoloration, cold to touch, unable to palpate pulses, APRN #1 was on the unit, and a STAT doppler completed. A diagnostics report dated 8/9/21 identified that Resident #1 had no blood flow visualized in the left lower extremity arteries with limited evaluation for the LLE arteries. APRN #1's progress note dated 8/9/21 identified that Resident #1's foot had greater discoloration and increased pain. Additionally, the APRN's physical exam lacked documentation of a skin assessment but identified that ultrasound revealed no blood flow visualized in the LLE arteries, evaluation limited and that the plan was that Resident #1 had an occlusive DVT of LLE be sent to the Emergency Department (ED) for evaluation. A hospital ED progress note dated 8/9/21 at 10:54 PM identified that Resident #1 presented from the nursing home with 2 days of painful, purple, and pulseless, left lower extremity and patient had obtained a left lower extremity duplex study prior to arrival significant for no flow visualized in the left lower extremity arteries. A review of systems identified that the entire left lower extremity with purple discoloration becoming more cyanotic at the feet, poikilothermia (cold) from the knee down with no palpable or doppler pulse. The progress note further indicated that this presentation raised concern for arterial occlusion, plan to consult vascular surgeon as Resident #1 had an ischemic probably non-viable left lower extremity, vascular surgeon at bedside and took Resident #1 to the operating room. A hospital procedure progress note dated 8/10/21 at 12:12 AM identified that Resident #1 had an above the knee amputation, (two thirds above the knee). Interview with LPN #1 on 8/19/21 at 12:00 PM identified that she had cared for Resident #1 on the 7:00 AM to 3:30 PM shift from 8/2/21 to 8/6/21 and could not recall any special care or monitoring that she had completed, only noting that Resident #1 was on [MEDICATION(S)] and was diagnosed with a DVT. Interview and review of the facility schedule with LPN #2 on 8/19/21 at 12:24 PM identified that she had cared for Resident #1 initially right after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1's left leg and the Nursing Supervisor was notified. LPN #2 further stated that she cared for Resident #1 on the 7:00 AM to 3:30 PM shift on 8/7/21 and did not recall visualizing/monitoring Resident #1's left leg. LPN #2 again cared for Resident #1 on the 7:00 AM to 3:30 PM shift on 8/9/21 and was asked by the NAs to assist to position Resident #1. At that time, she noticed that Resident #1's leg looked worse with the toes and bottom of the leg discolored and she notified the Nursing Supervisor. Interview with APRN #1 on 8/19/21 at 12:52 PM identified that he had checked Resident #1's left lower leg on 8/4/21 and 8/6/21 stating that he had not noted any changes or concerns but did not provide details of a comprehensive assessment (circulation, movement, sensation, presence of pulses) other than observing the condition of the LLE. He continued by stating that he did not document his findings on 8/4/21 and 8/6/21. Interview and staffing review with LPN #4 on 8/19/21 at 1:00 PM identified that she had cared for Resident #1 on the 11:00 PM to 7:30 AM shift on 8/2/21, 8/4/21, 8/7/21 and 8/8/21 and identified that she was unaware that Resident #1 had a DVT but had known Resident #1's leg was swollen and was elevating the leg. Interview with RN #1 (Nursing Supervisor on the 7:00 AM to 3:30 PM shift on 8/2/21) on 8/19/21 identified that an evaluation of circulation, motor and sensory and pulses would be done each shift and if there were changes noted by the Charge Nurse, the Charge Nurse would contact her to further assess the area and document the assessment in the clinical record. She continued by identifying that she had assessed Resident #1 with the initial diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1. Interview with the Director of Nurses (DNS) on 8/19/21 at 1:20 PM identified the staff would evaluate the resident as outlined in the RCP. Interview and review of the Resident #1's RCP identified that staff should inspect legs and feet for skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish, red, warm along course if vein (superficial) and to monitor laboratory values to monitor/document effect of anticoagulant therapy. The DNS further identified that there should be at least a daily assessment of those listed items and would expect to see documentation that it was completed. She further identified that she would expect a verbal communication from shift to shift on Resident #1's condition and monitoring results of Resident #1's leg condition. Interview and review of the clinical record with the DNS identified that the medical record lacked documentation of monitoring of Resident #1's LLE in the daily nurses note and only documentation on 7/31/21, 8/2/21 and 8/9/21 included information regarding the status of the LLE. The required nursing competencies lacked DVT education, and the DNS identified that education on DVTs was not provided to the nursing staff prior to caring for Resident #1. The facility policy regarding changes in condition identified that every resident's change in condition is assessed and documented properly (but failed to identify the frequency of assessments/documentation). The facility failed to ensure that 3 of the 4 nurses who provided direct care to Resident #1 were competent to effectively monitor a Resident with a DVT for changes that would be reported to the RN supervisor. Resident #1's medical record lacked documentation that monitoring, and assessments were completed after Resident #1's LLE was diagnosed with a DVT on 7/31/21 for all shifts on 8/1/21 and from 8/3/21 through 8/9/21 at which time Resident #1's LLE became totally occluded requiring an above the knee amputation. b. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on 8/7/21 at 9:00 AM. Interview with APRN #1 on 8/19/21 at 12:52 PM identified that he had checked Resident #1's left lower leg on 8/4/21 and 8/6/21 stating that he had not noted any changes or concerns but did not provide details of a comprehensive assessment other than observing the condition of the LLE. He continued by stating that he did not document his findings on 8/4/21 and 8/6/21. Interview with RN #1 on 8/19/21 at 2:32 PM identified that she had notified the APRN#1 with each change of condition she was aware of but could not recall any other specific conversations regarding Resident #1. Interview with APRN #1 on 8/19/21 at 3:00 PM identified that he had ordered the [MEDICATION(S)] for 5 days stating that on 8/7/21 he would change the anticoagulant medication for Resident #1 to [MEDICATION(S)] in order to continue Resident #1's necessary DVT treatment. As part of the requirements for use of [MEDICATION(S)], it was necessary to obtain a baseline INR to effectively monitor for the appropriate [MEDICATION(S)] dose. The INR was to have been completed on 8/7/21 (Saturday) after Resident #1 received his/her last dose of [MEDICATION(S)] and prior to initiation of [MEDICATION(S)]. Review of the medical record and interview with APRN #1 identified that he failed to write the order to obtain an INR. The medical record also lacked documentation of APRN #1's treatment plan to change to [MEDICATION(S)] after obtaining a baseline INR. He stated that he had discussed the treatment plan with the 7:00 AM to 3:00 PM Nursing Supervisor on 8/6/21 but could not recall her name. He further stated that there was not an established mechanism to report issues or pertinent information concerning residents for follow up to the covering APRN/provider and the staff would have known to call the on-call provider with the INR results. APRN #1 further stated that upon his evaluation of Resident #1 on 8/9/21, he identified that Resident #1 was not receiving any anticoagulant from of 8/7/21 to 8/9/21 because the INR had not been completed after [MEDICATION(S)] had been discontinued. Interview with the DNS on 8/19/21 at 3:30 PM identified that there was no mechanism for ongoing Nursing Supervisors to communicate shift issues to the oncoming Nursing Supervisors with the exception of a 24 hour report that generates nurse's notes for review. However, if licensed staff do not document in the nurse's notes, the Nursing Supervisors would have no knowledge of occurrences from the previous shift. Interview with the hospital surgeon on 9/1/21 at 10:30 AM stated anticoagulation in general was necessary to treat a DVT and should be continued throughout the course of treatment. Additionally, he identified that Resident #1's anticoagulation therapy would no longer be effective 12 hours after the last dose on 8/7/21 at 9:00 AM. APRN #1 failed to communicate Resident #1's treatment plan and failed to order a baseline INR and document/communicate the treatment plan for Resident #1's DVT therefore Resident #1 went from 8/7/21 to 8/9/21 without anticoagulant therapy. APRN #1 failed to document assessment data from visits of 8/4/21 and 8/6/21 with Resident #1, including his ongoing evaluations, treatment plan and order for a baseline INR, resulting in Resident #1 anticoagulant therapy not being initiated subsequent to the discontinuation of [MEDICATION(S)] on 8/7/21. Resident #1 was admitted to the hospital on 8/9/21 and an above the knee amputation was performed. On 8/20/21, the facility provided the Department with an immediate action plan that included the following: -Monday through Friday, the APRN will give a handoff to the weekend on-call APRN to ensure continuity of care. The on-call APRN will communicate weekend change in conditions to the APRN on Monday morning. A list will be maintained of conditions addressed, and a copy forwarded to the DNS. -APRNs will be inserviced on the process of reporting off/on (as above). -Inservice Licensed staff on resident change of condition to ensure residents are monitored appropriately. -Institution of a Charge Nurse Shift to Shift report form with instructions for completing the form and inservice staff for continuity of resident care and to identify residents that need further monitoring. -Institution of a Nursing Supervisor Shift to Shift report form with inservicing of Nursing Supervisors to ensure identification of concerns from previous shift so that monitoring can occur for the on-coming Nursing Supervisor. -Random audits will be conducted until substantial compliance is achieved. -Results will be forwarded to the QA committee.

Based on review of the clinical record, facility documentation, facility policy and staff interviews for one (1) of five (5) residents reviewed for hospitalization (Resident #1), the facility failed to ensure nursing staff monitored the Resident #1's leg subsequent to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of the lack of assessment and failing to order an INR, the resident was without the benefit of an anticoagulant for two (2) days resulting in a finding of Immediate Jeopardy. During the on-site visit, the Immediate Jeopardy was verified as corrected when the facility implemented an immediate action plan to mitigate further risk to all residents. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 was moderately cognitively impaired and required extensive assistance of two staff for bed mobility, personal hygiene and was dependent for transfers. A Resident Care Plan dated 7/31/21 identified Resident #1 had a problem with a DVT due to immobility and a [CONDITION(S)] with weakness. Interventions included to administer medications as ordered, monitoring for side effects and effectiveness, inspect legs and feet for skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish, red, warm along course of vein (superficial) and to monitor laboratory values to monitor/document effect of anticoagulant therapy. a. APRN #2's progress note dated 7/31/21 identified being called at home regarding Resident #1's left lower extremity (LLE) swelling, tenderness, and ruddy discoloration behind the knee. APRN #2's note further identified Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnostic report dated 7/31/21 at 2:42 PM identified that Resident #1 had a positive thrombus formation throughout the visualized venous circulation of the left lower extremity. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's clinical record dated 7/31/21 failed to identify that an assessment of the resident's legs and feet was documented as outlined in the plan of care. A RN's note dated 8/2/21 at 10:19 AM identified that Resident #1's LLE to the thigh area was discolored, tender to touch, bluish purple, had weak pulses, and was cold upon palpation. This assessment identified extension of the discoloration and the change in temperature of the limb, a worsening from the 7/31/21 assessment and that the APRN was notified. APRN #1's progress note dated 8/2/21 at 1:00 PM identified that Resident #1 presented with LLE discoloration (bluish hue), pain (rated as a 6 on a scale of 1-10 with 10 being the worst possible pain), positive DVT by doppler with a history of [CONDITION(S)], was on [MEDICATION(S)] twice a day, to be changed to [MEDICATION(S)]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 experienced a significant change in the LLE on 8/2/21. Review of the clinical record failed to reflect monitoring or an assessment of Resident #1's left leg from 8/3/21 to 8/8/21 (subsequent to Resident #1 being diagnosed on [DATE] with a DVT). A nurse's note dated 8/9/21 at 2:03 PM identified that Resident #1's LLE was with increased discoloration, cold to touch, unable to palpate pulses, APRN #1 was on the unit, STAT (urgent) doppler was completed. A diagnostics report dated 8/9/21 at 3:28 PM identified that Resident #1 had no blood flow visualized in the left lower extremity with limited evaluation of the LLE arteries. APRN #1's progress note dated 8/9/21 identified that Resident #1's foot had greater discoloration and increased pain. The APRN's physical exam lacked documentation of a skin assessment but identified that the ultrasound revealed no blood flow visualized in the LLE arteries, evaluation limited, and the plan was that Resident #1 with an occlusive DVT of LLE be sent to the Emergency Department (ED) for evaluation. A hospital ED progress note dated 8/9/21 at 10:54 PM identified that Resident #1 presented from the nursing home with 2 days of painful, purple, and pulseless LLE, a duplex study completed prior to arrival was significant for no flow visualized in the left lower extremity arteries. A review of systems identified that the entire LLE with purple discoloration becoming more cyanotic at the feet, poikilothermia (cold) from the knee down with no palpable or doppler pulse. The progress note further indicated that this presentation raised concern for arterial occlusion, plan to consult vascular surgeon as Resident #1 had an ischemic probably non-viable left lower extremity, vascular surgeon at bedside and was taking Resident #1 to the operating room. A hospital procedure progress note dated 8/10/21 at 12:12 AM identified that Resident #1 had an above the knee amputation, (two thirds above the knee). On 8/19/21 at 12:00 PM, interviews with LPN #1 and LPN #2 identified that although they worked and provided care for Resident #1 from 8/2/21 through 8/8/21, they could not recall any type of monitoring (circulation, movement and sensation) provided to Resident #1's LLE. LPN #2 identified that when she cared for Resident #1 on 8/2/21, the Nursing Assistant brought to her attention that Resident #1's leg looked worse, and she notified the Nursing Supervisor who assessed Resident #1's LLE . RN #1's assessment of the LLE on 8/2/21 identified weak pulses, discoloration present to the thigh area, bluish purple, sensation present, and cold upon palpation. Interview and review of facility staffing with LPN #4 on 8/19/21 at 1:00 PM identified that she had cared for Resident #1 on the 11:00 PM to 7:30 AM shift on 8/2/21, 8/4/21, 8/7/21 and 8/8/21 and identified that she was unaware that Resident #1 had a DVT but had known Resident #1's leg was swollen and was elevating the leg. Interview with the Director of Nurses (DNS) on 8/19/21 at 1:20 PM identified the expectation was for staff to evaluate the resident as outlined in the RCP. Interview and review of Resident #1's care plan identified that staff should inspect legs and feet for skin color/temperature (calf/thigh): pale, cool, edematous (DVT); pinkish, red, warm along course if vein (superficial) and to monitor laboratory values to monitor/document effect of anticoagulant therapy. The DNS further identified that there should be at least a daily assessment of those listed items and would expect to see documentation that it was completed. She further identified that she would expect a verbal communication from shift to shift on Resident #1's condition and monitoring results of Resident #1's leg condition. The DNS identified that the medical record lacked documentation of monitoring of Resident #1's LLE in the daily nurses note and only documentation on 7/31/21, 8/2/21 and 8/9/21 included information in regard to status of the LLE. The required nursing competencies lacked [CONDITION(S)] (DVT) education, and the DNS identified that education on DVTs was not provided to the nursing staff prior to caring for Resident #1. The facility policy regarding changes in condition identified that every resident's change in condition is assessed and documented properly (but failed to identify the frequency of assessments/documentation). The facility failed to ensure that three of the four nurses who provided direct care to Resident #1 were competent to effectively monitor a resident with a DVT for changes that would be reported to the RN supervisor. Resident #1's medical record lacked documentation that monitoring, and assessments were completed after Resident #1's LLE was diagnosed with a DVT on 7/31/21 for 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM on 8/1/21 and from 8/3/21 through 8/9/21 resulting in Immediate Jeopardy. b. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with APRN #1 on 8/19/21 at 12:52 PM identified that he had checked Resident #1's left lower leg on 8/4/21 and 8/6/21 stating that he had not noted any changes or concerns but did not provide details of a comprehensive assessment (circulation, movement, sensation, presence of pulses) other than observing the condition of the LLE. APRN #1 stated he did not document his findings on 8/4/21 and 8/6/21. Interview with RN #1 on 8/19/21 at 2:32 PM identified that she had notified APRN #1 with each change of condition but could not recall any other specific conversations regarding Resident #1. Interview with APRN #1 on 8/19/21 at 3:00 PM identified that he had ordered the [MEDICATION(S)] for 5 days stating that on 8/7/21 he would change the anticoagulant medication for Resident #1 to [MEDICATION(S)] in order to continue Resident #1's necessary DVT treatment. As part of the requirements for use of [MEDICATION(S)], it was necessary to obtain a baseline INR to effectively monitor for the appropriate [MEDICATION(S)] dose. The INR to have been completed on 8/7/21 (Saturday) after Resident #1 received his/her last dose of [MEDICATION(S)] and prior to initiation of [MEDICATION(S)]. Review of the medical record and interview with APRN #1 identified that he failed to write the order for the INR. The medical record also lacked documentation of APRN #1's treatment plan to change to [MEDICATION(S)] after obtaining a baseline INR. He stated that he had discussed the treatment plan with the 7:00 AM to 3:00 PM Nursing Supervisor on 8/6/21 but could not recall her name. He further stated that there was not an established mechanism to report issues or pertinent information concerning residents for follow up to the covering APRN/provider and the staff would have known to call the on-call provider with the INR results. APRN #1 further stated that upon his evaluation of Resident #1 on 8/9/21, he identified that Resident #1 was not receiving any anticoagulant from of 8/7/21 to 8/9/21 because the baseline INR had not been completed. Interview with the DNS on 8/19/21 at 3:30 PM identified the nurses can do INRs at the bedside but that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not a facility policy for documentation of provider encounters. The Agency for Healthcare Research and Quality: An Evidence-Based Handbook for Nurses, Rockville (MD): identified that the transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. This critical transfer point is known as a handoff. An effective handoff supports the transition of critical information and continuity of care and treatment. Interview with the hospital surgeon on 9/1/21 at 10:30AM identified that in general if a change had occurred to the LLE, that would indicate potential arterial thrombus as in a blue discoloration, change in pedal pulses and temperature of the affected extremity, additional doppler studies should be done. The surgeon continued by identifying that if the additional studies had shown arterial involvement, he would have transferred the patient to the hospital's intensive care unit where ongoing monitoring of the condition of the affected limb would be completed. Anticoagulation in general is necessary to treat a DVT and should be continued throughout the course of treatment. Additionally, he identified that Resident #1's anticoagulation therapy would no longer be effective 12 hours after the last dose of anticoagulant on 8/7/21 at 9:00 AM. APRN #1 failed to communicate Resident #1's treatment plan and failed to order a baseline INR and document/communicate the treatment plan for Resident #1's DVT therefore Resident #1 went from 8/7/21 to 8/9/21 without an anticoagulant. APRN #1 failed to document assessment data from visits of 8/4/21 and 8/6/21, including his ongoing evaluations, treatment plan and order for a baseline INR for Resident #1, resulting in Resident #1's anticoagulant therapy not being initiated subsequent to the discontinuation of [MEDICATION(S)] on 8/7/21. Resident #1 was admitted to the hospital on 8/9/21 and an above the knee amputation was performed. On 8/20/21 the facility submitted an immediate action plan and included the following: -Monday through Friday, the APRN will give a handoff to the weekend on-call APRN to ensure continuity of care. The on-call APRN will communicate weekend change in conditions to the APRN on Monday morning. A list will be maintained of conditions addressed, and a copy forwarded to the DNS. -APRNs will be inserviced on the process of reporting off/on (as above). -Inservice Licensed staff on resident change of condition to ensure residents are monitored appropriately. -Institution of a Charge Nurse Shift to Shift report form with instructions for completing the form and inservice staff for continuity of resident care and to identify residents that need further monitoring. -Institution of a Nursing Supervisor Shift to Shift report form with inservicing of Nursing Supervisors to ensure identification of concerns from previous shift so that monitoring can occur for the on-coming Nursing Supervisor. -Random audits will be conducted until substantial compliance is achieved. -Results will be forwarded to the QA committee.

Based on review of the clinical record, facility documentation, policy, and interviews for 1 of 7 residents (Resident #61) reviewed for falls, the facility failed to follow interventions in the care plan to prevent injury. The findings include: Resident #61's [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#61 with a roller walker and assistance of 2 staff, ambulate 50 feet with roller walker and assist of 2 with wheelchair to follow, twice daily with nursing staff. The care plan dated 10/25/17 identified that Resident #61 had a self-care performance deficit, limited physical mobility, weakness and was at risk for falls. Interventions included to provide the assistance of two staff with toileting, transfers and ambulation using a rolling walker with wheelchair to follow, PT to evaluate and treat as ordered. The 14 day MDS dated [DATE] identified Resident #61 was without cognitive impairment, and required extensive assistance of two staff with bed mobility, transfers, ambulation and toileting. The nurse's note dated 11/3/17 at 8:23 PM identified that Resident #61 was observed to have fallen in the room while ambulating with the NA. Resident #61 complained of right hip and right thigh pain. The physician ordered Resident #61 to be transferred to the hospital, and the family was notified. The nurse's note dated 11/3/17 at 10:38 PM identified that Resident #61 had a femur fracture. Review of the hospital radiology report dated 11/4/17 identified Resident #61 had a mildly comminuted [MEDICAL CONDITION]-mid femoral diaphysis with slight varus angulation of the distal diaphysis fragment. Review of the reportable event form dated 11/3/17 identified that Resident #61 lost his/her balance during a transfer from the bathroom to the bed. The investigation identified that NA #2 had transferred Resident #61 alone, did not use a gait belt, and did not have a wheelchair to follow. Additionally, Resident #61 was unsteady on his/her feet. NA #2's statement dated 11/3/17 identified that he/she and Resident #61 got up with the walker and while walking to the bed the resident lost his/her balance. NA #2 identified he/she had stopped to put the bed down, as it was too high, and that after putting the bed down Resident #61 stumbled and fell . Interview with the Acting DNS on 1/24/18 at 2:24 PM identified that he/she had been working as the 3-11 Supervisor and was called to the room. Resident #61 complained of severe pain in the thigh, and the leg was slightly internally rotated. The Acting DNS identified that he/she conducted an investigation and that NA #2, at that time, identified he/she walked Resident #61 out of the bathroom, left the resident to stand with the walker alone, and proceeded to lower the bed. The Acting DNS indicated that NA #2 reported that Resident #61 must have stumbled and fell while he/she was lowering the bed. The Acting DNS identified that Resident #61, at that time, required assistance of 2 staff with ambulation and a roller walker, with the wheelchair to follow, per the care plan and physician orders. Additionally, NA #2 did not have another staff member with him/her and did not use a gait belt. Interview with Resident #61 on 1/25/18 at 3:30 PM identified that the staff had told the resident he/she should have 2 staff in the bathroom and they only had 1 at the time of the fall. Resident #61 identified that NA #2 had left him/her standing alone with the walker, but not with the wheelchair while he/she went to lower the bed and that is when he/she fell . Review of the facility fall policy identified that residents at high risk for falls will have interventions initiated to prevent falls and that NA's follow directions for care as indicated on the resident care flow sheets. Attempts to reach NA #2 were unsuccessful.

Based on clinical record review, review of facility documentation and staff interviews for one sampled resident (Resident #68) reviewed for medication administration, the facility failed to ensure that the resident was free from a significant medication error. The findings include: Resident #68's [DIAGNOSES REDACTED]. The physician's orders [REDACTED].=2 units, 201-250 MG/DL=4u, 251-300 MG/DL=6u, 301-350 MG/DL = 8 units 350-400 MG/DL=10 u, over 400 MG/DL to call the Medical Doctor ( MD)/ Advance Practical Nurse (APRN). The Reportable Event (RE) dated 12/23/14 indicated Resident #68 experienced a hypoglycemic ( low blood sugar) reaction as the result of receiving an incorrect dose of insulin and noted that the resident was transferred to an acute care hospital for evaluation and treatment. The Reportable Event investigation dated 12/23/14 identified that on 12/23/14 at 4:40 P.M. the resident's blood sugar was 282 MG/DL (Normal 70-130 MG/DL). Although the current physician's orders [REDACTED]. The investigation noted that on 12/23/14 at approximately 4: 45 P.M. to 5:00 P.M., the charge nurse was informed that Resident # 68 vomited and did not eat dinner. A finger stick blood sugar obtained at the time noted a blood sugar of 40 MG/DL. The resident was given honey thicken orange juice ( 1 cup) and after 15 minutes the resident's blood sugar was 25 ( indicating a decrease of 15 points) , the supervisor was notified , Insta-glucose paste was given and 911 called. Review of the hospital documentation dated 12/23/14 indicated Resident #68 received an ample of [MEDICATION NAME] 50 by emergency medical service. Interview with Licensed Practical Nurse (LPN) #2 on 6/2/15 at 3:05 P.M. identified that she/he was aware that whenever writing an order for [REDACTED].#2 further stated that she/he wrote the word unit for 2 units and used u for the additional sliding scale coverage because she/he thought that would sufficient. Review of the facility's written statements and interview with Registered Nurse (RN#3) on 6/3/15 at 9:30 A.M. indicated that (60 units) of insulin was administered to Resident #68 instead of the schedule( 6 units) noting that the resident received 54 additional units then prescribed by the physician. RN#3 indicated that she/he checked Resident # 68's Medication Administration Record [REDACTED]. RN # 3 indicated that the ( u) looked like a zero. RN# 3 further indicated that although she/he thought 60 units was a high dose for a blood sugar of 282 MG/DL she/he should have checked the physician's orders [REDACTED]. A review of RN#3 statement further indicated that the resident received 1 cup of orange juice, Insta-glucose paste x 4, 2 Ensure [MEDICATION NAME] (nutritional supplement) with 2 sugar packet prior to transfer to acute care hospital. During an interview with Director of Nursing Services ( DNS) on 6/3/15 at 10:15 A.M. indicated that whenever an order is written for insulin the word unit should be written out and u should not be utilized. DNS indicated that guidelines for acceptable abbreviations was accessible and available as a reference for all facility staff. The facility's policy and procedures for the Institute for Safe Medication Practices List of Error-Prone Abbreviations, Symbol and Dose Designations notes for U or u ( intended meaning Unit) are mistaken as the number 0 or 4, causing a 10 fold overdose or greater ( e.g., 4U seen as 40 or 4u seen as 44) ; mistaken as cc so dose may be given in volume instead of units ( e.g. 4u seen as 4 cc). The facility's policy an procedures for Medication Administration direct the licensed staff responsibility to review physicians/ physician assistant orders and compare against Medication Administration Record.

Based on clinical record review, staff interview and observation for two of four residents reviewed for accidents (R#14, R#20) the facility failed to implement the plan of care with regards to transferring the resident with the assistance of 2 and/or a failure to ensure the resident's alarm was functioning to prevent a fall with injury. The findings included: 1. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with long and short term memory problems, moderately cognitively impaired extensive to total assistance with activities of daily living. A RE dated 10/25/12 at 10:45 AM identified R#14 as alert, disoriented, forgetful and anxious, required assistance with all activities of daily living and transfers with the assistance of two staff members. In addition, the resident was unable to move the right arm and complained of pain. Review of facility investigation dated 10/25/12 identified that on 10/24/12 at approximately 9:00 PM, NA #5 failed to transfer the resident with the assistance of two staff members. The resident had no complaints of pain after the transfer or during the rest of the evening shift. Review of NA#5' statement dated 10/25/12 identified that NA #5 transferred the resident to bed with no assistance. The statement identified that during the transfer the nurse aide placed her arm under the resident's arm and she pulled the resident back in the wheel chair by pulling on the back of resident's pants. An x-ray was obtained on 10/25/12 which identified a fracture of the right proximal humerus and the resident was transferred out to the hospital for treatment. Review of the NA#5's personnel file identified that she was terminated on 10/26/12 for failure to follow the plan of care. Interview with the DNS on 12/13/12 at 8:41 AM identified that NA#5 was terminated for failure to follow the plan of care. Attempts to interview NA#5 via telephone on 10/13/12 at 8:30 AM were unsuccessful. 2. Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. Although a review of a fall assessment identified the resident a high risk for falls, the assessment was not completed until 10/23/12, the day of the fall. An admission MDS assessment dated [DATE] identified the resident as severely cognitively impaired and requiring two person physical assist for transfers, and bed mobility, one person physical assist for ambulation and frequently incontinent of bowel and bladder. A RCP dated 10/08/12 identified the resident at risk for falls secondary to history of falls, use of psychotropic's and environmental changes and utilizes 1/4 side rails for bed mobility. Interventions included to place the bed in low position and provide bed and chair alarm. Review of nurse's aide care card indicated the resident continent of bowel and bladder, with a notation indicating incontinent at times, and requires assistance to the bathroom. A nurse's note dated 10/23/12 at 5:00 AM identified the resident was found on floor stating "she fell ", with the left foot externally rotated. An x-ray was obtained and the resident was diagnosed with [REDACTED]. Review of the Fall Investigation dated 10/23/12 at 5:15 AM identified the resident was ambulating unassisted in the bathroom and the alarm was not "on" nor functioning. Review of NA#3 statement dated 10/24/12 indicated she took the resident to the bathroom around 2:00 AM and the resident was agitated. NA#3 indicated that the alarm was functioning/sounding at the time. NA#3 indicated she pushed the reset button, and never turned the alarm off. However, NA#3 received a warning, because at the time of fall, the alarm was noted to be off. Review of NA#2 statement dated 10/23/12 indicated she was in another resident's room when she overheard R#20 calling out for help and upon arrival the resident was found on floor. NA#2 indicated she did not hear the alarm, at all. Review of NA #1 statement dated 10/23/12 indicated that the resident was "fidgety" until around 2:00 AM and had a bowel movement. NA#1 statement further indicated that when the resident was found on the floor she had some smearing (stool). Review of LPN#1's statement dated on 12/13/12 at 12:05 PM indicated that she was called to resident's room by a nurse aide and upon arrival R#20 was found on the floor. LPN#1 also indicated the resident was unable to verbalize where he/she was going or why. Review of R#20's MAR indicated the resident received trazadone 25 mg on 10/23/12 at 1:00 AM for restlessness. Review of resident's clinical record indicated that although resident received laxative and was agitated during the shift, the resident was toileted 3 hours prior to fall. Review of facility fall policy indicated all resident will be assessed for fall risk on admission, readmission, with a change of condition and quarterly thereafter. Resident with a high risk for falls will have interventions initiated to prevent falls. Implementation of fall preventions interventions include prevention measures in nurse aide assignment using the resident flow sheet and assist resident with transfers, ambulation and other activities. Attempts to interview NA#1, NA#2 and NA#3 were unsuccessful.

Based on clinical record reviews, interviews and review of facility documentation for two of five sampled residents (R#1, R#2), who required assistance with transfers, the facility failed to ensure adequate supervision to prevent an injury. The findings include: 1. Resident #1's [DIAGNOSES REDACTED]. A annual Minimum Data Set (MDS) assessment dated [DATE] identified short and long term memory deficits, severely impaired decision making abilities, and that the resident was totally dependent on staff for bed mobility and transfers. A care plan dated 12/17/10 identified at risk for falls with interventions that included the use of a bed alarm, chair alarm and to anticipate needs. Physician orders [REDACTED]. A review of the nurse's notes dated 12/17/10 at 3:30PM identified that the resident fell out of bed when the nurse aide(NA) lowered the side rail. The resident was transferred to the emergency room for an evaluations and returned to the facility at 10:15PM with a nasal fracture, nasal laceration and a hematoma and abrasion on the forehead. Interview with nurse aide (NA) # 5 on 4/5/11 at 2:10PM identified that he/she had provided care for R#1 during which time the resident was restless and fidgety and had lowered the siderail as he/she was waiting for assistance from another NA in order to get R#1 out of bed. He/she further identified that while the siderail was lowered, he /she reached to get the wheelchair closer to the bed for the transfer. Although NA #5 was positioned next to the bed, the resident fell out of the bed, exiting at the head of the bed and landed head first behind the nurse aide. Interview with Registered Nurse(RN) #1 on 4/5/11 at 2:00PM identified that following this incident NA #5 was provided education in addition to disciplinary action regarding the handling of a restless resident during transfers. 2. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. An initial nursing assessment dated [DATE] identified intact cognition, moderately impaired decision making abilities, extensive assistance of one staff member for bed mobility and total dependence on two staff members for transfers. A fall risk assessment dated [DATE] identified a score of 14 indicating a high risk for falls. A care plan dated 3/31/11 identified risk for falls with interventions that included chair alarm, anticipation of needs and a seat belt for pelvic positioning. A review of the nurse's notes dated 3/30/11 at 11AM identified R#2 fell out of the wheelchair while in Physical Therapy sustaining a hematoma on the left side of his/her head. R#2 was assessed by the Advanced Practice Registered Nurse(APRN) following the fall, who directed to send the resident to the emergency room for an evaluation. Nurse's note dated 3/30/11 at 6:05PM identified that the resident returned from the emergency room with a left clavicle fracture. Interview with the Occupational Therapist on 4/5/11 at 9:35AM identified that R#2 was working with Rehabilitation staff on sit to stand exercises with rest periods in between sets. The Occupational Therapist directed R#2 to sit and rest as he/she had done previously and left R#2's side (approximately 10 feet away ) to answer another resident's question when she observed R#2 start to lean forward and fall to the floor striking her head when she fell . The Occupational Therapist identified that the TAB alarm and /or positioning belt were not reapplied during the rest period as the staff member remained in the room and anticipated continuing therapeutic exercises and the facility practice is to keep the devices off during rehabilitation treatment.