Every finding on record at Ross Manor

Based on facility policy review, record reviews, and interviews, the facility failed to ensure that resident(s) and/or resident representative(s) were provided with written information and/or follow-up, concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, or appoint a surrogate for 3 of 10 residents reviewed for advanced directives (Resident 98 [R98], R36, and R6). Findings: Review of policy Advance Directives revised 3/25 states .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives; The resident or representative is provided with written information concerning the right to refuse of accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or representative indicates that he or she has not established advance directives. The resident or representative is given the option to accept or decline assistance .Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff . 1. Resident #98 was admitted in December of 2025. A review of Resident #98's entire clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. 2. Resident #36 was admitted in April of 2026. A review of Resident #36's entire clinical record lacked evidence that the facility provided resident and/or resident's representative written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. On 6/10/26 at 7:30 a.m., in an interview with the surveyor, the Licensed Social Worker confirmed that they had not located an advanced directive for R36. 3. R6 was admitted in April of 2026. A review of R6's clinical record lacked evidence that the facility followed up with the resident and/or resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. The documentation provided by R6's resident representative dated 11/4/17 Ross Manor Advanced Directive was not signed by the resident or resident representative. R6's Social Service Initial Evaluation dated 5/1/26 states 17. Advance Directive: a. Living Will. There is no evidence in the medical record of a Living Will. On 6/9/26 at 12:45 p.m. in an interview with the Social Worker, a surveyor confirmed that they did not follow up with R6 or his/her resident representative regarding the unsigned Ross Manor Advanced Directive dated 11/4/17.

Based on facility policy, record review, observations, and interviews, the facility failed to adequately ensure medications and biologics were stored at appropriate temperatures in 2 of 3 refrigerators observed for 4 of 4 months of medication refrigerator logs reviewed ([NAME] Unit and [NAME] Unit). Additionally, the facility failed to ensure medications were removed from medication cart after discharge for 1 of 7 carts reviewed ([NAME] Unit).Findings:1.Review of the [NAME] Treatment cart with Registered Nurse (RN)#2 on 6/9/26 at 9:02 a.m., revealed the following medications belonging to a resident that was discharged on 5/19/26, available for use: (1 )Multi-use vial of insulin Lispro, (1)Novolin R100 flex pen, and (1) multi-use vial of insulin Lantus. At this time RN#2 stated they were supposed to take the medications out within 2-3 days of discharge.2. Review of Medication Storage policy dated 1/25 states Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 ) are kept in a refrigerator with a thermometer to allow temperature monitoring.A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily.If no vaccines are stored in the refrigerator, document temperature checks at least once daily.On 6/9/26 at 11:05 a.m., observation of [NAME] Unit medication refrigerator, which contained insulins Novolog, Lantus, and Lispro, as well as Ativan, Tuberculin, and COVID vaccinations.Review of Med Room Fridge Temperature Log: [NAME]: states Required Temperature Range: 35F-46F: If not in this range notify maintenance immediately revealed the following:- Temperature logs from March 1, 2026, through March 31, 2026, lacked evidence temperatures were taken on 3/1/26, 3/2/26, 3/6/26, 3/9/26, 3/21/26, 3/22/26, 3/25/26, 3/27/26, 3/30/26 or 3/31/26. During the day shift on 3/13/26, 3/14/26, 3/15/26, 3/17/26, 3/20/26, or during the evening shift on 3/16/26, or 3/19/26.-Temperature logs from April 1, 2026, through April 30, 2026, lacked evidence temperatures were taken on 4/5/26, 4/9/26, 4/10/26, 4/17/26, or 4/26/26. During the day shift on 4/3/26, 4/11/26, 4/12/26, 4/20/26, 4/24/26, or 4/28/26. During the evening shift on 4/2/26, 4/8/26, or 4/16/26.-Temperature logs from May 1, 2026, through May 31, 2026, lacked evidence temperatures were taken on 5/16/26, 5/17/26, 5/21/26, 5/22/26, 5/23/26, 5/24/26, 5/29/26, 5/30/26 or 5/31/26. During the day shift on 5/9/26, 5/10/26, 5/15/26, or 5/26/2/6. During the evening shift on 5/11/26.-Temperature logs from June 1, 2026, through June 8, 2026, lacked evidence temperatures were taken 6/3/26, or during the day shift on 6/3/26, 6/4/26, 6/5/26, or 6/7/26.Review of Med Room Fridge Temperature Log LTC Med Room states Required Temperature Range: 35F-46F: If not in this range notify maintenance immediately revealed the following:-Temperature logs from March 1, 2026, through March 31, 2026, showed 22 of 57 temperatures were out of range. Temperatures were not documented during the day shift on 3/9/26, 3/15/26, 3/23/26, 3/28/26 or 3/29/26.-Temperature logs from April 1, 2026, through April 30, 2026, showed 49 of 60 temperatures were out of range.-Temperature logs from May 1, 2026, through May 31,2026 showed 41 of 62 temperatures were out of range.-Temperature logs from June 1,2026, through June 8, 2026, showed 15 of 16 temperatures were out of range. On 6/9/26 at 11:32 a.m., with 3 surveyors present, the Quality Improvement Project Manager (QIPM) stated that if medication refrigerator temperatures were not in range, she would double check the temperatures again and if it was still an issue, she would notify maintenance. At the time the refrigerator logs were reviewed with QIPM and above concerns were confirmed. Interview on 6/9/26 at 11:02 a.m., the Nurse Manager confirmed that vaccinations and insulins were kept in both the [NAME] and [NAME] medications refrigerators, and the temperatures are supposed to be logged, if they are over or under temperature, the first thing they need to do is recheck the temperature, if it is still off they should notify maintenance.Interview on 6/9/26 at 2:18 p.m., the Maintenance Director stated, if there was an issue with the medication refrigerators, he would address it or replace the refrigerator. In presence of 5 surveyors the Maintenance Director stated he has not received any work orders for the medication refrigerators.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety by failing to ensure foods were sealed, labeled, and dated in 2 reach-in refrigerators and a walk-in freezer for 1 of 2 kitchen tours and by failing to ensure staff perform hand hygiene during a breakfast service observation on 1 of 3 days of survey (6/10/26). Additionally, the facility failed to monitor refrigerator and dish machine temperatures for 3 of 4 months reviewed (March, April, and May). Findings: Review of facility policy Food Storage, dated 3/2025 states, .Refrigerated Food Storage. Foods must be maintained at or below 41 degrees F [Fahrenheit]. Every refrigerator must be equipped with an internal thermometer. Thermometers should be checked twice per day and recorded on a temperature log for the specified unit (s). All foods must be covered, labeled, dated and routinely monitored to assure foods are used by their use dates or discarded. Review of facility policy, Dish Machine Temperature Policy dated 2021 states, .The director of food and nutrition services will post a log near the dish machine for the staff to document temperatures and sanitizer readings. Staff will monitor dish machine temperatures. throughout the dishwashing process. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures and sanitizer readings are appropriate and staff is correctly monitoring and documenting dish machine temperatures and sanitizer readings. 1. On 6/8/26 from 10:38 a.m.-11:09 a.m., a surveyor conducted an initial kitchen tour with the Food Service Director (FSD), during which the following was observed: - The wash sink's sanitizer solution hose was immersed below the water in the sink. - The Kitchen reach-in refrigerator contained the following, available for resident use: A bowl of sweet potatoes, with the lid labeled with a 5/5/26 prep date and a 5/7/26 use by date A bowl of cottage cheese, with the lid labeled with a 5/5/26 prep date and a 5/7/26 use by date A 14-ounce (oz.) container of beef base and a 16 oz. container of chicken base, both dated 5/5. During an interview at this time, the FSD stated he thinks a kitchen staff member does not realize it is now the month of June and inadvertently labeled the above items wrong. - The Walk-in freezer contained the following, available for resident use: A box of ground beef patties, located on the left shelf, with the box top and inner bag open, exposing the patties to air. A box of donuts, located on the left shelf, with the box top and inner bag open, exposing the donuts to air. A 30-pound (lb.) box of peas, located on the top right shelf, with the box and inner bag open, exposing the frozen peas to air. Two 30 lb. boxes of cut green beans located on the right shelf, with the box and inner bag open, exposing the frozen green beans to air. The back left top shelf contained a metal tray of crab cakes labeled with a prep date of 6/5/26 and a use by date of 6/6/26. The tray was only partially covered with plastic wrap, exposing several of the crab cakes to air. The surveyor discussed the observation with the FSD, and the FSD removed and discarded the crab cakes. - The Aides reach-in refrigerator contained the following, available for resident use: Two 46 fluid oz. carton of Thickened Orange Juice from Concentrate. One of the cartons was labeled 4/7, and one was labeled 5/5. A 46 fluid oz. carton of Thickened Cranberry Cocktail labeled 1/4. The carton's stamped date states, Best if used by: 24 May 2026. The directions on the back of the above cartons stated, Directions: Refrigerate prior to serving . After opening, may be kept up to 7 days under refrigeration. At this time, the surveyor discussed the above finding with the FSD, and the FSD stated that the date marked on the carton indicates the received date, not the date opened and confirmed that he does not know when the above cartons of juice were opened and proceeded to discard the containers. The FSD then stated that items are supposed to be labeled with a received, open, and discard date. On 6/8/26 at 3:50 p.m., the surveyor discussed the above finding with the Administrator. 2. A review of the facility's Kitchen Refrigerator/Freezer Checks (temperature logs) states, Take temperature at a.m. opening and p.m. closing of department. Temperature should be at maximum 40 degrees F. Report to maintenance or supervisor if higher . and revealed the following missing entries and out-of-range temperatures: March 2026: The [NAME] Unit temperature (temp) log indicated that the refrigerator and freezer temps are monitored once per day and indicated above-range (greater than 41 degrees) refrigerator temperatures for the following dates: 3/13/26, 3/22/26, 3/27/26, 3/28/26, 3/30/26, and 3/31/26. The Pepsi refrigerator temp log indicated above-range temperatures on 3/19/26 a.m. and p.m. and lacked evidence that the p.m. temp was monitored on 3/30/26. The Condiments refrigerator indicated above-range temperatures on 3/26/26 Additionally, the above temperature logs lacked evidence that the out-of-range temperatures were reported to the FSD or maintenance. April 2026: The [NAME] Unit temp log indicated that the refrigerator and freezer temps are monitored once per day and indicated above-range refrigerator temperatures for the following dates: 4/4/26, 4/5/26, 4/10/26, 4/12/26, 4/14/26, 4/15/26, 4/18/26, 4/19/26, and 4/20/26. The temperature log lacked evidence that the out-of-range temperatures were reported to the FSD or maintenance. May 2026: The Dish machine temp log is missing temps for 5/24/26 (dinner) and for 5/26/26 and 5/31/26 (breakfast, lunch, and dinner). On 6/10/26 at 1:14 p.m. the surveyor discussed the above finding with the FSD. On 6/10/26 at 3:45 p.m., the surveyor discussed the above finding with the Administrator. 2. On 6/10/26 at 7:15 a.m., observed breakfast service in the main dining room. Observed Dietary Aide #1, serving food with gloved hands. Dietary Aide #1, with her gloved hand, picked up toast and plated it and then wiped the same gloved hand on her soiled apron. At approximately 7:20 a.m. and at 7:25 a.m., observed Dietary Aide #1, with gloved hand, pick up toast, plate it, then wipe her hands on her soiled apron. At 6/10/26 at 7:26 a.m., in an interview with the Dietary Aide, the surveyor discussed the observations and Dietary Aide #1 confirmed she had wiped her hand on her soiled apron after plating toast and did not change her gloves.

Based on observations, interviews, record review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of bedpans on 2 of 3 days of survey (6/8/26, 6/9/26) and hand hygiene during a dining observation. Findings: 1. Facility policy Handwashing/Hand Hygiene, revised 2/2026 states, .Hand hygiene is indicated. before preparing or handling food.after glove removal. Indications for Gloves. Use single-use disposable gloves: when enhanced barrier precautions are applicable; when contact precautions are applicable; before aseptic procedures; and when anticipating contact with blood or body fluids. The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed. On 6/9/26 at 11:08 a.m., during an observation of the lunch dining service in the Long-Term Care Dining Room with Dietary Aide (DA) #1 and DA #2, a surveyor observed DA #2 removing her glasses with her gloved right hand and then replace her glasses. DA #2 proceeded to remove and replace her glasses multiple times. Then, without sanitizing her hands, DA #2 removed a cup from the serving counter and started to pour ginger ale for a resident. At this time, the surveyor intervened and discussed the observation with DA #1 and DA #2. During an interview, DA #2 stated that she has to take her glasses on and off a ton and that she doesn't think about sanitizing her hands after removing dirty gloves or applying clean gloves. DA #1 then stated that she cannot sanitize her hands after removing her gloves because she will not be able to get a new pair of gloves onto her hands if they are wet. DA #1 then stated that she wears 3-4 pairs of gloves at a time so when the top layer of gloves is soiled, she can just remove them and have clean gloves underneath. On 6/9/26 at 11:20 a.m., during the same dining service observation and after the above interview, the surveyor observed DA #1 remove her gloves and rub her right eye with her right hand. DA #1 then rubbed her left eye and then rubbed her right eye again. Without sanitizing her hands, DA #1 removed a new pair of gloves from the box and started to apply them. The surveyor intervened and discussed the observation and asked DA #1 to wash her hands. On 6/9/26 at 11:46 a.m., the surveyor discussed the above observations with the FSD. On 6/9/26 at 12:15 p.m., the surveyor discussed the finding with the Administrator and the Director of Nursing. 2.Observation of the shared bathroom for room [ROOM NUMBER] on 6/8/26 at 11:03 a.m., an unlabeled, unbagged and soiled bed pan observed on top of a shower chair, clean bath towels observed next to/touching/hanging inside the bed pan. Additional observation of room [ROOM NUMBER] on 6/9/26 at 8:55 a.m., revealed unlabeled, unbagged bed pan tucked behind the grab bar in the shower. Observation of shared bathroom for room [ROOM NUMBER] on 6/8/26 at 11:15 a.m., revealed unlabeled bed pan lying on top of a clear plastic bag on shower chair. During interview on 6/9/26 at 2:30 p.m., Certified Nursing Assistant (CNA)#1 stated bed pans are supposed to be labeled and bagged. During an interview on 6/10/26 at 12:29 p.m., the Director of Nursing stated it was her expectation that bedpans are stored in a clear plastic bag in the bathroom and if it's a shared bathroom, they should be labeled. At this time a surveyor discussed the above concerns with Director of Nursing.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Version 3.0 Assessments were accurately coded in the area of dialysis for 1 of 2 sampled residents reviewed for dialysis (Resident #3).Finding:Resident #3's admission diagnoses included End Stage Renal Disease with dependence on renal dialysis. Review of Resident #3's clinical record indicated that Resident #3 has been receiving hemodialysis 3 times per week since prior to his/her admission to the facility. Resident #3's admission Minimum Data Set (MDS) Version 3.0 assessment, completed 5/7/26, Section O - Special Treatments, Procedures, and Programs indicated No under Dialysis and Hemodialysis. On 6/10/26 at 12:30 p.m., a surveyor discussed the above finding during an interview with the Director of Nursing.

Based on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder or trauma event to determine if a change in level of service was required for 1 of 2 sampled residents reviewed for PASRR (Resident #55 [R55]).Finding:On 6/9/26, R55's clinical record was reviewed. R55's PASARR, completed on 8/14/25, did not require a level II determination. On 9/10/25, R55 was diagnosed with Psychotic Disorder with Hallucinations, but the clinical record lacked evidence that the resident was referred to the State mental health authority for a new PASARR determination.On 6/10/26 at 12:55 p.m., during an interview with a surveyor and the Administrator, R55's clinical was reviewed, at this time the Administrator confirmed with the surveyor that R55 was not resubmitted for a PASRR determination to include R55's new diagnosis.

Based on record review and interviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 5 residents reviewed for baseline care plans (Resident #3).Finding:Resident #3 was recently admitted with diagnoses to include End Stage Renal Disease with dependence on renal dialysis.A review of Resident #3's clinical record indicated that Resident #3 has a left arm arteriovenous (AV) fistula (a type of hemodialysis access) and has been receiving hemodialysis 3 times per week since prior to his/her admission to the facility. A review of Resident #3's baseline care plan lacked evidence that goals and interventions were put into place for the AV fistula.On 6/10/26 at 12:30 p.m., a surveyor discussed the above finding during an interview with the Director of Nursing.

Based on observations and interviews, the facility failed to maintain respiratory equipment for 1 of 2 residents reviewed for respiratory (Resident [R] #41).Findings:Observations of R#41 on 6/8/26 at 11:00 a.m., 6/9/26 at 10:55 a.m., and 2:01 p.m.,Resident #41 was observed lying in bed, nasal cannula tubing is attached to his/her nose and connected to an oxygen concentrator. The oxygen tubing is dated [6/26] and the filter is observed to have caked on build up/debris.Review of Treatment Administration Record (TAR), dated 6/2026, states this was completed on 6/7/26.Review of order with start date of 10/26/25 states, Change 02 tubing weekly - label with date changed clean concentrator with sani cloth. Remove filter, rinse under running water, damp dry with paper towel, replace filter. Okay per Americoast if filter is still moist when replaced. every night shift every Sun for oxygen therapy.During an interview on 6/9/26 at 2:31 p.m., Registered Nurse (RN)#1 states that the oxygen concentrator filters are supposed to be removed and rinsed under water weekly during every tubing change and if it was done there would not be any dust on it.On 6/9/26 at 2:01 p.m., the Quality Improvement Project Manager stated the expectation is that nurses changed 02 tubing weekly and at that time are supposed to clean the concentrator and filter. At this time surveyor confirmed this finding.

Based on interviews, observation, and record reviews, the facility failed to obtain dental services for a resident with broken teeth for 1 of 3 resident reviewed for dental services (Resident #78 [R78]).Findings:On 6/8/26 at 11:47 a.m., during an interview with a surveyor, R78 stated he/she broke 2 teeth approximately 4 months ago. R78 had a dental appointment on 3/20/26, but R78 was unable to go because his/her chair would not fit through the door. R78 stated he/she has not heard anything about another appointment. At this time, the surveyor observed that a molar on R78's bottom left jaw was broken. Half of the tooth appeared to be missing with jagged edges on the remaining portion of tooth. The surveyor also observed a molar on R78's bottom right jaw was broken/chipped. R78 stated the broken teeth are painful and he/she needs to eat soft foods.On 6/9/26, R78's clinical record was reviewed and indicated the following:-On 3/1/26 at 5:30 p.m., a follow up note stated, [R78] reports difficulty falling and staying asleep, not napping during the day. Reports this is due to a tooth issue. Staff aware. Intermittent poor appetite.-On 3/15/26 at 6:30 p.m., a follow up note stated, Patient report: .Also, I have not gotten an appointment for my teeth. Dental complaint: 2 broken teeth (1 right lower molar, 1 left lower molar), tongue keeps getting caught and scraped; requesting referral to dentist. Nursing staff thinks [R78] might be above weight limit for portable wheelchair but will check; order written for DenTemp (putty for broken tooth protection) - patient could order online [his/her]self if unable to be ordered through facility.-On 3/16/26 at 8:45 a.m., a regulatory review note stated, Dental complaint: 2 broken teeth (1 right lower molar, 1 left lower molar), tongue keeps getting caught and scraped; requesting referral to dentist. Nursing staff thinks [R78] might be above weight limit for portable wheelchair but will check; order written for DenTemp (putty for broken tooth protection) - patient could order online [his/her]self if unable to be ordered through facility.-On 3/17/26, a provider order stated, Referral to dentist for broken teeth. -On 3/17/26 at 10:00 a.m., a medication management note stated, Dentemp Mouth/Throat Miscellaneous (Oral Hygiene Products) Give 1 application [under the tongue (sublingually)] every 24 hours as needed for broken tooth APPLY TO BROKEN TOOTH.-On 3/25/26 at 12:08 a.m., an SBAR stated, Situation: Resident has cough drops and numbing drops for tooth at bedtime and is requesting permission to keep them there and self administer. Background: Assessment (RN)/Appearance (LPN): Recommendations: Recommendations: Order to keep cough drops and numbing drops for tooth at bedside and self-administer.-On 3/29/26 a follow up note stated, Reports difficulty falling and staying asleep, not napping during the day. Sleep remains variable. Appetite and is eating things that [he/she] gets on [his/her] own. Report [his/her] tooth concern has not been addressed. They attempted an appointment, but [R78's] wheelchair would not fit through the door .Dental complaint: 2 broken teeth (1 right lower molar, 1 left lower molar), tongue keeps getting caught and scraped; requesting referral to dentist. Nursing staff thinks [R78] might be above weight limit for portable wheelchair but will check; order written for DenTemp (putty for broken tooth protection) - patient could order online [his/her]self if unable to be ordered through facility .Please discuss tooth and care concerns with resident.-On 3/30/26 at 9:15 a.m., a medication management note stated, Dentemp Mouth/Throat Miscellaneous (Oral Hygiene Products) Give 1 application sublingually every 24 hours as needed for broken tooth APPLY TO BROKEN TOOTH .Dentemp Mouth/Throat Miscellaneous (Oral Hygiene Products) Give 1 application sublingually every 24 hours as needed for broken tooth may keep at bedside.-On 4/1/26, 4/3/26, 4/8/26, 4/15/26, 4/17/26, and 4/20/26, clinical notes (including progress notes, acute visit notes, and follow up notes) stated, Dentemp Mouth/Throat Miscellaneous (Oral Hygiene Products) Give 1 application sublingually every 24 hours as needed for broken tooth may keep at bedside.-On 4/29/26 and 4/30/26, clinical notes stated, No natural teeth or tooth fragment(s) (edentulous): No. Obvious or likely cavity or broken natural teeth: Yes.-On 5/1/26, 5/4/26, 5/12/26, and 5/21/26, clinical notes stated, Dentemp Mouth/Throat Miscellaneous (Oral Hygiene Products) Give 1 application sublingually every 24 hours as needed for broken tooth may keep at bedside.-On 5/18/26 at 12:00 a.m., a follow up note stated, Please discuss tooth and care concerns with resident. [R78] again reports [his/her] tooth concern has not been addressed. They attempted an appointment, but [R78's] wheelchair would not fit through the door.-On 6/1/26 at 12:00 a.m., a follow up note stated, [R78] again reports [his/her] tooth concern has not been addressed .Please discuss tooth and care concerns with resident.-On 6/1/26 at 8:15 a.m., a physician note stated, Dentemp Mouth/Throat Miscellaneous (Oral Hygiene Products) Give 1 application sublingually every 24 hours as needed for broken tooth may keep at bedside.-On 6/10/26 at 8:29 a.m., during an interview with the surveyor, R78 stated he/she has not had Dentemp mouth at bedside or been given any sublingual medication for broken teeth. R78 has cepacol lozenges (used to temporarily relieve sore throats, sore mouths, canker sores, and minor throat irritation) at his/her bedside for numbing his/her mouth and throat.-On 6/10/26 at 10:37 a.m., during an interview with a surveyor, the Unit Secretary stated when she receives a referral, she usually calls for an appointment then schedules a time to follow up on referrals. The Unit Secretary stated the dental referrals are different and she is in the process of making improvements. Review of the active dental referrals did not include a referral for R78. At this time the surveyor confirmed with the Unit Secretary that R78 was unable to be seen by the dentist on 3/20/26, that no other appointments have been made for R78's broken teeth, and that there was no scheduled follow up to ensure R78 received dental services.-On 6/10/26 11:08 a.m., during an interview with a surveyor and the Director of Nursing (DON), R78's clinical record was reviewed. At this time the surveyor confirmed that the facility was aware R78 had 2 broken teeth but failed to ensure dental services were obtained. The DON stated the unit secretary should have been aware that the resident was not seen by the dentist and communicate concerns to the unit manager to follow up with the resident.

Based on record review, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 sampled residents reviewed for dialysis (Resident #3).Finding:Facility Policy Hemodialysis Catheters- Access and Care of, revised 3/2025 states, .Documentation.The nurse should document in the resident's medical record every shift as follows: Location of catheter. Condition of dressing (interventions if needed) . If dialysis was done during shift. Any part of report from dialysis nurse post-dialysis being given.Observations post-dialysis.Resident #3 was admitted in April 2026 with diagnoses including End Stage Renal Disease with dependence on renal dialysis. Review of Resident #3's clinical record indicated that Resident #3 has been receiving hemodialysis 3 times per week since prior to his/her admission to the facility. A review of Resident #3's active physician orders revealed the following:An order with a start date of 6/1/26 for Fistula to the left arm. Check Thrill and Bruit every shiftAn order with a start date of 6/1/26 for Fistula- left arm Check site for bleeding and signs or symptoms of infection every shiftAn order with a start date of 6/1/26 for .Dialysis- Monday, Wednesday, Friday.Further review of Resident #3's physician orders lacked evidence of a physician order for Dialysis or for monitoring of his/her left arm fistula from Resident #3's date of admission until the above orders with the start date of 6/1/26.Review of Resident #3's May 2026 Treatment Administration Record (TAR) lacked evidence that his/her fistula was being monitored. Further review of Resident #3's clinical record lacked evidence that the Pre/Post Dialysis Evaluation assessment is being completed.On 6/10/26 at 11:08 a.m. during an interview, Registered Nurse (RN) #4 stated that the nurse checks Resident #3's vital signs and access upon his/her return to the facility from dialysis. When the surveyor asked about the pre/post dialysis assessment, RN #4 stated that she is a per diem nurse and did not know if it should be completed.On 6/10/26 at 2:10 p.m. during an interview with the Director of Nursing (DON), the surveyor discussed the above finding. The DON stated that Resident #3 was hospitalized in May and that when he/she returned to the facility, his/her dialysis-related orders were never re-entered. The DON then stated that the nurse is expected to start the Pre/Post Dialysis Evaluation assessment in the clinical record before a resident leaves for dialysis and complete the assessment upon the resident's return and confirmed that Resident #3's clinical record lacks evidence that the Pre/Post Dialysis assessments are being done.

Based on clinical record reviews and interviews, the facility failed to follow physician orders for 2 of 19 residents reviewed. (Resident #64 [R64] and R90). Findings: 1. On 4/14/25 at 2:52 p.m. during a clinical record review for R64 there is documentation that shows he/she had an order for Levofloxacin 750 milligrams (mg) by mouth every 48 hours until 4/22/25 with a start date of 4/2/25. Review of the electronic medication administration record (MAR) shows documentation that R64 received a dose of Levofloxacin on 4/2/25 at 6:33 a.m. and he/she received an additional dose on 4/3/25 at 3:18 p.m. which was not 48 hours after the previous dose as ordered. On 4/16/25 at 1:00 p.m. during an interview with LPN1 and LPN 2, they stated the facilities Pyxis does not have that dose of Levofloxacin and thought the medication would come early in the morning the next day 4/3/25. Review of the MAR with LPN1 and LPN2 the surveyor confirmed that R64 received a dose of Levofloxacin two days in a row (4/2 and 4/3) and not every 48 hours as ordered by the Provider. 2. On 4/15/25 at 12:49 p.m., during a clinical record review for R90, the Treatment Administration Record for April shows that on 4/12/25, R90 had a Blood Sugar (BS) result of 422, per his/her sliding scale insulin coverage the facility would need to give R90 12 units of insulin and call the Medical Doctor (MD). Clinical record shows that they did call the MD and received an order to give an additional 3 units of insulin and to recheck BS in 2 hours. On 4/16/25 at 12:35 p.m. during an interview with LPN1 and LPN2 the surveyor confirmed there was no evidence in R90's clinical record that his/her BS was not rechecked in 2 hours as ordered.

Based on clinical record reviews, and interviews, the facility failed to provide physician ordered respiratory services for 1 of 1 resident (Resident [R2]) reviewed with a continuous positive airway pressure (CPAP) machine when the facility failed to obtain missing tubing for R2's machine. Finding: On 4/15/25 during a record review for R2, he/she was admitted with an order to apply CPAP every evening with a start date of 2/21/25. Nursing progress note dated 2/21/25 documents that the CPAP was not used, no tubing with machine. His/her clinical record documents that R2 was hospitalized on [DATE] with a return date of 2/27/25, he/she was hospitalized on [DATE] with a return date of 4/4/25 and was sent to the hospital on 4/6/25 with a return date of 4/10/25. All admission orders had the order to apply CPAP every evening. Documentation in the nursing progress notes and on the electronic treatment administration record (ETAR) shows that R2 was not using the CPAP as ordered due to missing parts. The facility did not assist the resident to obtain the missing parts which resulted in R2 having hospital readmissions. R2's last hospitalization was from 4/6/25 to 4/10/25 and since his/her return, the facility was able to obtain the missing part and R2 has been using it daily since receiving the part. On 4/15/25 at 10:00 a.m. during an interview with the Assistant Director of Nursing (ADON) she stated that when R2 first came to the facility, his/her CPAP was brought in and did not have the tubing, when the facility contacted the previous place of residence, they said R2 didn't have any parts there. The facility contacted the previous medical equipment provider (Lincare), and they said he/she was not allowed to get parts until September, the facility then contacted a local medical equipment provider (Americoast) and was able to get the parts (tubing) on 4/11/25. It was stated that R2 was refusing to use their CPAP or had stated they would not use it. During this interview the surveyor confirmed that if R2 wanted to use their CPAP they were not able to due to the missing part. On 4/15/25 at 10:00 a.m. during the interview with the ADON, the surveyor confirmed that for all admissions R2 was not able to use his/her CPAP as ordered due to missing parts and the facility had failed to obtain the missing part since his/her admission on 2/20/25 resulting in R2 having 4 hospital admissions relating to hypoxia (low oxygen levels). The missing part was ordered and received by 4/11/25 (50 days after initial admission)

Based on observations and interviews, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 3 kitchen equipment that require a 1 air gap on 4 of 4 days of survey. Finding: On 4/14/25, at 12:05 p.m. during the initial kitchen tour, a surveyor observed there was an improper air gap provided on the drain lines of the ice machines, one located in the hallway leading to the kitchen and one located in the kitchen. This direct connection of wastewater and potable water was in violation of the 10-114 State of Maine Rules Chapter 226, definition Section A, which defines an Air-Gap Separation - A physical separation between the free-flowing discharge end of a potable water supply pipeline and an open or non-pressure receiving vessel. An air-gap separation shall be at least twice the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than one inch (2.54 cm). On 4/14/25, at 12:05 p.m., a surveyor confirmed this finding with the Food Service Director (FSD). On 4/15/25 during a second visit to the kitchen, to observe meal preparation a surveyor observed the ice machines continued to have an improper air gap on the drain lines. On 4/16/25, during a third visit to the kitchen to observe a meal service, a surveyor observed the ice machines continued to have an improper air gap on the drain lines. On 4/17/25, during a final kitchen tour a surveyor observed the ice machines continued to have an improper air gap on the drain lines and the vegetable sink had the proper 1 air gap. On 4/17/25 at 10:00 a.m., during an interview with the FSD, a surveyor confirmed the improper air gaps remained on the ice machines.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 3 of 4 days of survey (4/14/25, 4/15/25, and 4/16/25). Findings: On 4/14/25, a surveyor observed the following: -In the shared bathroom for Rooms 302A and 302B, a commode seat in use as an elevated toilet seat was observed over the toilet bowl. Dried blood was observed on the right side of the seat, and stool was observed smeared on the front of the commode seat. Dried blood droplets were observed on the floor in a trail leading toward the bathroom sink. A bed pan was observed unlabeled and exposed to the environment, resting against handrail and the bathroom wall. -In the shared bathroom for Rooms 303A and 303B, a large bed pan was observed to be soiled with stool, unlabeled, and exposed to the environment. -In room [ROOM NUMBER]B, a soiled linen bed chuck was observed on the floor. -In the bathroom of room [ROOM NUMBER], a surveyor observed a hole in the floor of the shower creating an uncleanable surface. -In room [ROOM NUMBER]A, a soiled linen bed chuck was observed on the floor. -In room [ROOM NUMBER] blood was observed on the bed frame of Resident #63 (R63) On 4/14/25 at 11:43 a.m., during an interview with a surveyor and a Registered Nurse (RN2), the following were observed and confirmed: -In the shared bathroom for Rooms 302A and 302B, a commode seat in use as an elevated toilet seat was observed over the toilet bowl. Dried blood was observed on the right side of the seat, and stool was observed smeared on the front of the commode seat. Dried blood droplets were observed on the floor in a trail leading toward the bathroom sink. A bed pan was observed unlabeled and exposed to the environment, resting against handrail and the bathroom wall. -In the shared bathroom for Rooms 303A and 303B, a large bed pan was observed to be soiled with stool, unlabeled, and exposed to the environment. RN2 stated bed pans should be in a bag until they are used, they should be labeled to identify who they belong to; after a bed pan is used it should be sanitized, then bagged for future use. On 4/14/25 at 1:00 p.m., during an interview with a surveyor and a Certified Nursing Assistant (CNA), the blood on R41's bed frame was observed and confirmed, the CNA was unable to identify where the blood came from. On 4/15/25 at 7:05 a.m., a surveyor observed residual blood dried on R63's bed frame. On 4/15/25 at 7:22 a.m., a surveyor observed CNA2 assist Resident #60 (R60) with using a bed pan. After CNA2 assisted R60 with peri care, CNA2 returned R60's toiletries to drawers while still wearing soiled gloves. CNA2 then began handling R60's clean clothing while still wearing soiled gloves, at this time the surveyor intervened and confirmed that CNA2 did not remove the soiled gloves or perform hand hygiene before contacting drawers and the resident's clean clothes. On 4/15/25 11:19 a.m., a surveyor observed opened dressing wrappers on Resident #41 (R41) blankets. At 11:27 a.m., this observation was confirmed with RN2. On 4/15/25 at 11:44 a.m., a surveyor observed Resident #47 (R47) in the hall, self-propelling in a wheelchair. R47's foley bag was observed dragging on the floor under the wheel chair. A surveyor observed and confirmed this finding with CNA-M. On 4/16/25 at 11:03 a.m., in an interview with the Director of Nursing (DON), a surveyor reviewed and confirmed the above findings. During the interview the surveyor and the DON observed and confirmed the following: -In the bathroom of room [ROOM NUMBER], the floor of the shower has a hole creating an uncleanable surface. -The commode seat used as a raised toilet seat in the shared bathroom, for Rooms 302A and 302B, was observed to have blood on the left side of the seat. This was confirmed at the time of the observation. -The bed frame in room [ROOM NUMBER]A was observed and confirmed to have residual blood on it (consistent with the original observation on 4/14/25).

Based on clinical record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 sampled residents admitted for skilled care services (Resident #2[R2]). Finding: Review of R2's clinical record noted that he/she was initially admitted to the facility on [DATE], discharged on [DATE] and returned on 2/27/25. The clinical record lacked evidence that the base line care plan was developed with instructions needed to provide minimum healthcare information necessary to properly care for R2 until 3/3/25. On 4/17/25 at approximately 10:15 a.m., during an interview with the Assistant Director of Nursing, the surveyor confirmed that that baseline care plan was not developed/initiated until 3/3/25 4 days after admission and not within the 48 hours after admission.

Based on interview, observation, and record review, the facility failed to consistently provide Activities of Daily Living (ADL) care in the area of oral hygiene for 1 of 1 residents reviewed for dental care [Resident #58 (R58)]. Finding: On 4/15/25 at 10:15 a.m., during an interview with a surveyor, R58 stated staff do not soak or wash his/her dentures at night. At that time the surveyor observed the denture to be soiled with food debris. On 4/16/25, R58's clinical record was reviewed. The clinical record indicated R58 is cognitively intact. The Care Plan indicates a focus of [R58] has an ADL self-care performance deficit [related to] . hemiplegia affecting left non-dominant side . need for assistance with personal care. The Care Plan intervention for this focus states PERSONAL HYGIENE/ORAL CARE: the resident requires limited to extensive assist. Review of Oral Hygiene documentation indicates oral hygiene was not completed after the evening meal for 13 out of 31 days in March (3/1/25, 3/3/25, 3/5/25, 3/7/25, 3/9/25, 3/10/25, 3/14/25, 3/15/25, 3/16/25, 3/21/25, 3/22/25, 3/28/25, and 3/30/25). On 4/16/25 at 10:55 a.m., during an interview with a surveyor and the Director of Nursing (DON) the Oral Hygiene documentation was reviewed. The DON stated evening shift would document Not Applicable if they did not provide this service and she would not expect evening shift to complete this task if the previous shift had already documented it as completed. At this time the surveyor confirmed that oral hygiene was not provided consistently after the evening meal.

Based on record review and interviews, the facility failed to ensure there was a physician ordered renewal for an as needed (PRN) psychotropic medication without a stop date, making it available for administration for 1 of 19 residents reviewed (Resident #6 [R6]). Finding: On 4/15/25 at 12:19 p.m., during R6's clinical record review, the record indicated that on 2/12/25 an order for Haldol (atypical antipsychotic medication) dose of 0.25 milliliters (ml) by mouth every 4 hours as needed was started. This medication order did not include a stop date for re-evaluation and the physician progress notes did not include a rationale for continued use of this medication. On 4/16/25 at 12:45 p.m., during interviews with LPN1 and RN, the surveyor confirmed that the order for the Haldol was still active beyond the 14-day limit without a rationale to continue, the order did not contain a stop date for a re-evaluation.

Based on a clinical record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 19 sampled residents (Resident #2 [R2], and [R1]). Findings: 1. On 4/15/25 at 10:00 a.m., during a clinical record review for R2 there was an order dated 2/21/25 which instructed nursing to apply continuous positive airway pressure (CPAP) daily at bedtime. Review of the Treatment administration record (TAR) for March 2025 has documentation of the CPAP being applied on 3/3, 3/4, 3/5, 3/13, 3/18 and 3/19/25. Documentation in R2's clinical record indicates that the CPAP had missing parts and was not able to be used. On 4/15/25 at 10:00 a.m., during an interview and clinical record review with the Assistant Director of Nursing (ADON), she stated that when R2 first came to the facility, his/her CPAP was brought in and did not have the tubing (had missing part). The surveyor confirmed that documentation on the TAR was inaccurate when it was signed off as the CPAP being applied on the above dates when the missing part was not received until 4/11/25. 49635 2. On 4/16/25, R1's clinical record was reviewed. Review of the Medication Administration Record (MAR) indicated that R1 was prescribed Benztropine Mesylate (used to treat Parkinson's disease and side effects of other drugs) for Parkinson, and Ziprasidone (used to treat schizophrenia and bipolar disorder) for psychosis. Review of the active diagnosis list for R1 did not include a diagnosis of Parkinsons disease or Psychosis. Review of the provider notes indicated Benztropine Mesylate was prescribed to treat drug induced tremor, and Ziprasidone was prescribed for a diagnosis of bipolar disorder. On 4/16/25 at 2:45 p.m., during an interview with a surveyor and the Director of Nursing (DON), R1's clinical record was reviewed. The DON stated R1 does not have a diagnosis of Parkinson's or Psychosis. At this time a surveyor confirmed the MAR contained inaccurate information related to the diagnosed indication for the medications Benztropine Mesylate and Ziprasidone.

Based on record review and interviews, the facility failed to ensure that the resident's representative was notified of a change in the resident's discharge plan, failed to notify the representative of the resident going outside the facility and failed to notify the medical provider of resident's elopement risk and exit seeking behaviors for 1 of 1 sampled resident (Resident #1) Findings: On 2/4/25 at 2:50 p.m., during an interview and record review, it was documented that the interdisciplinary team and resident representative made a decision that Resident #1 was going to need 24-hour supervision. A plan was made for Resident #1 to go over to [NAME] Place, an assisted living memory care unit, on Saturday 1/11/25. A decision was made not to transfer Resident #1 to the memory care unit and the facility failed to notify the resident representative of this change. On 2/4/25, during a clinical record review for Resident #1, a nursing note documents that Resident #1 went out the door that morning and attempted to climb over a railing. Resident #1 was redirected back into the facility. The clinical record lacks evidence that his/her representative was made aware of this incident. On 2/4/25 at 12:35 p.m., during an interview with Resident #1's provider, who was involved in his care since admission on 1/2/25, stated that she was not aware of Resident #1 having a wander guard or that he/she was an elopement risk. She examined Resident #1 on 1/16/25 after their elopement. On 2/5/25 at 8:30 a.m., during an interview with the Administrator, the surveyor confirmed that the resident representative was not aware of the change to his/her discharge plan. On 2/5/25 at 9:00 a.m., during an interview with the Director of Nursing and the Unit Manager, the surveyor confirmed the lack of evidence that that resident representative was made aware of the incident on 1/13/25.

Based on record reviews and interviews, the facility failed to supervise and monitor 1 of 1 (Resident #1) wandering resident resulting in the resident eloping from the facility; wandered a mile away from the facility in 14-degree Fahrenheit weather, and being found near the Convenient MD building. Finding: On 2/4/25, a review of Resident #1's clinical record was completed. Resident #1 was admitted on [DATE] with a diagnosis of left frontal parietal subarachnoid hemorrhage with history of Alzheimer's disease. A Wandering Risk Assessment was completed the day of admission and indicated Resident #1 was a risk for wandering, a wander guard was put on Resident #1. On 1/3/25, staff observed Resident #1 exit seeking and wanting to leave, the resident was re-directed without incident. On 1/6/25, staff observed Resident #1 exit seeking and wanting to leave, the resident was re-directed without incident. On 1/8/25, the facility spoke with POA, and recommended Resident #1 be moved to the locked Memory Care unit for 24/7 supervision. On 1/9/25, staff observed Resident #1 exit seeking and wanting to leave, the resident was re-directed without incident. On 1/13/25, staff observed Resident #1 exit through the front door and the resident was re-directed back into the facility without incident. On 1/15/25, in the early morning hours staff observed Resident #1 exit seeking with his/her belongings packed in a clear bag and stated they wanted to leave and go home, the resident was re-directed without incident. On 1/15/25 at approximately 10:30 p.m. Resident #1 eloped and was missing for 2-3 hours. Documentation on the facility's elopement investigation indicated that at 10:30 p.m. Resident #1 was observed in their bed with his/her eyes closed. At 11:30 p.m. the nurse found that Resident #1 was not in his/her room. A search of the facility was done, and Resident #1 was not found. Upon inspection of his/her room it was noted the window in his/her room was open and the window screen was on the ground outside. Local law enforcement and management were called, a search of the local area was completed, and Resident #1 was returned to the facility at approximately 1:15 a.m. -1:30 a.m. The facility reports state that a complete assessment was done and did not identify any new injuries or areas of concern. The facility assigned a 1 on 1 staff to sit with Resident #1 for the remainder of his/her stay at the facility. On 2/4/25 at 8:13 p.m., during an interview with the Charge Nurse, she stated that on 1/15/25 in the early morning before shift change at 6:00 a.m., Resident #1 was carrying around a bag with his/her clothes and trying to get out the door on the 701 and 708 hallway saying that he/she wanted to go home. She stated that she told the Director of Nursing and the Unit Manager that Resident #1 was trying to get out that morning. On 1/16/25 Resident #1 returned to the facility at approximately 1:15 a.m. by the Police, Resident #1 was found at the beginning of the main road near the Convenient MD building (approximately 1 mile from facility). When Resident #1 returned his/her temperature was documented at 93.2. The on-call provider was called and was made aware that Resident #1 eloped from the facility and was out in the community for about 2-3 hours (exact time unknown, last seen at 10:30 p.m.) in 14-degree Fahrenheit weather. A video conference was held with the on-call provider who gave orders to treat his/her hypothermia and to continue the warming blankets and monitoring their vital signs and to notify the provider of any change in condition. During interviews throughout this investigation the surveyor identified that the facility was aware of Resident #1's attempts to leave the facility, with one occasion being successful on 1/13/25 with Resident #1 exiting the building through the door and attempting to climb a railing. They were aware the morning of 1/15/25 that Resident #1 packed his/her belongings and had stated that he/she wanted to go home. In the late night of the 15th with the last visual of Resident #1 being at 10:30 p.m. Resident #1 did elope out his/her bedroom window and was gone/missing for approximately 2-3 hours on a 14-degree Fahrenheit night and who was not dressed in appropriate winter clothing. On 2/5/24 at 9:10 a.m. during an interview with the Director of Nursing and the Unit Manager the surveyor confirmed that they were aware of Resident #1's increased elopement risk and Resident #1 eloping on 1/15/25.

Based on review of the facility internal investigation, clinical record review, facility Medication Administration Policy and Procedure, and interviews, the facility failed to protect a resident from receiving another residents medications resulting in the resident being transferred to the Acute Care Emergency Department (ED) for evaluation and monitoring of low blood pressure and a drop in hemoglobin and hematocrit for 1 of 1 resident reviewed (Resident #1 [R1]). Finding: On 9/3/24, a review of the facility's internal investigation was completed. The investigation indicated that on 8/27/24, during morning medication pass, Certified Nurse Assistant-Medication (C.N.A.-M) administered the wrong medications (Aspirin 81 milligrams (mg),Cholestyramine 1 packet for high cholesterol, Clopidogrel Bisulfate for atrial fibrillation, Isosorbide 90 mg [Imdur-used to prevent angina], Psyllium Husk Powder for constipation, Metoprolol Tartrate [used to treat high blood pressure/atrial fibrillation], and Tylenol 1000 mg for pain to R1. C.N.A.-M administered Resident #2's (R2's) medications to R1 in error. R1 was not allergic to any of the wrongfully administered medications. R1 was immediately assessed and a physician who was at the facility ordered the resident to be sent to the Emergency Department (ED). R1 was monitored in the ED for low blood pressure and was treated with intravenous fluids (IV) and R1's labs showed a mild drop in hemoglobin and hematocrit. The Skilled Nurse Manager documented in her investigation that C.N.A.-M stated she read the name in the computer system incorrectly, thinking that R1's name was R2's name. The medications were administered. When C.N.A.-M noticed the error, she immediately notified the nurse and R1 was evaluated and sent to the ED. The follow up to this incident was the facility audited the profiles of all residents to ensure pictures were connected to all residents. Audits were continued to monitor that all resident pictures are on their electronic Medication Administration Record (MAR). The Director of Nursing placed the facility's Medication Administration policy and sign sheets on all units to be reviewed by those who pass medications and ensured this was completed by 9/3/24. Documentation in R1's clinical record under the physician orders indicated R1 had an order for Metoprolol Tartrate (used to treat high blood pressure) 25 milligrams (mg) give 0.5 tablet by mouth two times a day for hypertension. Documentation on R1's Minimum Data Set 3.0, dated 8/20/24, was coded to indicate the resident's Brief Interview for Mental Status (BIMS) was a '12'. For this scoring system of 0-15, a score of 8-12 indicates mild cognitive impairment. R1 is alert and confused at times. A nurse's note dated 8/27/24 at 9:54 a.m., written by RN1, Laurel Unit Nurse Manager, indicated R1 was given medications that were not prescribed to him/her, one of which contained anti-hypertensives. Resident subsequently started to have low blood pressures for him/her, which was 88/60. Provider notified. Emergency Medical Services (EMS) called for emergent transfer immediately after error was noted. Resident transferred to bed. The Provider stated to put R1 in a Trendelenburg position (position used for hypotension-to help blood return to the heart and restore adequate brain perfusion) while waiting EMS arrival. A nurses note dated 8/27/24 at 10:44 a.m., written by RN2, [NAME] Unit Nurse Manager, indicated R1 was transferred to the ED after a medication pass error. R1 had been given Metoprolol 50 mg and Isosorbide (Imdur-used to prevent angina) 90 mg. Provider notified and resident son notified after call back. Resident transported to ED for evaluation. Documentation in the ED Provider note indicated R1 was inadvertently given the wrong medications. These medications included Imdur, Plavix (antiplatelet medication), aspirin, and a higher dose of Metoprolol. R1 was given IV fluids as her blood pressure was low for a period of time. R1's lab work was overall unremarkable other than a mild drop in hemoglobin and hematocrit (H+H) with no signs of bleeding (this was not a pre-existing problem). Documentation in R1's physician progress note, dated 8/30/24, indicated R1 transferred to ED on 8/27/24 was given wrong meds-Metoprolol 50 mg and Imdur 90 mg. Blood pressure was low and resident feeling lightheaded. H+H low-follow up labs to be done. Facility Medication Administration Policy and Procedure, under #6: The individual administering medications must verify the resident's identity before giving the resident his/her medications which include checking photograph attached to medical record and if necessary, verify resident identification with other facility personnel. Under #7: check the medication label three times for right individual, right medication, right dose . On 9/12/24 at 8:30 a.m., in an interview with the surveyor, R1 stated he/she was given the wrong medications and within a half hour of taking these medications R1 stated he/she felt dizzy/lightheaded. R1 stated he/she did not know who gave the medications, but he/she trusts them to give the correct medications. On 9/12/24 at 12:20 p.m., in an interview with the surveyor, C.N.A.-M confirmed that she gave R1 the wrong medications. She confirmed that she gave R2's medications to R1 on the morning of 8/27/24. C.N.A.-M stated she had come back to work after not working at this facility for about two months. She stated she remembered some residents but not others. It was breakfast time and in the small dining room near the 100/200 rooms, she saw R1 sitting at the table and thought it might be R2. C.N.A.-M stated she thought R2's last name was a females name. C.N.A.-M stated she did not recognize the resident and the name on her computer screen (electronic Medication Administration Record (MAR). R2's name was displayed on the MAR screen. C.N.A.-M stated she asked R1 if his/her name was the last name for R2. C.N.A.-M stated the resident acted as if he/she couldn't hear her, so C.N.A.-M got closer to the resident, spoke a little louder and asked again. C.N.A.-M stated the resident (R1) answered yes and she gave R1 the medications. C.N.A.-M stated she did not know R1 was confused. C.N.A.-M proceeded down the hall to the rooms. She put a room number in the computer and R2's name came up and showed that R2's medications had already been given. C.N.A.-M stated she was confused so she went through all the people she had given medications to and realized she gave R1 the wrong medications. C.N.A.-M stated she gave R2's medications to R1. C.N.A.-M stated she immediately told RN1. As a result of this isolated incident, the following corrective actions were initiated between 8/27/24 and 9/3/24. On 8/27/24, the Skilled Nurse Manager re-educated C.N.A.-M on the medication administration policy and procedure. On 8/27/24, copies of the Medication Administration policy and procedure along with sign sheets was placed at the nurse's stations and all medication technicians and nurses that administer medications were mandated to review the policy and procedure and sign the sheet that they did the review. This was completed by 9/3/24. In addition, the facility recognized that not all residents had a picture attached to their electronic MAR for facial identification. Audits of all the residents MARs was completed to ensure they all had a picture. The Skilled Nurse Manager stated about three residents needed a picture. On-going audits are being done by the director of Nursing and/or the Skilled Nurse Manager weekly for a month to ensure new residents have a picture taken and attached to their MAR.