Every finding on record at Seabury

Based on observations, interviews, review of facility documentation and policy, the facility failed to ensure residents were free from potential burns after high water temperatures were identified but the facility failed to take action directed toward resident safety resulting in immediate jeopardy. The findings include:Observation on 12/10/25 at 10:30 AM identified hot water temperatures exceeded 120 degrees Fahrenheit (F) in 30 out of 61 rooms observed. Water temperatures ranged from 120.2 degrees F to 131.2 degrees F.Interview with the Director of Engineering and Campus Safety on 12/10/25 at 11:46 AM identified that he was aware the facility had an ongoing issue with high hot water temperatures. He indicated that 1 of 2 domestic hot water storage tanks malfunctioned in June or July of 2025 and at the time, an order was placed for a replacement tank. Subsequently, a temporary water storage tank was installed in June or July of 2025 with the permanent tank replacement arrival due in December 2025. Further, he identified that the temporary water storage tank did not regulate water temperatures properly and the high-water temperature issues were not resolved with the installation of the temporary tank. He indicated that water temperatures were randomly checked daily in resident rooms, and if identified as high (exceeding 120 degrees F), the mixing valve was adjusted. Following the adjustment, he never rechecked the rooms in which temperatures exceeded 120 degrees F to ensure normalization occurred and the facility failed to notify residents to use caution due to the potential for burns, when using hot water. He indicated he initially informed the Administrator at the time the high-water temperatures were first identified but failed to report findings of subsequent high-water temperature readings to the Administrator. Interview and observations with the Maintenance Technician on 12/10/25 at 12:29 PM, using a surveyor calibrated thermometer and the facility calibrated thermometer, identified temperatures exceeded 120 degrees Fahrenheit (F) in 30 out of 30 rooms observed. Water temperatures ranged from 120.1 degrees F to 130.8 degrees F. The Maintenance Technician indicated he was responsible for checking water temperatures and checked them once daily in the morning in randomly chosen resident rooms. He indicated that if water temperatures were identified as high, he would adjust the mixing valve and report the findings to his director. He indicated that he did not recheck water temperatures in rooms identified as exceeding the acceptable temperature of 120 degrees F because he didn't have the time. The Maintenance Technician indicated that he should have rechecked the temperatures 1 hour after adjusting the mixing valve to ensure temperatures had returned to within the acceptable range. Review of water temperature logs identified that from 7/1/25 to 12/10/25, high water temperatures were identified 95 out of 102 days with at least 1 resident room where the hot water temperature exceeded 120 degrees F.Interview with the Director of Nursing (DNS) on 12/10/25 at 12:46 PM identified she had not been made aware of the ongoing issue with high hot water temperatures. The DNS indicated that she should have been notified, and had she been, she would have notified and educated staff to test the water temperature ensuring an appropriate temperature level and would have sent a notification to residents and resident family members since it was a widespread issue. Additionally, the DNS identified that it was the responsibility of the Maintenance Department to ensure water temperatures were in an appropriate and safe range. Interview with the Administrator on 12/10/25 at 1:37 PM identified that he was not aware of the ongoing issue with high hot water temperatures. The Administrator indicated that he was aware 1 of the 2 water heating tanks needed to be replaced due to a leak, but due to supply chain issues a new tank would not be available until December 2025, so a temporary water tank was installed. The Administrator indicated that it was the responsibility of the Maintenance Department to monitor and ensure water temperatures were in the acceptable range and that he should have been made aware of the high hot water temperatures. Review of the undated Safe Water Temperature policy directed, in part, that water temperatures will be set to a temperature of no more than 120 degrees F and that maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. The failure of the Director of Engineering and Campus Safety to communicate to the Administrator and DNS the ongoing high water temperature readings and lack of interventions to prevent and protect residents from scalding due to excessive water temperatures in resident care areas including resident bathrooms resulted in a finding of Immediate Jeopardy. On 12/10/25 at 3:23 PM the IJ Template was provided via email to the Administrator. On 12/10/2025 at 4:29 PM the facility submitted the removal plan which was accepted by the State Agency. The removal plan included:1. Signs will be placed in all resident areas, sinks, showers, etc.2. Water temperatures will be checked every shift in all areas.3. Water temperatures will be rechecked if they are noted to be too high.4. Adjustments have been made to the mixing valve/mechanicals. A permanent repair is being expedited, and repairs are expected to be completed within one week.5. Staff education has been implemented to monitor all residents with independent access to water to ensure safety. Additionally, direct care staff will monitor safe water temperatures prior to use.6. Residents and families have been notified.The Immediate Jeopardy was removed on 12/10/25 at 5:00 PM

Based on observation, clinical record review, facility documentation, facility policy, and interviews, the facility failed to administer its resources effectively and to ensure timely and effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings include:The facility administration failed to: Ensure appropriate administration of the grievance process.Ensure the State Agency was notified, in a timely manner, of reportable event. Ensure allegations of abuse were investigated timely and thoroughly.Ensure residents received timely assistance with activities of daily living.Ensure resident assessments were performed on a quarterly basis.Ensure residents were provided with an environment free from hazards.Ensure as needed psychotropics had appropriate stop dates.Ensure appropriate medication labeling and storage.Ensure the clinical record was complete and accurate.Ensure the kitchen was provided meals at the appropriate temperature and maintained the kitchen in a sanitary condition.Please cross reference F585, F609, F610, F677, F684, F689, F757, F761, F804, F812, and F880. Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the areas of accidents, hazards, and supervision.Interview on 12/17/25 at 9:00 AM with the Administrator and DNS identified that although both were responsible for implementing the abuse policy, the allegation of neglect had not been reported to the State Agency. Subsequent to surveyor inquiry, the State Agency was notified on 12/17/25 at 9:16 AM (12 days following the initial allegation of neglect).Interview with the Director of Engineering and Campus Safety on 12/10/25 at 11:46 AM identified that he was aware the facility had an ongoing issue with high hot water temperatures. He indicated he initially informed the Administrator at the time the high-water temperatures were first identified but failed to report findings of subsequent high-water temperature readings to the Administrator. Interview with the Administrator on 12/10/25 at 1:37 PM identified that he was not aware of ongoing issues with high hot water temperatures. The Administrator indicated that he was aware 1 of the 2 water heating tanks needed to be replaced due to a leak, but due to supply chain issues a new tank would not be available until December 2025, so a temporary water tank was installed. The Administrator indicated that it was the responsibility of the Maintenance Department to monitor and ensure water temperatures were in the acceptable range and that he should have been made aware of the high hot water temperatures. Although the Administrator was initially made aware of high-water temperatures by the Director of Engineering, and that the facility was in need of a water tank replacement, he failed to provide appropriate oversight of the environment to ensure there were no ongoing concerns with water temperatures in resident areas. Review of the [NAME] President of Health Services (Administrator) job description identified the responsibility of the Administrator was to implement and interpret policies and procedures to staff, resident, families, visitors, and government agencies as necessary; develop organize, implement, evaluate, and direct the programs and services in the skilled nursing unit; develops and implements systems for providing and assuring delivery of quality care and services to residents and meet the requirements of DPH; CMS; OBRA; OSHA; CCAC; monitor Health Center culinary systems and delivery to assure quality of presentation, food quality, temperature, regulatory compliance and resident satisfaction; handles grievance resolution for residents, families and staff members, supervises the Director of Nursing Services.The facility failed to utilize resources effectively to attain/maintain the resident's well-being.

Based on interviews, observations, and facility policy, the facility failed to ensure the Grievance policy was in view for residents in wheelchairs, failed to ensure access to grievance forms, and failed to ensure residents had an awareness of the purpose of filing a grievance, and for the only sampled resident (Resident #32) reviewed for dignity, the facility failed to follow their grievance policy. The findings include:1.On 12/15/25 at 1:30 PM a meeting of residents who regularly attended Resident Council meetings (Resident #'s 21, 32, 45, 48, 58, 65, and 66), failed to identify awareness of the purpose or use of a grievance form. The resident's indicated that any concerns would be brought forth during Resident Council meetings and the Recreation Director then brought the concern to the appropriate department for review and resolution. Although Resident #58 indicated there was a bulletin board covered by protective plastic, he/she was unaware if grievance information was posted on the bulletin board. Observation of the bulletin board with Resident #58 identified that the Grievance policy was posted on the bulletin board as well as a copy of the Grievance form, however, residents were unable to remove the protective plastic independently to read the policy or to access a form. Additionally, for any residents or visitors requiring the use of a wheelchair, the information was posted well above their reach and vision. An interview with the Recreation Director on 12/16/25 at 12:40 PM indicated she attended the Resident Council meetings but failed to review the grievance process with the residents. An interview and observation with Social Service #2 on 12/16/25 at 12:46 PM identified that she did not review the grievance process with residents as the grievance process was in the admission Packet and given on admission. Observation of the grievance posting information with Social Service #2 showed that the height of the Grievance policy and Grievance form was too high to read for those who required a wheelchair, and she stated she would be lowering the information. She indicated that currently the process used for communicating concerns was via email to the Director of Nursing Services (DNS), the Assistant Director of Nursing Services (ADNS), and the Administrator. The information would then be reviewed to make a decision as to whether the concern was actually a grievance that needed to be addressed with a response or did not rise to the level of a grievance. Social Service #2 indicated that she had never filled out a grievance form. An interview with the Nursing Supervisor Registered Nurse (RN) #1 on 12/16/25 at 1:00 PM indicated she had never been asked by a resident to file a grievance and had not seen a grievance during the 3 years she had worked in the facility. RN #1 indicated if a resident asked her for a Grievance form, she would ask the DNS or ADNS for a form as there are no Grievance forms located at the nursing stations. During an interview with the DNS and Administrator on 12/16/25 at 2:11 PM they stated that staff completed the Grievance form when the grievance was brought forward. Although they identified the process, they were unable to identify how residents and family members who wanted to complete a Grievance form on their own or anonymously were able to do so without the availability of accessible forms. 2.Resident #32's diagnoses included Parkinsonism, muscle weakness, abnormal posture, bilateral knee and hip osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 had a Brief Interview Mental Status score of 13, indicating no cognitive impairment, required maximal assistance for bed mobility, and was dependent with personal/toileting hygiene and transfers. The Resident Care Plan (RCP) in effect from 9/29/25 through 12/10/25 identified Resident #32 required assistance with Activities of Daily Living (ADL's) and mobility. Interventions included to use the assistance of 2 staff with a mechanical sit to stand type lift. The Resident Care Card identified Resident #32 was to have an assist of 2 with the Sarita mechanical lift for transferring and toileting tasks. An interview with Resident #32 on 12/10/25 at 11:55 AM identified about 2 weeks ago on the overnight shift (11:00 PM to 7:00 AM) a Nurse Aid (NA) failed to answer the call light after 30 minutes, so he/she called the nurse's station. The call was forwarded to the security office due to nursing staff's failure to answer the telephone; the security officer instructed him/her to give staff an additional 20-30 minutes. When 30 minutes had passed, Resident #32 again called the nurse's station, and a NA came to provide assistance. Resident #32 indicated he/she reported the incident to Social Worker (SW) #1 due to feeling uncomfortable. Resident #32 noted the NA walked into his/her room numerous other times that night, turned off the call light and left without asking what Resident #32 needed. After reporting the incident to SW #1, Resident #32 stated he/she again spoke with SW #1 who indicated that the NA had been reassigned. Resident #32 indicated that the NA had not worked with him/her since he/she complained. Review of the clinical record identified an entry by SW #1 on 12/4/25 that Resident #32's nursing concerns relayed to nursing admin as requested. An interview with SW #1 on 12/15/25 at 10:53 AM identified Resident #32 had complained to her a few weeks ago about a NA not appropriately answering the call light. SW #1 stated the resident did not remember the NA's name but recalled her hair color. SW #1 also indicated she reported this incident to the Assistant Director of Nursing Services (ADNS). SW #1 identified since then, the NA had not been assigned to Resident #32, and that he/she (SW #1) spoke to the resident at least once per week. Earlier this morning Resident #32 had made a similar complaint regarding delayed call bell response times over the weekend of 12/13/25 and 12/14/25. SW #1 stated the resident did not know the NA's name in question, only her hair texture and she, (SW #1) sent the ADNS an email that morning informing her of Resident #32's continued concerns with call bell response times. Interviews conducted with the Assistant Director of Nursing Services (ADNS) on 12/15/25 at 11:28 AM, 12/16/25 at 9:34 AM, and 12/16/25 at 1:52 PM identified she believed Nurse Aide (NA) #5, from the agency was the NA from the concern a few weeks back (12/4/25). She stated NA #5 had been scheduled to work with Resident #32 the next evening, but she had informed the 3:00 PM to 11:00 PM Registered Nurse (RN) supervisor to reassign NA #5 off Resident #32's assignment permanently. The ADNS indicated that she had not written anything formally like a grievance and had probably jotted down some notes, however, was never able to provide notes or any documentation of the incident stating I do not have a good answer for that. The ADNS identified that she did not know who the appointed Grievance Official was for the facility. Per the facility policy, the Grievance Official was designated to follow up and investigate grievances to a conclusion. The ADNS stated SW #1 kept the grievance book in her office noting that Social Workers did not document grievances or perform any of the investigations. The ADNS noted the process for following up with resident grievances/complaints depended on the time of day, the severity of the complaint, and which resident was making the complaint. She further stated it will vary between verbal reports, emails, or writing it down on a sticky (note) or something for one of us (her or the DNS) for follow up. The ADNS identified she did receive the email this morning from SW #1 regarding Resident #32's concern from the weekend, stating it had something to do with a call bell. Subsequent to surveyor inquiry, the ADNS noted she would follow up with Resident #32 and SW #1 regarding this most recent complaint. Subsequent to interviews, the ADNS stated she would report the incident (12/4/25) and document it late to the best of her ability. A re-interview with Resident #32 on 12/17/25 at 10:52 AM related to the weekend incident identified on 12/13/25 and 12/14/25 NA #6 came to his/her room numerous times during her shift stating she would have his/her NA provide care in about 30 minutes. Resident #32 indicated he/she waited over 30 minutes before ringing the call bell a second time and NA #6 answered and indicated it would be another 20 minutes before the resident's NA would be able to provide toileting care. Resident #32 identified he/she sat in a wet diaper for over an hour, until after change of shift which ended at 7:00 AM. Resident #32 indicated that he/she had tried to call the nursing station on both 12/13/25 and 12/14/25 to request toileting assistance, but the calls went to the Security Office. The security officer indicated the unit nurse would be called to inform the staff of Resident #32's request. Resident #32 indicated that he/she had spoken with NA #6 on 12/16/25 and that NA #6 indicated that she never notified another NA that he/she (the resident) had requested assistance on either night. Review of the facility's call bell log from 12/13/25 and 12/14/25 identified Resident #32's call bell response times greater than 15 minutes was as follows: 12/13/25 at 5:23 AM 28 minutes and 25 seconds. 12/13/25 at 7:34 AM 19 minutes and 22 seconds. 12/13/25, at 9:52 AM 23 minutes and 45 seconds. 12/13/25 at 12:59 PM 18 minutes and 49 seconds. 12/13/25 at 6:23 PM 42 minutes and 19 seconds. 12/13/25 at 9:00 20 minutes and 6 seconds. 12/13/25 at 11:09 PM 15 minutes and 43 seconds. 12/14/25 at 9:39 AM 21 minutes and 3 seconds. 12/14/25 at 11:00 PM, 21 minutes and 40 seconds. A review of the Grievance policy directed, in part, that the Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. That staff member will also be required to forward the grievance form to the Grievance Official as soon as practicable. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: The date the grievance was received; the steps taken to investigate the grievance; a summary of the pertinent findings or conclusions regarding the resident's concern(s); a statement as to whether the grievance was confirmed or not confirmed; any corrective action taken or to be taken by the facility as a result of the grievance; the date the written decision was issued. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision.

Based on observation, review of the clinical record, and facility policy during an observation of dining services, the facility to ensure meals delivered to residents on the unit were served at the appropriate temperature. The findings include: Resident #9's diagnoses included dysphagia (oral phase), vitamin D deficiency (unspecified), and vascular dementia.Interview on 12/10/25 at 11:37 AM with Resident #9 identified that the food that was served was noted to be cold on a hot plate.Observation in the kitchen on 12/16/25 at 7:30 AM identified the temperature of a ham and cheese frittata to be 187.9 degrees Fahrenheit ( F) prior to leaving the kitchen. Observation and interview with the Head Chef on 12/16/25 at 8:30 AM of Brewer's food cart leaving the skilled dining room identified that the Nurse Aids were passing out food trays as soon as the food arrived on the unit. The last tray to be delivered to a resident on the Brewer Unit on 12/16/25 at 8:43 AM identified the temperature of the ham and cheese frittata to be 127.3 F with the surveyor's thermometer and 125 F with the chef's thermometer. The Head Chef indicated that proper holding temperatures should be 135 F. He reported the facility recently obtained new carts due to past temperature concerns. He indicated that having a steamer would have helped to keep food warm but would affect the cold items. Interview on 12/16/25 at 9:33 AM with the Director of Culinary Operations indicated that the blue heating pallets and other food transport carts/equipment may need heating packs to help maintain warm temperatures. He stated they would review the equipment and implement new interventions.The facility's Food Temperatures Policy indicated, in part: All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 F.

Based on tour of the Dietary Department, staff interview, and review of facility policy, the facility failed to ensure items in the kitchen were consistently dated and labeled. The findings include:During a tour of the Dietary Department on 12/10/25 at 9:30 AM with the Director of Dietary Services the following was identified:A. Observation at 9:35 AM identified a light brown, paste-like item in a round container in the refrigerator lacking a label or date. The Head Chef described the item as peanut sauce.B. Observation at 9:40 AM a identified a pre-cooked, flour-like substance in the refrigerator lacking a label or open date. The Head Chef described the item as [NAME] pasta.C. Observation of Freezer #2 at 9:42 AM identified a meat-like substances shaped into patties lacking a label or date.D. Observation of Freezer #2 at 9:43 AM identified 8 bags of a flat, breaded, meat-like item lacking a label or a date. Of the 8 bags, 5 were opened (totaling 14 meat-like items), lacking a label or a date. The Head Chef described these items as chicken patties.E. Observation of the dry storage area at 9:50 AM identified an undated open 5 lb. Gold Medal Complete Buttermilk Pancake Mix.An interview on 12/10/25 at 9:45 AM with the Head Chef indicated that all items in the refrigerator and freezer should be labeled per the policy to identify what the items were and the date opened. He reported that all chefs were responsible for dating and labelling items and was unsure why the policy had not been followed. Subsequent to the inquiry, the Head Chef directed staff to label all the items.The facility's food storage policy, revised 11/2023, indicates in part: All items are appropriately labeled with.open dates as needed.

Based on interviews, review of clinical record, review of facility documentation, and facility policy for 1 of 2 sampled residents, (Resident #55) reviewed for dignity, the facility failed to report an allegation of neglect to the State Agency within the appropriate time requirement. The findings include:Resident #55's diagnoses included osteoarthritis, osteoporosis with pathological fracture, and hypertension.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, had bilateral lower extremity impairment, was always incontinent of bowel and bladder, and was not on a toileting program. The Resident Care Plan (RCP) dated 10/24/25 identified Resident #55 was at risk for pressure ulcers and skin injuries related to immobility and incontinence. Interventions included providing incontinence care after each incontinence episode, minimize skin exposure to moisture, and keep linens clean, dry, and wrinkle free.A Physicians order in effect from 10/24/25 through 12/17/25 directed the extensive assistance of 1 for all lower body bathing and toilet hygiene.A social service note dated 12/4/25 identified Resident #55 had concerns to share and would notify Social Worker (SW) #1 when a written list was completed.Review of information provided by Social Worker (SW) #1 identified an undated written statement written by Resident #55 indicating on 11/25/25 he/she had used his/her call bell multiple times and asked to be changed. Resident #55 indicated that each time he/she called for help, care was not provided, resulting in a 3 hour wait for incontinence care. Review of an email sent to the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) by SW #1 identified Resident #55 had made an allegation of neglect. Resident #55's written statement was attached to the email. Interview on 12/10/25 at 9:57 AM with Resident #55 identified on 11/25/25 he/she had not received incontinence care on several occasions and often needed to wait over 2 hours to be changed. Further he/she stated this made him/her feel disrespected and afraid that the long waits would result in the development of a pressure injury due to sitting in a soiled brief from bowel and bladder incontinence. Resident #55 indicated that SW #1 was notified of the neglect and that the information was given to the DNS.Interview on 12/16/25 at 12:22 PM with SW #1 identified that Resident #55 had provided her with a written complaint of neglect on 12/5/25. Further SW #1 indicated she had informed both the ADNS and DNS verbally of the complaint on 12/5/25 and it was their responsibility to report and investigate the allegation.Interview on 12/16/25 at 12:31 PM with the ADNS identified that she had been made aware of Resident #55's complaint of neglect on 12/5/25 both verbally and via email by SW #1. Further, she had discussed the Resident #55's complaint on 12/5/25 with the DNS, and the DNS was responsible for following up on the allegation of neglect.Interview on 12/16/25 at 12:51 PM with the DNS identified that she was made aware of Resident #55's complaint of neglect on 12/5/25. The DNS indicated she had not notified the State Agency according to the facility's abuse reporting policy. The DNS stated she did not consider Resident #55's complaint of neglect to be categorized as abuse because he/she did eventually receive incontinence care. The DNS was unable to indicate what an appropriate time frame would be to wait before identifying a resident was neglected.Interview on 12/17/25 at 9:00 AM with the Administrator and DNS identified that the allegation of neglect had not been reported to the State Agency to date. Subsequent to surveyor inquiry, the State Agency was notified on 12/17/25 at 9:16 AM.Re-interview with Resident #55 on 12/17/25 at 10:10 AM identified that he/she was anxious and uncomfortable for the remainder of the day after waiting over 3 hours to have incontinent care provided. Resident #55 stated that he/she was worried that if the call bell was rung again, staff would not come or would ignore him/her due to voicing his/her care concern. Interview on 12/17/25 at 11:42 AM with Nurse Aide (NA) #3 identified Resident #55 had reported to her on multiple occasions that he/she often experiences delays in receiving care. Further NA #3 stated Resident #55 told her that on 11/25/25 that NA #4 had gone into his/her room [ROOM NUMBER] to 3 times and did not perform incontinence care each time requested. NA #3 indicated that she failed to report Resident #55's complaint of neglect to the DNS at that time because she was afraid of being retaliated against and felt she had been retaliated against, in the past, for reporting similar concerns.Review of the facility's Abuse Policy identified, in part, that neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Employees will be trained to identify what constitutes abuse including neglect, exploitation, and misappropriation of resident property. Indicators of abuse can come from residents, staff or family reports. Written procedures should include reporting to the State Agency immediately but not later than 2 hours after the allegation is made involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or serious bodily injury.

Based on interviews, review of clinical record, facility documentation, and facility policy for 1 of 2 residents, (Resident #55) reviewed for dignity, the facility failed to investigate an allegation of neglect. The findings include:Resident #55's diagnoses included osteoarthritis, osteoporosis with pathological fracture, and hypertension.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, had bilateral lower extremity impairment, was always incontinent of bowel and bladder, and was not on a toileting program. The Resident Care Plan (RCP) dated 10/24/25 identified Resident #55 was at risk for pressure ulcers and skin injuries related to immobility and incontinence. Interventions included to provide incontinence care after each incontinence episode, minimize skin exposure to moisture, and keep linens clean, dry, and wrinkle free.A physician's order in effect from 10/24/25 through 12/17/25 directed the extensive assistance of 1 for all lower body bathing and toilet hygiene.A social service note dated 12/4/25 identified Resident #55 had concerns to share and would notify Social Worker (SW) #1 when a written list was completed.Information provided by Social Worker #1 identified an undated written statement by Resident #55 indicating on 11/25/25 he/she had used his/her call bell multiple times and asked to be changed. Resident #55 stated that each time he/she called for help, care was not provided resulting in a 3 hour wait for assistance. Additionally, review of an email sent to the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) by SW #1 identified Resident #55 had made an allegation of neglect. Resident #55's written statement was sent as an attachment to the email. Interview on 12/10/25 at 9:57 AM with Resident #55 identified on 11/25/25 he/she had not received timely incontinence care and, on several occasions, often needed to wait over 2 hours to be changed when soiled. Further he/she stated this made him/her feel disrespected and afraid that the long waits would result in the development of a pressure injury due to sitting in a soiled brief from both bowel and bladder incontinence. Resident #55 indicated that SW #1 was notified of the neglect and that the information was given to the DNS.Interview on 12/16/25 at 12:22 PM with SW #1 identified that Resident #55 had provided her with a written complaint of neglect on 12/5/25. Further SW #1 indicated she had informed both the ADNS and DNS verbally of the complaint on 12/5/25 and it was their responsibility to report and investigate the allegation.Interview on 12/16/25 at 12:31 PM with the ADNS identified that she had been made aware on 12/5/25, of Resident #55's complaint of neglect both verbally and via email by SW #1. Further, she had discussed Resident #55's complaint on 12/5/25 with the DNS, and the DNS was responsible for following up on the allegation of neglect. The ADNS indicated 3 hours was too long to wait for incontinence care when staff were aware care was needed, which resulted in him/her being treated in an undignified manner. Further she stated that depending on how Resident #55 perceived the wait, it could be considered neglect, and an investigation should have been completed.Interview on 12/16/25 at 12:51 PM with the DNS identified that she was made aware of Resident #55's complaint of neglect on 12/5/25. Further the DNS indicated she had not begun an investigation, had not attempted to identify which staff was responsible for Resident #55's untimely incontinent care, and had failed to follow the facility policy for investigating allegations of neglect. The DNS stated she did not consider Resident #55's complaint of neglect to be abusive because he/she did eventually receive incontinent care.Interview on 12/17/25 at 9:00 AM with the Administrator and DNS identified that an investigation into Resident #55's allegation of neglect had not yet begun. Subsequent to surveyor inquiry, on 12/17/25 (12 days after the allegation was reported) an investigation into Resident #55's allegation of neglect was initiated.Re-interview with Resident #55 on 12/17/25 at 10:10 AM identified that he/she had reported to the Administrator, on 12/17/25, that the facility care was not good, and he/she was anxious and uncomfortable for the remainder of the day after waiting over 3 hours to have incontinent care provided on 11/25/25. Additionally, Resident #55 stated that he/she was worried that when he/she now rang the call bell staff would not come or would ignore him/her due to voicing his/her care concern to staff. Interview on 12/17/25 at 11:42 AM with Nurse Aide (NA) #3 identified Resident #55 had reported to her on multiple occasions that he/she often experiences delays in receiving care. Further NA #3 stated Resident #55 told her that on 11/25/25 that NA #4 had gone into his/her room [ROOM NUMBER] to 3 times and did not perform incontinence care each time requested. NA #3 indicated that she failed to report Resident #55's complaint of neglect to the DNS because she was afraid of being retaliated against and felt she had been retaliated against, in the past, for reporting similar concerns.Interview on 12/17/25 at 12:16 PM with NA #4 identified that she was unaware of any complaints or incidents that Resident #55's incontinent care had not been provided by her.Interview on 12/17/25 at 12:41 PM with Person #1 (Resident #55's family member) identified that Resident #55 had informed him/her of the incident of neglect on either 11/25/25 or 11/26/25 and he/she encouraged Resident #55 to report the incident of neglect to the facility. Person #1 stated they did not report the complaint of neglect to the DNS because he/she (the resident) had previously been told that he/she had no issues with his/her memory and was encouraged to be independent and advocate for his/herself. Person #1 indicated that Resident #55 was angry about the incident of neglect and may have experienced anxiety and feelings of disrespect stating that the facility had never called him/her to discuss the incident reported. Additionally, Person #1 indicated that she had reviewed and helped Resident #55 edit his/her written statement that had been presented to facility management.Review of the facility's Abuse policy identified, in part, that an immediate investigation is warranted when reports of abuse, neglect or exploitation occur. The facility will identify, and interview all involved persons, including the alleged victim, the perpetrator, witnesses and others who might have knowledge of the allegation. The facility will ensure reporters of abuse are free from retaliation or reprisal.

Based on a review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #8) reviewed for psychotropic/opioid medication use, the facility failed to ensure that a psychotropic medication order included a stop date per the requirement. The findings include:Resident #8's diagnoses included other spondylosis with myelopathy, thyroid disorder, and chronic kidney disease.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 as moderately cognitively impaired, requiring partial assistance with toileting hygiene, supervision or touching assistance for personal hygiene, and was independent with chair-to-stand transfers.The Resident Care Plan dated 10/17/25 indicated that Resident #8 required assistance with Activities of Daily Living (ADLs) and mobility related to spondylosis. Interventions included assisting Resident #8 with ADLs, transfers, and mobility as needed.A physician's order dated 11/14/25 directed staff to administer Lorazepam Intensol (concentrated oral solution) 0.5 milligrams (mg) every 6 hours as needed. The order failed to include a stop date.Review of Resident #8's Medication Administration Record (MAR) indicated that on 11/21/25, the as needed (PRN) 0.5 mg Lorazepam Intensol was administered due to agitation/restlessness.An interview with the Director of Nursing Services (DNS) on 12/16/25 at 8:11 AM indicated that psychotropic medications should have a 14-day stop date and that nursing staff are responsible for revising orders and reporting any concerns. The DNS was unable to identify why Resident #8's lorazepam order failed to direct any stop date whatsoever. The Psychotropic Medication policy dated 2/2025 directed, in part, PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber providing a rationale for the extended time period and indicating a specific duration.

Based on interviews, review of clinical record, facility documentation, and facility policy for 1 of 2 sampled residents, (Resident #55) reviewed for dignity, the facility failed to ensure timely incontinence care was provided to a dependent resident. The findings include:Resident #55's diagnoses included osteoarthritis, osteoporosis with pathological fracture, and hypertension.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, had bilateral lower extremity impairment, was always incontinent of bowel and bladder, required partial/moderate assistance with bed mobility, and was dependent on staff for toileting hygiene.The Resident Care Plan (RCP) dated 10/24/25 identified Resident #55 was at risk for pressure ulcers and skin injuries related to immobility and incontinence. Interventions included to provide incontinence care after each incontinence episode, minimize skin exposure to moisture, and keep linens clean, dry, and wrinkle free.A physician's order in effect from 10/24/25 through 12/17/25 directed the extensive assistance of 1 for all lower body bathing and toilet hygiene.A social service note dated 12/4/25 identified Resident #55 had concerns to share and would notify Social Worker (SW) #1 when a written list was completed.Information provided by Social Worker #1 identified an undated written statement by Resident #55 indicating on 11/25/25 he/she had used his/her call bell multiple times and asked to be changed. Resident #55 stated that each time he/she called for help, care was not provided resulting in a 3 hour wait for assistance. Additionally, review of an email sent to the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) by SW #1 identified Resident #55 had made an allegation of neglect. Resident #55's written statement was sent as an attachment to the email. Interview on 12/10/25 at 9:57 AM with Resident #55 identified on 11/25/25 he/she had not received timely incontinence care and, on several occasions, often needed to wait over 2 hours to be changed when soiled. Further he/she was afraid that the long waits would result in the development of a pressure injury due to sitting in a soiled brief from both bowel and bladder incontinence. Resident #55 indicated that SW #1 was notified and that the information was given to the DNS.Interview on 12/16/25 at 12:22 PM with SW #1 identified that Resident #55 had provided her with a written complaint of neglect on 12/5/25 and she had informed both the ADNS and DNS verbally of the complaint.Interview on 12/16/25 at 12:31 PM with the ADNS identified that she had been made aware on 12/5/25, of Resident #55's complaint of neglect both verbally and via email by SW #1. Further, she had discussed Resident #55's complaint on 12/5/25 with the DNS indicating that 3 hours was too long to wait for incontinence care when staff were aware care was needed. Further she stated that depending on how Resident #55 perceived the wait, it could be considered neglect, and an investigation should have been completed.Interview on 12/16/25 at 12:51 PM with the DNS identified that she was made aware of Resident #55's complaint of neglect on 12/5/25 but had not yet begun an investigation and not yet attempted to identify which staff was responsible for Resident #55's untimely incontinent care. The DNS stated she did not consider Resident #55's complaint of neglect to be abusive because he/she did eventually receive incontinent care.Interview on 12/17/25 at 9:00 AM with the Administrator and DNS identified that an investigation into Resident #55's allegation of neglect had not yet begun. Subsequent to surveyor inquiry, on 12/17/25 (12 days after the allegation was reported) an investigation into Resident #55's allegation of neglect (3-hour wait for incontinence care) was initiated.Interview on 12/17/25 at 11:42 AM with Nurse Aide (NA) #3 identified Resident #55 had reported to her on multiple occasions that he/she often experiences delays in receiving care. Further NA #3 stated Resident #55 told her that on 11/25/25 that NA #4 had gone into his/her room [ROOM NUMBER] to 3 times and did not perform incontinence care each time care was requested. Interview on 12/17/25 at 12:16 PM with NA #4 identified that she was unaware of any complaints or incidents that Resident #55's incontinent care had not been provided by her.Interview on 12/17/25 at 12:41 PM with Person #1 (family member) identified that Resident #55 had informed him/her of the incident of neglect on either 11/25/25 or 11/26/25 and he/she encouraged Resident #55 to report the incident of neglect to the facility. Person #1 indicated that she had reviewed and helped Resident #55 edit his/her written statement that had been presented to facility management.Review of the Pressure Injury policy dated 11/2023 directed, in part, that the facility is committed to the avoidance of the development of pressure injuries. Examples of risk factors included impaired/decreased mobility and decreased functional ability, and the exposure of skin to urine and fecal incontinence. Interventions for prevention included minimize exposure to moisture and keep skin clean, especially of fecal contamination.

Based on observations, review of facility documentation, record review, facility policies, and interviews for 1 of 3 medication carts (Brewer) the facility failed to ensure Resident #10's insulin pen was discarded in accordance with the manufacturer's recommendations, for 1 of 3 medication rooms (Brewer) the facility failed to ensure medications were stored at a temperature in accordance with the facility policy, and for 1 of 3 medication rooms (Larus) the facility failed to ensure medication refrigerator temperatures were monitored per the facility policy and for the only resident (Resident #31) observed during the initial facility tour to have medications noted at the bedside, the facility failed to ensure poured medications given to a resident for administration were properly stored and secured. The findings include:1.A. Resident #10 was admitted to the facility in January 2024 with diagnoses that included type 2 diabetes mellitus. A physician's order dated 11/11/25 directed to administer Insulin Aspart U-100 insulin pen; 100 unit/ml (3 ml) per sliding scale; if blood sugar is 0-249, give 0 units, if blood sugar is 250-300, give 4 units, if blood sugar is 301-350, give 5 units, if blood sugar is greater than 350, give 6 units subcutaneously. Review of Resident #10's November and December 2025 Medication Administration Records identified Insulin Aspart U-100 insulin pen was administered on 11/22, 12/5, and 12/8/25. Observation of the Brewer Medication Cart with the ADNS on 12/10/25 at 12:15 PM identified Resident #10's Insulin Aspart-U-100 Injection Flex Pen, had an open date of 10/23/25 (open for 48 days). Interview with the Assistant Director of Nursing (ADNS) on 12/10/25 at 12:15 PM identified that Insulin Aspart-U Injection Flex Pens should be labeled with an open date by the nurse who opens the medication, and the medication should be discarded within 28 days after opening or per the manufacturer's recommendation. Interview with the Charge Nurse Registered Nurse (RN) #1 on 12/10/25 at 1:08 PM identified that insulin pens were good for 3 months after opening, and that she had used the Insulin Aspart-U Injection Flex Pen dated 10/23/25 for Resident #10's coverage, when needed. Interview with the Pharmaceutical Manufacturer Representative (Person #1) on 12/10/25 at 1:15 PM identified that Insulin Aspart-U Injection Flex Pens are to be discarded 28 days after initial use. Interview with the Director of Nursing (DNS) on 12/10/25 at 2:19 PM identified that insulin pens were to be disposed of after 28 days, per the facility policy or in accordance with the manufacturer's recommendation. The facility's Medication Administration-Insulin Pens policy directed insulin pens should be disposed of after 28 days or according to the manufacturer's recommendation. B. During a tour of the Brewer Medication Room and review of the November and December 2025 Brewer Medication Refrigerator Temperature Logs with the ADNS on 12/10/25 at 12:38 PM identified refrigerator temperatures were to be maintained within 36-46 degrees Fahrenheit. In November 2025, 3 temperatures had no documentation, and 21 of 60 temperature readings were out of range and for December 2025, 12 of 19 temperature readings were out of range as follows: 11/1 AM Temp 35 degrees F, PM Temp not documented 11/2 AM Temp 35 degrees F, PM Temp not documented 11/3 AM Temp 32 degrees F, PM Temp 33 degrees F 11/4 AM Temp 32 degrees F, PM Temp 30 degrees F 11/5 AM Temp 34 degrees F, PM Temp 32 degrees F 11/7 AM Temp 34 degrees F 11/8 AM Temp 34 degrees F 11/13 AM Temp 32 degrees F 11/14 AM Temp 32 degrees F 11/15 AM Temp 34 degrees F 11/16 AM Temp 32 degrees F 11/17 AM Temp 32 degrees F 11/18 AM Temp 32 degrees F 11/21 AM Temp 30 degrees F 11/28 AM Temp 32 degrees F 11/29 AM Temp 32 degrees F, PM Temp 32 degrees F 11/30 AM Temp 34 degrees F, PM Temp not documented 12/1 AM Temp 32 degrees F 12/2 AM Temp 32 degrees F, PM Temp 30 degrees F 12/3 PM Temp 32 degrees F 12/4 AM Temp 32 degrees F 12/5 AM Temp 34 degrees F 12/6 AM Temp 32 degrees F 12/7 AM Temp 32 degrees F 12/8 AM Temp 32 degrees F 12/9 AM Temp 34 degrees F 12/10 AM Temp 32 degrees F The Brewer medication refrigerator contained the following medications: 2 pre-filled Dupixent 300 mg injection pens (anti-inflammatory medication), a bottle of Acidophilus Probiotics, a package containing 12 -Acetaminophen 650 mg rectal suppositories (for pain relief and fever reduction), Abrysvo 120 mcg intramuscular injection (RSV vaccine), and 2- Insulin Aspart-U 110units/ml Flex Pen (to improve blood glucose). Interview with the Assistant Director of Nursing (ADNS) on 12/10/25 at 12:40 PM identified that temperature oversite was the responsibility of the 11:00 PM to 7:00 AM charge nurse to obtain and document the AM temperature, and it was the responsibility of the 3:00 PM to 11:00 PM charge nurse to obtain and document the PM temperature. The ADNS indicated that medication refrigerator temperatures were to be maintained between 36- and 46-degrees Fahrenheit, per the parameters outlined on the refrigerator temperature log, any readings obtained outside of that range should be reported to management or the Infection Control Nurse, and a task should be initiated for maintenance to evaluate the medication room refrigerator temperature for function. Interview with the Maintenance Director on 12/10/25 at 1:34 PM identified that he could not particularly recall if low temperature readings for the Brewer Medication Refrigerator had been reported in November or December, but he had received numerous notifications prior, and the refrigerator and thermometers had been replaced. Follow-up interview with the ADNS on 12/10/25 at 2:13 PM identified that after reviewing the task system (system used by staff to report maintenance concerns) the last notification placed in the system regarding a medication refrigerator concern was 8/26/25, and the system did not have a record of the Brewer Medication Room refrigerator having temperature readings out of range, in November or December. The ADNS further identified that after a review of her emails from September through December 2025, she had not received any notifications alerting her to the low temperature readings in the Brewer Medication Room refrigerator. Interview with Maintenance Technician #1 on 12/10/25 at 2:18 PM failed to identify that he had received any reports that temperatures were out of range for the Brewer Medication Refrigerator in November or December, of this year. Interview with the Director of Nurses (DNS) on 12/10/25 at 2:19 PM identified that she was unaware that Brewer medication refrigerator temperature readings were out of range in November and December of 2025, and that it had not been reported to her by nursing staff. The DNS indicated that refrigerator temperatures that are out of range should be reported to maintenance, and subsequent to surveyor inquiry, a work order (task) had been placed, and the refrigerator would be evaluated and medications in the refrigerator reviewed. C. Tour of the Larus Medication Room and review of the October 2025 through December 2025 Silver and Black Larus Medication Refrigerator Temperature Logs with the ADNS on 12/10/25 at 12:59 PM identified the following days/shifts failed to have a documented temperature (temp) readings for the Silver Refrigerator (containing vaccines and insulins): 10/8/25 PM Temp, 10/10-PM Temp, 10/14-PM Temp, 10/15-PM Temp, 10/19-PM Temp, 10/22-PM Temp, 10/30-PM Temp, 11/7- PM Temp, 11/12- PM Temp, 11/21- PM Temp, 11/29- PM Temp, 11/30- PM Temp, and 12/5- AM and PM Temp; the following days/shifts failed to have a documented temperature (temp) readings for the Black Refrigerator (containing medications): 10/1/25-PM Temp, 10/8- PM Temp, 10/10- PM Temp, 10/14- PM Temp, 10/15- PM Temp, 10/22- PM Temp, 10/30- PM Temp, 11/7- PM Temp, 11/12- PM Temp, 11/21- PM Temp, 11/29-AM and PM Temp, 11/30- PM Temp, and 12/5-AM and PM Temp. Interview with the Assistant Director of Nurses (ADNS) on 12/10/25 at 12:59 PM identified that there were dates with missing documentation on October, November, and December 2025 Black and Silver Refrigerator Temperature Logs, and that it was the responsibility of the 11:00 PM to 7:00 AM charge nurse to obtain and document the AM temperature, and it was the responsibility of the 3:00 PM to 11:00 PM charge nurse to obtain and document the PM temperature. The ADNS indicated that medication refrigerator temperatures should be documented twice daily, per the facility policy. Interview with the Director of Nurses (DNS) on 12/10/25 at 2:19 PM identified that per facility policy the medication rooms refrigerator temperatures were to be checked and documented, twice daily, and it was the responsibility of the charge nurse to complete that task. The facility's Medication Storage policy directs all medications requiring refrigeration are stored in refrigerators located in each medication room, temperatures are maintained within 36 to 46 degrees F, charts are kept on each refrigerator and temperature levels are recorded twice daily by the charge nurse or other designee, in the event that a refrigerator is malfunctioning the person discovering the malfunction must promptly report such findings to the Maintenance Department for emergency repair. In the event that emergency repairs cannot be made timely, temporary or emergency space is available in the refrigerators located at each medication room. 2.Resident #31's diagnosis included congestive heart failure, anxiety disorder, and right eye choroidal hemorrhage. The significant change Minimum Data Set assessment dated [DATE] identified Resident #31 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, and was independent with eating, oral hygiene, and transfers. The Resident Care Plan dated 10/20/25 identified Resident #31 had a potential for visual changes related to eye surgery. Interventions included to monitor for pain/discomfort and administer eye drops as ordered. Physician orders dated 7/20/25 directed the following medications were scheduled for administered at 9:00 AM: 1. Atenolol (a medication to treat cardiovascular disease) 25 milligram (mg) tablet, give 0.5 tablet (12.5 mg dose) by mouth every morning. 2. Spironolactone (a medication to treat cardiovascular disease) 25 mg tablet by mouth daily. 3. Torsemide (a medication to treat fluid retention) 20 mg tablet by mouth once daily. Observation during the initial facility tour on 12/10/25 at 9:34 AM, identified a clear plastic medication cup on Resident #31's bedside table with multiple medications (2 and 1/2 tablets) contained in the cup. Resident #31 was observed swallowing 2 and 1/2 tablets as the surveyor approached. Resident #31 indicated that the nurses always placed his/her medications on the bedside table and left the room without observing that the medications were swallowed because they know I will take them. Additionally, 2 open, undated Equate dry eye relief lubricant eye drop bottles were observed on Resident #31's nightstand. Resident #31 indicated that the eye drop bottles were brought from home and there so he/she could independently administer the medication for dry eyes. Interview, observation, and review of the clinical record with Registered Nurse (RN) #1 on 12/10/25 at 10:39 AM identified she had poured Resident #31's 9:00 AM medications and had left the medications at the bedside. RN #1 indicated that she had not observed Resident #31 administer the medications because he/she got upset when she stayed to observe. RN #1 indicated that she would go back to the room at a later time to see if he/she had taken the medications by observing the empty medication cup. RN #1 indicated that the facility policy directed her to observe the residents swallowing all medications before leaving and that it was her responsibility to ensure the medications were administered as ordered. Additionally, RN #1 indicated that she did not know that Resident #31 had two (2) Equate dry eye relief bottles in his/her room and this medication should have had a physician order. RN #1 indicated that residents who want to self-administer medications needed a self-administer medication assessment and a Resident Care Plan for self-administration. RN #1 indicated that she would remove the eye drops from Resident #31's room and contact the provider for an order. RN #1 was unable to identify why Resident #31 did not have a self-administer medication assessment and Resident Care Plan for self-administering his/her eye drops per the facility policy. Interview and review of the clinical record with the Director of Nursing (DNS) on 7/31/25 at 11:35 AM identified that as a standard of practice, the nurse administering Resident #31's medications should have stayed with him/her until all the medication was taken. A review of Resident #31's clinical record failed to identify a self-administration of medication assessment, a Resident Care Plan for self-administration, or a physician order for the use of Equate eye drops. The DNS was unable to explain the absence of the information, but if Resident #31 was self-administering medications and using Equate eye drops, the information should have been present in the clinical record. Review of the Resident Self-Administration of Medication policy dated 4/2025 directed, in part, that a resident can only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely and that the results of the assessment are recorded on the self-administration medication observation form. The care plan must reflect resident self-administration and storage arrangements for medications. Additionally, the policy directed that medications will be stored in a lock box within the residents' room and the resident will retain the key. Review of the facility policy, Medication Administration, dated 3/16/2022, directed to administer medications as ordered and to observe the resident consumption of the medication.

Based on observation, interviews, facility documentation, and policy review for the only sampled resident (Resident # 75) reviewed for a urinary catheter (a tube inserted into the bladder to drain urine) the facility failed to follow the appropriate infection control standards for a resident with an indwelling device. The findings include:Resident #75 diagnoses included malignant neoplasm of the bladder, idiopathic gout and bacterial pneumonia.The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #75 had a Brief Interview of Mental Status (BIMS) score of 5 indicating severe cognitive impairment, was independent for eating, and dependent for toileting and transfers. The Resident Care Plan dated 12/14/25 identified Resident #75 had an indwelling urinary catheter related to urinary retention and a history of bladder and prostate cancer. Interventions included a voiding trial, encouragement of fluids, and reporting signs of a Urinary Tract Infection (UTI).Observations outside Resident #75's room on 12/10/25 at 10:56 AM and on 12/10/25 at 4:01 PM failed to identify any precaution signage posted outside the room or a Personal Protective Equipment (PPE) cart .Observation of Resident #75's room on 12/15/25 at 12:00 PM identified Contact Precautions signage posted outside the room.Review of the facility's Enhanced Barrier Precaution list failed to identify Resident #75 listed.Interview and observation with Licensed Practical Nurse (LPN) #1 on 12/15/25 at 12:04 PM identified Resident #75 had a Contact Precautions sign posted, but LPN #1indicated that the sign most likely should have been an Enhanced Barrier Precautions sign due to his/her indwelling urinary catheter. Additionally, LPN #1 identified the Infection Prevention nurse had the responsibility to post signs, so she would have to check with her to verify the reason Resident #75 required a sign prior to entering.Interview, observation, and review of facility documentation with the Infection Prevention Nurse (RN) #2 on 12/15/25 at 12:54 PM identified the facility policy directed that residents with a history of a Multi Drug Resistant Organism (MDRO) or those who had an indwelling medical device were to be on Enhanced Barrier Precautions (EBP) and it was her or the charge nurse's responsibility to put up the correct signage. Additionally, RN #2 identified Resident #75 was put on EBP this past weekend (12/13/25 or 12/14/25) due to having an indwelling urinary catheter. Review of the facility Enhanced Barrier Precaution list with RN #2 failed to identify Resident #75 had been added to her list.RN #2 identified that she had not initiated EBP earlier because she was under the impression that medical devices had to be chronic in nature and Resident #75's urinary catheter was not chronic. Observation of signage outside Resident #75's room with RN #2 identified a contact precautions sign posted, RN #2 identified it was an error, Resident #75 did not have a MDRO, and most likely it was put up in error because it was the same color as the EBP sign. Subsequent to surveyor inquiry RN #2 removed the contact precautions sign and replaced it with an EBP sign and entered a physician's order in the clinical record to maintain EBP.Review of the Enhanced Barrier Precautions Policy revised 9/25 directed in part that it was facility policy to implement EBP for the prevention of transmission of MDRO's. Additionally, personal protective equipment will be available for residents on EBP and EBP orders will be obtained for any residents with wounds or indwelling medical devices (e.g. urinary catheters).Review of the Infection Prevention and Control Policy revised 12/24 directed in part that residents will be placed on the least restrictive transmission-based precautions.

Based on review of the clinical record, interview, and facility policy for 1 of 3 sampled residents (Resident #50) reviewed for nutrition, the facility failed to document physician notification of 3 recorded weight gains greater than 3 pounds (lbs.) and failed to ensure staff documented the reason an ordered weight was not obtained. The findings include:Resident #50's diagnosis included Congestive Heart Failure (CHF).The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #50 had a Brief Interview of Mental Status score of 15 indicating intact cognition and was independent with eating and was independent with sit to lying to sitting and had a weight gain.The Resident Care Plan in effect from 2/13/25 through 12/15/25 indicated Resident #50 had CHF with interventions including to update the physician of significant changes including greater than a 3 lbs. weight gain.A physician order dated 5/5/25 directed to obtain Resident #50's weight 3 times per week on Mondays, Wednesdays, and Fridays, on the 7:00AM to 3:00 PM shift and to notify the physician for a weight gain of more than 3 lbs. Weights documented in the Vitals Report of Resident #50's clinical record showed a weight gain of over 3 pounds as follows:5/16/25 187 lbs. to 5/19/25 191 lbs. (a 4-pound weight gain).6/11/25 195.8 lbs. to 6/13/25 199 Lbs. (a 3.2-pound weight gain)10/15/25 199 lbs. to 10/17/25 202.6 Lbs. (a 3.6 Pound weight gain)An interview and clinical record review with the Director of Nursing Services (DNS) on 12/15/25 at 12:00 PM failed to identified documentation in the clinical record as to why a weight was not obtained on 10/6/25 as ordered by the physician. The DNS further indicated not being able to locate documentation notifying the physician or other medical provider when Resident #50 had a weight gain of 3 lbs. or more. Further, if Resident #50 was out of the building or refused to have the weight, the nurse on duty should have documented the information in the clinical record and informed the physician.Review of the Medical Record policy dated 6/20/25, directed, in part, that in accordance with accepted standards of practice, the facility must maintain medical records that are complete and accurate.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 69 of 69 residents (Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #19, Resident #20, Resident #21, Resident # 22, Resident #23, Resident # 25, Resident #26, Resident #28, Resident #30, Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #46, Resident #47, Resident #48, Resident #49, Resident #50, Resident #51, Resident #52, Resident #53, Resident #54, Resident #55, Resident #57, Resident #59, Resident #60, Resident #61, Resident #63, Resident #64, Resident #65, Resident #66, Resident #67, Resident #68, Resident #69, Resident #70, Resident #71, Resident # 75, Resident #76, Resident #77, Resident # 78, Resident #79, Resident #80, Resident # 81, and Resident #82) reviewed for falls and pressure ulcers, the facility failed to recognize and assess risk factors placing the resident at risk for specific conditions and problems; complete quarterly risk assessments for Braden Scale for Predicting Pressure Score Risk, dehydration risk, elopement risk, and fall risk per the facility policy. The findings include:1. Resident #3 's diagnoses included severe dementia with psychotic disturbance, contracture of muscle in multiple sites and constipation.2. Resident #4's diagnosis included chronic diastolic congestive heart failure, chronic kidney disease and polymyalgia rheumatica.3. Resident #5's diagnosis included Parkinson's disease, dementia and chronic kidney disease.4. Resident #6's diagnosis included osteoporosis, dementia and chronic kidney disease.5. Resident #7's diagnosis included dementia, chronic kidney disease and fall6. Resident #8's diagnosis included dysphagia (swallowing difficulty), protein-calorie malnutrition and chronic kidney disease.7. Resident #9's diagnosis included vascular dementia, bipolar disorder with psychotic features and chronic kidney disease.8. Resident #10's diagnosis included dementia, pressure ulcer lower back; stage 3, and severe protein calorie malnutrition.9. Resident #11's diagnosis included dementia, dysphagia, and history of falling.10. Resident #12's diagnosis included paraplegia, chronic systolic heart failure and neuromuscular dysfunction of the bladder.11. Resident #13's diagnosis included dementia, malignant neoplasm of the lung and chronic kidney disease.12. Resident #14's diagnosis included Alzheimer's disease, hypo osmolality and hyponatremia (low sodium in the blood) and polymyalgia rheumatica.13. Resident #15's diagnosis included Alzheimer's disease, chronic systolic heart failure and repeated falls.14. Resident #16's diagnosis included malignant neoplasm of prostate with bone malignancy and pathological fracture due to neoplastic disease, and moderate protein calorie malnutrition.15. Resident #17's diagnosis included Malignant neoplasm of the rectum, dementia and peripheral vascular disease.16. Resident #19's diagnosis included Alzheimer's disease, protein calorie malnutrition and contractures of both knees.17. Resident #20's diagnosis included dementia, severe protein calorie malnutrition and pressure ulcer of left heel stage 3.18. Resident #21's diagnosis included cerebral infarction with hemiplegia and hemiparesis affecting right dominant side (stroke), Dysphagia following cerebral infarction (swallowing difficulty) and diabetes.19. Resident #22's diagnosis included dementia, protein calorie malnutrition and history of falling.20. Resident #23's diagnosis included dementia, chronic diastolic heart failure and chronic kidney disease.21. Resident #25's diagnosis included traumatic subdural hemorrhage, multiple fractures of the ribs and pelvis and dementia.22. Resident #26's diagnosis included vascular dementia, dysphagia and low back pain.23. Resident #28's diagnosis included aphasia following a cerebral infarction, syncope and collapse and bradycardia.24.Resident #30's diagnosis included dementia, hydronephrosis with renal calculus obstruction and hypo osmolality and hyponatremia.25. Resident #31's diagnosis included chronic diastolic heart failure, atrial fibrillation and pulmonary hypertension.26. Resident #32's diagnosis included parkinsonism, chronic diastolic heart failure, hypo osmolality and hyponatremia.27. Resident #33's diagnosis included Alzheimer's disease, chronic kidney disease and dysphagia.28. Resident #34's diagnosis included fracture acetabulum (socket in pelvis for hip joint), fracture pubis and repeated falls.29. Resident #35's diagnosis included dementia, chronic diastolic heart failure, and chronic kidney disease.30. Resident #37's diagnosis included cerebral infarction with hemiplegia and hemiparesis affecting left non dominant side, dysphagia and paroxysmal atrial fibrillation.31. Resident #38's diagnosis included vascular dementia, chronic kidney disease and history of falling.32. Resident #39's diagnosis included chronic systolic heart failure, ischemic cardiomyopathy and atrial fibrillation.33.Resident #40 Diagnosis included chronic diastolic heart failure, chronic kidney disease and repeated falls.34. Resident #41's diagnosis included Alzheimer's disease repeated falls and dysphagia.35. Resident #43's diagnosis included Alzheimer's disease, dysphagia and contracture of right hand, left hand, right knee and left knee.36. Resident #44's diagnosis included dementia, paroxysmal atrial fibrillation, and dysphagia.37. Resident #45's diagnosis included cerebral infarction with hemiplegia and hemiparesis affecting the left non dominant side, dysphagia and chronic diastolic heart failure.38. Resident #46's diagnosis included dementia, dysphagia and seizures.39. Resident #47's diagnosis included malignant neoplasm of the frontal lobe brain mass, vascular dementia and dysphagia.40. Resident #48's diagnosis included spinal stenosis, polyneuropathy and difficulty walking.41. Resident #49 diagnosis included Alzheimer's disease, moderate protein calorie malnutrition and hypo osmolality and hyponatremia.42. Resident #50's diagnosis included frontal temporal neurocognitive disorder, diabetes and chronic diastolic heart failure.43. Resident #51's diagnosis included chronic kidney disease, cerebral infarction without residual deficits and spinal stenosis.44. Resident #52's diagnosis included dementia, chronic kidney disease and dysphagia.45. Resident #53's diagnosis included Parkinson's disease chronic kidney disorder and low back pain.46. Resident #54's diagnosis included dementia, diabetes and chronic diastolic heart failure.47. Resident #55's diagnosis included cardiomyopathy, chronic pain syndrome and age-related osteoporosis.48. Resident #57's diagnosis included dementia, diabetes and unsteadiness on feet.49. Resident #59's diagnosis included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia and dysphagia.50. Resident #60's diagnosis included vascular dementia, diabetes and chronic kidney disease.51. Resident #61's diagnosis included dementia, age related osteoporosis and history of falling.52. Resident #62's diagnosis included vascular dementia, chronic diastolic heart failure and muscle weakness.53. Resident #63's diagnosis included dementia, hypo osmolality, hyponatremia and muscle weakness.54. Resident #64's diagnosis included dementia, cirrhosis of the liver and chronic kidney disease.55. Resident #65's diagnosis included protein calorie malnutrition, adult failure to thrive and dementia.56, Resident #66's diagnosis included heart failure, dysphagia and transient cerebral ischemic attack.57. Resident #67's diagnosis included Alzheimer's disease, chronic kidney disease and anemia.58. Resident #68's diagnosis included hypo osmolality, hyponatremia, syndrome of inappropriate secretion of antidiuretic hormone and moderate protein calorie malnutrition.59. Resident #69's diagnosis included dementia, diverticulosis of intestine and history of falling.60. Resident #70's diagnosis included dementia, paroxysmal atrial fibrillation and hypothyroidism.61.Resident #71's diagnosis included dementia, age related osteoporosis and repeated falls.62. Resident #75's diagnosis included acute kidney failure, metabolic encephalopathy and malignant neoplasm of the bladder.63. Resident #76's diagnosis included longstanding persistent atrial fibrillation, cardiac arrest and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.64. Resident #77's diagnosis included repeated falls, muscle weakness and constipation.65. Resident #78's diagnosis included Parkinson's disease, weakness and fall.66. Resident #79's diagnosis included focal traumatic brain injury with loss of consciousness, muscle weakness and fall.67. Resident #80's diagnosis included fracture of first cervical vertebra, muscle weakness and pneumonitis due to inhalation of food and vomit.68. Resident #81's diagnosis included diabetes, chronic diastolic heart failure and chronic kidney disease.69. Resident #82's diagnosis included pleural effusion, hypokalemia and dementia.Interview with the Assistant Director of Nursing (ADNS) on 12/15/25 at 12:53 PM identified that risk assessments: Braden, elopement, and falls should be done quarterly by the MDS Coordinator. The unit nurse and nursing supervisor complete the admission assessments on admission, then quarterly assessments are completed by unit nurses, but we need to put a better system in place.Interview with the MDS Coordinator Registered Nurse (RN) #3 on 12/15/25 at 12:59 PM identified the quarterly assessment schedule had been done but was no longer being completed. RN #3 would give nursing a handwritten list of assessments needing to be done per the MDS assessment schedule, but that process stopped about a year ago. Residents have not had risk assessments completed for about a year. Residents are being assessed for completion of the MDS assessments by utilizing nursing judgement, flowsheets, nutrition documentation, weights, and provider notes. Falls are coded by nursing documentation, observation, cognition, poor safety behaviors, therapy notes and nursing notes. RN #3 further stated that to code the skin section of the MDS assessment she does not utilize the Braden risk assessment but utilizes nursing judgement regarding incontinence, mobility and if the resident was in a wheelchair. RN #3 was unaware of the facility policy for completing quarterly assessments. Additionally, she stated that the staff was not completing the risk assessments when she had posted the schedule of assessments due, so she stopped posting the schedule. RN #3 was not sure she communicated that she had stopped posting the schedule anyone but if she did, she would have told the Director of Nursing (DNS).Interview with DNS on 12/15/25 at 2:16 PM identified that the DNS was unaware that a schedule for quarterly risk assessments had not been posted or that the quarterly assessments were not being completed for the last year. She indicated that she did not look through every chart, and quarterly assessments were not discussed during morning meetings. The DNS indicated that RN #3 (the MDS Coordinator) was responsible for providing the schedule to nursing and for ensuring that the risk assessments were being completed per the schedule that was provided. If RN #3 noted that the risk assessments were not completed by nursing, she should have notified her. The DNS further indicated that MDS assessments are coded according to the formal assessments tools per the policy and regulations. The DNS was unable to answer why the formal assessments had not been completed for approximately 1 year. The surveyor requested and was supplied with a spreadsheet to include the last quarterly assessments that had been completed for each of the residents indicated. Review of the facility provided quarterly assessment spreadsheet for the last year identified the following:Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #19, Resident #20, Resident #21, Resident # 22, Resident #23, Resident # 25, Resident #26, Resident #28, Resident #30, Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #46, Resident #47, Resident #48, Resident #49, Resident #50, Resident #51, Resident #52, Resident #53, Resident #54, Resident #55, Resident #57, Resident #59, Resident #60, Resident #61, Resident #63, Resident #64, Resident #65, Resident #66, Resident #67, Resident #68, Resident #69, Resident #70, Resident #71, Resident # 75, Resident # 76, Resident #77, Resident # 78, Resident #79, Resident #80, Resident #81, and Resident #82's medical records failed to reflect completed dehydration risk assessments upon admission or ongoing.Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21, Resident # 22, Resident #23, Resident #26, Resident #28, Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #46, Resident #47, Resident #48, Resident #49, Resident #50, Resident #51, Resident #52, Resident #53, Resident #54, Resident #57, Resident #59, Resident #60, Resident #61, Resident #64, Resident #65, Resident #66, Resident #69, Resident #70, and Resident #71's medical records failed to reflect Braden risk assessments were completed quarterly per the MDS assessment schedule.Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21, Resident # 22, Resident #23, Resident #26, Resident #28, Resident #30, Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #46, Resident #47, Resident #48, Resident #49, Resident #50, Resident #51, Resident #52, Resident #53, Resident #54, Resident #57, Resident #59, Resident #60, Resident #61, Resident #64, Resident #65, Resident #66, Resident #69, Resident #70, Resident #71, Resident #75, and Resident #82's medical record failed to reflect completed fall risk assessments quarterly per the MDS assessment schedule.Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #15, Resident #16, Resident #19, Resident #20, Resident #21, Resident # 22, Resident #26, Resident #28, Resident #30, Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #43, Resident #44, Resident #45, Resident #46, Resident #47, Resident #48, Resident #49, Resident #50, Resident #51, Resident #52, Resident #53, Resident #54, Resident #57, Resident #59, Resident #60, Resident #61, Resident #64, Resident #65, Resident #66, Resident #69, Resident #70, Resident #71 and Resident #79's medical record failed to reflect completed elopement risk assessments quarterly and per the MDS schedule.The Patient risk assessment and monitoring policy revised 4/2025 directed in part, initial risk assessments must be completed for every patient upon admission to the facility. Follow-up assessments must be conducted on a quarterly basis and following any significant change in a patient's condition. The required risk assessments include, but are not limited to, the following areas: Bowel and bladder function, Braden Scale, Covid 19 risk, dehydration risk, Elopement risk, fall risk, pain management and smoking risk. All assessment scores must be documented in the patient's medical record.The assessment frequency/timeliness policy revised 9/2025 directed in part, The MDS/RAI Coordinator will be responsible for tracking due dates for all MDS assessments including OBRA and Medicare PPS assessments. A calendar of scheduled assessments including type of assessment and assessment reference date will be communicated to those individuals responsible for completing portions of the MDS on a monthly and prn basis.The fall risk assessment policy revised 9/2025 directed in part, the risk assessment will be completed by the nurse or designee upon admission, quarterly or when a significant change is identified.The hydration policy revised 10/2025 directed in part, nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols.The pressure injury risk assessment revised 11/2024 directed in part, pressure injury risk assessments will be conducted by a license or registered nurse on admission/readmission, weekly times four weeks then quarterly. Assessments may also be conducted after a change of condition or after any newly identified pressure injury. Standardized pressure injury risk assessments will be conducted using a validated risk assessment tool or scale. Braden has been designated as the standardized tool.

Based on observation in the Dietary Department, staff interview, and facility policy, the facility failed to ensure food items were labeled and dated, and failed to ensure an adequately clean water filter system for the steam receptacles. The findings include: During a tour of the Dietary Department on 3/15/24 at 10:38 AM with the Executive Chef the following was identified: a. A 40-gallon plastic bin containing loose sugar (approximately 1/4 full) failed to identify the date the sugar was poured into the bin and failed to identify the expiration date of the sugar. b. A 40-gallon plastic bin containing loose rice flour (approximately 1/3 full) failed to identify the date the rice flour was poured into the bin and failed to identify the expiration date of the rice flour. c. A 40-gallon plastic bin containing loose brown rice was (approximately 1/16 full) failed to identify the date the brown rice was poured into the bin and failed to identify the expiration date of the brown rice. d. A 40-gallon plastic bin of approximately 2 cups of loose flour failed to identify the date the flour was poured into the bin and failed to identify the expiration date of the flour. e. A water filter system that feeds a steam receptacle was noted to be soiled and streaked with green/white substances. This filter system was located above a food storage unit and empty food containers. Subsequent to surveyor's inquiry, the water filter system was cleaned. Interview with the Executive Chef on 3/15/24 at 10:38 AM noted that he was unable to explain the reason the bins of rice flour, flour, sugar, and brown rice were not dated when filled or why an expiration date was not identified. He explained that the evening staff conducted nightly inventory checks on all supplies before clocking out which ensured the kitchen was fully stocked and prepared for meal prep the following day. Additionally, the Executive Chef was unable to identify the substances that were noted to have streaked down the water filter system. The facility's Food Storage policy directed culinary managers to maintain adequate food and supplies for food service operations. Additionally, the policy stated that all items were to be appropriately labeled with the expiration or opening date as needed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #7) reviewed for pressure ulcers, the facility failed to ensure a weekly skin check was conducted by a licensed staff member and for 1 of 5 sampled residents, (Resident #48) reviewed for unnecessary medications, the facility failed to follow physician orders regarding pain medications. The findings include: 1. Resident #7 had a diagnosis of cerebral infarction with paralysis, hypertension, and congestive heart failure. Review of the physician orders dated 8/14/23 directed Resident #7 to have skin assessments performed weekly on Mondays. The Minimum Data Set assessment dated [DATE] identified Resident #7 was without cognitive impairment, was dependent on staff for transfers and personal hygiene, and required maximal assistance from staff for bathing, and toileting. Resident #7's Resident Care Plan dated 1/26/24 identified Resident #7 was at risk for pressure ulcers/injury related to the use of a splint (medical device) to the left upper extremity, skin integrity was to be monitored, and to thoroughly wash and dry the hand/arm prior to splint application daily. Additionally, splint removal was to occur daily for a thorough skin check and staff was to notify the physician for any signs of skin breakdown. Observation of Resident #7 on 3/15/24 at 12:11 PM identified him/her with a small red area noted to his/her left thumb. Resident #7 indicated the area was caused by a blue splint indicating a splint which was lying next to him/her. Resident #7 stated that s/he had informed staff the area had become red within the last week. Review of Resident #7's 14-day weekly skin assessment dated [DATE] and signed by LPN #1 identified intact skin. Observation and interview on 3/18/24 at 10:15 AM with Resident #7 identified that the left thumb area was red, uncovered and that no treatment had been administered. Additionally, Resident #7 indicated that s/he had been given a shower this morning. Review of the nursing progress notes from 3/15/24 through 3/19/24 failed to identify any alteration in Resident #7's skin. In an interview with LPN #1 on 3/19/24 at 12:38 PM LPN #1 identified that although she had signed for Resident #7's weekly skin review on 3/18/24, the NA (Nurse Aid) had conducted the skin check on 3/18/24. LPN #1 indicated that she usually performed resident skin assessments, however, she had been too busy with other tasks on 3/18/24 and relied on the NA report of Resident #7's intact skin condition for her observation. In an interview with the Wound Care Nurse (RN#5) on 3/20/24 at 10:51 AM, identified that licensed staff members were to perform weekly skin checks and that skin checks were to be conducted on the resident's shower day. Additionally, RN #5 indicated that it was not an acceptable practice for a NA's to perform weekly skin checks. The facility Skin Assessment policy states that a full body audit, or head to toe skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. 2. Resident #48's diagnoses included dementia, mood disorder, and muscle weakness. A physician's order dated 6/27/23 directed to administer Acetaminophen (Tylenol) 650 mg four times a day as needed. A physician's order dated 6/28/23 directed to administer Tramadol 50 mg every 8 hours as needed for severe back pain if not responsive to Tylenol. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 was moderately cognitively impaired and was totally dependent on staff for toileting, bathing, and upper/lower body dressing, and required partial/moderate assistance with walking. The MDS further identified that Resident #48 was not on a scheduled pain medication regimen and had not received any as needed (PRN) pain medication in the last 5 days. The Resident Care Plan updated 10/6/23 identified the potential for pain related to immobility. Interventions included to administer an opioid as ordered, attempt to gradually decrease frequency of use as able, and to complete a pain assessment each shift. Review of the Electronic Medication Administration Record (EMAR) indicated that Resident #48 had received Tramadol (an opioid medication) on 11/10/23, 11/11/23, 11/29/23, 12/7/23, 12/20/23, 12/21/23, 12/22/23, 12/23/23, 12/25/23, 12/26/23, 12/27/23, 1/2/24, 1/5/24, 1/11/24, 1/12/24, 1/13/24, 1/20/24, 1/22/24, 1/26/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/14/24, 2/18/24, 2/22/24, 2/23/24, 2/26/24, 2/28/24, 2/29/24, 3/4/24, 3/5/24, 3/13/24, 3/17/24, and 3/18/24 (35 times in approximately 4 months) without first receiving Tylenol. Additionally, Resident #48 had received the Tramadol predominantly for reasons other than the physician prescribed reason, severe back pain. A nurse's note dated 11/29/23 at 1:13 AM identified Tramadol was given for left neck/arm pain per Resident #48's request, and that the resident had refused Tylenol first. Interview with RN #3 on 3/20/24 at 12:42 PM identified that the physician orders indicate to administer Tylenol 650 mg four times a day as needed, and to administer Tramadol when Tylenol was not effective for severe back pain. Additionally, RN #3 identified that there was no indication when to use the Tylenol order, however, stated this would be given for pain or fever. RN #3 indicated that she gave Tramadol for reasons other than back pain and without giving Tylenol first because Resident #48 would indicate that s/he wanted Tramadol instead of Tylenol. Subsequent to surveyor inquiry, RN #3 contacted PA #1 on 3/20/24 at 12:56 PM and received a verbal order to change Tramadol to be administered for severe pain (not solely for severe back pain) if the pain was not responsive to Tylenol. Interview with PA #1 on 3/21/24 at 10:11 AM identified that Tramadol was directed to be given to Resident #48 after administering and making the determination that Tylenol was ineffective. Tramadol had been prescribed this way due to the possible sedating side effect of Tramadol. PA #1 indicated she would have expected nurses to notify her both when the Tylenol was ineffective in relieving Resident #48's pain, and when Resident #48 refused Tylenol and requested Tramadol be given first. PA #1 indicated if she had been notified, she would have counseled Resident #48 on the side effects of Tramadol and would have reassessed Resident #48 for pain, possibly directing changes to Resident #48's pain medication regimen. Review of the PRN Medications policy directed, in part, that orders for medications to be given on an as needed basis shall have clear instructions about how and when to administer them. Additionally, when administering a PRN medication, legally authorized staff are to verify the physician's order for the medication, document the reason voiced by the resident and/or assessment findings that show the resident needs the medication, and verify the reason is for the prescribed indication for the medication. 50177

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #28) reviewed for advanced directives, the facility failed to have a signed advanced directive available in either the paper or electronic clinical record. The findings include: Resident #28's diagnoses included congestive heart failure and chronic kidney disease. The admission Minimum Data Set assessment dated [DATE] identified Resident #28 was severely cognitively impaired and required moderate assistance for bed mobility and transfers. The Resident Care Plan dated 2/11/24 identified that Resident #28 was a Do Not Resuscitate (DNR) and a Do Not Hospitalize (DNH). Review of the monthly physician's orders for January, February, and March 2024 failed to identify a current or discontinued order for a DNR or DNH. In an interview and clinical record review with the DNS and ADNS on 3/20/24 at 9:21 AM, Resident #28's clinical record failed to reflect a completed and signed advanced directive form and failed to demonstrate a physician's order for an advanced directive. The DNS and ADNS indicated that the facility policy required an advance directive to be signed on admission and have a subsequent physician's order in the clinical record. Neither the DNS nor ADNS could explain why the clinical record failed to contain the required advance directive documentation. Interview with RN #2 on 3/20/24 at 11:28 AM indicated that if a resident was found unresponsive, she would check in the electronic or paper clinical record for a code status however, she was unable to find a physician's order or consent for Resident #28. RN #2 indicated that there was a banner in the electronic clinical record which identified Resident #28 was a DNR/DNH but was unable to identify where or how the information had been placed there without the corresponding order or consent. RN #2 indicated that Resident #28's code status should have been obtained when s/he was admitted to the facility. Review of the Advanced Directive policy dated 2022 directed, in part, that upon admission, should the resident have an advanced directive, copies will be made and placed in the chart as well as communicated to the staff.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #14) reviewed for edema, the facility failed to notify the provider of a significant change in the resident's weight. The findings include: Resident #14's diagnoses included heart failure, anemia, and atrial fibrillation (irregular heartbeat). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was moderately cognitively impaired, required substantial/maximal assistance of staff to transfer, and required substantial/maximal assistance of staff to propel the wheelchair. The Resident Care Plan dated 11/5/23 identified that Resident #14 had heart failure and was at risk of having too much fluid in his/her circulatory system. Interventions included notifying the medical staff if the resident had any signs or symptoms of heart failure and updating the medical staff of any significant changes in the resident's condition. A physician's order dated 1/21/24 directed to weigh Resident #14 each morning before breakfast and to notify the provider if the resident gained more than 2-3 pounds in 24 hours or more than 5 pounds in a week. Review of Resident #14's documented weights from 1/21/24 through 3/20/24 identified the following weight changes in a 24-hour period: A 5.8-pound increase from 1/29/24 to 1/30/24. A 4.0-pound increase from 2/3/24 to 2/4/24. A 15.5-pound increase from 2/8/24 to 2/9/24. A 6.4-pound increase from 2/19/24 to 2/20/24. Review of Resident #14's documented weights from 1/21/24 through 3/20/24 identified the following weight changes in a week: An 8.2-pound increase from 1/29/24 through 2/4/24. A 11.2-pound increase from 2/3/24 through 2/9/24. A 16.1-pound increase from 2/8/24 through 2/14/24. A 22.8-pound increase from 2/27/24 through 3/6/24. In an interview and review of Resident #14's clinical record with the Assistant Director of Nursing (ADON) on 3/20/24 at 9:06 AM, the ADON failed to identify documentation that any provider had been notified of Resident #14's weight increases per the physician ordered parameters. Although provider notification is expected to be documented in the nursing progress notes, via text message on the supervisor's cell phone, or with an entry on a physician notification log, when the documentation was reviewed, the ADON failed to reflect notification to the provider. During an interview with PA #1 on 3/20/24 at 10:45 AM, it was reported that facility staff inconsistently communicate weight changes as instructed by the physician's order. PA #1 further explained that she frequently discovered uncommunicated weight changes while reviewing resident records. Review of the Change of Condition policy dated 2/2022, directed, in part, to consult with the resident's physician when there is a need to alter the resident's treatment, such as an exacerbation of a chronic condition.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #14) reviewed for edema, the facility failed to follow the provider's order for daily weights, and for 1 of 2 sampled residents (Resident #18) reviewed for skin conditions the facility failed to ensure a treatment order was correctly transcribed to the kardex and that post-surgical wound treatments were performed. The findings include: 1. Resident #14's diagnoses included heart failure, anemia, and atrial fibrillation (irregular heartbeat). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was moderately cognitively impaired, required substantial/maximal assistance of staff to transfer, and required substantial/maximal assistance of staff to propel the wheelchair. The Resident Care Plan dated 11/5/23 identified that Resident #14 had heart failure and was at risk of having too much fluid in his/her circulatory system. Interventions included notifying the medical staff if the resident had any signs or symptoms of heart failure and updating the medical staff of any significant changes in the resident's condition. A physician's order dated 1/21/24 directed to weigh Resident #14 each morning before breakfast and to notify the provider if the resident gains more than 2-3 pounds in 24 hours or more than 5 pounds in a week. Review of Resident #14's weight and vital sign clinical records from 1/21/24 to 3/20/24 identified 59 opportunities for Resident #14 to be weighed and that documentation of Resident #14's weight occurred 35 times since the physician order commenced on 1/21/24 (24 opportunities of missed resident weights). During an interview with RN #2 (the resident's nurse) on 3/20/24 at 8:53 AM, she indicated that all weight measurements and refusals should be documented in the clinical record and identified several missing entries as well as a lack of documentation that Resident #14 had refused to be weighed. Review of the paper log of monthly weights with RN #2 failed to reflect the missing weight documentation. RN #2 stated according to the facility practice, the nursing assistants (NAs) were responsible to obtain Resident #14's weight and that the licensed nurses were responsible to oversee and ensure that NA were weighing and documenting each weight. RN #2 was unable to explain the missing entries, indicated that Resident #14 was dependent on staff to be weighed, and that subsequent to surveyor inquiry, she would obtain Resident #14's weight. Interview with the ADON on 3/20/24 at 9:06 AM, identified that Resident #14 had a physician's order to be weighed prior to breakfast. The ADON was unable to identify why staff were not following the physician directed order's. Additionally, the ADON was unable to locate any documentation related to the 24 missing weights. Review of the Weight Monitoring policy (2/2022), directed, in part, to monitor a resident's weight daily, if clinically indicated, and to document the weight at the time it was obtained. 2. Resident #18's diagnoses included bipolar disorder, delusional disorder, hypothyroidism, and skin lesion. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was cognitively intact and required set-up or clean up assistance with eating and oral hygiene, supervision or touching assistance with upper body dressing, and personal hygiene, and had open lesions. The Resident Care Plan dated 3/15/24 identified Resident #18 had impaired skin integrity and was at risk for pressure ulcers and skin injuries. Interventions included keeping the area clean and dry, monitor for pain and discomfort, monitor for signs and symptoms of infections, and minimize skin exposure to moisture. Observation of Resident #18 on 3/18/24 at 11:59 AM identified a clean, dry, and intact dressing to the left forearm that lacked a dressing date (indicating when the treatment was last performed). Review of the physician's order dated 2/26/24 directed facility staff to cleanse the left dorsal (backside) of the wrist with normal saline, pat dry, apply Telfa (non-stick pad), wrap with kerlix gauze daily and as needed. The physician's order on the first electronic record screen was noted to have been discontinued on 2/26/24 but when the original order was fully opened in the electronic record, the discontinue date was noted to have been 3/7/24. The nursing note dated 2/27/24 at 11:11 AM identified Resident #18 was to continue with the current treatment orders of the left dorsal wrist area. Review of the Medication Administration Record (MAR) where treatments were documented and signed as completed, and nursing progress notes from 2/27/24 until 3/6/24 failed to show wound care treatments had been completed for Resident #18. Interview with the DNS on 3/20/24 at 10:26 AM identified that there was a gap in wound care treatments being completed because no wound care orders were in place from 2/27/24 until 3/6/24. The DNS believed the reason were not completed was due to a glitch in the electronic health record. The DNS indicated that although the order was correctly transcribed, the system failed to bring the orders forward and facility staff failed to identify that treatment orders were missing. Subsequent to surveyor inquiry the DNS indicated she would call the electronic health record provider to identify the issue. Interview with MD #1 on 3/21/24 at 10:05 AM identified that there should have been wound care orders in place from 2/27/24 through 3/7/24 and wound treatments should have been performed during that timeframe. Review of the facility policy for physician orders last revised on 11/2023 identified all physician orders in the medical record must be accurate, timely and meet all requirements by state and federal regulations. 50095

Based on observations, review of the clinical record, facility policy, and staff interviews for 1 of 3 residents, (Resident #7), reviewed for pressure ulcers, the facility failed to ensure that a weekly skin assessment was completed by a licensed staff member. The findings included: Resident #7's diagnosis included hypertension, congestive heart failure, and hemiplegia/ hemiparesis following a cerebral infarction affecting the left side. Review of the physician orders dated 8/14/23 directed Resident #7 to have weekly skin checks completed on Mondays during the day shift. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was cognitively intact, was dependent on staff for transfers, required set up for eating, and personal hygiene, and required maximal assistance for bathing, and toileting. The Resident Care Plan dated 1/26/24 identified Resident #7 was at risk for pressure ulcers/injury related to the use of a splint (medical device) to left upper extremity, skin integrity was to be monitored, and skin was to be thoroughly washed and dried prior to daily splint application. The splint was to be removed daily for a thorough skin check and staff were to notify the physician of any signs of breakdown. Observation and interview with Resident #7 on 3/15/24 at 12:11 PM identified s/he had a small, red area noted to the left thumb. Resident #7 stated the area was from a blue splint (which was lying next to him/her.) Resident #7 indicated that s/he had previously informed staff of the area, and that the area had become red within the last week. Re-observation and re-interview with Resident #7 on 3/18/24 at 10:15 AM identified that the left thumb area continued to be red area. The red area was noted to be open to air (uncovered) and Resident #7 indicated that s/he had a shower earlier in the morning. Review of the clinical record weekly skin audit identified that on 3/18/24 Resident #7 had a skin check performed by LPN #1, and that Resident #7's skin was noted to be intact. Interview and review of the weekly skin observation with LPN#1 on 3/19/24 at 12:38 PM identified that she usually performed Resident #7's skin check while the Nurse Aid (NA) provided care, but she was too busy giving out medications on 3/18/24. Further, LPN #1 indicated that she had relied on the NA to conduct the skin observation, the NA had identified and reported that Resident #7 had no skin impairment and that was why she had documented she had completed the observation on the Treatment Administration Record (TAR) and documented that Resident #7's skin was intact. Subsequent to surveyor inquiry Resident #7 was noted with a blister to the left thumb and was to be seen by the PA. Review of the PA note dated 3/19/24 at 1:47 PM identified that Resident #7 had been wearing a day splint for several months without issues and had a newer night splint for a left hand contracture. A small closed blister was noted on the left lateral thumb that appeared may have been rubbing on the splints that were worn. The PA indicated that the area was likely due to shearing against the splint, directed discontinued use of all splints until the area healed, and that Occupational Therapy evaluate splint use. Interview with the Wound Nurse (RN #5) on 3/20/24 at 10:51 AM identified that per the facility policy, a licensed staff member was to perform weekly skin checks and that skin checks were to occur on the resident's shower day. Additionally, RN #5 indicated that it was not acceptable for a NA to perform a weekly skin check. The facility policy for Pressure Injury Prevention and Management stated that licensed nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings would be documented in the medical record and the assessment for pressure injuries would be performed by a licensed nurse and documented on the wound tracker sheet.

Based on observations, review of the clinical record, facility policy, and interviews for 2 of 3 sampled residents (Resident #10 and #215) reviewed for respiratory issues, the facility failed to obtain a physician's order for oxygen administration. The findings include: 1. Resident #10's diagnosis included malignant neoplasm of the frontal lobe, atrial fibrillation (irregular heartbeat), and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 was severely cognitively impaired and was totally dependent on staff for toileting and personal hygiene. The Resident Care Plan dated 2/28/24 identified Resident #10 utilized oxygen with interventions that included regularly monitoring his/her oxygen saturation levels and application of oxygen via nasal cannula as needed. Review of the nursing note dated 3/7/24 at 7:21 AM identified that at 12:30 AM Resident #10 had a low oxygen saturation level on room air (without oxygen) ranging between 85 percent (%) to 87 %, oxygen was applied at 2 Liters (L), and Resident #10's oxygen saturation was rechecked and was 91 % on 2L of oxygen. A Physician Assistant progress note dated 3/7/24 at 3:36 PM identified Resident #10 was still requiring oxygen at 2L. Additionally, the PA progress note identified Resident #10's oxygen saturation levels decreased when the resident self-removed the tube providing the oxygen. Resident #10 was currently taking Moxifloxacin (an antibiotic) for bronchitis/possible pneumonia and was on scheduled nebulizers. The nursing note dated 3/8/24 at 7:06 AM identified Resident #10's oxygen saturation, at the beginning of the shift, was 84% on room air, oxygen at 2L was applied, and the oxygen saturation level was 91% on 2L of oxygen. The nursing note dated 3/8/24 at 4:07 PM identified Resident #10's oxygen saturation was 94% on oxygen via nasal tubing. Review of physician orders in effect on 3/7/24 and 3/8/24 failed to identify a physician order that oxygen was directed despite oxygen being applied on 3/7/24 at and 3/8/24. Interview with LPN #1 on 3/19/24 at 2:35 PM identified Resident #10 was on antibiotic therapy and receiving oxygen for a respiratory illness. Additionally, LPN #1 noted there should have been a physician order in the computer for oxygen, but she had failed to review the physician orders to ensure oxygen was ordered due to needing to tend to her assignment. Interview with the ADNS on 3/19/24 at 2:45 PM identified when oxygen was initiated the nurse on the shift should have obtained an order for oxygen. Additionally, the ADNS identified that if a resident had a low oxygen saturation level, the nurse would put the resident on oxygen and then notify and obtain a physician's order from a provider for oxygen administration. Subsequent to surveyor inquiry, an order was obtained on 3/19/24 at 3:33 PM from the PA that directed staff to apply 1 L of oxygen as needed (PRN) for an saturation level less than 89%. 2. Resident #215's diagnoses included heart failure, atrial fibrillation (irregular heartbeat), and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #215 was severely cognitively impaired, required setup for personal hygiene, and supervision assistance for bed mobility and transfers. The MDS did not identify oxygen therapy was in use. Observation on 3/15/24 at 11:40 AM identified Resident #215 was in bed and an oxygen concentrator, turned to the off position, was at the bedside. Observation on 3/18/24 at 9:42 AM identified an oxygen concentrator at Resident #215's bedside with oxygen tubing labeled 3/17/24 from the 11:00 PM to 7:00 AM shift. The oxygen nasal cannula was on the resident and the concentrator was running at 2.0 Liters Per Minute (LPM). Review of the physician, APRN, and nursing progress notes from 2/16/24 through 3/18/24 failed to identify that Resident #215 had been ordered or was utilizing oxygen. Review of the physician orders in effect from 2/20/24 through 3/19/24 failed identify that Resident #215 had an order for oxygen use. Interview and observation with LPN #1 on 3/19/24 at 2:32 PM identified that if she had any residents on oxygen, the order would show up on the Medication Administration Record (MAR) and there would be a physician's order. LPN #1 indicated that if there was an emergency, staff would administer the oxygen first, and then call the provider and get an order before the end of the shift. If a resident appeared distressed or complained of shortness of breath or difficulty breathing, she indicated she would take vital signs and an oxygen saturation level, followed by notifying the provider of her assessment. Upon observation of Resident #215 with LPN #1, she said that she had not previously noticed the concentrator in the room and did not know the resident to ever have used oxygen. Further, LPN #1 identified she was unaware who had put the concentrator in the room as there was no order for oxygen therapy. Interview with LPN #2 on 3/19/24 at 2:42 PM identified that Resident #215 was complaining of shortness of breath earlier in the shift and checked an oxygen saturation level which was noted to be 97% on room air. LPN #2 reported Resident #215 was able to calm down and no new interventions were put into place. LPN #2 denied placing the oxygen concentrator in the room or putting the nasal cannula on the resident. LPN #2 was unable to identify how long the concentrator had been in the room but stated she had seen it at the beginning of the shift. Subsequent to surveyor inquiry, a physician's order dated 3/19/24 was obtained directing staff to apply 1.0 to 2.0 liters of oxygen via a nasal cannula for shortness of breath as needed. Review of the Oxygen Administration policy dated 1/2024 directed, in part, that oxygen was administered under orders of a physician. except in the case of an emergency. In such cases, oxygen was administered and orders for oxygen were obtained as soon as practicable when the situation was under control. 50249

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for wandering, the facility failed to ensure the wanderguard system was checked for functioning which resulted in an accident with injuries. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], dementia, [CONDITION(S)], a history of falls and status post clavicle fracture. Hospice services were requested by the family. The admission Minimum Data Set, dated dated dated [DATE] identified Resident #1 had severely impaired cognition, required limited to extensive assistance of two for transfers and ambulation, was not steady with transfers and walking, and sustained a fracture related to a fall in the previous 6 months (prior to admission). A Resident Care Plan dated 3/1/21 identified a problem with activities of daily living for function/rehabilitation potential. Interventions included assistance of one with ambulation with hand held assistance, wheelchair to follow, up to 10 feet. A nurse's note dated 3/9/21 indicated Resident #1 continued to wander but was easily directed, wanderguard placed and functional to Resident #1's left lower extremity. Physician's order dated 3/9/21 directed a wanderguard to Resident #1's left lower extremity, check for placement every shift. A Resident Care Plan dated 3/10/21 identified a problem with being at risk for elopement due to wandering tendency. Interventions included the use of a wanderguard, monitor proper functioning and assure that resident does not remove, check for placement every shift and check for proper functioning once daily. Wanderguard tracking documentation dated 3/10/21 through 3/17/21 identified the wanderguard was checked for placement every shift as directed. Physician's progress note dated 3/11/21 identified Resident #1 was initially confused and had difficulty ambulating but since being treated for a urinary tract infection, Resident #1 had returned to baseline. Resident #1 was no longer agitated, no longer required a reclining wheelchair for safety, ambulated and sat in the hall, and was forgetful/pleasantly confused. A Reportable Event dated 3/17/21 indicated, through security footage, Resident #1 exited the 5th floor nursing unit and approximately 5 minutes later the security footage displayed the resident falling down the set of stairs on the 4th floor. It was assumed, while out of security footage for 5 minutes, Resident #1 ambulated from the unit to the main stairwell and successfully ambulated partially down the stairs before falling. Resident #1 was noted to have a small laceration to the outer aspect of the right eye, a laceration across the nasal bridge and complained of pain to right side of head, right hip and right knee. Resident #1 was transferred to the emergency room and diagnosed with a right femoral fracture. Facility staff removed the wanderguard from Resident #1 and found the door which Resident #1 exited from exhibited inconsistent alarming, sometimes alarming and allowing egress and other times would not alarm and still allow egress. Staff interviews indicated the alarm was not heard or reset during the investigated time frame so it was assumed Resident #1 exited the unit without the alarm sounding. Facility policy for wander/elopement alarms indicated wanderguards are checked nightly on the 11:00 PM to 7:00 AM shift with the wanderguard checking device. If the wanderguard checking device is not functioning, the wanderguard must be checked by taking the patient or wheelchair to the door. Interview with the Manager of Engineering and Security and the Vice President of Engineering on 3/23/21 at 12:00 PM indicated they only perform regular door inspections per the fire code and do not check the functioning of the wanderguard on the doors because they were not aware the wanderguard system required that. They further indicated, since the incident, they have ordered a wanderguard checking device which will allow checking of both the bracelet and door component. Interview with the Administrator on 3/23/21 at 1:00 PM indicated he took the wanderguard bracelet to the box to check it when needed and was not aware a wanderguard checking device existed. Additionally he indicated he checks the system a couple times a month but has not documented such, and since the incident occurred, he has been auditing the doors' functions. Interview with the DNS on 3/23/21 at 1:15 PM indicted she was not aware of a wanderguard checking device. Interview with a representative from the wanderguard supplier on 3/25/21 at 11:15 AM indicated the facility had purchased a secure care wanderguard system tester. The representative indicated the facility should have had a tester and the tester was always quoted with the purchase of the alarm system. The representative further indicated, although manufacturers are leery to mention recommendations, it is recommended the door be checked with the tester daily and the bracelet be checked with the tester or at the door weekly.

Based on clinical record review and interview for one (R#1) of four residents reviewed for falls, the facility failed to provide adequate supervision to the resident. The findings include: R#1's [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status score as 3 (0-7 severe impairment), the need for extensive assistance with transfers, ambulation did not occur, balance was not steady moving on/off the toilet and was only able to stabilize with human assistance, and that R#1 was not experiencing pain. The Fall Risk assessment dated [DATE] identified a score of 9 (10 or above represents high risk). The resident care plan dated 12/10/10 identified potential for falls related to poor safety awareness and history of falls with interventions to provide chair alarm, fall mats and not leave the resident alone in the bathroom. Review of nurse's notes dated 1/13/11 identified that R#1 requested to be toileted, appeared confused and forgetful and fell from the toilet. R#1 was assessed and complained of pain to the right hip. The radiology report dated 1/13/11 suggested but couldn't conclude a right hip fracture. A radiology report dated 1/14/11 identified a right subcapital fracture with no displacement. Facility documentation dated 1/13/11 identified NA#1 was standing in the bathroom doorway and NA#1 could not get to the resident in time to assist. Interview with the DNS on 3/30/11 at 2:30 PM identified that although the nurse aide was at the doorway, he/she was not close enough to intervene and prevent the fall. NA#1 was unavailable for interview.