Every finding on record at Shady Knoll Center for Health & Rehabilitation

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure a medication was labeled correctly when received from the pharmacy, resulting in a medication error. The findings include: Resident #1 had a diagnosis of rheumatoid arthritis. Physician order dated 6/4/2025 directed to administer Methotrexate (immunosuppressive drug use to treat rheumatoid arthritis) subcutaneous solution auto-injector 10 milligrams (mg)/0.4 milliliters (ml). Inject 25 mg subcutaneously every Tuesday. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he/she was alert and oriented. The Resident Care Plan (RCP) dated 6/10/2025 identified Resident #1 had arthritis. Interventions directed to administer medications as ordered. Facility incident report dated 6/18/2025 identified Resident #1 received the wrong medication dose. APRN #1's note dated 6/18/2025 at 9:45 AM identified Resident #1 was seen for follow up after he/she was inadvertently given 50 mg of Methotrexate on 6/10 and on 6/17/2025 (prescribed dose was Methotrexate 25 mg). The note indicated that APRN #1 was notified by the pharmacy manager that the pharmacy had sent the incorrect dose with an incorrect label which led to the administration of the 50 mg dose. Resident #1's rheumatologist (prescribing physician) was notified and directed to hold the next scheduled dose of Methotrexate (scheduled on 6/24/2025). Further, the rheumatologist directed blood work: a complete blood count, basic metabolic panel, and Methotrexate levels. Blood work was obtained which showed no significant abnormalities and the resident was started on IV hydration, and the plan of care was discussed with Resident #1. APRN #1's note dated 6/19/2025 at 8 AM identified Resident #1 was seen for follow up, and had no adverse effects from the medication error, and no significant abnormalities were noted in the laboratory results. Facility incident summary dated 6/19/2025 identified the facility received a call from the pharmacy and the pharmacy explained the label on the packaging of the Methotrexate was transcribed incorrectly by the pharmacy. The Methotrexate vial sent to the facility on 6/5/2025 stated 50 mg was two (2) ml and the packaging label stated 25 mg was two (2) ml. Resident #1 should have received 25 mg. LPN #1 and LPN #2 stated when they administered the Methotrexate on 6/10 and 6/17/2025, they administered the full vial. LPN #1 and LPN #2 indicated they read the packaging label and dispensed the medication due to the packaging label saying 25 mg was two (2) ml. Resident #1 was stable and aware of the medication error. Interview with APRN #1 on 7/21/2025 at 11:01 AM identified she was notified by the pharmacy on 6/18/2025 that the Methotrexate was mislabeled by the pharmacy (with the wrong dose instructions) and that Resident #1 received the wrong dose of Methotrexate on 6/10 and 6/17/2025 (received 50 mg instead of the 25 mg ordered). APRN #1 identified Resident #1 had no adverse effect from the medication error; blood work was normal, IV fluids were administered as a precaution, and Resident #1 was monitored for nausea, vomiting or diarrhea. Interview with the Pharmacy Manager on 7/21/2025 at 11:22 AM identified she was notified of the error on 6/17/2025 when the facility reordered the Methotrexate too early. The pharmacy identified the label directions placed on the vials by the pharmacy were incorrect. The labels directed 25 mg was two (2) ml of solution, but the manufacturer label said 25 mg was per one (1) ml. The Pharmacy Manager stated she did not know why the pharmacy label was incorrect, and indicated the pharmacy contacted the facility about the error. Interview with LPN #1 on 7/21/2025 at 11:47 AM identified she administered the Methotrexate dose per the electronic health record on 6/17/2025, but did not remember the dose she administered. LPN #1 further stated she does not check the manufacturer labels on a vial, and she only checks the label that the pharmacy attaches to a vial. Interview with LPN #2 on 7/21/2025 at 11:56 AM identified administered the Methotrexate on 6/10/2025 and indicated the dose he administered was from a new, unopened vial and he administered the entire vial. Interview with the Director of Nursing (DNS) on 7/21/2025 at 12:51 PM identified LPN #2 administered the wrong dose of Methotrexate on 6/10 and LPN #1 administered the wrong dose of Methotrexate on 6/17/2025. The DNS indicated both nurses administered Methotrexate 50 mg, instead of the ordered dose of 25 mg. The DNS stated reason for the error was that the pharmacy label was wrong. The pharmacy label indicated a 25 mg dose was two (2) ml of the solution, and the manufacturer's label on the vial indicated 50 mg was two (2) ml of solution. The DNS stated neither LPN #1 or LPN #2 checked the manufacturer's label against the pharmacy label and did not identify the discrepancy in labeling and Resident #1 received the wrong dose. Interview failed to identify why staff did not read both labels on the Methotrexate vials. Subsequent to surveyor inquiry, staff were provided education, during the survey, to check both the manufacturer and pharmacy labels, and if there was any discrepancy, to check the physician orders and call the pharmacy and provider for clarification.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure medication was administered in accordance with physician orders, and failed to ensure staff read the manufacturer label prior to administering a medication, resulting in a medication error. The findings include: Resident #1 had a diagnosis of rheumatoid arthritis. Physician order dated 6/4/2025 directed to administer Methotrexate (immunosuppressive drug use to treat rheumatoid arthritis) subcutaneous solution auto-injector 10 milligrams (mg)/0.4 milliliters (ml). Inject 25 mg subcutaneously every Tuesday. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he/she was alert and oriented. The Resident Care Plan (RCP) dated 6/10/2025 identified Resident #1 had arthritis. Interventions directed to administer medications as ordered. Facility incident report dated 6/18/2025 identified Resident #1 received the wrong medication dose. APRN #1's note dated 6/18/2025 at 9:45 AM identified Resident #1 was seen for follow up after he/she was inadvertently given 50 mg of Methotrexate on 6/10 and on 6/17/2025 (prescribed dose was Methotrexate 25 mg). The note indicated that APRN #1 was notified by the pharmacy manager that the pharmacy had sent the incorrect dose with an incorrect label which led to the administration of the 50 mg dose. Resident #1's rheumatologist (prescribing physician) was notified and directed to hold the next scheduled dose of Methotrexate (scheduled on 6/24/2025). Further, the rheumatologist directed blood work: a complete blood count, basic metabolic panel, and Methotrexate levels. Blood work was obtained which showed no significant abnormalities and the resident was started on IV hydration, and the plan of care was discussed with Resident #1. APRN #1's note dated 6/19/2025 at 8 AM identified Resident #1 was seen for follow up, and had no adverse effects from the medication error, and no significant abnormalities were noted in the laboratory results. Facility incident summary dated 6/19/2025 identified the facility received a call from the pharmacy and the pharmacy explained the label on the packaging of the Methotrexate was transcribed incorrectly by the pharmacy. The Methotrexate vial sent to the facility on 6/5/2025 stated 50 mg was two (2) ml and the packaging label stated 25 mg was two (2) ml. Resident #1 should have received 25 mg. LPN #1 and LPN #2 stated when they administered the Methotrexate on 6/10 and 6/17/2025, they administered the full vial. LPN #1 and LPN #2 indicated they read the packaging label and dispensed the medication due to the packaging label saying 25 mg was two (2) ml. Resident #1 was stable and aware of the medication error. The APRN note dated 6/20/2025 at 8:30 AM identified the IV fluids were discontinued, and Resident #1 had not experienced any adverse side effects or significant abnormalities in the laboratory results after the medication error. Interview with APRN #1 on 7/21/2025 at 11:01 AM identified she was notified by the pharmacy on 6/18/2025 that the Methotrexate was mislabeled by the pharmacy (with the wrong dose instructions) and that Resident #1 received the wrong dose on 6/10 and 6/17/2025. APRN #1 identified Resident #1 had no adverse effect from the medication error; blood work was normal, IV fluids were administered as a precaution, and Resident #1 was monitored for nausea, vomiting or diarrhea. Interview with the Pharmacy Manager on 7/21/2025 at 11:22 AM identified she was notified of the error on 6/17/2025 when the facility reordered the Methotrexate too early. The pharmacy identified the label direction placed on the vials by the pharmacy directed 25 mg was two (2) ml of solution, but the manufacturer label said 25 mg was per one (1) ml. The Pharmacy Manager stated she did not know why the pharmacy label was incorrect, and indicated the pharmacy contacted the facility about the error. Interview with LPN #1 on 7/21/2025 at 11:47 AM identified she administered the Methotrexate on 6/17/2025. LPN #1 stated the pharmacy label was wrapped around the vial and she gave the dose per the electronic health record but did not remember the dose she gave. LPN #1 further stated she does not check the manufacturer labels on a vial, and she only checks the label that the pharmacy attaches to a vial. Interview with LPN #2 on 7/21/2025 at 11:56 AM identified administered the Methotrexate on 6/10/2025, but did not remember what dose he administered. LPN #2 stated he checked the physician order prior to administering the medication and discarded the vial afterwards. LPN #2 indicated the dose he administered was from a new, unopened vial and he administered the entire vial. Interview with the Director of Nursing (DNS) on 7/21/2025 at 12:51 PM identified LPN #2 administered the wrong dose of Methotrexate on 6/10 and LPN #1 administered the wrong dose of Methotrexate on 6/17/2025. The DNS indicated both nurses administered Methotrexate 50 mg, instead of the ordered dose of 25 mg. The DNS stated the pharmacy label indicated a 25 mg dose was two (2) ml of the solution, and the manufacturer's label on the vial indicated 50 mg was two (2) ml of solution. The DNS stated neither LPN #1 or LPN #2 checked the manufacturer's label against the pharmacy label and subsequently administered the entire vials of 50 mg of Methotrexate to the resident on 6/10 and on 6/17/2025 in error. The DNS stated education was conducted for both LPN #1 and LPN #2 and for all licensed staff in the facility. Review of facility documentation identified LPN #1 and LPN #2, and additional nursing staff were educated regarding the 5 rights of med pass: right dose, right resident, right route, right med, and right time. Review failed to identify the staff were educated to check both the manufacturer and pharmacy labels, and if there was any discrepancy, to call the pharmacy or the provider for clarification. Subsequent to surveyor inquiry, staff were provided education, during the survey, to check both the manufacturer and pharmacy labels, and if there was any discrepancy, to check the physician orders and call the pharmacy and provider for clarification. Review of facility medication pass policy dated 9/23/2024 directed in part, to administer medications per the physician's orders, and when the prescription label and electronic medication administration record are different, the orders must be verified with the actual provider before medication administration.

Based on review of facility documentation and staff interview, the facility failed to ensure the 1st quarter Payroll Based Journal (PBJ) report was submitted. The findings include:Review of the [NAME] 1st Quarter (10/1/24 through 12/31/24) PBJ Staffing Data Report identified there were no submittals for Registered Nurse hours and for licensed nursing coverage 24 hrs./day for 10/1/24 through 10/10/24.An interview with the Administrator on 6/30/25 at 9:43 AM and 6/30/25 at 2:30 PM identified the former owners of the facility were responsible for nursing staff PBJ submissions and failed to complete transmissions 10/1/24 through 10/10/24 as an oversight before the change of ownership which was effective 10/10/24.Although a policy for PBJ submission was requested, none was provided.

Based on clinical record review, facility documentation, facility policy and staff interviews for 1 of 5 residents (Resident #93) reviewed for unnecessary medications, the facility failed to review and respond to pharmacy recommendations in a timely manner. The findings include:Resident #93 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety, and hypertension.A physician's order dated 12/10/24 directed to administer Citalopram Hydrobromide (Celexa) (an antidepressant medication) 40 milligrams(mg) 1 tablet by mouth once a day.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 was severely cognitively impaired, dependent on bathing, dressing, and toileting. Also identifying Resident #93 required maximal assistance for personal and oral hygiene and was receiving an antidepressant medication. The Pharmacy medication review dated 12/12/24 identified Resident #93 was receiving Citalopram (Celexa) 40 mg per day and noted Celexa was no longer recommended to be used at doses greater than 20 mg per day in those of [AGE] years of age because it can cause dose-dependent QT interval prolongation (a heart rhythm-disorder that can cause fast, chaotic heartbeats).The Medication Administration Record dated from 12/11/24 through 4/28/25 identified Resident #93 was receiving Celexa 40 mg every day, then discontinued on 4/28/25 due to Resident #93 being on medical leave. Also identifying Resident #93 was restarted on Celexa 10 mg to take 2 tablets to equal 20 mg every day on 5/25/25.The Resident Care Plan (RCP) dated 12/26/24 identified Resident #93 had psychotropic medication used with interventions that included to give medication as ordered, and monitor, document and report as needed any adverse reactions of the psychotropic medications such as falls, weight loss, vomiting and hallucinations. The Pharmacy medication review dated 2/12/25 noted a second request identifying Resident #93 was still receiving Celexa 40 mg every day and the Pharmacist recommended to evaluate and consider tapering Celexa to 20 mg daily and monitor the effect.The Pharmacy medication review dated 4/8/25 noted a second request (even though it was the third request) identifying Resident #93 was still receiving Celexa 40 mg every day and the Pharmacist recommended to evaluate and consider tapering Celexa to 20 mg daily and monitor the effect. The Pharmacy medication review dated 5/9/25 identified a fourth request regarding Celexa 40 mg for evaluation and tapering to 20 mg every day and monitor the effect. A Pharmacist note dated 5/9/25 at 10:44 AM identified the medication regimen was reviewed and recommendations have been made for nursing to review. The physician order dated 5/27/25 directed for Celexa 10 mg 1 tablet to be given every day (physician responded after 4 pharmacy reviews with recommendations). Interview with the Director of Nursing (DNS) on 6/30/25 at 12:37 PM identified that the Pharmacist recommendations for Celexa were to decrease the dosage, the same recommendation was made again 2/12/25 and these recommendations had not been addressed by the physician. Also identifying that once a recommendation was made by the Pharmacist, the Advanced Practice Registered Nurse (APRN) was to review the recommendations and either change the order or chart a reason for not changing the order and no record could be identified regarding decreasing the Celexa. Further identifying that she reviews the Pharmacist recommendations monthly and it was an oversight that Celexa had not been decreased since 12/12/24 and it should have been addressed within the first month of the recommendation.An interview with APRN #2 on 6/30/25 at 1:02 PM identified she had stopped working at the facility in January 2025 and at the time some residents had transferred from another facility causing confusion on which provider covered the new transferred residents.An interview with the Pharmacist on 6/30/25 at 1:04 PM identified that she does not usually write consecutive recommendations which was the reason the decrease in dosage of Celexa was not addressed by pharmacy in January 2025 and March 2025. Also, identifying that when a recommendation was not addressed, she would let the DNS know but there was no documentation for this until 5/9/25. Further identifying that the recommendation for the dose reduction of Celexa was made 4 times over 5 months. Review of the facility policy for Pharmacy medication review identified that the Consultant Pharmacist reviews the medication regime of each resident at least monthly. The findings and recommendations are communicated to those with responsibility to implement the recommendation, and to answer in a timely fashion. The Consultant Pharmacist will submit their monthly recommendation reports to the DNS and follow the recommendations to verify that appropriate action has been taken or responded to within a reasonable time frame. Physicians may accept and act on the recommendations or reject the recommendation and provide an explanation for disagreement. If there was a potential for serious harm and the attending Physician does not concur with or refuses to document an explanation for disagreeing with the recommendation, the DNS and/or Pharmacist will contact the Medical Director. Clinical recommendation will be addressed by the licensed nurse. The completed pharmacy recommendation will be uploaded in the electronic medical record.

Based on the tour of the Dietary Department, staff interviews, and review of facility policies, the facility failed to ensure opened items were labeled and dated when opened, and expired food was discarded. The findings include:Tour of the Dietary Department on 6/23/25 at 9:55 AM during the initial walk through with the Dietary Director identified the following:a. A large bag of Ciabatta Garlic bread sticks opened, not dated, located in the walk-in freezer.b. 4 (gallon sized) opened freezer bags of frozen chicken wings observed in the walk-in- freezer were not dated when opened.c. 1 (1 pound) bag of coconut half full, not dated and open to air located in the dry storage room.d. 1 (24-ounce) package of powdered gravy mixed which was opened and dated 1/21/25 in the dry storage room which was not sealed closed.e. 11 individual 0.98-ounce packages of oatmeal not in the original box (which identified the expiration date) with no expiration date noted.An interview with the Dietary Director on 6/23/25 at 10:00 AM identified that all food that was opened should be labeled with a date when opened and any expired food should be discarded. Also identifying that the cooks were responsible for labeling and dating the items. Further identifying that she would not use the dry gravy mix.An observation of the tray line with the Dietary Director on 6/25/25 at 11:45 AM identified the following:a. 1 (46-ounce) container of orange juice which was 1/4 full with an open date of 12/17/24 and an expiration date of 6/4/25 (21 days passed the expiration date) which was on the beverage cart during tray line, but it was not utilized.An interview with the Dietary Director on 6/25/25 at 11:50 AM identifying the orange juice should have been thrown away and not used after the expiration date. Also identifying that all dietary staff were responsible for discarding expired items.Review of the facility policy for Storage of food and supplies food, by dates. Also identified was food removed from its original container must be labeled with the common name of the food. Further identifying that refrigerator time/temperature safety, ready-to-eat food that was opened but not completely used and was held for longer than 24 hours should be labeled with the common names and use by day, with day 1 counted as the day the item was opened. Rotate food product (dry, refrigerated, or frozen) to ensure the oldest inventory was used first. Discard food that exceeds their used by date or expiration date, was damaged, spoiled, has the time/temperature danger zone requirements, or was incorrectly stored such that it was unsafe, or its safety was uncertain.

Based on a temperature meal tray sample taken with the Dietary Director and staff/resident interviews, the facility failed to ensure meals was served at appropriate temperatures.During the Resident Council meeting on 6/24/25 at 1:34 PM, residents complained of ongoing issues with food being served cold. On 6/25/25 at 12:35 PM, a test tray was conducted. The following was identified:The lunch meal was plated and left the Dietary Department on a variety of serving carts which were two tiered and open to air starting at 11:45 AM which were filled with 7 to 8 meals on each serving cart, plated and covered with a clear plastic lid with a hole in the center. Dietary Aides transferred meal trays to the third floor first, returning after the serving carts were emptied to refill with meals plated in the kitchen, then returned to the units to finish serving. The food temperature log was reviewed with all foods identified at appropriate temperatures for each item on the steam table. The test temperature tray was plated at 12:35 PM and brought up to the second-floor unit at 12:40 PM. One Nurses Aid was on the unit passing trays even though other Nurses Aids were seen down the hall of the second floor. The last tray was served to a resident at 12:50 PM and temperatures were obtained of the temperature test tray at 12:50 PM with the Dietary Director identifying the following:a. The chicken cutlet entrees' internal temperature was 128 degrees with both the Dietary Director and surveyor's thermometer. b. The baked potato's internal temperature was 128 degrees with both the Dietary Director and surveyor's thermometer. c. The cooked spinach's internal temperature was 129 degrees with both the Dietary Director and surveyor's thermometer.d. The mashed potato's internal temperature was 129 degrees with the surveyor's thermometer and 130 degrees with the Dietary Director's thermometer.An interview with the Dietary Director on 6/25/25 at 12:55 PM identified that all the Nurse's Aides were responsible for passing the trays. Also, the Dietary Director provided a copy of the Test Tray form with the acceptable temperature for all hot items being served at 135 degrees. Further identifying that all the food that was temperature tested was cold and that the food was not served in a timely manner. The Dietary Director identified there was a portable steam table that the dietary staff was using but it was too difficult to transport to the unit, and it did not have enough areas to hold all the food item options during meals, which was the reason it was no longer being utilized. Also, identifying that all staff should be serving trays during mealtimes which included department heads, and Nurses Aids. On 6/26/25 at approximately 9:30 AM the DNS and Administrator identified that they assisted with passing breakfast trays on the second-floor unit that morning which took about 15 minutes and when they performed a temperature check of the meal being served it was all cold. Also identifying that they contacted corporate regarding food temperature and the plan was to have closed carts ordered to keep the food warm.

Based on review of the clinical record, staff interviews, facility documentation, and facility policy for 1 of 3 residents (Resident #31) reviewed for pressure ulcers, the facility failed to follow physician orders timely and initiate treatment orders for a newly identified wound. The findings include:Resident #31's diagnoses included unspecified dementia, chronic kidney disease, and essential hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was severely cognitively impaired and dependent on staff for shower/bathing, lower body dressing, and putting on/taking off footwear.Review of a skin condition binder located on the 3rd floor identified on 4/28/25 a new skin issue/concern for Resident #31 was identified on the 3:00 PM to 11:00 PM shift as a right heel open area and that the on-call Advanced Practice Registered Nurse (APRN) and supervisor were notified.An on-call APRN progress note dated 4/28/25 at 6:17 PM identified Resident #31 had a chief complaint of a pressure wound. The summary identified a right heel open area measuring 2.0 centimeters (cm) by 2.0 cm, that a scab fell off and follow-up with wound care in the morning. Additionally, the note failed to recommend any type of treatment to the right heel.An on-call APRN order dated 4/28/25 at 6:17 PM directed follow up with wound care in the morning and notify a clinician of any changes in condition. Additionally, the order failed to recommend any type of treatment to the right heel.A nursing note dated 4/28/25 at 7:32 PM identified Resident #31 had an open wound to the right heel measuring 2.0 cm by 2.0 cm, the on-call APRN was made aware, resident to be seen by the wound care team the next day, the resident's family member was made aware with a request for a follow up call from the wound care team, but no treatment was ordered.A Resident Care Plan meeting note dated 4/29/25 at 4:15 PM identified Resident #31 had a wound on right heel and was to be seen by the wound care team.The Resident Care Plan dated 5/1/25 identified Resident #31 had the potential for skin breakdown due to decreased mobility and incontinence. Interventions included offloading heels when in bed as tolerated by the resident, pressure redistribution cushion, pressure redistribution mattress, skin checks with care, turn and reposition every two to three hours as tolerated by resident, and weekly skin evaluations.A wound care specialist progress noted dated 6/6/25 (39 days after the physician order dated 4/28/25 to follow up with wound care in the morning) at 9:40 PM identified Resident #31 was seen as a consultation for evaluation of a right heel ulcer. The wound assessment identified a Stage two pressure ulcer to the right heel with a size of 0.9 cm by 0.3 cm by 0.2 cm and calculated area of 0.27 square cm. Additionally, the note identified the wound status as new. A treatment order was started directing staff to cleanse right heel with normal saline and apply collagen and kerlix every day on evening shift and as needed (39 days after the development of the right heel wound). Although weekly skin assessments had been completed, review of skin and wound total body skin assessments dated 4/3/25, 4/10/25, 4/17/25, 4/24/25, 5/1/25, 5/18/25, 5/22/25, 5/29/25, and 6/5/25 identified no new wounds (despite Resident #31 developing a pressure ulcer to the right heel on 4/28/25).Interview and record review with Infection Prevention Registered Nurse (RN) #2 on 6/26/25 at 10:32 AM identified that for a new wound, the APRN, resident family member, and wound care team would be contacted and that any nurse can make contact. The wound care specialist was at the facility weekly and was responsible for weekly tracking/assessments. Additionally, review of the clinical record with RN #2 identified that Resident #31 was not seen by the wound care team until 6/6/25 (39 days after the APRN order) and that was the reason weekly tracking/assessments and wound care orders were not initiated on 4/28/25. Additionally, RN #2 identified that she was responsible for monitoring wounds in the facility but was not made aware of Resident #31's heel wound until 6/6/25 (39 days after the development). RN #2 indicated that if they were made aware then she would have tracked the wound in coordination with the wound care team. Interview with RN #4 on 6/26/25 at 10:55 AM identified that while performing care for Resident #31, an open area to the right heel was identified on 4/28/25. RN #4 indicated that she made the on-call APRN aware and entered a progress note with her findings. Additionally, RN #4 indicated that the finding was provided during report to the oncoming shift and that the finding was entered into the skin assessment binder which she understood to be an additional reporting tool to the wound care team when they come to the facility.Interview and record review with the DNS and Administrator on 6/26/25 at 3:15 PM identified that the facility policy for transcription of orders was that when an order was given, whether over the phone, verbal or paper, the nurse or supervisor can input those orders into the electronic health record. The DNS and Administrator indicated that the skin observation binder was no longer in use as a communication tool and did not know why it was still on the unit. Additionally, it identified that the physician order for Resident #31 to follow up with the wound specialist from the on-call agency was scanned into the documents folder in Resident #31's electronic health record and not inputted into the orders section which was how staff identify orders. The interview identified that by the order not being transcribed properly into Resident's #31 chart, that was the reason the resident was not seen by wound care as ordered.Interview with the DNS on 6/30/25 at 10:46 AM identified that the policy for treatment of new wounds was that orders for treatment should be put into the electronic health record upon finding of the new wound. The DNS indicated it was the responsibility of the nurse who finds the wound to input the orders. The interview failed to identify the reason the orders were not inputted.Review of the wound treatment protocols policy dated July 2023, identified that after assessment of a new pressure ulcer, a wound evaluation of each wound identified will be completed weekly until resolved.Review of the transcription of orders policy dated January 2024, identified that orders from an authorized licensed independent practitioner are accepted by an RN or Licensed Practical Nurse (LPN) and are considered but not limited to medications, labs, diagnostics, and consultations. Additionally, it identified that the procedure for the transcription of orders is to follow the Point Click Care (PCC) business process.

Based on clinical record review, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 44) reviewed for unnecessary medications, the facility failed to ensure that a comprehensive care plan was developed for a resident with a recent history of smoking/vaping and issues with smoking contraband. The findings include: Resident # 44 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, and failure to thrive.A Hospital Discharge summary dated [DATE] identified Resident #44 was transferred to the facility on 3/1/25 following hospitalization, had a prior history of vape use, and recent tobacco use which included smoking a 1/2 pack of cigarettes (10 or more cigarettes) per day.The nursing admission assessment dated [DATE] at 9:47 PM identified that Resident #44 had an unknown history of smoking or tobacco use.A nursing note dated 3/1/25 at 10:00 PM identified Resident #44 was found to have 2 vape devices in his/her possession upon admission to the facility. The note identified that Resident #44 had one pink, and one green vape device which he/she stated belonged to his/her late spouse. The nursing note further identified that the vape devices were removed from the resident and stored in a safe place. Review of the clinical record failed to identify any documentation related to smoking assessments on or after 3/1/25 and subsequent to the vape devices being found.Review of Resident #44's care plans from 3/1/25 to current failed to identify a care plan had been developed for Resident #44's history of vaping or interventions related to Resident #44's prior history of vape use, recent tobacco use, or vape devices observed on admission by facility staff on 3/1/25The 5-day Minimum Data Set (MDS) dated [DATE] identified Resident # 44 had intact cognition, was always incontinent of bowel, frequently incontinent of bladder, and was dependent on staff for assistance with bathing, dressing, and toileting. Review of the clinical record identified Resident #44 was hospitalized from [DATE] related to atrial flutter and returned to the facility on 4/3/25. A nursing note dated 4/3/25 at 2:39 PM identified Resident #44 reported difficulty breathing, had an oxygen saturation of 76%, was subsequently transferred back to the hospital and admitted to the hospital from [DATE] to 4/12/25 for acute hypoxic respiratory failure. Review of the hospital discharge documentation dated 4/12/25 identified Resident #44 as a smoker who had smoked 3 packs of cigarettes per day since his/her teenage years. Review of Resident #44's care plan failed to identify the care plan was comprehensive to include Resident #44's history of vaping and tobacco use following readmission to the facility on 4/12/25 and therefore no interventions were in place.An APRN progress note dated 4/17/25 and written by APRN #1 identified Resident #44 was observed at the nurse's station with 'another' vape in his/her hand. APRN #1 identified that the vape device was given to a nursing supervisor, and that the importance of not smoking or vaping had been consistently discussed with Resident #44. Upon entrance to the facility on 6/23/25 as part of an annual recertification survey, the facility identified that it was a non-smoking facility following a change of ownership on 10/10/24 and identified that residents in the facility who were smokers at the time of the change had been grandfathered in and provided list of identified residents. Review of the facility list of residents grandfathered into smoke failed to identify Resident #44.Interview with the DNS on 6/26/25 at 4:00 PM identified that Resident #44's care plan should have included a previous history of smoking/vaping.The facility policy on Baseline/Comprehensive Person-centered Care plan directed that the interdisciplinary team would utilize the comprehensive person-centered care planning process to address the residents strengths, needs, and or problems as identified on the admission and discharge summary, as well as other professional assessments and orders from the health care provider, dietary team, therapy, social services and PASARR and MDS. The person-centered care plan was developed to include information necessary to properly care for the resident and would address the resident's preferences, goals, desired outcomes and plan for discharge.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #33) reviewed for mistreatment, the facility failed to ensure an allegation of rushed and rough care which potentially caused a left hand bruise was thoroughly investigated. The findings include:Resident #33's diagnoses included atrial fibrillation, anxiety, and chronic idiopathic constipation.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was moderately cognitively impaired, had no physical/verbal symptoms directed toward others, and had no behavior of rejection of care. The MDS assessment also identified Resident #33 was dependent for toileting hygiene and required substantial/maximal assistance with lower body dressing and bed mobility.The Resident Care Plan (RCP) dated 6/5/25 identified Resident #33 had the potential for verbal aggression related to mental/emotional illness, poor impulse control, and was inclined to yell and scream at the staff. Interventions included to give Resident #33 as many choices as possible about care and activities and when Resident #33 was noted to be aggressive, staff were to leave/redirect and reapproach at a later time. The RCP further identified Resident #33 had the potential for verbal expressions of distress and/or persistent anger with self or others. Interventions included conversing with the resident during care, use a calm, gentle approach, and if Resident #33 refuses/resists care, honor requests and attempt at a later time.A facility Reportable Event form dated 6/16/25 for the 3:00 PM to 11:00 PM shift identified Resident #33 was noted with a bruise to the left hand and Resident #33 stated he/she hit the Nurse Aide (NA) during care. The Reportable Event form further identified Resident #33 was not sure if he/she hit the NA or the siderail when he/she obtained the bruise, further indicating the NA was laughing at him/her and rough.A Facility Summary Report dated 6/18/25 identified upon facility investigation, Resident #33 was interviewed by the DNS and Administrator. The Summary Report identified Resident #33 reported that the NAs came into the room to do care, and he/she was hitting the staff with his/her hands back and forth in the air. The report identified Resident #33 was unsure if he/she got bruised by hitting the staff or the side rail and further indicated the NA was laughing at him/her and rough. The report identified there were 2 staff members (NA #6 and NA #7) present in the room for care and both staff were interviewed. Both NAs stated Resident #33 was hitting and cursing at them, and both NAs reported they stopped care and explained to Resident #33 that he/she was soiled. The report identified Resident #33 stopped hitting the NAs, care resumed and the NAs stated they had sped up care to avoid further agitation of Resident #33. The report identified both NAs denied making fun of Resident #33 or being rough with care and the facility was unable to substantiate any mistreatment towards Resident #33.Interview with the DNS on 6/30/25 at 1:25 PM identified she had completed the investigation for the allegation of abuse for Resident #33 and her process for investigation of an allegation of abuse was after determining the cause of the allegation she interviewed all staff working the shift when the event occurred, spoke with the resident involved, the family, the APRN, and the roommate if the resident resided in a double room. The DNS further identified Resident #33 was able to recall and provide the names of the 2 NAs that he/she indicated had mistreated him/her, that she interviewed Resident #33, and had interviewed Resident #20 (Resident #33's roommate) who had told her the same story as Resident #33 so she didn't include Resident #20's interview in her investigation.Review of the facility accident and incident investigation documentation identified signed statements by NA #6, NA #7, and the DNS.Review of the facility investigation documentation failed to identify a resident witness interview (roommate/Resident #20) dated, documented, and signed by the nursing supervisor or designee.Review of the facility investigation documentation failed to identify interviews with relevant staff on that unit with written statements that were dated and signed. NA #4, NA #5, Licensed Practical Nurse (LPN) #4, and LPN #5 were working on that unit on the 3:00 PM to 11:00 PM shift on 6/15/25 and their statements were not within the investigation documentation.Review of the facility investigation documentation failed to identify documentation of statement from NA #3 who was informed by Resident #20 and Resident #33 of the incident the morning of 6/16/25 and who observed the bruise to Resident #33's left hand and reported it. Review of the Abuse Policy & Procedure directed, in part, mistreatment would include not following the assignment resulting in potential or actual harm to the resident. The policy directed staff training should include appropriate interventions to deal with aggressive reactions of residents. The policy directed that any suspicion of resident abuse was to be thoroughly investigated and reported and the facility investigation would be completed within 5 days of the incident. The policy directed the investigation would include: interview resident or other resident witnesses that are dated, documented, and signed by supervisor/designess, interview of implicated staff member(s) with documentation of their version of the event signed and dated, interview of staff witnesses and any relevant staff that are dated and signed.

Based on clinical record review, observations, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #44) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure a PASRR Level II assessment was completed following an exempted short term approval for a resident with a suspected serious mental illness. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and bipolar disorder.A Notice of PASRR Level I screen outcome dated 3/5/25 identified Resident #44 had a suspected or had been diagnosed with a serious mental illness and received a 7 day emergency short term post hospital discharge approval for Level I. Recommendations included a re-screen for Level I screen and, as necessary, a Level II evaluation on or before the 7th day if the individual was to remain in the nursing facility.The discharge Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was discharged to an acute care hospital with an anticipated return.The PASRR episode tracker dated 3/14/25 identified Resident #44 was referred for a Level II evaluation and was subsequently cancelled by the screening authority on 3/17/2.A review of the facility census identified Resident #44 was re-hospitalized [DATE], readmitted back to the facility on 4/3/25 then subsequently discharged back to the hospital from [DATE] to 4/12/25.The PASRR episode tracker dated 3/17/25 to 6/23/25 failed to identify a Level II PASSRR was completed following readmission to the facility on 4/12/25.An interview with Social Worker (SW) #1 on 6/24/25 at 3:03 PM identified she was responsible for tracking and ensuring the completion of Level I and Level II PASRR evaluations for newly admitted residents and changes thereafter. SW #1 identified that a PASRR Level II was requested for Resident #44 for 3/14/25. However, Resident #44 was discharged to the hospital on 3/13/25 resulting in the cancellation of the assessment on 3/17/25. SW #1 indicated she did not follow up on referring Resident #44 for a Level II evaluation upon readmission to the facility from the hospital as an oversight.An interview with the DNS on 6/30/25 at 2:44 PM identified she would expect PASRR referrals to be completed as recommended.Although requested, a policy related to PASRR referrals was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #35) reviewed for unnecessary medications, the facility failed to ensure that weekly weight monitoring was completed timely. Additionally, for 1 of 5, (Resident #44) reviewed for activities of daily living (ADL), the facility failed to re-evaluate the continued use of mobility equipment and plan of care for its continued use following the removal of a motorized chair. The findings include:1.Resident # 35 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and heart failure.A hospital Inter-Agency Referral (W-10) document dated 4/2/25 identified Resident #35 was hospitalized from [DATE] to 4/2/25 for acute and chronic respiratory failure. The hospital documentation identified that Resident #35 was discharged to the long-term care facility on 4/2/25 with medication orders to continue Furosemide (a diuretic medication used for fluid buildup in heart failure) 40 milligrams (mg) daily, and a new medication order for Acetazolamide 250 mg (a medication used for fluid buildup) twice weekly.A physician's order dated 4/4/25 directed Furosemide 40 mg daily for heart failure and Acetazolamide 250 mg twice weekly on Monday and Friday to reduce fluid buildup.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 had intact cognition, was always incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The Resident Care Plan dated 4/4/25 identified Resident #35 had a history of heart failure that required prescribed diuretic medication with interventions that included to monitor weights as ordered.A review of the clinical record identified that on 5/12/25, Resident #35 weighed 356.5 lbs. Further review of the clinical record identified that on 6/2/25, Resident #35 weighed 365.3 lbs. (a weight gain of 8.8 lbs. or 2.46% over 3 weeks).An APRN order dated 6/2/25 written by APRN #1 directed to obtain weekly weights for 4 weeks beginning on 6/11/25.Review of the June 2025 Medication Administration Record (MAR) and weight record failed to identify any weekly weight documentation until 6/19/25 (8 days after the APRN order for weekly weights).A review of the clinical record identified that on 6/19/25, Resident #35 weighed 399.1 lbs. (a weight gain of 33.8 lbs. or 9.25% since 6/2/25 (17 days)). Further review of the clinical record identified APRN #1 was notified of the weight gain on that date.Interview with the DNS on 6/26/25 at 4:00 PM identified that Resident #35 routinely refused weight monitoring, and that nursing staff may have forgotten to document a refusal in the clinical record.Interview with APRN #1 on 7/1/25 at 9:35 AM identified that Resident #35 had a history of heart failure, respiratory failure, and fluid retention and she was aware of Resident #35's recent weight gain. APRN #1 identified she would expect the facility nursing staff would follow the provider's orders related to weight monitoring.Review of the clinical record failed to identify any documentation related to Resident #35's refusals of weight monitoring.Review of the clinical record failed to identify any care plans or interventions related to Resident #35's refusals of weight monitoring.The facility policy on weight directed that weights would be obtained and recorded. The policy further directed that residents experiencing significant weight changes may require weekly weights.The facility policy on weight policy and procedures directed that residents with significant unintended weight changes would be added to weekly weights for 4 weeks or until weight stabilizes as determined by the IDT. The policy further directed that significant weight changes would have verification of weight measurement for accuracy and documentation purposes, and that significant weight changes included 5 % in 30 days, 7.5% in 90 days, or 10% in 180 days.2a. Resident #44 diagnoses included deep vein thrombosis of the left lower extremity and recent history of pneumonia.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 was cognitively intact, required one person assist with bed mobility/transfers and mobilized with the use of a manual wheelchair and assist of one.The Resident Care Plan (RCP) dated 5/3/25 identified Resident #44 had a deficit in functional mobility and was non ambulatory. Interventions included ambulation with rehabilitation staff only and assist of two with transfers.An Occupational Therapy note dated 5/3/25 identified Resident #44's personal power chair was brought to the building where Resident #44 was assessed for safety with operation. Resident #44 was provided education in maintaining the slowest speed while in the building due to frequent obstacles and other residents. Further assessment and training were required to clear Resident #44 for independent use of the power chair. An Occupational Therapy note dated 5/5/25 identified Resident #44's personal power chair was assessed for safety. Resident #44 was able to drive from his/her room to the nurse's station, to the elevator and gym and back with intermittent cues for safety. Resident #44 was cleared for use of the power chair on the unit only. Resident #44 was to be assessed for further clearing to go off the unit with the chair.An Occupational Discharge summary dated [DATE] identified Resident #44's electric wheelchair was brought into the facility and currently not cleared for use. Recommendations included assist of one with activities of daily living (ADLs) and assist of one with transfers with no restorative/functional maintenance program established.A review of physician progress notes, nursing progress notes, rehabilitation notes and care plans dated 5/5/25 through 6/22/25 failed to identify a rationale for the removal of the motorized chair, a re-evaluation for safety and plan of care for continued use.b. Resident #51 had diagnoses that included chronic kidney disease and diabetes Type II.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 was moderately cognitively impaired and independent with mobility with the use of a wheelchair.The Resident Care Plan dated 4/28/25 identified Resident #51 had a self-care deficit with interventions that included to provide assistance of one with bed mobility and transfers.A facility Reported Event form dated 5/6/25 at 10:15 PM identified Resident #51 complained of right foot pain following an unwitnessed event where another resident accidentally ran over his/her foot while both were self-propelling in their wheelchairs at the same time. The resident representative and physician were notified. X-rays were obtained that identified no fractures. No predisposing environmental or situational factors were identified that contributed to the fall.An investigation statement dated 5/7/25 identified Resident #44 stated he/she accidentally ran over the foot of another resident while they were both moving at the same time. It was explained to the resident in order to ensure he/she was able to move around the nursing station in the wheelchair (safely), therapy would evaluate Resident #44 driving the wheelchair.An interview with Resident #44 on 6/24/25 10:25 AM identified he/she had a motorized wheelchair that was removed after another resident put his/her foot in front of Resident #44's chair during operation. Resident #44 asked the Director of Rehabilitation on multiple occasions about the return of his/her chair and was told he/she was not getting the chair back but did not give a reason.An interview and clinical record review with the Director of Rehabilitation on 6/25/25 at 11:54 AM identified a motorized personal chair belonging to Resident #44 was brought into the facility. Operation of the chair was evaluated on 5/3/25 and 5/5/25 where it was determined Resident #44 could safely operate the chair on the unit only with recommendations for further training before safe operation off the unit. Subsequently, an incident occurred where Resident #44 may have come into contact with another resident while operating the motorized chair. As a result, the chair was removed from Resident #44 by nursing. The Director of Rehabilitation identified that while the decision for continued use of the chair was interdisciplinary, rehabilitation services were responsible for re-evaluating Resident #44's ability to safely use the motorized chair and was unable to provide an explanation why any formal re-evaluation had been completed following the removal of the motorized chair. The Director of Rehabilitation further identified he discussed the return of the chair with the DNS at Resident #44's request but was told more time was needed without a plan of care for restoration.An interview with the DNS on 6/25/25 at 12:38 PM identified for any safety concern related to the use of motorized adaptive equipment for mobility would be referred to rehabilitation services for evaluation. The DNS indicated nursing staff observed unsafe use of the motorized scooter including driving fast and running into objects. Based on these observations, a rehabilitation evaluation should have been completed to determine if additional training and education was needed and any plan of care for its continued use.An interview and clinical record review with Occupational Therapist (OT) #1 on 6/25/25 at 1:46 PM identified on 5/5/25, he assessed Resident #44 for safe use of the motorized chair and cleared him/her for operation on the unit only. Nursing subsequently indicated they did not want Resident #44 to use the chair. OT #1 identified he would normally re-evaluate the continued use of the chair but was not directed to do so in this case. According to OT #1, Resident #44 was agreeable with the decision but was crying when told he/she would not have use of his/her chair.A review of the facility policy for Therapy Services directs that admissions to rehabilitation services will be made by appropriate credentialed therapists according to the patient's needs and in accordance with federal, state, and facility requirements. Patients are identified through the screening process or evaluated without the screening process if the interdisciplinary team identifies a significant change in medical or functional condition. If appropriate for rehabilitation intervention, a physician's order for therapy will be obtained to proceed with the appropriate evaluation. Upon receipt of the physician's order, the evaluation will be completed within 48 hours. The treatment plan should be entered into the resident care plan.

Based on review of the clinical record, staff interviews, and facility policy for 1 of 4 residents (Resident #102) reviewed for activities of daily living (ADL), the facility failed to refer resident to physical therapy (PT) and occupational therapy (OT) after identifying a decline in ADLs. The findings include:Resident #102's diagnoses included unspecified Alzheimer's disease, functional quadriplegia, and weakness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 was severely cognitively impaired and required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, and partial to moderate assistance with personal hygiene.The quarterly MDS assessment dated [DATE] identified Resident #102 was severely cognitively impaired and dependent on staff for eating, oral hygiene, and personal hygiene (a decline from the 1/29/25 quarterly MDS).The Resident Care Plan dated 5/19/25 identified Resident #102 had a deficit in self-care related to cognitive loss and decreased mobility. Interventions included resident was dependent on eating/feeding with 1 facility staff helping complete the activity and resident was dependent on personal hygiene/oral care with 2 facility staff helping complete the activity.Physican orders for the month of May 2025 failed to identify orders for physical therapy/occupational therapy (PT/OT) to assess/address Resident #102's decline in status.Interview and record review with the MDS Coordinator Registered Nurse (RN) #5 on 6/30/25 at 9:41 AM identified that Resident #102 had a decline in ADL's assessed at the quarterly MDS on 5/1/25. RN #5 indicated that if a resident had a decline in ADL's, orders should be input for referral to PT and OT. RN #5 identified that it was the responsibility of the MDS Coordinator to ensure referrals for PT/OT were input after a decline was identified and could not provide a reason a PT/OT referral was not completed.Interview with the Director of Rehabilitation on 6/30/25 at 10:07 AM identified that they would expect to receive a referral and assess a resident who was identified as having a decline in ADLs. The interview identified that they receive notice of resident decline and referrals through paper reports, orders in the electronic health record, and morning report. Additionally, the interview identified the last time Resident #102 was seen by PT or OT was in January 2025 and that with the decline documented in the quarterly MDS dated [DATE], Resident #102 should have been referred to PT and OT.Review of the therapy admissions policy dated 1/2018 identified admissions to rehabilitation services will be made by appropriately credentialed therapists according to the patient's needs. Additionally, it stated patients are identified through the screening process or can be evaluated without the screening process if the interdisciplinary team identifies a significant change in medical and/or functional condition.

Based on clinical record review, observations, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #67) reviewed for choices, the facility failed to ensure a meal was provided according to preference and served in a timely manner. The findings include:Resident #67 had diagnoses that included chronic kidney disease and calculus of the gallbladder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was cognitively intact and independent with eating.The Resident Care Plan dated 5/19/25 identified Resident #67 with a nutritional diagnosis of obesity with limited mobility. Interventions included providing the diet as ordered and honoring the resident's food/beverage preferences.Physician orders dated 5/30/25 directed a 2 gram (GM) Sodium (2 GM Na+) diet, regular texture with thin (no thickening agent required) consistency fluids.An interview with Resident #67 on 6/23/25 at 11:04 AM identified he/she cannot have salt or milk as it caused gastrointestinal symptoms and the concern was discussed with dietary staff. However, Resident #67 continued to receive food items with milk or that were salty.The facility menu dated 6/24/25 identified a main lunch meal of garlic herb pork loin/marinated chicken, garlic mashed potatoes and steam vegetables with a white dinner roll with butter.A lunch meal ticket dated 6/24/25 for identified Resident #67 ordered 1 serving of scrambled eggs, 1/2 cup penne pasta and 1 dinner roll with butter.A subsequent observation on 6/24/25 at 12:43 PM identified Resident #67 received garlic herb pork loin, garlic mashed potatoes and steam vegetables for lunch (not the scrambled eggs, penne pasta and dinner roll with butter as Resident #67 requested).An interview with Resident #67 on 6/24/25 at 12:43 PM identified Resident #67 was not served any eggs with the lunch meal and instead, NA #8 served pork with mashed potatoes. Resident #67 refused the meal and requested NA #8 to prepare a personal soup kit, but she never returned.An interview and photographic image review of the meal with NA #8 on 6/24/25 at 2:40 PM and 6/30/25 at 10:59 AM identified she would contact the kitchen to request any food items for residents who report not receiving what was ordered. NA #8 identified meal ticket selections were to be verified before serving resident meal trays. NA #8 served Resident #67 the lunch meal tray on 6/24/25 but only verified the name and room number without also verifying the meal choice. NA #8 indicated Resident #67 reported to her that he/she did not receive eggs as ordered, however, NA #8 did not contact the kitchen to obtain an alternate meal according to resident preference as Resident #67 requested she prepare a personal soup kit instead. NA #8 further identified she had not yet prepared and served the soup to Resident #67, (approximately two hours after the request) as she was toileting other residents.An interview with the Food Service Director (FSD) on 6/30/25 at 8:21 AM identified meal tickets were to be verified at the time they were plated in the kitchen and when dietary staff bring to the units.An interview with the Administrator on 6/30/25 at 8:23 AM and 6/30/25 at 8:23 AM identified once the meal trays were on the units, nurse aide staff were expected to verify meal tickets before serving to the residents. The Administrator indicated meals should be provided according to preference and served in a timely manner.Although requested, a policy for the provision of meal according to preference was not provided.Although requested, a policy for verifying resident meal choices was not provided.

Based on clinical record review, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 44) reviewed for unnecessary medications, the facility failed to ensure that a resident with recent history of tobacco use was assessed for smoking upon admission and re-admission to the facility; and failed to ensure that the resident was free of smoking materials within the facility; and failed to ensure interventions were in place following the identification of smoking/vaping materials within the facility. The findings include:Resident # 44 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), diabetes, and failure to thrive. A hospital Discharge summary dated [DATE] identified Resident #44 was transferred to the long term care facility on 3/1/25 following hospitalization. The hospital discharge summary further identified Resident #44 had a prior history of vape use, and recent tobacco use which included smoking a 1/2 pack of cigarettes (10 or more cigarettes) per day.The nursing admission assessment dated [DATE] at 9:47 PM identified that Resident #44 had an unknown history of smoking or tobacco use.A nursing note dated 3/1/25 at 10:00 PM identified Resident #44 was found to have 2 vape devices in his/her possession upon admission to the facility. The nursing note identified that Resident #44 had one pink, and one green vape device which he/she stated belonged to his/her late spouse. The nursing note further identified that the vape devices were removed from the resident and stored in a safe place. Review of the clinical record failed to identify any documentation related to smoking assessments initiated or completed for Resident #44 on or after 3/1/25.Review of the Resident Care Plans failed to identify any care plans or interventions related to Resident #44's prior history of vape use, recent tobacco use, or vape devices observed on admission by facility staff.The 5-day Minimum Data Set (MDS) dated [DATE] identified Resident # 44 had intact cognition, was always incontinent of bowel, frequently incontinent of bladder, and was dependent on staff for assistance with bathing, dressing, and toileting.Review of the clinical record identified Resident #44 was hospitalized on [DATE] for anemia and atrial flutter and returned to the facility on 4/3/25. A nursing note dated 4/3/25 at 2:39 PM identified Resident #44 reported difficulty breathing, had an oxygen saturation of 76%, and was subsequently transferred back to the hospital. Review of the clinical record identified Resident #44 was subsequently re-hospitalized from [DATE] through 4/12/25 for acute hypoxic respiratory failure. Review of the hospital Discharge summary dated [DATE] identified Resident #44 as a smoker who had smoked 3 packs of cigarettes per day since his/her teenage years. Review of the clinical record failed to identify any documentation related to smoking assessments initiated or completed on or after 4/12/25.Review of the Resident Care Plans failed to identify any revisions or interventions related to Resident #44's history of vaping and tobacco use following readmission to the facility on 4/12/25.An APRN note dated 4/17/25 written by APRN #1 identified Resident #44 was observed at the nurse's station and that she observed Resident #44 with 'another' vape in his/her hand. APRN #1 identified that the vape device was given to a nursing supervisor, and that the importance of not smoking or vaping had been consistently discussed with Resident #44. Review of the clinical record failed to identify any additional documentation related to counseling or education provided to Resident #44 related to smoking or vaping.Review of the clinical record failed to identify any documentation related to smoking assessments initiated or completed on or after 4/17/25.Upon entrance to the facility on 6/23/25 as part of an annual recertification survey, the facility identified that it was a non-smoking facility following a change of ownership on 10/10/24 and identified that residents in the facility who were smokers at the time of the change had been grandfathered in and provided list of identified residents. Review of the facility list of residents grandfathered into smoke failed to identify Resident #44.Interview with the DNS on 6/26/25 at 4:00 PM identified that Resident #44 had not had any recent smoking or vape use in the facility and that Resident #44 had only been found to have a single vape device which the facility had confiscated on initial admission to the facility on 3/1/25. The DNS identified that Resident #44 had a visitor at the facility who initially provided the vape device on 3/1/25 and the visitor had been instructed that the device was not allowed in the facility. The DNS then identified that the visitor had brought the device in and out of the facility on multiple occasions. The DNS identified that APRN #1 had contacted her regarding the vape device on 4/17/25 and that facility nursing staff reached out to Resident #44's visitor to remove the device from the facility. The DNS identified the vape device observed by APRN #1 on 4/17/25 was the same device that was observed on 3/1/25. The DNS identified that Resident #44 had no recent history of smoking, had not been observed using the vape devices, and therefore she did not complete an investigation regarding the issue. The DNS also identified that Resident #44 was cognitively impaired on 4/17/25 at the time that APRN #1 identified the vape device in Resident #44's hand and she believed that was why Resident #44 continued to have the vape device in the facility. The DNS identified that Resident #44's care plan should have included a previous history of smoking however the DNS did not feel there were any issues smoking assessments due to Resident #44's cognitive impairment issues and Resident #44's sentimental attachment to the vape device. The DNS also identified she did not feel that any investigations should have been completed following the documentation in the clinical record regarding 3 separate vape device incidents and Resident #44's history of smoking 10 or more cigarettes per day as of 1/22/25 as she did not feel there was an issue.Interview with APRN #1 on 7/1/25 at 9:35 AM identified that she was aware of a prior incident on 3/1/25 related to Resident #44 being found with 2 vape device prior to 4/17/25. APRN #1 identified that her understanding was that the vape devices had sentimental meaning to Resident #44 and that Resident #44 had not been observed using the devices in the facility but just holding them. APRN #1 also identified that Resident #44 was a prior smoker and had not smoked in some time prior to admission to the facility. APRN #1 identified that the DNS advised her that a visitor of Resident #44 had been bringing a vape device into the facility but was unable to provide specifics and identified any information regarding this did not pertain to her. APRN #1 also identified that she and the DNS had open communication but was unable to a specific discussion via phone with the DNS on 4/17/25 and identified that Resident #44 was cognitively intact with no issues related to confusion or impairment on 4/17/25 when she discussed the vape device with the resident.Review of the clinical record failed to identify any documentation related to any issues identified by the DNS related Resident #44 and vape devices being brought into the facility by a visitor. The clinical record also failed to identify any documentation related to any education to Resident #44 or any of Resident #44's visitors regarding smoking or vape devices.The facility policy on charting and documentation directed that documentation in the clinical record would include the medical plan of treatment, assessment, evaluations, interventions, responses to care and treatment by multiple health care providers, or identification of significant changes, accidents, or unusual occurrences that may impact the residents physical or emotional well-being. The policy also directed the purpose was to provide a complete account of the residents total stay at the facility from admission through discharge, and provide information about the resident that would be used in developing a plan of care and as a tool of measuring the quality of care provided to the resident.The facility policy on Safe Smoking directed that facilities that allowed smoking would accommodate residents who choose to smoke including electronic devices within a framework structured to ensure the resident's safety and well-being as well as the safety and well-being of other residents. The policy directed that a facility could elect to become non-smoking which would include electronic cigarettes and vape devices, and new admissions to the facility would be informed of the facility policy prohibiting smoking and would be offered smoking cessation support. The policy also directed that a smoking evaluation would be completed on all residents who smoke including residents who use E cigarettes and bait pens at the time of admission and readmission, with significant changes in medical status, and with a change in the resident smoking status. The policy also directed that a smoking care plan would be added to the resident's clinical record. The policy also directed that residents who were non-compliant with the smoking policy would be reevaluated by the interdisciplinary team. The interdisciplinary team would develop new interventions to ensure the safety of the residents and other residents and that the new interventions along with the facility smoking policy would be reviewed with the resident.The policy directed that any resident who exhibited unsafe smoking behavior put themselves and or other residents at risk. The policy directed that those residents may have their room or belonging search with the residence permission only after obtaining the health care providers order to do so and that the resident would be re educated on the smoking policy and safety hazards of not adhering to the policy. The policy also directed that new interventions would be added to the residence plan of care to ensure that safety measures were in place period.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #103) reviewed for choices, the facility failed to support a resident's choice related to assistance with oral care. The findings include:Resident #103 had diagnoses that included hemiplegia (paralysis)and hemiparesis (muscle weakness) following a stroke affecting the left side, Moyamoya disease, and cognitive communication deficit.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #103 was moderately cognitively impaired and the behavior of rejection of care was not exhibited. The MDS assessment also identified Resident #103 required setup or clean-up assistance with oral hygiene, was dependent with personal hygiene, and required substantial/maximal assistance with bed mobility.The Resident Care Plan (RCP) dated 5/27/25 identified Resident #103 required assistance with activities of daily living (ADL) care and mobility related to a significant stroke resulting in left side hemiplegia. Interventions included oral care 2 times a day as needed, treatment for dry mouth per physician order, and assistance with bed mobility.Interview with Person #1 on 6/23/25 at 1:32 PM and 6/24/25 at 12:04 PM identified Resident #103 wanted to brush his/her teeth (oral care) 2 times a day and required setup to complete this task but staff were not assisting with setup of the necessary supplies 2 times a day. Person #1 identified that Resident #103 often reported to him/her that nursing staff had not assisted him/her with setup of the toothbrush and supplies. Person #1 identified that a concern related to Resident #103 receiving assistance with oral care had been brought up with the facility administrator and nursing staff on multiple occasions, but the assistance was still not consistently being provided 2 times a day. Person #1 identified he/she had placed a sign on the wall in Resident #103's room with instructions on how Resident #103 preferred to be setup for oral care but stated that the sign didn't help. Person #1 identified Resident #103 required 3 cups of water and his/her toothbrush with a small amount of toothpaste applied to the bristles. Person #1 identified that if the proper supplies were provided, Resident #103 could brush his/her teeth, rinse his/her mouth, and rinse his/her toothbrush without additional staff assistance until he/she required clean-up of the supplies. Person #1 further identified the nursing staff were not providing setup of these supplies 2 times a day as Resident #103 preferred.Interview with Resident #103 on 6/25/25 at 12:00 PM identified he/she had not been assisted with brushing his/her teeth yet today. Interview with Nurse Aide (NA) #1 on 6/25/25 at 12:05 PM identified that she had assisted Resident #103 with brushing his/her teeth by setting Resident #103 up with an emesis basin, toothbrush, and a couple cups of water.Interview with NA #1 on 6/25/25 in Resident #103's room with Resident #103 at 12:10 PM identified the toothbrush she stated she had provided Resident #103 that morning was not the toothbrush that Resident #103 uses. NA #1 identified she had not known Resident #103's toothbrush was in the bathroom. NA #1 identified she assisted Resident #103 with brushing his/her teeth when she worked on the 7:00 AM to 3:00 PM shift and could not identify if she was aware of Resident #103's preference for brushing his/her teeth and the supplies preferred for this task, and acknowledged that she was aware of the sign on Resident #103's wall, but that she did not pay attention to the sign. NA #1 could not identify if the instructions were on the NA care card, was unable to locate the NA care card, and was unable to identify where to find the NA care card if it was not hanging within Resident #103's closet.Review of the NA care card dated 6/25/25 identified nursing staff were directed to provide Resident #103 oral care 2 times a day as needed, treatment for dry mouth per order. The NA care card failed to identify Resident #103's preference for assistance with oral care to be automatically provided 2 times a day without him/her having to request assistance, and the care card failed to identify directions of the oral care supplies Resident #103 prefers so he/she can perform oral care.Interview with Registered Nurse (RN) #1 6/25/25 at 3:00 PM identified she was not aware of who was responsible for ensuring the NA care cards were up to date with accurate information. RN #1 identified the information on the NA care cards was automatically generated from the physician orders and that she did not review them. RN #1 identified the NA care cards were located within through electronic medical record (EMR) platform, NAs could access them using their tablets, and it had been a long time since they were inside the resident closets. RN #1 identified she was not aware of signs in Resident #103's room placed by a family member to explain how and when Resident #103 would like assistance with oral care. RN #1 identified she was unaware how to enter resident specific care requests into the EMR so that it would be reflected on the NA care cards. RN #1 further identified Resident #103's oral care preferences should be included in his/her NA care card so that the nursing staff would see it, and RN #1 was unable to identify how the NAs would know to assist with oral care twice a day if it wasn't on the NA care card.Subsequent to surveyor inquiry, the NA care card was updated on 6/26/25 and identified a nursing staff were directed to provide Resident #103 with oral care 2 times a day with toothbrush and toothpaste, treatment for dry mouth per order. The revised care card failed to identify the 3 cups of water that Resident #103 requested to be provided for him/her to perform oral care.Review of the Activities of Daily Living (ADL) policy directed, in part, the purpose of the policy was to provide the level of care required by each individual resident. The policy directed staff provide assistance to complete all ADL activities per the person centered evaluation and care plan including personal hygiene and grooming.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1) reviewed for ADLs, the facility failed to ensure the clinical record was complete and accurate to include oral care provided and/or refused. The findings include: Resident #1's diagnoses included Parkinson's disease, dysphagia (difficulty swallowing) and a cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required set up assistance with oral hygiene. The Resident Care Plan (RCP) dated 4/9/2024 identified Resident #1 had forgetfulness/confusion at times due to dementia and Parkinson's. Interventions directed allow the resident to make daily decisions about clothing, daily care, meal alternatives, offer support/reassurance as needed. Review of nurse aide care card dated/revised 4/5/2024 directed set up for personal hygiene. Review of May 2024 ADL flowsheet indicated oral hygiene was not documented on the 3 PM to 11 PM or 7 AM to 3 PM shifts on 5/2, 5/3, 5/4, 5/10, 5/11 or 5/22/2024 and additionally was not documented as provided more than one time per day on an additional 14 out of 31 days. Interview and clinical record review with the DNS on 6/17/2024 at 2:15 PM identified the ADL flowsheets did not reflect the oral care was provided on 5/2, 5/3, 5/4, 5/10, 5/11 or 5/22/2024 and more than one time per day on an additional 14 out of 31 days. On 6/18/2024 at 3:04 PM interview and clinical record review with NA #2 identified that she was the NA assigned to Resident #1 on 5/2, 5/3, 5/4 and 5/10/2024. NA #2 stated she offered Resident #1 oral care and he/she refused care. She further indicated that she cannot document refused in the system and indicated that she notified the nurse. Interview and clinical record review with NA #1 on 6/18/2024 at 3:45 PM identified that on 5/3, and 5/10/2024 that she was the NA assigned to Resident #1 and she provided oral care. NA #1 indicated if she did not document then that was an oversight. Interview and clinical record review on 6/18/2024 at 3:17 PM with DNS identified that the NAs should have documented the care provided and staff should have documented if the care was offered and refused. The DNS state the electronic system did not allow for the NAs to document refusals, and there should be a corresponding nursing note to identify the refusals. The DNS was unable to provide documentation of the refusals for oral care on the dates listed. Review of the ADL flowsheet identified a Resident Refused option to be documented as RR. The DNS stated the facility was not using the RR code for documentation. Review of facility Documentation Policy directed in part, to document information related to the resident's condition and care provided in the resident's medical record.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #2) reviewed for dialysis, the facility failed to ensure transportation was scheduled timely for a resident who required dialysis treatments, and failed to maintain a dialysis communication book for a resident who required dialysis treatments. The findings include: Resident #2's diagnoses included end stage renal disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 2 was alert and oriented and required dialysis. The Resident Care Plan (RCP) dated 12/4/2022 identified that Resident #2 required hemodialysis. Interventions directed resident requires dialysis three (3) times per week, and facility to provide/schedule transportation. A physician order dated 12/27/2022 directed dialysis days: Monday, Wednesday, and Friday, AMR ambulance pick up at 10:10 AM via wheelchair to dialysis center. The nursing note dated 12/28/2022 at 4:31 AM identified the dialysis center called and indicated that since Resident #2 was positive for COVID-19, Resident #2 would need to be transported to dialysis at 10:00 AM via Veyo transport and not Valley Transit. The dialysis center directed the facility to call Veyo for the transportation and Resident #2 was notified. Review of clinical record failed to identify that Resident #2 received dialysis on Wednesday 12/28/2022. The nursing note dated 12/30/2022 at 4:41 PM identified Resident #2 was unable to go to dialysis due to transportation issues. APRN was notified that Resident #2's last dialysis session was on Monday and a new order was obtained to send Resident #2 to the hospital for evaluation and dialysis. Resident #2 and the responsible party were notified of the transfer to the hospital. Review of hospital History & Physical Report dated 12/30/2022 identified Resident #2 presented to the hospital due to missed two (2) dialysis treatments (12/28 and 12/30/2022), and was admitted with a diagnosis of COVID-19 and request nephrology consult for dialysis. Record review identified Resident #2 was not readmitted to the facility. Interview, clinical record review, and facility documentation review with the DNS on 6/17/2024 at 11:50 AM identified that Resident #2 missed two (2) scheduled dialysis treatments (12/28 and 12/30/2022) due to the transportation was not booked. The DNS stated the facility should have booked the transportation and was unable to explain why the transportation was not booked. Interview with Dialysis Provider #1 on 6/17/2024 at 12:25 PM confirmed the last dialysis treatment provided for Resident #2 was on 12/26/2022. The missed treatment on 12/28 was rescheduled to 12/29 and that was also missed, along with the scheduled treatment on 12/30/2022. Although attempted on 6/17/2024 at 12:51 PM, an interview with Veyo Transportation was not obtained. a. Record and facility documentation review failed to identify a dialysis communication book. Interview with the DNS on 6/17/2024 at 12:48 PM identified the facility empties the dialysis communication log monthly and was unable to provide a copy of the dialysis communication log for December 2022. Although requested, a facility policy was not provided for surveyor review regarding dialysis communication logs. Review of the facility Documentation policy directed in part all resident/patient record forms are kept in the resident's/patient's medical record.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for dialysis, the facility failed to ensure the physician was notified of a missed dialysis treatment timely. The findings include: Resident #2's diagnoses included end stage renal disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 2 was alert and oriented and required dialysis. The Resident Care Plan (RCP) dated 12/4/2022 identified that Resident #2 required hemodialysis. Interventions directed resident requires dialysis three (3) times per week, and facility to provide/schedule transportation. A physician order dated 12/27/2022 directed dialysis days: Monday, Wednesday, and Friday, AMR ambulance pick up at 10:10 AM via wheelchair to dialysis center. The nursing note dated 12/28/2022 at 4:31 AM identified the dialysis center called and indicated that since Resident #2 was positive for COVID-19, Resident #2 would need to be transported to dialysis at 10:00 AM via Veyo transport and not Valley Transit. The dialysis center directed the facility to call Veyo for the transportation and Resident #2 was notified. Review of clinical record failed to identify that Resident #2 received dialysis on Wednesday 12/28/2022. Additional review failed to identify the physician/APRN was notified of the missed dialysis treatment. Review of APRN note dated 12/29/2022 at 12:01 AM by APRN #1 identified although Resident #2 was seen for follow up for COVID-19, the note failed to identify APRN #1 was notified of the missed dialysis appointment on Wednesday 12/28/2022. Interview, clinical record review, and facility documentation review with the DNS on 6/17/2024 at 11:50 AM identified that Resident #2 missed the dialysis treatments on 12/28/2022 and was unable to provide documentation that the physician/APRN were notified. The DNS stated the facility should have notified the physician/APRN after the first treatment was missed on 12/28/2022. Interview with Dialysis Provider #1 on 6/17/2024 at 12:25 PM identified Resident #2 missed his/her dialysis treatment scheduled on 12/28 and it was rescheduled to 12/29/2022. Dialysis Provider #1 further stated that Resident #2 also missed the scheduled 12/29/2022 treatment. On 6/17/2024 at 1:10 PM interview and clinical record review with APRN #1 identified she was not notified Resident #2 missed his/her dialysis treatment on 12/28 and 12/29/2022. APRN #1 indicated if she was notified, she would have included that in her documentation note from her visit on 12/29/2022. Review of facility Condition: Significant Change Policy directed in part, staff will communicate with the physician regarding changes in condition to provide timely communication of resident/patient status change which is essential to quality care management. This notification shall be documented in the clinical record.

Based on observations and interviews of the third floor call bell system, the facility failed to ensure that the call bell system was audible at the call bell panel at the nurse's station and could be heard throughout the nursing unit. The findings include: Tour of the third floor on 4/16/24 at 9:45 AM identified that rooms [ROOM NUMBERS] call lights were lit up and blinking above the door, however, the call bell had no audible sound and could not be heard. Observation of the nurse's station where the call bell system panel was located identified that the rooms where the call bells were activated were lit up on the system, however there was no sound coming from the system panel. When standing by the medication room, adjacent from the nurses station, a faint call bell sound could be heard, although the the sound was not loud enough to be heard on the nursing unit. Interview with the Administrator at the time of the observation identified that the call bell should be ringing at the nurse's station loud enough to be heard on the unit, and she would be contacting maintenance to come to the floor and take a look at the call bell system. Interview with the assistant maintenance director on 4/16/24 at 10:15 AM identified that there was no sound coming from the call bell system panel at the nurse's station, and he thought there might be something wrong with the volume. He stated that he could not figure it out, so the vendor was called, and would be coming in that afternoon to look at the system. Interview with the call system vendor on 4/16/24 at 2:00 PM identified that the muffled call light sound heard coming from the medication room is from a call light system located in the medication room to alert anyone in the medication room of a call light going off. He stated he would be placing an enunciator outside the medication room that is connected to the call light system in the medication room that will allow the call lights to be heard throughout the unit. Interview with the maintenance director on 4/16/24 at 2:30 PM identified that he checks the call light system monthly and the last check on 2/29/24 identified that a few of the call lights were not sounding at the nurse's station. He stated that he had gotten a bid to replace the system on the third floor and submitted it to corporate about 1.5 months ago and had not heard back yet. The Maintenance director stated that he did not inform the administrator of the call lights that were not sounding at the nurse's station. Interview with the Administrator on 4/16/24 identified that she was aware that the system needed to be replaced, and a bid had been submitted however, she was not aware that some of the call lights were not sounding at the nurse's station. if she had been aware she would have taken action such as moving the residents to different rooms. The facility did not have a call bell policy in place.

Based on review of clinical records, facility documentation, and interviews for one (1) of three (3) residents reviewed for a change in condition, (Resident #1), the facility failed to notify the physician of a decline in a resident's oral intake. The findings included: Resident #1's diagnoses included diffuse traumatic brain injury, and hemiplegia. Review of the Care Card dated 7/27/23 identified Resident #1 was a total feed. Review of the Quarterly Diet Nutrition Evaluation dated 12/18/23 identified that the resident required an estimated fluid need of 1975 milliliters (ml) to 2370 ml per day. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had sever cognitive impairment and was dependent with eating. The Resident Care Plan dated 1/9/24 identified Resident #1 as at risk for dehydration related to fluid volume deficit, at increased nutritional risk due to mechanically altered diet, dysphagia, and required staff to feed at meal time with interventions that directed to monitor intake and output as needed, to provide, serve diet as ordered and to monitor intake and record each meal. Review of the Food and Fluid Intake log sheet dated March 2024 indicated Resident #1's usual meal intake was between 75 and 100%. On 3/10/24 Resident #1 had an intake of 25% of his/her breakfast, 0% of his/her lunch, and 50% of his/her dinner, had no notation of food/beverage consumption on 3/11/24 (all areas left blank), and had eaten/drank only 25% of his/her breakfast and lunch on 3/12/23. Review of the Advanced Practicing Registered Nurse's (APRN) note dated 3/12/24 identified he/she evaluated Resident #1 as he/she presented with a fever of 100.9 at 3:36 PM, orders for Tylenol, a rapid COVID swab, polymerase chain reaction COVID-19 test, a stat complete blood count, blood work to check red blood cell and white blood cell counts) basal metabolic panel (blood test to check blood chemistry), chest x-ray, urinalysis and vitals every four hours were given. Review of a nurse's note dated 3/12/24 at 6:47 PM identified Resident #1 was alert, lethargic, complained of headache, was febrile, had a blood pressure of 149/55, and heart rate of 174. The APRN was notified and instructed the facility to transport Resident #1 to the emergency room for further evaluation. Review of the hospital Discharge summary dated [DATE] identified that the resident was admitted on [DATE] with a serum sodium level of 162 (normal levels range from 136-144) upon admission to the hospital and had resulted from sepsis and poor oral intake. Interview with the APRN on 4/16/24 at 3:00 PM identified he/she was unaware Resident #1's intake had declined on 3/10/24 and subsequent and would expect to be notified of this change to further evaluate the resident and explore the potential causes of his/her reduced intake as the resident was rarely ill. Interview with the Director of Nurses (DNS) on 4/16/24 at 1:08 PM identified residents would be placed on an intake and output monitoring schedule at the facility based on the practitioner's findings and/or a change in the resident's status. The DNS indicated Resident #1 was not on an intake and output monitoring schedule as he/she had been stable. The DNS indicated a decline in food/beverage intake of 0% to 50% on 3/10/24 would be cause for concern and the APRN should have been notified of the resident's reduced intake, Resident #1 should have been further assessed, the physician notified. Review of the change in condition policy identified that the physician will be notified of any change in resident condition.

Based on clinical record review, review of facility documentation, review of facility policies, and interviews, for one of two sampled residents reviewed for falls (Resident #1), the facility failed to identify the symptoms of a change in condition presented by Resident #1, after his/her fall at the faciltiy, were potentially related to neurological changes which could be life threatening and failed to ensure a Registered Nurse (RN) assessment was completed in a timely manner when a change in condition was identified and notify the physician/Advanced Practice Registered Nurse of such changes. The findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission fall risk assessment dated [DATE] identified Resident #1 had no falls in the past 3 months. (of note, documentation in the clinical record identified Resident #1 had a recent fall with an injury prior to admission). physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's history and physical exam dated 6/10/20 identified Resident #1 was oriented to person and place and identified both prognosis and rehabilitation potential were good. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition, no behaviors, walked in room with supervision of one staff, was eating independently with set up help only, had one fall with an injury since admission (the MDS did not reflect an additional fall without injury which occurred on the same day, per the clinical record), had no signs or symptoms of a possible swallowing disorder, and was administered an anticoagulant. The care plan dated 6/24/20 identified a focus area initiated on 6/9/20, identifying Resident #1 had staples to his/her head related to a fall in previous facility. Interventions included treatment as ordered. Resident #1 was at risk for falls related to being newly admitted , having decreased strength and endurance, generalized weakness, impaired sense of balance, and unsteady gait, and having a previous history of falls. Interventions included to instruct Resident #1 to ask for assistance prior to attempting transfer or ambulation. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Activities of Daily Living (ADL) flow sheets for transfer and walking in room for the dates of 7/7/20-7/16/20 reflected that Resident #1 was independent in these activities with no help from staff. Nursing note written by Registered Nurse (RN) #1, dated 7/16/20 at 5:40 AM, identified RN #1 was called to Resident #1's room at 5:30 AM. Resident #1 was found on the floor on the right side of the bed, lying on his/her right side with arms folded beneath head, as if was sleeping, and legs outstretched. The note further identified the following: Positive range of motion, pupils equal and reactive to light, no areas noted to head at this time, bilateral strong grip, no bruising noted at this time. Nursing note written by RN #1 dated 7/16/20 at 6:47 AM identified: Call placed to family member, notified resident was found on floor 5:30 AM, no apparent injury but continuing to monitor and neurological checks initiated. Nursing note written by RN #2, dated 7/16/20, at 11:06 AM identified Advanced Practice Registered Nurse (APRN) #1 was notified of Resident #1 being found on floor at 5:30 AM, no injuries noted. Nursing note written by LPN #1, dated 7/16/20, at 12:56 PM identified status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Therapy Evaluation dated 7/16/20, signed 7/17/20 by Physical Therapist (PT) #1, identified: Resident #1 was independent with transfers prior to fall. Patient requires assist of two for transfers at time of evaluation. Clinical impressions: Resident presents with significant decrease in functional mobility, impaired strength proximally and distally, and decreased activity tolerance. Resident presents with congested cough. Resident nonverbal during treatment. Primary nurse aware and calling APRN to assess. Review of the clinical record failed to reflect that this had occurred. Nursing note written by Licensed Practical Nurse (LPN) #2, identified as a late entry, with effective date of 7/16/20 at 10:18 PM identified: Day one for found on floor, with neuro checks. At start of shift body audit performed, skin intact. Neurological checks performed, were within normal limits. Around 5:00 PM Nurse Aide (NA) came to LPN #2 and reported Resident #1 was having difficulty eating his/her dinner. Writer went to resident's room and gave ordered medications and fluids to drink and Resident #1 took medications without difficulty. Diet was downgraded to pureed and requested swallow evaluation. Shift supervisor made aware. No complaints of pain or discomfort this shift. Review of the clinical record failed to reflect an RN Assessed Resident #1 regarding the noted change in condition and failed to indicate that the APRN or physician were notified of the changes. Nursing note written by RN #2, dated 7/17/20, 10:45 AM, identified Resident #1 was alert and not verbal. The Charge Nurse reported Resident #1 was coughing with fluids. Breath sounds adventitious to lung fields. Tracheal congestion, temperature 98.6, [pulse 22], BP 122/68, pulse oximetry 97%. Resident #1 was lying in bed without difficulty breathing, however, a change in mentation was noted. APRN #1 in facility, was notified at approximately 10:00 AM, and evaluated Resident #1. See new order to send to hospital. Review of the clinical record failed to reflect that Resident #1 was assessed by an RN between 7/16/20 when the changes were noted and 7/17/20 at 10:45AM. Summary completed by the Director of Nurses (DNS) dated 7/18/20, identified the hospital informed the DNS that a neurology consultation had identified Resident #1 was not a candidate for surgery and the family wished to place Resident #1 on comfort measures. Interview with RN #2 on 8/6/20 at 2:55 PM identified RN #2 had worked day shift on both 7/16/20 and 7/17/20. RN #2 had assessed Resident #1 on 7/16/20 between 8:00 AM and 9:00 AM, did not complete a nurse ' s note but did assess as part of fall investigation, and assessment showed no changes or injuries. RN #2 assessed Resident #1 in bed and did not ask the resident to get up but saw Resident #1 moving in bed without difficulty. No reports were made to RN #2 of any changes in Resident #1's condition that day. Interview with LPN #2 on 8/6/20 at 3:12 PM identified LPN #2 worked the evening shift on 7/16/20, she/he was informed in report that Resident #1 had fallen that morning and was to be monitored, neurological checks were completed and were noted to be within the resident's normal limits. At suppertime LPN #2 was told by NA #1 that the resident was having difficulty eating. LPN #2 informed RN #3 of the resident having difficulty eating and asked what the protocol was, and RN #3 walked LPN #2 through downgrading the diet and requesting a Speech evaluation. LPN #2 did not notify the APRN or Physician (MD), as RN #3 said he/she would do that. LPN #2 did not know if RN #3 had assessed the resident. LPN #2 did complete neurological checks for Resident #1 that shift and did not think the eating difficulty could be related to the fall earlier that day, as Resident #1 had no changes noted and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #3 would have known. Interview with RN #3 on 8/6/20 at 3:45 PM identified it was reported to RN #3 that a resident was having difficulty eating, was taking a long time to chew, however, the name of the resident was not told to RN #3. RN #3 assisted LPN #2 in downgrading the diet and requesting a Speech evaluation. RN #3 did not go at that time to assess the resident but did take a quick look at the resident at 8:30 PM and noted he/she was fine and able to drink without difficulty. RN #3 did not assess Resident #1 for a change in eating but was told he/she finished his/her meal after diet downgraded. RN #3 did not document any information regarding this but recalls leaving a note for the APRN. RN #3 did not recall speaking to an APRN. RN #3 did know the resident had a fall that day, and at 10:30 PM RN #3 talked again with LPN #2 who identified the resident was still at baseline. RN #3 did not think the change in eating was related to the fall, RN #3 again identified that the LPN did not tell the RN the name of the resident with the eating difficulty. RN #3 identified that for changes, the RN would be expected to assess the resident, and that she/he did go to see the resident at 8:30 PM, no problems were noted, and he/she did not document, but may have thought that he/she did. Interview with the DNS on 8/6/20 at 5:00 PM identified that for any change in condition, including change from independent to assist for transfers, and need for diet downgrade/difficulty eating, nursing should have ensured RN assessments were completed. Review of the clinical record failed to reflect RN assessments were completed for Resident #1 ' s change in condition including eating or transfer/ambulation status in a timely manner and/or that the physician/APRN were notified of the changes. The DNS further identified RN assessments and physician notifications were not done for the diet and activity changes and noted that nursing should have ensured this and should have obtained orders from the physician. The DNS further identified that the nurses supervising and nurses caring for the resident on 7/16/20 and 7/17/20 were long term staff, all working at the facility for over one year. In addition, The DNS identified that there was no documentation of any nursing training or competencies for neurological checks, the facility does not do competency checks for all assessments separately, neurological checks are reviewed during initial orientation and there is no specific documentation of this; the staff development nurse retired in the past year, duties have been covered by the DNS and corporate staff. The DNS identified the staff development position had been recently filled, and the staff is being trained now. The facility policy for Neurological Signs identified, in part: Any resident who sustains a head injury or when a head injury is questioned or suspected will have neurological signs monitored as follows: Every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, every four hours for sixteen hours, every eight hours for 48 hours. Neurological signs to be evaluated are inclusive of: Pupils reaction to light, level of consciousness, change in mental status, change in speech, change in strength in extremities, vital signs-blood pressure, pulse, respirations, head pain, nausea/vomiting. The findings of each evaluation are compared, analyzed and documented in the medical record. The physician is promptly notified of any abnormal findings. There was no indication Resident #1 ' s physician or APRN were notified at the time when Resident #1 ' s presented with a change in ambulation/transfer status and a change in his/her eating ability. This was not consistent with the facility ' s policy for Neurological Signs. The training outline for Licensed Nurse Orientation identified in part: There should be a basic general review of all systems and forms- getting a PT screen, doing an admission/discharge, getting lab work, notifying the MD, etc. Review of paperwork. Further detailed review can be done when the new employee is doing clinical orientation on the unit. In Class Review: 11. Assessments. 19. Notifying the physician. The training outline did not reflect further information regarding assessments and did not reflect physician orders, or dietary or activity/therapy orders. The facility failed to provide documentation that identified that the nursing staff was competent in assessing neurological changes, especially in a resident with an unwitnessed fall and the added complication of being on anticoagulant therapy. The facility submitted a plan for the Removal of Immediate Jeopardy alleging compliance on 8/10/20. The plan included the in-service education that was provided to nursing staff prior to their next shift. The education addressed notification of the physician/APRN of a change in condition. RNs were also educated on the Connecticut Nurse Practice Act and the need to assess a resident following a fall or a change in condition and on neurological assessments. The facility is conducting audits to ensure timely physician notification and completion of an RN assessment. The plan was accepted. The Immediate Jeopardy was removed as of 8/10/20.

Based on clinical record review, review of facility documentation, review of facility policies, and interviews, for one of two residents reviewed for falls (Resident #1), the facility failed to ensure the physician or Advanced Practice Registered Nurse were notified of a change in condition in a timely manner, resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 receive [MEDICATION(S)] tablet, (an anticoagulant medication), 5 mg by mouth every 12 hours for [CONDITION(S)]; aspirin 81 mg by mouth one time a day for anti-platelet aggregation; and diet consistency of regular with thin (regular) liquids. A physician's history and physical exam dated [DATE] identified Resident #1 was oriented to person and place and identified both prognosis and rehabilitation potential were good. The nutrition assessment dated [DATE] identified Resident #1's feeding ability as independent with self-feeding. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition, no behaviors, walked in room with supervision of one staff, independent with eating, had one fall with an injury since admission, had no signs or symptoms of a possible swallowing disorder, and was administered an anticoagulant. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated [DATE] identified Resident #1 was at risk for falls related to being newly admitted , having decreased strength and endurance, generalized weakness, impaired sense of balance, unsteady gait, and having a previous history of falls. Interventions included, instruct Resident #1 to ask for assistance prior to attempting transfer or ambulation. Review of the Activities of Daily Living (ADL) flow sheets for period of [DATE]-[DATE] reflected that Resident #1 was independent with transfers and walking in room. Nursing note written by Registered Nurse (RN) #1, dated [DATE] at 5:40 AM, identified RN #1 was called to Resident #1's room at 5:30 AM. Resident #1 was found on the floor on the right side of the bed, lying on his/her right side with arms folded beneath head and legs were outstretched. The note further identified the following: positive range of motion, pupils equal and reactive to light, no areas noted to head at this time, bilateral strong grip, no bruising noted at this time. Resident's brief, tee-shirt, sheet, and mattress were noted to be wet. Resident with no complaints of pain or discomfort and walker was next to the resident. Resident #1 did not say what he/she was trying to do. Neurological checks initiated, on floor blood pressure (BP) ,d+[DATE], ,d+[DATE] in bed, pulse 92, temperature 97.9, respirations 18, and oxygen saturation 93% on room air. Nursing note written by RN #1 dated [DATE] at 6:47 AM identified: Call placed to family member, notified resident was found on floor at 5:30 AM, no apparent injury but continuing to monitor and neurological checks initiated. A second note at 11:06 AM identified Advanced Practice Registered Nurse (APRN) #1 was notified of Resident #1 being found on the floor at 5:30 AM, no injuries noted. Nursing note written by Licensed Practical Nurse (LPN) #1, dated [DATE], at 12:56 PM identified status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A physical therapy evaluation conducted on [DATE] by Physical Therapist (PT) #1, identified that Resident #1 was independent with transfers prior to fall. Patient required assist of two for transfers at the time of evaluation. Clinical impressions: resident presents with significant decrease in functional mobility, impaired strength proximally and distally, and decreased activity tolerance. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation that the physician and/or APRN was notified of the resident's change in transfer and ambulation status. Interview with PT #1 on [DATE] at 2:35 PM identified, PT #1 had screened Resident #1 in the afternoon on [DATE] around 2:00 PM due to a fall and found Resident #1 required an assist of two with transfers and ambulation, PT #1 could not determine if the fall had caused the decline. Nursing note written by Licensed Practical Nurse (LPN) #2, identified as a late entry, with effective date of [DATE] at 10:18 PM identified that at the start of the shift, a body audit of Resident #1 was performed and identified, intact skin, neurological assessment noted that neurological signs were within normal limits. The note further identified that around 5:00 PM a Nurse Aide (NA) came to LPN #2 and reported Resident #1 was having difficulty eating his/her dinner. LPN #2 further noted that she went to the resident's room and gave ordered medications and fluids to drink and Resident #1 took medications without difficulty. Diet was downgraded to pureed consistency and a swallow evaluation was requested. Shift supervisor made aware. No complaints of pain or discomfort this shift. Review of the clinical record failed to reflect an RN assessment and/or that the physician was notified of the diet change. The facility policy for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the neurological assessments from [DATE] to [DATE] were complete and identified no changes until [DATE] at 9:00 AM, when the resident was noted to be lethargic and drowsy, not alert, not oriented to person, not responding to commands, not verbally appropriate, and not able to follow finger with eyes. Nursing note written by RN #2, dated [DATE], 10:45 AM, identified Resident #1 was alert and non-verbal. The charge nurse reported Resident #1 was coughing with fluids. Breath sounds adventitious to lung fields. Tracheal congestion, temperature 98.6, pulse 22, BP ,d+[DATE], pulse oximetry 97%. Resident #1 was lying in bed without difficulty breathing, however, a change in mentation was noted. APRN #1 was in facility and was notified at approximately 10:00 AM and evaluated Resident #1. See new order to send to hospital. APRN #1 note dated [DATE] identified in part he/she was asked to see Resident #1 due to chest congestion and resident not acting self per nursing. Nursing reports Resident #1 had an unwitnessed fall yesterday with no injuries reported. Nursing reports last evening Resident #1 had trouble eating and diet was downgraded. Upon APRN assessment, unable to obtain review of systems due to mental status changes. Physical exam/objective, mild distress, head atraumatic, no bumps found on scalp. Pale with no visual ecchymosis. Breathing labored, rhonchi noted. Not following commands, non-verbal. Pupils sluggish. Flat affect. Given acute change in mental status, resident needs emergent emergency room evaluation. 911 called by nursing. Report given by APRN to Emergency Medical Personnel and emergency room staff. Resident #1 was sent to the hospital at approximately 10:15 AM. Nursing note written by LPN #1, dated [DATE], 11:13 AM, identified Resident #1 noted to cough on thin liquids this morning during breakfast. Lungs clear to auscultation, no shortness of breath noted, no coughing noted after resident coughed on thin liquids. Vital signs stable: BP ,d+[DATE], Temperature 98.6, pulse 88, respirations 20, oxygen saturation 97% on room air tolerating well. This writer downgraded diet to honey thick liquids. When this writer gave Resident #1 honey thick liquids and medications, Resident #1 was noted with a congested cough. Resident #1 continued with lungs clear to auscultation and no signs of acute respiratory distress noted. Resident #1 noted with change in mental status. Resident #1 will open eyes when name is said but will not verbally answer. Resident #1 will not raise bilateral upper/lower extremities but when lifted will slowly pull back down. PERRLA (Pupils equal, round, reactive to light and accommodation) bilaterally. Resident would not hand grasp when asked to squeeze this writer's hands. This nurse felt Resident #1 move left hand in attempt to squeeze but did not fully squeeze. No facial grimacing or drooping noted. No fluids coming from mouth. APRN ordered to send resident to hospital for evaluation. Emergency Department documentation dated [DATE] identified the results of CT scan of head and cervical spine without contrast findings: Brain: multiple acute, subacute, and chronic hemorrhages in the brain. Nursing note written by the Director of Nurses (DNS), dated [DATE], 8:54 AM, identified the DNS spoke with the family and hospital on [DATE] regarding CT scan results. Scan shows acute, subacute and chronic bleed. Resident admitted to hospital. Fall investigation documentation, summary completed by the DNS dated [DATE], identified the hospital informed the DNS that a neurology consultation had identified Resident #1 was not a candidate for surgery and the family wished to place Resident #1 on comfort measures. A Social Service note dated [DATE] identified Resident #1 expired at the hospital on [DATE]. Interview with RN #2 on [DATE] at 2:55 PM identified RN #2 had worked day shift on both [DATE] and [DATE]. RN #2 had assessed Resident #1 on [DATE] between 8:00 AM and 9:00 AM but did not complete a nurse's note but did assess as part of fall investigation, and assessment showed no changes or injuries. No reports were made to RN #2 of any changes in Resident #1's condition that day. Interview with LPN #2 on [DATE] at 3:12 PM identified LPN #2 worked the evening shift on [DATE], she/he was informed in report that Resident #1 had fallen that morning and was to be monitored, neurological checks were completed and were noted to be within the resident's normal parameters. At suppertime LPN #2 was told by NA #1 that the resident was having difficulty eating. LPN #2 informed RN #3 of the resident having difficulty eating, RN #3 walked LPN #2 through downgrading the diet and requesting a speech evaluation. LPN #2 did not notify the APRN or Physician (MD), as RN #3 said he/she would do that. LPN #2 did not know if RN #3 had assessed the resident. LPN #2 did complete neurological assessments for Resident #1 that shift and did not think the eating difficulty was related to the fall earlier that day, as Resident #1 had no neurological changes noted and had a past diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RN #3 on [DATE] at 3:45 PM identified it was reported to RN #3 that a resident was having difficulty eating, was taking a long time to chew, however, the name of the resident was not told to RN #3. RN #3 assisted LPN #2, explaining how to downgrade the diet and request a Speech evaluation. RN #3 did not assess Resident #1 for a change in eating but was told he/she finished his/her meal after diet was downgraded. RN #3 did not document any information regarding this but recalls leaving a note for the APRN. RN #3 did not recall speaking to the APRN or physician. RN #3 was aware that the resident had fallen that day and at 10:30 PM RN #3 spoke with LPN #2 who identified the resident was still at baseline. RN #3 identified that a change in eating should be reported to the APRN/MD and did not recall if this was done and could not produce documentation that the APRN or the physician was notified of the residents swallowing/eating difficulties and RN #3 could not provide physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 with the changes in eating/swallowing. Interview with the DNS on [DATE] at 5:00 PM identified that for any change in condition, including change from independent to assist for transfers and need for diet downgrade/difficulty eating and RN assessment should be completed and the physician/APRN notified. The DNS identified there were no RN assessments or physician/APRN notifications for these changes, and nursing should have ensured RN assessments and notifications to practitioner were completed. The DNS further identified that he/she had done training on [DATE] for nursing staff on post fall documentation and would now initiate an action plan with additional training to ensure RN assessments and APRN/MD notifications for changes in condition. Interview with APRN #1 on [DATE] at 10:30 AM identified APRN #1 was notified on [DATE] at 8:15 AM of a fall for Resident #1 that occurred at 5:30 AM and resulted in no apparent injuries. Neither APRN #1 nor any medical staff on-call were notified of any further changes on [DATE], including a decline requiring a change in activity orders or difficulty eating resulting in nursing downgrading Resident #1's diet. APRN #1 identified that she would expect to be notified for significant changes in the resident condition. If notified of either change, APRN #1 identified that she would have discussed with the RN on duty and sent the resident to the hospital right away for evaluation, as resident is known to APRN #1 and was on a medication regimen that included anticoagulant medications Interview with LPN #1 on [DATE] at 10:59 AM identified LPN #1 was informed of fall when he/she came in on [DATE], he/she completed neurological checks and Resident #1 was at baseline for the shift. LPN #1 was told by PT #1 of the change in activity orders and that Resident #1 was having trouble standing. LPN #1 did not notify the RN or the APRN as it was the end of his/her shift and PT #1 was still working with the resident Interview with Nurse Aide (NA) #1 on [DATE] at 12:06 PM identified that on [DATE] NA #1 noted Resident #1 was having trouble eating, so NA #1 took the meal away and told LPN #2 that the resident was having trouble eating and was coughing a little bit. Prior to this event Resident #1 required a set up only for the meal and was independent in eating, so this change eating was very different for Resident #1. Previously Resident #1 would not cough when eating and would eat and chew with no problems. At that time, Resident #1 would not chew and coughed a little bit. LPN #2 came to see Resident #1 and had pureed food sent for the resident. Resident #1 did eat some of the pureed food. No other changes were noted, NA #1 provided bedtime care, and Resident #1 was noted to be usual self, no other aides provided care for the resident that evening, and the resident was last seen between 9:00 and 10:00 PM, peaceful, relaxing, with eyes closed. Review of the clinical record failed to reflect that the Physician or APRN were notified of Resident #1's change in condition including eating or transfer/ambulation status in a timely manner. Interview with the DNS on [DATE] at 9:30 AM identified there is no facility policy for nursing downgrading a diet or a policy for diet order changes, the nurse can downgrade diet and then notify the physician and obtain orders. The DNS further identified that there was no specific policy for obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS further identified RN assessments and physician notifications were not done for the diet and activity changes and noted that nursing should have ensured this and should have obtained orders from the physician. The DNS further identified that the nurses supervising and nurses caring for the resident on [DATE] and [DATE] were long term staff, all working at the facility for over one year. In addition, The DNS identified that there was no documentation of any nursing training or competencies for neurological checks, the facility does not do competency checks for all assessments separately, neurological checks are reviewed during initial orientation and there is no specific documentation of this; the staff development nurse retired in the past year, duties have been covered by the DNS and corporate staff. The DNS identified the staff development position had been recently filled, and the staff is being trained now. Interview with RN #7 on [DATE] at 3:20 PM identified: Staff educators are to review neurological assessments, along with all other assessments, with new nurses during orientation. An outline is used to guide training, there are no presentations, checklists or competencies required. The training outline is the same for both RN and LPN training, though they do train regarding scopes of practice. Although documentation identified that neuro signs were completed and noted to be normal following the fall, the nurses failed to identify Resident #1's change in ambulation and eating status as possible neurological changes related to the fall and notify the the physician/APRN of such changes in a timely manner. The facility policy for Condition: Significant Change identified the physician, resident and/or responsible party will be notified by the nurse in the event of a change in condition. The facility policy for Neurological Signs identified, in part: Any resident who sustains a head injury or when a head injury is questioned or suspected will have neurological signs monitored as follows: Every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, every four hours for sixteen hours, every eight hours for 48 hours. Neurological signs to be evaluated are inclusive of: Pupils reaction to light, level of consciousness, change in mental status, change in speech, change in strength in extremities, vital signs-blood pressure, pulse, respirations, head pain, nausea/vomiting. The findings of each evaluation are compared, analyzed and documented in the medical record. The physician is promptly notified of any abnormal findings. The training outline for Licensed Nurse Orientation identified in part: There should be a basic general review of all systems and forms- getting a PT screen, doing an admission/discharge, getting lab work, notifying the MD, etc. Review of paperwork. Further detailed review can be done when the new employee is doing clinical orientation on the unit. In Class Review: 11. Assessments. 19. Notifying the physician. The training outline did not reflect further information regarding assessments and did not reflect physician orders, or dietary or activity/therapy orders. The facility submitted a plan for the Removal of Immediate Jeopardy alleging compliance on [DATE]. The plan included the in-service education that was provided to nursing staff prior to their next shift. The education addressed notification of the physician/APRN of a change in condition. RNs were also educated on the Connecticut Nurse Practice Act and the need to assess a resident following a fall or a change in condition. The facility is conducting audits to ensure timely physician notification and completion of an RN assessment. The plan was accepted. The Immediate Jeopardy was removed as of [DATE].

Based on review of the clinical record, facility documentation and interviews for one of four residents (Resident #209) reviewed for accidents, the facility failed to provide the necessary supervision during a transfer resulting in an injury. The findings include: Resident # 209 was re-admitted to the facility on [DATE] after a twelve day hospitalization with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] at 3:30 PM identified Resident # 209 was alert and oriented with agitation and anxiety, was non ambulatory and the primary mode of locomotion was a wheelchair. The assessment further identified to transfer the resident with the assistance of two nurse aides. The accident/incident report and investigation dated 1/10/16 at 6:00 AM identified Resident # 209 rang the call bell for assistance and was observed by NA #4 with his/her legs hanging off the bed and attempting to go to the bathroom. NA #4 transferred Resident #209 to the bathroom and back to bed without the benefit of another staff member assisting. Upon returning the resident to bed, NA #4 observed a skin tear on the right shin. An assessment of the area by the RN Supervisor identified a deep 5.0cm x 4.0cm skin tear on the right shin. The physician assessed the resident and directed to transfer the resident to the Emergency Department for treatment of [REDACTED]. Review of the interagency report dated 1/10/16 identified a laceration on the right lower leg that required six sutures to approximate the wound. The facility investigation identified the resident caught the right leg on the leg rest attachment of the wheelchair. Review of NA #4's written statement dated 1/10/16 identified that at the beginning of the 11-7:00 AM shift on 1/9/16 he/she was told by the charge nurse that Resident # 209 required assistance of two people for transfers. NA #4 indicated the call light was going off at 6:00 AM and she/he entered the room to answer the light. NA #4 saw Resident #209 with his/her legs off the side of the bed attempting to get out of bed. Resident #209 said they needed to use the bathroom. NA #4 asked Resident #209 if they could do it and said she/he always walks to the bathroom. NA #4 helped the resident from the side of the bed into the wheelchair and into the bathroom. The toilet seat was too high so NA #4 brought the resident backed to the bed and provided the resident with a bedpan. NA #4 indicated at that time she/he noted bleeding from the resident's right leg. The written statement failed to identify why NA #4 did not transfer the resident with two people per the plan of care. Interview with the ADNS on 2/3/16 at 1:00PM identified the facility policy states all new admissions will be transferred with an assistance of two until they are evaluated by the physical therapy department. The second person may not necessarily provide physical care but provides stabilization or verbal cueing. Several attempts to interview NA #4 were unsuccessful.

Based on observations, review of the clinical records and staff interviews for two of six sampled residents reviewed for accidents (R#30, R#86) the facility failed to provide appropriate supervision to prevent an accident and/or fall with injury. The findings include: 1. Resident #86's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident had intact cognition (BIMS 15), required extensive assistance of two staff for bed mobility, dressing, toilet use, personal hygiene, was totally dependent on two staff for transfers and was non-ambulatory. The care plan dated 3/19/14 indicated to provide assistance of two staff for interaction care, use positioning wedges as needed when in bed, transfer out of bed via Hoyer lift with assistance of two staff, and provide assistance of two staff for toileting and clothing management. A/I report dated 4/14/14 at 10:35 AM identified the resident rolled out of bed and was lowered to the floor by NA#1. A written statement by NA#1 dated 4/14/14 documented that as another aide was entering the room he/she was rolling R#86 over to put the Hoyer pad underneath him/her and the residents weight shifted. Although NA#1 tried holding onto the residents shirt, by the time NA#2 ran over it was too late the resident had already been lowered to the floor. A written statement from NA#2 on 4/15/14 identified he/she was walking through the door to assist NA#1 and noted NA #1 was putting the Hoyer pad under the resident. Interview with Resident #86 on 12/30/14 at 9:30 AM when asked about the incident identified that NA#1 rolled him/her too quickly and rolled him/her right out of the bed. The residents weight shifted and it was too late to assist because NA#1 had already eased R#86 down to the floor by his/her shirt. A radiology report dated 4/14/14 identified a non displaced age-indeterminate fracture. Nurse's note dated 4/14/14 identified the resident was transferred to the hospital for evaluation. Orthopedic consult dated 4/17/14 identified the resident had a right tibial plateau fracture with interventions that included to wear a right knee hinged brace, remove only for hygiene and recheck x-rays in 6 weeks. The A/I report summary documented that the fracture occurred when the resident rolled out of bed on 4/14/14 as there have been no other identified events or trauma. Additionally, education provided 4/17/14 documented that when a residents care plan and care card indicate the resident requires assistance of two staff for bed bed mobility, two caregivers must be present at the bedside. Interview with the DNS on 12/23/14 at 12:45 PM identified that the residents care card directed assistance of two staff for care and two NA's should have been at the bedside providing care on 4/14/14. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. The MDS dated [DATE] identified the resident had short-term memory problems, severely impaired cognition, required total assistance with bed mobility, transfers, dressing, toilet use, and bathing. The care plan dated 1/09/14 identified the resident had decreased mobility with interventions that included to transfer via a Hoyer lift with the assistance of two staff to a custom wheelchair with a seatbelt for pelvic stability per the 24-hour positioning plan. Accident/Incident (A/I) report dated 1/29/14 at 2:00 PM identified the resident's head was bumped on the Hoyer bar during transfer back to bed. NA#5's statement dated 1/29/14 identified that the resident's right frontal head came in contact with the Hoyer bar during transfer back to bed. The investigation identified a small red raised area the size of a dime on the resident's forehead. Interview with the DNS on 12/22/14 at 2:15 PM identified that NA#5 transferred the resident via the Hoyer without the benefit of a second staff member. A subsequent interview with the DNS on 12/23/14 at 2:22 PM identified that NA#5 did report that the resident bumped his/her head on the Hoyer bar during the transfer, however, he/she did not report that he/she transferred the resident alone, without the benefit of a second staff member. Interview with the DNS on 12/29/14 at 11:00 AM identified that it is standard of practice and the facility expectation that two staff be present during the Hoyer transfer. The Nursing Policy & Procedure directs that in all cases, a minimum of two staff members are to be present during all lift transfers. Interview with NA#5 on 12/29/14 at 1:10 PM identified that although he/she was aware that two staff members were required to Hoyer lift residents, he/she tried but could not find anyone to help transfer the resident back to bed and the resident had tears in his/her eyes and was begging to go back to bed. NA#5 stated it was a stupid thing to do but the facility was short staffed and he/she just wanted to help the resident.