Every finding on record at Touchpoints at Manchester

Based on clinical record review, facility documentation/policies, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for competent nursing staff, the facility failed to ensure licensed nursing staff were competent to perform assigned duties of accurately reconciling and transcribing hospital discharge medication orders, recognizing and responding to electronic medication safety alerts, completing the required secondary review of readmission orders, and ensuring a newly assigned agency Registered Nurse Supervisor (RN #2) was oriented to the responsibilities of the 11:00 PM to 7:00 AM shift, including verification of readmission orders. As a result, Resident #1 received concurrent administration of Apixaban, Clopidogrel, and Aspirin for three (3) days after the hospital had discontinued Clopidogrel and Aspirin, resulting in a gastrointestinal (GI) bleed requiring hospital transfer.Resident #1's diagnoses included atherosclerotic heart disease, peripheral vascular disease and other disorders of the circulatory system.The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had intact cognition, had a suprapubic catheter (a tube that goes directly into the bladder to drain urine), was incontinent of bowel and bladder and required substantial assistance with activities of daily living (bathing, transfers, bed mobility, and dressing).The Resident Care Plan dated [DATE] identified anemia related to low hemoglobin and hematocrit. Interventions directed to give medications as ordered and monitor for side effects and effectiveness.Physician's orders dated [DATE] directed to give Clopidogrel 75 milligrams (mg) (a medication to prevent the blood from clotting) once a day and to give Aspirin 81 mg once a day.The Interagency Patient Referral Report from the hospital dated [DATE] directed to discontinue Clopidogrel 75 mg and Aspirin 81 mg and to start Apixaban 5 mg (a medication to prevent the blood from clotting) once a day.The physician's orders dated [DATE] directed to give Apixaban 5 mg every 12 hours. The physician's orders failed to include orders directing to discontinue the Clopidogrel 75 mg and Aspirin 81 mg.Review of the Medication Administration Record (MAR) dated [DATE] identified Resident #1 received Aspirin 81 mg on [DATE], [DATE] and [DATE] for a total of 3 doses after the medication should have been discontinued. The MAR identified Resident #1 received Clopidogrel 75 mg on [DATE] and [DATE] for a total of 2 doses after the medication should have been discontinued. Additionally, the MAR identified Resident #1 received the physician ordered dose of Apixaban 5 mg twice a day on [DATE] and [DATE] for a total of 4 doses.The Order note dated [DATE] at 11:35 PM identified the addition of Apixaban 5 mg triggered the following drug protocol alerts/warnings: drug to drug interaction with Aspirin 81 mg, Aspirin may enhance the anticoagulant effect of direct oral anticoagulants (e.g., Apixaban 5 mg) as well as interaction of Clopidogrel 75 mg antiplatelet (part of the blood that assists in preventing the blood from clotting) inhibitors may enhance the anticoagulant effect of direct oral anticoagulants (e.g., Apixaban 5 mg).Interview with RN #1 on [DATE] at 12:09 PM identified on [DATE] when Resident #1 returned to the facility from the hospital RN #1 reviewed and entered the medication orders into the electronic medical record (EMR). RN #1 identified she was not aware the EMR system alerted there was a potential drug interaction between the Apixaban, Clopidogrel and Aspirin and therefore did not address the potential for the drug interaction.Interview with the Assistant Director of Nursing Services (ADNS) on [DATE] at 12:32 PM identified the facility policy for readmission medication orders directed the licensed staff member should perform medication reconciliation to ensure the medications were entered correctly, and the 11:00 PM to 7:00 AM shift supervisor was responsible for verifying readmission orders were entered correctly. The ADNS identified the policy was not followed on [DATE] by both the readmitting nurse (RN #1) and the 11:00 PM to 7:00 AM shift supervisor (RN #2).Interview and clinical record review with the Director of Nursing Services (DNS) on [DATE] at 1:01 PM identified that when Resident #1 was readmitted on [DATE], the electronic medical record (EMR) generated an Order Note alert identifying potential drug interactions between Apixaban, Clopidogrel, and Aspirin; however, RN #1 did not recognize or address the alert. The DNS identified the readmitting Registered Nurse Supervisor was responsible for reconciling the hospital discharge summary with the resident's current physician orders, ensuring discontinued medications were removed from the active medication profile, verifying new orders were entered accurately, and cross-referencing all readmission orders. The DNS further identified the 11:00 PM to 7:00 AM Registered Nurse Supervisor was responsible for independently performing a secondary verification of all readmission orders to ensure accuracy. The DNS identified RN #2 was working only her second shift at the facility and her first 11:00 PM to 7:00 AM shift on [DATE]. The DNS identified RN #1 was responsible for orienting RN #2 to the responsibilities of the night shift, including completion of the required secondary review of all readmission orders, but there was no formal checklist to ensure all shift-specific responsibilities were reviewed. The DNS confirmed the required secondary verification was not completed, resulting in Resident #1 continuing to receive Clopidogrel and Aspirin after the medications had been discontinued by the hospital.Interview with the medical director (MD) #1 on [DATE] at 10:04 AM identified the medication error was a significant medication error and Resident #1 should not have received the extra doses of Clopidogrel and Aspirin.Interview with RN #1 on [DATE] at 10:38 AM identified on [DATE], she was not aware that it was RN #2's first time working the 11:00 PM to 7:00 AM shift at the facility. RN #1 identified that she was aware of the facility process that directed to orient new agency staff nurses to the facility policies and procedures for third shift. RN #1 identified she attempted to orient RN #2 to the facility policies and procedures, but RN #2 informed RN #1 that she was aware of the policies and procedures so did not pursue further orientation.Although attempted, an interview with RN #2 was unable to be obtained.Review of the facility policy titled admission Nursing Process, last reviewed [DATE], directed, in part, prior to beginning the admission assessment, quickly review the discharge summary and the W-10 (an interagency discharge form) and when a resident is a readmission, upon the resident return, the admission documentation must be redone in its entirety.Review of the facility policy titled Physician Orders-Twenty-four Hour Check, last revised [DATE], directed, in part, a double check of all medical records is to be completed daily by the night supervisor to ensure that all new orders are confirmed/transcribed accurately.The facility policy titled Physician Review of Medical Orders, effective date [DATE], directed, in part, all medical orders for residents of the facility are timely, accurate, clinically appropriate and reviewed by a licensed physician in accordance with all applicable regulations and requirements. The policy further directed, in part, discontinued or expired orders shall be clearly identified and removed from active treatment records.The facility policy titled Physician Orders-Transcription, last revised [DATE], directed, in part, physician orders will be transcribed or directly entered into the EMR by a licensed nurse and followed through in a manner consistent with quality standard of care practices. The policy further directed, in part, enter and/or review the orders in the EMR and confirm accuracy.

Based on clinical record review, facility documentation/policies, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure Resident #1's hospital discharge medication orders were accurately reconciled, transcribed, and verified upon readmission to the facility on [DATE]. Specifically, the facility failed to discontinue Clopidogrel 75 mg and Aspirin 81 mg as directed by the hospital, failed to recognize and address an electronic medical record alert identifying potential drug interactions between Clopidogrel, Aspirin, and newly ordered Apixaban, and failed to complete the required secondary verification of the readmission medication orders. As a result, Resident #1 received Clopidogrel, Aspirin, and Apixaban concurrently for three (3) days, resulting in a gastrointestinal (GI) bleed requiring transfer to the emergency department. The findings include:Resident #1's diagnoses included atherosclerotic heart disease, peripheral vascular disease and other disorders of the circulatory system.The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had intact cognition, had a suprapubic catheter (a tube that goes directly into the bladder to drain urine), was incontinent of bowel and bladder and required substantial assistance with activities of daily living (bathing, transfers, bed mobility, and dressing).The Resident Care Plan dated [DATE] identified anemia related to low hemoglobin and hematocrit. Interventions directed to give medications as ordered and monitor for side effects and effectiveness.The physician's orders dated [DATE] directed to give Clopidogrel 75 milligrams (mg) (a medication to prevent the blood from clotting) once a day and to give Aspirin 81 mg once a day.The Interagency Patient Referral Report from the hospital dated [DATE] directed to discontinue Clopidogrel 75 mg and Aspirin 81 mg and to start Apixaban 5 mg (a medication to prevent the blood from clotting) twice a day.The physician's orders dated [DATE] directed to give Apixaban 5 mg every 12 hours. The physician's orders failed to include orders directing to discontinue the Clopidogrel 75 mg and Aspirin 81 mg.Review of the Medication Administration Record (MAR) dated [DATE] identified Resident #1 received Aspirin 81 mg on [DATE], [DATE] and [DATE] for a total of 3 doses after the medication should have been discontinued. The MAR identified Resident #1 received Clopidogrel 75 mg on [DATE] & [DATE] for a total of 2 doses after the medication should have been discontinued. Additionally, the MAR identified Resident #1 received the physician ordered dose of Apixaban 5 mg twice a day on [DATE] and [DATE] for a total of 4 doses.The order note dated [DATE] at 11: 35 PM identified the addition of Apixaban 5 mg had triggered the following drug protocol alerts/warnings: drug to drug interaction with Aspirin 81 mg, Aspirin may enhance the anticoagulant effect of direct oral anticoagulants (e.g., Apixaban 5 mg) as well as interaction of Clopidogrel 75 mg antiplatelet (part of the blood that assists in preventing the blood from clotting) inhibitors may enhance the anticoagulant effect of direct oral anticoagulants (e.g., Apixaban 5 mg).The nurse's note dated [DATE] at 12:30 PM identified that Resident #1 vomited dark brown vomitus and there was active rectal bleeding. The note further identified Resident #1 was assessed by the Advanced Practice Registered Nurse (APRN #1) and was found to have small to moderate amount of rectal bleeding, dark brown in color with small clots present and the resident reported feeling sleepier than usual with intermittent nausea and a blood pressure reading of 96/54 (normal blood pressure range is 91-120 for the top number and 61-80 for the lower number). The note further identified due to the concern for GI bleeding Resident #1 was sent to the ED for evaluation.Interview with RN #1 on [DATE] at 12:09 PM identified on [DATE] when Resident #1 returned to the facility from the hospital, she entered the orders from the hospital into the electronic medical record system (EMR). RN #1 identified she sent the orders to the medical director for verification. RN #1 indicated that she believed she discontinued the medications that were ordered for discontinuation (Clopidogrel and Aspirin). RN #1 identified she was not aware that the EMR system alerted that there was a potential drug interaction between the Apixaban, Clopidogrel and Aspirin and therefore did not address the potential for the drug interaction.Interview with APRN #1 on [DATE] at 12:16 PM identified on [DATE] she was reviewing Resident #1's hospital discharge paperwork and identified that the hospital discontinued Clopidogrel and Aspirin and added Apixaban to the resident's medication regimen. APRN #1 identified she went to Resident #1's medical record and found that the Clopidogrel and Aspirin had not been discontinued as ordered and Resident #1 received all three medications throughout the weekend. APRN #1 identified that this was a medication error and that the medication orders should have been sent to the provider for verification and entered into the system as ordered.Interview with the Assistant Director of Nursing Services (ADNS) on [DATE] at 12:32 PM identified on [DATE] APRN #1 reported that Resident #1 had not had his/her Clopidogrel and Aspirin discontinued as ordered by the hospital and had received all three medications (Clopidogrel, Aspirin and Apixaban) throughout the weekend. The ADNS identified the facility policy regarding medication orders after readmission directed the staff member should perform medication reconciliation to ensure that the medications were entered correctly, and the night (11:00 PM-7:00 AM) supervisor was to verify readmission orders were entered correctly as a backup. The ADNS further identified the policy was not followed for Resident #1 on [DATE] by both the readmitting nurse (RN #1) and the night supervisor (RN #2).Interview and clinical record review with the Director of Nursing Services (DNS) on [DATE] at 1:01 PM identified that when Resident #1 was readmitted on [DATE], the electronic medical record (EMR) generated an Order Note alert identifying potential drug interactions between Apixaban, Clopidogrel, and Aspirin; however, RN #1 did not recognize or address the alert. The DNS identified the readmitting Registered Nurse Supervisor was responsible for reconciling the hospital discharge summary with the resident's current physician orders, ensuring discontinued medications were removed from the active medication profile, verifying new orders were entered accurately, and cross-referencing all readmission orders. The DNS further identified the 11:00 PM to 7:00 AM Registered Nurse Supervisor was responsible for independently performing a secondary verification of all readmission orders to ensure accuracy. The DNS confirmed the required secondary verification was not completed, resulting in Resident #1 continuing to receive Clopidogrel and Aspirin after the medications had been discontinued by the hospital. Interview with the medical director (MD #1) on [DATE] at 10:04 AM identified the medication error for Resident #1 was a significant medication error and Resident #1 should not have received the extra doses of Clopidogrel and Aspirin.Review of the facility policy titled admission Nursing Process, last reviewed [DATE], directed, in part, prior to beginning the admission assessment, quickly review the discharge summary and the W-10 (an interagency discharge form) and when a resident is a readmission, upon the resident return, the admission documentation must be redone in its entirety.Review of the facility policy titled Physician Orders-Twenty-four Hour Check, last revised [DATE], directed, in part, a double check of all medical records is to be completed daily by the night supervisor to ensure that all new orders are confirmed/transcribed accurately.The facility policy titled Physician Review of Medical Orders, effective date [DATE], directed, in part, all medical orders for residents of the facility are timely, accurate, clinically appropriate and reviewed by a licensed physician in accordance with all applicable regulations and requirements. The policy further directed, in part, discontinued or expired orders shall be clearly identified and removed from active treatment records.The facility policy titled Physician Orders-Transcription, last revised [DATE], directed, in part, physician orders will be transcribed or directly entered into the EMR by a licensed nurse and followed through in a manner consistent with quality standard of care practices. The policy further directed, in part, enter and/or review the orders in the EMR and confirm accuracy.

Based on review of clinical records, interviews, and review of facility documentation and policies for one of three residents (Resident #1) reviewed for change of condition, the facility failed to ensure the clinical record was complete and accurate to include timely notification of a change in condition. The findings included: Based on review of clinical records, interviews, and review of facility documentation and policies for one of three residents (Resident #1) reviewed for change of condition, the facility failed to ensure the clinical record was complete and accurate to include timely notification of a change in condition. The findings included: Resident #1 had diagnoses that included anxiety disorder, and chronic systolic heart failure. Review of the medical record on 9/2/2025 identified Person #1 was the court appointed Conservator of Person (COP). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of zero (0), indicating severe cognitive impairment and was dependent for personal hygiene. Review of the Resident Care Plan dated 7/23/2025 identified a self-care deficit. Interventions directed to provide assistance as indicated, and to discuss with resident/family/power of attorney any concerns. Respiratory Therapist's note dated 7/30/2025 identified Resident #1 was scratching his/her eyes and they were red. Physician order dated 7/30/2025 directed to instill one (1) drop of Artificial Tears Ophthalmic Solution (Artificial Tear Solution) in both eyes every four (4) hours as needed for reddened sclera (white area of the eye) to both eyes. Review of the nursing notes dated 7/30 and 7/31/2025 failed to identify the COP was notified Resident #1's eyes were noted to be red and failed to identify the COP was notified of the new order for Artificial Tear eye drops. Nursing note dated 7/31/2025 at 7:43 PM identified the COP requested Resident #1 be transferred to the hospital for evaluation of his/her eyes. Resident #1 was transferred to the hospital at 8:07 PM. Review of a hospital Discharge summary dated [DATE] identified Resident #1 was seen for eye swelling and was diagnosed with conjunctivitis (infection of the eye). The hospital administered Ofloxacin (an antibiotic used to treat eye infections) eye drops and was discharged with an order for Ofloxacin 0.3% eyedrops, one drop to both eyes four (4) times daily. Nursing note dated 8/1/2025 at 7:16 PM identified Resident #1 returned to the facility with a new order for Ofloxacin 0.3% eyedrops. Record review failed to identify Resident #1's COP was notified of the conjunctivitis diagnosed at the hospital, and failed to identify he/she was notified of the new orders for Ofloxacin eye drops. Interview with APRN #1 on 9/2/2025 at 9:11 AM identified on 7/30/2025 he/she was notified that Resident #1's eyes were red and irritated. APRN #1 stated she gave a new order to administer Artificial Tears, and informed staff that he/she would see Resident #1 on 8/1/2025. Interview with RN #1 on 9/2/25 at 10:40 AM identified Resident #1 was readmitted from the hospital on Ofloxacin eye drops. Further, the interview failed to identify the COP was notified of the diagnosis of conjunctivitis and the new orders for eye drops. Although RN #1 stated the facility practice was to inform the family/resident of new orders, and she may have called the COP to inform him/her, she stated she did not document any call was made. Interview failed to identify why the COP was not notified. Interview with the ADNS on 9/2/25 at 11:02 AM identified the facility should have contacted the COP regarding the new diagnosis and new eye drop orders, and it should have been documented in the resident's chart. Interview failed to identify why the COP was not notified. Interview with the Director of Nursing Services (DNS) on 9/2/2025 at 4:16 PM identified the COP had contacted the facility prior to Resident #1's return from the hospital and informed him/her of Resident #1's conjunctivitis diagnosis and treatment, however the DNS stated she did not write a nursing note to indicate she had notified the COP. The DNS indicated a note should have been written in the resident's medical record. Review of the undated Change of Condition Policy directed in part, the resident and/or responsible party will be notified of a resident change of condition, and document in the nurse's notes regarding changes, physician notification, and resident and/or responsible party notification.

Based on observations, review of facility documentation, review of facility policy and procedures, and interviews, the facility failed to ensure that an accurate accounting of all controlled medications were maintained and reconciled periodically, to ensure the accurate disposition of the controlled medications. The findings include: A review of the narcotic reconciliation process on 8/11/25 at 12:35 PM with the DNS identified that the narcotic audits are completed twice per month and include counting the narcotic medications on each medication cart, reviewing the signatures on the shift-to-shift count sheet to ensure that the count is being conducted and signed for and inspecting the packs of medications (blister) to ensure they have not been tampered with, and she reviews narcotic medications that were ordered on an as needed basis but were not administered. Additionally, the DNS identified that when the pharmacy delivers narcotic medications, the medications come with a white and yellow controlled substance disposition record (CSDR), which are individual sheets that are duplicates of each other for each medication delivered. It contains the name of the medication, the dose and the amount that was delivered along with the resident's name that the medication is ordered for. The delivered medications are also noted on a pink sheet that is given to the facility upon delivery. The yellow controlled substance disposition records (CSDR) are kept in the DNS office in a file cabinet and the white CSDR are placed in a binder on the cart where the medication is located. The DNS further identified the process for reconciling the medications when they are finished, discontinued or needed to be destroyed consists of the white CSDR records being matched up with the yellow CSDR records to ensure the medications are accounted for. Observation on 8/11/25 at 12:40 PM identified two narcotic binders that contained the yellow CSDR records organized alphabetically by resident. The binders contained 226 unmatched yellow CSDRs that dated back to 2019 through 2025. Interview on 8/11/25 at 12:45 PM with the DNS identified that she has held the position since 2020. She noted that when she started her position she could not account for the disposition of all the narcotic medications identified by the yellow CSDR records and so she left the records in the binders. The DNS further noted that she does not take the binders to the units to verify the narcotic medications are still accounted for in the facility. The DNS identified that the reconciliation/audit process was newly introduced at the beginning of 2025 and although the first step identified in the procedure directed to compare the yellow CSDR records with the corresponding white CSDR records in use in the facility, she noted that she has not been doing that and may not have read or understood the entire reconciliation/audit procedure. Interview on 8/12/25 at 11:40 AM with the DNS and ADNS identified they were going through the past narcotic medication destruction log and the filed CSDR records trying to ascertain what happened with the medication for the timeframe of 7/25/23 through 8/12/25. Interview on 8/13/2025 at 11:11 AM with the DNS indicated they removed the 2019 through 2022 sheets although they were not reconciled and are organizing by unit and have verified the amount of narcotics still in use in the facility. The DNS provided the completed white CSDR records that were located from some of the original unmatched yellow CSDR records and indicated there were still 13 outstanding/unmatched CSDR records for the lookback period. Following the facility's audit of the CSDR records for the time period of 7/25/23 through 8/13/25 identified thirteen yellow CSDR records that they could not account for the disposition of the medications, the medications included the following: 1. Clonazepam (benzodiazepine)1 mg tab (#21) delivered to the facility on 9/7/232. Lorazepam (benzodiazepine)1 mg tab (#60) delivered to the facility on [DATE]. Clonazepam 0.5 mg tab (#60) delivered to the facility on [DATE]. Lacosamide (anticonvulsant) 10 mg/ml oral solution (400ml) delivered to the facility on [DATE]. Lacosamide 10 mg/ml oral solution (400ml) delivered to the facility on [DATE] 6. Hydromorphone (opioid analgesic)1mg/ml solution (30ml) delivered to the facility on 2/6/247. Lorazepam 0.5mg tab (#7) delivered to the facility on 2/21/248. Tramadol (opioid analgesic)100 mg tab (#30) delivered to the facility on 3/27/249. Oxycodone-APAP (opioid analgesic)5-325mg (#30) delivered to the facility on 4/25/2410. Pregabalin (anticonvulsant)100 mg capsule (#60) delivered to the facility on 5/7/24.11. Morphine (opioid analgesic)20mg/ml concentrate (30 ml) delivered to the facility on 5/14/2412. Oxycodone IR 5 mg tab (#30) delivered to the facility on [DATE]. Lorazepam 0.5 mg tab (#21) delivered to the facility on 2/18/25 The controlled substance handling policy identified that all controlled drugs will be subject to special receipt, handling, storage, disposal and record keeping and the facility will keep all controlled substance accountability records and audit records on file for a period of no less than 5 years. The narcotic control and accountability audit procedure identified the auditor reviews all controlled substances on the unit for accuracy of count and compares the white and yellow controlled substance disposition records to ensure that all controlled substances are accounted for and the date of the audits should be noted.

Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure refrigerated food items were dated, labeled, discarded within set time frames and failed to ensure staff did not store personal food items in the commercial reach in refrigerator designated for resident food storage. The findings include:Observation during the brief initial kitchen tour on 8/6/25 at 10:30 AM with the Dietary Manager identified six carafes of orange juice, six carafes of apple juice, two pitchers of white cranberry juice, and two pitchers of fruit punch with no preparation date. Interview on 8/6/25 at 10:35 AM with Dietary Manger identified the carafes and pitchers should be labeled with the preparation date and usually they are prepared the day before for the next day and there is a piece of parchment paper put on top of them with the date, however the person who prepared them did not put the label there. Observation on 8/6/25 at 10:42 AM with the Dietary Manager identified the walk-in refrigerator contained five plastic containers of apple sauce and six plastic containers of vanilla pudding dated 7/31/25. Interview on 8/6/25 at 10:48 AM with the Dietary Manager identified that once prepared the apple sauce and pudding should have been thrown out after three days. Observation on 8/6/25 at 10:55 AM identified the reach in refrigerator contained an unlabeled plastic container of greens and rice. Interview on 8/6/25 at 11:00 AM with the Dietary Manager identified the plastic container was a staff member's food and that the staff food should not be stored in the reach in refrigerator with food designated for the residents. Review of the food storage policy identified refrigerated ready-to-eat foods shall be discarded within 72 hours of the date opened. The facility uses a date marking policy in conjunction with the food storage policy. Although a Staff food storage policy was requested the facility did not have one to provide.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #107) with a fracture to the right ankle of unknown origin and who required the use of a total mechanical lift for transfers, the facility failed to complete a thorough investigation inclusive of determining that two staff members were utilized when the resident was transferred. The findings include:Resident #107 ‘s diagnoses included dementia, stiffness in bilateral knees, and reduced mobility.The quarterly Minimum Data Set assessment dated [DATE], identified Resident #107 was severely cognitively impaired, had no behaviors and was dependent for activities of daily living and transfers.A nurses note dated 12/23/24 at 2:43 PM identified Resident #107 complained of right ankle pain with movement, swelling and mild bruising around the outer ankle, and a yellow discoloration noted to the left shin. The APRN was updated, evaluated the resident and ordered x-rays. The note further identified that Tylenol 650mg was administered with good effect.A physician's order dated 12/23/24 directed to have an x-ray of the right ankle completed.The x-ray results dated 12/24/24, at 1:11 AM identified that the right ankle had an acute right bimalleolar (bony area on the side of the ankle) fracture with minimal displacement (slightly out of alignment) and associated swelling and modest osteoporosis (weak, brittle bones). It further noted that the ankle alignment was anatomical (normal straight position). The reportable event report dated 12/24/24 at 9:00 AM identified NA #2 last observed Resident #107 at 3:00 PM and had provided incontinent care and a change of clothes. The resident was noted to be in bed. And had no complaints. No bruising or nonverbal cues to pain identified. It also indicated NA #2 transferred Resident #107 utilizing a Hoyer lift (mechanical lift). The report did not identify who assisted NA #2 with the Hoyer transfer. Investigation of Reportable Event form dated 12/24/24 at 9:00 AM, indicated Resident #107 was unable to recall what happened to the ankle, if it was hit by something or hit during transfer. The resident acknowledged it was painful. The Reportable Event report (investigation documentation) dated 12/25/24 at 2:30 PM indicated NA #3 observed Resident #107 at 10:30 AM on 12/24/24. The resident was resting and had no behaviors, however, did complain of pain. NA #3 observed a bruise to the left leg on 12/21/24. No mention of the right leg or ankle in the report. Or where the bruise was on the left leg. NA #3 repositioned Resident #107 on 12/20/24 at which time the resident complained of pain. No identification of where Resident #107 was having pain. The form also indicated NA #3 transferred the resident on 12/20/24 with another staff member. NA #3 took care of Resident #107 on 12/20, 12/21 & 12/22/24. The care plan dated 3/11/25 identified the resident's functional status was an extensive assist with a 2-person physical assist for transfers, via a mechanical lift to an adaptive wheelchair. It also indicated a self-care deficit with interventions that included assistance for eating, personal hygiene, oral care, toileting and transferring. Interview on 8/12/25 at 10:03 AM with LPN #3-unit nurse, indicated while administering medications to Resident #107 the resident was complaining of pain in the right ankle. The LPN #3 then contacted the APRN on call to report the change. An x-ray was ordered and completed, looks like the 11-7 nurse received the results and reported them. The resident was not sent to the hospital as she was on hospice at the time. Hospice was updated on 12/24/24 as both the nurse and aide were on site at bedside. Recommendations were made for a wrap, ice and pain management. I'm not sure how the fracture happened, I thought about it, and I'm not sure. Interview on 8/12/25 at 2:06 PM with NA #3, identified that there was a bruise or discoloration found on the resident, so I reported it to the nurse. I think the nurse on was one of the weekend nurses. I can't really remember a lot, that was awhile back. I do remember the resident was an assist of 2 with a Hoyer lift for transfers. I transferred to Resident #07 with one of the nurses that weekend. Interview on 8/12/25 at 2:12 PM with Person #1, indicated that the Person #1 received an email from a staff member from hospice, explaining that Resident #107 had an ankle fracture. I was not updated by the facility. I'm looking at notes I have from that time. Hospice told me that the facility was managing the care, with an ace wrap, ice and elevation. The hospice staff added an ointment (arnica) for pain management. No mention of how the injury occurred. The resident was fragile, and I received no explanation from the facility. Most of the updates were from the hospice provider. The resident has declined, had weight loss; however, did not meet criteria to continue hospice and was discharged a few months ago from hospice. Interview on 8/12/25 at 3:10 PM with NA #2 identified she could not recall all the details due to the events occurring a while ago. She noted that when she arrived to work, she was told by the nurse that Resident #107 had an injury and then she observed the wrapped ankle. NA #2 further noted that the resident required two staff for transfers and conveyed that she would not transfer the resident without assistance. She further noted that she was not sure why she had not documented who assisted with the transfer and could not recall at the time of the interview who had assisted her. Additionally, she noted she was made aware that the resident had a fracture but did not know what caused the fracture. Interview on 8/13/25 at 7:51 AM with the DNS identified that she conducted the investigation into Resident #107's fracture of unknown origin. She could not recall why she did not ascertain who assisted NA #2 with the transfer because that is a stated question on the investigation form and it would have been important in determining if the transfer had been conducted appropriately or whether there was a chance that the fracture could have occurred during the transfer. The DNS could not identify whether or not the resident had been transferred appropriately and did not give an explanation of how the fracture to Resident #107's right ankle may have occurred. The Mechanical Lift policy indicated that there should always be two people to perform the transfer procedure. One to operate the lift and one person at the resident's feet to guide the resident's lower body during a transfer.

Based clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #54) reviewed for accidents, the facility failed to provide adequate supervision to prevent the resident from smoking in the bathroom and failed to ensure the facility had posted signage to remind visitors not to give smoking materials to the residents in accordance with the facility's smoking policy. The findings include:Resident #54's diagnoses included schizoaffective disorder, heart failure, and chronic obstructive pulmonary disease (COPD).The smoking policy acknowledgment form, the smoking agreement form, and the notification of contraband form signed by Resident #54 and his/her responsible party on 12/23/24 identified that residents were not allowed to have smoking materials in their possession.The quarterly MDS assessment dated [DATE] identified Resident #54 had intact cognition and was independent with dressing, hygiene, transfer, and ambulation without assistive device.The nurse's note dated 6/24/25 at 11:05 PM identified Resident #54 called 911 and reported that he/she couldn't breathe. Resident #54 was sent out to the hospital for evaluation.The nurse's note dated 6/25/25 at 9:04 PM identified that a police officer called the facility to report Resident #54 had left the hospital and to call the police officer if he/she showed up at the facility. The facility called Resident #54s responsible party and was notified by the responsible party that Resident #54 returned to the hospital.The nurse's note dated 6/26/25 at 6:57 AM written by LPN #1 identified Resident #54 returned from the hospital at 2:00 AM via ambulance. Resident #54 was alert, declined to have his/her lungs assessed or body audit completed. LPN #1 left the room and went back to the resident after few minutes and noted Resident #54 smoking in the bathroom. Resident #54 refused to answer any questions. With 2 staff members presence, 2 packs of cigarette and a lighter was removed from the resident's undergarment. Resident #54 was placed in every 15 minutes visual check.Resident # 54's care plan dated 7/1/25 identified he/she enjoy smoking. The care plan interventions directed to observe for any signs ad symptoms of unsafe smoking, smoking evaluation per facility policy, smoking will be supervised at designated times, and facility smoking policy and agreement will be reviewed with the resident per facility policy.\Interview with LPN #1 on 8/11/25 at 2:25 PM identified that Resident #54 came back from the hospital on 6/26/24 at 2:00 AM. She identified that Resident #54 refused to be assessed and walked to use the bathroom. When she came back to the resident room, she identified that the Resident #54 bathroom was locked. She identified that she was able to open the bathroom and that when she saw Resident #54 dropped the cigarette in the toilet and could smell the cigarette smoke in the bathroom. She identified that she called the nursing staff to watch the resident while she called the nursing supervisor. She identified that she perform the body audit for Resident #54 and found 2 pack of cigarette and lighters that were hidden in the resident undergarment. She also identified that Resident #54 refused to answer any questions and was not able to find out who give her/him the cigarette and the lighter. She identified that this was the first time that Resident #54 was smoking in the room and he/she typically just sleeping through the night. She further identified that she did not have suspicion that Resident #54 had cigarette or lighter in his/her possession because he/she came from the hospital.Interview with the DNS on 8/12/25 at 1:30 PM identified all residents admitted to the facility would have smoking assessment and responsible party and/or resident would sign the smoking agreement, smoking policy acknowledgement, and list of contraband not allowed in the facility. She identified that she was made aware of Resident #54 incident of smoking in the bathroom. She identified that Resident #54 belonging would be search with permission when he/she goes out with the responsible party; however, she wouldn't have suspicion Resident #54 would have cigarette and lighter with her/him because he/she came back from the hospital. She identified that Resident #54 refused to answer who provider her/him the cigarette and lighter. She further identified that all residents who smoke would have staff supervision and not allowed to smoke without supervision.Review of the facility up-to-date smoking policy with DNS and administrator on 8/12/25 at 2:00 PM identified in the environmental safety that the facility will post a signage to remind all visitors not to give smoking materials to any residents and reminder that all smoking would be at designated area and times. The DNS and administrator identified that there was no posted signage to remind the visitor not to give smoking that indicated in the facility policy.The facility smoking policy identified any residents preference to smoke would be reasonably accommodated while maintaining the health and safety of the residents and other residents. The policy also indicated that resident smoking was not allowed within the facility and in other areas on facility property that was not designated as smoking areas.

Based on review of clinical records, review of facility documentation, review of facility policy, and interviews for three sample residents (Residents #2, #29 and #123) with incomplete medical records, the facility failed to ensure timely documentation of a physician's medical evaluation and failed to ensure the signed pharmacy recommendation was available in the resident's clinical record. The findings include:1. Resident #2's diagnoses included schizophrenia, bipolar disorder, and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #2 had severely impaired cognition, required maximal assistance with dressing, personal hygiene, bed mobility and transfers. Review of Resident #2's clinical record from January 2025 through August 2025 failed to identify physician evaluations/notes from MD #1. Subsequent to surveyor's inquiry, MD #1's evaluations/notes dated 1/25/25, 3/15/25. 5/24/25, and 7/26/25 were added to the electronic medical record Interview with the DNS on 8/11/25 at 11:35 AM identified that all physician's visits should be documented in the EMR under the progress notes section. The DNS further identified that her expectation is that all physician visit documentation is entered in the EMR after each encounter is completed and noted she was unaware that the physician visit progress notes were not being entered in the EMR. Interview with the Medical Director (MD #1) on 8/11/25 at 12:45 PM identified that he evaluates residents every 60 days and as needed. He identified that his physician's visit progress notes are entered in the EMR for each resident. He identified that he had been seeing Resident #2 and Resident #123 at least every 60 days. He further identified that the facility recently migrated to PCC (Point Click Care) and thought it automatically uploaded his physician's visit to PCC. MD #1 identified that he was not aware that his progress notes/assessments were not automatically uploaded to PCC. He further identified that the facility was working on obtaining a system that would be compatible with PCC so all of his physician's visit will be 2. Resident #29's diagnoses included schizoaffective disorder, alcohol abuse, anxiety, and cocaine use. The quarterly MDS assessment dated [DATE] identified Resident #29 had severe cognitive impairment and was dependent for all personal hygiene and activities of daily living. Review of the monthly pharmacist's reviews from January 2025 through August 2025 identified that the pharmacist visits on 1/13/25, 6/17/25, and 7/15/25 had recommendations that required physician evaluation. A request for the pharmacy recommendation records was made on 8/7/25 for pharmacy reviews dated 1/13/25, 6/17/25, and 7/15/25, but the facility did not provide the pharmacy recommendations with the physician's response to the recommendations. Interview with the DNS on 8/11/25 at 11:30 AM identified that the pharmacist visits monthly to review the resident record and make recommendations as needed. She identified that she receives the pharmacy recommendations via e-mail (electronic mail) and she then makes them available for the physician to address. She identified that Resident #29 had pharmacy reviews with recommendations made on 1/13/25, 6/17/25, and 7/15/25 that required physician evaluation and/or response. She identified that the pharmacy recommendation had been addressed, and changes made to Resident #29's plan of care; however, she could not locate the signed pharmacy recommendation in the clinical record. Further, she identified that the pharmacy recommendations are a part of the clinical record and could not explain what happened to the pharmacy recommendation with the physician's response. The DNS further identified that the medical records staff was responsible for scanning the pharmacy recommendation into the clinical records. Interview with the Medical Records staff on 8/11/25 at 11:45 AM identified that she was responsible for scanning the pharmacy recommendation into the resident medical record. She identified that she collects all the pharmacy recommendation from the supervisor's office every Tuesday and Thursday and scans them into the resident's EMR. She could not identify whether she had collected the pharmacy recommendation for Resident #29; however, she identified that the pharmacy recommendation for Resident #29 should be scanned into the EMR. The Staff Responsibility policy identified that the facility maintains a clinical medical record for each resident which reflects the total care provided to the resident, is maintained in accordance with accepted professional standards and practices, and each medical record is complete, accurate and readily accessible in order to facilitate prompt retrieval and compilation of the information. 3. Resident #123 was admitted in May 2025 with diagnoses that included bipolar disorder, history of pulmonary embolism, major depressive disorder and anxiety disorder. Nursing admission note dated 5/22/25 at 12:00 PM identified resident #123 was admitted to the facility following a suicide attempt. Resident was placed on the secured unit on admission. The admission MDS assessment dated [DATE] identified Resident #123 had a memory problem but was independent with cognitive skills for daily decision making. Was independent with position changes, but required varying assistance with personal hygiene, care. The care plan dated 6/13/25 identified Resident #123 was at risk for self-harm, anxiety, depression, bi-polar and suicide ideation with interventions to include allowing Resident #123 to verbalize frustrations and report any verbalization of intended self-harm or suicide ideation, follow up with psych team as needed and transfer to ED for evaluation if actual risk of harm to self or others becomes evident. Review of the clinical record from 5/23/25 through 7/11/25 identified Resident #123 failed to identify Resident #123 had been seen by MD#1. Interview on 8/13/2025 at 9:48 AM with MD#1 identified that newly admitted residents are usually seen within two days of admission. MD#1 identified that some of the visit notes were not transcribing to the clinical chart. Subsequent to surveyor inquiry, MD #1's progress note/assessment dated [DATE] was added to the clinical record.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #2) who had a witnessed fall with no initial injuries noted, the facility failed to notify the physician after a change in condition was identified. The findings include: Resident #2's diagnoses included malignant neoplasm of the oropharynx, anxiety, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had poor short- and long-term memory recall. The nurse's note dated 1/9/25 at 3:08 PM identified Resident #2 had a witnessed fall at 2:45 PM in the hallway. Resident #2 was ambulating in the hallway, lost his/her balance and fell. Resident #2 complained of right hip and knee pain, there were no bruises or discoloration seen at that time and Resident #2 had positive range of motion (ROM) to all extremities. The note identified the Advanced Practice Registered Nurse (APRN) #1 was updated and directed a stat x-ray order for the right knee and hip along with neurological checks for seventy-two (72) hours. The nurse's note dated 1/9/25 at 10:16 PM identified the x-ray was done. The physician's progress noted dated 1/10/25 at 2:45 PM identified APRN #1 evaluated Resident #2 for follow-up after the fall on 1/9/25 and reviewed the x-ray results. APRN #1 identified Resident #2 continued to report right hip pain at ten (10) out of ten (10), Resident #2 had full ROM in all joints, there was no bruising, upper extremity deformity, normal muscle bulk and tone, edema, joint swelling, or deformity, Resident #2 moved all extremities equally, and had tenderness on exam. The right hip x-ray dated 1/9/25 identified mild osteoarthritis and right knee x-ray identified modest osteoarthritis and no acute fracture was identified on the x-ray. APRN #1 directed to continue the pain medication Resident #2 was currently on for palliative care, monitor pain levels and mobility, and encourage use of the walker and assist with ambulation as needed. APRN #1 directed to monitor for any delayed symptoms or complications from the fall. The 7AM-3PM nurse's note dated 1/11/25 at 3:09 PM identified Resident #2 continued to complain of right hip pain and was unable to fully extend his/her leg, Morphine was given with good effect and the Nursing Supervisor was made aware. The nurse's note dated 1/12/25 at 4:15 PM identified Resident #2 complained of right hip pain at 10 out of 10 not relieved by pain management. The physician on call was notified and the physician directed to increase the Morphine dose for two (2) days and have APRN #1 follow-up the next day. The physician's progress note dated 1/12/25 at 4:40 PM from the on-call physician identified Resident #2 continued to complain of right hip and knee pain and given the limitation of ambulation at baseline, questionable to repeat or escalate the imaging to a CT or MRI. Plan to increase analgesia coverage and have primary team reassesses. Review of the clinical record from 1/11/25 through 1/13/25 failed to reflect documentation the provider was notified when Resident #2 was unable to fully extend his/her leg. The physician's progress note dated 1/13/25 at 4:45 PM identified APRN #1 evaluated Resident #2 for increased right hip pain with swelling. Previously on 1/10/25 Resident #2 had pain 10 out of 10 and full ROM. The note indicated Resident #2 was now identified with swelling and tenderness to the proximal right femur, decreased ROM in the right leg, unable to lift the right leg or bear weight on leg, and due to worsening symptoms APRN #1 directed to send Resident #2 to the Emergency Department (ED) for further evaluation and treatment. The nurse's note dated 1/17/25 at 7:33 PM identified Resident #2 returned to the facility after being diagnosed with a right hip proximal femoral fracture. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 6/20/25 at 11:45 AM identified on 1/11/25 Resident #2 complained of pain and was unable to extend his/her right leg and after administering Morphine, Resident #2 was more comfortable but was still unable to extend his/her leg. LPN #1 identified that she notified the Nursing Supervisor but could not recall the response. Interview with the Assistant Director of Nursing (ADON) on 6/20/25 at 11:55 AM identified she was called to the unit on 1/9/25 when Resident #2 fell. The ADON indicated although Resident #2 complained of right hip pain but had no noted abnormalities and she along with the nurse aide and charge nurse assisted Resident #2 up and walk back to his/her room with no difficulty. Interview with APRN #1 on 6/20/25 at 12:40 PM identified she evaluated Resident #2 on 1/10/25 and although Resident #2 had a high pain level which was not uncommon for Resident #2 to have due to her chronic co-morbidities. APRN #1 indicated although Resident #2's x-rays were negative, Resident #2 should be monitored and staff needed to notify her if there was any change in status or symptoms so that further testing could be ordered. APRN #1 identified the staff should have notified her on 1/11/25 when Resident #2 was unable to extend his/her leg and if she had been notified, she would have sent Resident #2 out for further evaluation at that time. Interview with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #2, on 6/20/25 at 1:45 PM identified she was the Supervisor working on 1/11/25. RN #2 explained she could not recall being notified Resident #2 was unable to extend his/her leg and if she had been notified, she would have assessed Resident #2, documented the assessment, and called the physician for further direction. Interview with the Director of Nursing (DON) on 6/20/25 at 2:12 PM identified if a nurse noted a change in condition, they need to inform the Nursing Supervisor who would assess then update the physician to get direction. The DON indicated that on 1/11/25 when Resident #2 no longer had full range of motion in his/her right leg, that would have been classified as a change in condition. Review of the facility policy Change of Condition identified it was the facility's policy to notify the physician when the residents' condition or status changed. The policy further identified if the resident is evaluated by a charge nurse to have a changed in condition, the charge nurse would notify the RN supervisor on duty who would do a follow-up assessment. The follow-up assessment would be documented and reported to the physician. Although attempted, an interview with the 3-11PM Nursing Supervisor was not obtained.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for medication administration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) timely of medication omissions. The findings include Please cross reference F 684. Resident #2's diagnoses included cellulitis (bacterial skin infection) and spondylosis of the lumbar region (degeneration of the bones and disks in the lower spine). The Resident admission Profile dated 8/16/24 identified that Resident #2 was alert and oriented to person, place and time and was independent with eating and required assistance with transfers and mobility. Review of Resident #2's Face sheet identified that the resident was admitted to the facility on [DATE] at 6:30 PM. Review of Resident #2's admission orders dated 8/16/24 directed that the resident was to be administered: 1) Tylenol (pain reliever) 500 milligrams (mg), 2 tablets (1000 mg) by mouth three times daily at 6:00 AM, 2:00 PM and 10:00 PM. 2) Lipitor (used to lower blood cholesterol and fat) 10 milligrams (mg), 1 tablet daily in the evening at 5:00 PM. 3) Clonazepam (used to treat anxiety, prevent seizures and promote relaxation) 1 milligram (mg) tablet by mouth four times daily at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. 4) Zanaflex (muscle relaxer) 2 milligram (mg) tablet by mouth every eight (8) hours around the clock at 6:00 AM, 2:00 PM and 10:00 PM. 5) Albuterol (relaxes and opens air passages to the lungs to make breathing easier) 108 micrograms (mcg) inhaler, inhale 1 puff every eight (8) hours around the clock at 6:00 AM, 2:00 PM and 10:00 PM. 6) Keflex (antibiotic) 500 milligram (mg) capsule by mouth four times daily at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. 7) Robaxin (muscle relaxer) 750 milligrams (mg) 1 tablet by mouth three times daily at 9:00 AM, 1:00 PM and 5:00 PM. 8) Lyrica (used to treat nerve and muscle pain and seizures) 75 milligram (mg) capsule by mouth twice daily at 9:00 AM and 5:00 PM. 9) Lyrica 150 milligram (mg) capsule, administer 2 capsules (300 mg) by mouth at bedtime (9:00 PM). 10) Metformin (used to treat high blood sugar levels) 500 milligrams (mg) tablet by mouth twice daily at 8:00 AM and 8:00 PM. 11) Remeron (used to treat depression) 15 milligram (mg) tablet by mouth at bedtime (9:00 PM). 12) Flonase (used to relieve allergic and non-allergic nasal symptoms) 50 microgram(mcg) nasal spray, administer 2 sprays each nostril every morning at 8:00 AM. 13) Breo Ellipta (used to treat asthma and chronic obstructive pulmonary disease) 100/25 micrograms (mcg) inhaler, inhale 1 puff daily at 9:00 AM. 14) Cozaar (used to treat high blood pressure) 25 mg tablet by mouth daily at 9:00 AM. Resident Grievance Report dated 8/19/24 identified, in part, that Resident #2 reported that his/her medications were not in from the pharmacy in a timely manner. The report identified that nursing responded (no staff name identified) stating the Medication Administration Record (MAR) was inspected and the resident received all medications on 8/17/24 and upon arrival on 8/16/24 at 6:30 PM, his/her medications were faxed to the pharmacy and arrived at 3:00 AM on 8/17/24. The report identified that the resident received pain medication and diabetic medication on admission. No supporting documentation was attached to the Grievance Report. Review of the Medication Administration Record (MAR) for August 2024 identified that Resident #2's Tylenol 1000 mg tablets were not administered on 8/16/24 at 10:00 PM or on 8/17/24 at 6:00 AM, Clonazepam 1 mg tablet was not administered on 8/16/24 at 9:00 PM or on 8/17/24 at 9:00 AM or 1:00 PM, Zanaflex 2 mg tablet was not administered on 8/16/24 at 10:00 PM, Albuterol 108 mcg inhaler was not administered on 8/16/24 at 10:00 PM, Keflex 500 mg capsule was not administered on 8/16/24 at 9:00 PM, , Lyrica 75 mg capsule was not administered on 8/17/24 at 9:00 AM, Lyrica 300 mg capsules were not administered on 8/16/24 at 9:00 PM, Metformin 500 mg tablet was not administered on 8/16/24 at 8:00 PM, Remeron 15 mg tablet was not administered on 8/16/24 at 9:00 PM, Flonase 50 mcg nasal spray was not administered on 8/17/24 at 8:00 AM, Breo Ellipta 100/25 mcg inhaler was not administered on 8/17/24 at 9:00 AM and the Cozaar 25 mg tablet was not administered on 8/17/24, 8/18/24 or 8/19/24 at 9:00 AM. Review of the hospital discharge paperwork dated 8/16/24 identified that all the above medications were to be taken upon transfer to the facility and that Resident #2 was last administered medications at 1:33 PM in the hospital. Review of the nurse's notes dated 8/16/24, 8/17/24, 8/18/24 and 8/19/24 failed to identify that the above medications were unavailable, and that the provider was notified of the missed doses of medications. Interview with LPN #2 (Resident #2's charge nurse for 3:00 PM to 11:00 PM on 8/16/24) on 3/3/25 at 9:18 AM identified that in August 2024, she was new to the facility and stated she could not recall Resident #2. She reported that for new admissions, the Nursing Supervisor will obtain the physician's orders and then gather the medications available within the facility and give them to the charge nurse responsible for the new admission to administer. She identified that if any medications are unavailable, the Nursing Supervisor contacts the provider to notify them, reporting that she (LPN #2) will then sign off the medications that she administers in the MAR. Interview with RN #1 (3:00 PM to 11:00 PM Nursing Supervisor on 8/19/24) on 2/28/25 at 1:57 PM identified that after she finishes an admission and faxes the physician's orders, she will attempt to gather the resident's medications that are available within the facility and the Omnicell. She reported that if the medications are unavailable, she will communicate to the resident that they are awaiting the pharmacy delivery and that medications usually arrive on the overnight run, and they will administer the medication(s) when available. RN #1 identified that the Tylenol and the Clonazepam should have been available but was unsure if she had attempted to obtain the Clonazepam from the Omnicell. She reported that if the medications are more than one hour past their administration time, she should have contacted the APRN or the Medical Director to get a new order or an order to administer the medication once it was available but stated she was unsure if she had done that, stating she should have documented the notification in the clinical record if she had. Interview with APRN #1 on 2/28/25 at 2:05 PM identified that if medications are ever not available for a resident, nursing should be contacting the facility provider or on-call provider to report that the medication(s) is/are unavailable. She reported that although she was unsure if she had been contacted regarding Resident #2, she stated that if she was, she would have adjusted or given new orders for alternative medications or given an order to administer the medication when it arrived from the pharmacy. Additionally, she identified that with all the medications that were omitted for Resident #2, she did not attribute any of them as significant medication errors and was unaware of any change in condition that occurred due to the medication omissions. Interview and review of the August 2024 MAR for Resident #2 with the DNS on 2/28/25 at 1:39 PM identified that the facility utilizes an Omnicell (an automatic medication dispensing system) for overflow prescription and emergency medications, stating that the Nursing Supervisors are responsible for notifying the provider of any medications that are not available as either house stock or in the Omnicell on admission, as nursing has one hour after the administration is due to administer the medication before the provider must be notified. She reported that in August of 2024, the 3:00 PM to 11:00 PM Nursing Supervisors would have faxed the admission physician's orders to the pharmacy and if the medications were unavailable within the facility, their night delivery would usually arrive between 10:00 PM and 1:00 AM from the pharmacy. The DNS identified that although the resident should have received his/her medications on admission, if nursing didn't sign off on the Medication Administration Record (MAR) that the medications were given and there were no nursing notes indicating that the provider was notified of the missed doses, she would have classified that as a medication error, stating she was unaware that the Resident did not receive his/her medications and had medication omissions on the MAR. Additionally, she stated she was unsure why the 8/19/24 Grievance Report identified that Resident #2 received all of their medications on 8/17/24 and did not validate that he/she was not administered all of his/her medications on 8/16/24, when according to the documentation he/she did not. She identified that she was unable to pull reports from the Omnicell back to August 2024 but stated she would contact the pharmacy to see if any of Resident #2's medications were pulled from the Omnicell on 8/16/24 or 8/17/24. .Documentation provided by the DNS on 3/3/25 at 10:20 AM via email failed to identify that any of Resident #2's omitted medications were pulled/obtained through the Omnicell by staff on 8/16/24 or 8/17/24. Although requested, facility policies for Medication Errors and Provider Notification was not provided.

Based on review of the clinical record, facility policy, and interviews for the one (1) of three (3) residents (Resident #1) reviewed for diabetes management, the facility failed to revise the care plan to include the resident's diagnosis and concerns related to his/her diabetic plan of care. The findings include: Resident #1's diagnoses included Congestive Heart Failure (CHF) and Chronic Kidney Disease (CKD). The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with showering/bathing self, bed mobility and transfers. Review of Resident #1's hospital Discharge summary dated [DATE] identified that Resident #1 had a diagnosis of diabetes mellitus, type II and was discharged to the facility on insulin glargine (lantus) 100 units per milliliter (mL) directing to inject 12 units under the skin at bedtime. A physician's order dated 1/25/25 directed to continue Lantus 12 units daily at bedtime and implement blood glucose monitoring before meals and notify provider if blood glucose is <70 or >400. Advanced Practice Registered Nurse (APRN) note dated 1/27/25 at 8:00 AM identified that Resident #1 was on 36 units of Lantus at home, but it was decreased due to some hypoglycemia (low blood sugar) in the hospital. He/she has a monitor in place for the blood sugar. He/she does not use short acting insulin at home. A Resident Care Conference note dated 2/7/25 at 1:15 PM identified that diabetic education as well as teaching was discussed. Interview with the DNS on 2/28/25 at 2:30 PM identified that per the policy, a Comprehensive Care Plan for Resident #1 should have been developed by the Interdisciplinary Team (IDT) within seven (7) days of the completion of the MDS dated [DATE]. She identified that although a Resident Care Conference for Resident #1 was held on 2/7/25 and diabetic teaching and education was discussed, she was unsure why a Care Plan was not developed for the resident's diabetic care. Review of the Care Plan policy dated 4/17/24 directed, in part, that within seven (7) days of completing the MDS, the Interdisciplinary Team (IDT) develops, reviews and revises the plan of care to ensure it is person-centered and individualized to meet the needs of the resident.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for medication administration, the facility failed to ensure that a newly admitted resident was provided with medications in accordance with hospital discharge summary directions and physician's orders. The findings includePlease cross reference F 580Resident #2's diagnoses included cellulitis (bacterial skin infection) and spondylosis of the lumbar region (degeneration of the bones and disks in the lower spine).The Resident admission Profile dated 8/16/24 identified that Resident #2 was alert and oriented to person, place and time and was independent with eating and required assistance with transfers and mobility.Further Review of the Resident admission Profile identified that RN #1 completed Resident #2's admission assessment on 8/16/24 at 6:16 PM.Review of Resident #2's admission orders dated 8/16/24 directed that the resident was to be administered:1) Tylenol (pain reliever) 500 milligrams (mg), 2 tablets (1000 mg) by mouth three times daily at 6:00 AM, 2:00 PM and 10:00 PM.2) Lipitor (used to lower blood cholesterol and fat) 10 milligrams (mg), 1 tablet daily in the evening at 5:00 PM.3) Clonazepam (used to treat anxiety, prevent seizures and promote relaxation) 1 milligram (mg) tablet by mouth four times daily at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM.4) Robaxin (muscle relaxer) 750 milligrams (mg) 1 tablet by mouth three times daily at 9:00 AM, 1:00 PM and 5:00 PM.5) Lyrica (used to treat nerve and muscle pain and seizures) 75 milligram (mg) capsule by mouth twice daily at 9:00 AM and 5:00 PM.6) Lyrica 150 milligram (mg) capsule, administer 2 capsules (300 mg) by mouth at bedtime (9:00 PM).7) Flonase (used to relieve allergic and non-allergic nasal symptoms) 50 microgram(mcg) nasal spray, administer 2 sprays each nostril every morning at 8:00 AM.9) Breo Ellipta (used to treat asthma and chronic obstructive pulmonary disease) 100/25 micrograms (mcg) inhaler, inhale 1 puff daily at 9:00 AM. 10) Cozaar (used to treat high blood pressure) 25 mg tablet by mouth daily at 9:00 AM.A Resident Grievance Report dated 8/19/24 identified, in part identified that Resident #2 reported that his/her medications were not in from the pharmacy in a timely manner. The report identified that nursing responded (no staff name identified) stating the Medication Administration Record (MAR) was inspected and the resident received all medications on 8/17/24 and upon arrival on 8/16/24 at 6:30 PM, his/her medications were faxed to the pharmacy and arrived at 3:00 AM on 8/17/24. The report identified that the resident received pain medication and diabetic medication on admission. No supporting documentation was attached to the Grievance Report.Review of the Medication Administration Record (MAR) for August 2024 identified that Resident #2's Tylenol 1000 mg tablets were not administered on 8/16/24 at 10:00 PM or on 8/17/24 at 6:00 AM (which was available as a house stock medication), Clonazepam 1 mg tablet was not administered on 8/16/24 at 9:00 PM (which was stocked in the Omnicell and available) or on 8/17/24 at 9:00 AM or 1:00 PM, Lyrica 75 mg capsule was not administered on 8/17/24 at 9:00 AM, Flonase 50 mcg nasal spray was not administered on 8/17/24 at 8:00 AM, Breo Ellipta 100/25 mcg inhaler was not administered on 8/17/24 at 9:00 AM and the Cozaar 25 mg tablet was not administered on 8/17/24, 8/18/24 or 8/19/24 at 9:00 AM.Review of the hospital discharge paperwork dated 8/16/24 identified that all the above medications were to be taken upon transfer to the facility and that Resident #2 was last administered medications at 1:33 PM at the hospital.Review of the nurse's notes dated 8/16/24, 8/17/24, 8/18/24 and 8/19/24 failed to identify that the above medications were unavailable, and that the provider was notified of the missed doses of medications.Interview with LPN #2 on 3/3/25 at 9:18 AM (nurse who was working on 8/16/24 when the resident was admitted ) identified that in August 2024, she was new to the facility and stated she could not recall Resident #2. She reported that for new admissions, the Nursing Supervisor will obtain the physician's orders and then gather the medications available within the facility and give them to the charge nurse responsible for the new admission to administer. She identified that if any medications are unavailable, the Nursing Supervisor contacts the provider to notify them, reporting that she (LPN #2) will then sign off the medications that she administers in the MAR.Interview with RN #1 (the 3:00 PM to 11:00 PM Nursing Supervisor on 8/16/24) on 2/28/25 at 1:57 PM identified that after she finishes an admission and faxes the physician's orders, she will attempt to gather the resident's medications that are available within the facility and the Omnicell. She reported that if the medications are unavailable, she would communicate to the resident that they are awaiting the pharmacy delivery and that medications usually arrive on the overnight run, and they will administer the medication(s) when available. RN #1 identified that the Tylenol and the Clonazepam should have been available on the medication cart and in the omnicell, however, she was unsure if she had attempted to obtain the Clonazepam from the Omnicell. She reported that if the medications are more than one hour past their administration time, she should have contacted the APRN or the Medical Director to get a new order or an order to administer the medication once it was available but stated she was unsure if she had done that, stating she should have documented the notification in the clinical record if she had.Interview with APRN #1 on 2/28/25 at 2:05 PM identified that the medication omissions would not be considered significant medication errors and was unaware of any change in condition that occurred due to the medication omissions.Interview and review of the August 2024 MAR for Resident #2 with the DNS on 2/28/25 at 1:39 PM identified that the facility utilizes an Omnicell (an automatic medication dispensing system) for overflow prescription and emergency medications, stating that the Nursing Supervisors are responsible for notifying the provider of any medications that are not available as either house stock or in the Omnicell on admission, as nursing has one hour after the administration is due to administer the medication before the provider must be notified. She reported that in August of 2024, the 3:00 PM to 11:00 PM Nursing Supervisors would have faxed the admission physician's orders to the pharmacy and if the medications were unavailable within the facility, their night delivery would usually arrive between 10:00 PM and 1:00 AM from the pharmacy. The DNS identified that although the resident should have received his/her medications on admission, if nursing didn't sign off on the Medication Administration Record (MAR) that the medications were given and there were no nursing notes indicating that the provider was notified of the missed doses, she would have classified that as a medication error, stating she was unaware that the Resident did not receive his/her medications and had medication omissions on the MAR. Additionally, she stated she was unsure why the 8/19/24 Grievance Report identified that Resident #2 received all of their medications on 8/17/24 and did not validate that he/she was not administered all of his/her medications on 8/16/24, when according to the documentation he/she did not. She identified that she was unable to pull reports from the Omnicell back to August 2024 but stated she would contact the pharmacy to see if any of Resident #2's medications were pulled from the Omnicell on 8/16/24 or 8/17/24.Documentation provided by the DNS on 3/3/25 at 10:20 AM via email failed to identify that any of Resident #2's omitted medications were pulled/obtained through the Omnicell by staff on 8/16/24 or 8/17/24.Although requested, facility policies for Medication Errors was not provided.

Based on review of facility smoking policy and Leave of Absence (LOA) policy and staff interviews, the facility failed to ensure that facility policies honored the resident's rights. The findings included: 1. On 7/21/2023 at 1:00 PM an interview and policy review with the Administrator, the [NAME] President of Operations, Registered Nurse (RN #6), and the Director of Nursing Services (DNS) identified the smoking policy and smoking agreement signed by the resident/responsible party indicated in part a potential removal of smoking privileges from a resident who was not complied with the facility smoking rules. The Administrator and [NAME] President of Operations further indicated the smoking rules were in place to ensure that residents who smoke adhere to the rules to prevent a potential emergent situation of all residents if a fire was started by a resident who was not following the rules, kept smoking items in their own possession and started a fire in the facility. The Administrator further indicated to his knowledge smoking privileges have yet to be taken away from any residents in the facility. The Administrator also indicated it is the hopes of the facility that by having the rules in place and signing the agreement that would prevent any unexpected outcomes. RN #6 indicated that the determination of need for changes in a resident's smoking privileges would be reviewed by the Interdisciplinary Team including an infraction sheet kept for those residents who do not follow the policy rules for smoking. The [NAME] President of Operations indicated that although it may seem punitive to take away smoking privileges if all facility smoking is supervised by staff members in an approved location with smoking materials kept by the facility until time of distribution, the goal is to provide a safe environment for all the residents. RN #6 indicated smoking privileges suspension is decided by the physician. On 7/21/2023 at 1:20 PM a telephone call with the facility Medical Director (MD # 3) indicated he/she is only involved in the medical aspect of residents who smoke and is not involved in the actual determination of removal of smoking privileges. The Medical Director (MD #) further indicated he would meet with any smoker and discuss smoking is not healthy and offer the use of a smoking patch to assist in cessation, reinforce smoking materials used during the supervised smoking sessions cannot be brought back into the facility by the residents. MD #3 also indicated to his/her knowledge the facility has not had to provide a 30-day notice of discharge to any resident due to frequent reminders by staff to follow the smoking policies. The MD #3 further indicated that he/she is not actively involved in the decision process regarding whether a resident's smoking privileges would be taken away but to the contrary is informed by facility staff of issues that have occurred. The Medical Director did indicate he/she is involved with review of the facility policies and to his/her knowledge no smoking privileges have been suspended. The facility Smoking Agreement revised 12/6/2021 indicated in part that violation of the smoking policies may result in being placed on frequent checks, a progressive modification of smoking schedules up to and including the elimination of smoking breaks, restriction of LOA privileges, smoking privileges being suspended, immediate termination of smoking privileges if the resident places other residents or the environment at risk and the issuance of a 30 day notice of discharge. 2. A review of the facility Leave of Absence (LOA) policy with RN #6 on 7/21/2023 at 1:00 PM in the presence of the Administrator and [NAME] President of Operations identified the Leave of Absence policy requires residents to give a 72-hour notice so that staff has adequate time to obtain medications for residents LOA period and for the Interdisciplinary Team to decide if the resident is appropriate to leave the facility. RN#6 indicated a short notice LOA would be considered on a case-by-case basis. On 7/21/2023 at 1:20 PM a telephone call with the facility Medical Director (MD #3) identified that his/her role in the Leave of Absence policy which requires the provision of 72-hour notice to the facility is to determine whether the nursing home resident is physiologically, psychologically, and emotionally ready to safely go into the community or home for a LOA. The Medical Director further indicated it is necessary that the caretaker understands the medical conditions and can identify changes in the residents and to screen residents to see if they are safe and medically stable to have an LOA. The Medical Director further indicated that being a smoker is not a hard stop to not providing the ability to have a LOA of but is part of determining safety. The Medical Director also indicated the facility informs him/her of the resident circumstances of violation of policy and the residents are provided with instructions for safety but if they had a repeated violation, the facility would decide the next step. He further indicated that the Medical Director is involved with the medical aspect of the resident to determine if any testing, laboratory work or new orders might be needed based on any changes of the resident upon return from an LOA. The facility policy labeled Smoking-Resident, last revised 9/19/2016 presented as the current policy in effect, indicated in part on admission a facility representative would review the smoking agreement with the resident (or responsible party) who is an active smoker or smoking up to the time of hospitalization and would obtain appropriate signatures on the agreement form. The policy further indicated that if a smoker who has LOA privileges may request his/her smoking material for the LOA the resident must return them for safe storage by the facility upon return. The policy further indicated that the Interdisciplinary Team may suspend a resident's leave of absence (LOA) privileges when the resident's safety or the environment is at risk. The policy further indicated that in the event of a policy infraction(examples: failure to extinguish cigarette/smoking materials appropriately, lighting cigarette from another resident's cigarette, improper sharing of cigarettes, collecting cigarette butts, shoving /pushing in line, bringing smoking materials into the facility, smoking in the facility, smoking in unsupervised areas and/or any unsafe behavior related to smoking) corrective action to promote and ensure safety will be applied in a progressive manner based on the severity of the infraction and the resident's needs with examples of interventions that included in part an individualized behavior plan and smoking schedule modification. The facility policy for Travel Pass for Leave of Absence dated 12/8/2022 presented as the most current policy indicated in part that all patient's and or the Conservator will need to provide a 72-hour notice for each request to be reviewed for consideration by the interdisciplinary team, but consideration will be given on a case-by-case basis for approval with shorter notice. The interdisciplinary team will review each request in accordance with the individual resident's needs and make recommendations based on that review. The physician will then sign off or deny the request for a travel pass.

Based on clinical record reviews, review of policy and staff interviews and facility policy for 3 of 9 sampled Residents (Residents #38 # 69 and # 92) reviewed for Advanced Directives, the facility failed to ensure the resident advanced directive was placed in the electronic medical record timely and in the clinical record and for Resident ( 109), the facility failed to ensure the resident's advanced directive was addressed timely. The findings include: 1. Resident # 38's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), hypernatremia, anemia, thrombosis, cytopenia, osteoarthritis acute cystitis, acute metabolic encephalopathy, Urinary Tract Infection (UTI), seizures and Transient Ischemic Attack (TIA) schizoaffective disorder and diabetes mellitus. The physician's order dated 10/28/22 directed Do Not Resuscitate (DNR), Do Not Intubate (DNI), Don Not Hospitalize (DNH), Comfort Measures Only (CMO) and nurse may pronounce. The advanced directive in the paper chart on 6/23/23 the nursing unit noted poor prognosis, DNR, Registered Nurse Pronouncement (RNP) The significant change MDS assessment dated [DATE] identified the resident was moderately cognitively impaired, required extensive one-person physical assist for bed mobility, transfers, toileting, and personal hygiene. The significant change assessment also noted the resident was incontinent of bladder and bowel and was receiving hospice care. A review of the facility Electronic Medical Record (EMR) soft on 7/20/23 and 7/25/23 failed to reflect that Resident # 38's advanced directive was noted in the EMR. Interview and review of Resident # 38's EMR with RN # 4 on 7/25/23 from 9:40 AM identified prior to 7/1/23 to 7/25/23 at 9:45 AM the resident's code status was note in the EMR on admission per her and facility practice. 2. Resident # 69's diagnoses included bipolar anxiety and depressive disorder paraplegia type 2 diabetes mellitus, kidney stone and adrenal insufficiency. The quarterly MDS assessment dated [DATE] identified the resident was moderately cognitively impaired, required extensive assistance with two persons physical assist for bed mobility and toileting and noted total dependence two persons physical assistance with personal hygiene. The assessment also noted the utilization of Foley catheter and indicated the resident was occasionally incontinent of stool. A review of June 2023 physician's order identified Resident # 69 was a full code signed by the APRN. A review of the clinical record physician's orders on 7/14/23 identified a code status DNR, DNI and RN May Pronounced which was signed by the Advanced Practice Registered Nurse (APRN) dated 7/11/23. A physician orders for 7/14/23 also noted DNR and DNI and RN may pronounce. Interview with RN # 1 (day supervisor) on 7/25/23 at 9:59 AM identified the resident during a brief stay in the hospital was a full code but when return to the facility was a DNR. RN # 4 also indicated that status was just changed back to DNR these last two weeks, and she could not provide evidence that the resident's change in code status have been entered into the EMR. 3. Resident # 92's diagnoses included Congestive Heart Failure (CHF), COPD, Chronic Kidney Disease, dementia, hypertension, and behavioral disturbances. The quarterly MDS assessment dated ,d+[DATE] identified the resident was moderately cognitively impaired and noted independent to supervision with ADLs. The assessment also noted the resident was incontinent of bowel and bladder. The Advanced Directive / Codes Status Consent Form dated 11/22/22 identified DNR with no date signed by the physician. However, review of the physician's order / Progress note form noted DNR and RNP with MD signature of 11/29/22. On 7/18/23 12:17 PM a review of the clinical record paper chart identified a code status DNR, RN pronouncement. A review of physician's orders dated 4/1/23 through present 7/20/23 identified for Advanced Directive DNR and RN may pronounce but failed to identify a signature by the physicians for the resident's 30- or 60-day orders. Interview with RN # 1 (day supervisor) on 7/20/23 at 11:50 AM identified she could not provide evidence that the resident Advanced Directive orders had been signed by the physician after March 2023 and the advanced directive of DNR and RN Pronounce was noted in the EMR. Further review of the clinical record on 7/25/23 identified the resident's last signed physician's orders in the paper chart was 3/31/23. Additionally review of Resident # 92's EMR failed to reflect the resident's Advanced Directive DNR and RN may pronounce. 4. Resident #109 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure, asthma, anxiety, and schizophrenia. The Annual MDS assessment dated [DATE] indicated Resident #109 was severely cognitively impaired. On 7/18/23 at 1:56 PM review of Resident #109's clinical record identified the resident's Advanced Directives sheet was signed and dated on 10/5/2022 by a staff member and the Conservator for Resident #109 signed the advanced directive form on 12/13/2022 (67 days after the resident's readmission). A progress note dated 11/10/2022 indicated the Social Worker (SW#1) was informed Resident #109 had paperwork that needed to be signed and SW #1 reached out to the Conservator of Person (COP) who indicated to the SW#1 s/he would be in to sign the paperwork needed on the upcoming weekend. On 7/20/23 at 8:20 AM an interview and record review with SW#identified that he/she is occasionally would be asked to assist the Assistant Director of Nursing Services (ADNS) who is responsible for the advanced directives for all the residents. SW#1 also indicated on 11/10/22 s/he made a progress note about how s/he assisted with the advanced directives for Resident #109. SW#1 further indicated that the COP for Resident#109 had some health issues which may have prevented him/her from coming in on the weekend he/she had indicated but in talking with the COP in the past. SW # 1 further indicated in talking with the resident's COP s/he was adamant Resident#109 should be a full code but in reviewing the clinical record could not provide documentation of the discussion. SW#1 indicated advanced directives are always reviewed at that care plan meeting and is checked off on the care plan meeting sign in sheet and if the resident or conservator wants the status changed, the facility would proceed with the process to do so. An interview and record review with the ADNS on 7/20/23 at 8:55 AM identified residents will be a Full Code until the paperwork is signed by the COP and the physician. The ADNS also was not aware if the physician or APRN discussed advanced directives with the resident or responsible parties. The ADNS further indicated that the completion of advanced directives is a shared responsibility of the charge nurse and nursing supervisor on the day of admission/readmission, and the ADNS was responsible for following up later to check for completion. On 7/20/23 at 9:09 AM interview and clinical record review with the ADNS indicated there was no baseline care plan that addressed advanced directives and none in the present care plan. The ADNS further indicated the advanced directive sheet was signed by a staff member on the readmitted [DATE]. The ADNS was unable to explain why it was signed by the staff member on the day of admission and not by COP. The ADNS further indicated it was possible that the staff member had a conversation with the COP and received verbal consent, however, no supportive documentation or provision of a reason for the delay in completion of the advanced directive form was provided. On 7/20/2023 at 11:00AM an interview with the DNS indicated the facility does not create care plans that address advanced directives as they are reviewed at the care plan meeting when held and checked off on the signature sheet. The facility policy labeled Advanced Directive-Decision-Making, Policy revised on 12/6/202 notes in part, the policy of the facility is to provide information and to discuss all health care decisions with the resident and or authorized decision makers. The policy further indicated the facility will review and make part of the medical records any advanced directive documents presented to the facility at admission or anytime thereafter. A physician or any health care provider shall record in the medical record any oral communication concerning any aspect of the patient's health care including the withholding or withdrawal of life support systems made directly to the healthcare provider. 46046

Based on clinical record review, facility documentation, and policy review and interviews for 1 of 1 sampled resident (Resident #33) reviewed for specialized treatment, the facility failed to ensure the resident's care plan for weight monitoring was followed. The finding include: Resident # 33's diagnoses included: Acute and Chronic Respiratory Failure, diabetes mellitus, depression, Heart Failure, Congestive Heart Failure (CHF), COPD, End Stage Renal Failure, and Kidney Transplant with Rejection. An admission MDS assessment dated [DATE] identified Resident #33 as alert and cognitively intact, the resident required limited assistance of one for transfers, dressing, toilet use, and personal hygiene, supervision with assistance of one for bed mobility, and independent with set-up for eating. The Treatment Administration Record (TAR) for the month of June 2023 indicated daily weights per CHF/COPD guidelines, if over 2 pounds in 24 hours or 5 pounds in 1 week, notify MD. A physician's order dated 7/10/23 indicated weigh weekly x 4, then monthly. A Resident Care Plan dated 7/10/23 identified the resident was at risk for device failure related to chronic conditions. Interventions included: monitoring weights and vital signs pre and post specialized treatment, sending resident out with special treatment communication book when out for treatments as a means of communicating with the staff from both the center and the nursing home, monitoring for worsening of symptoms of a weight gain of 2 pounds in a day or 5 pounds in a week should be reported, weights daily, at the same time and in the same amount of clothing, ideally in the morning after using the bathroom and before breakfast and a fluid restriction as indicated. The TAR dated 7/10/23 failed to indicate weight monitoring for a resident with chronic disease processes. According to the Journal of Cardiac Failure Volume 29, Issue 1, January 2023, heart failure fluctuations in weight can provoke symptoms, worsen outcomes and is responsible for almost half of the deaths of patients on dialysis. The facility Dialysis Communication Form(s) provided by the facility located in the Communication binder included forms dated 7/11, 7/13, 7/15, 7/18 and 7/20/23, and identified the facility provided the residents vital signs, and the nurse's signature. However, the dialysis complete forms dated 7/11, 13, 18 and 20, 23 failed to include the resident's weights. The areas on the form completed by the Specialized Treatment Center failed to provide vital signs, pre and post treatment weights, care provided/recommendations, a provider's signature, or date of signature. Interview and review of facility documentation on 7/20/23 at 2:22 PM with RN #1 identified monthly weights are kept in a binder at the nursing station, she was unable to provide information how often the weights were to be checked for Resident #33. Interview and review of facility documentation review with DNS identified the last weight change history in the EMR was dated 7/10, and further indicated the care plan identified weights were to be obtained daily and were to be reported if weight gain was noted of 2 pounds in a day or 5 pounds in a week. She additionally indicated that she felt it was the physician's decision and should not be because of an automatic enrollment in a program. Interview and clinical record review on 7/20/23 at 2:59 PM with MDS Coordinator #1 identified Resident #33's care plan interventions indicated monitoring and reporting a weight gain of 2 pounds in 24 hours or 5 pounds in a week. He further indicated that he used a template typical for a specific disease process, but failed to identify if staff were following the care plan.

Based on observations and interviews, the facility failed to maintain the Nourishment Room in a sanitary manner. A tour of the second floor Nourishment Room with the Infection Control Nurse on 7/21/23 at 10:45 AM identified the following: a. The refrigerator was noted to have some debris on the refrigerator shelves and refrigerator door shelves. b. The cabinets were noted to have brown stains and drips on the outside of the cabinet doors and drawers. c. The floor had significant debris, was noted to be sticky with brownish stains on the floor. d. The corner of the walls directly upon entrance to the room were chipped with peeling paint. Interview with the Housekeeping Supervisor on 7/21/23 at 11:29 AM identified that the second floor Housekeeper was responsible for cleaning the second floor Nourishment Room at 7:00 AM and after breakfast. The Housekeeping Supervisor indicated that the second floor Housekeeper sanitizes the room, mops the floor, cleans the counter and refrigerator, spot cleans the walls, and takes out the garbage but was unable to identify the reason for the uncleanliness of the Nourishment Room, if it had been cleaned thoroughly at 7:00 AM on 7/21/23.

Based on observations, review of facility documentation and staff interviews, the facility failed to act on recommendations from Resident Council concerns. The findings include: Review of Resident Council meeting minutes dated 4/27/23 indicated the residents requested to receive silverware and drinks before getting their meals. Facility's response indicated they would communicate to Nurse Aides (NAs) and kitchen staff to improve timing and that silverware and drinks would be passed earlier to ensure residents receive them before the meal. Observation of dining on the first floor A Wing on 7/18/23 at 11:20 AM identified a steam table was brought to the unit by Dietary staff, food was plated and served to residents eating in their room (by Dietary staff). Additionally, a NA was observed to be passing juices from a cart and another NA was passing out silverware, however, residents had to wait to receive juices/silverware because they were not delivered with the meal. Interview with the Food Service Director on 7/18/23 at 11:40 AM identified that NAs are responsible for passing out silverware and drinks. He was not aware of how it was timed and indicated that this was the process they use. Interview with NA #1 on 7/18/23 at 2:13 PM indicated NAs are were responsible for handing out silverware and drinks prior to meals being served, but if the NAs were providing resident care, the silverware and drinks would be passed after the meal was served. During the Resident Council meeting on 7/19/23 at 10:05 AM, residents indicated that silverware and drinks were still being passed out after the meal was served. The Resident Council noted that nothing had improved since their request at the 4/27/23 Resident Council meeting. Interview with the Administrator on 7/20/23 at 10:33 AM failed to identify NAs/dietary staff had been educated on the timeliness of passing juices/silverware as a result of facility interventions from 4/27/23. The facility began staff education regarding passing out silverware and drinks prior to meals being served after they were made aware of the concern during the survey. Education was provided to staff by the Infection Control Nurse and the Director of Food Services beginning on 7/20/23.

Based on observations, review of facility documentation, and staff interviews, the facility failed to ensure the environment was maintained in good repair and in a homelike manner. The findings include: Observations on 7/21/23 at 1:04 PM through 1:45 PM with the Administrator, Director of Operations, Director of Maintenance and the Regional Director of Housekeeping identified the following issues: a. A curtain rod was observed to be bent causing the [NAME] to sag in the second floor East lounge. b. Approximately 24 tiles were observed with linear zigzag cracking located from the doorway to the far wall in the second floor East lounge. c. The ceiling between 2 windows were noted with a black stain and drip marks, paint was observed to be peeling on the wall below the drip marks in the second floor East lounge. d. The second floor Social dining room was observed missing the cove base molding on all 5 walls, exposing peeling, chipped sheetrock. Debris and dust was noted where tile meets the wall. In addition, a light cover was missing over the light closest to the doorway, dust and debris was noted inside other light covers. e. room [ROOM NUMBER], #226 and #227 were observed with window blinds with broken slats. f. room [ROOM NUMBER] was observed with a wardrobe bureau which was damaged and chipped, the baseboards and walls were observed to be soiled, and broken cabinets were noted. g. room [ROOM NUMBER] B was observed to have trim above the head of the bed pulled away from the wall with the tips of 8 screws exposed. h. room [ROOM NUMBER] was observed with a black substance noted in the vents of the window unit air conditioner. i. room [ROOM NUMBER] was observed with peeling paint on the walls. Quality Rounds were completed on 5/4/23 by the Director of Maintenance but none of the surveyor identified areas were on the list. Quality Rounds were completed on 6/29/23 but none of the surveyor identified areas were on the list. Interview with the Director of Maintenance on 7/17/23 at 1:05 PM indicated that maintenance of the facility was ongoing. The Director of Maintenance indicated that staff were responsible to notify the maintenance department with issues or problems that require repair via a work log binder that was kept at the Nurses Station. The Director of Maintenance indicated he checks this log daily and completed repair orders were filed in a binder in his office. The Director of Maintenance indicated he does Quality Audits every 2 weeks and this month they were focusing on furniture in the Quality Audits. Interview with the Administrator on 7/21/23 at 1:10 PM indicated he was aware of the issues identified with the environment during the survey. The Administrator indicated it was the responsibility of the maintenance department to oversee the repairing of any issues regarding the facility. The Administrator indicated a contract had been signed for renovations on the second floor, which included the second floor East lounge and second floor Social dining room which would include painting (walls and ceiling) and replacing furniture. In addition, the resident rooms would be painted and furniture replaced. The Administrator identified that the contract for renovations had been signed, a deposit placed for the renovations and the renovations were scheduled to begin the end of August 2023.

Based on clinical record reviews, review of policy and interviews for 1 of 2 sampled residents (Resident #31) reviewed for Pressure Ulcer, the facility failed to ensure the care plan was revised to accurately reflect the resident's condition and for for 1 of 2 sampled residents (Resident #79) who was reviewed for Accidents, the facility failed to revise the resident's care card to reflect placement of the oxygen concentrator The findings included: 1. Resident # 31's diagnoses included Stage 3 Pressure ulcer of the buttock, congenital and neurological disorders, and open wound of the left buttock. On 12/13/2022 the facility Wound Assessment Report dated 12/23/2022 identified a stage 2 pressure ulcer wound of the coccyx area present on admission. On 12/13 2022 the facility weekly Wound Assessment Report dated 12/23/22 identified a stage 3 pressure ulcer of the left buttock present on admission. The two 12/13/22 reports indicated the presence of two pressure ulcers, one of the coccyx and one of the left buttock. The facility Weekly Wound Assessment reports 12/14/22 through 1/20/23 indicated the stage 2 coccyx wound remained unchanged but was healing without signs of infection. Although requested, no further documentation regarding the status of the coccyx wound was provided. The quarterly MDS assessment dated [DATE] indicated Resident #31 was cognitively intact, was a risk for pressure ulcers and had a stage 4 pressure ulcer that was not present upon admission. The facility Wound Assessment Report dated 5/3/23 identified a stage 3 pressure ulcer of the left hip, acquired at the skilled nursing facility on 5/3/2023. An APRN note dated 5/05/2023 at 3:56 PM indicated Resident #31 was seen for follow up and management of the new wound on the left hip (wound #2 left hip) and a stage 4 on the left ischium (wound #1 left ischial), the APRN identified the new wound as a stage 3 pressure ulcer of the left hip #2. On 5/9/2023 the clinical record identified Resident #31 was transferred to the hospital. A physician order dated 5/17/2023 directed to cleanse the right ischium with Baza spray and Impreva wipes, apply a thin layer of Triad cream and rub in thoroughly followed by covering with a Mepilex dressing. The order further directed to cleanse the ischium and the sacrococcygeal are with normal saline an to apply lightly moistened hydrofera blue spiral cut to fit the wound bed leaving a tail and to cover with xeroform gauze and apply barrier ointment to the wound edge followed by a Mepilex sacral dressing. On 5/17/2023 the facility identified the resident with a right ischium wound, a Sacro-coccygeal wound, a right buttock pressure ulcer identified throughout Resident #31's clinical record without a timeline or reference to the left buttock or left ischium wounds indicated earlier in the clinical record. The facility Wound Assessment Report dated 5/26/2023 indicated an unstageable pressure ulcer to the right buttock was identified as present on admission (5/17/2023) after return from the hospital. The Care Plan dated 5/24/2023 indicated in part that Resident #31 has a stage 4 pressure injury to the coccyx, an unstageable left buttock pressure ulcer and returned from the hospital on 5/17/23 with an unstageable pressure ulcer on the right buttock. The quarterly MDS assessment dated [DATE] indicated Resident #31 was cognitively intact, was at risk of pressure ulcers and had one stage 4 pressure ulcer and 2 unstageable pressure ulcers. The facility weekly Wound Assessment Report dated 5/31/2023 indicated pressure ulcer wound location was left hip and left buttocks with wound identified on 5/3/2023 as an unstageable pressure ulcer was not present on admission from the hospital. The facility weekly Wound Assessment Report dated 6/9/23 indicated a stage 3 pressure ulcer wound of the left hip identified on 5/3/2023 and on 7/5/23 the wound Assessment report again identified the location as the left hip. Facility wound consultations (contracted vendor) dated 6/9/2023, 6/19/23, 6/28/2023, and 7/5/2023, indicated in part, Resident #31 had a pressure ulcer of the right buttock, left buttock and left ischium (3 pressure ulcers no indication of a coccyx wound). Facility wound consultation dated 7/18/2023 indicated the presence of a right ischium and left ischium wound (2 wounds) without indication of a coccyx wound or a right buttock wound. Observation of wound care provided by the Infection Preventionist (IP), Licensed Practical Nurse (LPN #2) on 7/20/23 at 11:25 AM indicated two wound areas the IP noted on right and left buttock and indicated by pointing to a full thickness healed skin area on the left buttock as the pressure ulcer which was acquired at the skilled nursing facility on 5/3/2023 the wound was healed on 7/18/2023. On 7/25/23 at 3:15 PM an interview and clinical record review including the current care plan, with the IP, LPN #2 and the DNS noted a coccyx wound was indicated on the care plan but stated no longer existed may have been renamed. Review of wound documentation that had been completed by the IP weekly indicated there were two pressure ulcers to the right and left buttock and the wound clinic documentation names the 2 wounds the right and left ischium. Interview with the IP, LPN #2 indicated her wound documentation software only allows her to choose wound locations that are in the program( like right and left buttock)and further indicated it was difficult to follow the wound documentation by the care providers, APRN, IP and the Wound Center due to different location names for the wounds and could label them using the wound care providers wound locations by typing them into the system so the wounds can be easily tracked. The DNS indicated although the care plan still indicated the facility acquired pressure ulcer remained in the current care plan (7 days after healing) and had not been updated since the last wound MD appointment on 7/18/2023 and no documentation was provided indicating that the area had healed, further indicated that the care plan would be updated. The IP, LPN#2 indicated that she knew the facility acquired wound had healed on 7/18/23 due to the lack of documentation of that area on the wound consult sheet and that the wound physicians never indicate that a wound is healed they do not indicate it anymore as being treated. The DNS further indicated the care plan indicated the coccyx wound's name was changed and the care plan was not revised to reflect the status of the resident. The DNS further agreed although no errors in wound care had occurred, not having clear consistent wound locations could potentially lead to an error in care. Subsequent to inquiry on 7/25/2023 the care plan was revised to reflect that Resident #31 has pressure ulcers injuries to the left ischium(buttocks) stage 4 and the left ischium(hip unstageable) and on 5/17/23 returned from the hospital with a pressure ulcer of the right ischium( buttocks )and on the wound to the left ischium( left hip)( resolved on 7/18/2023 ) the care plan also noted that Resident #31 currently has community acquired pressure ulcers to the left and right ischium (buttocks) and is seen by an outside provider. 2. Resident # 79's diagnoses included dementia, unspecified abnormalities of gait and mobility, and difficulty walking. The annual Minimum Data Set assessment dated [DATE] identified Resident #79 was severely cognitively impaired and required one-person limited assistance with bed mobility and locomotion on the unit, and one-person extensive assistance with dressing, toilet use, and personal hygiene. The nurse's note dated 6/1/23 at 2:57 PM identified Resident #79 had fallen while walking around his/her bed to attach his/her nasal cannula to his/her concentrator when he/she lost balance and fell . A physician's order dated 6/4/23 directed oxygen to provide oxygen at 2 liters per minute as needed via nasal cannula for shortness of breath. The Resident Care Plan dated 6/4/23 identified additional assistance needed with activities of daily living related to diagnosis and decline in mobility and a risk for falls related to impaired mobility. Interventions directed to transfer and ambulate as ordered, allow the resident to perform activities of daily living as much as possible, and to observe for signs and symptoms of decreased balance, leaning, dizziness, and fatigue. The Reportable Event Summary Report submitted to the state agency dated 6/7/23 indicated the oxygen concentrator would be placed on the left side of Resident #79's bed to prevent reoccurrence of a fall. Interview with the Director of Nurses (DNS) on 7/20/23 at 3:38 PM indicated the direction to place the oxygen concentrator on the left side of Resident #79's bed would be in his/her chart. Review of Resident #79's paper chart identified the revision to the care plan in writing to place the oxygen concentrator on the left side of Resident #79's bed. When the DNS was asked how staff would know where to place the concentrator on the left side of Resident #79's bed, the DNS identified it would have to be placed on the resident's care card. Review of Resident #79's on 7/20/23 Treatment Administration Record failed to indicate placement of the oxygen concentrator on the left side of his/her bed. Review of Resident #79's care card failed to indicate placement of the oxygen concentrator on the left side of the bed. Interview with the [NAME] President of Operations on 7/20/23 at 3:45 PM indicated nurses would have been instructed to place the oxygen concentrator on the left side of Resident #79's bed and once placed on the left side, it would remain on the left side per general practice. 47491

Based on clinical record review and interviews for 1 of 2 sampled residents (Resident # 79) reviewed for Accidents, the facility failed to ensure physician's orders were verified for daily weights to meet professional standards and facility practice. The findings include: Resident # 79's diagnoses included heart disease, pulmonary hypertension, and dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident # 79 was severely cognitively impaired and required one-person limited assistance with bed mobility and locomotion on the unit, and one-person extensive assistance with dressing, toilet use, and personal hygiene. The Resident Care Plan dated 6/4/23 identified a diagnosis or history of coronary artery disease and pulmonary hypertension, nutritional risk secondary to medical condition, and need of more assistance with activities of daily living related to diagnosis, decline in mobility and right hip fracture. Interventions directed weight as ordered and to monitor status for any changes. A physician's order dated 6/4/2023 directed to weigh resident daily per CHF/COPD guidelines. A review of Resident #79's weight record identified weights taken once weekly on 6/6/23 at 115 lbs., 6/13/23 at 114 lbs., 6/20/23 at 115 lbs., and 6/27/23 at 113 lbs. However, further review of the resident's weight record on 7/19/23 failed to reflect daily weights were conducted on 6/5/23, 6/7/23 through 6/12/23, 6/14/23 through 6/19/23, 6/21/23 through 6/26/23 and 6/28/23 through 7/18/23. Interview with RN#1 on 7/19/23 at 2:07 PM indicated the 11:00 PM to 7:00 AM nurse on flip night (the night physician's orders are reviewed for the following month) is responsible for reviewing the physician's orders, ensuring the accuracy of the physician's orders, and implementing the orders into the plan of care. Interview with the Director of Nursing Services (DNS) on 7/19/23 at 2:47 PM identified the nurse that obtain a telephone order and verify the physician's orders are responsible for reviewing and ensuring the accuracy of the physician's order. The DNS identified Resident #79 was never on the heart failure program, which required daily weights, as Resident #79 had stable weights and experienced no exacerbations during her/his stay at the facility. Subsequent to inquiry, a physician's order for daily weights was discontinued. Interview with RN #2 on 7/20/23 at 7:40 AM identified the responsibility of reviewing physician's orders for accuracy and implementing them into the plan of care was primarily the charge nurse's responsibility. RN #2 further indicated the physician's order for daily weights for Resident #79 could have been overlooked, but s/he was unsure, and policy directed to check the physician's orders for accuracy and to correct errors. Although requested, a facility policy for physician's orders was not provided.

Based on review of clinical records, review of facility documentation, review of policies and procedures, and interviews, for two of nine residents reviewed for potential and/or actual alterations in skin, (Residents #173, #82,) the facility failed to ensure that comprehensive wound/skin assessments were conducted and/or documented and/or that wound care specialist recommendations were implemented and/or that weekly skin assessments including daily diabetic foot monitoring was conducted. The findings include: a. Resident #173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified intact cognition, difficulty sleeping, delusions, independent after set-up with bed mobility and locomotion on unit; supervision with one person physical assist or set-up for transfer, walking in room and corridor, locomotion off unit, eating, and toilet use; extensive assist of one staff for personal hygiene; active [DIAGNOSES REDACTED]. An admission nursing data collection tool dated 05/30/2017 by RN #4 identified pink, warm, intact, skin with normal skin turgor, plus one [MEDICAL CONDITION], and palpable pedal pulses. A progress note dated 05/31/2017 by APRN #1 identified [DIAGNOSES REDACTED]. A history and physical dated 06/01/2017 by the former Medical Director, MD #2, identified [DIAGNOSES REDACTED]. Skin was assessed, however, pedal pulses were not documented. Review of the Resident Care Plan (RCP) dated 6/19/17 (initiated 05/31/17) identified the problem of DM with scheduled blood glucose monitoring and insulin and at risk for skin breakdown. Interventions included to monitor for diabetic distress, preventive skin care as advised, and inspect skin for signs/symptoms of redness or breakdown. Review of progress notes documented by APRN #1 on 6/7/17, 6/28/17, 7/13/17, 7/21/17, 7/24/17, 7/25/17, 7/26/17, 8/1/17, and 8/02/17 identified problems that included failure to utilize nicotine [MEDICATION NAME], left foot and second toe pain (without [DIAGNOSES REDACTED]), gout, [MEDICAL CONDITION], left hip pain, change in mental status, hypovolemia secondary to diarrhea, abnormal labs, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A progress note dated 6/28/17 directed to administer [MEDICATION NAME] for seven days for gout; utilize as needed acetminophen for left second toe pain, and apply skin prep twice a day for twenty one days to the [MEDICAL CONDITION] on the left second toe. Review of progress notes failed to identify that APRN conducted and/or documented a comprehensive physical assessment related to the problems identified and/or monitored the resident's response to the medication, [MEDICATION NAME], and/or the location of the [MEDICAL CONDITION] identified on 6/28/17. Review of the nursing notes dated 6/29/17, 7/2/17, 7/05/17 identified that R #173's second toe on the left foot remained reddended and swollen and that he/she remained on [MEDICATION NAME] (treatment for [REDACTED]. Further review of the nursing progress notes from 7/7/17 through 7/18/17 failed to identify any issues with the resident's left second toe. Review of R #173's physican orders and/or treatment documentation for 7/2017-8/2017 failed to identify an order for [REDACTED]. Interview with LPN #1 on 2/15/18 at 12:30 PM identified that, in the past, Diabetic Foot Monitoring were completed on the evening shift. Review of weekly skin audits dated 6/2017-8/2017 identified that skin assessments were coded of zero for no skin issues/skin intact: one for previously noted skin injury and two for new skin injury. The 6/2017 skin audits were not available. Review of the 8/2017 skin audits included that on 8/6/17, Resident #173's skin was intact. On 8/13/17, the skin audit was identified as complete, however, the options for coding contained the intials of the nurse but was not coded. On 8/20/17, the skin audit was identified as complete and coded as a one but lacked a description of the previously noted skin area. Review of the progress note dated by 8/10/17 by APRN #1 identified that staff had reported that R #173 was experiencing bilateral great toe pain and redness. APRN #1 ordered a uric acid level and [MEDICATION NAME] 0.3mg (milligrams) was to be administered daily for seven days and then re-evaluated. Further review failed to identify that the APRN #1 failed to conduct a physical examination of the bilateral toes, including assessment of the pedal pulses. Review of the nurses note dated 8/10/17 by LPN #1 identified that R #173 had been evaluated by APRN #1, however the nurses note lacked documentation that LPN #1 had assessed the resident's reddended toe including palpation for pedal pulses. Interview with APRN #1 on 1/27/18 at 1:00 PM identified that he/she was unable to recall if she conducted an assessment of Resident #173's toes on 8/10/17. Review of the physician progress notes [REDACTED].#172 feels fine and listed the resident's diagnoses, but failed to identify that the resident's skin, reported great toe pain and/or redness was assessed. Review of the nursing treatment record dated 8/13/17 identified no skin issues. Review of the progress note dated 8/15/17 by APRN #1 identified that staff reported inflammation to the great toenails bilaterally with no pain, no bleeding, and no trauma reported. APRN #1 documented skin eruption/onchomycosis. Review of APRN #1's plan included to obtain a podiatry consult, open toe shoes, normal saline wash followed by [MEDICATION NAME] and dry clean dressing. Review of the clinical record failed to identify that a podiatry consult was ordered and/or that open toed shoes or an alternative were implemented. Review of an addendum nursing note dated 8/16/17 (for 8/15/17) identified that Resident #173 had dried blood on the toenails and pulses were diminished. Resident 173 was evaluated by the APRN, had a new order for a podiatry consult, and the scheduler was notified. Further review failed to identify that a comprehensive assessment was conducted and furthe action was taken when the resident had pulses that were diminished. Interview with the scheduler on 2/7/18 at 10:15 AM identified that Resident #173 refused in-house podiatry and an appointment was made with a community provider. Interview with APRN #1 on 1/27/18 at 1:00 PM identified that he/she was not aware that there would be a delay in obtaining the podiatry consult and/or that an open toed shoe was not readily available. Review of the nursing note dated 8/18/17 at 7:01 AM identified that Resident #173 complained of toe discomfort and Tylenol was administered with good effect, however, the documentation failed to include an assessment of Resident #173's toes. Review of the consult by the wound care specialist, MD #1 on 8/18/17 identified that Resident #173 was assessed with [REDACTED]. MD #1 identified that Resident #173 had no palpable pulses on either foot and complained of pain. An antibiotic was ordered for a [DIAGNOSES REDACTED]. A telephone order by MD #2 dated 8/18/17 directed to discontinue the ABI to bilateral toes. Interview with MD #1 on 2/7/18 at 1:00 PM identified that Resident #173 needed the ABI study immediately as the test would determine if there was an arterial problem/blockage and if a vascular surgeon was needed. MD #1 identified that he/she was not aware that the ABI recommendation was not followed. Review of the clinical record identified that MD #2 failed to document a rational for the decision to discontinue the ABI study. Interview with the Director of Nursing Services (DNS) on 2/7/18 at 12:00 PM identified that based on facility investigation, MD #2 did not approve the ABI because he wanted to wait to observe the resident's response to treatment. MD #2 no longer worked for the facility and was unable to be interviewed Review of the nursing note dated 8/22/17 at 1:32 PM identified that Resident #173's toe wounds had worsened and the resident exhibited increased shaking and tremors. Review of the progress note dated 8/22/17 by APRN #2 identified new areas of necrosis and open bilateral great toes and second toes that developed over the last 5 days. APRN #2 identified that the new wounds were evidence of arterial insufficiency and noted the absence of pulses. APRN #2 identified that Resident #173 required evaluation in the emergency room for a diagnosis. Resident #173 was transferred to the hospital at 4:10 PM per physician's order. Review of the hospital records dated 8/22/17 identified that Resident #173 had necrotic wounds, black in color tothe right and left big toes over the distal aspect of the big toes that are dry without bleeding or discharge. Further review identified that [DIAGNOSES REDACTED] that moves proximal down toe, both feet are warm on palpation, distal pulses are normal with no [MEDICAL CONDITION]. Review of hospital records identified that an MRI conducted on 8/31/17 identified bilateral toe osteo[DIAGNOSES REDACTED] and Resident #173 underwent bilateral great toe amputations on 09/01/17 followed by a right transfemoral amputation on 10/20/17. The facility failed to ensure that Resident #173 received comprehensive, timely, assessments of his/her feet and/or that interventions were implemented in a timely manner resulting in a delay in receiving further diagnostic assessment, hospitalization , and/or appropriate treatment. b. Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS with reference date of 12/28/17 identified Resident #82 with intact cognition, required supervision for locomotion (electric wheelchair) and eating, required extensive assistance of two staff for bed mobility, transfer, toilet use, and personal hygiene, was at risk for pressure ulcers, and utilized pressure relieving devices for bed and chair and a turning and repositioning program. Review of the resident care plan dated 1/8/18 identified the problem of risk for skin breakdown due to MS, bowel and bladder incontinence, multiple bruises to the lower extremities, and excoriation of the penis with interventions to inspect skin during care for signs of breakdown. Review of physician's orders dated 1/28/18 directed skin audit every week on Wednesday. Review of treatment records including weekly skin audits for 7/2017 to 1/2018 identified that weekly skin audits were not comprehensive and/or complete. Review of facility policy regarding pressure ulcer prevention identified that the facility will perform body audits to assess skin integrity. Review of the facility policy entitled diabetic foot monitoring identified that the resident's feet, toes, ankles, soles and heels will be observed for alteration in skin integrity, color, temperature, cleanliness and toenails will be also be observed for shape, color and length. Any alterations in skin integrity will be reported to the supervisor and/or physician.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents reviewed for abuse for (Resident # 23), the facility failed to ensure the resident was free from a non-consensual sexual act and /or failed to consistently follow the plan of care. The finding include: 1. Resident #38's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #38 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicative of no cognitive impairment and required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, supervision with walk in room and/or corridor, locomotion on and/off unit and exhibited no behaviors. The Resident Care Plan (RCP) dated 11/2/16 identified Resident #38 [DIAGNOSES REDACTED].#38 had a history of [REDACTED]. Interventions directed to remind Resident #38 of appropriate boundaries with others as needed. The nurse's note dated 11/9/16 at 2:26 P.M. identified Resident #38 was observed by staff member attempting to pull down his/her pants in front of another resident (Resident # 23) and staff was able to redirect Resident # 38 without difficulty. Further the nurse's note identified a new order was obtained and staff was directed to ensure a no contact boundaries between Resident # 38 and Resident # 23 for 2 weeks. A physician's orders [REDACTED].#23 for 2 weeks. The Resident Care Plan (RCP) dated 11/9/16 identified Resident #38 had a history of [REDACTED].#38 was observed by a staff member attempting to pull his/her pants down in front of male peer(Resident #23). Interventions directed no contact boundaries for 2 weeks between Resident #23 and noted a psychiatric follow up. The Accident/Incident report dated 12/4/16 at 1:45 P.M. identified Resident #38 was found sitting on the floor. The facility investigation identified Resident #38 was trying to participate in an action that involved him/her getting up and fell . Intervention directed to stay out of male resident room. The nurse's note dated 12/4/16 at 4:42 P.M. identified Resident #38 was observed sitting on the floor at 1:45 PM. Additionally, the nurse's note dated 12/4/16 noted no bodily injuries and Resident # 38 denied any pain and/or discomfort. The Resident Care Plan (RCP) dated 12/4/16 identified Resident #38 had a history of [REDACTED]. Intervention directed to reinstate no contact boundaries with Resident #23. 2. Resident # 23's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident # 23 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen, indicative of moderate cognitive impairment and required extensive assistance of one person with dressing, toilet use, personal hygiene and was independent with bed mobility, transfer, walk in room and/or corridor, locomotion on and/or off unit, and exhibited no behaviors. The nurse's noted dated 11/9/16 at 3:42 P.M. identified Resident #23 was placed on no contact boundaries with Resident #38 for 10 days when Resident #38 attempted to expose himself/herself to Resident #23 and indicated Resident # 38 was unable to complete task. The nurse's noted dated 12/5/16 at 2:16 P.M. noted no contact boundaries between Resident #38 and Resident # 23 maintained, no behavior issues observed. The Resident Care Plan (RCP) dated 12/5/16 identified an inappropriate touching, Resident #38 will refrain from sexual interaction with male peer, Resident #23. Interventions directed no contact boundaries with peer Resident #23, staff will redirect Resident #38 as needed. The Treatment Administration Record (TAR) from 12/4/16 through 12/14/16 failed to identify that staff consistently monitored Resident #38 for no contact boundaries on 11:00 P.M. to 7:00 A.M. shift and 3:00 P.M. to 11:00 P.M. shift in accordance to plan of care. Additionally, the facility failed to consistently monitor Resident #38 for no contact boundaries on 11:00 P.M. to 7:00 A.M. shift and on 12/17/16 and 12/18/16 on 3:00 P.M. to 11:00 P.M.shift per plan of care. TAR from 12/4/16 through 12/14/16 failed to identify Resident #23 was monitored for no contact boundaries in accordance with plan of care. The Accident/Incident report dated 12/14/16 at 4:30 P.M. identified Resident #38 engaged in non-consensual sexual act with another resident (Resident # 23) and indicated Resident #38 violated his/her no-contact agreement. Additionally, noted Resident # 38 and Resident # 23 exhibited no injury, distress and /or discomfort at the time of the incident. The facility investigation dated 12/14/16 identified Resident # 23 alleged that Resident # 38 forced/made him/her perform a sexual act which he/she did not consent to and indicated the act was witnessed by another resident . The investigation also noted that Resident # 38 violated his/her no contact boundaries once again. Further review of the investigation noted the residents were immediately separated, authorities were notified and Resident #38 was transported to the emergency room (ER) for observation. However, Resident # 23 refused to go to ER to be evaluated. The nurse's note dated 12/14/16 at 6:48 PM identified Resident #38 violated the no-contact rule and engaged in questionable activity with another resident, who did not consent to the activity. Further, the nurse's note identified that Resident #38 was transported to ER due to violation of no contact rule and facility rules. The Behavioral Health note dated 12/15/16 at 3:00 P.M. identified on 12/14/16 Resident #23 reported to staff he/she was engaged in a sexually inappropriate behavior with a peer (Resident #38). The Behavioral Health note identified Resident #23 did not consent to the act and Resident #23 was referred for a psychiatric evaluation and support. The physician's orders [REDACTED].# 38 directed constant visual observation pending review. Additionally, the physician's orders [REDACTED]. Interview with Resident # 38 on 3/22/17 at 4:00 P.M. identified he/she recalls having sexual inappropriate acts with Resident # 23 but could not recall when the act occurred. Interview with Resident #23 on 3/22/17 at 4:30 P.M. identified he/she did not consent to the sexual interaction with Resident #38 on 12/14/16. Resident # 23 also indicated he/she was forced by Resident # 38 to perform sexual inappropriate acts three times ( but could not remember when) but does remember the 12/14/16 incident and indicated he/she did not report the sexual acts because he/she was afraid of Resident # 38 and what he/she may do to him/her. Interview with RN # 3 ( RN Supervisor on duty 12/4/16) at 3:00 P.M. identified Resident # 38 was in Resident # 23's room on 12/4/16 attempting to pull his/her pants down in the presence of Resident # 23, when Resident # 38 fell . Interview with LPN #2 on 3/22/17 AT 3:20 P.M. identified she/he was instructed to make sure Resident # 38 and Resident # 23 were not in the same dining room and the residents needed to be 20 feet away from each other. Interview with LPN # 1 on 3/22/17 at 3: 25 P.M. identified she/he was educated to make sure Resident 38 and Resident # 23 are not sitting at the same table during dinner and activities. Interview with the DNS on 3/23/17 at 1:50 P.M. identified from November 9, 2016 through December 14, 2016 staff was made aware of Resident # 38 no contact boundaries plan of care and not to have Resident # 38 and Resident # 23 close to each other and to know the residents whereabouts. The DNS also indicated when Resident # 38 violated his/her no contact boundaries on 12/14/16 with Resident # 23, Resident # 38 was sent to emergency room for an evaluation and Resident # 23 was moved to a different unit. The facility policy and procedure for Abuse Prohibition notes each resident has the right to be free from abuse and neglect. Additionally, noted sexual abuse includes but is not limited to, non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault and notes the Administrator or on-call designee and DNS will be notified immediately of sexual assault and indicated staff will remove the resident from the alleged abuser.

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews for one of four sampled residents (Residents #8) who was reviewed for accidents, the facility failed to provide the necessary care and services to prevent injuries. The findings include: 1. Resident #8 (R #8) had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #8 had severely impaired cognition, disorganized thinking, delusions, and required extensive assistance with bed mobility and was totally dependent on two staff for transfers and toilet use. The care plan dated 12/3/13 identified that R #8 had impaired cognitive skills due to dementia with interventions that included to transfer the resident using the hoyer lift with assist of two staff to a custom wheelchair with pelvic posittioning belt as tolerated. Review of facility documentation that included an accident/incident documentation dated 2/1/14 at 12:00 AM identified that R #8 alleged that a girl twisted his/her right knee. The documentation identified that R #8's right knee was edematous and that the resident was in pain. A nurse's note dated 2/1/14 at 6:11 AM identified that R #8 complained of right knee pain and on inspection, was edematous. The physician was notified and R #8 was transferred to the acute care hospital for evaluation. Review of the acute care hospital history and physical dated 2/1/14 identified that R #8 was able to tell hospital staff that he/she was being transferred in a hoyer lift and that during the transfer from the wheelchair to the bed, the staff had caught his/her knee and caused an injury. Review of the medical imaging report of R #8's right knee dated 2/1/14 identified that R #8 had sustained an acute impacted fracture of the right distal femoral metaphysis extending to the intercondylar notch. Review of the hospital discharge summary dated 2/1/14 identified that the fracture was in good position and as the resident was not weight bearing, conservative treatment would be the best option. In addition, a recommendation for an immobilizer and treatment with Vitamin D with Calcium and medication for pain management was recommended. Although multiple staff members were interviewed, an exact determination of when the injury occured could not be determined. However, review of the facility investigation concluded that although no intentional mistreatment/abuse was identified, R #8's fracture had occurred during a transfer.