Every finding on record at Waterbury Center for Nursing & Rehabilitation LLC

Based on interviews, review of the clinical record, facility documentation, and facility policy for 3 of 6 residents (Resident #1, Resident #4 and Resident #45) reviewed for hospitalization, upon Resident #1's re-admission from the hospital, insulin orders were held for 2 days per physician orders, the facility failed to follow up with the physician after the 2-day hold, resumed insulin without verifying with the physician , which caused Resident #1 to receive excessive insulin, resulting in severe hypoglycemia, mental status changes and a blood glucose level of 27 milligrams per deciliter (mg/dl) which resulted in a significant medication error. Additionally, due to Resident #1 becoming severely hypoglycemic, Glucagon (an emergency injectable medication used to treat life-threatening low blood sugar) was required to be administered intramuscularly (IM). Additionally, for Resident #4 and Resident #45, the facility failed to correctly transcribe insulin orders from the hospital discharge instructions and therefore failed to administer the correct dose of insulin resulting in Resident #4 and Resident #45 experiencing hyperglycemia (elevated blood sugar) which required additional insulin be administered to lower blood sugar levels. These failures resulted in the findings of Immediate Jeopardy (IJ): 1.Resident #1's diagnoses included Type 2 diabetes mellitus, pneumonia, and depression. A physician order dated 10/1/26 directed to administer Lantus Solostar U-100 Insulin (Insulin Glargine a long-acting insulin) 20 units subcutaneously in the PM (between 7:00 PM and 11:00 PM). A physician's order dated 10/2/26 directed to administer Lantus Solostar U-100 Insulin (Insulin Glargine) 40 units subcutaneously in the AM (between 5:00 PM and 7:00 PM). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #1 had diabetes mellitus and received Insulin injections daily. The Resident Care Plan dated 1/2/26 identified Resident #1 was at risk for abnormal blood glucose levels related to diabetes. Interventions included administering diabetic medications as ordered, monitoring for signs and symptoms of hypo and hyperglycemia, to perform blood glucose checks as ordered and report abnormal values to the physician. a. A nursing note dated 1/3/26 at 10:31 PM identified Resident #1 was found very lethargic and unresponsive with increased mucous in his/her mouth and inability to cough up secretions. Oxygen saturation was 77% and the resident's oxygen was increased to 5 liters via nasal cannula with decrease in oxygen saturation to 74%. Resident #1 was then put on a non-rebreather mask, and oxygen was increased resulting in an oxygen saturation increase to 88%. The nursing note failed to indicate if a blood glucose level was obtained. Resident #1 was transferred to the hospital emergency department for further evaluation and treatment. A Hospital Inpatient Discharge summary dated [DATE] at 3:08 PM identified Resident #1 was admitted on [DATE] after being found unresponsive and hypoglycemic at his/her skilled nursing facility. The resident's fingerstick blood glucose was in the 30's (severe hypoglycemia) and his/her mental status returned to baseline following dextrose administration. The principal problem during this admission was hypoglycemia. The resident was admitted to the intensive care unit (ICU) for close monitoring, hourly blood glucose and a dextrose infusion. At discharge the resident's blood sugars were trending up slowly and the Lantus 20 units at bedtime was to resume and Lantus 40 units in the morning remained on hold and should be resumed at the discretion of the nursing facility physician. A hospital Inter-Agency Patient Referral report (W-10) dated 1/6/26 indicated Resident #1 was admitted to the hospital on [DATE] with a primary diagnosis of hypoglycemia. The medication list directed that Insulin Glargine 100 units/ml prefilled pen injection 40 units under the skin daily was to be paused until the physician indicated it should be started again and Insulin Glargine 100 units/ml prefilled pen injection 20 units under the skin nightly was to continue. A Nursing admission note written by the Assistant Director of Nursing Services (ADNS) dated 1/6/26 at 10:16 PM identified Resident #1 had been readmitted to the facility with a diagnosis of hypoglycemia and the resident's insulin orders were put on hold until the APRN could re-evaluate. The nursing note indicated APRN #1 had verified the readmission orders. A physician order dated 1/6/26 directed blood sugars twice a day (between 6:30 AM and 8:30 AM and between 4:30 PM and 6:30 PM) and notify the provider if the blood sugar was less than 70 milligrams (mg) per deciliter (dl) or greater than 400 mg/dl. Additionally, a physician order dated 1/6/26 directed to hold Lantus Solostar Insulin (Insulin Glargine) 100 unit/ml 40 units daily at 6:00 AM from 1/7/26 to 1/8/26 (which corresponded with the hospital discharge recommendations placing Lantus Solostar (Glargine) 40 units on hold until the physician indicated it should be started again) but failed to identify to resume after the 2 day hold or discontinue. Additionally, a physician order dated 1/6/26 directed to hold Lantus Solostar Insulin (Insulin Glargine) 100/units/ml 20 units at bedtime from 1/6/26 to 1/10/26. An admission progress note written by Advanced Practice Registered Nurse (APRN) #2 on 1/8/26 at 9:00 AM identified Resident #1 was found to be hypoglycemic upon admission to the hospital (1/3/26) and Lantus Insulin was on hold while the resident was in the hospital, however Resident #1's blood sugars continued to rise, and Lantus was resumed at a lower dose. The resident was previously on 40 units daily and was to continue on 20 units daily (the nighttime dose). APRN #2's progress note indicated to continue blood glucose monitoring and titrate insulin as appropriate based on blood sugar readings, hypoglycemia risk (blood sugar 122 mg/dl on 1/8/26) and as clinically indicated. The progress note indicated all medications had been reviewed and reconciled by APRN #2 (however there were no corresponding orders in the physician/APRN orders indicating when and at what dose the insulin was to resume). Review of Resident #1's Medication Administration Record (MAR) for January 2026 identified Lantus Solostar (Glargine) U-100 Insulin 40 units subcutaneous AM dose had directions indicating order on hold from 1/7/26 to 1/8/26 and the Lantus Solostar U-100 20 units subcutaneous PM dose had directions indicating order on hold from 1/6/26 to 1/10/26. Despite the directions to hold both insulin orders, Lantus Solostar 40 units subcutaneous AM dose was administered on 1/7/26 (which should have been on hold) and the Lantus 20 units subcutaneous PM dose was administered on 1/6/26 and 1/10/26 (which should have been on hold during that time). Per the MAR, after 1/10/26, Lantus Solostar U-100 Insulin 40 units subcutaneous AM and Lantus Solostar U-100 Insulin 20 units subcutaneous PM doses continued to be administered to Resident #1 (the clinical record failed to identify APRN #2 or the physician was contacted to question if insulin was to resume or be discontinued after it was on hold). A progress note written by APRN #2 on 1/23/26 at 11:00 AM identified Resident #1 was being seen for a medication renewal. The progress note indicated Lantus Solostar U-100 Insulin 100 units/ml insulin pen (no dosage) was to be administered subcutaneously once a day (a discrepancy because Resident #1 was receiving insulin twice a day per the MAR). The progress note indicated all medications had been reviewed and reconciled. b. The MAR from 1/23/26 through 2/17/26 (AM) identified Lantus Solostar U-100 Insulin 40 units subcutaneous AM and Lantus Solostar U-100 Insulin 20 units subcutaneous PM doses both continued to be administered to Resident #1 (despite APRN #2's progress notes from 1/23/26 indicating insulin was to be administered only once a day which resulted in Resident #1 receiving an extra 40 units of insulin daily for 15 days in error). A nursing note written by Registered Nurse (RN) #7 on 2/17/26 at 4:00 PM identified she was called into Resident #1's room for a change in Resident #1's mental status. The resident was found minimally responsive with stertorous breathing (a low-pitched, heavy, snoring sound) noted and the resident's initial blood sugar was 27 mg/dl (severely hypoglycemic). Glucagon 1 milligram (mg) intramuscularly (IM) was given immediately per orders with a slow but steady rise of blood sugar to over 100 mg/dl with improvement to the resident's baseline mental status (Resident #1 did not require a transfer to the hospital). A nursing note written by RN #7 on 2/17/26 at 4:37 PM identified she had notified APRN #2 of the resident's hypoglycemic episode and had received new orders to hold Lantus Insulin 20 units that night and to discontinue the current order for Lantus 40 units in the AM. The nursing note indicated Lantus 20 units in the AM would start on 2/18/26 and Resident #1's family had been updated on the hypoglycemia and new insulin orders. Review of the MAR for February 2026 identified on 2/15/26 Resident #1 had a blood glucose of 65 mg/dl (hypoglycemia) at 6:30 AM. Lantus Solostar U-100 Insulin 40 units subcutaneous AM dose continued to be administered to the resident until it was discontinued on 2/17/26. Further, Lantus Solostar U-100 20 units subcutaneous PM dose continued to be administered to Resident #1 until 2/17/26, when the order was put on hold for one dose and resumed. An additional Lantus Solostar U-100 20 units subcutaneous AM dose was administered to Resident #1 on 2/18/26 and 2/19/26 and then was discontinued. A progress note written by APRN #2 on 2/20/26 at 11:00 AM identified Resident #1 was being seen for hypoglycemia and a Lantus dosing error. After the resident presented with periods of hypoglycemia a review of the insulin regimen revealed a medication administration error. The resident was only supposed to be administered Lantus once daily consisting of 20 units at bedtime but was incorrectly administered additional doses of consisting of Lantus 40 units in the morning in error. The morning dose of Lantus 40 units was discontinued, and the resident was placed on the correct regimen of Lantus 20 units at bedtime only. The progress note indicated Resident #1 had an accidental Insulin overdose secondary to a medication administration error and when the error was identified, the insulin regimen was corrected. Further, blood sugar monitoring was to continue with notification of the physician for recurrent hypoglycemia or persistently elevated blood sugars following correction of the insulin dosage to be administered at bedtime only. An APRN order (from APRN #2) dated 2/20/26 directed to discontinue Lantus Solostar U-100 Insulin (Insulin Glargine) 20 units subcutaneous once a day between 7:00 AM and 11:00 AM. Interview and review of the clinical record with the Director of Nursing Services (DNS) on 7/6/26 at 11:08 AM identified she was not aware of Resident #1's insulin medication error and was not aware that the resident's insulin dosage should have changed upon readmission to the facility on 1/6/26. The DNS indicated she was not notified by APRN #2 or any other staff when an insulin medication error was discovered by APRN #2 on 2/20/26. The DNS indicated when Lantus 40-unit dose in the AM was put on hold from 1/7/26 to 1/8/26 and was not addressed further, the physician's order automatically resumed and the Lantus 40-unit dose in the AM continued to be administered, in error and should not have been. The DNS further stated although APRN #2's progress note on 1/8/26 identified the correct insulin dosages for Resident #1, the progress note was not reviewed by the charge nurse or nursing supervisor after the APRN visit but should have been. Interview and review of the clinical record with the ADNS on 7/6/26 at 11:35 AM identified she was the admitting nurse when Resident #1 returned to the facility from the hospital on 1/6/26. The ADNS indicated although she reviewed the hospital discharge orders, put the AM Lantus 40 units order on hold and left a note for APRN #2 to review the readmission orders, she was unsure if APRN #2 had received the sticky note. Review of APRN #2's progress note dated 1/8/26 with the ADNS identified the correct dosages of insulin had been documented by APRN #2 in the progress note. The ADNS stated she had made a mistake on 1/6/26 when she transcribed the AM Lantus 40-unit dose as being order on hold and should have discontinued the order because when the order was not addressed on 1/8/26 by APRN #2 the order automatically resumed after the hold date (of 1/8/26) had passed. Further, causing Resident #1 to be administered Lantus 40 units in the AM in error until 2/17/26 when the resident experienced severe hypoglycemia that required emergency intervention. The ADNS stated she was not aware of APRN #2's review of Resident #1's medication regimen that identified the insulin dosage error on 2/20/26 and although APRN #2 identified the medication error in her progress note, APRN #2 did not tell anyone at the facility about the error. The ADNS further indicated that APRN progress notes were only reviewed when needed and not reviewed on a routine basis. The ADNS further noted that APRN #2's progress note from 2/20/26 must not have been reviewed because the facility was not aware of the insulin dosage error until surveyor inquiry on 7/2/26. Interview and review of nursing notes with RN #7 on 7/8/26 at 3:20 PM identified she was the nursing supervisor working the 3:00 PM to 11:00 PM shift on 2/17/26 when Resident #1 had an episode of severe hypoglycemia and required emergency intervention with the administration of Glucagon IM. RN #7 indicated she informed APRN #2 of the resident's blood sugar of 27 mg/dl and obtained new physician orders for the resident's Insulin from APRN #2 but did not otherwise fully recall the incident. RN #7 stated she did not discuss anything further with APRN #2 on 2/17/26 and she was not aware a medication error had been discovered regarding Resident #1's insulin dosage on 2/20/26. Interview with the Regional Pharmacy consultant on 7/8/26 at 3:37 PM identified if the resident received an overdosage of Lantus 40 units in error it would have contributed to Resident #1 having a severe hypoglycemic reaction. Interview with the Medical Director on 7/9/26 at 9:50 AM identified he had reviewed Resident #1's medical records and the medication error for Resident #1 was a significant medication error which contributed to the resident's severe hypoglycemia that required emergency intervention (with Glucagon IM) on 2/17/26. The Medical Director indicated that when the resident was readmitted from the hospital on 1/6/26 it was the responsibility of the admitting nurse to ensure the insulin dosages were transcribed correctly. Interview and review of APRN #2's progress notes with APRN #2 on 7/9/26 at 12:30 PM identified although she reviewed Resident #1's readmission orders on 1/8/26 she was not aware that the admitting nurse (ADNS) had put the Lantus 40 units in the AM dose on hold from 1/6/26 through 1/8/26 and that the ADNS should have discontinued the order on admission (based on the hospital discharge orders) and until APRN #2 was able to review the Insulin orders in person on 1/8/26 at which time she would have discontinued the AM Insulin . APRN #2 indicated by putting the Lantus 40 units in the AM dose order on hold, the order would automatically resume after the hold date (of 1/8/26) had passed and she had not received a note or other notification from the ADNS regarding Resident #1's Insulin orders. APRN #2 identified, (based on her progress note dated 1/8/26), the order for Lantus 40 units in the AM should have been discontinued and the resident should have continued to only receive Lantus 20 units in the PM. APRN #2 stated although she reviewed the resident's hospital discharge medications and orders she did not enter a new order to discontinue the Lantus 40-unit dose in the AM. APRN #2 noted she was not aware the order was only on hold and was not aware Resident #1 had continued to receive the dosage until the resident's episode of severe hypoglycemia on 2/17/26 (at which point she discontinued Lantus 40 units in the AM dose). Review of her progress note on 2/20/26 indicated her subsequent review of the resident's medication regimen had identified the Lantus 40 units in the AM dose medication error which was corrected. APRN #2 stated she was unsure who at the facility she informed of the insulin medication error on 2/20/26 but she would have informed the charge nurse and nursing supervisor of the error when she discovered it. Additionally, APRN #2 indicated the insulin overdose was a significant medication error and by not administering the correct insulin dose, it contributed to the severe and dangerous hypoglycemia on 2/17/26 (blood sugar of 27 mg/dl) which required emergency intervention (Glucagon IM was administered). 2. Resident #4's diagnoses included insulin dependent diabetes mellitus with hyperglycemia (high blood sugars), malnutrition, and hypertension (high blood pressure). A hospital Inter-Agency Referral Document (W-10) and Discharge summary dated [DATE] directed Insulin Glargine (Lantus) 100 units/milliliter (u/ml) give 40 units subcutaneously (under the skin) daily at bedtime A physician order dated 4/1/26 directed Insulin Glargine (Lantus) 100 units/ml give 4 units (a discrepancy with the hospital discharge instructions directing 40 units of Insulin Glargine at bedtime) subcutaneously daily at bedtime (36 units less of Insulin Glargine from the hospital instructions). A progress note dated 4/3/26 at 8:15 AM and written by Advanced Practice Registered Nurse (APRN) #2 indicated Resident #4 orders for Insulin Glargine (Lantus) 100 units/ml give 40 units subcutaneously daily at bedtime, Insulin Lispro 100 units/ml, give 15 units three times a day with meals, hold for blood glucose less than 100, and monitor blood glucose daily before breakfast and dinner. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition and required one person to assist with taking off/putting on footwear, lower body dressing, and walking. The Resident Care Plan dated 4/7/26 identified Resident #4 was at risk for abnormal blood glucose (sugar in the blood) levels and at risk for complications related to diabetes. Interventions directed to provide diabetic medications and or Insulin as ordered by medical doctor (MD), evaluate response, monitoring for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), observing for changes in mental status, lethargy, dizziness, and diaphoresis (excessive sweating without exposure to heat or physical activity). Review of the Medication Administration Record (MAR) dated April 2026 noted Insulin Glargine (Lantus) 100 units/ml give 4 units daily at bedtime (a discrepance from the hospital directions of Insulin Glargine 40 units at bedtime) from 4/1/26 through 4/10/26 when the dose was increased to Insulin Glargine (Lantus) 100 units/ml give 10 units daily at bedtime. There was no order for glucose monitoring before breakfast and dinner in the MAR until 4/10/26 despite the APRN #2 ordering them. There were no blood glucose monitoring results from 4/2/26 through 4/11/26 and from 4/16/26 through 4/30/26 despite physician orders. Review of the physicians orders and MAR from May 2026 failed to identify blood glucose monitoring was completed from 5/1/26 through 5/6/26 despite physician orders directing blood glucose monitoring before breakfast and dinner. On 5/15/26 Insulin Glargine (Lantus) 100 units/ml was increased from 10 units daily at bedtime to 15 units daily at bedtime. Blood sugars were documented from 5/7/26-5/15/26 and ranged from 229-398 mg/dl. On 5/20/26, APRN #2 added a medication Glipizide (an oral medicine to help lower blood sugar) 2.5 mg by mouth once daily and a sliding scale insulin order for Insulin Lispro (a fast-acting insulin used to lower blood sugars) 100 unit/ml three times a day before meals. On 5/28/26 the Insulin Glargine (Lantus) 100 units/ml order was increased from 15 units daily at bedtime to 25 units daily at bedtime. Blood sugars were recorded from 5/15/26-5/28/26 and ranged from 187-525 mg/dL. Review of the physicians orders and MAR from May 2026 failed to identify blood glucose monitoring was completed from 5/1/26 through 5/6/26 despite physician orders directing blood glucose monitoring before breakfast and dinner. On 5/15/26 the Insulin Glargine (Lantus) 100 units/ml was increased from 10 units daily at bedtime to 15 units daily at bedtime. On 5/28/26 the Insulin Glargine (Lantus) 100 units/ml order was increased from 15 units daily at bedtime to 25 units daily at bedtime. Review of physicians orders and MAR for June 2026 indicated Insulin Glargine (Lantus) 100 units/ml was increased from 25 units daily at bedtime to 30 units daily at bedtime on 6/4/26. Blood sugars were documented from 5/28/26-6/3/26 and ranged from 104-390 mg/dl. On 6/18/26 APRN #2 increased Resident #4's Glipizide from 2.5 mg by mouth daily to 5 mg by mouth daily. Review of the MAR for May 2026 and June 2026 indicated Insulin Lispro sliding scale coverage was administered 55 times between 5/20/26 through 6/24/26. Review of physicians orders and MAR for June 2026 indicated Insulin Glargine (Lantus) 100 units/ml was increased from 25 units daily at bedtime to 30 units daily at bedtime. An Accident and Incident Medication Error form dated 7/8/26 identified a transcription error of Insulin Glargine 10 units/ml, give 4 units subcutaneously daily at bedtime had been made that had resulted in a significant medication error. The medication error form indicated the correct dosage should have been Insulin Glargine 100 units/ml, give 40 units subcutaneously daily at bedtime. The medication error form indicated Resident #4 presented with elevated blood sugars and noted the admission nurse had been rushing and missed the error on double checking (this incorrect dose of insulin occurred from 4/1/26 through 7/7/26). Interview with Director of Nursing Services (DNS) on 7/8/26 at 10:05 AM indicated the facility failed to correctly review and reconcile admission orders for Resident #4 (upon readmission from the hospital). The DNS indicated the admission Registered Nurse (RN) supervisor (RN #6), was responsible for reconciling the admission orders. The DNS indicated when the provider completes an admission visit for the resident after admission they would review the orders for accuracy. The DNS stated she was not aware of the error for Resident #4 and was made aware of the medication error by the surveyor. Interview with the Medical Director on 7/9/26 at 9:50 AM indicated the facility failed to administer the correct dosage of insulin (not enough Insulin) for Resident #4 resulting in a significant medication error. The Medical Director indicated it was the responsibility of the admission nurse to ensure orders were followed and transcribed correctly. The Medical Director stated the incorrect dose of insulin given could have resulted in Resident #4 experiencing hyperglycemia. Interview with the Regional Pharmacy Consultant on 7/9/26 at 10:13 AM indicated the facility failed to transcribe and administer the correct dose of insulin for Resident #4 resulting in a medication error. The Regional Pharmacy Consultant stated a medication error of not receiving the correct dose of insulin could have resulted in hypoglycemia or hyperglycemia, diabetic ketoacidosis (a serious and potentially life-threatening complication of diabetes), neuropathy, and blurred vision. Interview with APRN #2 on 7/9/26 indicated she had failed to review the orders transcribed by the facility upon Resident #4's readmission that resulted in a medication error. APRN #2 stated she had reviewed Resident #4's chart prior to surveyor interview and stated she had reviewed the hospital admission orders during her visit with Resident #4 on 4/3/26 but was not aware Resident #4's orders for Insulin Glargine 100 units/ml, give 40 units subcutaneously daily at bedtime had been transcribed incorrectly (as Insulin Glargine100 units/ml, give 4 units subcutaneously daily at bedtime). APRN #2 indicated Resident #4 not receiving the correct dosage of insulin could result in hyperglycemia which was usually noted with blood sugar checks and dosing would be adjusted. APRN #2 was not aware Resident #4 did not have blood sugar checks as ordered from 4/2/26 through 4/11/26 and 4/16/26 through 5/6/26. Attempts to interview the admitting nurse (RN #6) were unsuccessful. 3.Resident #45 was admitted to the facility in November 2025 and readmitted after a hospital stay in January 2026 with diagnosis that included Type 1 diabetes, chronic kidney failure and anemia. Physician orders dated 11/5/25 directed to administer Insulin Tresiba (once a day long-acting Insulin) flexTouch 100 units/milliliter (ml) give 18 units subcutaneously at bedtime, Insulin Lispro (rapid acting insulin) 100 units/ml give 10 units subcutaneously before meals (3 times a day) and Insulin Lispro 100 units/ml 3 times a day subcutaneously per sliding scale; if blood sugar (BS) is less than 70 milligrams (mg) per deciliter (dl) call the physician, if blood sugar is 150 mg/dl to 200 mg/dl give 2 units, if blood sugar is 201 mg/dl to 250 mg/dl give 4 units, if blood sugar is 251 mg/dl to 300 mg/dl give 6 units, if blood sugar is 301 mg/dl to 350 mg/dl give 8 units, if blood sugar is 351mg/dl to 400 mg/dl give 10 units, and if blood sugar is greater than 400 mg/dl call the physician. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #45 was cognitively intact, required moderate assistance with activities of daily living (ADLS) and received Insulin 7 days a week. The Resident Care Plan dated 11/22/25 identified diabetes as an area of focus with interventions that included checking A1c labs per orders, provide diabetic medications and/or Insulin as ordered, being aware of efficiency, adverse effects, evaluating response, monitoring during peak action time according to medication regime, providing finger sticks as ordered, monitoring for sign of hypo/hyperglycemic episodes, recording daily food intake, notifying the nurse and MD when intake was below 25% or less of a meal greater than 3 times per week, and documenting diet refusals. Nursing notes dated 1/2/26 at 6:00 PM indicated that Resident #45 was sent to the hospital for abnormal lab values indicative of severe anemia (low red blood cell count). Resident #45 was admitted to the hospital with anemia and hyponatremia (low sodium), was discharged from the hospital on 1/5/26 and re-admitted to the facility. The hospital discharge summary included a medication list dated 1/5/26 which directed, in part, to administer *Insulin Tresiba U-200 200 unit/ml (3ml) concentrated injection pen, inject 36 units at bedtime, *Tresiba 100 unit/ml (3ml) give 32 units under the skin at bed time (you were taking this medication differently than prescribed), and Lispro 100 unit/ml injection pen give 6 units 3 times a day with meals. * (asterisk) This list has 2 medications that are the same as other medications prescribed for you. Read the directions carefully and ask your doctor or other care provider to review with you. The Omnipod 5 automated Insulin delivery system (Insulin pump). Omnipod 5 G6- G7 (G- compatible with Dexcom/continuous blood glucose monitoring) starter kit and Omnipod 5 G6- G7 Pods (each pod is a small, tubeless insulin pump that sticks to the skin, filled with rapid acting insulin) inject 1 EA (the prescribed rapid acting Insulin). re-admission physician orders dated 1/5/26 and received by Registered Nurse (RN) #10 directed to administer Tresiba (once a day long-acting Insulin) flexTouch 100 units/milliliter (ml) give 18 units subcutaneously at bedtime (a discrepancy from the hospital discharge orders that directed to administer Tresiba 32/36 insulin units at bedtime), Insulin Lispro (rapid acting insulin) 100 units/ml give 10 units subcutaneously before meals 3 times a day (a discrepancy from the hospital discharge orders which directed to administer 6 Units of Lispro 3 times a day before meals) and Insulin Lispro 100 units/ml 3 times a day subcutaneously per sliding scale; if blood sugar is less than 70 milligrams (mg) per deciliter (dl) call the physician, if blood sugar is 150 mg/dl to 200 mg/dl give 2 units, if blood sugar is 201 mg/dl to 250 mg/dl give 4 units, if blood sugar is 251 mg/dl to 300 mg/dl give 6 units, if blood sugar is 301 mg/dl to 350 mg/dl give 8 units, if blood sugar is 351mg/dl to 400 mg/dl give 10 units, and if blood sugar is greater than 400 mg/dl call the physician. Resident #45's hospital Discharge Summary medication lists were not implemented on re-admission. The new orders for Tresiba 32/ 36 units at bedtime, Lispro 6 units 3 times a day, and a new order for an Insulin pump were not transcribed on the facility physician re-admission orders dated 1/5/26 as indicated per hospital discharge paperwork. A nursing note written by Registered Nurse (RN) #10 and dated 1/5/26 at 9:00 PM indicated that Resident #45 was readmitted , orders were confirmed and the only medication change was Labetalol (for high blood pressure). RN #10 did not indicate in her nursing note that the readmission orders differed from the discharge summary provided from the hospital. RN #10 made no reference related to the Insulin order or an Insulin pump. A nursing note completed by Licensed Practical Nurse (LPN) #7 and dated 1/5/26 at 10:53 PM indicated that Resident #45 returned at 4:00 PM from hospital, BS 327 mg/dl sliding scale and scheduled Insulin given. A re-admission progress note dated 1/6/26 at 8:00AM by Advanced Practice Registered Nurse (APRN) #2 indicated that Resident #45 returned from the hospital after being sent out last week due to a Hemoglobin (red blood cells) of 6 grams (g) per deciliter (dl) (normal range is 13.5 to 17.5 g/dl for men and 12.0 to 15.0 g/dl for women), Resident #45 was asymptomatic at the time of transfer. At the hospital Hemoglobin was 7.7 g/dl and did not require a blood transfusion. Resident #45 was found to be hypovolemic (low amount of fluid circulating in the body) and received intravenous (IV) fluids and IV iron. Resident #45's Labetalol was increased. Insulin was listed as: take 1 Insulin pen subcutaneous (no dose listed) and Insulin Lispro 100 unit/ml insulin pen take 1 Insulin pen subcutaneous (no dose listed). APRN #2's progress note further identified Resident #45 had Type 1 Diabetes Mellitus with hyperglycemia and continued with poorly controlled diabetes with A1C (blood test that shows average blood sugar over past 2-3 months of 14.8% (normal is below 5.7%). Continuing sliding scale Insulin along with Tresiba 32 units at night for improved hyperglycemic control (Resident #45 did not have a physician order for 32 units of Tresiba at night). Resident was a Type 1 diabetic since [AGE] years of age and had managed own diabetes without endocrinology care. BS have been consistently elevated. Adjusting Insulin dosages to improve glycemic control. A review of Resident #45's BS from 1/6/26 through 1/15/26 noted Resident #45 required sliding scal

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #3) reviewed for falls, the facility failed to ensure staff implemented the required accident prevention interventions, specifically a gait belt and 1 person assistance with ambulation, resulting in Resident #3 falling and sustaining a head injury requiring 2 staples to the back of the head. The findings include: Resident #3s diagnosis included dementia, abnormalities of gait and balance, and convulsions. The Resident Care Plan dated 11/22/25 identified that Resident #3 was at risk of falling with interventions that included to use assistance of 2 for early morning transfers, monitor/assist with toileting needs and keeping personal items within reach. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired, required substantial/maximal assistance from staff with toileting, bathing, dressing, and partial/moderate assistance for transferring. Additionally, the MDS noted Resident #3 used a walker and no falls. The fall risk assessment dated [DATE] identified Resident #3 was at risk for falls. A physician order dated 3/1/26 directed to provide limited assist of 1 for room ambulation with use of rolling walker for Resident #3. The Resident Care Card dated 3/12/26 identified to use a gait belt when ambulatory. A facility-initiated investigation form dated 3/31/26 at 8:45 AM identified that Resident #3 fell on 3/31/26 while being transferred to bed with the assistance of 1 staff member and a walker. Nurse Aide (NA) #6 dropped the toiletries coming out of the bathroom with Resident #3, who had the walker in front of him/her and as NA #6 bent down to pick the items up. Resident #3 fell backwards hitting his/her head sustaining a laceration. The resident was sent to the emergency room for evaluation. An Advanced Practice Registered Nurse (APRN) progress note dated 3/31/26 at 10:45 AM identified Resident #3 fell, hit his /her head and had a 1/2 inch gash to the top of the head with a skin flap present and swelling was noted around the open area. Also, identifying the fall was unwitnessed and the resident was sent to the emergency room. A nursing note dated 3/31/26 at 11:04 AM identified that Resident #3 fell in the bathroom and was bleeding from his/her head. Resident #3 was complaining of pain to his/her head and sustained a 2-centimeter laceration to the back of the head with a small bump. A nursing note dated 3/31/26 at 6:30 PM identified Resident #3 was seen by the APRN, the resident had an abrasion on the head status post fall. APRN noticed a flap area, no bleeding, complaints of distress or pain noted. Resident #3 was sent to the emergency room for evaluation of head trauma. A facility-initiated Reportable Event form dated 4/1/26 i(the event occurred on 3/31/26 per nursing notes) identified Resident #3 lost his/her balance, falling backwards while leaving the bathroom hitting his/her head, and sustaining a 2-centimeter laceration to the back of the head. Also, identifying the fall was witnessed by Nurse Aid (NA) #6 (a discrepancy with the APRN progress note dated 3/31/26 which identified the fall was unwitnessed). A hospital Discharge summary dated [DATE] identified Resident #3 required 2 staples to his/her head, needed more physical therapy and to return to the hospital for new or worsening symptoms. Interview on 7/7/26 at 8:51 AM with NA #6 identified on 3/31/26 she was assisting Resident #3 out of the bathroom with a walker when NA #6 dropped some toiletries, bent down to pick them up and when she did this Resident #3 fell backwards. Interview on 7/7/26 at 12:43 PM with the DNS identified Resident #3 required extensive assist with a rolling walker for transfers/ambulation. Also, identifying the NA should have had her hands on Resident #3 at all times and should not have bent down to pick up any dropped items off of the floor. Interview on 7/8/26 at 8:50 AM with NA #6 identified on 3/31/26 she did not use a gait belt when transferring and ambulating Resident #3 because she did not have one at the time of the fall. Also, identifying she should have used a gait belt. Interview on 7/9/26 at 4:39 PM with Licensed Practice Nurse (LPN) #14 identified she did not witness the fall but as per NA #6, the NA and Resident #3 were coming out of the bathroom, Resident #3 was using the walker and fell backwards but could not remember if the NA used a gait belt. Interview on 7/9/26 at 4:40 PM with the DNS identified on 3/31/26 if a gait belt had been used when NA #6 was transferring Resident #3, she could have guided Resident #3 to the floor and possibly prevented the injury to the resident's head. Also, identifying the NA should have left the dropped items on the floor and retrieved them after the transfer of Resident #3 was complete. Further identifying the facility policy was to use a gait belt with all residents and that NA #6 did not follow the facility policy. Review of the Gait Belt policy dated 1/1/25 directed, in part, to provide a safe method for assisting residents with transfers and walking.

Based on review of the clinical record, facility policy and interviews for 6 of 6 residents (Resident #3, Resident #52, Resident #87, Resident #91, Resident #106, Resident #114) reviewed for care planning, the facility failed to ensure quarterly Resident Care Plan (RCP) meetings were conducted. The findings include: 1. Resident #3 had diagnoses that included dementia, abnormalities of gait and balance, and convulsions.The Resident Care Plan (RCP) dated 3/22/25 identified Resident #3 was at risk of falling. Interventions included using the assistance of 2 staff for early morning transfers, monitor/assist with toileting needs, and keep personal items within reach.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired, used a walker, was independent with eating and bed mobility, supervision or touching assistance with walking, and required partial/moderate assistance with chair/bed transfers.Review of the clinical record identified a quarterly care plan meeting was held for Resident #3 on 5/28/25 or thereafter.Interview with Social Worker (SW) #2 on 7/6/26 at 12:15 PM identified Resident #3's last quarterly care plan meeting was in May of 2025.2. Resident #52 had diagnoses that included osteomyelitis, cirrhosis of the liver, and atherosclerosis.The Resident Care Plan (RCP) dated 8/11/25 (17 days before Resident #52's admission) identified Resident #52 was at risk for altered health maintenance. Interventions included monitor alternating pressure low air loss mattress function every shift, and nursing to report new skin issues.Review of the clinical record failed to identify a quarterly care plan meeting was held for Resident #52 since admission on [DATE].Interview with Social Worker (SW) #2 on 7/6/26 at 12:15 PM identified Resident #52 had not had a quarterly care plan meeting conducted since admission on [DATE].3. Resident #87 had diagnoses that included vascular dementia, diabetes, and adult failure to thrive.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 was severely cognitively impaired, used a wheelchair, and was dependent for eating and wheelchair mobility, and required substantial/maximal assistance with bed mobility and chair/bed transfers.The Resident Care Plan (RCP) dated 7/8/25 identified Resident #87 was at risk for impaired decision making related to a diagnosis of dementia. Interventions included encourage family/conservator/power of attorney to attend care plan meetings, call with any changes, and provide rehabilitation services as needed.Review of the clinical record identified a quarterly care plan meeting was held for Resident #87 on 7/8/25 and was attended by 2 staff members and the resident representative.A social services note dated 2/2/26 at 8:29 PM identified a quarterly assessment which indicated she met with Resident #87 who had impaired cognition and was unable to participate in the assessment. The note indicated Resident #87 was not in psychosocial distress and had no mood or behavior changes. The note indicated the social worker was available as needed. The note failed to identify a care plan meeting was held with Resident #87 and/or his/her responsible party.Review of the clinical record failed to identify a care plan meeting was held for Resident #87 after the RCP on 7/8/25.Interview with Social Worker (SW) #2 on 7/6/26 at 12:15 PM identified Resident #87's last quarterly care plan meeting was in July of 2025.4. Resident #91 had diagnoses that included Alzheimer's disease, hypertension, and stage 3 chronic kidney disease.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #91 was cognitively intact, used a walker, and was independent with eating, bed mobility, transfers, and ambulation. The Resident Care Plan (RCP) dated 7/1/25 identified Resident #91 was at risk for impaired decision making related to a diagnosis of dementia. Interventions included encourage family/conservator/power of attorney to attend care plan meetings, call with any changes, and provide rehabilitation services as needed.Review of the clinical record identified a quarterly care plan meeting was held for Resident #91 on 7/1/25 and was attended by 2 staff members and indicated the responsible party was updated.A social services note dated 8/6/25 at 12:55 PM identified Resident #91 was cognitively intact, had full code advance directives, had an involved supportive family who visited often, and that the care plan was reviewed. The note failed to identify a care plan meeting was held with Resident #91 and/or his/her resident representative.A social services note dated 2/2/26 at 8:12 PM identified a quarterly assessment which indicated she met with Resident #91 who had impaired cognition and was not in any psychosocial distress. The note indicated the social worker was available as needed. The note failed to identify a care plan meeting was held with Resident #91 and/or his/her resident representative.Review of the clinical record failed to identify a care plan meeting was held for Resident #91 after 7/1/25 and failed to identify the RCP was reviewed after 8/6/25.Interview with Social Worker (SW) #2 on 7/6/26 at 12:15 PM identified Resident #91's last quarterly care plan meeting was in July of 2025.5. Resident #106 had diagnoses that included aphasia following a stroke, diabetes, and traumatic brain injury.The Resident Care Plan (RCP) dated 5/20/25 identified Resident #106 had cognitive loss related to a traumatic brain injury. Interventions included encourage small group programs, assign consistent caregivers as often as possible, and provide supervision for tasks.Review of the clinical record identified a quarterly care plan meeting was held for Resident #106 on 5/21/25.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106's preferred language was Nepali, he/she had a short term memory problem, and was independent with eating, bed mobility, transfers, and ambulation.A quarterly social services note dated 8/18/25 at 5:16 PM identified Resident #106 had confusion and forgetfulness related to a traumatic brain injury, that he/she spoke Nepali and very little English. The note indicated conservatorship was pending and his/her friend was involved and supportive. The note further indicated the care plan was reviewed. The note failed to identify a care plan meeting was held with Resident #106 and/or his/her responsible party.A social services note dated 2/16/26 at 5:12 PM identified a quarterly assessment was completed and that she had met with Resident #106's staff because he/she was unable to participate due to a language barrier. The note indicated Resident #106 spoke Nepali and understood basic English. The note indicated the social worker was available as needed. The note failed to identify a care plan meeting was held with Resident #106 and/or his/her responsible party.Review of the clinical record failed to identify a care plan meeting was held for Resident #106 after 5/21/25 and failed to identify the RCP was reviewed after 8/18/25.Interview with Social Worker (SW) #2 on 7/6/26 at 12:15 PM identified Resident #106's last quarterly care plan meeting was in May of 2025.6. Resident #114 had diagnoses that included chronic obstructive pulmonary disease (COPD), anxiety, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #114 was cognitively intact, used a walker, and was independent with eating, bed mobility, transfers, and ambulation.The Resident Care Plan (RCP) dated 11/12/25 identified Resident #114 was at risk for impaired psychosocial well-being. Interventions included provide opportunities to express feelings, obtain family input as needed, and invite Resident #114 and/or the responsible party to care plan meetings.Review of the clinical record identified a 72 Hour Meeting form (admission care plan meeting) was held for Resident #114 on 11/17/25 and was attended by 3 staff members. The form failed to identify a signature from Resident #114 and/or his/her responsible party.Review of the clinical record failed to identify a care plan meeting was held for Resident #114 after 11/17/25.Interview with Social Worker (SW) #2 on 7/6/26 at 12:15 PM identified Resident #114 had not had a quarterly care plan meeting conducted since admission on [DATE].Interview with SW #2 on 7/7/26 at 10:50 AM identified when she started working at the facility in March 2026 she had been instructed by the (previous) Director of Social Services at that time to focus her time on filling out her section(s) of the MDS assessments for residents. Additionally, she indicated that this was her first position as a SW inside a skilled nursing facility and that she had previously worked with children in a different setting. She indicated it wasn't until Social Worker #1 started in the position of Director of Social Services in June 2026 that she had become aware that quarterly care plan meetings were required for all residents. She further indicated that her and SW #1 began conducting quarterly care plan meetings in June 2026.Interview with the Director of Nursing Services (DNS) on 7/9/26 at 11:30 AM identified that she had just become aware that quarterly care plan meetings had not been conducted for facility residents since 2025 until SW #1 started in her position in June 2026 and began conducting quarterly care plan meetings. She indicated that care plan meetings should be conducted with the resident and/or responsible party quarterly (every 3 months) and that it was the responsibility of the Social Services department to ensure they were conducted. She was unable to identify why that had not been happening and indicated that the previous SW had not informed her at any time that there were any issues with completion of quarterly care plan meetings.Review of the Care Conference policy, revised on 1/1/25, directed, in part, the facility will hold care conferences (care plan meetings) to review and update the individual RCPs. The policy directed input from the resident and/or responsible party and member of the interdisciplinary team would be included in the care conference. The policy directed that care conferences would be held at least every 3 months (quarterly) and/or sooner if there were a significant change in resident condition. The policy further directed care conferences must be documented and all changes to the plan of care signed by the resident and/or responsible party.

Based on staff interviews, test tray temperatures, review of food committee minutes and a tour of the Dietary Department, the facility failed to ensure food was served at appropriate and palatable temperatures. Review of the food committee meeting minutes for 8/19/25, 5/5/26, and 6/16/26 identified the food was served cold, and at the 9/9/25 meeting the members identified the hamburgers were cold.During initial tour on 6/30/26 at 11:15 AM, residents complained of ongoing issues with food being served cold.On 7/6/26, a test tray was conducted. The following was identified:The lunch meal was plated and left the Dietary Department on 2 different styles of carts, 1 was open, the other was closed with doors, the trays were placed in the carts starting at 12:30 PM and filled with numerous trays. Numerous bowls of soup were observed on a metal tray already plated in a plastic bowl covered with a plastic disposable lid. The hamburger was in a stainless-steel container on the steam table. Plates came from a plate warmer then placed in a pellet system warmer, the food was then placed on the carts. A Dietary Aide transferred the meal trays to the second floor along with the Dietary Director. The food temperature log was reviewed with all foods identified at appropriate temperatures for each item. The test temperature tray was plated at 12:43 PM, placed on the open cart and brought up to the second-floor unit at 12:45 PM. Several Nurse Aids on the unit were passing trays. The last tray was served to a resident at 1:08 PM and temperatures were obtained of the temperature test tray at 1:09 PM with the Dietary Director identifying the following: a. The pulled pork internal temperature was 130 degrees with the Dietary Director and the surveyor's thermometer.b. The French Fries internal temperature was 120 degrees with both the Dietary Director and surveyor's thermometer. c. The mashed potato's internal temperature was 126 degrees with both the Dietary Director and surveyor's thermometer.d. The pureed green beans internal temperature was 124 degrees with the surveyor and the Dietary Director's thermometer.e. The cream of chicken soup internal temperature was 109.4 degrees with the surveyor's and the Dietary Director's thermometer.f. The hamburger internal temperature was 115.9 degrees with the surveyor's and the Dietary Director's thermometer.Interview with the Dietary Director identified that the cream of chicken soup temperature should be served at 125-130 degrees and the hamburger should be served at 135 degrees. Also, she was unable to identify why the soup and hamburger were cold.Interview on 7/8/2026 at 9:08 AM with the Dietary Director identified the soup was plated at 11:45 AM and placed on the metal tray with the plastic lids. When reviewing the time the soup was brought up to the unit at 12:45 PM with the Dietary Director who then identified that the soup was cold because the item was plated at 11:45 AM and sat out for 1 hour without being heated.Although requested, a facility policy for food being served temperatures was not provided.

Based on observation, facility policy, and interviews for 1 of 3 residents (Resident #91) reviewed for medication administration and for 1 of 3 sampled residents (Resident #52) reviewed for pressure ulcers, the facility failed to ensure licensed nursing staff performed hand hygiene according to infection control standards. Additionally, for the only resident (Resident #54) reviewed for tube feeding, the facility failed to ensure appropriate personal protective equipment (PPE) was donned (placed on) prior to incontinent care and a mechanical lift transfer for a resident on enhanced barrier precautions (EBP). 1.Resident #52's diagnoses included Extended Spectrum Beta Lactamase (a Multidrug Resistant Organism), cirrhosis of the liver, and hepatitis. Nursing notes dated 2/18/26 identified an open area to Resident #52's coccyx measuring 1.3 centimeters (cm) by (x) 1.0 cm. Also, identifying new orders were obtained to cleanse the wound with Normal Saline, pat dry, apply Calcium Alginate and cover with dry, clean dressing every day and as needed. Further, identifying the wound Advance Practice Registered Nurse (APRN) to assess on weekly rounds. An Advanced Practice Registered Nurse (APRN) progress note dated 2/26/26 identified Resident #52 was seen for evaluation and treatment recommendation regarding a pressure ulcer to the sacrum, the nursing staff noticed the wound last Wednesday. Also, identifying the pressure ulcer to the sacrum measured 1.2 cm x 1.2 x 0.2 centimeters with 30% slough,70% granulation with moderate serosanguinous drainage. An APRN progress note dated 3/2/26 identified Resident #52 was seen for evaluation and treatment for a pressure ulcer to the sacrum. Also, identifying the measure 1.2 cm x 1.2 cm x 0.2 centimeters with serosanguinous drainage. Further, identified the sacrum wound had 10% slough and 90% granulation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 was severely cognitively impaired and dependent with toileting, bathing, eating, bed mobility, and transfers. The MDS indicated Resident #52 was at risk for developing a pressure ulcer and failed to identify Resident #52 had a pressure ulcer. The Resident Care Plan dated 3/13/26 identified altered health maintenance related to a Stage 3 pressure ulcer to the sacrum/coccyx measuring 1.2 cm x 1.2 cm x 0.2 cm. Interventions included to complete wound treatments as ordered by the physician, and the resident will be seen weekly by wound physician/nurse. Physician Order dated 5/13/26 directed to enhanced barrier precautions, history of extended spectrum beta lactamase in urine every shift, days, evening and nights. A physician order dated 6/29/26 directed to cleanse the wound to the coccyx with Normal Saline, pat dry, apply Thera honey followed by Calcium Alginate, cover with a dry, clean dressing every day and as needed. Observation and interview on 7/6/26 at 10:15 AM of the dressing change completed by APRN #1 noted APRN #1 cleansed her hands, donned (applied) personal protective equipment consisting of gloves, a gown, a mask and removed the old dressing. APRN#1 was then observed to cleanse the wound with Normal Saline, took measurement of the wound (4.1 cm x 3.4 cm x 0.3 cm) without the benefit of completing hand hygiene and changing her gloves after removing the old dressing. APRN #1 was then noted to change her gloves without cleansing her hands after removing the dirty gloves, applied Thera honey followed by Calcium Alginate to the wound and covered the wound with a clean, dry dressing. APRN #1 then pulled back the dressing to Resident #52's left forearm but did not cleanse her hands and change her gloves after completing the coccyx treatment and before pulling back the dressing on Resident #52's left forearm to evaluate. APRN #1 identified she thought she had washed her hands with hand sanitizer and changed her gloves before cleansing Resident #52's coccyx with Normal Saline. APRN #1 was unable to locate the hand sanitizer she used but stated it was usually at the beside. Also, identifying she should have cleansed her hands after removing the old dressing from the coccyx wound. Further, identifying she knew the policy was to cleanse your hands between the dirty and clean, stating I usually do if there's a visual reminder. Interview on 7/7/26 at 12:26 PM with the DNS identified when performing wound care one should cleanse their hands, then apply gloves before removing the old dressing, remove the old dressing, cleansing hands after removing the old, dirty gloves, apply new gloves, then cleanse the wound, remove the gloves, cleanse hands and apply new gloves before applying the clean, dry dressing. Review of the Handwashing policy dated 1/1/25 directed, in part, all staff must adhere to hand hygiene protocol before and after resident contact, after contact with potentially contaminated surfaces, and as otherwise indicated. The purpose was to prevent the spread of infections by ensuring that all healthcare personnel follow proper hygiene practices in accordance with Center for Disease Control and CMS guidelines. Hand hygiene must be performed: before and after direct resident contact, before performing aseptic tasks such as wound care, after exposure to body fluids or excretions, before donning and removing gloves. 2. Resident #54's diagnosis included cerebral vascular accident (stroke) with gastrostomy status, dysphagia (difficulty swallowing), and nutritional deficiency. A physician order dated 3/26/26 and currently in effect directed Enhanced Barrier Precautions due to Gastrostomy tube every shift. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was severely cognitively impaired, required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. Additionally, the MDS identified Resident #54 had a diagnosis of gastrostomy status with tube feedings (TF) for calorie and fluid intake. The Resident Care Plan (RCP) dated 6/24/26 identified Resident #54 was on EBP due to an indwelling medical device (Gastrostomy Tube) with interventions that included signage would be posted on door and gown and gloves were to be worn by staff during high contact care activities such as dressing, bathing, hygiene, changing a brief and assistance with toileting and transfers. Observation on initial tour of Resident #54's room on 6/30/26 at 11:00 AM identified EBP signage was posted on the door frame which directed staff must wear gloves and a gown for dressing, bathing, providing hygiene and changing briefs. A wall unit containing disposable isolation gowns and other personal protective equipment (PPE) was located on the wall outside of and next to Resident #54's room. Observation and interview with Nurse Aide (NA) #1 on 6/30/26 at 11:52 AM noted NA #1 was providing AM care (incontinent care, bathing and dressing) without the benefit of wearing an isolation gown. NA #1 indicated although she had observed the signage outside of the resident's room and was aware what EBP was, she thought the resident was no longer on EBP. She also stated it had slipped her mind and she made a mistake. Observation and interview on 6/30/26 at 11:55 AM noted NA #2 had entered Resident #54's room to assist NA #1 with a mechanical lift transfer without the benefit of wearing an isolation gown or gloves. NA #2 completed the mechanical lift transfer with NA #1 and when asked stated she should have worn an isolation gown and gloves during the transfer, but she came into the room to help NA #1 and forgot. NA #2 further indicated although she saw the signage outside of the resident's room and was aware what EBP was, she failed to put on an isolation gown and gloves because it had slipped her mind. Interview with Licensed Practical Nurse (LPN) #1 on 6/30/26 at 11:57 AM identified NA #1 and NA #2 should have worn an isolation gown and gloves when providing AM hygiene care and a mechanical lift transfer for Resident #54. LPN #1 indicated it was the responsibility of NA #1 and NA #2 to pay attention to the posted signage and ensure that EBP was followed for Resident #54 (because of the resident's GT) and she was unsure why that was not done. Interview with the DNS on 7/8/26 at 9:33 AM identified Resident #54 was on EBP with signage posted and PPE available and NA #1 and NA #2 should have worn isolation gowns and gloves when providing AM hygiene care and a mechanical lift transfer for Resident #54. The DNS indicated she was unsure why the NA's did not put on the required PPE when caring for Resident #54 and she would need to provide the NA's further education. Review of facility policy, Transmission Based Precautions, dated 6/2025, directed to prevent the transmission of infectious organisms within the skilled nursing facility the facility shall implement Transmission Based Precautions for residents who are known or suspected to be infected or colonized with pathogens that require additional infection prevention measures beyond Standard Precautions. Enhanced Barrier Precautions (EBP) would be implemented for residents with wounds or devices in accordance with current CDC recommendations. For residents on EBP, staff shall wear isolation gowns and gloves during high contact resident care activities. 3.Observation of medication administration on 7/2/26 at 7:40 AM identified Licensed Practical Nurse (LPN) #2 prepared medications for Resident #91 which included an inhaler. During administration the inhaler was handled by LPN #2's ungloved hand and held in resident's mouth by the resident. LPN #2 touched the bedside table, moved the medication cart to next resident room, and prepared medications for the next resident without the benefit of hand hygiene. Interview with LPN #2 on 7/2/26 at 7:50 AM identified that hand hygiene should be done between residents during medication administration and that LPN #2 forgot to perform task. Interview with the DNS on 7/9/26 at 10:30 AM identified that hand hygiene should be performed between patients during medication administration. Review of the Medication Administration policy dated February 16, 2018 directed, in part, to always wash hands before preparing or administering medications.

Based on interviews, observation of dining, and facility policy the facility failed to ensure a dignified dining experience. The findings include: Observation on 6/30/26 at 12:18 PM noted on the [NAME] 1 unit all cold beverages were served in small plastic disposable cups, and 4 residents were served lunch on trays in the dining room without the benefit of the plates being removed from the lunch trays and served on the table.Observation on 6/30/26 at 12:40 PM of the residents eating in the TV lounge East 2 second floor noted the food was served on trays during lunch (without the benefit of the plates being removed from the lunch trays and served on the table), and every cold beverage was served in a small plastic disposable cup.Observations on 7/1/26 and 7/2/26 during lunch time in the East 2 unit TV lounge, beverages (cold drinks) were served in plastic disposable cups.Observation on 7/2/26 at 9:00 AM noted breakfast being served on both the first and second floor unit, all cold beverages were served in small plastic disposable cups.Observation on 7/7/26 at 9:05 AM noted 6 residents in the TV lounge on the second floor East 2 unit, eating breakfast and all were served on trays lunch (without the benefit of food plates being removed from the lunch trays and served on the table) and using plastic disposable drinking cups.Interview on 7/7/26 at 9:22 AM with Registered Nurse (RN) #4 identified residents have been served small plastic cups for cold beverages since Covid-19 in 2020 and the facility stopped using the big dining room and started using the TV lounge. Also identifying serving cold beverages in a small plastic cup was not homelike.Interview on 7/7/26 at 12:21 PM with the Director of Nursing Services (DNS) identified serving residents with small plastic cups for their cold beverage and serving on their trays was not homelike environment. She could not identify why the dining rooms were not being utilized, identifying the TV lounges were used for meals.Interview on 7/7/26 at 3:55 PM with the Administrator identified small disposable cups for cold beverages have been utilized at the facility since he started in January of 2026. The Administrator further noted that serving meals on trays was not homelike and was unsure of the reason the residents were served like that. Further, identifying the dining rooms have not been utilized since Covid-19 in 2020, but the dining rooms were available.Review of the Resident Dining policy dated 1/1/25 directed, in part, the facility will provide each resident with meals and dining services consistent with the resident's need, prescribed diet, food preference, cultural and religious practice, functional abilities and choices. Residents will be treated with dignity and provided appropriate assistance and adaptive equipment to promote the highest practicable level of independence. The purpose was to ensure all residents receive meals in a safe, dignified, person-centered, and homelike environment that supports nutritional needs, preferences, independence, and quality of life.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #45) reviewed for a glucose monitoring device, the facility failed to complete a self-administration assessment prior to Resident #45 self-applying the device. The findings include: Resident #45 was readmitted to the facility in January 2026 with diagnoses that included Type 1 diabetes mellitus with ketoacidosis, chronic kidney disease and hyperglycemia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was cognitively intact and was independent with toileting, bed mobility and transfers. The MDS indicated Resident #45 had a diagnosis of diabetes mellitus and received insulin injections daily. A physician's order dated 5/14/26 and currently in effect directed to check placement of Dexcom Monitor every shift and notify Registered Nurse (RN) when dislodged. The Resident Care Plan (RCP) dated 6/29/26 identified Resident #45 had Type 1 diabetes mellitus and was at risk for abnormal blood glucose levels. Interventions included to administer diabetic medications/insulin as ordered, monitor for signs and symptoms of hypo and hyperglycemia, perform blood glucose checks as ordered and report abnormal values to the physician. The RCP failed to identify Resident #45 wore a continuous glucose monitoring device (Dexcom) which was inserted with a needle in the arm and changed every 10 days or as needed and failed to identify Resident #45 was self-applying and monitoring the device. Observation on initial tour on 6/30/26 at 11:45 AM noted Resident #45 in a 4-person occupied room, resting in bed and on the top of the bedside table next to the window were 4 boxes of unopened Dexcom supplies. Resident #45 proceeded to lift his/her posterior left upper arm which had a white disc attached and stated the supplies were for use when he/she would need to reapply the continuous glucose monitoring device every 10 days. Resident #45 indicated he/she was removing and reapplying the device on his/her own and without staff supervision since admission to the facility. Resident #45 stated the nursing staff were aware he/she acquired the supplies when on leave of absence from the facility or his/her family would bring the supplies to the facility. Additionally, Resident #45 indicated the boxes of supplies were always kept unsecured and on top of the bedside table, where he/she could easily reach them. Observation and interview with LPN #1 on 6/30/26 at 12:00 PM found 4 unopened boxes of Dexcom supplies on the bedside table next to Resident #45. LPN #1 indicated she was aware the supplies were kept there because the resident removed and reapplied the Dexcom sensor on his/her own and without staff supervision. Interview with the Registered Nurse supervisor (RN #1) on 6/30/26 at 12:10 PM identified the resident should not have been removing and self-applying the device without a self-administration assessment and supervision by a nurse. Observation on 6/30/26 at 1:10 PM found the Dexcom supplies were no longer on Resident #45's bedside table. The resident indicated the supplies were going to be kept in the nurse's medication cart now and he/she would need to ask for them when needed. Interview and review of the clinical record with the DNS on 7/8/26 at 9:36 AM identified she was aware the unopened Dexcom supplies were found on Resident #45's bedside table. The DNS the resident should not have applied the device independently without a self-administration assessment completed, which was unable to be located in the clinical record and without supervision by a nurse. The DNS indicated the Dexcom supplies would be secured in the nurse's medication cart and the resident was made aware to ask for the supplies when needed. Additionally, the DNS stated that going forward the charge nurse or nursing supervisor would change the sensor until the resident was assessed for self-administration and the applied sensor would be monitored for placement every shift. Subsequent to surveyor inquiry, a physician's order dated 7/8/26 directed to complete a self-administration of medication observation once an evening (3:00 PM to 11:00 PM) and document whether resident can accurately place Dexcom device. Subsequent to surveyor inquiry, a nursing progress note dated 7/8/26 at 5:16 PM identified the nursing supervisor had observed the resident demonstrate how to use Dexcom for blood sugar reading and the resident stated his Dexcom gets changed every 10 days. Subsequent to surveyor inquiry, a Self-Administration of Medication observation dated 7/8/26 at 5:28 PM indicated Resident #45 used a Dexcom to read his/her blood sugars and wants to do his/her own blood sugar testing with use of Dexcom. The observation indicated Resident #45 was appropriate to self-administer medications and the medication would be stored in the nursing medication cart. Review of facility policy, Self Medication, undated, directed to allow for self-administration of medication where appropriate and to promote independence and maximization of resident capabilities each resident is assessed by interdisciplinary team members for capacity to participate in the self-medication program. The assessment includes physical, mental and emotional strengths and handicaps. A physicians order for self-medication will be maintained and will include drug name, dose, frequency and route and self-medication approval. Nursing staff will in-service the resident on administration, directions and storage procedures. Residents on the program are periodically reassessed for continuation of self-medication. All decisions should be documented in the clinical record and comprehensive care plan.

Based on review of the clinical record, facility documentation, facility policy and interviews for the 1 of 3 residents reviewed for diabetes (Resident #1), the facility failed to notify the physician of a low blood sugar reading per the physician's order. The findings include: Resident #1's diagnoses included Type 2 Diabetes Mellitus, pneumonia and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #1 had diabetes mellitus and received insulin injections daily. The Resident Care Plan dated 1/2/26 identified Resident #1 was at risk for abnormal blood glucose levels related to diabetes. Interventions included to administer diabetic medications as ordered, monitoring for signs and symptoms of hypo and hyperglycemia and to perform blood glucose checks as ordered and report abnormal values to the physician. A physician order dated 1/6/26 directed blood sugars twice a day at 6:30 AM and 6:30 PM and notify the physician if blood sugar is less than 70 milligrams (mg) per deciliter (dl) or greater than 400 mg/dl. Review of the Medication Administration Record (MAR) for February 2026 identified on 2/15/26 at 6:30 AM, Resident #1 had a blood glucose reading of 65 mg/dl (hypoglycemia). The Special Instructions noted on the MAR indicated that the physician was to be notified of a blood glucose reading of less than 70 mg/dl or greater than 400 mg/dl. Interview and review of the clinical record with the DNS on 7/6/26 at 11:08 AM identified Resident #1 had a blood glucose reading of 65 mg/dl at 6:30 AM on 2/15/26. Review of the progress notes for Resident #1 failed to indicate the charge nurse had identified the low blood glucose reading or notified the nursing supervisor (RN #11) or physician about it. The DNS stated that per the physician's order, Resident #1's blood glucose reading of 65 mg/dl should have been reported to the physician for further intervention and it would have been the responsibility of the charge nurse or the nursing supervisor to notify the physician. Interview with LPN #9 on 7/8/26 at 1:03 PM identified she worked the 3:00 PM to 11:00 PM shift on 2/15/26 and was not told about Resident #1's low blood glucose reading that day from the t 6:30 AM blood glucose reading) in shift report. LPN #9 indicated she did not know what was done for the resident or if the physician had been notified by LPN #11. Interview with LPN #12 on 7/9/26 at 10:19 AM identified she worked the 7:00 AM to 3:00 PM shift on 2/15/26 and did not recall being told about Resident #1's low blood glucose reading that day (at 6:30 AM) in shift report. LPN #9 indicated she did not know what was done for the resident or if the physician had been notified by LPN #11. Further identified Resident #1 should have been given juice or a snack and the physician should have been notified and the blood glucose level should have been rechecked. Interview with LPN #11 on 7/9/26 at 11:03 AM identified she worked the 11:00 PM to 7:00 AM shift on 2/15/26 and obtained and documented Resident #1's blood glucose level of 65 mg/dl on the MAR for 6:30 AM. LPN #11 indicated she thought she might have told the nursing supervisor about it but did not recall who the nursing supervisor was. LPN #11 stated although she could not remember providing any interventions for Resident #1, she would usually give a resident something if they had a low blood glucose level. LPN #11 further indicated that she may have made a mistake and entered the wrong blood glucose level on the MAR, but she could not really remember. Interview with the Medical Director on 7/9/26 at 9:50 AM identified if Resident #1 had a blood glucose reading of 65 mg/dl on 2/15/26, the nurse should have notified the physician, and he was unsure why that was not done. The Medical Director indicated it was the nurse's responsibility to notify him, ensure interventions were provided for the resident and a nurse's note should have been written. Additionally, the Medical Director stated if he had been notified on 2/15/26 he would have instructed the nurse to make sure the resident was provided food/drink or administered glucose gel and Resident #1's blood glucose level should have been rechecked afterward. Interview with Advanced Practice Registered Nurse (APRN) #2 on 7/9/26 at 12:30 PM identified she was not notified by the nurse about Resident #1's blood glucose reading of 65 mg/dl on 2/15/26 at 6:30 AM and she should have been. APRN #2 stated had she been notified on 2/15/26 she would have instructed the nurse to make sure the resident was provided food/drink or administered the glucose gel and Resident #1's blood glucose level should have been rechecked afterward. Attempts to contact the RN supervisor (RN #11) were unsuccessful. Review of facility policy, Blood Glucose, dated 1/1/25, directed point of care blood glucose testing was to determine the amount of glucose (sugar) present in the blood and assist in the management of diabetes. When the test is complete the result will be displayed on the glucometer screen and the result should be noted and correctly documented in the resident's record in the electronic medical record (EMR). Review of facility policy, Compliance with and Implementation of Physician's Orders, dated 1/1/25, directed it is the policy of the facility to ensure that all physician orders are implemented accurately, timely and in accordance with applicable federal and state regulations. Services ordered by a licensed physician or authorized non-physician provider are to be provided as prescribed. Orders must be carried out as written unless contraindicated. In such cases, the physician must be notified, and documentation must reflect the clinical rationale.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #3) reviewed for activities of daily living, the facility failed provide a cup with a lid during the lunchtime meal per the Resident Care Plan (RCP). Resident #3's diagnosis included dementia, muscle weakness and diabetes.The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired, dependent on bathing, toileting, and transfers. Also, identifying Resident #3 was independent for eating.The Resident Care Plan (RCP) dated 5/28/26 identified Resident #3 was at nutritional risk related to poor diet compliance. Interventions included providing adaptive equipment, cup with a lid, divided plate recommended by therapy, assist resident with meals as needed, and encourage the resident to eat in the dining room.Observation on 6/30/26 at 12:40 PM noted Resident #3 seated in his/her wheel chair, using a small disposable, plastic cup without a lid and observed squeezing the cup while attempting to drink from it.Resident #3 had decreased ability to hold a cup, noted on medication rounds, question a sippy cup or cup with a lid.On 6/30/26 the Diet Requestion and Change form was completed to add adaptive equipment, a cup with lid and straw by Occupational Therapy (OT) #1.Observations made throughout the lunch meal on 7/1/26 and 7/2/26 identified Resident #3 was seated in a wheelchair, at the dining room table, etc attempting to drink out of the small, disposable plastic cup without a lid which the resident was squeezing while attempting to hold the cup.Observation on 7/7/26 at 9:05 AM of Resident #3 having breakfast in the TV lounge being served a small, plastic disposable cup of juice. Also, Resident #3 was squeezing the cup without a lid while attempting to drink the juice. Further, identifying Resident #3 was served coffee without a lid.Interview and review of the RCP on 7/7/26 at 9:15 AM with Nurse Aid (NA)#7 identified she usually works on the unit Resident #3 resides on and thinks resident would benefit from a cup with a lid. Also, identifying the RCP identified Resident #3 required a cup with a lid and the intervention was added 5/28/26. Further, identifying the information on the Resident Care Card was to provide Resident #3 with a cup with a lid, therapy provides adaptive equipment, and the kitchen sends the cup with a lid to the unit with meals.Interview on 7/7/26 at 9:22 AM with Registered Nurse (RN)#4 identified she was unaware Resident #3 required a cup with a lid, and the kitchen provides the cup with a lid once it was ordered by therapy.Interview with the Dietary Director on 7/7/26 at 9:55 AM identified she did not have any residents in the facility that required a cup with a lid. Also, identifying therapy was responsible for letting the kitchen know when a resident needs a cup with a lid. Further, identifying the kitchen did not have a supply of cups with lids.Interview on 7/7/26 at 10:21 AM with Occupational Therapist (OT) #1 identified she fills out a form for the kitchen when a cup with a lid was required for a resident, and she did not have a record of this form for Resident #3. Also, identifying she updated Resident #3's RCP in May of 2026 and ordered cups with lids over the last month, but the cups have gone missing. Further, identifying the order was put in place incorrectly and that was the reason Resident #3 has not had a cup with a lid for 47 days.Interview on 7/7/26 at 12:21 PM with the DNS identified she or therapy was responsible for oversight for the order of the cup with a lid for Resident #3 and the Administrator was responsible for ordering cups with lids.Interview on 7/7/26 at 3:55 PM with the Administrator identified central supply was responsible for ordering cups with lids and the facility should have a stock of the cups available. Also, identifying he was unsure if the facility had a supply of cups with lids.Interview on 7/8/26 at 8:40 AM with the Administrator identified central supply did not have any cups with lids and he was responsible.Review of the Feeding Assistance and Dining Support policy dated 1/1/25 directed, in part, the facility shall provide each resident with assistance, supervision, adaptive equipment, and interventions necessary to maintain adequate nutritional and fluid intake consistent with the resident's assessed needs, physician or practitioner orders, dietary recommendations, and personal preferences. The purpose to ensure residents receive safe, individualized, and person-centered assistance with eating and drinking in a manner that promotes adequate nutrition, hydration, dignity, independence, and quality of life while reducing the risk of choking, aspiration malnutrition, and dehydration.

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #18) reviewed for pressure ulcers, the facility failed to document a nursing assessment that was completed for a newly identified pressure ulcer. The findings include: Resident #18's diagnoses included adult failure to thrive, moderate protein calorie malnutrition, and need for assistance with personal care. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was moderately cognitively impaired, required substantial assistance for lower body dressing, putting on and off footwear, showering/bathing, and toilet hygiene. Additionally, the MDS identified Resident #18 was at risk for developing pressure ulcers and did not have any pressure ulcers at the time of the MDS assessment. The Resident Care Plan dated 6/25/26 identified a risk of impaired ability to perform activities of daily living (ADL's), a risk for impaired skin integrity, and risk for decreased activities/weakness. Interventions included to provide assistance with ADL's as needed, report any skin changes to Medical Doctor (MD)/ Advanced Practice Registered Nurse (APRN), weekly skin checks, check skin every shift, protect bony prominences (area where bone is close to the skin), teach how to shift weight if applicable, when in chair position every 1 hour, use barrier cream with incontinent changes, when changing position lift, don't drag. A Braden Scale for Prediction Pressure Ulcer Risk was completed by Licensed Practical Nurse (LPN) #8 on 6/5/26 and indicated resident was at risk for developing a pressure ulcer and Resident #18's skin was intact upon admission. A nursing assessment dated [DATE] at 7:18 PM written by LPN #8 noted Resident #18's skin was intact with no alteration in skin integrity. The assessment stated there were no pressure injuries to the sacrum, heels, hips, ankles, elbows, ears, and other bony prominences. A nursing admission note dated 6/5/26 at 7:49 PM by Registered Nurse (RN) #6 stated Resident #18's skin was intact. A nursing note dated 6/28/26 at 11:02 PM by LPN #8 identified Resident #18 had an open area to their left buttock (discrepancy, pressure ulcer was to Resident #18's sacrum per subsequent APRN and nursing notes) and LPN# 8 notified the supervisor. She noted a treatment was in place until Resident #18 could be seen by the wound doctor. A nursing note on 6/29/26 at 4:22 PM by RN#2 indicated that Resident #18 was seen by the wound provider. A wound progress note dated 6/29/26 and written by Advanced Practice Registered Nurse (APRN) #2 indicated Resident#18 had an unstageable pressure ulcer (a full thickness pressure ulcer/wound whose depth and severity can't be determined because the wound bed is hidden by dead tissue) to the sacrum that measured 3.1 centimeters (cm) by (x) 2.6 cm x 0.2 cm. The wound bed was 100% slough (dead tissue) with moderate purulent drainage (thick pus like drainage that indicates infection) and induration (skin tissue that has become hardened due to inflammation, infection, or other underlying conditions) to the skin surrounding the wound. A physician's order dated 6/29/26 by MD #1 directed to cleanse the pressure ulcer to Resident #18's sacrum with Normal Saline, then apply Mupirocin (an antibiotic ointment), followed by Calcium Alginate and a dry clean dressing daily and as needed. A progress note dated 6/30/26 at 12:00 AM by APRN #2 indicated Resident #18 presented with concern for possible infection to the sacrum pressure ulcer. The pressure ulcer was noted to be foul smelling with moderate pain to the area. APRN #2 started Resident #18 on Bactrim DS (an antibiotic) twice daily for 7 days. She directed to monitor Resident #18 closely for signs of sepsis (a life-threatening infection). A nursing note dated 6/30/26 at 12:20 PM by RN#4 indicated wound care had been provided to the sacrum and the wound bed appeared sloughy (dead tissue). Interview with LPN #8 on 7/7/26 at 1:17 PM indicated she had identified the pressure ulcer to Resident #18's sacrum on 6/28/26. LPN #8 indicated she reported the pressure ulcer to the RN supervisor, RN #5. She stated RN # 5 was responsible for completing the assessment and documentation of the wound. Interview with RN #5 on 7/7/26 at 1:54 PM identified she had failed to document her assessment of a new pressure ulcer for Resident #18. RN #5 stated she had been notified of the new pressure ulcer for Resident #18. She stated she wrote in the wound doctor's book for Resident #18 to be seen. RN #5 stated she cleansed the area on Resident #18's sacrum and covered it with a dry clean dressing. RN #5 stated she did not document her assessment of the wound because the other nurse had written it in her note. When surveyor asked if she should have documented it, she stated now that she was thinking about it yes, she should have. Interview with the Director of Nursing Services (DNS) on 7/8/26 at 9:55 AM indicated RN #5 failed to document a new pressure ulcer for Resident #18. She stated RN #5 was responsible and should have assessed the pressure ulcer and documented her findings in the clinical chart. Review of the facility policy Skin and Wound Management dated 1/19/2018 directed: the nurse shall describe and document/report the following: a. full assessment for pressure sore including location, stage, length, width, depth, and presence of exudates (fluids produced by the body in response to tissue injury)or necrotic tissue (dead nonfunctioning tissue), b. pain assessment, c. resident's mobility status, d. current treatments including support surfaces, e. all active diagnosis.

Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #81) reviewed for activities, the facility failed to ensure Resident #81, who remained in bed the majority of time, was provided with individualized activities. The findings include: Resident #81 was admitted to the facility in December 2017 with diagnoses that included muscular dystrophy, schizophrenia with hallucinations and delusions, and anxiety disorder. An Annual Minimum Data Set (MDS) assessment dated [DATE] identified books, newspapers, magazines, music, news and religious services were all somewhat important to Resident #81.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #81 was moderately cognitively impaired, refused care daily, required set up for meals and was totally dependent on staff for washing and dressing.The Resident Care Plan (RCP) dated 6/24/26 identified independent activities as an area of focus with interventions that included offer special events, offer supplies for independent activities, provide calendar, and provide visits at bedside. Physician orders dated 6/26/26 directed activity as tolerated, assist of 1 with bed mobility, ambulation with rolling walker with assist from therapy only, document all refusals of care and medications referral to acute facility need notes and behaviors, and recreational activities as tolerated. Observations on 6/30/26 at 10:45 AM, 7/1/26 at 10:00 AM and 12:29 PM noted Resident #81 was lying on his/her back without the benefit of any activities. Resident #81 had no television (TV) or radio in his/her room. Resident #81 had a chronicle paper on his/her over the bed table that was not open. There were no observations made of Resident #81 having any visits from recreational staff in his/her room or Resident #81 reading the newspaper.Observation and interview with Resident #81 on 7/2/26 at 8:42 AM noted Resident #81 was lying flat on his/her back in bed holding dollar bills tightly in his/her right hand. Resident #81 was in a pleasant mood stating, it was my birthday. Resident #81 had a large gift bag on his/her bedside nightstand that had Happy Birthday written on the bag. Resident #81 smiled and started to sing Born in the USA. Resident #81 continued to sing for several minutes with a large smile on his/her face engaging with surveyor and asking surveyor to sing along with him/her. Resident #81 stated that he/she enjoyed music and liked to sing. Interview with the Therapeutic Recreational Director (TRD) on 7/2/26 at 10:30 AM revealed that Resident #81 enjoyed music and would frequent music programs when he/she was out of bed. The TRD indicated that Resident #81 usually accepts 1:1 social visits from recreational staff. The TRD could not explain why Resident #81 did not have music/radio in his/her room since Resident #81 enjoyed music and spent most of his/her time in bed. The TRD stated, it is a good idea, I will get him a radio. The TRD stated that was recreation along with other staff members to provide Resident #81 with activities and that recreation provided Resident #81 with the newspaper. Review of Resident # 81's recreation participation calendars on 7/4/26 for April, May, and June of 2026 identified that the only code documented on the participation calendar were social visits. Resident #81's participation calendar for April (30 days) and May (31 days) had 22 social visits documented each month. The month of June (30 days) had 26 social visits documented. The participation calendars for Resident #81 did not indicate the amount of time spent with Resident #81 or if an activity was provided. A review of Recreational Calendar on 7/4/26 for April, May, and June revealed music activity programs were available for residents on April 5th,, 6th, and 21st. In May music activity programs were available on the 1st, 5th and 28th. Lastly, in June, music activity programs were available on June 1st, 5th, 9th and 19th. There was no documentation in Resident #81's participation record or recreation progress notes that Resident #81 was offered to attend music programs and Resident #81 refused. Subsequent to surveyor inquiry, a radio was provided to Resident #81.tAlthough requested, a policy on activities was not provided.

Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #80) reviewed for falls, the facility failed to ensure timely assessment by the provider toprevent a delay in treatment for a resident with complaints of shoulder pain with decreased range of motion and subsequent x-ray which revealed a humeral fracture. The findings include: Resident #80 had diagnoses that included peripheral vascular disease, seizures, and a right below the knee amputation.The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was cognitively intact, used a wheelchair, was independent with eating, upper/lower body dressing, bed mobility, and walking and required setup or clean-up assistance with chair/bed/toilet transfers. The MDS assessment dated failed to indicate Resident #80's wheelchair mobility level.The Resident Care Plan (RCP) dated 3/4/26 identified Resident #80 was non-compliant with use of a custom wheelchair. Interventions included to encourage Resident #80 to be compliant with the plan of care, discussion of risk factors with Resident #80 and family, and to obtain social work consultations as needed.A nursing note dated 3/14/26 at 9:00 AM identified Resident #80 was assessed for a fall. The note indicated Resident #80 was alert, with unlabored breathing, sitting upright against the closet door. The note indicated Resident #80 denied hitting their head, had no visible injuries, denied pain, and had positive range of motion to upper extremities, left lower extremity and right amputated leg. The note indicated Resident #80 stated he/she was getting clothes out of the closet and that he/she was encouraged to use the call bell for assistance.A nursing note written by Registered Nurse (RN) #6 on 3/18/26 at 4:00 PM identified Resident #80 was assessed following a fall. The note indicated Resident #80 was sitting upright on the floor in front of the closet. The note indicated Resident #80 stated he/she was taking things out of a bag to put in the closet and slipped. The note indicated Resident #80 denied hitting their head, had no visible injuries, and was able to move all extremities.A nursing note written by RN #6 on 3/18/26 at 5:50 PM identified Resident #80 was observed sitting on the bathroom floor facing the door and toilet. The note indicated Resident #80 initially stated he/she did not know what happened but then said that falling was his/her way of getting attention. The note indicated Resident #80 denied pain and had a skin tear to the left calf, and 2nd and 3rd toes.A nursing note written by Licensed Practical Nurse (LPN) #3 on 4/1/26 at 2:38 PM identified Resident #80 complained of pain to the right shoulder with decreased range of motion. The note indicated the RN and APRN were notified and she was waiting for new orders.An RN supervisor nursing note dated 4/1/26 at 9:40 PM identified APRN #2 was updated regarding Resident #80's complaint of right shoulder pain. The note indicated APRN #2 gave instructions to utilize the as needed (PRN) Tylenol order and that she would see Resident #80 in the morning.Review of the nursing progress notes failed to identify a nursing note or APRN progress note written between 4/1/26 at 9:40 PM and 4/6/26 at 2:02 PM.An APRN progress note written by APRN #2 dated 4/9/26 at 9:15 AM identified Resident #80 presented with multiple falls over the past week and now complained of pain to his/her right shoulder. The note indicated an x-ray to the right shoulder would be ordered. (The progress note failed to identify Resident #80 first complained of the pain to the right shoulder on 4/1/26).A nursing note written by LPN #3 on 4/9/26 at 2:44 PM identified Resident #80 complained of discomfort and decreased range of motion to the right shoulder, and an x-ray order was obtained.A note written by LPN #4 on 4/9/26 at 11:53 PM identified the x-ray to the right shoulder was completed and the results were pending.An APRN progress note written by APRN #2 dated 4/10/26 at 8:30 AM identified Resident #80 presented with severe right shoulder pain and had multiple falls over the past few weeks. The note indicated the right shoulder x-ray revealed a fracture which involved the humeral head and neck with minimal displacement. The note indicated the fracture likely occurred during one of Resident #80's recent falls. Additionally, the note identified the x-ray radiology report indicated the fracture appeared old, however APRN #2 indicated Resident #80 had never had an x-ray showing a fracture previously. The note further identified Resident #80 was placed in a sling, with new orders for an orthopedic consultation for evaluation and management of the right humeral fracture, and application of a lidocaine 4% topical patch to the right shoulder daily as needed for pain.Interview with the Director of Nursing Services (DNS) on 7/9/26 at 11:30 AM identified APRN #2 was notified Resident #80 complained of right shoulder pain that was accompanied by decreased range of motion. She indicated she was unable to identify why there had been a delay in the APRN evaluating Resident #80's shoulder pain and decreased range of motion and further indicated there should not have been a delay and Resident #80 should have been seen by APRN #2 on 4/2/26 as she had instructed the nursing supervisor on 4/1/26 that she would.Interview with APRN #2 on 7/9/26 at PM identified she recalled seeing Resident #80 for decreased range of motion to the right shoulder but was unable to identify why there was a gap in time from the 4/1/26 notification to her and her initial assessment on 4/9/26. She indicated that she may have been away that week, or she may have seen Resident #80 and just failed to write a progress note.Review of the Change of Condition policy revised on 1/30/25 directed, in part, the facility must immediately notify the APRN or medical doctor when there is a significant change in the resident's mental, physical, or psychosocial condition including new onset of pain. The policy directed any resident with a change in condition will receive intervention which is timely and appropriate. The policy further directed the APRN will be notified in person or by phone which will be documented in a nursing note for continuity of care.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 sampled residents (Resident #1, Resident #52 and Resident #54), reviewed for positioning and mobility, the facility failed to apply upper extremity splints per the physician's order for residents with contractures (Resident #1 and Resident #54). Additionally, the facility failed to provide rehab therapy to Resident #52 who had an upper extremity contracture. The findings include: 1.Resident #1's diagnoses included hemiplegia (paralysis) affecting left nondominant side, anoxic brain damage, muscle weakness, and aphasia. An Occupational Therapy (OT) Discharge summary dated [DATE] at 5:43 PM identified Resident #1 had met the goal to safely wear the left resting hand splint during night hours only without skin irritation and swelling/edema in order to maintain passive range of motion (PROM) and to prevent skin breakdown. The discharge summary indicated the resident was wearing the left-hand splint up to 8 hours per day. Review of the OT Evaluation and Plan of Treatment dated 1/8/26 at 11:35 AM identified Resident #1's left upper extremity (LUE) was flaccid proximally with increased muscle tone distally specifically in digits 2-5 with joint flexion contractures noted. The resident had a left resting hand splint that he/she was wearing overnight. The Nurse Aide (NA) care card for Resident #1 indicated a start date of 3/4/26 with directives to apply splint/brace as per physician's order at bedtime. A physician's order dated 3/7/26 and currently in effect directed a left resting hand splint on after PM care, off after AM care and to check skin integrity with application and removal. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent with toileting, bed mobility, and transfers. The MDS indicated Resident #1 had hemiplegia affecting the left dominant side but failed to indicate the resident had an upper extremity impairment. The MDS also failed to indicate the use of orthotics or splint/brace assistance. The Resident Care Plan (RCP) dated 6/25/26 identified Resident #1 had impaired mobility in the left upper extremity and needed a resting hand splint with interventions that included application of the splint/brace per the physician's order.Observations on 6/30/25 at 10:20 AM and 7/2/26 at 8:00 AM noted Resident #1 was in bed wearing a hospital gown, his/her eyes were closed, the left hand was visible over the covers and Resident #1 was not wearing a left resting hand splint on. Interview, observation and review of the NA care card with Licensed Practical Nurse (LPN # 7) and NA #2 on 7/6/26 at 8:40 AM identified Resident #1 was in bed with a hospital gown on, his/her eyes were closed and was without the benefit of a left resting hand splint on. NA #2 indicated she had not yet provided AM care to the resident and she was unsure why the resident's hand splint was not on as it should have been per the NA care card. LPN #7 and NA #2 identified the 3:00 PM to 11:00 PM nursing staff were responsible to apply Resident #1's left hand splint after PM care. LPN #7 stated the left resting hand splint should have been on the resident and she was unsure why it was not on. Although LPN #7 attempted to locate the splint she was unable to and indicated she would need to notify the rehab department. Interview and review of the clinical record with the DNS on 7/6/26 at 9:32 AM identified if Resident #1 had a physician's order to have a left resting hand splint applied, the splint should have been applied as ordered. The DNS indicated it was the responsibility of the nursing staff to ensure splints were applied as ordered and if the splint was unable to be located, the physician and rehab department should have been notified. Further, the DNS stated hand splints were for residents with contractures with the purpose of ensuring contractures did not get worse. Interview with the Rehab Director on 7/8/26 at 10:45 AM identified Resident #1 had left hand contractures and a left resting hand splint was ordered to be worn PM to AM. The rehab director indicated the resident should have had the splint in place as ordered to prevent his/her contractures from getting worse. Further the rehab director stated she was not aware the nursing staff were unable to find the splint and that she would need to contact the splint person to get another one. Subsequent to surveyor inquiry the NA care card dated 7/9/26 for Resident #1 indicated resting hand splint to LUE was on hold until new splint arrived. 2. Resident #52's diagnoses included muscle weakness, atherosclerosis, and osteomyelitis.A Physical Therapy (PT) evaluation and treatment plan dated 9/3/25 identified Resident #52 had right and left upper extremity impaired flexion contractures.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 was severely impaired and dependent with toileting, bathing, eating, bed mobility, and transfers. The MDS indicated Resident #52 had an upper extremity impairment on both sides and failed to indicate the use of orthotics or splint/brace assistance or therapy/restorative services.The Resident Care Plan (RCP) dated 6/26/26 identified Resident #52 was at risk for skin impairment. Interventions included repositioning every 2 hours, pre-medicate for pain as needed and placing heel lift boots at all times except during care or as needed for therapy.Observation on 6/30/26 at 2:30 PM noted Resident #52 to have bilateral hand contractures without an order for splints.Observation on 7/6/26 at 10:15 AM noted Resident #52 in bed with bilateral lower extremity heel lift boots in place, Resident #52 had bilateral hand and upper extremity contractures and could not reposition him/herself.Interview on 7/7/26 at 8:46 AM with Licensed Practice Nurse (LPN) #5 identified she had contacted therapy in the past regarding Resident #52's contractures to his/her upper extremities but was unsure of the outcome.Interview on 7/7/26 at 10:02 AM with Occupational Therapist (OT) #1 identified she had never evaluated Resident #52 since she was hired in November of 2025, and Resident #52 had not received a therapy assessment since June 2025. Also, identifying the facility required quarterly therapy assessments to be completed for residents but she was unaware of that policy and had received 2 notices of quarterly assessments for other residents since November of 2025. Further, identifying she would expect to be notified of any resident with a question of contractures, and any staff member can make the request, but she could not locate any request for screening for Resident #52. OT #1 identified there was a procedure/policy for making a referral and nursing was to fill out a screening request form, but failed to provide a written policy upon request.Interview on 7/7/26 at 12:16 PM with the DNS identified a resident with a fall, significant change or recommendation should be evaluated for therapy services. Also, identifying the facility required therapy quarterly assessments to be completed on residents.Subsequent to surveyor inquiry a screening was completed on 7/7/26. The OT evaluation and treatment plan dated 7/7/26 identified Resident #52 presented with impaired right elbow range of motion indicating the need for OT for ranging and splint assessment. Also, identifying Resident #52 would receive OT services 2-3 times a week.Interview on 7/8/26 at 11:20 AM with OT #1 identified Resident #52 had a screening on 7/7/26 and had a need for a right elbow splint. Also, identifying she could not locate any old screenings for Resident #52.Interview on 7/8/26 at 12:08 PM with LPN #5 identified Resident #52 has had bilateral upper extremity contracture for at least 6 months and the unit Resident #52 lived on was the unit she usually worked on.Interview on 7/8/26 at 12:28 PM with Nurse Aide (NA) #7 identified she had taken care of Resident #52 for a long time and knew the resident well. Also, identifying Resident #52 has had contractures to his/her upper extremities for a while which started after his/her admission to the facility in August 2025. Further, identifying she had reported the contractures to the nurses on the unit about 6 months ago and stated that the contracture was obvious to see when making an observation of the resident.Although requested, a facility policy for therapy screening was not provided. 3. Resident #54's diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the right dominant side, muscle weakness, and aphasia following cerebral infarction. A physician's order dated 3/11/26 and currently in effect directed a right resting hand splint don (apply) after PM and doff (remove) with AM care. Check skin integrity to right hand when donning splint with PM care and doffing with AM care. The Nurse Aide (NA) care card for Resident #54 identified a start date of 5/26/26 to apply right resting hand splint don in AM and doff in PM. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was severely cognitively impaired required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. Although the MDS indicated Resident #1 had hemiplegia affecting the right dominant side and an upper extremity impairment on one side, the MDS failed to indicate the use of orthotics or splint/brace assistance. The Resident Care Plan (RCP) dated 6/24/26 identified Resident #54 had hemiplegia with impaired mobility in the right upper extremity which required the resident to wear a right resting hand splint. Interventions included right resting hand splint, don in PM and doff in AM and to apply the splint/brace as per the physician's order. Observations on 6/30/26 at 10:30 AM and 7/2/26 at 6:25 AM found Resident #54 in bed with a hospital gown on and without the benefit of a right resting hand splint on. Observation and interview with NA #2 on 7/2/26 at 8:00 AM identified Resident #54 was in bed and she had not yet provided AM care. NA #2 indicated she was not sure why the resident did not have his/her right resting hand splint on because she did not usually work on this unit and did not review the NA care card for the resident. NA #2 stated she did not see the hand splint on Resident #1 and did not apply it overnight because she did not know the resident needed it. Further indicating she would need to ask the charge nurse about the splint. Interview and observation with the rehab director on 7/2/26 at 8:05 AM identified she was aware Resident #54 had a physician's order for a right resting hand splint, due to a hand contracture, but the resident did not have the splint applied. The rehab director indicated it would have been the responsibility of the nursing staff to apply the residents hand splint every evening after PM care. Although the rehab director attempted to locate Resident #54's hand splint she was unsuccessful and further stated if the resident failed to have the splint applied as ordered his/her hand contracture would get worse. Interview and observation with LPN #1 on 7/2/26 at 8:43 AM identified Resident #54 was in bed and without the benefit of the right resting hand splint on. LPN #1 indicated the resident had not yet received AM care and should have had the splint applied to the right upper extremity. LPN #1 indicated she was not aware the hand splint could not be located and she would need to follow-up with rehab to see what they wanted to do about it. Further stating it would have been the responsibility of the nursing staff on the 3:00 PM to 11:00 PM shift to ensure Resident #54's splint was applied after PM care was provided and she was unsure why that was not done. Another observation on 7/2/26 at 1:30 PM noted Resident #54 seated in a wheelchair which was placed by the nurse's station with a right resting hand splint applied. LPN #1 indicated rehab had arrived and applied the hand splint to the resident but stated she would need to check the physician's order to be sure the hand splint was supposed to be on. LPN #1 checked the physician's order for Resident #54's hand splint (which indicated it should not be applied after AM care) and proceeded to remove the hand splint from the resident. LPN #1 further stated since the right resting hand splint had now been located, the nursing staff would apply it to Resident #54 per the physician's order. Observation and interview with LPN #11 and NA #2 on 7/6/26 at 8:30 AM identified Resident #54 was in bed wearing a hospital gown and was without the benefit of the right resting hand splint. NA #2 indicated she had not yet provided the resident with AM care and was unsure why the resident's hand splint had not been applied. LPN #11 entered the room and proceeded to search for the resident's hand splint and located it on the floor and wedged between the resident's nightstand and closet. LPN #11 indicated the resident should have had the right resting hand splint applied as ordered and she was unsure why Resident #54 did not have the hand splint applied. Interview and review of the clinical record with the DNS on 7/6/26 at 9:35 AM identified if Resident #54 had a physician's order to have a right resting hand splint applied, the splint should have been applied as ordered. The DNS indicated it was the responsibility of the nursing staff to ensure splints were applied as ordered and if the splint was unable to be located, the physician and rehab department should have been notified. Further, the DNS stated hand splints were ordered for residents with contractures with the purpose of ensuring contractures did not get worse. Review of facility policy, Splint Application and Monitoring, dated 1/1/25, directed the facility shall ensure that all residents prescribed a splint receive proper assessment, fitting and monitoring to prevent injury, promote function and maintain skin integrity. The nursing staff is responsible for daily monitoring, application, documentation, and communication of changes and any deviation from protocol (loss of device) must be reported and documented.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only resident (Resident #54) reviewed for tube feeding, the facility failed to notify the physician and obtain a physician's order prior to changing a gastrostomy tube (GT). The findings include: Resident #54's diagnosis included cerebral vascular accident (CVA) with gastrostomy status, dysphagia (difficulty swallowing), and nutritional deficiency. A physician order dated 3/6/36 and currently in effect directed a tube feeding (TF) of Jevity 1.2 at 105/hr for 17 hours on at 4:00 PM and off at 9:00 AM with water flushes of 240 cubic centimeters (cc) every shift at 6:00 AM, 2:00 PM and 10:00 PM. There were no physician orders directing changing the GT within the facility should it be clogged or dislodged or with what size tube to utilize if changing the GT. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was severely cognitively impaired required substantial/maximal assistance with bed mobility and was dependent with toileting and transfers. Additionally, the MDS identified Resident #54 had a diagnosis of gastrostomy status with tube feedings (TF) for calorie and fluid intake.The Resident Care Plan (RCP) dated 3/25/26 identified Resident #54 had malnutrition and was at risk for dehydration related to dysphagia, nothing by mouth and the need for TF related to CVA. Interventions included providing TF via GT with water flushes per physician's order and assessing tube for placement and function. A nursing note written by Registered Nurse (RN) #8 on 5/24/26 at 9:45 PM identified at about 9:30 PM Resident #54's GT was replaced due to it being clogged and the ADNS was made aware. A nursing note written by Licensed Practical Nurse (LPN) #10 on 5/24/26 at 11:44 PM identified Resident #54's GT was unable to flush after many attempts, and the nursing supervisor was called to the floor to assess. The resident's GT was replaced by a drainage catheter (size 14F with 10cc balloon), the insertion was effective and the new tube was aspirating and flushing well after replacement. An interview with the RN supervisor (RN #8) on 7/9/26 at 12:48 PM identified she was the nursing supervisor working the 3:00 PM to 11:00 PM shift on 5/24/26. RN #8 indicated Resident #54's GT was clogged and she changed it with LPN #11 at the resident's bedside that evening. RN #8 identified although she notified the ADNS, she failed to notify the physician or obtain a physician's order to change the GT. RN #8 indicated the physician should have been notified and a new physician order should have been obtained by her before Resident #54's GT was changed but she thought the ADNS had called the physician. Interview and review of the clinical record with the ADNS on 7/9/26 at 9:00 AM identified Resident #54's GT was changed on 5/24/26 without physician notification or a physician's order in place. The ADNS indicated although she was notified by RN #8 about the resident's clogged GT, it would have been RN #8's responsibility to ensure the physician was notified and a new physician's order was obtained before RN #8 replaced Resident #54's GT and she was unsure why that was not done. Interview with LPN #11 on 7/9/26 at 11:35 AM identified she was the charge nurse working the 3:00 PM to 11:00 PM shift on 5/24/26. LPN #11 indicated Resident #54's GT was clogged and she changed it with RN #8 at the resident's bedside that evening. LPN #11 identified although she did not notify the physician or obtain a physician's order prior to replacing the GT, she was unsure if RN #8 had done so and further indicated RN #8 should have. Interview and review of the clinical record with the DNS on 7/9/26 at 12:56 PM identified Resident #54's GT was changed on 5/24/26 without physician notification or a physician's order in place. The DNS indicated it would have been RN #8's responsibility to ensure the physician was notified and a new physician's order was obtained before RN #8 replaced Resident #54's GT and she was unsure why that was not done. Subsequent to surveyor inquiry, a physician's order dated 7/9/26 directed on 5/24/26 per physician, may reinsert using drainage catheter (14F/10cc) related to GT being clogged. Review of facility policy, G-Tube Re-Insertion, dated 1/1/25, directed G-tube reinsertion will only be performed by a registered nurse (RN) when permitted by state regulations, facility policy and a valid provider order. The RN will notify the provider of any concerns or complications, follow the physician's order and the procedure and notifications will be documented in the medical record.

Based on observations, interviews, review of clinical record and facility policy for 1 of 2 sampled residents (Resident #10) reviewed for respiratory care, the facility failed to ensure a nebulizer mask was stored appropriately. The findings include:Resident #10 was admitted in January 2024 with diagnosis that included chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia (body tissue does not receive enough oxygen), and lung cancer.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was cognitively intact and required moderate assistance with activities of daily living (ADLs).Physician orders dated 6/4/26 directed to administer Ipratropium Albuterol (a fast-acting rescue medication used to quickly open the airways) solution 0.5 milligrams (mg) -3mg/3millilters (ml) for nebulization, give 3ml every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM and every 4 hours as needed and change respiratory tubing and set up bag for oxygen; label with patient name and date weekly, once a day on Sunday; 12:00 AM-7:00 AMThe Resident Care Plan (RCP) dated 6/9/26 identified COPD as an area of focus with interventions that included providing supplemental oxygen/bipap/cipap as ordered, monitor skin integrity for breakdown related to oxygen tubing and mask, keep head of bed elevated, monitor for signs of respiratory distress, check oxygen saturation as needed, and monitor for shortness of breath. Observations on 6/30/26 at 10:20 AM and 2:02 PM and 7/1/26 at 9:44 AM noted a nebulizer mask uncovered, laying on the windowsill in Resident #10's room and not dated.Observation on 7/2/26 at 9:02 AM noted the nebulizer tubing dated 7/2/26 11-7 shift and bagged on the windowsill. The Medication Administration Record identified that Resident #10 received his/her nebulizer treatment on 6/30/26 and 7/1/26 at 6:00 AM, 2:00 PM, and 10:00 PM. There was not any as needed nebulizer treatments administered. Interview with the DNS on 7/7/26 at 7:30 AM identified that she would need to review the policy regarding the care of nebulizer tubing and mask after use. The DNS indicated the charge nurse would be responsible to ensure that proper care of nebulizer tubing and mask. The DNS indicated that it was usually the responsibility of the 11-7 nurse to change and date tubing and store the nebulizer mask in a plastic bag. Furthermore, the DNS stated that the licensed nurse that administers the nebulizer should rinse the mask after each medication administration. The Aerosolized Policy not dated directed, in part, that nebulizer mask will be bagged after use.

Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #9) reviewed for COVID-19 vaccines, the facility failed to provide a COVID-19 vaccine upon consent. The findings include: Resident #9 was admitted to the facility on [DATE] and the clinical record face sheet identified Resident #9 as [AGE] years of age.A vaccine consent form for a COVID-19 vaccine signed on 6/17/26 by the resident representative agreeing to receive a Flu vaccine, Pneumonia Vaccines, and COVID-19 Vaccine. No earlier vaccine consent form was provided.Review of the immunization section of the electronic medical record (EMR) failed to identify that Resident #9 had received any COVID-19 vaccines since admission. Last documented COVID-19 vaccine received was 12/23/21 prior to admission.Interview, clinical record review, and facility documentation review with the Infection Preventionist (IP), (RN #2) on 7/6/26 at 10:00 AM identified that she had started in the Infection Preventionist position in February of 2026 and had not reviewed the residents to determine who was eligible to receive the COVID-19 vaccine. She also indicated she did not have any mechanism in place to track residents' current vaccine status. She was not aware of any COVID-19 vaccine clinics held or scheduled and that it was her responsibility to ensure that residents were up to date with COVID-19, Flu, and Pneumonia vaccines.Interview with the DNS and RN #3 on 7/7/26 at 7:30 AM identified there should be a mechanism in place to maintain surveillance and the COVID-19 vaccine should be offered annually. They both stated that the Infection Preventionist was responsible.Review of policy Covid 19 Vaccine dated 1-19-2018 indicated that the vaccine will be offered annually to encourage and promote the benefits associated with vaccinations against Covid 19 and that the Infection Preventionist will maintain surveillance data on Covid 19 coverage and reported rates of Covid 19 among residents.

Based on observations, review of facility documentation, facility policy and interview regarding access to State Agency information, the facility failed to post a list of names, addresses, and telephone numbers of all relevant State Agencies with information that residents may file a complaint with the State Survey Agency. The findings include: a. On 7/2/26 at 11:10 AM a Resident Council meeting was held that was attended by 9 residents (Resident #17, Resident #26, Resident #28, Resident #42, Resident #91, Resident #98, Resident #106, Resident #107, and Resident #117). The residents were asked during the resident council meeting if they knew how to file a complaint with the State Survey Agency if they felt that their care needs weren't being met or they had other concerns they wanted to report. Resident #17 was the only resident who was able to state that he/she had information within the admission packet that he/she received which had indicated how to contact the State Agency. The additional 8 residents in attendance did not know how to file a complaint if needed and were not aware of the location of information related to the State Survey Agency that they could access to file a complaint.b. Observation on 7/2/26 at 2:02 PM identified a bulletin board enclosed in a glass case which contained facility information and notices. The bulletin board was located on the wall next to the elevators on the 1st floor. Although the bulletin board contained various facility information (cost of hairdresser, smoking policy,etc), it failed to identify a notice related to a list of names, addresses, and telephone numbers of all relevant State Agencies and that the residents may file a complaint with the State Survey Agency.On 7/2/26 at 2:05 PM observations were made on all units of the facility failed to identify a posting that residents may file a complaint with the State Agency and contact information on how to make a complaint to the State Survey Agency. Observation and interview with the Director of Recreation (DR) on 7/8/26 at 11:10 AM identified she reviewed information on the State Survey Agency and how to file a complaint periodically in the Resident Council meetings. She confirmed that there was no notice within the glass case of the bulletin board on the 1st floor related to a list of names, addresses, and telephone numbers of all relevant State Agencies with information that the resident may file a complaint with the State Survey Agency. She was unable to identify the reason that information wasn't included within the board. Additionally, she confirmed that there were no notices posted on the 2nd floor or anywhere else on the 1st floor. She indicated there used to be another bulletin board hung on the 1st floor with notices, but it was no longer accessible due to the current renovations in progress. She was unable to identify the reason there were no notices besides how to contact the Ombudsman on the 2nd floor for those residents who were unable to access the 1st floor on their own.Review of Resident Council Minutes from 7/15/25 through 6/16/26 failed to identify information on the State Survey Agency and how to file a complaint were reviewed with the residents in attendance during that time period.Review of additional Resident Council documentation located in a binder in the Recreation office identified resident attendance sheets for the meetings and a checklist reviewed at each meeting for resident concerns. The binder and checklists failed to identify information on the State Survey Agency and how to file a complaint was reviewed with residents from 7/15/25 through 6/16/26.Review of the Resident Right to Report Complaints to State Survey Agency policy directed, in part, residents had the right to report complaints related to concerns regarding care and services to the Department of Public Health (DPH). The policy directed residents will be informed of their right to file a complaint on admission and when requested. The policy directed that contact information for DPH will be posted in a visible location in the facility.

Based on observations, interviews, review of clinical record, facility documentation and facility policy, the facility failed to ensure resident's clothing was not missing, including missing clothing for Resident #3. Additionally, for 1 of 2 residents (Resident #59) reviewed for environment, the facility failed to ensure Resident #59's wheelchair was maintained in a clean manner. The findings include: 1. Resident # 53 was admitted to the facility in July 2025 with diagnoses that included muscle weakness, depression, and alcohol dependency. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #53 was cognitively intact and was independent with all activities of daily living (ADLs). Physician orders dated 6/18/26 directed for Resident #53 to ambulate independently with a rolling walker (RW), independent with bed mobility, and moderate independence with ADLs. The Resident Care Plan dated 6/24/26 identified ADLs as an area of focus with interventions that included independence with ADLs, provide assistance as needed, therapy as needed, and ambulate with a RW. Interview with Resident #53 on 6/30/26 at 10:00 AM identified that he/she had a concern regarding missing clothing since admission to the facility. Resident #53 stated that many of his/her socks, shirts, underpants, and sweatpants never return from the laundry. In addition, he/she would see other residents wearing his/her clothes. Resident #53 indicated that he/she was unsure how the facility misplaces the clothing because they are washed by an outside service and not at the facility. Resident #53 stated that all his/her clothes were labeled with his/her name and when the facility was doing his/her laundry that the dirty clothing were placed in a mesh bag; staff would pick up the mesh bag for washing for the laundry service. The clothing was delivered to his/her room once washed and returned to the facility. Resident #53 indicated that he/she had never written a formal grievance about his/her missing clothes but had told everyone and nothing was ever done. Furthermore, Resident #53 stated it was a big problem at the facility and there were several other residents with missing clothes. Resident #53 indicated that he/she now washes his/her own clothes at the facility due to being fearful that the clothes would not return from the laundry and he/she would not have clothing to wear. Observation and interview with Resident #53 at 9:45 AM noted he/she had 5 pairs of socks drying across the windowsill and 3 pairs of sweatpants drying over his/her RW. Resident #53 indicated that he/she washed clothes last night in the bathroom sink and was allowing them to dry. Resident #53 stated that he/she had his/her own laundry soap in a plastic storage container. Resident #53 stated that a family member will do his/her laundry occasionally, but they do not visit frequently. Interview with the Administrator on 7/7/26 at 10:00 AM indicated that he was not aware that Resident #53 had a concern regarding missing clothing or that Resident #53 started washing his/her own clothing because of being fearful clothing would not return from the laundry service. The Administrator stated that missing laundry had been a huge concern at the facility and he had been working closely with the laundry vendor. The Administrator stated that he just purchased a labeler for the facility but had not started using it yet. Furthermore, he indicated that he had been doing auditing with residents regarding missing clothing, but he did not have anything in writing. Also, the Administrator indicated that the facility had received clothing belonging from another facility with a similar name. He indicated that although denied by the laundry service, he wondered if some of the personal items had been delivered to the wrong facility. Interview with Nurse Aide (NA) #2 on 7/7/26 at 10:15 AM (one of Resident #53's primary NA during the day) stated that she was unaware that Resident #53 was washing his/her own clothes. NA #2 stated she could not remember specifically if Resident #53 complained about missing clothing but stated there were many residents who were concerned about the laundry and missing clothing. NA stated that they normally assist in labeling a resident's clothes by putting a white tape label on the article of clothing and write the resident's last name on the white tag with a permanent black marker. Furthermore, NA #2 indicated that when a resident was admitted to the facility, the NA completes a Personal Inventory Form that lists all the clothing a resident was admitted with and any other personal items. The Personal Inventory Form was then given to the licensed nurse so it can be filed in the resident's chart or scanned into the computer for the individual resident. Resident #53's chart and electronic medical record lack documentation that a Personal Inventory Form was completed on admission or thereafter. Interview with the Laundry Service Vendor Account Manager on 7/7/26 at 2:00 PM indicated that he was aware that the facility was having issues with missing laundry; however, he indicated that it was more of a systems problem at the facility. He indicated that he suggested to the administrator to purchase a labeler for clothing so clothing can be identified. Furthermore, he indicated that although laundry has been delivered to the wrong facility in error there have been no outstanding concerns or issues related to this matter. Interview with the Laundry Aide (LA )#1 on 7/8/26 at 8:35 AM indicated that she along with another LA were responsible for delivering the laundry to resident rooms when it returns from the laundry service. LA #1 indicated she was not aware of any concerns regarding Resident #53 missing clothes or that Resident #53 was washing his/her own clothes in the room. LA #1 indicated that she knew that other residents had concerns. LA #1 stated that no one at the facility had reviewed with her the concerns regarding laundry from Resident Council. In addition, LA #1 was unaware of who was responsible for labeling residents' clothing. Interview with the Director of Maintenance (DOM) on 7/8/26 at 9:00 AM indicated that he received the concerns from Resident Council regarding the clothing. He indicated that he worked with staff on the unit to help locate missing items. He does not provide the LAs with the information regarding missing clothing. The DOM stated he was not aware Resident #53 was missing clothing and that he/she was washing clothes in his/her bathroom. Interview with the Director of Nursing (DNS) on 7/8/26 at 11:30AM indicated that she was not aware Resident #53 was washing his own clothes due to his/her clothes missing in the past, The DNS indicated that a resident should not feel they have to resort to washing his/her own clothes because he/she is fearful the clothing will go missing, The DNS indicated that a Personal Inventory and labeling of clothing should be completed by the NAs on admission in order to determine if a resident had personal items such as clothing go missing. The Personal Item Inventory Item policy, revised on 1/19/2018, directed, in part, the facility will maintain an inventory of each resident's personal belongings upon admission, readmission, and as needed during the resident's stay. The inventory will include clothing, eyeglasses, dentures, hearing aids, jewelry, assistive devices, and other personal items. The inventory will be updated when personal items are added or removed. Any missing personal items will be reported to management and investigated accordingly. 2.Resident #59 had diagnoses that included cerebral atherosclerosis (narrowing of arteries in the brain due to buildup of fatty plaques), heart failure, and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was severely cognitively impaired, used a walker and wheelchair, was dependent for eating, personal hygiene, bed mobility, transfers, and wheelchair mobility. The Resident Care Plan (RCP) dated 6/24/26 identified Resident #59 required assistance with functional activities of daily living. Interventions included Resident #59 was non-ambulatory, required assistance of 1 staff member for transfers to the wheelchair with a rolling walker, and required assistance of 1 staff member for eating. Review of the June 2026 Room of the Day schedule identified Resident #59's room and wheelchair were scheduled for cleaning on 6/11/26. Observation on 6/30/26 at 10:50 AM identified Resident #59 was seated in his/her wheelchair and the wheelchair was observed to be soiled with food and debris on the sides of the wheelchair cushion and on top of the wheelchair cushion. Observation on 7/8/26 at 8:04 AM identified a wheelchair in the hallway labeled with Resident #59's name and located outside his/her room which was observed to be heavily soiled with crumbs in the grooves, crevices, and along ridges of the armrest and wheelchair cushion with smears of unknown substances across the top of the seat. Additionally, the soiled leg rests were observed placed on top of the wheelchair cushion inside Resident #59's unoccupied wheelchair. Interview with the Director of Maintenance (DOM) on 7/8/26 at 8:40 AM identified the housekeeping/maintenance department was responsible for the cleaning of resident wheelchairs. He indicated wheelchairs were cleaned as part of the Room of the Day. He indicated there was a monthly schedule of the Room of the Day and every room and wheelchair gets cleaned according to the schedule. He indicated that when a room was designated as a Room of the Day, each resident wheelchair in that room was cleaned. He indicated those rooms typically were cleaned shortly after breakfast and if a resident was in their wheelchair the Nurse Aides (NA) could bring the wheelchair down to the basement for cleaning. He indicated there was a night cleaning schedule which would clean any wheelchairs brought down by the staff at night so that it was ready for the resident the following morning. He indicated the process for cleaning a wheelchair depended on if there were electronics or not, and if there were no electronics the wheelchair was brought outside and sprayed down with soap and water to clean it, the remaining wheelchairs were wiped down with bleach spray and a wipe. He indicated the NAs could bring wheelchairs down anytime they needed cleaning and they would get cleaned by his night staff. He further indicated that he did not have a written log of wheelchair cleaning aside from the Room of the Day schedule of which he only kept the current schedule, he indicated previous cleaning schedules were kept by the Infection Control Nurse. Observation on 7/8/26 at 3:39 PM identified Resident #59 was seated in his/her wheelchair, and the wheelchair was observed to be soiled with food and debris on the sides of the wheelchair cushion and on top of the wheelchair cushion. Interview with NA #13 on 7/8/26 at 3:40 PM identified Resident #59 was sitting in his/her wheelchair in the hallway next to the nursing station. NA #13 indicated she brought resident wheelchairs down for cleaning according to the Room of the Day schedule and referred to the June 2026 schedule posted on the wall behind the nursing station. She indicated when she saw her assigned resident room number was listed as the Room of the Day she would bring their wheelchair down to be cleaned after the resident went to bed. She further indicated that resident wheelchairs could be brought down any evening for cleaning if they were soiled and needed to be cleaned and that they did not have to wait for them to be the Room of the Day. Interview with NA #11 on 7/8/26 at 3:43 PM identified she was Resident #59's NA and that she had brought Resident #59's wheelchair down to be cleaned about 2 weeks ago and that it had looked clean the next time she saw it after that. She indicated that Resident #59 tried to feed him/herself sometimes but would drop a lot of food on him/herself. Observation of Resident #59's wheelchair and interview with NA #11, NA #13 and Licensed Practical Nurse (LPN) #7 on 7/8/26 at 3:45 PM identified that they also indicated Resident #59's wheelchair was heavily soiled and needed to be cleaned. They indicated that it was not homelike to be seated in a wheelchair that had that much food and debris on it. LPN #7 indicated that they would get the wheelchair cleaned that evening. Subsequent to surveyor observation on 7/9/26 at 10:00 AM Resident #59 was seated in his/her wheelchair and the wheelchair was clean with no visible food stains, smears, or crumbs observed on the sides of the wheelchair or wheelchair cushion visible beneath Resident #59. Review of the clinical record nursing notes from 4/5/26-7/3/26 failed to identify a note which indicated Resident #59's wheelchair was cleaned as part of Room of the Day. Review of the July 2026 Room of the Day schedule identified Resident #59's room and wheelchair were scheduled for cleaning on 7/17/26. Review of the Wheelchair Inspection and Maintenance policy directed, in part, the facility will maintain all facility-owned wheelchairs in a safe working condition. The policy purpose directed for wheelchairs to be safe, clean and well maintained. The policy directed wheelchairs will be cleaned routinely and between residents. The policy directed the nursing, rehabilitation and maintenance departments were equally responsible for identifying equipment concerns. 3. Resident Council Minutes dated 7/15/25 indicated resident's clothing was missing and residents were displeased. The minutes failed to identify which residents were missing clothes, what clothes were missing, when the clothes were first reported missing, and confirmation that all items were returned. The Resident Council Minutes dated 10/21/25 indicated a few residents were missing some clothing and that a list of residents missing clothing items was given to the Laundry Director (who is also the Director of Maintenance (DOM)). The minutes failed to identify which residents were missing clothes, what clothes were missing, when the clothes were first identified as missing, and if they had reported the missing clothing to anyone else. The Resident Council Minutes dated 11/11/25 identified that a few resident's laundry items were found, but that the DOM was aware a few residents were still missing and indicated a new list was provided. Resident Council Minutes dated 12/9/25 indicated residents' clothing was found and residents were pleased. The minutes failed to identify which residents were missing clothes, what clothes were missing, when the clothes were first reported missing, and confirmation that all items were returned. Resident Council Minutes dated 4/14/26 indicated residents voiced laundry issues with the timeframe of getting their laundered clothing back and that the DOM was informed and provided with a list of residents waiting for clothing to be returned. Resident Council Minutes dated 5/5/26 indicated residents reported receiving the missing/delayed clothing items. The minutes indicated the laundry vendor had given the facility clothing from another facility which had delayed the receipt of their clothing. The minutes further indicated the laundry department was doing their best to ensure the correct clothing was returned to the correct resident and/or placed into the correct closet. The minutes failed to identify which residents received missing clothes, which clothes were returned, when the clothes were first reported missing, and confirmation that all items were returned. Additionally, the minutes failed to identify when and to whom residents had reported concerns related to receipt of incorrect clothing and/or their clothing being placed in the wrong closets. Resident Council Minutes dated 6/16/26 indicated the laundry department was doing their best to ensure the correct clothing was getting back to the correct resident and/or correct closet. The minutes further identified residents missing clothing filled out grievance forms with the Director of Recreation (DOR). The minutes failed to identify which residents were missing clothing for cross-reference to the Grievance Log. On 7/2/26 at 11:10 AM a resident council meeting was held with the state surveyor and was attended by 9 residents (Resident #17, Resident #26, Resident #28, Resident #42, Resident #92, Resident #98, Resident #106, Resident #107, and Resident #117). The residents were asked if they had any concerns related to laundry services at the facility and they indicated laundry was done offsite by a vendor. 8 out of 9 residents (Resident #17, Resident #26, Resident #28, Resident #42, Resident #91, Resident #98, Resident #107, and Resident #117) responded to questions about the laundry services. They indicated laundry was often slow to return after being sent out for laundering. They indicated that often there were clothing items missing even if they were labeled, and that there were times when clothes would be found in the wrong closet or they would see another resident wearing their missing clothes. Resident #17 indicated upon admission to the facility he/she heard that laundry services were very unreliable and he/she did not want to deal with that so he/she had laundry done by family. Resident #91 also indicated that laundry was done by family and so he/she had no laundry concerns for him/herself and only what was heard from other residents. Residents (Resident #26, Resident #28, Resident #42, Resident #98, Resident #107, and Resident #117) indicated they often voiced concerns in the resident council meetings and that the Director of Recreation would write them down. One resident (Resident #26) expressed that they received reimbursement for missing clothing items and some residents (Resident #42 and Resident #98) expressed that they did not receive reimbursement for missing clothing items. Residents (Resident #107 and Resident #117) indicated they had laundry items go missing that were never returned but they did not confirm if they had or had not received reimbursement. None of the residents with laundry concerns were able to identify if their laundry concerns were put into a grievance form after they reported them. Interview with the Administrator on 7/7/26 at 10:00 AM indicated that missing laundry had been a major concern at the facility and he had been working with the laundry vendor. He indicated he had been doing audits with residents regarding missing clothing but did not have anything in writing. He indicated the facility had received clothing belonging to another facility with a similar name and although it was denied by the laundry vendor, he wondered if some of the personal items had gotten delivered to the wrong facility. He further indicated a Quality Assurance and Performance Improvement (QAPI) plan had been done related to the laundry issues which included education but was unable to provide documentation of the QAPI or education and indicated it had all been verbally completed. Interview with the Director of Maintenance (DOM) on 7/7/26 at 11:10 AM identified resident personal laundry was sent down to the laundry department in mesh bags which were labeled with the resident room and bed (A,B,C,or D). He indicated that each resident had their own labeled mesh bags. He indicated when the laundry was picked up by the laundry vendor on Sunday, Wednesday, and Friday the facility counted the number of mesh bags sent out but indicated that number was not documented anywhere. He indicated the laundry vendor washed the personal clothing inside the mesh bags (sometimes the bag opens and small items fall out), but he was not aware of the drying process. He indicated when the clothing was returned to the facility the clothes would all be placed on 1 wire hanger for each resident labeled with the resident room and bed and their small items (socks and underwear) would be inside the labeled mesh bag. He indicated that all of 1 residents clothing would be on that 1 wire hanger and accompanied mesh bag. He indicated that the laundry department did not verify that the clothing on the wire hangers labeled by the laundry vendor were in fact labeled with the correct resident room and bed and indicated that the girls who returned the laundry to the residents knew everyone's clothes and would notice if something was out of place when they put the hangers of clothes in the closets. He indicated that he would receive lists from the Director of Recreation (DOR) about once a month for residents missing clothing but he did not keep those lists because everything would be found within a couple days. He indicated that 9 times out of 10 when the laundry aides looked inside the resident's closets they would find all of the missing clothing they were looking for inside their own closet. He indicated if they were unable to locate a resident's clothing he would notify Administration so the resident could be reimbursed. He indicated the laundry department did not label resident clothing because many families had told them it was like jail and so they left it up to the resident families to label any clothing. Interview with the DOR on 7/8/26 at 11:10 AM identified she reviewed grievances with residents in the resident council meetings, and that she would fill out grievances when needed for residents who brought forward concerns. She indicated that when she received laundry concerns from residents in the resident council meetings, she would write them down on a paper and give it to the DOM to address. She indicated that she did not keep a copy of those papers so that when the DOM followed up with her to say laundry items were found she was unable to compare what he said with the list of items she had originally written down to see if all items were found or if there was something still unaccounted for. She indicated that she did not write grievances for laundry concerns until last month, in June she was instructed to write the laundry concerns from resident council as grievances, and that she should have written grievances for the missing clothing each time it was reported but she had not realized that.

Based on observation, facility documentation, facility policy and interviews for 1 of 9 residents (Resident #114) reviewed for grievances, the facility failed to ensure a grievance was investigated and reviewed with the resident and resident representative for satisfaction. The findings include: Resident #114's diagnoses included chronic obstructive pulmonary disease, major depressive disorder and generalized anxiety disorder.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #114 was cognitively intact and independent for self-care and mobility.Interview with Resident #114 on 6/30/26 at 12:30 PM indicated that a grievance was filed for lost items in December 2025 and he/she remained very upset that he/she was never reimbursed. Resident #114 stated that he/she went out on leave of absence (LOA) and subsequentially ended up admitted to the hospital. Upon return to the facility Resident #114 reported that his/her belongings were in a small bag and his/her personal items were missing, specifically, a [NAME] sweatshirt, electric razor and cartridges, and multiple toiletries. Resident #114 further indicated that the facility stated they weren't responsible to replace or reimburse but did not offer what measures were implemented to look for the missing items.Review of facility grievance book on 7/1/26 at 1:00 PM identified a grievance filed 12/29/25 by Resident #114 and the Social Work Director was designated to investigate the concern. There were no attached investigation/interviews on the grievance form. Resolution stated facility was not responsible because the resident took his/her belongings with him and the grievance was documented as resolved on 12/30/25.Review of the medical record on 7/1/26 at 1:30 PM identified there were no personal inventory logs documented for Resident #114.Interview with the Administrator on 7/9/26 at 10:30 AM indicated that he was unaware of the specific incident and stated that if a resident isn't satisfied with the outcome of a grievance, then it should not be considered resolved. The Administrator further explained that personal inventory logs should be done with the residents but had noted this process had been inconsistent.Interview with the DNS on 7/9/26 at 2:23 PM indicated that she was unaware of this specific event but when a resident files a grievance the facility should work together with the resident until they are satisfied with the resolution.Interview with Social Worker (SW) #1 on 7/9/26 at 2:45 PM indicated she had only been employed at the facility since 6/3/26 and was not aware of the specificgrievance. SW #1 further explained that grievances normally were filed when a staff member received a complaint from a resident, that any staff member could file a grievance, and that once a grievance was filed, the complaint was brought to the appropriate department to be addressed.Review of the facility policy title Personal Item Inventory dated 8-20-2018 identified upon admission to the facility, the security/front desk employee will secure the residents personal belongings and complete an inventory form to be signed by both parties and filed in resident's chart upon arrival.Review of the facility policy titled Grievances, dated 1-19-2018, identified that residents could express a complaint or grievance verbally or in writing. The policy stated that the Director of Social Services was responsible for following up on a grievance and the procedure would be used for tracking of lost items. Number 5 and 6 of the policy, stated that the Director of Social Services or designee would document the findings of what actions were taken and the final disposition would be conveyed to the individual to assess satisfaction with a goal of being completed

Based on review of the clinical record, facility documentation, facility policy and interviews for 5 of 7 sampled resident (Resident #11, Resident #36, Resident #66, Resident #119 and Resident #120) reviewed for hospitalization, the facility failed to provide the required notification of the transfer/discharge to the State Ombudsman's office and failed to provide Resident #11, Resident #45, Resident #48 with notification of the bed hold policy. The findings include: 1a.Resident #11's diagnoses included schizophrenia, dementia, and diabetes.The Resident Care Plan (RCP) dated 2/18/26 identified Resident #11 had malnutrition and was at risk for dehydration. Interventions included encouraging fluids, monitor for signs and symptoms of dehydration, and provide diet as per MD orders.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired, requiring supervision/touching assistance with eating, toileting, and personal hygiene. Also, identified Resident #11 required partial/moderate assistance with transfers, bathing and dressing.A nursing note dated 4/17/26 at 6:03 PM identified Resident #11 had an elevated potassium level of 3.1 and was sent to the hospital for evaluation.A nursing note dated 4/18/26 at 5:47 AM identified Resident #11 was admitted to the hospital.b. Resident #36's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, and Parkinson's disease.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 had intact cognition and required assistance with toilet hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and transferring between surfaces (wheelchair to stand, etc.).A progress note dated 5/1/26 and written by Advanced Practice Registered Nurse (APRN) #2 indicated Resident #36 was to be transferred to the emergency department for symptoms that included dyspnea (difficulty breathing), cough with sputum, acute respiratory distress and was having hypoxemia (low oxygen levels in the blood) even though they had tried treating him/her in the facility. A clinical record review indicated that the Ombudsman had not been notified of Resident #36's discharge to the hospital on 5/1/26. c. Resident #66 had diagnoses that included paraplegia (partial or complete paralysis of the lower body), diabetes, and vascular dementia.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 was severely cognitively impaired, used a wheelchair, was independent with eating, required substantial/maximal assistance with bed mobility, and was dependent for transfers and wheelchair mobility.A nursing note written by Registered Nurse (RN) #5 on 12/28/25 at 11:00 PM indicated Resident #66 was very lethargic and staff were unable to arouse him/her. The note indicated Advanced Practice Registered Nurse (APRN) #2 was notified of Resident #66's condition and directed to send Resident #66 to the hospital for evaluation.Review of the Resident Census report identified Resident #66 was hospitalized from [DATE] to 1/1/26.Review of the facility documentation failed to identify the Ombudsman was notified of Resident #66's emergent hospital transfer.d. Resident #119 had diagnoses that included congestive heart failure (CHF), hypertension, and dementia.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #119 was severely cognitively impaired, used a walker and wheelchair, was independent with eating, bed mobility, and wheelchair mobility, and required setup or clean-up assistance for bed/chair transfers.A nursing note written on 8/18/25 at 4:05 AM indicated Resident #119 was on anticoagulation (receiving blood thinners), had a large amount of rectal bleeding, the on-call Advanced Practice Registered Nurse (APRN) was notified and directed to send Resident #119 to the hospital for evaluation and treatment.Review of the Resident Census report identified Resident #119 was hospitalized from [DATE] to 8/21/25.Review of the facility documentation failed to identify the Ombudsman was notified of Resident #119's emergent hospital transfer.A nursing note dated 2/14/26 at 7:00 AM identified Resident #119 complained of difficulty breathing and had an oxygen saturation of 85%. The note indicated the Medical Director evaluated Resident #119 and gave an order to transfer to the hospital for evaluation and treatment.Review of the Resident Census report identified Resident #119 was hospitalized from [DATE]-[DATE].Review of the facility documentation failed to identify the Ombudsman was notified of Resident #119's emergent hospital transfer.A nursing note dated 6/10/26 at 11:39 PM identified Resident #119 was combative and aggressive towards staff during care and was unable to be redirected. The note indicated care was stopped for resident and staff safety and the resident was sent to the hospital for evaluation and further assessment.Review of the Resident Census report identified Resident #119 was hospitalized from [DATE]-[DATE].Review of the facility documentation failed to identify the Ombudsman was notified of Resident #119's emergent hospital transfer.e. Resident #120's diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and dementia.An Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #120 was moderately cognitively impaired and required total assistance with activities of daily living (ADL) care (toilet hygiene, personal hygiene), substantial/maximal assistance with eating, and partial/moderate assistance with bed mobility and transfers.Nursing notes dated 4/14/26 at 12:08 AM identified Resident #120 was observed to be clammy with his/her eyes open and a blank stare. Resident #120 was nonverbal when trying to stimulate a response, blood pressure was faint 90/60, and oxygen saturation was 94% on 2 liters of oxygen. 911 was called and Resident #120 was sent to the hospital on 4/13/26 at 8:15 PM.Review of the facility Census report identified Resident #120 was discharged from the facility on 4/13/26 and readmitted to the facility on [DATE].The clinical record failed to reflect documentation that the facility notified the Ombudsman of Resident #120's discharge to the hospital.Interview on 7/6/26 at 12:00 PM with Social Worker (SW) #2 identified she did not notify the Ombudsman of resident discharges to the hospital, and she only recently had access to the portal as of 6/11/26 to notify the Ombudsman.Interview on 7/6/26 at 12:30 PM with SW #1 identified she did not notify the Ombudsman of resident discharges to the hospital because she was not aware of the requirement. Also, SW#1 was unable to provide information of the Ombudsman being notified of the transfer/discharge to the hospital on 4/17/26 for Resident #11. Further, identifying that she was not working at the facility at that time.Interview with the Director of Nursing Services (DNS) on 7/9/26 at 11:30 AM identified the Social Services department was responsible for updating the Ombudsman of facility discharges. She indicated that in June 2026 when the Director of Social Services (SW #1) was hired she had been informed that the Ombudsman was not being notified of discharges and that SW #1 had initiated doing the monthly Ombudsman report. She further indicated she had not been aware that the Ombudsman was not being notified of hospital transfers and additionally, she was not aware this was required. Interview with the Administrator on 7/9/26 at 11:50 AM identified he had not been aware that the Social Services department was not sending notification to the Ombudsman of hospital discharges.Review of the Transfer/Discharge policy dated 1/1/25 directed, in part, when the facility transfers or discharges a resident under any circumstances, the facility will document the transfer or discharge in the resident's medical record and appropriate information is to be communicated to the receiving health care institution or provider. The regional long term care ombudsman will be notified by the long-term portal. 2a.Resident #11's diagnoses included schizophrenia, dementia, and diabetes.The Resident Care Plan (RCP) dated 2/18/26 identified Resident #11 had malnutrition and was at risk for dehydration. Interventions included encouraging fluids, monitor for signs and symptoms of dehydration, and provide diet as per MD orders.The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired, requiring supervision/touching assistance with eating, toileting, and personal hygiene. Also, identified Resident #11 required partial/moderate assistance with transfers, bathing and dressing.A nursing note dated 4/17/26 at 6:03 PM identified Resident #11 had an elevated potassium level of 3.1 and was sent to the hospital for evaluation.A nursing note dated 4/18/26 at 5:47 AM identified Resident #11 was admitted to the hospital.b. Resident #45 was admitted to the facility in November 2024 with diagnosis that included Type 1 diabetes and chronic kidney failure.The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #45 was cognitively intact, required moderate assistance with activities of daily living (ADLS) and received insulin 7 days a week. The clinical record indicated that Resident #45 was sent to the hospital on 1/2/26 for abnormal lab values indicative of severe anemia. Resident #45 was admitted to the hospital with anemia (low blood count) and hyponatremia (low sodium).The facility's Resident Census Report indicated Resident #45 was in the hospital from [DATE] through 1/5/26. readmitted to the facility on [DATE].The Bed Hold Notification Form could not be located for Resident #45.c. Resident #48 was admitted to the facility in December 2018 with diagnoses that included Type 2 diabetes, chronic kidney failure, and hypertension.The discharge Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #48 was severely cognitively impaired and was unable to participate in a Brief Interview for Mental Status and required moderate assistance with activities of daily living (ADLs).The clinical record indicated that Resident #48 was sent to the hospital on [DATE] related to an unwitnessed fall. Resident #48 was diagnosed with Influenza A and respiratory failure. The facility's Resident Census Report indicated that Resident #48 was hospitalized from [DATE] through 12/17/25 and readmitted to the facility on [DATE].The Bed Hold Notification form could not be located for Resident #48.Interview on 7/9/26 at 1:26 PM with the Assistant Director of Nursing Services (ADNS) who identified she could not locate the Bed Hold notification form that was sent to the hospital with Resident #45. Identifying the policy was for the supervisor on duty to scan the Bed Hold notification form into the electronic medical record upon transfer to the hospital. Interview on 7/9/26 at 1:26 PM with the Assistant Director of Nursing Services (ADNS) identified that she could not locate a copy of the bed hold form that was sent to the hospital with Resident #11 at the time of transfer to the hospital. Also, identifying the policy was for the supervisor on duty to scan all the documents including the bed hold form into the electronic medical record upon a residents transfer to the hospital. Review of the Bed Hold policy dated 1/1/25 directed, in part to inform residents and their representatives of the facility's bed-hold policy and readmission practices in accordance with 41 CFR 483.15(e), and applicable state requirements. To ensure compliance with federal and state regulations governing residents' rights related to bed-hold and the facility's policy on returning residents after hospital or therapeutic leave. Upon admission and in advance of any transfers, the residents and their representative shall be provided: a copy of the facility's bed-hold policy. Specifics of any state Medicaid bed-hold coverage (if applicable). Written notice regarding the duration of the bed hold and the resident's rights regarding readmission. The following must be documented provision of bed-hold notification to residents and representatives. Bed-hold acceptance or decline and applicable payer source. Dates of hospitalization or leave and return.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two sampled residents (Resident # 300) reviewed for abuse, the facility failed to ensure a resident was free from sexual mistreatment by another resident (Resident #47). The findings include: Resident #47 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was without cognitive impairment, independent with bed mobility and transfers, required limited assist with ambulation while using a walker and to assist with dressing. The care plan dated 3/28/22 identified Resident #47 was at risk for mood changes related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: to observe the resident for signs and symptoms of depression/anxiety, to provide emotional support and to allow independence with a rolling walker. The Reportable Event dated 5/16/22 identified at 1:00 PM a Nurse Aide (NA # 5) entered room [ROOM NUMBER] to find (Resident #300) with his/her pants off laying on his/her bed and Resident #47 with his/her pants around the ankles. The residents were separated, body audits completed and both resident 's Power of attorney (POA)/conservator of person (COP) were updated. Resident #47 was moved to another unit. The Medical Director and APRN were notified. Abuse Intervention Line was called and a message left. Per request of Agency 2 staff was directed to send Resident # 47 to the emergency room for evaluation to see if sexual intercourse took place. The Emergency Department Physician Documents dated 5/16/22 noted a resident with a history of Intellectual Disabilities presents to the ED for a medical evaluation following a sexual encounter with another resident, which may have been nonconsensual. Resident #47 reported to the ED physician s/he licked another resident (Resident # 300) genitals and that resident touched his/her breasts, s/he allowed this act by adding the encounter was consensual and s/he enjoyed it. The evaluation findings later noted (Resident #47 's) family member arrived and spoke with (Resident #47) and requested the ED physician to speak to Resident #47 once again. (Resident #47) then stated s/he did not want to participate in the sexual activities, and that s/he felt s/he had to, stating s/he felt scared. (Resident #47) also stated his/her pants were down at the feet, but his/her underwear was on the entire time. The other resident (Resident #300) did not touch him/her anywhere on the underwear. An evaluation of body systems did not identify any signs of trauma, tenderness, ecchymosis, abrasions, lacerations, and indicated Resident #47 was cooperative with appropriate affect. Resident #300 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] identified Resident #300 had severe cognitive impairment and was independent with bed mobility, transfers, ambulation and required assist with dressing. The Care plan dated 3/23/22 identified had cognitive loss/ dementia and a potential with ADL deficits. Interventions included using nonverbal communication techniques such as touch, gestures, do not rush and allow independence with transfers, ambulation, and minimal assist with dressing. Reportable Event summary dated 5/18/22 identified on the afternoon of 5/16/22, a NA (NA #5) knocked and entered Resident #300 ' s room and heard (Resident #47) talking. NA #5 pulled back a drawn curtain to Resident #300 ' s bed where she observed Resident #300 laying on his/her in bed, naked from the waist down and legs crossed with Resident #47 sitting on the bed on the opposite side facing him/her with the brief and pants around his/her ankles and his/her hand on (Resident #300 ' s) genitals. Resident #47 stated, Oh God. NA #5 summoned the nursing staff while remaining with the residents who were immediately separated. Resident #47 was calm and cooperative, showed no signs of distress and was escorted back to his/her room. Neither resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Both residents were in the TV room just prior to the incident. Both residents received a telehealth psychiatric visit and would also receive followed up with social services. Resident #47 ' s guardian was called, and the case discussed. It was agreed Resident #47 would move to a separate floor. The Medical Director and APRN were updated on the events. An interview on 5/31/22 at 10:22AM with NA #5 identified on 5/16/22, just before lunch time, she was looking for Resident #47and heard his/her voice as she walked by Resident #300 ' s room. NA #5 knocked entered Resident #300 ' s room and observed the curtains were closed so she pulled them back and observed Resident #300 laying on his/her back on top of the bed, naked from the waist down, with arms and legs crossed and with Resident #47 sitting on the opposite side of the bed near Resident #300 ' s legs facing him/her with his/her own pants and brief down around the ankles and his/ her hand on Resident #300 ' s genitals. NA #5 indicated Resident #47 stated Oh God, and quickly released Resident #300 ' s genitals and began to reach down to pull up her/his pants. NA #5 summoned the nursing staff while staying with the residents. NA #5 did not notice if Resident #300 was sexually aroused and did not notice if there were any body fluids on the residents or on the surface areas of the bedding. NA #5 indicated she had last seen the two residents together in the TV room [ROOM NUMBER] minutes prior to the incident. An interview on at 5/31/22 at 10:54 AM with Licensed Practical Nurse (LPN #6) identified she was the assigned nurse working during the afternoon of 5/16/22. LPN #6 was at the nursing station when she heard NA #5 call for her to come. LPN #6 walked in and observed Resident #300 lying in bed, pants down, leaning to one side, propped up elbow and Resident #47 standing beside the bed pulling up his/her pants. The Nursing Supervisor Registered Nurse (RN #3) also entered the room and immediately escorted Resident #47 out the room. LPN #6 indicated body audits were completed for Resident #47 and Resident #300 and there were no signs of injury. The social worker was also summoned. LPN #6 indicated Resident #300 could not recall the incident and Resident #47 did not want his/her family member to know about the incident. An interview on 5/31/22 at 11:15AM with RN #3 indicated she was the assigned Nursing Supervisor of the shift on 5/16/22. RN #3 indicated she was at the nurse station approximately 10 feet from Resident #300 's room when NA #5 reported both residents had their pants down and Resident #47 had her/his hand on Resident #300 ' s genitals. RN #3 went into the room and the curtains were pulled around his/her bed per usual request. RN #3 went around to the other side of the curtain and observed Resident #300 sitting on the edge of the bed near the head and his/her pants were down. Resident #47 was fully dressed and standing by the window. RN #3 stated both residents appeared calm with no real emotion. RN #3 escorted Resident #47 out of the room and notified the DNS, Administrator and social worker who took over the investigation. An interview on 5/31/22 at 11:45AM and at 1:00PM with Social Worker (SW #1) identified she spoke with Resident #47 following the incident and that his/her mood was stable and noted no signs of distress. There were no concerns but had previously noted the two residents had a friendship but never observed inappropriate behaviors. Resident #47 stated s/he touched Resident #300 ' s genitals and put it in her/his mouth. Resident #47 also stated Resident #300 touched his/her breasts. Resident #47 was seen by psychiatric services and evaluated at the ED who indicated no penetration had occurred. Resident #300 had limited recollection of the event stating they had just held hands. An interview on 5/31/22 at 1:09 PM with Psychiatrist #1 identified he met with both residents following the incident and identified the following: Resident #47 had some cognitive delay but had clear recall of the event, was fully participatory and fully aware of what was going on. Psychiatrist #1 also met with Resident #300 who did not recall the incident but had the capacity to voluntarily engage in the activity without coercion. Psychiatrist #1 determined the encounter to be consensual as from a clinical standpoint, cognitive limitation does not mean you do not have capacity to consent and did not render incapable of doing certain things. Psychiatrist #1 indicated he was aware Resident #47 was fearful of how conservator would react to the incident. An interview on 5/31/22 at 1:46 PM with the DNS identified she was notified of the incident by RN #3 who reported NA#5 found Resident #47 on the bed with Resident #300 both with their pants down. The DNS went to speak with Resident #300 who was fearful that a family member was going to be mad and reassured him/her many times that s/he did nothing wrong. Resident #47 stated s/he put Resident #300 ' s genitals in his/her mouth and that Resident #300 touched his/her breasts. The DNS also attempted to speak with Resident #300 who could not recall the incident. The DNS indicated Resident #47 was sent to the emergency per the responsible party ' s request, the abuse investigation line was contacted, and Resident #47 was moved to a separate floor while staff were provided education on recognizing signs and symptoms of sexual behaviors. The DNS further indicated after consulting with the facility psychiatrist and social worker, it was determined the encounter was consensual between Resident #47 and Resident #300. The facility failed to ensure that Resident # 300 was free from sexual abuse from Resident # 47. The facility policy for Resident Abuse directs that all residents be free from any type of abuse including sexual abuse which is defined as any form of sexual contact by force or threat of impose upon any person who lacks decisional capacity to make informed decisions about sexual contact.

Based on review of the clinical record, review of facility documentation, interviews, and facility policy and procedures for one of three residents reviewed for accidents, (Resident #23), the facility failed to ensure that R #23 was provided with adequate supervision by NA #1 and/or that the environment was safe during the provision of incontinent care that included turning and repositioning in the bed, which resulted in the resident's fall from the bed and subsequent [DIAGNOSES REDACTED].#77), the facility failed to ensure unapproved and/or unlisted extension cords were not in use. The findings include: 1. Resident #23 (R #23) had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] identified that R #23 was severely impaired regarding tasks of daily living skills and was totally dependent on one staff member for bed mobility. Review of the care plan last updated on 4/24/15, identified that R #23 had a self-care deficit with bed mobility and was totally dependent on one staff person for repositioning and turning in bed every two hours and as needed. In addition, the care plan identified that R #23 was incontinent of bowel and bladder and was totally dependent on staff for incontinent care. Interventions included to provide care every two hours and as required for incontinence. Review of R #23's fall risk assessment dated [DATE] identified that the resident was a high risk for falling. Review of the monthly physician orders [REDACTED]. Review of facility documentation, including a Reportable Event form dated 5/6/15 at 2:15 AM, identified that R #23 rolled off the bed onto the floor while the Nursing Assistant (NA #1) was on the opposite side of the bed rendering care. Review of NA #1's statement identified that he/she planned to provide incontinent care to the resident and found that there was tube feeding formula on the resident's sheet and gown. NA #1 wrote that he/she pulled off the resident's gown, replaced it, turned the resident on his/her side to replace one side of the sheet and went to the opposite side of the bed. NA #1 indicated he/she was going to the other side of the bed and heard something going on with the air in the mattress but that by the time he/she got to the other side, R #23 rolled over the edge of the bed. NA #1's statement further identified that it looked like the resident's mattress was flat and that the resident was dumped over the side of the bed. Following R #23's fall from the bed on 5/6/15, the resident was moaning in pain and was assessed by RN #2. The physician was notified and R #2 was transferred to the emergency room for further evaluation. R #23 was subsequently diagnosed with [REDACTED]. Interview with NA #1 on 9/22/15 at 1:00 PM identified that R #23 was in bed watching television on 5/6/15 and that he/she went into the room to provide incontinent care. NA #1 stated that R #23 had tube feeding formula on his/her pajamas and on the sheets. NA #1 stated that the resident was in the middle of the bed and that both upper side rails were in the up position. NA #1 stated that he/she began to change the resident and placed a new pajama top on R #23. NA #1 stated R #23 was then turned to the opposite side to change the sheet and then back toward him/her. NA #1 stated that he/she went to the opposite side of the bed to remove the old sheet and heard a noise from the bed. NA #1 stated that R#23 rolled off the side of the bed and fell on to the floor. NA #1 stated that although R #23 was unable to use her/his arms or legs to help with bed mobility, nursing assistants always changed and repositioned R #23 in bed with one person before 5/6/15. Interview with RN #2 on 9/23/15 at 1:45 PM stated that prior to the incident on 5/6/15, R #23's bed mobility was very poor due to a recent cerebral vascular accident which resulted in hemi paralysis and that the resident was totally dependent on staff for care. RN #2 stated that R #23 had poor cognition and was unable to follow commands. RN #2 stated that he/she updated R#23's care plan to reflect that the resident would require two staff persons for all bed mobility after the fall because it was the safest thing to do for the resident. Review of facility policies that included the Certified Nursing Assistant Job description, directed in part that staff utilize proper techniques and devices to position/re-position a resident, provide proper turning /repositioning in bed, and maintain a safe resident environment. 2. Resident # 77 (R #77) had [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that R # 77 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen, indicative of moderate cognitive impairment and was independent with ADLs. The Resident Care Plan (RCP) dated 6/30/15 identified that R #77 had limited physical mobility related to his/her CVA and weakness with interventions that included that the resident be out of bed to a chair as tolerated and to ambulate with a walker and assistance. Observation on 9/21/15 at 11:29 AM identified R #77 had an extension cord in use next to the bed with two items (television and DVD player) plugged into the extension cord. Observation and subsequent interview with the Administrator on 9/21/15 at 11:40 AM identified that staff were to check for extension cords once a week and that extension cords should not be in use. Subsequent to surveyor inquiry, the Administrator removed the extension cord and the two plug wall outlet had been replaced with a four plug outlet. Interview with the Administrator on 9/23/15 at 12:04 PM identified that the facility did not have a written policy regarding extension cord use.

Based on clinical record review, observation and staff interview for 2 of 2 sampled residents (Resident #152 and 198) reviewed for elopement and for one of six residents (Resident #31) reviewed for accidents, the facility failed to ensure the residents were free from accident hazards. The findings include: 1. Resident #31's [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] identified the resident with severely impaired cognition and requiring extensive assist with transfers and walking in the room. A resident care plan dated 4/6/12 identified a problem with risk for falls. Interventions included gripper socks and utilize transfer aide (gait belt). Review of a nurse's note dated 4/12/12 at 10:50 AM noted Resident #31 was being assisted with toileting by nurse aide #1 (NA #1) when the resident unexpectedly crossed his/her legs and lost his/her balance. Nurse aide #1 was unable to hold the resident and the resident fell landing on his/her face. A jagged 2.5 cm irregular shaped laceration and hematoma was noted above the left eyebrow with some bleeding. At 12:30 PM the resident complained of a headache and was sent to the emergency room for evaluation. The resident returned at 4:30 PM with 3--5 sutures to the left forehead laceration. An interview and review of a reportable event/investigation dated 4/12/12 on 1/2/13 at 3:15 PM with the Assistant Director of Nursing (ADON) indicated she was in the next room when Resident #31 fell on [DATE] in room 219. She heard a loud sound and NA #1 yelled that Resident #31 had fallen and was bleeding. When she entered the room NA #1 had left the room. The ADON noted the resident was on the floor face down. The resident had on a pair of thin socks, no shoes and/or slipper socks on, and no gait belt was noted on the resident. She further indicated that although NA #1 left the room with the resident on the floor, the resident was attended to immediately. An interview and review of NA # 1's statement on 1/7/13 at 9:50 am with NA # 1 indicated on 4/12/12 she was asked to assist Resident #31 with tioleting. The resident was at the edge of the wheelchair seat so used the bathroom in room 219, which was not the resident's room. She held the back to the resident's pants with one hand and held one of the resident's arms with the other hand. She did not use a gait belt on the resident because the resident was on the edge of the wheelchair seat. When she stood the resident, the resident's legs crossed and he/she slipped and fell hitting his/her head. Nurse aide #1 indicated she panicked and ran out of the room and yelled that the resident had fallen. Nurse aide #1 indicated she did not pay attention to what was on the resident's feet at the time of the transfer, but after the fall she realized the resident had no slipper socks and/or shoes on. The facility failed to implement measures to ensure a safe transfer. 2. Resident #152's [DIAGNOSES REDACTED]. A Elopement Risk assessment dated [DATE] identified the resident was at high risk for wandering. The care plan dated 11/24/12 identified the resident was at risk for wandering with interventions that included to utilize a wanderguard and 15 minute checks. A nurse's note dated 11/24/12 identified the resident was found in the stairwell and his wanderguard bracelet was not functioning. A accident/incident report dated 12/1/12 identified that at 2:00 PM the resident was observed walking on road of the facility by another resident's family and was transported back to the facility, uninjured, by the family member. The facility investigation dated 12/3/12 identified that NA#12 had heard the wanderguard alarm at the second floor elevator area and shut it off. Interview with NA#12 on 1/8/13 at 1:15 PM identified that on 12/1/12 after lunch he was did hear the alarm at the elevator and shut it off. He further stated that he was not aware that the alarm sounding signified a wanderguard device. He thought it meant the door to the elevators were open too long. Subsequently, he was immediately educated on the wanderguard alarm and policy. Interview with Corporate Nurse #1 on 1/8/13 at 12:00 PM identified that although there is no written policy, when staff hear the wanderguard alarm, they are directed to notify a supervisor and account for all residents with a wanderguard device. Additionally, she stated that NA#12 should not have turned off the alarm until all the residents were accounted for. 3. Resident #198 ' s [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Minimum Data Set assessment dated [DATE] identified severe cognitive impairment and independence for ambulation and locomotion. The elopement risk assessment dated [DATE] identified the resident was at risk for elopement. The resident care plan dated 12/8/11 identified a risk for elopement due to wandering off the unit with interventions that included the use of a Wanderguard and to check placement every shift. The nurse's note dated 2/14/12 for the 3-11pm shift indicated the resident wandered off the unit at approximately 5:15pm. An investigation identified the Wanderguard bracelet was identified as not working properly at the time and was repaired. The nurse's note dated 2/25/12 at 4:00pm identified Resident #198 was found outside the facility on the road and was returned to the facility in a car by an off duty employee. An assessment conducted at the time identified the resident had not injury and the Wanderguard bracelet that was on the resident ' s left wrist when checked was functioning. The reportable event investigation dated 2/25/12 indicated the audible alarm for the Wanderguard system did not trigger when R #198 passed through the secured area and the issue was repaired by maintenance. Review of the resident care plan at that time noted that although the care plan was reviewed and revised on 2/28/12, there was no documentation of review and/or revision on 2/14/12 when the resident wandered off the unit. Interview on 1/7/13 at 12:35pm with Maintenance Worker #1 indicated he did not recall and/or could not provide documentation that the Wanderguard system was repaired on 2/14/12. Interview on 1/8/13 at 11:40am with Licensed Practical Nurse (LPN) #6 indicated she did not recall where and/or how Resident #198 wandered off the unit on 2/14/12. She could not recall if she notified the Nursing Supervisor and/or maintenance department. LPN # 6 further indicated she did not complete an accident & incident report when the resident was found outside the building. Interview on 1/10/13 at 3:20pm with the Assistant Director of Nursing (ADNS) indicated Wanderguard bracelets are checked nightly by the 11 - 7am Nursing Supervisor. The ADNS further indicated if the Wanderguard bracelet malfunctions the Nursing Supervisor will replace the bracelet and document the replacement. The ADNS was unable to find documentation that the Wanderguard bracelet was checked and/or replaced on 2/14/12.

Based on clinical record reviews, review of facility policies, observations and interviews for one of four patients reviewed for medication administration (Resident #1), the facility failed to ensure that the resident received the correct medication as ordered. The findings include: Resident #1 had [DIAGNOSES REDACTED]. The hospital discharge paperwork (W-10) dated 1/4/11 directed Orazinc 220mg by mouth daily. The handwritten physician orders [REDACTED]. Nursing and/or progress notes from 1/9/11 to 1/14/11 noted that the resident developed increased difficulty swallowing, became increasingly lethargic and hospice care was initiated on 4/11/11. Progress notes by Advance Practice Registered Nurse #1 dated 1/14/11 indicated that Resident #1 received [MEDICATION NAME] instead of Orazinc during a 9 day period, had sedation with decreased mentation, and had [MEDICATION NAME] toxicity. Facility documentation noted that the faxed physician orders [REDACTED].#1, [MEDICATION NAME] (antipsychotic) 200mg and 10mg tablets were delivered to RN #2 on 1/5/11 (instead of Orazinc). The facility documentation dated 1/14/11, including pictures of the [MEDICATION NAME] blister packs, indicated that 7 doses of the medication were removed from the packs and the resident received [MEDICATION NAME] 220mg from 1/5/11 to 1/12/11 (excluding 1/10/11). Interviews on 4/8/11 with LPNs #1 and #2, who administered the medication, indicated that they believed Orazine was what was ordered and that this might have been another name for [MEDICATION NAME]. Interview with RN #2 on 4/8/11 at 8:25 AM noted that h/she received many medications on 1/5/11 including medications for Resident #1 and checked the medications with the typed form from the pharmacy that listed the medications. RN #2 identified that h/she had worked in the facility for [AGE] years and never checked the received medication with the physician's orders [REDACTED]. Interview with RN #1 on 4/8/11 at 3PM noted that h/she reviewed all of the resident's readmission orders [REDACTED]. H/she further identified that h/she faxed the w-10 and the orders to the pharmacy, reviewed all of the readmission orders [REDACTED]. Interview with APRN #1 on 4/7/11 at 12:30 PM indicated that the resident's condition deteriorated while taking the [MEDICATION NAME], the medication was discontinued on 1/14/11 and the resident slowly improved to almost baseline with the medication discontinuation and administration of IV fluids. The facility pharmacy policy for receiving medications directed that each delivered prescription be checked against the original order for correctness (i.e. resident name, drug name, strength, etc.). The facility policy for administration of medications identified that the nurse compares the MAR indicated [REDACTED]

Based on observation, clinical record review and staff interview for one of three residents in the survey sample reviewed with pressure ulcers (R#19), the facility failed to ensure that an at risk resident had heel offloading to prevent pressure sore development and/or that once the pressure sore developed, pressure offloading was continued. The findings include: Resident #19's (R #19) [DIAGNOSES REDACTED]. A quarterly minimum data assessment dated [DATE] identified R #19 with short and long-term memory problems, total care for bed mobility and transfer, did not walk, and had no pressure ulcers identified. A resident care plan dated 9/10/10 identified impaired skin integrity as a problem. Interventions included to off-load both heels on pillows when in bed. A subsequent entry dated 9/13/10 identified a right heel open blister. Interventions included treatment per physician orders. A physician order [REDACTED]. A nurse's note dated 9/13/10 at 5:30 PM indicated that during routine care, the nurse noted an open blister on the resident's right heel; "APRN to evaluate in the morning". A wound assessment record dated 9/13/10 noted a 2.5 cm x 1.5 cm blister on the right heel. A nurse practitioner (APRN) wound note dated 9/14/10 identified an unstageable 3.5cm x 3.0 cm pressure ulcer on the right heel. The area was noted to be discolored with expressed serous drainage from a small pin-hole sized opening. Intermittent observations on 9/16/10 between 9:00 AM and 12:00 noon identified R #19 lying in bed with his/her heels flat on the mattress without the benefit of an off-loading device. An interview and review of the resident care plan on 9/16/10 at 12:00 noon with RN #1 indicated R #19's heels should be off-loaded with pillows when he/she is in bed. At that time, extra pillows where not observed in the room by the surveyor. After surveyor inquiry, RN #1 called the housekeeping department for pillows. An interview on 9/16/10 at 12:30 PM with Nurse Aide # 2 indicated she started her shift at 7:00 AM. Her first observation of R #19 was at 7:30 AM and his/her heels were not elevated off the bed. She further indicated she was not aware the resident needed his/her heels elevated off the mattress. An observation on 9/16/10 at 1:45 PM with RN #2 and LPN #4 noted a 3.0cm x 2.0 cm purple blister with a 2.5 cm x 1.75 cm white center on R # 19's right heel.