Every finding on record at Wellington Rehabilitation and Healthcare

Based on observations, record review and staff interviews, the facility failed to revise the comprehensive care plan to accurately reflect the code status (Resident #12), a pressure ulcer (Resident #13) and the discontinuation of bed rails (Resident #7). This was for 3 of 20 comprehensive care plans reviewed. 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease dependent on hemodialysis. Review of Resident #12's medical record revealed an advance directive physician's order dated [DATE] indicating he was a full code, meaning he wished to have cardiopulmonary resuscitation (CPR) performed should his heart stop. Review of a hard copy of Resident #12's advance directive kept in a book at the nurses' station indicated Resident #12 was made a full code on [DATE]. Review of Resident #12's care plan, last revised [DATE] revealed his code status as being Do Not Resuscitate (DNR), meaning he would not want CPR performed should his heart stop. Review of Resident #12's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. In an interview with Unit Manager #1 (UM #1) on [DATE] at 11:58 AM she stated the MDS Nurses were responsible for keeping the code status in a resident's care plan updated. In an interview with MDS Nurse #1 on [DATE] at 12:03 PM she stated the Social Worker (SW) would have been responsible for updating Resident #12's code status on the care plan. An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 12:18 PM. The ADON indicated the MDS Nurses were responsible for updating a resident's code status on their care plan. In an interview with the Director of Nursing (DON) on [DATE] at 12:25 PM she stated the MDS Nurses were responsible for updating the code status in a resident's care plan. The DON further stated the care plan should have included the correct code status for Resident #12. In an interview with the SW on [DATE] at 1:46 PM she stated the MDS Nurses were responsible for changing a resident's code status on the care plan. The SW further stated she could change it if she noticed it was incorrect. An interview was conducted with the Administrator on [DATE] at 3:41 PM. The Administrator indicated the MDS Nurses were responsible for changing or updating a resident's care plan to reflect the accurate code status. She was unaware Resident #12's care plan had an inaccurate code status. The Administrator stated that a resident's care plan should include the most up to date code status for a resident. 2. Resident #13 was readmitted to the facility on [DATE] with diagnoses that included a Stage 4 pressure ulcer of the sacrum. Review of Resident #13's quarterly MDS assessment dated [DATE] indicated she was at risk to develop pressure ulcers. Review of Resident #13's comprehensive care plan last revised [DATE] revealed a focus of having had actual impairment to skin integrity related to impaired mobility to include a stage 4 pressure ulcer to her sacrum and a post-surgical abdominal wound. The goal was for Resident #13 to maintain or develop clean and intact skin by the review date. Interventions included treatments as ordered. The care plan did not include a stage 3 pressure ulcer to the right buttocks. Review of Resident #13's physician's orders revealed an order dated [DATE] for wound care to the stage 3 pressure wound on the right buttocks that read: cleanse wound with wound cleanser, place iodoform packing strips in collagen powder, pack wound, cover with large sacral dressing, apply skin prep around wound every day shift and as needed. In an interview with MDS Nurse #1 on [DATE] at 12:31 PM she stated the stage 3 pressure wound to the right buttock should have been added to the impairment in skin integrity care plan with the stage 4 pressure ulcer to her sacrum and the abdominal surgical wound. She further stated MDS Nurses were responsible for this update after they learned of new wounds in morning meeting. MDS Nurse #1 was unsure why the stage 3 pressure ulcer was not added to Resident #13's care plan. In an interview with the ADON on [DATE] at 12:55 PM she stated the stage 3 pressure ulcer to right buttock should have been added to the impairment in skin integrity care plan with the other two wounds. The ADON indicated the MDS Nurses would be responsible for this addition to the care plan. In an interview with the Administrator on [DATE] at 12:58 PM, she stated the stage 3 pressure ulcer to the right buttock should have been added to the skin integrity care plan with the stage 3 pressure ulcer and abdominal surgical wound by the MDS Nurse. 3. Resident #7 was admitted to the facility on [DATE] with a diagnosis of stroke. Resident #7's current comprehensive care plan revealed a focus area for the use of bed rails. The goal dated as last revised on [DATE] by Minimum Data Set (MDS) Nurse #1 was for Resident #7 to be free from injury and to improve in positioning with bed rails through the next review date. Resident #7's significant change MDS assessment dated [DATE] revealed bed rails were not used in bed as a restraint. On [DATE] at 10:30 AM Resident #7 was observed in bed. No bed rails were observed on his bed. On [DATE] at 8:10 AM Resident #7 was observed in bed. No bed rails were observed on his bed. On [DATE] at 8:46 AM an interview with Nurse Aide (NA) #7 indicated she cared for Resident #7 on [DATE] and [DATE] on the 7AM-3PM shift. She stated she did not usually care for him. She reported Resident #7 did not have bed rails. On [DATE] at 8:48 AM an interview with Nurse Aide #8 indicated she regularly cared for Resident #7 on the 7AM-3PM shift 5 days per week for the last 4 to 5 months. She reported she did not recall Resident #7 having bed rails. On [DATE] at 10:32 AM an interview with MDS Nurse #1 indicated Resident #7 would have been due for a care plan review in [DATE]. She stated if a resident had bed rail use reflected on their comprehensive care plan and the bed rails were removed, nursing could communicate this with her and she could revise the care plan, or nursing could do this themselves. She did not indicate that she recalled a discussion regarding the removal of Resident #7's bed rails. On [DATE] at 11:19 AM an interview with the Assistant Director of Nursing (ADON) indicated Resident #7 did have bed rails at one time. She reported on [DATE], she made the determination that Resident #22 was no longer able to utilize the rails, and they were no longer appropriate for him. She indicated she had asked for maintenance to remove the bed rails. She stated she shared this at the morning meeting on [DATE] with the Interdisciplinary Team. The ADON went on to say the MDS Nurses were present at that meeting, and she would have thought MDS would have updated Resident #7's comprehensive care plan to reflect Resident #7 no longer using bed rails. On [DATE] at 1:21 PM an interview with the Administrator indicated Resident #7 used bed rails at one time, but his cognition had changed, and he could no longer safely use these. She stated once this decision had been made, and the rails were removed from his bed, his comprehensive care plan should have been updated to accurately reflect this.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Pre-admission Screening and Resident Review (PASARR) status, medication, and falls for 3 of 22 resident MDS assessments reviewed (Resident #43, Resident #4, Resident #53).Findings included: 1. Resident #43 was admitted to the facility on [DATE]. Her active diagnoses included cerebral infarction. Review of Resident #43's PASARR Level II Determination Notification letter dated [DATE] revealed an expiration date of [DATE]. Review of Resident #43's admission MDS assessment dated [DATE] revealed she was coded as not currently considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on [DATE] at 1:36 PM the Social Worker stated on [DATE] Resident #43 had a Level II PASARR determination which expired on [DATE]. She was reassessed and currently had a Level II PASARR determination with no end date. During an interview on [DATE] at 1:40 PM MDS Nurse #2 stated Resident #43's MDS dated [DATE] was marked in error and should have been coded as having a Level II PASARR determination. During an interview on [DATE] at 3:14 PM the Administrator stated the PASARR status should be accurately reflected in resident MDS assessments. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included history of cerebrovascular accident (CVA, stroke). Review of Resident #4's physician orders revealed an order dated [DATE] for Aspirin oral tablet chewable 81 milligrams (mg) to be given one time a day for CVA. Review of Resident #4's [DATE] medication administration records (MAR) revealed Aspirin chewable 81 mg was given daily. Review of Resident #4's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not coded as receiving an antiplatelet medication. In an interview with MDS Nurse #1 on [DATE] at 12:11 PM she stated Resident #4's MDS assessment should have been coded as receiving antiplatelet medication as Aspirin fell in that category of medications. MDS Nurse #1 further stated the error in coding was made due to human oversight. In an interview with the Administrator on [DATE] at 3:44 PM, she stated the MDS assessment should have been coded correctly, showing the resident received antiplatelet medication (Aspirin). 3a. Resident #53's Pre-admission Screening Resident Review (PASRR) Level II Determination Notice dated [DATE] revealed in part her Level II screening determined Nursing Facility Placement was appropriate. Resident #53 was admitted to the facility on [DATE] with a diagnosis of progressive neurological (nervous system) condition. Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On [DATE] at 10:18 AM an interview with the facility's Regional Director of Clinical Reimbursement indicated the MDS Nurse who coded Resident #53's admission MDS assessment dated [DATE] no longer worked for the facility. She reported the coding on Resident #53's admission MDS assessment was not accurate. b. A nursing progress note for Resident #53 dated [DATE] at 11:17 PM written by Nurse #10 revealed Resident #53 was found on the floor in her bathroom. She had a small laceration to her forehead. She was sent to the hospital emergency room (ER) for an evaluation. A nursing progress note for Resident #53 dated [DATE] at 12:21 PM written by Nurse #11 revealed Resident #53 returned from the hospital ER. The laceration to her forehead had been repaired with sutures. Resident #53's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she had no falls since her prior MDS assessment. On [DATE] at 8:12 AM an interview with MDS Nurse #2 indicated she coded the falls section of Resident #53's discharge MDS assessment dated [DATE]. She reported she would have reviewed nursing progress notes to assist with coding the section. She stated Resident #53's fall with injury on [DATE] should have been captured on her discharge MDS assessment. MDS Nurse #2 stated she had missed this and did not know why. She went on to say the coding that Resident #53 had no falls since her prior MDS assessment would not be accurate. On [DATE] at 1:21 PM an interview with the Administrator indicated resident's MDS assessments should be coded accurately.

Based on observation, record review and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when the business office manager failed to perform hand hygiene while passing a meal tray. This was for 1 of 8 staff members observed for hand hygiene practices (Business Office Manager). Findings included: A review of the facility policy titled Hand Hygiene with a review date of 2/5/21 stated in part: Hand hygiene should be performed after contact with inanimate objects (including medical equipment) in the immediate patient vicinity, and, before initiating a clean procedure. The policy definition of hand hygiene stated: cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e. alcohol-based sanitizer including foam or gel). An observation was started on 9/29/25 at 11:51 AM. The facility Business Office Manager was observed entering a resident's room to deliver the resident's lunch tray. The Business Office Manager set the tray on the resident's overbed tray table next to a urinal with approximately 2 inches of straw-colored urine in it. The Business Office Manager then asked the resident if it was ok for the Business Office Manager to move the resident's urinal and the resident agreed. The Business Office Manager picked up the urinal and moved it to the bedside table. Afterwards, the Business Office Manager asked the resident if he could help him with anything else and the resident requested the Business Office Manager remove the lid from his lunch plate and open his carton of milk. The Business Office Manager proceeded to take the lid off of the lunch plate and open the carton of milk without performing hand hygiene first. The resident then asked the Business Office Manager to place a straw in the milk carton, and the Business Office Manager proceeded to do so. In an interview with the Business Office Manager on 9/29/25 at 11:56 PM he stated he hadn't thought touching the urinal then opening the milk and the straw was an infection control issue as he touched the body of the urinal, not the handle of the urinal that the resident would have touched. The Business Office Manager further stated he was unaware that putting the lunch tray on the overbed table with the urinal was an infection control issue. In an interview with the Infection Preventionist (IP) on 9/29/25 at 12:16 PM, she stated the Business Office Manager should have set the lunch tray in a different location, donned clean gloves, moved the urinal, removed the gloves, performed hand hygiene and then proceeded to help the resident with his tray. The IP indicated by touching the urinal, then opening the milk and the straw, the Business Office Manager could have transferred disease causing bacteria from the urinal to the milk carton and/or straw. In a follow-up interview with the Business Office Manager on 9/29/25 at 12:23 PM he stated he was a new employee of less than 4 weeks. He further stated he had training on hand hygiene and infection control upon hire. On 9/29/25 at 12:41 PM, the IP provided documentation that the Business Office Manager had been training on infection control and hand hygiene upon hire on 9/8/25. In an interview with the Director of Nursing (DON) on 9/29/25 at 12:35 PM she stated the Business Office Manager should have set the lunch tray in a different location before donning gloves, moving the urinal, removing the gloves and performing hand hygiene before moving the tray to the overbed table and assisting with opening the milk carton and placing a straw in it. In an interview with the Administrator on 9/29/25 at 3:23 PM, she stated the business office manager should have set the lunch tray on a clean surface away from the urinal. She further stated he should have donned clean gloves, moved the urinal off of the overbed table, removed the gloves and performed hand hygiene before continuing to assist the resident with his lunch tray. The Administrator indicated cross-contamination could have occurred between the urinal and the milk carton and straw.

Based on observations, record review, staff and resident interviews, the facility failed to attempt alternatives prior to installing side rails, complete a siderail assessment, assess entrapment risk, review the risks and benefits of side rails with the resident and obtain informed consent, complete a care plan for side rail usage and obtain a physician's order prior to siderail use for 1 of 3 residents (Resident #57) reviewed for side rails.Findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic, progressive neurological disorder that affects movement and other bodily functions). Review of Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was cognitively intact, did not have side rails as a restraint and was independent with bed mobility. Review of Resident #57's care plan last revised 9/8/25 revealed no care plan indicating the use of bilateral quarter length side rails. Review of Resident #57's medical record revealed no assessment for use of side rails, no assessment for entrapment risk, no signed consent reviewing the risks and benefits of side rail use, or physician's order for use of side rails. Resident #57 was observed lying in bed with bilateral quarter length side rails in the raised position on 9/29/25 at 10:50 AM. Resident #57 was observed lying in bed with bilateral quarter length side rails in the raised position on 10/1/25 at 2:27 PM. In an interview with Unit Manager (UM) #1 on 10/2/25 at 11:02 AM she stated Physical Therapy completed a side rail assessment and let the Director of Nursing (DON) know when someone was approved for the use of side rails and the DON had maintenance put them on the resident's bed. UM#1 indicated she had never completed a nursing side rail assessment for any resident. In an interview with the Assistant Director of Nursing (ADON), who was acting as Director of Nursing (DON) on 10/2/25 at 11:12 AM, she stated therapy should always evaluate a resident for side rail usage first. The ADON further stated that after therapy approved a resident for side rails, a Nurse would complete a nursing side rail assessment which included entrapment risk assessment, obtain consent from the resident or their responsible party, obtain a physician's order and add side rail usage to the resident's care plan. The ADON revealed she was unable to locate a side rail assessment including entrapment risk, signed consent form, physicians order or care plan for Resident #57's side rail usage. The ADON was unsure why Resident #57 was overlooked. In an interview with Resident #57 on 10/2/25 at 11:25 AM he stated he had Parkinson's disease that caused him to have decreased muscle control. Resident #57 further stated he had side rails on his bed since admission and used them for positioning, mobility and the side rails were especially helpful when getting out of bed. A telephone interview was conducted with the Director of Therapy on 10/2/25 at 11:30 AM. The Director of Therapy stated she was under the impression side rails were not allowed in the building and therapy only assessed for side rails if a newly admitted resident had side rails at home. An interview was conducted with the Physical Therapist (PT) on 10/2/25 at 12:18 PM. The PT revealed she did not complete side rail assessments. The PT was unsure who was responsible for assessing residents for the safe use of side rails. In an interview with the Administrator on 10/2/25 at 12:45 PM she stated residents were assessed by therapy for the use of side rails. She further stated that after they were approved for side rails by therapy, nursing completed a nursing assessment, obtained a physician's order, reviewed risks and benefits with the resident or their responsible party and put in a request for maintenance to put side rails on the resident's bed. The Administrator was unsure why Resident #57 had bilateral quarter length side rails on his bed and had not been assessed for safe usage including entrapment risk by therapy or nursing, why no consent form was completed, no physicians order obtained, and no care plan entered regarding side rail usage.

Based on observation, record review and staff interviews the facility failed to follow professional standards of practice and infection prevention measures when Unit Manager #2 (UM #2) failed to remove soiled gloves, perform hand hygiene and don clean gloves during tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) through the front of the neck to create an artificial airway and assist with breathing) care for 1 of 1 residents reviewed for tracheostomy care (Resident #17). Findings included: Resident #17 was admitted to the facility on [DATE] with a diagnosis of quadriplegia and tracheostomy status. Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Resident #17 was coded in the MDS as receiving tracheostomy care in the facility. Resident #17's care plan with a revision date of 6/22/25 revealed him to have a tracheostomy. A continuous observation of tracheostomy care was conducted on 10/2/25 starting at 8:14 AM. Unit Manager #2 (UM #2) entered the resident's room, performed hand hygiene and donned a gown and gloves. UM#2 then removed the soiled split gauze from behind the tracheostomy flange and threw it in the trash. UM#2 then opened the clean split gauze and placed it behind the tracheostomy flange. At 8:18 AM, UM#2 removed the soiled inner cannula and threw it away. She proceeded to open the new sterile inner cannula and insert it into the tracheostomy. UM #2 then removed the soiled gloves, performed hand hygiene, removed her gown, put it into the trash, removed the trash bag, tied it closed and removed it from the room. UM #2 proceeded to take the trash bag and dispose of it. In an interview with UM #2 on 10/2/25 at 8:27 AM, she indicated she thought she was performing tracheostomy care correctly. UM #2 was unaware she should have changed gloves and performed hand hygiene between soiled and clean parts of the procedure. In an interview with the Infection Preventionist (IP) on 10/2/25 at 8:45 AM The IP indicated she would expect Nurses to think critically about the procedures they were performing. In this case, UM #2 should have considered the possibility of spreading disease causing organisms to the resident's airway by not removing soiled gloves after handling the soiled split gauze and soiled inner cannula, performing hand hygiene and donning new gloves to place the clean split gauze and clean inner cannula. The Administrator was interviewed on 10/2/25 at 9:01 AM. The Administrator stated to decrease the risk of spreading disease causing organisms to the residents' airway, UM #2 should have split tracheostomy care into clean and soiled parts. She further stated UM #2 should have donned clean gloves, removed the soiled split gauze and soiled inner cannula, removed the soiled gloves, performed hand hygiene, donned clean gloves and placed the clean split gauze and clean inner cannula.

Based on observation, and resident and staff interviews, the facility failed to place a resident's call light device within reach to allow for the resident to request assistance as needed for 1 of 1 dependent resident reviewed for accommodation of needs (Resident #13). Findings included: Resident #13 was readmitted to the facility on [DATE] with diagnoses of multiple sclerosis (a chronic autoimmune disease affecting the central nervous system that leads to disruption of nerve signals traveling to the muscles of the body), and post-polio syndrome (a condition that can develop in people who previously had polio leading to a gradual decline in muscle function). Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and was dependent on staff for all activities of daily living (ADL). Review of Resident #13's care plan last revised on 8/5/25 revealed a focus of the resident being at risk for falls with interventions including to be sure the call light is within reach and to encourage Resident #13 to use it to call for assistance if needed. An observation and interview were conducted with Resident #13 on 9/29/25 at 12:15 PM. Resident #13 was lying in her bed on her back. The resident's pancake call bell was clipped to her upper right chest between the shoulder and the breast. During the observation, Resident #13 stated her call bell was not in the right position as she could only use it if it is directly under the side of her neck. Resident #13 revealed that due to having multiple sclerosis and having had polio as a child, she had control of only her neck muscles so she could tilt her head slightly and press the pancake bell with the side of her jaw. Resident #13 indicated she was able to yell out to staff passing by, but her voice was not very loud due to the symptoms of multiple sclerosis. A continuous observation of Resident #13 was conducted on 10/1/25 starting at 1:39 PM. The resident was lying in her bed on her back. The bed was positioned so the head of the bed was pulled away from the wall and was facing the door. The bed was on the door side of the room, and Resident #13 did not have a roommate although there was another bed in the room. Resident #13's pancake call bell was lying on the floor between the bed and the wall. At 2:00 PM, Nurse #14 entered Resident #13's room. While in the room she checked the level of urine in Resident #13's catheter bag and proceeded to empty it. Nurse #14 then gave Resident #13 a drink that she requested. At 2:04 PM Nurse #14 left the room without having checked if Resident #13 had her call bell available. At 2:22 PM two staff members entered the room. The staff members were the Speech Therapist (ST) and Resident #13's assigned Nursing Assistant (NA #1). The ST went to the side of the bed where the pancake call bell was lying on the floor, she picked it up and positioned it on Resident #13 under her jaw on the right side and clipped it in place on the resident's nightgown. NA #1 was entering the room with the mechanical lift. In a follow-up interview with Resident #13 on 10/2/25 at 9:17 AM, she revealed staff left the room without ensuring she had her call bell correctly placed at least once daily. Resident #13 further revealed that being without her call bell made her feel terrible and helpless, like the staff don't care. In an interview with NA #1 on 10/1/25 at 2:24 PM she stated she had dressed Resident #13, left the room and took the lunch cart back to the kitchen and was planning to come right back with the mechanical lift to get Resident #13 out of bed to attend activities. NA #1 revealed she sat down for a few minutes to rest after returning the lunch cart to the kitchen but did not think she was gone that long, and Resident #13 could have yelled out for help if needed. NA #1 indicated she had been trained to make sure a dependent resident had their call bell within reach before she left a resident's room. In an interview with Nurse #14 on 10/1/25 at 2:54 PM, she stated she did not look to see if Resident #13 had her call bell within reach when she was in the room emptying her catheter. Nurse #14 further stated she was nervous at the time and did not look for the call bell. Nurse #14 revealed she had been trained to ensure a dependent resident had their call bell within reach before she left a resident's room. The ST was interviewed on 10/1/25 at 3:04 PM. The ST stated she made it a habit to check if residents have their call bells in reach as she walked through the facility. She further stated she noticed Resident #13 did not have her call bell readily available and entered the room for the purpose of locating it and placing it where Resident #13 could use it. In an interview with Unit Manager (UM #1) on 10/1/25 at 3:09 PM she stated all staff who entered a resident's room should ensure the resident had their call bell within reach before leaving that resident's room, even if the staff member believed they would be right back. UM #1 further stated Resident #13 was capable of yelling out for help if needed. The Director of Nursing (DON) was interviewed on 10/2/25 at 8:44 AM. The DON stated residents should have their call bell in reach at all times, even if there was a staff member in the room with the resident and especially if a staff member left the room. In an interview with the Administrator on 10/2/25 at 9:14 AM, she stated residents should have their call bell in reach at all times. She further stated that even if a resident was capable of yelling out for help, they shouldn't have to do so.

Based on observations, record review, and resident and staff interviews, the facility applied a resting hand splint (a brace used to keep the hand, wrist, and fingers in a neutral position preventing stiffness and contractures) without a physician's order, therapy instructions or in accordance with a splint wearing schedule. This deficient practice was for 1 of 3 residents reviewed for position and mobility (Resident #38).Findings included:Resident #38 was admitted to the facility on [DATE] with a diagnosis of right-hand contracture.Resident #38's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She had functional limitation of range of motion on both sides of her upper and lower extremities. She received 2 days of occupational therapy beginning on 9/9/25. She was not in a restorative nursing program. Resident #38 did not receive splint or brace assistance.Resident #38's medical record did not reveal a physician's order for a resting hand splint.Resident #38's current comprehensive care plan revealed a focus area dated as initiated on 9/19/25 for alteration in musculoskeletal status related to contractures. The goal was for Resident #38 to remain free from injuries or complications from contractures through the next review. An intervention was to monitor and document as needed any sign or symptom or complication related to contracture formation or joint changes.On 9/29/25 at 3:01 PM Resident #38 was observed in her room. A resting hand splint was observed on her nightstand. An interview with Resident #38 at that time indicated she did not know what the splint was for or when she wore it.On 10/1/25 at 12:36 PM Resident #38 was observed in her room. A resting hand splint was observed on her nightstand.On 10/1/25 at 12:37 PM an interview with Nurse #11 indicated she was caring for Resident #38 that day and was familiar with her. She reported Resident #38 was admitted to the facility with a resting hand splint for her right hand that night shift applied to Resident #38. She stated Resident #38 had been wearing her splint when she took over her care this morning at 7:00 AM, but it was halfway off. Nurse #11 stated she reapplied the splint, but a short time later when she went back into Resident #38's room, Resident #38 had it off again. She reported she was waiting for Resident #38 to finish her lunch, and them she would reapply the splint. She indicated Resident #38 was not being seen by therapy, because she was a long term care resident. Nurse #11 stated there was no physician's order for Resident #38's right hand splint, or any splint wearing schedule, but she just assumed that Resident #38 was supposed to be wearing the splint during the day and having it removed at night.On 10/2/25 at 8:13 AM a telephone interview with Nurse Aide (NA) #9 indicated she was assigned to care for Resident #38 on the shift beginning at 11:00 PM on 9/30/25 and ending at 7:00 AM on 10/1/25. She reported Resident #38 had been wearing a right hand splint during that shift, but she had not applied it to Resident #38. She reported she did not know who applied the splint. NA #9 stated if a resident was supposed to have a splint applied, it showed up as a task for her in the computer. She reported she did not recall seeing application of a splint for Resident #38.On 10/2/25 at 9:21 AM a telephone interview with Nurse #12 indicated she was assigned to care for Resident #38 on the shift beginning at 11:00 PM on 9/30/25 and ending at 7:00 AM on 10/1/25. She stated she really couldn't remember if she had applied a splint to Resident #38. She reported if a resident was supposed to wear a splint, it would appear for her on the resident's Treatment Administration Record (TAR) so she would know when to apply and remove it and could document the application and removal.A review of Resident #38's TAR did not reveal any information regarding the application or removal of a right resting hand splint.On 10/1/25 at 2:20 PM an interview with the Therapy Director indicated she was familiar with Resident #38 and had been working with Resident #38 since her admission. She reported Resident #38 was receiving Occupational Therapy services. She stated Resident #38 had been admitted to the facility with a right-hand contracture, but not a resting hand splint. She indicated she had ordered the resting hand splint for Resident #38 and been working with this during Resident #38's therapy sessions. The Therapy Director stated Resident #38 was not tolerating her splint and had only been wearing it for less than 30 minutes while supervised during therapy sessions. She reported until Resident #38 could tolerate the splint for more than 1 hour, Resident #38 would not be released to the restorative nursing program with a splint wearing schedule. She stated about a week before Resident #38 was released to wear the splint regularly, an order would be placed, she would train the nursing staff on the application of the splint, monitoring for any skin breakdown and provide a splint schedule that specified how many hours a day the splint was to be worn. The Therapy Director reported while it would not cause Resident #38 any harm for nursing to have applied the splint, Resident #38 had not been released to wear it except during therapy sessions.On 10/2/25 at 2:28 PM an interview with the Assistant Director of Nursing indicated Nurses and NAs should not be applying a splint to a resident without a physician's order and instructions on how to do so.On 10/1/25 at 2:42 PM an interview with the Administrator indicated she felt that having Resident #38's splint in her room was confusing to the nursing staff. She stated she felt that if Resident #38 had not been released by therapy to have her splint applied by nursing staff, therapy should keep the splint and not leave it Resident #38's room.

Based on observations, record review, and resident, staff, and Nurse Practitioner (NP) interviews the facility failed to remove a topical pain patch in accordance with the physician's order. This was for 1 of 2 residents (Resident #82) reviewed for professional standards.Findings included:Resident #82 was admitted to the facility on [DATE] with a diagnosis of pain.The nursing admission Data Collection form for Resident #82 dated 9/24/25 at 6:02 PM completed by Nurse #10 revealed Resident #82 was alert and oriented times 4 (to person, place, time and situation).A physician's order for Resident #82 dated 9/26/25 revealed lidocaine (topical pain medication) patch 4 percent (%) apply to shoulders and chest topically one time a day for pain apply 3 patches - one on each shoulder and chest and remove per schedule. There was no physician's order for Resident #82 to self-administer medications.On 9/29/25 at 11:10 AM an observation was conducted in conjunction with an interview with Resident #82. During the observation, Resident #82 used both hands to pull down the front of her gown in response to a question from the surveyor regarding whether or not she had any wounds or skin conditions. This revealed one lidocaine topical patch on her chest and one on each shoulder, for a total of 3 lidocaine patches, dated 9/28/25 with the initials of Nurse #11. In an interview at that time Resident #82 stated she received the patches once daily. She reported they were supposed to be on for 12 hours, and then off for 12 hours. She indicated the nurse put the patches on in the morning, and then she took them off herself whenever.Resident #82's Medication Administration Record (MAR) revealed documentation indicating that on 9/28/25 and 9/29/25 at 9:00 AM Nurse #11 applied lidocaine 4% patches topically to Resident #82's shoulders and chest in accordance with the physician's order. It further revealed documentation indicating that on 9/28/25 at 8:59 PM Nurse #10 removed the lidocaine 4 % patches from Resident #82's shoulders and chest in accordance with the physician's order.On 9/29/25 at 1:58 PM a telephone interview with Nurse #10 indicated when she had gone in to remove the lidocaine patches from Resident #82's chest and shoulders on 9/28/25, Resident #82 told her she would remove them herself. Nurse #10 stated she had never gone back to check to be sure Resident #82 had actually removed them.On 9/29/25 at 1:30 PM an observation of Resident #82 revealed one lidocaine topical patch on her chest and one on each shoulder dated 9/29/25 with the initials of Nurse #11.On 9/29/25 at 1:38 PM an interview with Nurse #11 indicated she applied the lidocaine 4% patches topically to Resident #82's shoulders and chest on 9/28/25 in the morning. She reported she dated and initialed the patches. She stated she also applied the patches to Resident #82 on 9/29/25, and initialed and dated the patches. Nurse #11 went on to say when she applied the patches to Resident #82 on 9/29/25, she noticed that the patches she applied on 9/28/25 were still on. She stated she recalled this happening before, and she had notified Unit Manager #1 because the patches were supposed to be removed from Resident #82 each evening. Nurse #11 reported she had not notified Unit Manager #1 on 9/29/25.On 9/29/25 at 1:45 PM an interview with Unit Manager #1 indicated she did not recall Nurse #11 ever notifying her that Resident #82's lidocaine patches were not being removed in the evening in accordance with the physician's order.On 9/29/25 at 1:49 PM an interview with the Director of Nursing indicated Nurse #10 should have removed Resident #82's lidocaine patch herself in accordance with the physician's order.On 10/02/2025 at 12:20 PM an interview with NP #1 indicated that while no harm would have occurred to Resident #1 from not having her lidocaine patch removed, there was a reason the physician's order for the lidocaine patch included a removal time. She reported the patch was only effective for a certain amount of time. She stated Nurse #10 should have removed Resident #82's lidocaine patch in accordance with the physician's order.On 10/2/25 at 1:21 PM an interview with the Administrator indicated Nurse #10 should have removed Resident #82's lidocaine patch herself in accordance with the physician's order.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that included Pre-admission Screening Resident Review (PASRR) Level II (Resident #53 and Resident #43) and hospice (Resident #8) for 3 of 20 comprehensive care plans reviewed.Findings included: 1. Resident #53's Pre-admission Screening Resident Review (PASRR) Level II Determination Notice dated 9/17/24 revealed in part her Level II screening determined Nursing Facility Placement was appropriate. Resident #53 was admitted to the facility on [DATE] with a diagnosis of progressive neurological (nervous system) condition. Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #53's current comprehensive care plan revealed her Level II PASRR status was not reflected in her care plan until a focus area was initiated by the facility's Social Worker (SW) on 3/24/25. On 10/1/25 at 10:26 AM an interview with MDS Nurse #1 indicated the Social Worker (SW) would be responsible for ensuring a resident's Level II PASSR status was reflected in the comprehensive care plan. On 10/1/25 at 10:56 AM an interview with the SW indicated she normally was not responsible for ensuring that a resident's Level II PASRR status was included in their comprehensive care plan. She reported the MDS Nurses did this. She stated she might have added this to Resident #53's care plan on 3/24/25 because she had not seen it there. On 10/1/25 at 11:24 AM an interview with the Assistant Director of Nursing indicated that because the SW was responsible for overseeing the facility's PASRR process, she would be responsible for ensuring a PASRR Level II status was reflected on a resident's comprehensive care plan. On 10/2/25 at 1:21 PM an interview with the Administrator indicated Resident #53 was admitted to the facility with a Level II PASRR. She reported this should have been reflected in her comprehensive care plan before 3/24/25. 2. Resident #43 was admitted to the facility on [DATE]. Her active diagnoses included cerebral infarction. Review of Resident #43's Level II PASARR Determination Notification letter dated 8/21/25 revealed an expiration date of 9/20/25. Resident #43's Level II PASARR Determination Notification letter dated 9/22/25 revealed it had no expiration. Review of Resident #43's care plan dated 9/4/25 revealed no care plan for the Level II PASARR. During an interview on 10/1/25 at 2:43 PM MDS Nurse #1 stated Level II PASARR should be in the care plan, and it was not for Resident #43. She stated that ensuring Level II PASARR was on the care plan was the responsibility of both MDS and Social Work. During an interview on 10/1/25 at 2:49 PM the Social Worker stated Resident #43 had a Level II PASARR determination which should be captured on the care plan. She stated when the Level II PASARR determination notification letter came to the facility it was not uploaded into the system, which was possibly why it was missing on the care plan. During an interview on 10/1/25 at 2:54 PM the Administrator stated Level II PASARRs should be care planned. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of the hospice provider notes indicated Resident #8 was accepted into hospice care services on 7/30/25. Resident #8's care plan last revised on 8/5/25 did not reveal a focus area, goal, or intervention regarding hospice care services. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was receiving hospice care services. An interview on 9/30/25 at 2:30 PM was held with MDS Nurse #2, she stated hospice care services should have been included in the care plan for Resident #8. MDS Nurse #2 indicated she was responsible for this task and should have added it to the care plan. During an interview with the Director of Nursing on 9/30/25 at 2:45 PM, she revealed her expectation would have been that hospice care services were included in the care plan for Resident #8. An interview was conducted with the Administrator on 9/30/25 at 2:55 PM. She stated she would have expected the care plan to have been updated by the MDS Nurse when the family agrees to hospice care services for any resident.

Based on record review and resident and staff interviews, the facility failed to obtain further approval and screening through a Level II evaluation process in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Determination Notification. This was for 1 of 2 residents (Resident #53) reviewed for PASRR.Findings included:Resident #53's Pre-admission Screening Resident Review (PASRR) Level II Determination Notice dated [DATE] revealed Nursing Facility Placement was appropriate for a limited nursing facility stay, lasting no more than thirty (30) calendar days. The PASRR expiration date was [DATE].Resident #53 was admitted to the facility on [DATE] with a diagnosis bipolar affective disorder (a chronic mental health condition characterized by extreme mood swings).Resident #53's current comprehensive care plan revealed a focus area dated as initiated on [DATE] for Level II PASRR. The goal was for Resident #53 to show no change in mental status through the next review. An intervention was to monitor for and document any changes in mental status.Resident #53's PASRR Level II Determination letter dated [DATE] revealed nursing facility placement was appropriate for Resident #53. The letter had no expiration date. No specialized services were required.On [DATE] at 2:25 PM an interview with Resident #53 indicated she was receiving all the care she needed in the facility. She reported she didn't have any concerns.On [DATE] at 9:53 AM an interview with the Social Worker (SW) indicated although Resident #53 was admitted with a Level II PASRR, the letter itself didn't get scanned into Resident #53's electronic record, so she did not realize it had an expiration date. She reported she did a 100 percent (%) audit of PASRRs at the end of [DATE] or the first of [DATE], which she does periodically, and she discovered Resident #53's PASRR was expired so she then initiated a new Level II review for Resident #53. The SW stated she would have been responsible for tracking all resident's PASRR statuses ensuring they were current and addressing any that had expiration dates. She reported a corrective action plan had been initiated to ensure this didn't happen again.On [DATE] at 10:04 AM an interview with the Administrator indicated the facility should be monitoring for all resident's PASRR status, verifying that each resident's PASRR status was accurate, and if there was an expiration date, ensuring that rescreening was done in a timely manner.On [DATE] at 2:25 the facility provided the following corrective action plan:Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice:On [DATE], resident #53's PASRR was found to be expired. The facility submitted the PASRR Preadmission Screening and Resident Review) for resident #53 on [DATE].Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All residents have the potential to be affected by the deficient practice.On [DATE] the facility made the decision to conduct a 100% audit on all residents to include Preadmission Screening and Resident Review (PASRRs); to ensure proper level of care and quality was being provided to all residents by ensuring each resident had a current PASRR and no expired PASRR existed in the facility. Findings of the audit revealed that there were no other residents identified without a current PASRR. No others expired PASRRs were found during the audit. The audit was completed by the Assistant Director of Nursing on [DATE].Address what measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur:The Assistant Director of Nursing educated the Social Worker and Admissions Director to check PASRRs on admission and check all current PASRRs monthly to make sure no PASRR is expired. This education was completed on [DATE].The Assisted Director of Nursing will educate any new Social Worker and Admissions Director upon hire; to check PASRRs on admission and check all current PASRRs monthly to make sure no PASRR is expired.Indicate how the facility plans to monitor it's performance to make sure that solutions are sustained:The Assistant Director of Nursing will do monthly PASRR audits to make sure there are no expired PASRRs for 3 months. The Executive Director will present these findings to the QAPI committee, monthly for 3 months.Corrective action plan completion date: [DATE].On [DATE] at 2:30 PM the facility's corrective action plan was validated through a review of the facility's initial 100% audit, a review of the facility's education in-service training record dated [DATE] titled PASSR, interviews with the SW, the Assistant Director of Nursing and the Admissions Director, the facility's monthly audits, and the facility's QAPI meeting minutes. The corrective action plan completion date of [DATE] was validated.

Based on record review, and staff, Responsible Party (RP) and Physician interviews the facility failed to administer seizure medication to Resident #19 on 10/2/23 after he returned to the facility from the hospital, resulting in 4 missed doses of seizure medication. Resident #19 did not receive Keppra (an anti-seizure medication) beginning on 10/2/23 when he returned to the facility from the hospital through 10/4/23. On 10/4/23 Resident #19 suffered seizures in the facility, requiring readmission to the hospital. On 10/4/23 Resident #19 suffered a tonic/clonic seizure (loss of consciousness and violent muscle contractions which can be dangerous and potentially life threatening) lasting about 1 minute in the hospital which required the administration of intravenous (IV) Keppra. This was for 1 of 5 residents (Resident #19) whose medication administration was reviewed. Findings included: Resident #19 was admitted to the facility on [DATE] with a diagnosis of stroke (blockage of blood supply to the brain). A review of Resident #19's care plan revealed a focus area last revised on 8/13/23 of seizure disorder related to stroke. The goal was for Resident #19 to have minimal risk of injury from seizure activity through the next review. An intervention was to administer Resident #19's seizure medication as ordered by his physician. A review of a physician's progress note for Resident #19 dated 9/25/23 at 7:43 PM written by Physician #1 indicated Resident #19 was sent to the hospital Emergency Department (ED) on 5/25/2022 for seizure like activity where he was started on Keppra 500 mg by mouth twice daily. A review of Resident #19's September 2023 facility Medication Administration Record (MAR) revealed a physician's order with a start date of 5/22/23 for Keppra 500 milligrams (mg) by mouth twice daily for seizures. It further revealed documentation Keppra 500 mg was last administered to Resident #19 on 9/25/23 at 5:00 PM. The next dose due was on 9/26/23 at 9:00 AM. A review of a nursing progress note for Resident #19 dated 9/26/23 at 8:14 AM written by Nurse #2 revealed Resident #19 was sent to the hospital emergency room for evaluation due to hypotension (low blood pressure). A review of Resident #19's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. A review of Resident #19's hospital discharge summary dated 10/2/23 revealed Resident #19 was admitted to the hospital on 9/26/23 and treated for a urinary tract infection. He had history of seizure disorder. The list of his discharge medications included Keppra 500 milligrams (mg) by mouth twice daily. A review of Resident #19's hospital MAR revealed documentation Resident #19 last received a dose of Keppra 500 mg by mouth on 10/2/23 at 9:01 AM in the hospital. A review of a nursing progress note for Resident #19 dated 10/2/23 at 5:41 PM written by the Unit Manager revealed Resident #19 was readmitted to the facility. A review of Resident #19's facility admission medication orders dated 10/2/23 at 5:00 PM entered into his electronic medical record by Nurse #2 did not reveal any evidence of the entry of an order for Keppra 500 mg daily. A review of Resident #19's October 2023 facility MAR did not reveal any documentation Keppra 500 mg was administered to Resident #19 on 10/2/23, 10/3/23 or 10/4/23. A review of a nursing progress note for Resident #19 dated 10/4/23 at 10:41 AM written by Nurse #2 revealed Resident #19 was sent to the hospital for treatment and evaluation of active seizures. A review of Resident #19's hospital record dated 10/4/23 revealed Resident #19 presented to the hospital Emergency Department (ED) for evaluation of seizure like activity on 10/4/23 at 10:43 AM via Emergency Medical Services (EMS). EMS had reported no seizure like activity. Resident #19 initially had some altered mental status and was usually alert and oriented to himself but had not been alert at all that morning. He presented from his nursing facility with breakthrough seizures times three, followed by a prolonged postictal state (a period characterized by disorienting symptoms such as confusion, drowsiness, headache, and nausea that begins when seizure subsides and ends when a person returns to baseline). Resident #19 had reportedly been fine after his most recent return to the facility from the hospital on 10/2/23 until 10/4/23. On 10/4/23 Resident #19 was reported to have 3 separate seizures within a 5 minute period at the facility. Resident #19 had another tonic/clonic seizure on 10/4/23 at 11:34 AM in the ED which lasted about 1 minute. He was administered Keppra 1500 mg IV in the ED and Keppra 500 mg IV twice daily would be started in the morning on 10/5/23. Facility staff reported there had been a mistake when Resident #19 returned to the facility from the hospital on 10/2/23, and Resident #19 had not been given his Keppra for the last 2 days. Resident #19's seizures were most likely secondary to his inadvertent medication non-compliance. Resident #19 was discharged back to the facility on [DATE] with an order to continue his Keppra 500 mg by mouth twice daily. On 8/29/24 at 9:04 AM an interview with the Unit Manager indicated when Resident #19 returned from the hospital on 10/2/23 Nurse #2 entered his medication orders into Resident #19's electronic medical record. She stated this was supposed to be done based on the medication orders that were listed on the hospital discharge summary, and Nurse #2 should have gotten a second nurse to check the medication orders she entered against Resident #19's hospital discharge summary to ensure the medication orders entered were accurate. The Unit Manager stated that because Resident #19's order for Keppra was not entered by Nurse #2 on 10/2/23, it did not appear of his Medication Administration Record to be administered to him, and he missed getting doses of this medication in the facility. In a follow-up interview on 8/30/24 at 11:56 the Unit Manager stated any nurse on the hall could enter a resident's hospital discharge medications into the electronic medical record when a resident returned from the hospital. She reported the nurse entering the medication orders should always have a second nurse verify the entered orders against the hospital discharge summary to ensure accuracy. She went on to say any second nurse could do the verification. On 8/29/24 at 7:07 PM a telephone interview with Nurse #2 indicated when Resident #19 was readmitted to the facility from the hospital on 10/2/23, she entered the medication orders from his hospital discharge summary into his electronic medical record. She went on to say she could not say why she missed entering Resident #19's Keppra medication order that day. She stated she was supposed to have another nurse check the medications she entered against the hospital discharge summary to ensure that the medications she entered for Resident #19 were accurate, but she had not. Nurse #2 stated she did not recall ever hearing anything about Resident #19's levetiracetam medication being missed. She reported she was caring for Resident #19 on 10/4/23 when he began having seizures. She went on to say she had been assigned to care for Resident #19 at times for the past 2 years that she had been working at the facility, and had never seen him have a seizure before. She stated Resident #19 began to have seizure activity which included jerking movements on 10/4/23, although she really couldn't recall any specific details. Nurse #2 further stated she had immediately notified the physician, and Resident #19 had been sent to the hospital that day. On 8/29/24 at 10:09 AM a telephone interview with Resident #19's Responsible Party (RP) indicated Resident #19's seizures were diagnosed after he was admitted to the facility. She stated they had been handled at the facility with medication and he had not needed to go to the hospital for them previously. She stated in October 2023 Resident #19 had seizures, his physician wanted him sent to the hospital, and although she felt being sent out to the hospital was very disruptive for Resident #19, she had agreed. Resident #19's RP reported she did not feel that Resident #19 suffered any permanent changes in his mental or other abilities after the seizures he experienced in October 2023. On 8/29/24 at 11:03 AM a telephone interview with Physician #1 indicated Resident #19 had been receiving Keppra for some time at the facility to treat seizures that were a result of his stroke. He stated Resident #19's seizures had been successfully managed in the facility. He went on to say when Resident #19 initially returned to the facility from the hospital on 10/2/23, there had been an error in transcription by the facility, and Resident #19's Keppra medication had not been restarted even though it appeared on his hospital discharge summary. Physician #1 reported as a result of this, Resident #19 had missed 2 to 3 doses of the Keppra medication in the facility that he should have received. He went on to say Resident #19 was very sensitive to low levels of the medication, and this resulted in Resident #19 experiencing seizures on 10/4/23. He reported Resident #19 required hospitalization for these seizures and needed doses of IV Keppra to control the seizures in the hospital. He stated Resident #19 had severe cognitive impairment at baseline, and although there was a very small risk of brain damage and/or death from the type of seizure Resident #19 experienced on 10/4/23, he did not feel Resident #19 had suffered any additional brain damage. On 8/29/24 at 11:33 AM an attempt at telephone interview with Director of Nursing (DON) #2, the facility's DON on 10/4/23, using the telephone number provided by the facility's current DON, indicated the telephone number was no longer in service. No other telephone number for DON #2 was available. On 8/29/24 at 1:13 PM an interview with the facility's Consultant Pharmacist indicated it was likely that Resident #19 experienced seizure activity on 10/4/23 as a result of his missed Keppra medication. She stated while the pharmacy did review resident's readmissions to the facility, comparing the medication orders entered by the facility with the hospital discharge summary to ensure accuracy, a review of Resident #19's readmission medication orders would not have occurred until 10/4/23 after he had already been readmitted to the hospital. On 8/29/24 at 2:50 PM a telephone interview with Administrator #2 indicated he was no longer the facility's Administrator but had been on 10/4/23. He stated he did not recall whether the issue with Resident #19 missing doses of Keppra medication had been discussed while he was the facility's Administrator. He reported he had held daily morning clinical meetings, and if this issue had been discussed, there should be documentation of that. On 8/29/24 at 2:56 PM an interview with the facility's current Administrator indicated he had not previously been aware of the incident with Resident #19 missing doses of Keppra medication. He stated he had not been the Administrator at that time and was not aware of any corrective action plan for the incident. On 8/30/24 at 12:31 PM a follow-up interview with the Administrator indicated he had not been able to find any documentation that the issue with Resident #19 missing his Keppra medication in October 2023 had been discussed at a clinical meeting. On 8/30/24 at 12:22 AM an interview with the DON indicated she was not the DON at the facility on 10/4/23 and had not previously been aware of the issue with Resident #19 missing his levetiracetam medication. She stated when a resident was readmitted to the facility from the hospital, the nurse entering the resident's medication orders into the electronic medical record should enter these based on the discharge medications listed on the resident's hospital discharge summary. She stated a second nurse should also verify that the medication orders entered were accurate based on the discharge medications listed on hospital discharge summary to prevent any errors. The Administrator was notified of Immediate Jeopardy on 8/29/24 at 2:30 PM. The Administrator provided the following corrective action plan with a compliance date of 10/30/23: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 10/4/23 Nurse manager identified that between 10/2/23 and 10/4/23 resident #19 had a total of 4 doses of Keppra omitted due to a transcription error at readmission by the center 10/2/23. Orders were obtained for Keppra 500mg BID when returned from hospital on 10/6/23. The center recognizes that all newly admitted residents and residents that are readmitted have the potential to be affected from the prior noncompliance with obtaining and administering medications. A review of Resident #19's hospital medication administration record dated 10/2/23 at 2:01 PM revealed Resident #19's last administered dose of Keppra 500 milligram (mg) orally in the hospital was on 10/2/23 at 9:01 AM. The order was for Keppra 500 milligram (mg) orally twice daily. There was no documentation he received any Keppra after returning to the facility on [DATE]. There was no documentation of any doses administered in the facility on 10/3/23, and no documentation of doses in the facility on 10/4/23 before Resident #19 was transferred to the hospital on 10/4/23. He arrived at the hospital at 10:43 AM on 10/4/23. That adds up to 4 missed doses. All newly admitted residents and readmitted residents between 9/4/23 through 10/4/23 have had their medication orders audited by the Director of Clinical Services and Unit Managers. No discrepancies were noted. On 10/4/23 a Root Cause Analysis was completed by the Director of Nursing, and the Administrator regarding omission of medication administration for resident #19. It was determined through root cause and analysis that the medication was not administered due to the oversight of transcribing the orders. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice A quality review was completed on 10/5/23 of current residents with a diagnosis of seizure disorder. Identified residents were reviewed by the Director of Nursing and Nurse Managers to ensure all seizure medication was ordered, transcribed correctly, and given as ordered. A quality review of all admissions and re-admissions 30 days prior to October 4th, 2023, was conducted by the Director of Nursing and Unit Manager to ensure all other newly admitted or readmitted patients' medications were administered per Physician orders. There were no medication transcription errors noted during the quality review. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Director of Nursing and/or the nurse managers provided education on 10/4/23 to current nurses and med aides on the importance of transcribing all new orders from discharge summaries, verified by 2 nurses to ensure medications are transcribed and administered per physician orders to the residents. Newly hired nurses and med aides will be educated on hire during their orientation process. The Administrator provided oversight for the education of nurses and med aides to ensure that 100% of all licensed staff and med aides were reeducated on the importance of administering all ordered medications. The Director of Nursing and Nurse Managers will conduct Quality Improvement Monitoring of medication administration records of all new residents when admitted or readmitted to facility to ensure all medications are transcribed correctly and medications are administered as ordered per Physician starting 10/4/23. Upon receiving discharge summaries medication orders are verified with Provider, 1 Nurse transcribes all orders, and then 1 Nurse verifies/confirms that orders were transcribed correctly. This is the standard process that is in place. Additionally, the Director of Nursing and Nurse Managers will conduct quality improvement monitoring of all admissions/readmissions to ensure all medications are transcribed to medication record as indicated. The above Quality Improvement Monitoring will occur daily in clinical for 4 weeks, then weekly for 3 months ongoing beginning 10/4/23. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained On 10/04/2023, when the deficient practices was identified the center Executive Director conveyed an ADHOC Quality Assurance Performance Improvement meeting to determine the root cause analysis of the deficient practice, put a plan of action in place to include quality improvement monitoring and the frequency of monitoring beginning on 10/04/2023 to ensure medication administration orders were transcribed correctly and medications were administered as ordered including the Executive Director, Medical Director, Director of Nursing, the Manager of Social Services, the Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records Clerk, Central Supply Clerk, Admissions Director, Nurse Managers, Dietary Manager, and the Environmental Services Director. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly to ensure ongoing compliance times 4 months. Quality Improvement monitoring schedule will be modified based on findings of monitoring. The center Administrator alleges abatement of immediacy on 10/30/23. Validation of the corrective action plan was completed on 9/04/24. Interviews were conducted with a sample Nurses to verify education was conducted for Nurses regarding transcription of medication to the Medication Administration Record (MAR). Documentation of in-service records was reviewed. A review of audits of new admissions and their orders transcribed to the MAR dated 9/4/24 to 10/4/24 were verified to be completed. In an interview with the Nurse Manager on 9/4/24 at 1:18 pm, she stated that all Nurses, and Medication Aides had been educated transcribing medication on the MAR and 2 nurses reviewed to confirm accuracy of the transcription. She further stated that orientation included medication administration and transcription of medication orders to the MAR. An observation of the Resident #19's medical record revealed that Resident #19 had received all prescribed doses of Keppra (an antiseizure medication) from October 2023 (after the identified date of missed October 2023 doses) until today 9/4/24. The QAPI minutes were reviewed. The facility's alleged immediate jeopardy removal date and compliance date of 10/30/23 was verified.

Based on observation, record review and staff interviews, the facility failed to implement their hand hygiene policy when the Respiratory Therapist (RT) failed to perform hand hygiene after touching a contaminated surface and before touching the tracheostomy and failed to implement their policy for enhanced barrier precautions when the RT failed to wear a gown while performing tracheostomy care for 1 of 1 resident (Resident #53) reviewed for tracheostomy care, and failed to perform hand hygiene between the removal of soiled gloves and the application of clean gloves for 1 of 2 residents (Resident #71) reviewed for pressure ulcers. Findings included: 1. A review of the facility policy titled Handwashing/Hand hygiene dated August 2019 provided by the facility stated in part: This facility considers hand hygiene the primary means to prevent the spread of infection. 7. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: e. before or after handling an invasive device (e.g. urinary catheters, IV access sites). :g. before handling clean or soiled dressings, gauze pads, etc. :l after contact with objects in the immediate vicinity of the resident. A review of the enhanced barrier precautions policy stated in part: gown and gloves must be worn when providing personal care. Tracheostomy care is given as an example of care provided. During an observation of tracheostomy care by the RT on 8/27/24 at 4:47 PM, she failed to don a gown before entering Resident #53's room who was on enhanced barrier precautions. There was a sign on the door specifying staff wear a gown when performing care such as tracheostomy care. The RT stated that tracheostomy care was a clean procedure not a sterile procedure. She put on a pair of clean gloves, then put a pair of sterile gloves on over the clean gloves. Resident #53 requested she turn up the air conditioning. She went to the air conditioner and touched the button to turn it up. The RT continued to set up the sterile disposable cartons to pour sterile water and hydrogen peroxide into. She continued to pour the liquids into their containers and put gauze into them with her gloved hands. The RT proceeded to take out the resident's dirty disposable cannula and dispose of it. She then removed the dirty split sponge from under the resident's tracheostomy collar and disposed of it. The RT proceeded to put her gloved hand into the container with sterile water and gauze, picked up the gauze, squeezed out the excess water and proceeded to clean around the tracheostomy stoma. Resident #53 stated the stoma was tender. The RT retrieved her cell phone from the pocket of her top, turned on the flashlight and looked at the stoma by moving the collar with her gloved hand. After she put the phone away, she continued to clean around the stoma with wet gauze. When finished cleaning, she put the new, sterile cannula in. The RT then took off the outer layer of gloves and proceeded to change the residents trach collar. At this point she was finished. In a telephone interview with the RT on 8/30/24 at 8:50 AM she revealed she did not know if she was to wear a gown while providing tracheostomy care on a resident on enhanced barrier precautions. The RT stated she was taught that tracheostomy care was not a sterile procedure. She was unaware of the policy she was to follow to provide care. The RT revealed she was aware she should not have touched potentially dirty surfaces and continued with care without performing hand hygiene due to the risk of introducing harmful bacteria to the resident. A telephone interview was conducted on 8/30/24 at 3:50 PM with the RT Supervisor. The Supervisor stated a gown should have been worn to perform tracheostomy care and the RT should have performed hand hygiene after touching potentially dirty surfaces and before performing care on the resident. The Supervisor further stated the RT works for a contracted company, not the facility and as such, should have followed the tracheostomy care policy of the facility. In an interview with the Director of Nursing (DON) on 8/29/24 at 12:53 PM she stated the RT worked for a contracted company and she was not sure which policy the RT should have followed. She further stated the RT should have worn a gown to perform tracheostomy care due to enhanced barrier precautions and should have performed hand hygiene by washing her hands and donning clean gloves after touching a dirty surface and before continuing tracheostomy care on Resident #53. 41009 2. A review of the facility policy titled Handwashing/Hand hygiene dated last revised August 2019 provided by the facility revealed in part: This facility considers hand hygiene the primary means to prevent the spread of infection. 7. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves. On 8/27/24 at 3:21 PM an observation of pressure ulcer care was conducted for Resident #71 and the observation was followed by an interview with the Treatment Nurse who was performing the dressing change. During the observation, the Treatment Nurse was observed to perform hand hygiene and apply clean gloves. She removed the soiled dressing from Resident #71's left ischium (lower and back region of the hip bone) pressure ulcer using her gloved fingers and discarded the soiled dressing. The Treatment Nurse removed her soiled gloves, discarded them, and applied clean gloves without performing hand hygiene. As the Treatment Nurse reached for the wound cleanser moistened gauze to clean Resident #71's wound, she was asked to pause the dressing change. An interview with the Treatment Nurse at that time indicated she had not performed hand hygiene after removing the soiled dressing from Resident #71's pressure ulcer before she applied her clean gloves, and she should have. The Treatment Nurse reported she usually performed hand hygiene after the removal of her soiled gloves prior to applying clean gloves, but she had been nervous and forgotten. She stated performing hand hygiene after removal of soiled gloves before applying clean gloves reduced the chance of spreading infection. On 8/30/24 at 12:22 PM an interview with the Director of Nursing (DON) indicated the Treatment Nurse's gloves would have been soiled after she removed Resident #71's soiled dressing. She stated hand hygiene should always be performed after the removal of soiled gloves prior to the application of clean gloves to reduce the chance of the spread of infection.

Based on observations and staff interviews the facility failed to secure resident medications stored in an unattended medication cart (Rooms 143-150 hall) for 1 of 5 medication carts. Findings included: A continuous observation was conducted of the medication cart on 8/27/24 from 8:35 AM to 8:47 AM. The cart was parked between rooms [ROOM NUMBERS], facing out into the hallway. The cart was visible from the nurse's station but there were no staff there. There were two Nurse Aides passing breakfast trays on the hall. No residents were observed near the medication cart. The medication cart was observed to have the red dot on the push lock visible, which meant the push lock was not engaged. There was no staff member with the medication cart. Medication Aide #1 came out of resident room [ROOM NUMBER] which was at the end of the hall on the opposite side. She returned to the medication cart at 8:47 AM. Medication Aide #1 opened the top drawer without having to unlock the cart. During an interview with Medication Aide #1 at 8:47 AM she stated she left the medication cart unlocked. She further stated the cart should be locked any time she was not using it. In an interview with the Director of Nursing (DON) on 8/27/24 at 8:52 AM she stated the medication cart should be locked when the Medication Aide was not using it. An interview with the Administrator on 8/27/24 at 8:54 AM revealed medication carts should not be unlocked unless the Medication Aide was using it. The Administrator stated the Medication Aide assigned to that medication cart was responsible for it for their entire shift.

Based on observations, record review, and staff interviews the facility failed to keep dependent resident's fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #4). Findings included: Resident #4 was admitted to the facility on [DATE]. His active diagnoses included muscle weakness, and other lack of coordination. Review of Resident #4's Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He was assessed to have no rejection of care and required substantial/maximal assistance with bathing and setup or clean up assistance with personal hygiene. Review of Resident #4's care plan dated 8/27/24 revealed he was care planned for an Activities of Daily Living self-care performance deficit related to impaired mobility. The interventions included to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During observation on 8/26/24 at 2:29 PM Resident #4's fingernails were observed to be long. During an interview on 8/26/24 at 2:30 PM Resident #4 stated his fingernails were long and he would love to have them cut. He further stated staff tell him it will be done but then something comes up and they are not cut. During observation on 8/28/24 at 10:11 AM Resident #4's fingernails were again observed to be long. During an interview on 8/28/24 at 10:13 AM Nurse Aide #3 stated Resident #4 did not refuse care and did not refuse care doing his morning bath. He stated when he provided morning care, he would check residents' nails. He stated if he noticed any resident's nails were long, he would clip them. The nurse aide concluded he did not clip Resident #4's nails that morning because he did not notice how long they were. During an interview on 8/28/24 at 10:16 AM the Director of Nursing stated nails were to be trimmed on shower days, when staff noticed long nails, or as needed. After observing Resident #4's nails, the Director of Nursing stated she would have expected staff to have noticed how long his nails were and trimmed them prior to now.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medications for 1 of 5 residents (Resident #64) reviewed for unnecessary medications. Findings included: Resident #64 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #64's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She was taking antianxiety medication and an indication was noted. A review of Resident #64's physician orders revealed an order dated 3/25/24 for clonazepam (an antianxiety medication) 0.5 milligrams give one tablet by mouth every 8 hours as needed for anxiety for 5 days. There were no other physician's orders for antianxiety medication for Resident #64 from 3/19/24 through 3/30/24. A review of Resident #64's March 2024 Medication Administration Record (MAR) revealed no documentation clonazepam 0.5 milligrams was administered to her. It further revealed no documentation that any other antianxiety medication was administered to her from 3/19/24 through 3/30/24. On 8/29/24 at 3:25 PM an interview with the MDS Nurse indicated she coded the medication section of Resident #64's 3/25/24 admission MDS assessment. She stated the section was coded in error, and it was her mistake. She went on to say she was not sure why she coded the assessment to reflect antianxiety medication was taken by Resident #64. On 8/29/24 at 3:50 PM an interview with the Director of Nursing indicated Resident #64's MDS assessments should be accurate.

Based on record review and staff interviews the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident (Resident #78) reviewed for death and failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who discharged from hospice services for 1 of 1 resident (Resident #48) reviewed for accidents. Findings included: 1. Resident #76 was admitted to the facility on [DATE]. Her active diagnoses included chronic obstructive pulmonary disease, muscle weakness, and Alzheimer's disease. Review of Resident #76's hospice election form dated 5/29/24 revealed she was admitted to hospice on 5/29/24. Review of Resident #76's electronic health record revealed no significant change in status MDS assessment had been completed for Resident #76 following hospice election. During an interview on 8/27/24 at 2:17 PM the Director of MDS Education stated a significant change in status MDS assessment was required following a resident's election of hospice. She stated Resident #76 should have had a significant change in status MDS assessment following her hospice election and did not know why it was not completed. She concluded the MDS Nurse was responsible, and she could have further information. During an interview on 8/27/24 at 3:05 PM the MDS Nurse stated a significant change in status MDS assessment is required following a resident's election of hospice. She concluded Resident #76 elected hospice on 5/29/24 and the significant change in status MDS assessment was missed. During an interview on 8/28/24 at 9:43 AM the Director of Nursing stated MDS assessments should be completed according to the Resident Assessment Instrument (RAI) manual's schedule. 48230 2. Resident #48 was admitted to the facility on [DATE] with hospice services in place. A review of Resident #48's hospice discharge order revealed she was discharged from hospice on 7/4/24. A review of Resident #48's electronic health record revealed a significant change Minimum Data Set (MDS) was not completed within 14 days of discharge from hospice. In an interview with the MDS nurse on 08/29/24 at 1:47 PM she stated a significant change MDS would be completed if a resident were to be admitted to or discharged from hospice. She further stated she learned about significant changes in morning meeting every day and she was aware Resident #48 had been discharged from hospice. The MDS nurse revealed a significant change MDS should have been completed within 14 days of the resident's discharge from hospice. She was not sure how it was missed. An interview with the Director of Nursing (DON) was conducted on 8/29/24 at 2:15 PM. The DON stated a significant change MDS should have been completed for Resident #48 within 14 days of discharge from hospice. She was unaware it had not been completed. In an interview with the Administrator on 8/29/24 at 2:28 PM he stated he was unaware that a significant change MDS was not completed for Resident #48 when she was discharged from hospice. He further stated it should have been completed within 14 days of the discharge.

Based on record review, observations, staff and responsible party (RP) interviews the facility failed to identify bolsters as a restraint, failed to assess the bolsters as a restraint, and utilized them without medical justification and without a physician order. This was for 1 of 1 resident (Resident #48)reviewed for restraints. Findings included: Resident #48 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and blindness. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was severely cognitively impaired, was totally dependent on staff for all activities of daily living and did not have restraints in place. A review of Resident #48's assessments revealed there was no restraint assessment completed. An observation of Resident #48 was conducted on 8/26/24 at 3:37 PM. She was lying in bed on her back with her knees pulled up to her chest. The resident was nonverbal. Two bolster pillows were observed, one on either side of her under the fitted sheet. They were cylindrical and were measured by her RP as three feet long by 8 inches in diameter. The residents bed was not against the wall, there were no side rails, and her bed was in the lowest position with fall mats on both sides. A second observation on Resident #48 was conducted on 08/27/24 at 12:40 PM. She was lying in bed on her right side with her legs pulled up with her knees pushing on the bolster. The RP was at the bedside. A third observation of Resident #48 on 8/27/24 at 2:10 PM revealed she was in bed with the bolsters in place and no one was in the room with her. Her bed was in the lowest position with bilateral fall mats in place. In an interview with Resident #48's family member, who was her RP, on 8/27/24 at 12:40 PM he stated he had brought the bolsters in about 4 or 5 months ago to keep the resident from falling out of bed as she could move around in bed on her own. He further stated he was using body pillows before that, and staff informed him he could not use them, so he brought the round bolsters instead. The RP indicated nursing staff were aware of the bolsters. He further stated the resident had not had a fall since he started using them. An interview with Nurse #1 on 8/27/24 at 12:52 PM revealed she was aware Resident #48 had bolster pillows on her bed and staff did not remove them. Nurse #1 stated she did not feel the bolsters were a restraint. She further stated the residents RP brought the bolsters in and placed them under the fitted sheet to keep the resident from falling out of bed. Nurse #1 revealed there was no order in Resident #48's record for bolsters to be used and her last fall out of bed was 3/30/24. In an interview with Nurse Aide (NA) #1 on 8/27/24 at 3:44 PM, she stated she was familiar with Resident #48. She further stated she was aware the Resident had bolsters on her bed to keep her from falling and NA#1 removed them after the RP left in the evening, usually after supper. NA #1 revealed she thought the resident was only to have the bolsters in place while her RP was visiting. She further revealed the resident was not able to roll herself over the bolsters that she had seen. In an interview with the Director of Rehabilitation (DOR) on 8/28/24 at 9:24 AM she revealed the Rehabilitation department did not do an assessment on Resident #48 regarding restraints or bolsters. An interview with the MDS Nurse on 8/27/24 at 4:01 PM revealed a restraint was defined as anything that prohibited maximum free movement of arms legs or body. She stated Resident #48 was not coded as having a restraint on the MDS. The MDS nurse further stated bolsters or pillows under the fitted sheet would likely be a restraint and would need to be removed. An interview and observation with the Director of Nursing (DON) was conducted on 8/27/24 at 2:15 PM. The DON stated she was unaware Resident #48 had bolsters on her bed. During an observation of the bed with DON, she stated she did not believe the bolsters to be a restraint. The DON further stated she believed the Resident would be able to push them out from under the sheet or get over them as she moves around in bed independently. The DON stated she had not observed Resident #48 in bed with the bolsters as she was unaware she had them. In an interview with the Administrator on 8/29/24 at 8:48 AM he stated he was unaware Resident #48 had bolsters on her bed and felt they were a restraint. He further stated that the resident had end stage Alzheimer's and would not understand that the bolsters were there or be able to remove them herself so they likely restricted movement. The Administrator indicated the resident should have been assessed for safe use of bolsters.

Based on observation, record review, resident interviews, and staff interviews, the facility failed to ensure repairs for cracks, holes, a water damaged wall, broken blinds, and discolored flooring were completed for two (Residents # 6 and # 7) of two residents reviewed for environmental concerns and for two random rooms. The findings included. 1a. Resident # 7 was admitted to the facility on [DATE]. The resident's 1/3/24 quarterly MDS (Minimum Data Set) assessment coded the resident as having moderate cognitive impairment. According to Resident # 7's record, she had resided in the same room since 8/8/23. Resident # 7's room was observed on 1/22/24 at 10:35 AM and the following observations were made. The resident's AC/Heating unit was one which was installed through the wall. Around the unit, a large part of the wall was filled with plaster which had not been smoothed off or painted. Two slats were broken on her blinds. Resident # 7 stated the wall and blinds had been like that since she had moved into the room. She felt no one could see her through the broken blinds because the broken part was closer to the foot of the bed than the head of the bed. The Maintenance Director was interviewed on 1/23/24 at 11:20 AM and observations of Resident # 7's room was shared with him. The Maintenance Director reported the following. He had begun his employment in September 2023, and Resident # 7's wall was like it was currently when he arrived in September 2023. The previous Maintenance Director had not left a list of things that needed to be addressed. He (the current Maintenance Director) was trying to identify and correct things. The wall in Resident # 7's room had had water damage. The previous Maintenance Director had done the wood plaster and left it like it currently was. He (the current Maintenance Director) had not had time to address her wall as of yet. 1b. During a random observation of room [ROOM NUMBER] on 1/23/24 at 8:25 AM it was noted there were two holes in the wall above the head of the bed. The holes appeared to be approximately 6 inches long with approximately an inch width. At the time, there was a resident residing in the room who was unsure how long the holes had been there. At the time of the observation, the outside temperature was cold on 1/23/24. (The facility had signs posted in the hallway on 1/23/24 which directed that due to extremely low temperatures all faucets were to remain on to ensure no water froze in the pipes.) During the random observation of room [ROOM NUMBER], cold air movement could be felt coming through the holes in the wall. On 1/23/24 at 8:40 AM the Administrator was asked to view the holes with the surveyor. The Administrator reported he had not been alerted there was a problem and stated he would check into the situation. On 1/23/24 at 10:50 AM the Administrator reported he had spoken to the Maintenance Director who had said he did not have the patch to do the wall. On 1/23/24 at 11:20 AM the Maintenance Director was interviewed and reported the following. There had been a piece of railing board on the wall at the head of the bed. The paint was chipping off and it did not look good. On Friday (1/19/24) he had pulled the railing board off the wall. He had not been aware there were anchor bolts for the railing board into the wall. When the railing board was removed, it left the holes where the anchor bolts had been. He did not have enough patch to cover the holes. He had ordered the patch, but it was back ordered. Originally, it was back ordered for 5 days and then 13. After the Administrator talked to him after viewing the holes with the surveyor, the Administrator had told him to go to a local store and obtain wall patch. The Administrator was interviewed on 1/25/24 at 2:35 PM and reported if he had been notified of the inability to patch the wall because of materials, he would have told the Maintenance Director to go to the local store when the need first arose. 1c. During a random observation of room [ROOM NUMBER] on 1/22/24 at 10:02 AM, it was observed that the floor stood out as very discolored. There were patches of gray discoloration scattered throughout the flooring. On 1/23/24 at 11:20 AM the Maintenance Director was interviewed and reported the following. He was aware of the discoloring. He felt the floor tiling needed to be replaced in room [ROOM NUMBER] because it was worn out. There was no wax on the floor and he did not feel stripping it would help the problem. 1d. Resident # 6 was admitted to the facility on [DATE]. Resident # 6's annual Minimum Data Set assessment, dated 1/7/24, coded the resident with moderate cognitive impairment. The resident was interviewed on 1/22/24 at 10:10 AM and indicated he was concerned with any cracks in his room that might allow entry of bugs. It was observed that light from the outside was visible through a crack that had no caulking under Resident # 6's heating and AC unit which was installed in the wall by his bed. There was a coin shaped hole in his bathroom door also. On 1/23/24 at 11:20 AM the Maintenance Director was interviewed and reported the following. Since starting in September 2023 he had tried to identify and repair things. Staff were also to leave him a message or note so that he would know about things they identified. He had not had time yet to check underneath all the wall heating and cooling units to see if there were cracks in the seals. On 1/24/24 at 9:05 AM the small hole in Resident # 6's bathroom door remained as it appeared on 1/22/24 at 10:10 AM During an interview on 1/25/24 at 2:35 PM with the Administrator, who began employment on 1/11/24, the Administrator reported the following. He had just begun recently as Administrator, and he also was trying to identify issues and resolve them. He was also trying to look into environmental issues. He had already obtained floor samples and was starting to investigate flooring options for the facility.

Based on record review, resident interview, and staff interviews the facility failed to obtain medications from the pharmacy for administration. This was for two (Residents # 1 and # 5) of two residents whose medications were reviewed. The findings included: 1. Resident # 1 resided at the facility from [DATE] to [DATE]. The resident had diagnoses which included chronic obstructive pulmonary disease, hypertension, anxiety, coronary artery disease, and a history of coronary artery bypass surgery. Prior to residing at the facility, Resident # 1 had been hospitalized from [DATE] to [DATE] and treated for RSV (Respiratory Syncytial Virus) bronchitis. Resident # 1's care plan, dated [DATE], noted Resident # 1 contracted COVID on [DATE]. On [DATE] Resident # 1 was ordered to receive Molnupiravir 200 mg (milligrams) four capsules two times per day. (Molnupiravir is a an antiviral medication used to treat COVID.) Review of Resident # 1's [DATE] MAR (Medication Administration Record) revealed the medication was scheduled to be given at 9 AM and 5 PM. On [DATE] at 5 PM, Nurse # 6 documented the facility was awaiting delivery of the medication. The medication was not documented as given. On [DATE] at 9 AM, Nurse # 7 documented the facility was awaiting delivery of the medication. The medication was not documented as given. On [DATE] at 2:40 PM, the Director of Nursing (DON), was interviewed and reported the following. She had become DON on [DATE] and was beginning to identify and address medication issues. According to records she had reviewed, the pharmacy had delivered the Molnupiravir on [DATE] during their last delivery to the facility. It would have arrived between 9 PM and 11 PM that night. Nurse # 7 should have then started the medication the next morning. The Molnupiravir medication did not come in a bubble pack like many of the other medications. It came in a box. The DON speculated that the nurse may have looked for a bubble pack and not realized the medication was packaged differently. Nurse # 7 was interviewed on [DATE] at 2:25 PM and stated she did not know why it was not given. She could only go by what she had written in the note, which was awaiting pharmacy. Review of physician progress notes revealed Resident # 1 was evaluated by a physician on [DATE] who documented she had COVID without any fever, chills, or body aches. She was stable and doing well. 2. Resident # 5 was admitted to the facility on [DATE]. Prior to her facility residency, Resident # 5 had been hospitalized and had surgery for a Stage 4 pressure sore. She also had a diagnosis of a major depressive disorder. Review of admission orders revealed an order, dated [DATE], for Oxycodone-Acetaminophen ,d+[DATE] mg (milligrams) every four hours as needed for pain. Review of admission orders revealed an order, dated [DATE], for Acetaminophen 500 mg every eight hours as needed for pain and/or fever. Resident # 5 also had an admission order, dated [DATE], for Lorazepam 0.5 mg two times per day for anxiety for 14 days. Following the initial 14 days, the Lorazepam was to be tapered off by giving 0.5 mg daily times seven days. Review of Resident # 5's [DATE] Medication Administration Record (MAR) revealed Resident # 5 was not documented to receive any PRN doses of Acetaminophen or Oxycodone-Acetaminophen between the dates of [DATE] through [DATE]. Review of Resident # 5's [DATE] Medication Administration Record (MAR) revealed the Lorazepam was scheduled to be administered at 9 AM and 5 PM. The MAR also included the following. On [DATE] at 5 PM Nurse # 6 documented 9 beside the Lorazepam. There was no check mark the medication was given. On [DATE] at 9 AM, Nurse # 7 documented 9 beside the Lorazepam. There was no check mark the medication was given. On [DATE] at 5 PM, Nurse # 6 documented 9 beside the Lorazepam. There was no check mark the medication was given. On [DATE] at 9 AM, Nurse # 8 documented 9 beside the Lorazepam. There was no check mark the medication was given. On [DATE] at 5 PM, Nurse # 6 documented 9 beside the Lorazepam. There was no check mark the medication was given. The first time the Lorazepam was documented as given was on [DATE] at 9 AM. Resident # 5 was interviewed on [DATE] at 8:50 AM and reported she just arrived on [DATE]. They had not had her oxycodone available. They had given her Tylenol (Acetaminophen) over the week-end of [DATE] to [DATE], and it took a while to work. She was concerned about the availability of her medications. Nurse # 6 was interviewed on [DATE] at 3:15 PM and reported the following. When Resident # 5 arrived on [DATE], some of Resident # 5's prescriptions had not been sent with the discharge orders. The pharmacy needed the prescriptions. On Friday ([DATE]), she had not done the admission paperwork to realize the prescriptions were missing. On Saturday, [DATE], she realized the prescriptions were needed but she was not certain an on-call physician would give them. She therefore put the issue down for the physician/PA (physician assistant) to address on Monday [DATE] when they routinely came in. There were some back up medications in the facility, but most of the time some of them were out of date. She did not try to acquire the Lorazepam. She was not aware Resident # 6 had an order for Oxycodone-Acetaminophen and that it had not been delivered from the pharmacy and needed to be addressed. The resident was crying and hurting on the [DATE] evening shift and she gave her Acetaminophen. It seemed to work for her. She got quiet and rested after the administration of the Acetaminophen. She had not documented she had given her the Acetaminophen or its effectiveness. Interview with the MDS Nurse on [DATE] at 8:42 AM revealed on [DATE] she had printed off Resident # 5's discharge summary from the electronic system and had the Physician's Assistant sign it, but she had not been aware there was a problem with needed prescriptions. Nurse # 7 was interviewed on [DATE] at 2:25 PM and reported the following. She did not routinely work at the facility and did not recall Resident # 5 or the specifics of her care and medications. Nurse # 8 was interviewed on [DATE] at 2:35 PM and reported the following. She had just been employed at the facility since [DATE]. She did not have access to the medications in back up. There was no supervisor to get Lorazepam for her when she worked , and at times when she asked other nurses to obtain medications, they were expired. The facility did not keep Oxycodone in back up, but Resident # 5 did not complain to her of pain during her shift. The DON (Director of Nursing) was interviewed on [DATE] at 2:40 PM and [DATE] at 11 AM and reported the following. She had become the DON on [DATE]. She was aware there were some problems with medications being checked in the back up medication supply and reordered timely. She had submitted the paperwork to oversee the medications in back up to resolve issues with availability and expiration. Resident # 5 had arrived without some of her prescriptions on [DATE], and the nurses should have called the on- call physician and obtained the prescriptions so Resident # 5's medications would be available.

Based on record review and interviews with family, staff, physician assistant, independent apartment manager, staff from the Program of All-Inclusive Care for the Elderly (PACE), and contracted van driver for the PACE program, the facility failed to implement an effective discharge planning process that ensured care was coordinated with the resident's primary physician through PACE. On the day of discharge Resident #1 had a change in condition and the PACE physician was not made aware of the change prior to discharge. The PACE program is a community program that helps provide and coordinate medical care and basic care services for older adults. This was for one (Resident # 1) of three residents reviewed for discharge planning. The findings included: The hospital discharge summary dated 12/28/23 indicated Resident # 1 had been hospitalized from 12/19/23 to 12/28/23 and treated for RSV (Respiratory Syncytial Virus) bronchitis. Resident # 1 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), hypertension, anxiety, coronary artery disease, and a history of coronary artery bypass surgery. She was discharged on [DATE]. Upon admission, Resident # 1 was listed as her own responsible party in the medical record. Resident # 1's family member was listed as an emergency contact. Resident # 1's 1/4/24 admission Minimum Data Set Assessment coded Resident # 1 with moderate cognitive impairment. She was assessed to need partial to moderate assistance with her bathing and toileting. According to the assessment, her discharge goal was to go home to a community setting. Resident # 1's care plan, dated 1/3/24, did not note specific discharge goals. It did note that the resident contracted COVID on 1/2/24. Staff were directed on the care plan to notify the physician for any worsening of her condition. The facility's Social Worker was interviewed on 1/22/24 at 1:25 PM and reported Resident # 1 was a resident who received PACE services at home, and PACE had managed her care and discharge plan while she was the facility. During an interview with Resident # 1's family member on 1/22/24 at 12:07 PM by phone the family member reported prior to Resident # 1 becoming sick with RSV, being hospitalized , and residing at the facility, she had resided in an apartment by herself. Through the PACE program, someone came to her apartment one- time a week to help with basic care before she got sick. They also provided transportation for her to go to a Senior Center. Review of Resident # 1's facility physician's cumulative orders revealed the resident had an order, initiated on 12/29/23, for her oxygen levels to be checked every shift. The order also directed if her level was below 92% she was to have oxygen at 2 liters. A review of Resident # 1's oxygen levels from the date of 1/1/24 through 1/10/24 revealed they fluctuated in the range of 90 % to 99 %. Resident # 1 also had an order she could have a Ventolin inhaler 2 puffs as needed for wheezing. Review of physician progress notes revealed there was one entry while Resident # 1 resided at the facility. This was on 1/7/24. The physician noted Resident # 1 had COVID without any fever, chills, or body aches. She was stable and doing well. During an interview with the facility's DON (Director of Nursing), the DON reported the following. The physician who saw Resident # 1 on 1/7/24 was not part of the PACE program. The physician was a contracted physician who saw any facility resident with an urgent need on weekends. These physicians had also been asked to see residents with COVID while in the facility on the weekends, and the date of 1/7/24 had corresponded to a weekend when Resident # 1 had COVID. According to the record, Resident # 1 received physical therapy from 12/29/23 to 1/9/24 and occupational therapy from 12/29/23 to 1/10/24. According to therapy records, the resident had progressed from needing moderate assistance with bathing to set up/clean up for the bathing task. The therapist noted Resident # 1's level of function prior to hospitalization was that she could walk distances within her community using a rollator walker and moderate assistance. On 12/29/23, the day after facility admission, she was assessed to be able to walk 150 feet with her rollator walker and with contact guard assistance (the therapist had their hands on the resident but was not providing physical assistance for her to walk). Upon therapy discharge, she was assessed to be walking with her rollator walker. The ambulation distance she had achieved was not attempted due to environmental limitations (isolation for COVID). On 1/11/24 at 1:05 AM the night shift nurse, Nurse # 3, documented Resident # 1's vital signs to be 97.6 temperature, 68 pulse, 18 respirations, and 126/69 blood pressure. Nurse #3 further documented the resident had no shortness of breath and her lung sounds were clear. Nurse # 3 further noted the resident's oxygen was not in use at the time of 1:05 AM. Resident # 1's MAR (medication administration record) noted on 1/11/24 during the night at no specific time that the resident's oxygen saturation was 91%. Nurse # 3 was interviewed on 1/24/24 at 6:40 AM via phone and reported the following. During the night shift, which began on 1/10/24 and extended to 7:00 AM on 1/11/24, Resident # 1 had been fine. Her oxygen saturation did go down to 91 % at one point. She (Resident # 1) was a busy person within the room. She was up and down. Her oxygen saturation would fluctuate. She was placed on her oxygen when it dropped to 91%, and her level came up. She was talking about going home and was having no problems. On 1/11/24 a physician, who worked with the facility Medical Director's office, signed Resident # 1's discharge orders. The facility's Social Worker was interviewed on 1/22/24 at 1:25 PM and again on 1/24/24 at 12:50 PM and 1:16 PM and reported the following. Resident # 1's PACE contract (an agreement between the facility and PACE for Resident # 1 to receive reimbursement services at the facility) ended on 1/11/24 and PACE had determined she should be sent home. PACE had been aware she had COVID during her facility stay. The facility had just recently started taking PACE residents. The only contact number PACE had given the facility was a PACE Case Manager. The PACE Case Manager, who was a social worker, communicated by email with the facility Social Worker. The PACE Case Manager came to see the resident also. The facility was not provided with a number for the PACE physician provider. On the day of discharge, one of the physicians who worked with the Medical Director was in the facility, and she had asked that physician to sign Resident # 1's discharge order, but he did not see her. During the interview with Resident # 1's family member by phone on 1/22/24 at 12:07 PM the family member stated the PACE's social worker (case manager) had been the one who had coordinated her discharge from the facility. According to the family member, she (the family member) had been concerned that Resident # 1 was going home to be by herself on 1/11/24. The family member felt Resident # 1 had been more confused in the days prior to her facility discharge. Review of discharge papers revealed on 1/11/24 the facility Social Worker and the resident signed a discharge health checklist. The form noted Resident # 1 understood her medical condition and the symptoms she should call her physician regarding. Resident # 1 also checked an acknowledgement that she knew her home health company's number and her physician's number. On 1/11/24 at 1:27 PM, Nurse # 4 documented Resident # 1 was placed on oxygen at 2 Liters. On 1/11/24 at 1:44 PM, Nurse # 4 documented Resident # 1 was discharged to home. Transported by driver from PACE program. Resident became SOB [short of breath] when walking with walker to the van. O2 [oxygen] sats [saturation] were at 88 %, resident was given rescue inhaler, and placed on O2 for transport, resident stated she has O2 tank at home. PACE program instructed driver to take resident home. Nurse # 4 was interviewed on 1/22/24 at 1:55 PM and reported the following. Resident # 1 had been fine on 1/11/24 prior to her discharge. PACE had sent a driver to take her home. While Resident # 1 was walking to the van from her room, she became short of breath. Resident # 1 sat down in her rollator walker's seat in the facility's lobby. Nurse # 4 instructed the Van Driver not to put the resident in the van. She went to talk to Nurse Unit Manager # 1, who called the Medical Director's on call Physician's Assistant. While this was being done, the Van Driver put Resident # 1 in the van although instructed not to do so. The PA talked to Nurse Unit Manager # 1 and ordered that Resident # 1 be sent home with oxygen. Resident # 1 kept saying she wanted to go home and that she was okay. The Van Driver said he had called PACE. The resident was given her inhaler and placed on oxygen. Her oxygen level went up after this was done. She was unable to recall what the oxygen level went up to. Resident # 1 was determined to go home. Nurse Unit Manager # 1 was interviewed on 1/23/24 at 12:45 PM and reported the following. The resident had been fine prior to discharge. The only time she had been short of breath was when she started walking to the van. The Van Driver was rushing the staff and telling them he was late. He put Resident # 1 in the van. She seemed to be struggling to breathe and Resident # 1 refused to get out of the van and come back in the facility for an assessment to be done. She was determined to go home. Nurse Unit Manger # 1 called the Medical Director's on call PA because it was an emergency situation, and obtained an order to send her home with oxygen. She told Resident # 1 to let her family know she was having a harder time breathing and that she needed to be checked. The Van Driver, who had been hired by the PACE program to take Resident # 1 home, was interviewed by phone on 1/24/24 at 9:10 AM and reported the following. When he arrived to pick up Resident # 1 she was having a little trouble breathing. The nurses gave her some oxygen and an inhaler. She seemed to breathe better. She didn't do any walking to get to the van. He pushed her on the rollator walker while she sat in the seat. He put her in the van and the nurses were there. He kept a constant conversation going with Resident # 1 as he drove her to her apartment, and she seemed fine. Once she got to the apartment, she did not have her key. The Apartment Manager came to help with that. Once at the apartment, another apartment resident went and got her a wheelchair. Once Resident # 1 was in her apartment, he called PACE and let them know she was inside. The Apartment Manager was interviewed by phone on 1/23/24 at 10:21 AM and reported the following. When Resident # 1 arrived, she was summoned because the resident did not have a key. She walked to the van and found Resident # 1 slouched in the van seat. She asked her if she was okay and the resident responded, no. Resident # 1 was not able to complete sentences, and her chin kept dropping to her chest. The Van Driver practically carried her into the lobby area. Another resident obtained a wheelchair for her. They then got her from the lobby to her apartment. The Apartment Manager called Resident # 1's family member, who came in approximately 20 minutes later and called PACE. PACE sent out an employee who checked Resident # 1 and then called EMS (Emergency Medical Services.) EMS then transported Resident # 1 to the hospital. Review of Resident # 1's EMS records, dated 1/11/24, revealed the following information. EMS was called on 1/11/24 at 4:00 PM and arrived at 4:06 PM. They found Resident # 1 alert and oriented to person, place, time and situation. She was seated upright on her living room couch wearing her home oxygen and was in no obvious respiratory distress. The resident reported to EMS that she had more shortness of breath that day with movement. She had wheezing upon auscultation (listening with a stethoscope). She was transferred to the hospital for evaluation. Review of Resident # 1's hospital records revealed she was found in the ED (Emergency Department) on 1/11/24 to have progressive dyspnea (shortness of breath) and elevated lactic acid levels. She was admitted for further care. On 1/22/24 she was discharged from the hospital with her primary discharge diagnosis listed as lactic acidosis. (a build- up of lactic acid in the bloodstream which at times is caused by low oxygen levels). On 1/23/24 at 3:41 PM the Director of the local PACE program was interviewed by phone and reported the following. At discharge, it had been set up for Resident # 1 to have a home health aide check on Resident # 1 on the afternoon of 1/11/24 at no specific time. A nurse and therapist were to check on her the day following discharge from the facility. PACE had not been alerted that Resident # 1's oxygen saturation had lowered to 88 % right at discharge. If they had been told this, then they would have told the facility to keep her or have her sent to the hospital. They were not aware of any problems on 1/11/24 until Resident # 1's family member called them after she was already in her apartment. There was a main office that the facility should have called. On 1/24/24 at 10:20 AM Nurse # 4 was interviewed again and reported the nurses did not have a number to call the PACE physician. The Social Worker had only provided them with the PACE Case Manager's number. On 1/24/24 at 10:25 AM, Nurse Unit Manager # 1 was interviewed and reported she called the Medical Director's PA on 1/11/24 because it was an emergency, and they did not have the number for a physician at PACE to update their physician provider and request further instructions regarding what to do about Resident #1's discharge. On 1/24/24 at 10:00 AM PA # 1 was interviewed and reported PACE was a new program for the facility. The PA further reported the facility's Physician Assistants worked for the Medical Director. She had not been the PA who had been contacted on 1/11/24 but given that Resident # 1 had a diagnosis of chronic obstructive pulmonary disease, it would not be indicated to keep her oxygen level too high. (Residents with COPD can have a build -up of carbon dioxide from too much oxygen because of their impaired respiratory system, and therefore they tend to have a lower oxygen level than someone without COPD.) Theoretically, the staff were to call and talk to the PACE physician about PACE residents. The PACE physicians were the ones to make decisions about their care and be updated. The PAs in the facility's Medical Director's office covered for the facility when there was an emergency. Attempts were made to contact the PACE Case Manager on 1/22/24 at 1:27 PM and 1/23/24 at 1:30 PM. A voice mail was left asking for a return call, and none was received. During the interview with the PACE Director On 1/23/24 at 3:41 PM the Director reported the PACE Case Manager was on vacation. On 1/22/24 at 1:57 PM the Director of Nursing (DON) reported the staff had not reported a problem to her about Resident # 1's discharge. She had just begun as the DON on 1/11/24 (the day Resident # 1 was discharged .) On 1/24/24 at 11:50 AM, the DON reported she could not find any indication in the record that Resident # 1's PACE physician had been consulted on 1/11/24 regarding the discharge for that date. On 1/24/24 at 3:19 PM an interview with the Administrator, who also began on 1/11/24 (the date of Resident # 1's discharge), revealed the PACE program was also new to him and he had not been part of the set up with the program.