Every finding on record at West Haven Center for Nursing & Rehabilitation

Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse or neglect, the facility failed to ensure the State Agency was notified within two (2) hours after the resident reported the allegation of physical abuse and bullying to a staff member. The findings include: Resident #1's diagnoses included diabetes mellitus and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was alert and oriented and was independent for eating, transfer and mobility using a walker. The resident care plan dated 5/14/26 identified Resident #1 was at risk for mood alteration and coping ability due to little interest in doing things, was restless and had a tendency to fabricate incidents and have accusatory behaviors related to anxiety. Interventions included to provide opportunities to express self, provide emotional support, social services and psychiatric services as needed. A facility grievance form dated 7/26/26 written by Resident #1 identified on 7/26/26, Resident #1 went to the kitchen to ask for a new sandwich and a kitchen staff member closed the door on him/her while Resident #1 was talking to [NAME] #1 and the door hit Resident #1's shoulder. The grievance form indicated the kitchen staff member then was laughing in Resident #1's face like a bully gesture as the kitchen staff member let the door go. Resident #1 wrote they bully people and think its funny. Resident #1 called the police. The Facility Reported Incident form identified thatan event of staff to resident abuse without injury was first known on 7/26/26 at 7:00 PM was submitted in the state agency portal on 7/31/26, five (5) days after the incident occurred. The event description identified on 7/26/26 at 6:00 PM Resident #1 reported after requesting a meal substitution and receiving the meal, Resident #1 backed out of the kitchen doorway when the kitchen door was released making contact with Resident #1's shoulder. Resident #1 left the area and reported shoulder pain that was evaluated by the nursing supervisor, no injuries were identified and the provider and local police department were notified. Interview on 8/17/26 at 11:10 AM with the nursing supervisor, Registered Nurse (RN) #1, identified Resident #1 came to him on 7/26/26 at approximately 6:00 PM holding the right shoulder complaining of pain. Resident #1 reported Dietary Aid #1 was laughing at him/her when Resident #1 went to the kitchen door to ask for a replacement meal, was handed the replacement, and as Resident #1 was backing up to leave Dietary Aid #1 purposely shut the kitchen door on Resident #1, this resulted in the door hitting Resident #1's right shoulder as it closed. RN #1 identified the kitchen door was heavy and lacked a closer that would assist a slow closure of the door. RN #1 indicated he notified the Administrator of the allegation who directed him to get statements from the staff, he completed the interviews of Resident #1 and the kitchen staff and left the information for the Administrator for her review the next day. A review of the facility investigation documents and interview with the Administrator on 8/17/2026 at 1:00 PM identified on 7/26/2026 at approximately 7:00 PM, she received a call from RN #1 to inform her that Resident #1 had reported being hit by a kitchen door resulting in right shoulder pain and she discussed the need for statements and to contact the on-call provider to complete an evaluation. The Administrator could not recall if RN #1 had notified her that Resident #1 had alleged that the kitchen staff had laughed at Resident #1, that the kitchen door was intentionally closed to hit Resident #1 or that Resident #1 reported it to be abusive. The Administrator identified although Resident #1's 7/26/26 statement had alleged physical abuse by the kitchen staff, she did not report it as per the facility Abuse policy as she wanted to interview Resident #1 herself. The Administrator identified she completed the summary of the incident and submitted both the initial notification and summary report to the state agency at the same time on 7/31/26, five (5) days after the 7/26/26 incident. The facility policy Resident Abuse, Neglect, Exploitation, Misappropriation and Retaliation dated 1/1/25 directed un part that physical abuse was defined as an intentional infliction of physical pain or bodily harm. Allegations of abuse are to be reported to the state department of public health within two (2) hours of the initial allegation.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for facility discharges, the facility improperly discharged the resident by discharging him/her one (1) day prior to the thirty (30) day date and six (6) days prior to an involuntary discharge appeal's hearing. The findings include:Resident #1's diagnoses included depression, pain, hypertension (high blood pressure) and type II diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident had no memory recall deficits and was independent with eating, personal hygiene, bed mobility, transfers and ambulating. The Notice of Intent to Discharge form dated 8/27/25 identified Resident #1 was served a thirty (30) day involuntary discharge notice stating the facility intended to discharge Resident #1 on 9/26/25 due to Resident #1 no longer requiring the services of the facility due to improved health and Resident #1's nonpayment and the facility was planning on discharging Resident #1 to a hotel. The form identified Resident #1 had the right to appeal the discharge by requesting a hearing within twenty (20) days. The Notice of Administrative Hearing form dated 9/17/25 and addressed to Resident #1, identified an administrative hearing was requested for the involuntary discharge and the hearing was scheduled for 10/1/25 at 10:00 AM. The social service note dated 9/22/25 at 10:46 AM identified the Administrator met with Resident #1 to discuss discharge planning and Resident #1 expressed the hotel accommodation as presented on the thirty (30) day discharge notice was not his/her first choice, and discharge to a Residential Care Home (RCH) was a suitable option. The note indicated the RCH was enthusiastic about accepting Resident #1 and the required information was faxed to the RCH and Resident #1 was accepted. The social service note dated 9/23/25 at 1:33 PM identified the Administrator spoke with Resident #1 regarding discharge location and Resident #1 had accepted the RCH bed. The note identified the Administrator contacted the RCH to confirm placement details and discharge was scheduled for 9/25/25 at 12:00 PM (one (1) day prior to the Intent to Discharge thirty (30) day notice of 9/26/25 and six (6) days prior to the hearing date). The note identified transportation was scheduled and the Social Worker (SW) #1 would accompany Resident #1 to the RCH to support the discharge process and ensure a smooth transition. The social service note dated 9/25/25 at 3:00 PM identified SW #1 was present to support Resident #1 at the RCH and upon arrival Resident #1 was asked to present social security documentation as well as paying first and last month's rent. The note identified Resident #1 was unable to pay the full amount so Resident #1 chose to instead discharge to the original hotel location. The note indicated SW #1 verified with Resident #1 that he/she had all of their belongings, documentation, identification and medications and Resident #1 agreed with the plan. The social service note dated 9/25/25 at 3:50 PM identified the Administrator was contacted by SW #1 who reported although Resident #1's social security income was shared with the RCH upon acceptance of the bed, Resident #1 was unable to afford the presented cost and elected to discharge to the previously identified hotel. The note indicated the Administrator met Resident #1 at the hotel, assisted with the check-in process and ensured Resident #1 had all essential items and resources. Review of the clinical record and facility documentation identified the appeal's hearing date had been rescheduled to 10/6/25. The Administrative Hearing documentation dated 10/10/25 identified the hearing was held by telephone on 10/6/25 to address the facility's discharge of Resident #1 to a motel. The document identified on 9/25/25, the twenty-ninth (29th) day after the notice of discharge was served, the facility social worker (SW #1) brought Resident #1 to an RCH and then to a motel later the same day. The Notice of Decision identified on 10/10/25 the Fair Hearing Officer found the facility improperly discharged Resident #1 while his/her appeal was pending and before the thirty (30) days and the discharge was ordered rescinded. Review of the clinical record identified that Resident #1 was readmitted from the hotel to the facility on [DATE]. Interview with Resident #1 on 11/25/25 at 10:49 AM identified he/she arrived at the RCH on 9/25/25 and due to issues regarding payment and sharing a room, he/she stated he/she did not want to reside at the RCH. Resident #1 identified he/she was not given the choice to go back to the facility and reported both SW #1 and the Administrator stated that he/she was already discharged and if he/she did not want to stay at the RCH then he/she would need to go to the hotel that had been previously discussed. Interview with SW #1 on 11/25/25 at 1:38 PM identified she had been newly employed by the facility two (2) weeks prior to Resident #1's discharge and when she started there was no social worker so the Administrator had been handling everything and was the one to complete Resident #1's discharge planning. SW #1 stated that she was not involved until the day of the discharge on [DATE]. SW #1 identified Resident #1 should not have been discharged from the facility prior to the appeal's hearing that was scheduled for 10/6/25 and had she known the details of Resident #1's discharge notice and hearing. Interview with the Administrator on 11/25/25 at 2:03 PM identified leading up to Resident #1's involuntary discharge, she had no social worker, so she was acting as both the Administrator and the social worker. The Administrator identified because Resident #1 agreed to the RCH placement, she thought Resident #1 could voluntarily leave the facility prior to the appeal's hearing scheduled for 10/1/25 and was unaware Resident #1 was to remain in the facility until the hearing date unless the facility was unable to meet Resident #1's needs or Resident #1 was a danger to him/herself or others and reported Resident #1 did not fit those exceptions. The Administrator indicated she did not direct SW #1 to not allow Resident #1 to return to the facility after the failed RCH admission 9/25/25. Title 42 of the Code of Federal Regulations (C.F .R.) S 483.15(c)(1 )(ii) provides the facility may not transfer or discharge the resident while the appeal is pending, pursuant to S 431.230 of this chapter when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to S 431.220(a)(3) of this chapter unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. Review of the Transfer/Discharge policy dated 01/19/18 directed, in part, that the notice of transfer or discharge will be made by the facility at least 30 days before the resident is transferred or discharged . The exception to the 30-day notice is if: The safety or health of the individuals in the facility would be endangered; The resident's health improves sufficiently to allow a more immediate transfer or discharge; An immediate transfer or discharge is required by the resident's urgent medical needs; The resident has not resided in the facility for 30 days. If the information in the notice changes prior to affecting the transfer or discharge, the facility will update the recipients of the notice as soon as practicable once the update information becomes available. The facility will provide and document sufficient preparation and orientation to the resident(s) to ensure safe and orderly transfer or discharge.

Based on clinical records, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for medication administration, the licensed nursing staff failed to ensure the resident consumed oral medications and applied a topical patch prior to exiting the room and the medications were not left at the bedside. The findings include:Resident #1's diagnoses included pain, type II diabetes mellitus and dysphagia (difficulty swallowing). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident had no memory recall deficits and was independent with eating. A physician's order dated 10/14/25 directed to administer lidocaine 5 percent (%) adhesive patch topically (to the surface of the skin) to the lower back daily at 6:00 AM. The Self-Administration of Medication assessment dated [DATE] identified it was not appropriate for Resident #1 to self-administer any medications and Resident #1 did not want to self-administer medications. The Resident Care Plan dated 10/15/25 identified that Resident #1 is at risk for pain related to their physical condition. Interventions directed to monitor for pain and administer medications as applicable. Observations and interview with Resident #1 on 11/25/25 at 10:49 AM identified an unopened lidocaine patch labeled 11/25/25 11-7 on Resident #1's over-the-bed table. Resident #1 explained that the 11PM-7AM nurse placed the lidocaine patch and all of his/her oral medications in a cup on the over-the-bed table and the nurse left the room without ensuring that he/she took the medications. Resident #1 identified the 11PM-7AM nurse always leaves the lidocaine patch for him/her to apply. Resident #1 identified he/she takes the oral medications with breakfast and applies the lidocaine patch herself when he/she was ready, and he/she just has not gotten to it yet. Review of the active physician's orders on 11/25/25 failed to reflect a physician's order directing Resident #1 may self-administer the lidocaine patch or any other medications. Observations on 11/25/25 at 1:16 PM identified the unopened lidocaine patch labeled 11/25/25 11-7 was still present on Resident #1's over-the-bed table. Observations of Resident #1's room and interview with the Regional Nurse, Licensed Practical Nurse (LPN) #2, on 11/25/25 at 1:28 PM identified an unopened packaging of a lidocaine patch labeled 11/17 11-7 present on Resident #1's over-the-bed table. LPN #2 identified Resident #1 was not to self-administer any medications, including the lidocaine patch and should not have been left at the bedside for Resident #1 to apply. LPN #2 explained to Resident #1 that he needed to dispose of the lidocaine patch and when Resident #1 was ready for the patch, Resident #1 could request a new one from the nurse on duty, to which Resident #1 agreed, and the lidocaine patch was removed from the room and disposed of. Review of the facility schedule identified Licensed Practical Nurse (LPN) #1 was assigned to Resident #1 on the 11PM-7:00 AM shift on 11/17/25 and 11/25/25. Interview with Resident #1 on 11/25/25 at 1:35 PM identified he/she was unsure of what happened to the lidocaine patch that was on his/her over-the-bed table this morning and he/she was about to put the patch on but it was not there. Resident #1 stated he/she had an extra patch in his/her drawer (dated 11/17/25) that he/she did not apply so he/she placed it on the over-the-bed table in preparation of applying the patch. Although attempted, an interview with LPN #1 was not obtained. Review of the Medication Administration and Documentation policy (undated) directed, in part, that all medications must be administered by the same person who prepared the dose for administration and assures that medications are not left unattended and that they're kept secured in a locked area or in visible control at all times.

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure the DNS did not serve as the nursing supervisor. The findings include:Review of the Daily Staffing Breakdown dated 2/10/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Night Shift RN Supervisor, from 11:00 PM through 7:00 AM.Review of the Daily Staffing Breakdown dated 2/15/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Day Shift RN Supervisor, from 7:00 AM through 3:00 PM.Review of the Daily Staffing Breakdown dated 2/27/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Evening Shift RN Supervisor, from 3:00 PM through 11:00 PM.Interview with the DNS on 6/4/25 at 11:00 AM identified that the facility had an average daily census that was greater than 60 residents, and she had served as the RN Supervisor on 2/10/25, 2/15/25, and 2/27/25 subsequent to staff callouts. The DNS indicated that she could not recall how many additional shifts or hours she had put in as an RN Supervisor, since becoming the DNS. The DNS further indicated that she had picked up the additional hours and served as the RN Supervisor in an effort to meet the needs of the residents, following staff call-outs. The DNS identified that in the last month, the facility had hired an evening shift supervisor, a night shift supervisor, and a few per diem nurses that will pick up supervisor shifts, and finding supervisor coverage had improved following the new hires.During an interview with the Chief Clinical Officer (CCO), the Administrator, the DNS, and the survey team on 6/4/25 at 10:30 AM, the CCO identified that she was aware that there had been staffing shortages and the facility was actively recruiting and hiring nursing staff, including RN Supervisors. The facility's Staffing Guidelines policy directs the DNS will determine numbers and assignments of staff. The staffing coordinator will be responsible each month to complete a 28-day schedule and ensure that there is adequate staffing scheduled to meet the needs of each unit/floor. The DNS and staffing coordinator will assess and ensure coordination and maintain adequate staffing. The number of staff will be determined based on resident care, acuity, facility assessment, and services needed. This would include the type of staff members and healthcare professionals required to provide those services. Based on this assessment, adequate qualified staff will be maintained and recruited/hired as needed to maintain sufficient staffing.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Residents #43, 47, 61 and 65) the facility failed to notify the physician and/or resident representative when required. For 1 of 2 residents, (Resident #43) reviewed for death, the facility failed to ensure the physician was notified when medications were not administered according to the physician's orders, when blood sugar and blood pressures were not obtained as ordered, and when blood sugars were noted to be outside the parameter. For 1 of 3 residents (Resident #47) reviewed for accidents the facility failed to notify the physician of a fracture after a fall and a lung nodule.For 1 resident (Resident #61) reviewed for pain, the facility failed to notify the physician with the onset of new pain. For 1 of 5 residents (Resident #65) reviewed for infection control the facility failed to notify the resident representative following a change in condition. The findings include:1a. The hospital Discharge summary dated [DATE] identified Resident #43 was admitted to the hospital on [DATE] with diagnoses of acute heart failure with reduced ejection fraction (HFrEF) with hypertensive emergency due to medication nonadherence. Newly reduced Left Ventricular Ejection Fraction (LVEF) of 32%, hypertension emergency due to medication noncompliance. Comorbidities present on admission were diabetes type 2, hypertension, gout, gunshot wound to abdomen, chronic back pain, status post splenectomy, and Covid-19. Secondary diagnoses occurred during hospitalization included acute kidney injury, and diabetes with hyperglycemia. Resident #43 was discharged from the hospital on 2/26/25. Resident #43 was admitted to the facility on [DATE] with diagnoses that included chest pain, chronic congestive heart failure, hypertension, and diabetes.The care plan dated 2/27/25 identified Resident #43 was at risk for abnormal glucose levels, hypo/hyperglycemia secondary to diabetes. Interventions included to administer diabetic medications and/or Insulin as ordered.The admission MDS dated [DATE] identified Resident #43 had intact cognition and was independent with personal hygiene.The consultant cardiologist recommendations dated 4/30/25 included to start on SGLT2 inhibitor (medication used to treat type 2 diabetes) either Jardiance or Farxiga 10mg daily.The consultant visit summary dated 4/30/25 identified the heart failure with reduced ejection fraction was addressed. The form indicated to pick up Jardiance at an outside Pharmacy.The physician's order dated 5/1/25 directed to administer Jardiance 10 mg tablet (used to manage type 2 diabetes, heart failure, and chronic kidney disease (CKD) once a day at 8:30 AM. Review of the pharmacy documentation dated 5/1/25 at 8:47 AM identified medication not covered (Jardiance 10mg tablet once daily). An outside pharmacy filled and dispensed the medication. Resident #43 called the outside pharmacy yesterday (4/30/25) and requested all medications be filled and delivered to his/her significant other at his/her prior address.The nurse's note dated 5/1/25 at 12:38 AM identified Resident #43 was seen by the cardiologist on 4/30/25 related to recent heart failure and ejection fraction diagnoses. Recommendations to start either Jardiance or Farxiga 10mg daily. The care plan dated 5/1/25 identified Resident #43 had a recent diagnoses of chronic systolic heart failure (4/30/35) and was at risk for or complication due to disease process. Interventions included monitoring cardiorespiratory symptoms, increasing fatigue, and to administer medications as ordered. Further, the care plan dated 5/1/25 identified Resident #43 was at risk for alteration in cardiac output related to recent diagnosis of chronic systolic heart failure on 4/30/25. Interventions included to administer medications as ordered. The nurse's note dated 5/2/25 at 12:21 AM by RN #9 identified she spoke with the facility pharmacy regarding Resident #43 calling and telling the outside pharmacy that the medication would be picked up by his/her significant other. RN #9 indicated she would educate Resident #43 to not have anyone pick up medication while residing in the facility. The note failed to reflect that the physician, APRN, cardiologist, or the DNS were notified.Review of the APRN notes dated 5/8/25 and 5/13/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. The physician's order dated 5/29/25 directed to check blood pressure and pulse once a day at 9:30 AM. Review of the MAR dated 5/1/25 - 6/3/25 identified although the Jardiance 10mg was scheduled to be administered daily at 8:30 AM, the medication was not administered. The MAR identified the drug was unavailable and awaiting delivery from the pharmacy from 5/1/25 - 6/3/25, a total of 34 days.Review of the APRN note dated 6/3/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, APRN, cardiologist, or the DNS were notified that Resident #43 was not receiving the Jardiance per the physician's order from 5/1/25 - 6/3/25 (total of 34 days). Interview with APRN #3 on 6/6/25 at 2:53 PM identified she was not aware that Resident #43 was not receiving the Jardiance as ordered from 5/1/25 - 6/3/25, and that the pharmacy had not sent the medication to the facility. APRN #3 indicated the Jardiance was prescribed by a specialist (cardiologist). APRN #3 indicated when Resident #43 was first admitted to the facility, the facility was having issues with the medications being sent to his/her personal pharmacy. APRN #3 indicated if she had known the resident was not receiving the Jardiance due to a pharmacy issue, she would have had a discussion with the DNS and called the pharmacy.Interview with the DNS on 6/6/25 at 3:02 PM identified she was not aware that Resident #43 was not receiving the Jardiance from 5/1/25 - 6/3/25 (34 days), or that the Jardiance was never delivered to the facility. The DNS indicated had she known, she would have called the pharmacy and had the pharmacy bill the facility for the Jardiance. The DNS indicated that she would expect the licensed nurses to administer medication per the physician's order. Interview with MD #5 (cardiologist) on 6/10/25 at 10:27 AM identified he last saw Resident #43 on 4/30/25 at his office. MD #5 indicated Resident #43 had been admitted to the hospital in February 2025, with systolic heart failure, and heart failure with reduced ejection fraction (32%) with hypertensive emergency which caused pulmonary edema, and other comorbidities. MD #5 indicated on 4/30/35 he ordered Resident #43 to receive Jardiance 10mg once a day. MD #5 indicated he was not aware that Resident #43 never received the medication. MD #5 indicated his expectation is that the nurses should have administered the medication per the physician's order. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not aware that Jardiance 10mg was recommended to be given daily. MD #1 indicated he did not receive a phone call from the facility on 4/30/25 or 5/1/25 informing him that the cardiologist recommended Jardiance to be administered daily. MD #1 indicated he did not order Jardiance to be administered, and he was not aware that Resident #43 did not receive the Jardiance from 5/1/25 - 6/3/25 (total of 34 days). MD #1 indicated the nurse should administer medication per the physician's order. Review of the facility medication unavailable policy identified in the event that medication is unavailable for any reason the facility shall act promptly to notify appropriate practitioners for orders to be followed and the pharmacy to obtain medications in accordance with the updated orders. The facility shall investigate all instances where medications are not available, to assess whether appropriate actions were taken to ensure continuity of care. Upon identifying that a medication is apparently unavailable, immediately notify the nursing supervisor. Contact the pharmacy to determine when medication will be available. Inform the prescriber/attending; and in their absence, the Medical Director and obtain orders. Document actions and prescriber orders on 24 hour report, MD order sheet, and chart.b. The physician's order dated 5/1/25 - 5/31/25 directed to administer the following medications: Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Gabapentin 300mg capsule (for pain) at bedtime at 8:30 PM.Lantus Insulin U-100 unit/ml (diabetes) give 25 units subcutaneous at bedtime at 8:30 PM. Lipitor 80mg tablet (for hyperlipidemia) once a day at 8:30 PM. Miralax 17grams (for constipation) twice a day at 8:30 AM and 8:30 PM.Ozempic 4mg/3ml, 1mg/dose subcutaneous (for diabetes) on Mondays at 8:30 AM.Senna 8.6mg tablet (for constipation) twice a day at 8:30 AM, and 8:30 PM. Review of the May 2025 MAR identified the following. Coreg 25mg was not administered on 5/1/25 at 4:30 PM, 5/2/25 at 8:30 AM, 5/5/25 at 8:30 AM, 5/6/25 at 8:30 AM, 5/19/25 at 8:30 AM, and 5/28/25 at 8:30 AM. Gabapentin 300mg was not administered on 5/20/25 at 8:30 PM.Lantus Insulin U-100 unit/ml was not administered on 5/20/25 at 8:30 PM.Lipitor 80mg was not administered on 5/20/25 at 8:30 PM.Miralax 17grams was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 PM.Ozempic 4mg/3ml give 1mg/dose was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 AM.Senna 8.6mg was not administered on 5/20/25 at 8:30 PM. c. The physician's order dated 6/1/25 - 6/3/25 directed the following. Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Daily Blood Pressure and Pulse once a day at 9:30 AM.Daily Weights before breakfast (for chronic systolic congestive heart failure) once a day at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous (for diabetes) once a day on Mondays at 8:30 AM.Review of the June 2025 MAR dated identified the following. Coreg 25mg was not administered on 6/2/25 at 8:30 AM, and 4:30 PM.Daily Blood Pressure and Pulse was not recorded on 6/2/25 at 9:30 AM. Daily Weights were not obtained on 6/2/25 at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous was not administered on 6/2/25 at 8:30 AM.Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, or the APRN, were notified that Resident #43 did not receive medications on 5/1/25, 5/2/25, 5/5/25, 5/6/25, 5/19/25, 5/20/25, 5/28/25, and 6/2/25. d. The physician's orders dated 5/1/25 - 6/3/25 directed the following. Check Blood Sugar before meals (for diabetes) at 7:30 AM, 11:30 AM, and 4:30 PM. Special Instructions: If Blood Sugar is less than 80mg/dl and greater than 450mg/dl call MD/APRN. Review of the May 2025 and June 2025 MAR identified the following.The blood sugar on 5/6/25 at 11:30 AM was 76mg/dl.The blood sugar on 5/14/25 at 7:30 AM was 73mg/dl.The blood sugar on 5/15/25 at 7:30 AM was 71mg/dl.The blood sugar on 6/2/25 at 7:30 AM was 54mg/dl. Review of the nurse's note dated 5/1/25 - 6/4/25 failed to reflect documentation that the physician was notified when the residents blood sugar was low 5/6/26, 5/14/25, 5/15/25, and 6/2/25. e. The care plan dated 5/1/25 identified Resident #43 has a history of hypertension. Interventions included to monitor blood pressure every shift. The physician's order dated 5/1/25 - 5/28/25 directed to monitor blood pressure every shift, Days, Evening, and Nights.Review of the vital sign form identified the following missing blood pressures.5/1/25 evening and night, 5/2/25 day and night, 5/3/25 evening and night, 5/4/25 evening and night, 5/5/25 day and night, 5/6/25 day and night, 5/7/25 and 5/8/25 nights, 5/9/25 evening and night, 5/10 /25 - 5/13/25 nights, 5/14/25 evening and night, 5/15/25 night, 5/16/25 evening and night, 5/17/25 evening and night, 5/18/25 night, 5/19/25 day and night, 5/20/25 night, 5/21/25 - 5/27/25 nights, 5/28/25 day, evening, and night.The nurse's note dated 5/1/25 - 5/28/25 failed to reflect documentation that the physician was notified that blood pressure was not monitored as ordered. Interview with RN #1 on 6/9/25 at 12:26 PM identified she was not aware Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. RN #1 indicated it is the responsibility of the licensed nurses to administer the medication per the physician's order. RN #1 indicated the licensed nurses should have notified the physician or the APRN when the medications were not given and document the omissions in the resident clinical record. Interview with the DNS on 6/10/25 at 10:11 AM identified she was not aware that Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. The DNS indicated the licensed nurses should have notified the physician, or the APRN when Resident #43 did not receive his/her medications, when the blood sugars were low, and when blood pressure was not monitored as ordered. The DNS indicated that she would expect the licensed nurses to administer the medication per the physician's order. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not notified that Resident #43 was not receiving some of the medications between 5/1/25 - 6/3/25 on multiple occasions and when blood pressure was not monitored as ordered. Further, MD #1 indicated the licensed nurses should have notified him or the APRN when Resident #43's blood sugar was low on multiple occasions, and blood pressure was not monitored as ordered. MD #1 indicated the license nurse should administer the medication per the physician's order.Review of the facility change of condition policy identified the facility is to ensure that changes in resident's conditions are reported to providers and families. The facility must immediately inform the resident, consult with the resident's physician, APRN, and notify the resident's legal representative when there is a need to alter treatment significantly. Documentation will be noted in the resident's medical record and on the 24 hour report to ensure shift to shift communication and continuity of care.Review of the facility compliance with and implementation of physician's orders policy identified all physician orders are implemented accurately, timely, and in accordance with applicable federal and state regulations. Review of the facility taking a blood pressure policy identified to measure the force at which the heart pumps and returns blood. Notify the provider of the results and correctly document the results in the resident's record in the electronic record. 2. Resident #47 was readmitted to the facility on [DATE] with diagnoses that included ventricular tachycardia, atrial fibrillation, bradycardia, frontal temporal neurocognitive disorder, osteoarthritis right knee, spinal stenosis, and muscle weakness. The February 2025 monthly physician's orders directed Resident #47 to be provided supervision with stand pivot transfers, sand by assistance for gait using a 4 wheeled walker and independent with the wheelchair use in the facility. The quarterly MDS dated [DATE] identified Resident #47 had intact cognition and required maximum assistance with toileting, bathing, and personal hygiene. Additionally, Resident #47 required moderate assistance with toilet transfers, and from the bed to the chair and chair to the bed. Resident #47 required supervision or touching assistance for sitting to stand and ambulation walking 10 feet. The care plan dated 2/6/25 identified has had falls. Interventions included educating and to remind Resident #47 to use the call bell for assistance. a. A reportable event form dated 2/9/25 at 5:00 PM identified Resident #47 had an unwitnessed fall and sustained a skin tear to the right elbow. Resident #47 indicated he/she fell in the bathroom. Resident #47 was unable to stand up. Resident #47 was transferred to the emergency room. The nurses note dated 2/9/25 at 5:00 PM identified Resident #47 was alert and responsive with complaints of pain. This writer didn't witness the fall as it was reported by staff, but this writer observed Resident #47 in the room on the floor unable to get up with assistance. Resident #47 has a skin tear noted on the right elbow. Resident sent to emergency room for further observation. On call APRN and resident representative were made aware. The hospital Discharge summary dated [DATE] identified Resident #47 was diagnosed with Influenza and recurrent falls. Resident #47 had 2 unwitnessed falls at nursing facility over the last 2 days. X-ray of the pelvis identified minimally displaced fracture of the right inferior ramus and right sacral area. The nurses note dated 2/15/25 at 4:02 PM identified Resident #47 arrived back from the hospital and is alert and verbal. Resident #47 denies any pain or discomfort. Resident #47 has a cough and cough medication was given. Review of the nursing notes and physician notes dated 2/15/25 to 3/10/25 failed to reflect the physician or the APRN had been notified of the fracture identified after the fall on 2/9/25. Interview with the DNS on 6/4/25 at 7:09 AM indicated the intervention for the fall on 2/8/25 was to have a physical therapy screen and the intervention for the 2/9/25 fall was to remind Resident #47 to call for assistance and use call bell. The DNS indicated she did not see the Discharge summary dated [DATE] and did not see the x-ray results that identified a minimally displaced fracture of the right inferior ramus and right sacral area. The DNS indicated the supervisor was responsible to read the discharge summary when Resident #47 returned to the facility, but she has had a lot of different supervisors lately and has let them go because they were not doing what they should have. The DNS indicated she was responsible to read the discharge summary the next day, and she tries but does not always have time. The DNS indicated that if the supervisor had notified her when Resident #47 returned to the facility she would have notified the physician and the state agency of the fractures. b. A reportable event form dated 3/14/25 at 7:55 AM identified Resident #47 had an unwitnessed fall and sustained a bruised left brow and skin tear to the left lateral arm. Resident #47 was transferred to hospital for evaluation. The hospital Discharge summary dated [DATE] identified Resident #47 had an unwitnessed fall at nursing facility and has a laceration to the left eyebrow and left elbow. CT Scan of the cervical spine noted no fracture but noted a 6 mm pulmonary nodule at the left apex. If the patient was a smoker or at high risk for malignancy, follow up unenhanced chest CT scan in 12 months for further surveillance. The nurses note dated 3/14/25 at 1:10 PM identified Resident #47 returned to the facility alert and responsive via stretcher, noted with hematoma to left eyebrow with 9 sutures and bruising to the left eye and an abrasion to left elbow which resident sustained during unwitnessed fall. Resident #47 denied any pain or discomfort at this time. Review of the nursing notes and physician notes dated 3/14/25 to 3/20/25 failed to refelct the physician or the APRN were notified of the lung nodule noted at the hospital on 3/14/25. Interview with the DNS on 6/4/25 at 7:42 AM indicated after review of the hospital discharge summary, she was not aware of the 6mm nodule on the left lung. The DNS indicated she had not seen the Discharge summary dated [DATE]. Additionally, the DNS indicated she had reviewed the physician and nurses notes and they did not identify the physician was notified of the nodule in the left lung. Interview with RN #1 on 6/4/25 at 7:43 AM indicated she does not recall seeing in the discharge summary from 3/15/25 that identified Resident #47 had returned with a fracture to the pelvis and she indicated she left the discharge summary in the APRN folder. RN #1 indicated she had reviewed the discharge summary when Resident #47 had returned on 3/14/25 but did not notice the results of the test showing the nodule in the left lung. RN #1 indicated she did not notify the APRN or physician of the fracture of lung nodule when Resident #47 returned from the hospital, but she did inform the APRN of the 9 sutures in the forehead and when they would have to be removed. Interview with APRN #2 on 6/4/25 at 8:49 AM indicated the nursing staff should have notified her or the physician of the new fractures and lung nodule right away and if she had been notified she would have done a clinical assessment and treated Resident #47 for pain if needed and maybe sent the resident to a pulmonologist. The interview with the MD #4 (prior medical director) on 6/4/25 at 11:20 AM indicated that when a resident returns from the hospital the supervisor is responsible to inform her of what the hospital's findings are and then leave the discharge summary for her to review. MD #4 indicated she does not recall receiving the discharge summary. MD #4 indicated she was not informed of Resident #47 having a fracture after the fall. MD #4 indicated she recalls being informed of the Influenza but not a fracture. MD #4 indicated that if she was notified, she would have first done a physical assessment then she would have ordered medication for pain management and physical therapy because there was not a surgical option. MD #4 indicated that she was not informed of the lung nodule and indicated with a new nodule she would have done a physical assessment and would have spoken to Resident #47 and the resident's representative to see what they would or would not want done. MD #4 indicated that she would have ordered an x-ray in 6 months to see if it was the same size or bigger and maybe sent him/her to a pulmonology. Although attempted multiple times, an interview with APRN #1 was not obtained. Review of the Change of Condition Policy identified the facility was to ensure that changes in residents' condition are reported to the providers and families. This is to ensure every resident's change in condition is assessed and documented properly. The facility must immediately inform the residents, consult with the residents' physician, and if known notify the residents legal representative or an interested family member when there is an accident involving the resident which resulted in an injury, a significant change in the resident's physical, mental, or psychosocial status including a new onset of pain or increased pain. The LPN is to collect data and administer provider ordered treatments or medications. The RN will assess and determine if a change of condition has occurred. The RN will make the APRN or MD aware of a resident's current condition by in person or telephone call. 3. Resident 61 was admitted to the facility in August 2024 with diagnoses that included diabetes, stroke, osteoarthritis of the left shoulder. The monthly physician's orders dated 2/1/25 to 2/28/25 directed to apply lidocaine patch to the left shoulder in the morning and remove at bedtime for chronic pain. Additionally, Voltaren arthritic pain gel apply 2 grams topically to the right foot as needed every 6 hours. Tramadol 50 mg every 8 hours as needed for chronic pain. Review of the nursing and physician notes from 2/1/25 to 3/18/25 failed to reflect right shoulder pain. The quarterly MDS dated [DATE] identified Resident #61 had moderately impaired cognition and required set up or clean up assistance with toileting, dressing, and personal hygiene. Additionally, Resident #61 had occasional pain in the last 5 days and received pain medication as needed. The care plan dated 2/21/25 identified Resident #61 had a right foot wound. Interventions included monitoring signs and symptoms of infection. The nurse's note dated 3/19/25 at 2:51 PM identified Resident #61 complained of pain in his/her right shoulder and was given pain medication. The nurses note dated 3/20/25 at 2:33 PM indicated Resident #61 complains of limiting pain located in the right shoulder, in the acromion region, compared with the left shoulder, swelling is detected in that region. The nurses note dated 3/21/25 at 2:46 PM indicated Resident #61 has complaints of pain in his/her right shoulder and right foot. Resident #61 was given the as needed pain medication. The interview with Resident #61 on 6/1/25 at 8:30 AM indicated that he/she has pain in his/her bilateral shoulders and his/her right foot. Resident #61 indicated that he/she does receive pain medications as needed. Interview with RN #1 on 6/4/25 at 7:50 AM identified after clinical record review, there were notes for Resident #61 identifying a new onset of pain to the right shoulder for 3 days and that the RN supervisor, the APRN, and physician were not notified. RN #1 indicated that she was the supervisor on duty 3/19, 3/20 and 3/21/25 and was not notified of the new onset pain to the right shoulder. RN #1 indicated if she was notified, she would have done an assessment and notified the APRN. The interview with the DNS on 6/4/25 at 7:51 AM indicated that the new onset of right shoulder pain should have been reported to the RN who would have done an assessment and notify the APRN or physician. After clinical record review, the DNS noted that the physician nor APRN had been notified. The interview with APRN #3 on 6/4/25 at 8:44 AM indicated that she was not notified Resident #61 had a new onset of pain in the right shoulder. APRN #3 indicated that her expectation is that new onset of pain with any resident is communicated to her. APRN #3 identified had she been notified, an assessment would have been done. The interview with MD #4 (former medical director) on 6/4/25 at 11:19 AM indicated that she does not recall anyone notifying her that Resident #61 had a new onset of right shoulder pain. MD #4 indicated if she was notified, she would have done a physical assessment and would have done an x-ray to rule out a fracture versus arthritis. MD #4 indicated if she had seen Resident #61 for the new onset of pain to the right shoulder she would have written a note. Although multiple attempts were made, an interview with APRN #1 and LPN #6 was not obtained. The review of the Change of Condition Policy identified the facility was to ensure that changes in residents' condition are reported to the providers and families. This is to ensure every resident's change in condition is assessed and documented properly. The facility must immediately inform the residents, consult with the residents' physician, and if known notify the residents legal representative or an interested family member when there is an accident involving the resident which resulted in an injury, a significant change in the resident's physical, mental, or psychosocial status including a new onset of pain or increased pain. The LPN is to collect data and administer provider ordered treatments or medications. The RN will assess and determine if a change of condition has occurred. The RN will make the APRN or MD aware of a resident's current condition by in person or telephone call. 4. Resident #65 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, spinal stenosis, and chronic obstructive pulmonary disease (COPD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The care plan dated 1/23/25 identified Resident #65 was at risk for contracting influenza and had refused the influenza vaccine. Interventions included to reapproach the resident to offer the vaccine as indicated. Review of an influenza outbreak surveillance tracking list for 2/2025 identified that the facility had an influenza outbreak that began on 2/3/25.A physician's order dated 2/13/25 directed to administer Tamiflu (an antiviral medication for influenza) prophylactic once daily at 8:30 AM.A nurse's note dated 2/14/25 identified that Resident #65 was notified of an influenza outbreak in the facility but declined prophylactic treatment. A nurse's note dated 2/15/25 at 10:35 PM identified Resident #65 reported feeling hot and coughing all day. The note further identified that an on call APRN was notified and treatment orders included influenza testing, Tussin (a cough suppressant) 10 ml every 6 hours for 3 days, and vital signs every shift for 3 days.Review of the clinical record failed to identify that Resident #65's representative had been notified of the resident's symptoms of feeling hot and coughing all day, or the new orders to administer Tussin and obtain an influenza test. Interview with the DNS on 6/4/25 at 10 AM identified that she was unsure of the facility policy regarding change of condition, but did not believe Resident #65's representative should have been contacted since Resident #65 was responsible for self. The DNS identified she would have to look into the matter.The facility policy on change of condition directed that it was the policy of the facility to ensure that changes in the residents' conditions were reported to providers and families. The policy further directed that any alteration in the resident's baseline indicated a potential change of condition. The policy also directed that the facility must immediately inform the resident, consult the resident's physician, and if known, notify the resident's legal representative or interested family member when there was a need to alter treatment significantly.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #19 and 86) reviewed for dementia care and/or pain, for Resident #19, the facility failed to develop and implement a comprehensive person centered care plan for dementia and for 1of 2 residents (Resident #86) the facility failed to ensure a comprehensive care plan was developed for a resident with a history of pain. The findings include:2. Resident #86 was admitted to the facility on [DATE] with diagnoses that included anxiety, hypertension, and pain. The physician's orders dated 2/26/25 directed to administer the following.Diclofenac sodium gel 1%, 2 grams topically, apply to the right shoulder, every 6 hours as needed, for pain.Lidocaine adhesive medicated patch 4%, 2 patches topically, apply to both shoulders once daily at 9:00AM and remove at 9:00 PM, for pain.Ibuprofen tablet; 600 mg; 1 tablet by mouth, every 6 hours as needed, for chest or back pain.Tylenol (Acetaminophen); 325 mg: 2 tablets by mouth, every 6 hours as needed, for pain. A physician's order dated 3/5/25 directed that Resident #86 may go LOA independently. The quarterly MDS dated [DATE] identified Resident #86 had intact cognition, was independent with upper and lower body dressing, personal hygiene, and ambulating 10 feet, and had been on a scheduled pain mediation regimen in the last 5 days. Review of the care plan dated 3/26/25 failed to identify Resident #86 had a comprehensive, person-centered care plan that included measurable objectives and goals for his/her diagnosis of pain. The nurse's note dated 4/30/25 at 6:51 PM identified that Resident #86 was alert and oriented, makes his/her own decisions and was seen in Urgent Care today, 4/30/25. Recommendations: x-ray: LS Spine, APRN was made aware. The Urgent Care progress note dated 4/30/25 identified Resident #86 presented today with complaints of lower back pain after falling, while in the hospital, last year. Resident #86 now resides at short term rehab (STR), and reports that the more he/she walks and moves the more the pain hurts; pain is mainly in the lower back and sometimes he/she has pain down the left leg. Resident #86 receives medications and care at STR but wants medications more frequently. The treatment plan directed for Resident #86 was to order an x-ray: LS Spine. The progress note further identified that Resident #86 was getting medications at the STR and there were providers on staff; it was not appropriate to prescribe more medications that were not being reconciled by the STR. The facility's medical APRN's progress note dated 5/1/25 identified Resident #86 was seen today for complaints of bilateral knee pain; resident reported this pain was not new and was requesting pain management. Voltaren cream was ordered to be applied topically 3 times a day. Resident reports that he/she had good effect with Voltaren cream in the past. Resident #86 previously had an Orthopedic (ortho) consult in October of 2024 where knee replacement was not recommended. Follow up with ortho outpatient for chronic knee pain. Interview with Resident #86 on 6/1/25 at 8:30 AM identified that last year he/she fell off a stretcher while in the hospital and has experienced back pain ever since. Resident #86 further identified that in April of this year he/she did not feel like his/her back pain was being well managed at the facility and that the facility staff did not understand that the pain was crippling, at times; Resident #86 took an Uber to the Urgent Care because the facility was not giving him/her the medications that he/she needed. Resident #86 identified that the Urgent Care doctor told him/her that he/she will always have back pain but would need to ensure his/her pain was well managed in order to remain active. Resident #86 further identified that the facility has since made alterations to his/her pain management regimen and he/she is in a much better place with pain management and is also happy to be working with OT (Occupation Therapy). Resident #86 indicated that while his/her pain has been better managed and he/she remains independent with his/her own care and ambulation, he/she would like additional assistance from the nurse aides with tasks that require bending, such as making his/her bed. Interview with the MDS Coordinator (LPN #1) on 6/4/25 at 8:01 AM identified that she had been in her current role for approximately 6 months, and when she first stepped into the position there was a lot of catch-up that needed to be completed with MDS assessments and updating the care plans accordingly. LPN #1 indicated that Resident #86's comprehensive care plan should have included his/her diagnosis of pain with interventions and goals for pain management. LPN #1 further indicated that it was an oversight that Resident #86 did not have a care plan for pain management and that when she identified the oversight on 6/2/25, she created a pain management care plan. LPN #1 identified that she put into place self-audits to ensure all resident care plans are up to date. Interview with the DNS on 6/4/25 at 9:52 AM identified that she would expect Resident #86 to have a comprehensive care plan for pain and it would be the responsibility of the MDS Coordinator to ensure that the care plan was in place. The DNS further indicated that, recently, a new process was put in place to ensure baseline care plans reflect pain management and that pain management care plans were carried over to the comprehensive care pan, in order to ensure residents were properly managed for pain. The facility's Comprehensive Care-Planning policy directs nursing to develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timelines to meet the physical, psychosocial, and functional needs for each resident. The comprehensive, person-centered care plan will: include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, include the resident's stated goals upon admission and desired outcomes, incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strength, reflect the residents expressed wishes regarding care and treatment goals, and identify professional services that are responsible for each element of care. 1. Resident #19 was admitted to the facility in 10/5/23 with diagnoses that included stoke, fibromyalgia, and chronic pain. The quarterly MDS dated [DATE] identified Resident #19 had severely impaired cognition and required maximum assistance with dressing and personal hygiene and total assistance with toileting and dressing. Resident #19 had a diagnosis of chronic pain and was receiving antidepressant, opioid, and antipsychotic medications. The care plan dated 12/1/24 identified Resident #19 was receiving an antipsychotic medication. Interventions included initiating nonpharmacological interventions and attempting a gradual dose reduction to the lowest possible therapeutic level as indicated by the physician. Review of Resident #19's diagnosis report identified a new diagnosis added on 12/12/24 of dementia and paranoia disorder. A Neurological Consult dated 12/12/24 identified Resident #19 has dementia with hallucinations and paranoia with severe brain atrophy. The nurses note dated 12/12/24 at 12:00 PM noted Resident #19 had returned from the neurological appointment with recommendations to start Donepezil 5 mg at bedtime and Abilify 2mg as needed if Donepezil was not effective for a diagnosis of dementia with hallucinations and paranoia. The psychiatric note written by APRN #2 dated 12/19/24 identified Resident #19 had a consultation with a neurological clinic and was started on Donepezil, and Abilify will be added as needed. APRN #2 noted she will add the diagnosis of dementia with hallucinations and paranoia. The care plan dated 2/14/25 failed to reflect the residents diagnoses of dementia or interventions to address such. The interview with APRN #2 on 6/3/25 at 8:04 AM indicated Resident #19 was given a diagnosis of dementia, hallucinations, and paranoia at that visit. The interview with LPN #1 (MDS Coordinator) on 6/3/25 at 9:30 AM indicated she was responsible for updating the care plans. LPN #1 indicated she updates the care plans after admission by day 21 and then quarterly with the care conferences. LPN #1 indicated that there were 2 care plans specific for a diagnosis of dementia that she uses in the EMR for residents. After clinical record review. LPN #1 indicated that Resident #19 did not have a care plan for dementia. LPN #1 indicated that although Resident #19 had care conferences on 2/7/25 and 5/13/25 and she did not add a dementia care plan. Interview with the DNS on 6/3/25 at 9:35 AM indicated that the charge nurse or supervisor were responsible to update the care plans when a resident receives a new diagnosis, but the MDS coordinator, LPN #1, was responsible to make sure the care plans were updated to reflect any changes within the last 90 days. Review of the Comprehensive Care Planning Policy identified nursing was to develop a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs are developed and implemented for each resident. The care planning process will include an assessment of the residents' strengths and needs, incorporate the residents' personal and cultural preferences in developing the goals of care, include measurable objectives and timeframes, incorporate identified problem areas and any risk factors, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident condition changes. Review of the Dementia Care Management Policy identified the facility shall individualize person-centered care for residents with dementia, supporting cognitive function, managing behavioral and psychological symptoms, and ensuring safety. Care plans will be tailored to the residents' cognitive abilities, cultural background, preferences, and history. This policy applies to all licensed nurses, nurse's aides, physicians, consultants, mental health professionals, and the interdisciplinary team members involved in the care of a resident with dementia.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #44) reviewed for hospitalization, the facility failed to ensure the resident or resident representative were notified of the bed hold policy at the time the resident was sent to the hospital. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included seizure disorder, chronic lower back pain, and dementia. The census report identified the resident was sent to the hospital on 3/9/25, 3/21/25, and 4/23/25. Review of the clinical record failed to reflect that written notice, which specifies the duration of the bed-hold policy, had been provided to the resident and/or the resident representative when the resident was transferred to the hospital on 3/9/25, 3/21/25, and 4/23/25. Interview with the DNS on 6/2/25 at 10:21 AM indicated that she was not sure but thinks the supervisor sending the resident to the hospital was responsible to send a copy of the bed hold policy with the resident at the time of transfer. The DNS indicated that the supervisor is responsible to make a copy of the discharge packet being sent with the resident to the hospital for the facility's records, but she was aware the supervisors were not doing that. The DNS indicated that she was not sure if the supervisors had been educated to send a copy of the bed hold policy with resident's when they are being transferred to the hospital. After reviewing the clinical record, the DNS indicated there was not documentation that the bed hold policy had been provided to the resident and/or the resident representative when the resident was transferred to the hospital on 3/9/25, 3/21/25, and 4/23/25. Interview with SW #1 on 6/2/25 at 10:27 AM indicated she does not notify the resident or resident representative of the bed hold policy when a resident is sent to the hospital. After review of the clinical record, SW #1 indicated there no documentation regarding the bed hold policy for the hospitalizations on 3/9, 3/21, or 4/23/25. The interview with the Chief Clinical Officer (CCO) on 06/02/25 at 10:42 AM indicated that the nursing supervisor was responsible to provide the bed hold policy to the resident and/or resident representative and make a copy of all the documents being sent with the resident at the time of a hospital transfer. The COO indicated she was aware the facility was not providing the bed hold policy or making copies of the forms being sent with the resident to the hospital. Review of the Notice Regarding Reservation of the Residents Bed if the Resident is hospitalized identified the facility will for a Medicaid - assisted resident, the facility will reserve the bed for up to 7 days if the facility has not received information that the resident is not expected to return to the facility. The facility reserves the bed for up to an additional 8 days if the facility has not received information that the resident is not expected back to the facility. If a Medicaid -assisted resident wishes to reserve the bed during a period of hospitalization for any longer period, the bed will be reserved if payment is made by the resident or resident representative at the facilities usual Medicaid per diem rate. Review of the Bed Hold and readmission Rights Policy identified the purpose was to ensure compliance with federal and state regulations governing the rights related to bed hold. The bed hold is defined as a reservation of a resident's bed during a temporary absence such as hospitalization. Notification requirements upon admission and in advance of any transfer, the resident and his/her representative shall be provided with a copy of the facility's bed hold policy, specifics of any state Medicaid bed old coverage if applicable, and written notice regarding the duration of the bed hold and the residents' rights regarding readmission. A resident's bed will be held for up to 15 days for Medicaid beneficiaries provided the resident is hospitalized , Medicaid or other payer sources authorize the hold, and the resident agrees to any applicable private pay rate if Medicaid does not cover the full bed hold period. The following must be documented: provision of the bed hold notification to the resident or resident representative, bed hold acceptance or decline and applicable payer source, and dates of hospitalization.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #19) reviewed for PASARR and for 1 of 3 residents (Resident #32) reviewed for falls, for Resident #19 the facility failed to have a care plan for the resident who had positive level 2 PASARR and for Resident #32, the facility failed to revise the care plan following a fall with major injury that resulted in hospitalization. The findings include: 1. The PASARR dated 9/27/23 indicated that Resident #19 received a level 2 approval without specialized services. Resident #19 has a diagnosis of major depression, anxiety, and opioid dependance. Resident #19 was admitted to the facility on [DATE] with diagnoses that included stroke, fibromyalgia, and chronic pain. A physician's order dated 10/5/23 directed to administer Cymbalta extended release 30 mg once a day for depression. The quarterly MDS dated [DATE] identified Resident #19 had moderately impaired cognition and required maximum assistance with toileting and required touching assistance with dressing and personal hygiene. Resident #19 had a diagnosis of depression and was receiving antianxiety, antidepressant and opioid medications. The care plan dated 9/29/24 identified Resident #19 was receiving an antipsychotic medication. Interventions included initiating nonpharmacological interventions and attempting a gradual dose reduction to the lowest possible therapeutic level as indicated by the physician.The psychiatric note, written by APRN #2 dated 10/17/24 identified Resident #19 was on the medication Seroquel for diagnosis of delusional disorder that is moderate in severity. The psychiatric note written by APRN #2 dated 12/19/24 identified Resident #19 had a consultation with a neurological clinic and was started on Donepezil, and Abilify will be added as needed. APRN #2 noted she will add the diagnosis of dementia with hallucinations and paranoia. The care plan dated 1/1/25 failed to reflect Resident #19 has dementia, hallucinations, paranoia, or delusions or interventions to address such. Interview with SW #2 on 6/3/25 at 8:38 AM indicated she was the social worker when Resident #19 was admitted but she thought the MDS Coordinator was responsible to develop the care plan related to level 2 PASARR's. After clinical record review. SW #2 indicated there was not a care plan for the positive level 2 PASARR. SW #2 indicated that any resident that has a positive level 2 should have a specific care plan for the positive level 2 care plan. The interview with LPN #1 (MDS Coordinator) on 6/3/25 at 9:30 AM indicated she was responsible for updating all the care plans. LPN #1 indicated indicate social service was responsible to develop the initial level 2 PASARR care plan and she was responsible to update them quarterly if needed. The interview with the DNS on 6/3/25 at 9:40 AM indicated that the charge nurse or supervisor was responsible to do the baseline care plan on admission and the MDS Coordinator was responsible to develop the comprehensive care plan by day 21. The DNS indicated the social workers were responsible for all level 2 PASARR care plans. After surveyor inquiry, the care plan dated 6/3/25 identified Resident #19 had been determined a positive Level II. Resident #19 has the potential for altered thought process and difficulty adjusting to situations. Resident has the potential for alteration in psycho-social wellbeing. Interventions included for social services consult as needed, psychiatric supportive care as ordered and as needed, AIMS testing per facility protocol. Gradual dose reduction as ordered.Review of the Dementia Care Management Policy identified the facility shall individualize person-centered care for residents with dementia, supporting cognitive function, managing behavioral and psychological symptoms, describe any specialized services to be provided because of PASARR recommendations, and ensuring safety. Care plans will be tailored to the residents' cognitive abilities, cultural background, preferences, and history. This policy applies to all licensed nurses, nurse's aides, physicians, consultants, mental health professionals, and the interdisciplinary team members involved in the care of a resident with dementia. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, congestive heart failure, and hypertension.The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, was always continent of bowel and bladder, was independent with dressing and toileting, and required set up for bathing.The care plan dated 3/13/25 identified Resident #32 was at risk for falls. Interventions included to monitor for changes in ADL status, cognition, mood, behaviors, continence, and gait/balance.Review of a facility A&I report dated 4/17/25 identified Resident #32 had an unwitnessed fall on 4/17/25. The A&I report identified Resident #32 had no visible injuries but reported chest pain and was transported to the hospital for evaluation. Review of the clinical record identified Resident #32 was hospitalized from [DATE] - 4/25/25 for acute kidney injury on chronic kidney injury and fluid volume overload. The documentation also identified Resident #32 sustained left rib fractures (5th, 6th, 7th and 8th) related to the unwitnessed fall prior to hospital admission. Review of the clinical record failed to identify any revisions of Resident #32's care plan related to falls including interventions following readmission to the facility on 4/25/25.Interview with the DNS on 6/4/25 at 10:00 AM identified that Resident #32's care plan should have been revised related to Resident #32's unwitnessed fall on 4/15/25. The DNS identified while she had reviewed the hospital discharge paperwork and documentation related to Resident #32's hospitalization, she was not aware that Resident #32 sustained multiple rib fractures as a result of the 4/15/25 fall. The facility policy on falls directed that all residents would be assessed for falls upon admission and reassessments would be done upon a change of condition and as needed (i.e. after a fall incident) and that interventions would be implemented according to the resident's identified needs.The facility policy on Comprehensive Care Planning directed that assessments of residents were ongoing and care plans were revised as information about the residents and residents' condition changed. The policy also directed that the resident care plan must be reviewed and updated when the resident had a significant change in condition and when the resident was readmitted to the facility following a hospital stay.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #43, 32, 44, 62 and 65) the facility failed to provide care according to professional standards of practice. For 1 resident (Resident #43) reviewed for death, the facility failed to ensure medications were administered according to the physician's orders, failed to obtain blood sugar and blood pressures as ordered, failed to follow the physician's order to notify the physician with a blood sugar outside the parameter and failed to complete ongoing assessments after the resident experienced a change in condition. For Resident #32 the facility failed to obtain weights according to the physician's order.For 1 of 4 residents (Resident #44) reviewed for skin condition, the facility failed to ensure a newly identified open area was assessed upon identification and weekly until healed.For 1 of 4 residents (Resident #62) reviewed for skin conditions, the facility failed to complete and document skin checks as per the physician's order and facility policy. For Resident #65 the facility failed to complete vital signs according to the physician's order. 1a. The hospital Discharge summary dated [DATE] identified Resident #43 was admitted to the hospital on [DATE] with diagnoses of acute heart failure with reduced ejection fraction (HFrEF) with hypertensive emergency due to medication nonadherence. Newly reduced Left Ventricular Ejection Fraction (LVEF) of 32%, hypertension emergency due to medication noncompliance. Comorbidities present on admission were diabetes type 2, hypertension, gout, gunshot wound to abdomen, chronic back pain, status post splenectomy, and Covid-19. Secondary diagnoses occurred during hospitalization included acute kidney injury, and diabetes with hyperglycemia. Resident #43 was discharged from the hospital on 2/26/25. Resident #43 was admitted to the facility on [DATE] with diagnoses that included chest pain, chronic congestive heart failure, hypertension, and diabetes.The care plan dated 2/27/25 identified Resident #43 was at risk for abnormal glucose levels, hypo/hyperglycemia secondary to diabetes. Interventions included to administer diabetic medications and/or Insulin as ordered.The admission MDS dated [DATE] identified Resident #43 had intact cognition and was independent with personal hygiene.The consultant cardiologist recommendations dated 4/30/25 included to start on SGLT2 inhibitor (medication used to treat type 2 diabetes) either Jardiance or Farxiga 10mg daily.The consultant visit summary dated 4/30/25 identified the heart failure with reduced ejection fraction was addressed. The form indicated to pick up Jardiance at an outside Pharmacy.The physician's order dated 5/1/25 directed to administer Jardiance 10 mg tablet (used to manage type 2 diabetes, heart failure, and chronic kidney disease (CKD) once a day at 8:30 AM. Review of the pharmacy documentation dated 5/1/25 at 8:47 AM identified medication not covered (Jardiance 10mg tablet once daily). An outside pharmacy filled and dispensed the medication. Resident #43 called the outside pharmacy yesterday (4/30/25) and requested all medications be filled and delivered to his/her significant other at his/her prior address.The nurse's note dated 5/1/25 at 12:38 AM identified Resident #43 was seen by the cardiologist on 4/30/25 related to recent heart failure and ejection fraction diagnoses. Recommendations to start either Jardiance or Farxiga 10mg daily. The care plan dated 5/1/25 identified Resident #43 had a recent diagnoses of chronic systolic heart failure (4/30/35) and was at risk for or complication due to disease process. Interventions included monitoring cardiorespiratory symptoms, increasing fatigue, and to administer medications as ordered. Further, the care plan dated 5/1/25 identified Resident #43 was at risk for alteration in cardiac output related to recent diagnosis of chronic systolic heart failure on 4/30/25. Interventions included to administer medications as ordered. The nurse's note dated 5/2/25 at 12:21 AM by RN #9 identified she spoke with the facility pharmacy regarding Resident #43 calling and telling the outside pharmacy that the medication would be picked up by his/her significant other. RN #9 indicated she would educate Resident #43 to not have anyone pick up medication while residing in the facility. The note failed to reflect that the physician, APRN, cardiologist, or the DNS were notified.The nurse's note dated 5/8/25 at 8:34 PM by RN #6 identified Resident #43 was seen by the nephrologist on 5/7/25 and the plan of care was to continue Entresto, start Jardiance, and follow up with the cardiologist for perfusion scan and echocardiogram.Review of the APRN notes dated 5/8/25 and 5/13/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. The physician's order dated 5/29/25 directed to check blood pressure and pulse once a day at 9:30 AM. Review of the MAR dated 5/1/25 - 6/3/25 identified although the Jardiance 10mg was scheduled to be administered daily at 8:30 AM, the medication was not administered. The MAR identified the drug was unavailable and awaiting delivery from the pharmacy from 5/1/25 - 6/3/25, a total of 34 days.Review of the APRN note dated 6/3/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, APRN, cardiologist, or the DNS were notified that Resident #43 was not receiving the Jardiance per the physician's order from 5/1/25 - 6/3/25 (total of 34 days). Interview with APRN #3 on 6/6/25 at 2:53 PM identified she was not aware that Resident #43 was not receiving the Jardiance as ordered from 5/1/25 - 6/3/25, and that the pharmacy had not sent the medication to the facility. APRN #3 indicated the Jardiance was prescribed by a specialist (cardiologist). APRN #3 indicated when Resident #43 was first admitted to the facility, the facility was having issues with the medications being sent to his/her personal pharmacy. APRN #3 indicated if she had known the resident was not receiving the Jardiance due to a pharmacy issue, she would have had a discussion with the DNS and called the pharmacy.Interview with the DNS on 6/6/25 at 3:02 PM identified she was not aware that Resident #43 was not receiving the Jardiance from 5/1/25 - 6/3/25 (34 days), or that the Jardiance was never delivered to the facility. The DNS indicated had she known, she would have called the pharmacy and had the pharmacy bill the facility for the Jardiance. The DNS indicated that she would expect the licensed nurses to administer medication per the physician's order. Interview with RN #6 on 6/6/25 at 3:18 PM identified she recalled a conversation with the pharmacy at the beginning of May 2025 regarding the Jardiance. RN #6 indicated she passed the information onto the on-coming supervisor. RN #6 indicated she does not remember which supervisor. Interview with RN #1 on 6/9/25 at 12:26 PM identified she was not aware Resident #43 was not receiving the Jardiance from 5/1/25 - 6/3/25 (34 days), or that the Jardiance was never delivered to the facility. RN #1 indicated if she was aware of the Jardiance had not been delivered, she would have called the pharmacy and notified the DNS immediately. RN #1 indicated she would have informed the pharmacy to send the medication, and the facility would have been billed.Interview with MD #5 (cardiologist) on 6/10/25 at 10:27 AM identified he last saw Resident #43 on 4/30/25 at his office. MD #5 indicated Resident #43 had been admitted to the hospital in February 2025, with systolic heart failure, and heart failure with reduced ejection fraction (32%) with hypertensive emergency which caused pulmonary edema, and other comorbidities. MD #5 indicated on 4/30/35 he ordered Resident #43 to receive Jardiance 10mg once a day. MD #5 indicated he was not aware that Resident #43 never received the medication. MD #5 indicated his expectation is that the nurses should have administered the medication per the physician's order. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not aware that Jardiance 10mg was recommended to be given daily. MD #1 indicated he did not receive a phone call from the facility on 4/30/25 or 5/1/25 informing him that the cardiologist recommended Jardiance to be administered daily. MD #1 indicated he did not order Jardiance to be administered, and he was not aware that Resident #43 did not receive the Jardiance from 5/1/25 - 6/3/25 (total of 34 days). MD #1 indicated the nurse should administer medication per the physician's order. Although attempted, an interview with RN #7, and RN #8 was not obtained.Review of the facility medication unavailable policy identified in the event that medication is unavailable for any reason the facility shall act promptly to notify appropriate practitioners for orders to be followed and the pharmacy to obtain medications in accordance with the updated orders. The facility shall investigate all instances where medications are not available, to assess whether appropriate actions were taken to ensure continuity of care. Upon identifying that a medication is apparently unavailable, immediately notify the nursing supervisor. Contact the pharmacy to determine when medication will be available. Inform the prescriber/attending; and in their absence, the Medical Director and obtain orders. Document actions and prescriber orders on 24 hour report, MD order sheet, and chart.b. The physician's order dated 5/1/25 - 5/31/25 directed to administer the following medications: Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Gabapentin 300mg capsule (for pain) at bedtime at 8:30 PM.Lantus Insulin U-100 unit/ml (diabetes) give 25 units subcutaneous at bedtime at 8:30 PM. Lipitor 80mg tablet (for hyperlipidemia) once a day at 8:30 PM. Miralax 17grams (for constipation) twice a day at 8:30 AM and 8:30 PM.Ozempic 4mg/3ml, 1mg/dose subcutaneous (for diabetes) on Mondays at 8:30 AM.Senna 8.6mg tablet (for constipation) twice a day at 8:30 AM, and 8:30 PM. Review of the May 2025 MAR identified the following. Coreg 25mg was not administered on 5/1/25 at 4:30 PM, 5/2/25 at 8:30 AM, 5/5/25 at 8:30 AM, 5/6/25 at 8:30 AM, 5/19/25 at 8:30 AM, and 5/28/25 at 8:30 AM. Gabapentin 300mg was not administered on 5/20/25 at 8:30 PM.Lantus Insulin U-100 unit/ml was not administered on 5/20/25 at 8:30 PM.Lipitor 80mg was not administered on 5/20/25 at 8:30 PM.Miralax 17grams was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 PM.Ozempic 4mg/3ml give 1mg/dose was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 AM.Senna 8.6mg was not administered on 5/20/25 at 8:30 PM. c. The physician's order dated 6/1/25 - 6/3/25 directed the following. Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Daily Blood Pressure and Pulse once a day at 9:30 AM.Daily Weights before breakfast (for chronic systolic congestive heart failure) once a day at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous (for diabetes) once a day on Mondays at 8:30 AM.Review of the June 2025 MAR dated identified the following. Coreg 25mg was not administered on 6/2/25 at 8:30 AM, and 4:30 PM.Daily Blood Pressure and Pulse was not recorded on 6/2/25 at 9:30 AM. Daily Weights were not obtained on 6/2/25 at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous was not administered on 6/2/25 at 8:30 AM.Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, and the APRN, were notified that Resident #43 did not receive medications on 5/1/25, 5/2/25, 5/5/25, 5/6/25, 5/19/25, 5/20/25, 5/28/25, and 6/2/25. d. The physician's orders dated 5/1/25 - 6/3/25 directed the following. Check Blood Sugar before meals (for diabetes) at 7:30 AM, 11:30 AM, and 4:30 PM. Special Instructions: If Blood Sugar is less than 80mg/dl and greater than 450mg/dl call MD/APRN. Review of the May 2025 and June 2025 MAR identified the following.The blood sugar on 5/6/25 at 11:30 AM was 76mg/dl.The blood sugar on 5/14/25 at 7:30 AM was 73mg/dl.The blood sugar on 5/15/25 at 7:30 AM was 71mg/dl.The blood sugar on 6/2/25 at 7:30 AM was 54mg/dl. Review of the nurse's note dated 5/1/25 - 6/4/25 failed to reflect documentation that the physician was notified when the residents blood sugar was low 5/6/26, 5/14/25, 5/15/25, and 6/2/25. Further, the notes failed to reflect documentation of an RN assessment and follow up assessment regarding the low blood sugars.e. The care plan dated 5/1/25 identified Resident #43 has a history of hypertension. Interventions included to monitor blood pressure every shift. The physician's order dated 5/1/25 - 5/28/25 directed to monitor blood pressure every shift, Days, Evening, and Nights.Review of the May 2025 MAR failed to reflect blood pressure monitoring. Review of the vital sign form identified the following missing blood pressures.5/1/25 evening and night, 5/2/25 day and night, 5/3/25 evening and night, 5/4/25 evening and night, 5/5/25 day and night, 5/6/25 day and night, 5/7/25 and 5/8/25 nights, 5/9/25 evening and night, 5/10 /25 - 5/13/25 nights, 5/14/25 evening and night, 5/15/25 night, 5/16/25 evening and night, 5/17/25 evening and night, 5/18/25 night, 5/19/25 day and night, 5/20/25 night, 5/21/25 - 5/27/25 nights, 5/28/25 day, evening, and night.The nurse's note dated 5/1/25 - 5/28/25 failed to reflect documentation that the physician was notified that blood pressure was not monitored as ordered. f. The nurse's note dated 6/3/25 at 5:39 PM by RN #6 identified Resident #43 complained of feeling nauseated with no vomiting and was observed with visible tremors. Vital signs identified a temperature of 98.2 F, pulse 135, respiration rate 18, blood pressure 120/85, oxygen saturation 98% on room air. APRN #3 was notified and recommended Zofran 4mg every 6 hours as needed for nausea times 5 days. Will reassess. Review of the nurse's note dated 6/3/25 after 5:39 PM - 6/4/25 at 5:07 AM failed to reflect documentation of an RN reassessment following the pulse of 135 and feeling of nausea. Interview with RN #1 on 6/9/25 at 12:26 PM identified she was not aware Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. RN #1 indicated it is the responsibility of the licensed nurses to administer the medication per the physician's order. RN #1 indicated the licensed nurses should have notified the physician or the APRN when the medications were not given and document the omissions in the resident clinical record. Interview with the DNS on 6/10/25 at 10:11 AM identified she was not aware that Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. The DNS indicated the licensed nurses should have notified the physician, or the APRN when Resident #43 did not receive his/her medications, when the blood sugars were low, and when blood pressure was not monitored as ordered. The DNS indicated that she would expect the licensed nurses to administer the medication per the physician's order. The DNS indicated she was not aware Resident #43 had complained of nausea and had a pulse of 135, and indicated a follow-up RN assessment should have been performed. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not notified that Resident #43 was not receiving some of the medications between 5/1/25 - 6/3/25 on multiple occasions and when blood pressure was not monitored as ordered. Further, MD #1 indicated the licensed nurses should have notified him or the APRN when Resident #43's blood sugar was low on multiple occasions, and blood pressure was not monitored as ordered. MD #1 indicated the license nurse should administer the medication per the physician's order.Review of the facility medication administration policy identified the facility is to provide a safe and effective medication management framework to help eliminate any harm that could be caused at any level of the medication management process. To ensure that licensed facility staff will adhere to proper safety precautions in the administration of all medications. Administration: The medication should be administered using the 5 Rights. Right resident, right medication, right dose, right route, and right time. Review of the facility compliance with and implementation of physician's orders policy identified all physician orders are implemented accurately, timely, and in accordance with applicable federal and state regulations. Review of the facility taking a blood pressure policy identified to measure the force at which the heart pumps and returns blood. Notify the provider of the results and correctly document the results in the resident's record in the electronic record. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, congestive heart failure, and hypertension.The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, was always continent of bowel and bladder, was independent with dressing and toileting, and required set up for bathing.The care plan dated 3/13/25 identified Resident #32 was at risk for falls. Interventions included to monitor the resident for changes in ADL status, cognition, mood, behaviors, continence, and gait/balance.Review of a facility A&I report dated 4/17/25 identified Resident #32 had an unwitnessed fall on 4/17/25. The A&I report identified Resident #32 had no visible injuries but reported chest pain and was transported to the hospital for evaluation. Review of the clinical record identified a hospital discharge which identified Resident #32 was hospitalized from [DATE] - 4/25/25 for acute kidney injury on chronic kidney injury and fluid volume overload. The documentation also identified Resident #32 sustained left rib fractures (5th, 6th, 7th and 8th) related to the unwitnessed fall prior to hospital admission. A physician's order dated 4/25/25 directed to obtain daily weights and report any weight gain of 2 - 3 lbs. to the physician.The care plan dated 4/26/25 identified Resident #32 was at risk for decline in condition due to acute kidney injury. Interventions included to monitor for fluid buildup including edema, cough, congestion, and weight gain. Review of the clinical record failed to identify any weight documentation for Resident #32 on the following dates: 4/27, 5/1, 5/2, 5/4, 5/5, 5/6, 5/9, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, and 5/27/25.Interview and review of Resident #32's clinical record with the DNS on 6/4/25 at 10:00 AM identified Resident #32 frequently refused to allow care and the missing weight documentation was likely related to this. The DNS identified that the nursing staff should document in the clinical record when Resident #32 refused weights and notify the physician if weights were refused for multiple days.The facility policy on weights directed that the facility would utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in residents. The policy also directed weights would be obtained on admission, weekly for 4 weeks, and then monthly unless otherwise ordered by the physician. The facility policy on Compliance with and Implementation of Physician's Orders directed that orders must be carried out as written unless contraindicated, and in such cases, the physician must be notified, and the documentation must reflect clinical rationale. 3. Resident #44 was admitted to the facility on [DATE] with diagnoses that included seizure disorder, chronic lower back pain, and dementia. The quarterly MDS dated [DATE] identified Resident #44 had severely impaired cognition, was frequently incontinent of bowel and always incontinent of bladder and required moderate assistance with personal hygiene and touching assistance with transfers and ambulation. Further, the MDS identified Resident #44 was at risk for developing a pressure ulcer or injury and had a pressure reducing device for the bed. The care plan dated 3/19/25 identified the resident was at risk for skin breakdown related to incontinence. Interventions included elevating the heels while in bed and turning and repositioning resident at least every 2 hours. A physician's order dated 3/19/25 directed a stand pivot transfer with assistance of 2 staff, may use a mechanical lift (hoyer) as needed. The nurses note dated 3/20/25 at 1:57 PM, written the wound nurse, (RN #1) identified Resident #44 was lethargic lying in bed and had a change in mental status. Resident #44 was noted to have a pinpoint opening to the right ankle. RN #1 noted order in place for zinc oxide daily then cover with a dry clean dressing. The nurses note dated 3/20/25 at 1:59 PM, written by LPN #2, identified Resident #44 has a pinpoint opening to the right ankle, treatment ordered and done. Blue boots applied to off load pressure on the right ankle. The APRN #1's progress note dated 3/20/25 identified Resident #44 had a pinpoint open area to the lateral right ankle with treatment. A physician's order dated 3/20/25 directed to cleanse the right ankle with normal saline then apply zinc oxide daily during the 3:00 PM - 11:00 PM shift. Review of the nurses and ARPN/physician notes dated 3/20/25 to 4/17/25 failed to reflect an assessment of the right ankle including wound classification, size, description of the wound bed, description of the surrounding tissue, or if there was drainage or an odor. A physician's order dated 4/17/25 directed to discontinue right ankle treatment.A physician order dated 5/4/25 directed to apply heel boots while in bed.Interview with the RN #1 (wound nurse) on 6/2/25 at 10:57 AM indicated when there is a new wound or pressure area there would be an RN assessment in the progress notes or in the wound documentation section. RN #1 indicated she would be responsible to notify the physician and obtain an order for treatment and place the resident on the weekly wound rounds with the Wound Physician, (MD #2). RN #1 indicated that once MD #2 is notified of a new wound, he follows the wound weekly on Tuesdays until it is healed. RN #1 indicated as the facility RN wound nurse she makes weekly wound rounds with MD #2. RN #1 indicated the initial RN assessment should be documented in a progress note and must include the site, classification of pressure or non-pressure, description and measurements, drainage or not, and the surrounding tissue. RN #1 indicated that the weekly wound assessments would include all the same documentation. After clinical record review, RN #1 indicated she was the RN that evaluated the new right ankle wound on 3/20/25 but did not measure the wound, document a description of the wound or surrounding tissue, or classify the wound. RN #1 indicated that it was a small round open area on the lateral right ankle. RN #1 indicated that she put the treatment order in the EMR, but after review identified the treatment order was not a complete order. RN #1 indicated that she would expect weekly measurements until healed but did not see any documentation of such. RN #1 indicated when a treatment gets discontinued there should be a progress note explaining why it was discontinued. RN #1 indicated that she discontinued the treatment to the ankle on 4/17/25 but does not recall why and there was not a progress note explaining such. RN #1 indicated she would assume it healed. Interview with LPN #2 on 6/2/25 at 11:27 AM, who wrote a note on 3/20/25 at 1:59 PM, indicated that during morning care that day, the nurse aide had notified her that Resident #44 had an open area to the outside of the right ankle. LPN #2 indicated that she notified RN #1 who was the supervisor. LPN #2 indicated she thought the area was pressure from how Resident #44 would lie on the bed. LPN #2 indicated that the APRN had seen Resident #44 that day and ordered a treatment and she obtained the blue pressure relieving boots. Interview with the DNS on 6/2/25 at 11:34 AM indicated that if a new open area is found her expectation is that the RN supervisor would complete and document a wound assessment of the area including measurements, description of the wound bed and surrounding tissue, odor or drainage. Further the DNS indicated weekly wound assessments should be done until healed. After clinical record review, the DNS indicated there was not a complete initial RN assessment, weekly wound assessments documented, and MD #2 was not following weekly. The DNS indicated that her expectation RN #1 should have written a note when she discontinued the treatment to the right ankle on 4/17/25. Interview with MD #2 (wound physician) on 6/3/25 at 8:20 AM indicated if he was notified that the resident had a new open area on the ankle he would have assessed the wound, wrote a consultation note making recommendations, and ordered bilateral heel lift boots and a treatment. Further, MD #2 identified he would have followed the resident weekly until the wound healed. MD #2 indicated that he was not informed of the open area to the resident's ankle. Although attempted, an interview with APRN #1 was not obtained. Review of the Skin and Wound Management Policy identified the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document the following: full assessment of pressure sores including location, stage, length, width, and depth, presence of exudate or necrotic tissue. Pain assessment, resident's mobility status, current treatments and al active diagnosis. A registered nurse will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Residents with pressure ulcers and/or other skin conditions will be seen and followed by the facilities wound physician. Review of the Pressure Ulcer Identification Policy identified a pressure ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. Pressure ulcers occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of soft tissue. 4. Resident #62 was admitted to the facility on [DATE] with diagnoses that included stage 3 pressure ulcer of the left buttock, disorder of the skin and subcutaneous tissue, cellulitis of an unspecified part of limb, and diabetes mellitus due to an underlying condition with diabetic neuropathy. A physician's order dated 3/27/25 directed to complete a body audit weekly on shower days, Monday; 7:00AM - 3:00 PM and complete quarterly observations: Braden Scale (Braden Scale is a tool used to assess a resident's risk of developing a pressure ulcer), every 90 days on the 27th day of March, June, September, and December; 3:00 PM - 11:00 PM.The quarterly MDS dated [DATE] identified Resident #62 had intact cognition, was frequently incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene, required partial/moderate assistance with rolling left to right, sitting to standing, and chair/bed-to-chair transfers, had one or more unhealed pressure ulcers/injuries, and was at risk for developing pressure ulcers/injuries.The care plan dated 4/13/25 identified Resident #62 had an actual skin impairment as evidenced by: left ischial tuberosity opening. Interventions included reporting any skin changes to the physician/APRN, as necessary, and completing weekly skin checks.Review of the 2025 Weekly Nurses Note and Skin Check documents failed to identify documentation that skin checks were completed weekly as ordered between 1/1/25 through 5/4/25, and 5/19/25 through 5/31/25. Two weekly skin checks were completed during the week of 5/12/25 (1 out of 22 weeks). Interview and review of the clinical record with the DNS on 6/3/25 at 9:45 AM failed to provide documentation that weekly skin checks were completed, in accordance with the physician's orders. The DNS indicated that she had already identified that some nursing observations were not being documented in the clinical record, including weekly skin observations. The DNS further indicated that she has implemented a new process for the RN Supervisor to review the Charged Nurses' observation documentation, at the end of each shift. The DNS identified that she would expect to see weekly skin observations being completed, but the nurses had been completing frequent Braden Scales. The DNS indicated that additional staff education would be initiated to ensure that the nurses were completing both weekly skin observations and Braden Scales in accordance with the physician's order. Interview with LPN #3 on 6/3/25 at 12:35 PM identified that she could not recall if she had ever been assigned to Resident #62 on his/her shower day, as she floated to different units within the facility. LPN #3 indicated that it was the responsibility of the nurse assigned to the resident on the resident's shower day to complete the weekly skin observations. LPN #3 further indicated that after the skin observation has been completed, the nurse should document that the task was completed on the Treatment Administration Record (TAR) and document if the skin was intact or if a new skin issue has been identified on the Weekly Skin Check document. LPN #3 identified that Braden Scale and weekly skin observations were different, and both should be completed, per the physician's order. The facility's Skin and Wound Management policy directs a risk assessment to be completed if there is a significant change in condition, or as often as is required based on the resident's condition. The following information should be recorded in the residence medical record utilizing facility forms: type of assessment conducted, date, time, and type of skin care provided, name and title of the individual who conducted the assessment, any change in the resident's condition, the condition of the skin, how the resident tolerated the procedure or his/her ability to participate in the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment, observations of anything unusual exhibited by the resident, and documentation addressing family, guardian, or resident notification if a new skin alteration was noted. 5. Resident #65 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, spinal stenosis, and chronic obstructive pulmonary disease (COPD).The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The care plan dated 1/23/25 identified Resident #65 was at risk for contracting influenza and had refused the influenza vaccine. Interventions included to reapproach the resident to offer the vaccine as indicated. Review of an influenza outbreak surveillance tracking list for 2/2025 identified that the facility has an influenza outbreak that began on 2/3/25.A nurse's note dated 2/14/25 at 11:27 AM identified that Resident #65 was notified of an influenza outbreak in the facility but declined prophylactic treatment. A nurse's note dated 2/15/25 at 10:35 PM identified Resident #65 reported feeling hot and coughing all day. The note further identified that an on call APRN was notified and treatment orders included influenza testing, Tussin (a cough suppressant) 10 ml every 6 hours for 3 days, and vital signs every shift for 3 days.A physician's order dated 2/16/25 directed to obtain vital signs every shift (days,

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #142) reviewed for pressure ulcers, the facility failed to ensure an RN assessment of a pressure ulcer was completed on admission. The findings included:Review of the hospital Discharge summary dated [DATE] identified Resident #142 was admitted to the hospital on [DATE] and discharged on 1/25/25. Resident #142 had left foot osteomyelitis, and a debridement with a left trans metatarsal amputation (TMA). Surgery was consulted for wound debridement to sacral wound growing pseudomonas. Recommendations included to continue local wound care and no plan for surgical debridement given resident's heart failure exacerbation and Covid-19 status.Resident #142 was admitted to the facility on [DATE] with diagnoses that included diabetes, congestive heart failure, and osteomyelitis. The diagnoses form failed to reflect documentation of the stage 4 sacral pressure ulcer, and left trans metatarsal amputation (TMA).The nurse's note dated 1/25/25 at 6:00 PM by RN #2 identified Resident #142 arrived from the hospital with oxygen at 2 Liters via nasal cannula with no complaints of pain. Left arm PICC line and foley catheter in place. Left foot amputation wrapped with gauze, and stage 4 coccyx wound covered with Mepilex foam dressing. Review of the admission Braden Scale by RN #2 dated 1/25/25 at 6:28 PM identified Resident #142 was at mild risk for skin breakdown.Review of the admission observation form by RN #2 dated 1/25/25 at 6:54 PM identified Resident #142 alterations in skin assessment were not completed. The admission observation form failed to reflect documentation of a pressure ulcer assessment.Review of the physician's order dated 1/25/25 - 1/29/25 failed to reflect documentation for an order to apply an LAL mattress, and specialty cushion for the wheelchair.A physician's order dated 1/26/25 directed to medicate prior to wound care twice a day at 8:30 AM and 4:30 PM. Tylenol 650mg tablet every 6 hours for pain at 12:30 AM, 6:30 AM, 12:30 PM, and 6:30 PM. Oxycodone 5mg tablet every 8 hours as needed for pain. Morphine 15mg tablet at bedtime at 8:30 PM for pain management. A physician's order dated 1/27/25 directed to monitor for pain every shift with appropriate pain scale, wound consult as needed and administer Amoxicillin-Potassium Clavulanate (antibiotic) 875mg - 125mg tablet every 12 hours at 8:30 AM and 8:30 PM for osteomyelitis. Further, perform weekly body audit on shower day during 3:00 PM - 11:00 PM shift every Wednesday.Additionally, pack sacral wound with 1/4 strength Dakin's solution wet to dry gauze followed by dry clean dressing once a day on the 7:00 AM - 3:00 PM shift and as needed. The wound physician consult dated 1/29/25 identified Resident #142 was seen for initial evaluation and treatment recommendations regarding stage 4 pressure injury to sacrum. Resident #142 was on Doxycycline and Amoxicillin (antibiotics). A wound care assessment was performed, measurement 13 cm x 12 cm x 3 cm, with moderate serosanguinous drainage, 100% necrotic, foul-smelling drainage, and debridement done on 1/29/25. Treatment Dakin 1/4 strength wet to moist packing for now. Recommended Resident #142 to be sent back to the hospital for evaluation of the sacrum wound. Wound needs surgical debridement under anesthesia as wound is infected that showed necrotic tissue to bone with foul smell. Resident #142 would not be able to tolerate bedside debridement performed today needs more invasive intervention. A physician's order dated 1/29/25 directed to send Resident #142 to the hospital for evaluation due to sacral wound infection. The nurse's note date 1/29/25 failed to reflect documentation for the 7:00 AM - 3:00 PM shift regarding the wound physician's assessment and recommendation.The nurse's note dated 1/29/25 at 8:52 PM by RN #3 identified the 7:00 AM - 3:00 PM supervisor indicated to her that the wound physician assessed Resident #142 sacral pressure ulcer wound today and directed to transfer Resident #142 to the hospital for evaluation secondary to sacral pressure ulcer wound infection. Resident #142 was transferred to the hospital at 4:05 PM. Interview and clinical record review with the DNS on 6/3/25 at 6:45 AM identified she was not aware that the stage 4 sacral pressure ulcer was not assessed by a Registered Nurse upon the resident's admission to the facility. The DNS indicated it is the RN supervisor's responsibility to assess wounds on new admissions. The DNS indicated if she was aware that a wound assessment was not completed on Resident #142 on admission day, she would have completed the assessment on Monday 1/27/25. Interview and clinical record review with RN #1 on 6/3/25 at 12:42 PM identified she was not aware that a wound assessment was not performed and documented on Resident #142 on admission. RN #1 indicated if she was aware of the issue she would have performed the wound assessment. RN #1 indicated it is the responsibility of the RN supervisor on admission to perform the wound assessment and document.Interview with MD #2 on 6/4/25 at 10:04 AM identified his initial assessment of Resident #142 was on 1/29/25. MD #1 indicated Resident #142 should not have been discharged from the hospital with an infected stage 4 sacral pressure ulcer. MD #2 indicated Resident #142 was compromised and had many comorbidities and was on antibiotics. MD #2 indicated he assessed the wound and recommended that Resident #142 be transferred to the hospital for wound evaluation. MD #2 indicated the nursing supervisor should have completed a thorough wound assessment with measurements, description of the wound, and documented the findings in Resident #142 clinical record on admission.Although attempted, an interview with MD #4, and RN #2 was not obtained.Review of the facility skin and wound management policy identified the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcer, for example, immobility, recent weight loss, and a history of pressure ulcers. A registered nurse will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The nurse shall describe and document/report the following: Full assessment of pressure ulcer including location, stage, length, width, depth, presence of exudates or necrotic tissue, and pain.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #36) reviewed for discharge, the social worker failed to assist the resident when he/she requested to be transferred to another facility. The findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses that included chronic pain, thoracic intervertebral disc degeneration, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #36 had intact cognition and required supervision with toileting, dressing, and personal hygiene. Review of the January 2025 monthly physician's orders identified Resident #36 may go on a leave of absence (LOA) independently. The social worker note dated 1/22/25 at 10:37 AM identified she called Facility 1 and Facility 2 to follow up on Resident #36's request for transfer to another facility. The social worker note dated 1/27/25 at 1:50 PM identified she spoke with the resident at bedside and updated the resident she had made the calls for a transfer. The social worker identified she had called a facility and left a message for the admission director.The care plan dated 4/29/25 failed to reflect discharge planning or goals.The care plan meeting note dated 4/29/25 identified Resident #36 would like a transfer to another facility. Interview with Resident #36 on 6/1/25 at 8:30 AM indicated that he/she had informed the social worker and Administrator he/she wanted to be transferred to another nursing facility starting in January of this year after a bed bug problem and has continued to ask but nothing is being done. Resident #36 indicated that he/she does not understand why he/she is being held here in this facility when he/she has requested for months to be transferred to any other nursing facility. Resident #36 indicated that he/she just wants out of this facility. Resident #36 indicated he/she has a friend that does entertainment at other facilities and informed him/her that they do have empty beds, but the social worker here keeps telling him/her there are no beds available in any other nursing home. Resident #36 indicated that the social worker keeps informing him/her that all the beds in the area are full and he/she cannot be discharged at this time. Resident #36 indicated that this has gone on since January and he/she is very mad that he/she cannot be moved to another facility and wonders why it is taking so long to occur. The interview with SW #1 on 6/1/25 at 1:30 PM indicated that it would be the social workers' responsibility to assist a resident that wanted to transfer to another facility. The social worker note dated 6/1/25 at 2:56 PM identified Resident #36 approached her expressing interest in transferring to another facility located in Connecticut. Resident #36 specifically inquired about Facility #3. This writer contacted the facility to request an update on current bed availability via phone. Will follow up with the resident once a response is received. The writer will continue to assist with the transfer process as needed. The interview with SW #2 on 6/3/25 at 11:06 AM indicated if a resident wanted to transfer to another facility, she would send the referral and document what facility she sent the referral to and the response. SW #2 indicates that it shouldn't take more than a couple of weeks for a resident to transfer if that is what he/she wants and there is a bed available. SW #2 indicated that since January she was the only social worker, and she was doing the best she could. SW #2 indicated that she was aware Resident #36 wanted to be transferred to another facility since January 2025 but was waiting for Resident #36 to provide her with names of nursing homes. SW #2 indicated that Resident #36 initially gave her one name of a nursing home and 2 names for assisted livings. SW #2 indicated that Resident #36 was not appropriate for the assisted living and needed long term care. SW #1 indicated she did not go back to Resident #36 and inform him/her the names were for assisted living facilities and not long-term care facilities. SW #2 indicated that she was not sure if Resident #36 knew any names of the nursing facilities in the area. SW #2 indicated that she had not provided Resident #36 with a list of nursing homes in the area or within the state of Connecticut to pick from. SW #2 indicated she does not recall if she every called back facility #1 or facility #2 to see if they had a bed available and would accept Resident #36 and noted she does not have any notes as follow up from those facilities. SW #2 indicated she was sure she had spoken to Resident #36 multiple times because Resident #36 wanted to go to another facility but didn't put notes in and does not really recall what the conversations were about other than Resident #36 still wanted to be discharged somewhere else. After surveyor inquiry, the social worker note dated 6/3/25 at 11:40 AM identified she met with the resident at bedside. Per Resident #36's request, this writer placed calls to facility #3, facility #4, and facility #2 to inquire about potential transfer options. Resident #36 was present during the calls but was unable to personally speak with any staff and left voicemails requesting return calls. Resident #36 was educated on the process, and informed the social worker will follow up with the resident once additional information is received. Interview with the Administrator on 6/3/25 at 11:25 AM identified the social worker was responsible for discharge planning and responsible to send out referrals to other facilities when a resident wants to be transferred. The Administrator indicated that the social worker would be able to fax all documents for the referral within a day and no more than 2 days. The Administrator indicated that if a resident wants to transfer to another facility, it should not take more than a couple of weeks to occur or until a bed is available. The Administrator indicated that the social worker must document in the resident's clinical record every facility that a referral was sent to and then a note if the facility accepted or denied the resident. The Administrator indicated the social worker must inform the resident if they are accepted or declined and what the resident's response is to the outcome. The Administrator indicated that if a resident wants to be discharged to another facility it is the social workers' responsibility to assist in the process and provide information regarding other facilities in the area to the resident to find out the resident's preferences. The Administrator indicated that it should not have taken months to transfer Resident #36 to another facility and if it did there must be documentation to explain why it was taking so long to happen. Review of the Resident Initiated Transfer or Discharge Request identified is the policy of the facility to uphold each resident right to make informed decisions regarding their care and place of residence, including the right to voluntarily request transfer or discharge. All such requests will be reviewed, honored when appropriate, and executed timely, coordinated, and safe manners in accordance with applicable federal and state regulations. A transfer is the movement of a resident to another facility for care. A resident or representative may initiate the request for a transfer verbally or in writing. All requests must be documented in the medical record and reviewed with the interdisciplinary team. The social services will coordinate with the resident, resident representative, and the receiving facility to ensure continuity of care. Documentation must include the date and time of the request, reason for the transfer, the resident's decision making capacity, notification to the physician, and care plan updated and discharge summary. Discharges and transfers should occur in a timely manner. Review of the facility Resident [NAME] of Rights identified residents have the right to be treated equally with other residents in receiving care and services, and regarding transfer and discharge, regardless of the source of payment for your care.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident 36) reviewed for choices, the facility failed to ensure food choices were honored. The findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses that included chronic pain, thoracic intervertebral dis degeneration, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #36 had intact cognition, required supervision with toileting, dressing, and personal hygiene and was independent with eating. The care plan dated 12/30/24 identified Resident #36's has behaviors of hoarding and hiding hard boiled eggs in dresser drawers. Interventions included getting psychiatric evaluation for food insecurity and to provide specific food preferences. Review of physician's order dated 1/1/25 to 1/31/25 directed a regular diet. The dietitian note dated 3/27/25 at 1:29 PM indicated that she was asked to see Resident #36 for meal preferences. Spoke with resident at chairside in room this afternoon. Reviewed meal preferences such as request for he/she likes tilapia, hard boiled eggs, and salads. Preferences relayed to dietary/kitchen. The dietitian quarterly assessment dated [DATE] at 12:24 PM identified the resident is on a regular diet and eats independently. Resident #36's food preferences reviewed and updated with the kitchen. Spoke with Resident #36 and he/she likes hard boiled eggs, bacon and sausage. Resident meal intakes varied, and Resident #36 was at risk for malnutrition related to chronic conditions. Recommendations and goals were to honor food preferences as needed. The dietitian note dated 5/12/25 at 10:48 AM identified she was asked to see Resident #36 because of food complaints. Spoke with Resident #36 and he/she reports discrepancies on his/her meal tickets, and that he/she dislikes scrambled eggs. Concerns and meal preferences relayed to the food service director, kitchen staff, and social worker. Interview with Resident #36 on 6/1/25 at 8:30 AM indicated that the resident has verbalized his/her preference of 2 hard-boiled eggs daily, which is on the meal ticket. Resident #36 identified he/she does not like scrambled eggs and it has been over 3 weeks since he/she has received a hard-boiled egg. Resident #36 indicated that he had spoken to the Administrator last Friday and notified him that he/she was not receiving the 2 hard-boiled eggs daily with breakfast. Resident #36 indicated the Administrator then questioned Resident #36 if he/she was aware of the price of eggs currently being over $5 a dozen. Resident #36 indicated that the Administrator did nothing to fix his/her problem of not receiving hard boiled eggs. Observation on 6/1/25 at 8:45 AM identified Resident #36 did not receive hard boiled eggs with breakfast. Resident #36's meal ticket identified Resident #36 wanted 2 hard boiled eggs daily.Interview with [NAME] #1 on 6/1/25 at 9:35 AM indicated residents that requested hard boiled eggs receive them when they are available. [NAME] #1 indicated Resident #36 requested hard boiled eggs daily and it is on the meal ticket for breakfast. [NAME] #1 indicated when the hard-boiled eggs are not available, she substitutes them with toast or sausage for Resident #36. [NAME] #1 indicated that there have not been any eggs to make hard boiled eggs for at least a month. [NAME] #1 indicated that there were not any eggs this morning to make hard boiled eggs to give to Resident #36. [NAME] #1 indicated that Resident #36 has complained about not receiving hard boiled eggs daily and she has reported it to the Food Service Director (FSD) a few times every week and FSD informs her that he will take care of it. The interview with the Food Service Director on 6/1/25 at 10:15 AM indicated he places the food orders on Wednesdays, and the deliveries are on Mondays or Tuesdays. The FSD indicated that the food order must be approved by the purchase company before the food is delivered. The FSD indicated that he did not receive the egg order for the last 2 Mondays, so he resubmitted the order on Thursday those weeks. The FSD indicated that he was not aware the facility was not receiving eggs and Resident #36 was not receiving hard-boiled eggs daily. Review of the Resident [NAME] of Rights identified residents have the right to be treated equally with other residents in receiving care and services. Residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality. Residents have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences.

Based on observation, review of the clinical record, facility documentation, facility policy, and interview, the facility failed to ensure that surveillance monitoring for a respiratory outbreak was accurate and thorough, failed to ensure that the laundry area was maintained in a clean and sanitary manner and for 1 resident (Resident #65) the facility failed to ensure that infection control protocols were implemented following the onset of respiratory symptoms during an active outbreak. The findings include:1. During a review of the infection control program with RN #1 and the DNS on [DATE] at 8:54 AM, the DNS identified that the facility had one outbreak since the prior recertification survey. The DNS identified that the facility had an influenza A outbreak in February 2025 and approximately 8 residents were involved. The DNS identified she did not have the surveillance tracking list available for surveyor review as she kept it in her office and would need to locate it for review.Subsequent to surveyor inquiry, the DNS provided a February 2025 influenza surveillance tracking log, which identified a total of 10 residents who tested positive for influenza A from [DATE] - [DATE]. A review of the clinical record for Resident #65 identified that on [DATE], Resident #65 reported symptoms of feeling feverish and coughing. The clinical record identified treatment orders including influenza testing and Tamiflu (an antiviral medication used to treat influenza A and B). Further review of the clinical record failed to identify any documentation related to the influenza testing results for Resident #65.A review of the February 2025 influenza surveillance tracking log failed to identify surveillance tracking or documentation related to Resident #65 including onset of symptoms, initiation of Tamiflu, or influenza test results. Subsequent to surveyor inquiry, the DNS provided a report dated [DATE] for Resident #65 identified as a rapid viral respiratory culture result. Review of the report identified negative results for adenovirus, influenza A, influenza B, parainfluenza 1, 2, and 3, and RSV.Interview with the DNS on [DATE] at 10:00 AM identified Resident #65 should have been added to the influenza surveillance tracking log following the report of symptoms and need for influenza testing. The DNS identified she did not have a rationale why this was not done but identified it should have been.The facility policy on Outbreaks of Communicable Disease directed that outbreaks within the facility would be promptly identified and appropriately handled. The policy further directed that the Infection Preventionist and DNS would be responsible for receiving surveillance information and tabulating data and maintaining a line listing of identified cases with the appropriate line listing report.The facility policy on the Infection Prevention Program directed that if a problem was identified with an outbreak or infection cluster, surveillance continues to determine whether the problem was controlled. The policy also directed documentation related to surveillance data must include the date an infection was detected, the resident's name, signs and symptoms and type of infection. 2. Review of the monthly environmental rounding log documentation from 12/2024 - 5/2025 failed to identify issues with the facility laundry area.Observation during a tour of the facility laundry area with RN #1 and the DNS on [DATE] at 10:00 AM identified a large basin (approximately 96 long x 18 across x 24 deep) positioned directly behind 4 out of service washing machines. The basin was observed to be approximately 50% full of cloudy light gray liquid, and approximately 25 % of the surface appeared to have a light beige film covering. The basin was also observed to have 10 deceased black winged insects on the surface of the liquid and 2 black winged insects flying directly above the surface. Interview with RN #1 and the DNS during the observation identified they were both not aware of the liquid in the basin and that the washing machines directly in front of the basin had not been in use for at least a year. Interview with the Director of Maintenance on [DATE] at 10:15 AM identified she was first notified of the liquid in the basin on [DATE] sometime in the afternoon. The Director of Maintenance identified that she had not had any reports of drain issues for the basin prior to [DATE] and that she had contacted a plumber to address the issue. The Director of Maintenance also identified that she believed the housekeeping staff were pouring mop water into both the basin and into 2 utility sinks in the laundry area that fed into the basin and that was causing the issue. The Director of Maintenance identified she would be contacting a plumber to address the issue.Observation on [DATE] at 6:30 AM of the laundry room basin identified that all water had been drained. The entire basin bottom was observed to be covered in thick black (approximately 2 inches) sludge material.Interview with Laundry Aide #1 on [DATE] at 8:05 AM identified that she had worked at the facility for 8 years. Laundry Aide #1 identified that for the past 5 years, the facility had been sending out all laundry including linens and personal items and that the laundry area with the basin was used for holding washed items that had been returned by the outside laundry service provider. Laundry Aide #1 identified that she was aware of the basin with standing water and identified the issue had been ongoing for at least a year. Laundry Aide #1 identified that she had not observed any housekeeping staff using the basin or dumping any water into the utility sinks and she was unsure where the water was coming from but identified she reported the water multiple times to the Director of Maintenance and Maintenance Assistant #1, most recently the week prior. Laundry Aide #1 identified that Maintenance Assistant #1 had attempted to fix the drain for the basin but was not successful. Laundry Aide #1 also identified that the basin had a crack in the far-left corner which sometimes would leak under the wall and into her sorting area located on the other side of the wall when the basin, which also happened the week prior. Laundry Aide #1 identified that Maintenance Assistant #1 would place blankets at the wall to prevent the water from entering her area. Laundry Aide #1 identified that the Director of Maintenance was also aware of the issue and had contacted a plumber to fix the drain for the basin a few times over the last year and estimated the drain had to be addressed every 3 months. Laundry Aide #1 also identified that the basin would only fill halfway and never filled enough to overflow.Interview with Maintenance Assistant #1 on [DATE] at 8:22 AM identified that he first became aware of the issue with the basin a couple of days prior. Maintenance Assistant #1 identified that he was not aware of any issues with the basin prior, and that he had never attempted to fix the basin or drain. Maintenance Assistant #1 identified that he was aware of water seeping through the wall into Laundry Aide #1's work area, but then identified he had no information regarding this and did not place any blankets down related to any leaks in the laundry area. Observation on [DATE] at 7:21 AM of the laundry room basin identified that the sludge material had been removed, and positioned next to the left side of the base was a flat shovel with black sludge material. Interview with Person #2 (the owner and representative for 1 of 2 plumbing service providers contracted by the facility) on [DATE] at 8:42 AM identified that plumbing services were requested related to the laundry basin on [DATE]. Person #2 identified that the laundry basin issue was related to a washcloth lodged in the sewer line which was found several feet inside of the sewer drainage pipe. Person #2 also identified he did not have any other documentation of service requests specific to the laundry basin, but there had been multiple prior calls from the facility related to issues with the sewer lines, specifically related to trash including candy wrappers being flushed into the facility toilets. The facility policy on linens directed that facility personnel must handle and store linens as to prevent the spread of infections. The policy also directed that laundry equipment must be used and maintained according to the manufacturer's instructions in order to prevent microbial contamination. 3. Resident #65 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, spinal stenosis, and chronic obstructive pulmonary disease (COPD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The care plan dated [DATE] identified Resident #65 was at risk for contracting influenza and had refused the influenza vaccine. Interventions included to reapproach the resident to offer the vaccine as indicated. Review of an influenza outbreak surveillance tracking log for February 2025 identified that the facility has an influenza outbreak that began on [DATE].A physician's order dated [DATE] directed to administer Tamiflu (an antiviral medication for influenza) prophylactic once daily at 8:30 AM.A nurse's note dated [DATE] identified that Resident #65 was notified of an influenza outbreak in the facility but declined prophylactic treatment. A nurse's note dated [DATE] at 10:35 PM identified Resident #65 reported feeling hot and coughing all day. The note further identified that an on call APRN was notified and treatment orders included influenza testing, Tussin (a cough suppressant) 10 ml every 6 hours for 3 days, and vital signs every shift for 3 days.Further review of the clinical record failed to identify documentation related to the influenza testing results for Resident #65.Review of the clinical record failed to identify any documentation related to transmission-based precautions initiated or implemented for Resident #65 following the onset of symptoms and influenza testing on [DATE].A review of the February 2025 influenza surveillance tracking log failed to identify any surveillance tracking or documentation related to Resident #65 including onset of symptoms, initiation of Tamiflu, or influenza test results. Subsequent to surveyor inquiry, the DNS provided a report dated [DATE] for Resident #65 identified as a rapid viral respiratory culture result. Review of the report identified negative results for adenovirus, influenza A, influenza B, parainfluenza 1,2, and 3, and RSV.Interview with the DNS on [DATE] at 10 AM identified Resident #65 should have been placed on droplet precautions following the report of symptoms and need for influenza testing. The DNS identified she did not have a rationale why this was not done. The facility policy on influenza prevention and control directed that the purpose of the policy was to ensure that the safety and well-being of residents, healthcare personnel, and visitors by implementing a comprehensive approach to prevent and manage influenza outbreaks in long term care facilities. The policy further directed that residents with suspected or confirmed influenza should be placed on droplet precautions, begin antiviral treatment for residents with suspected or confirmed influenza within 48 hours of symptom onset, and continue infection control measures during treatment. The facility policy on Outbreaks of Communicable Disease directed that outbreaks within the facility would be promptly identified and appropriately handled. The policy further directed that symptomatic residents and employees were considered to be potentially infected and would be assessed for the appropriate actions. The policy also directed that nursing staff were responsible to initiate isolation precautions as necessary and confine symptomatic residents to their rooms as much as feasible if indicated.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure the Infection Preventionist (IP) worked at least part-time at the facility managing the Infection Prevention and Control Program. The findings include:A review of the Infection Control program with RN #1 (IP) and the DNS on 6/2/25 at 8:54 AM identified that RN #1 was working in multiple roles at the facility including managing the Infection Prevention and Control Program, wounds, staff development, and supervision during the 7:00 AM - 3:00 PM shift. RN #1 identified that she worked on the Infection Prevention and Control Program when she was able but did not have a specific amount of time set aside to cover the program. The DNS identified that she and RN #1 worked together on the program when time allowed but they were unable to quantify the amount of time that had been designated to the Infection Prevention and Control Program. Review of an influenza outbreak surveillance tracking list for February 2025 identified that the facility had an influenza outbreak that began on 2/3/25 and ended 2/26/25. Review of the 2025 influenza outbreak surveillance tracking log failed to identify Resident #65 as a potential resident, who had symptoms consistent with the influenza, who required influenza testing. Review of the nurse staffing daily assignment sheets for February 2025 identified RN #1 was assigned as the RN supervisor during the 7:00 AM - 3:00 PM shift 21 of 28 days in February. A review of RN #1's punch details for February 2025 identified that RN #1's (RN Supervisor) schedule corresponded to her assigned RN Supervisor dates on the daily assignment sheets. Further review of the punch details failed to identify any additional punches (or additional hours worked) outside of the assigned RN Supervisor role. The facility job description for the Infection Control Coordinator, RN, identified that the primary purpose of the position was to plan, organize, develop, and direct the infection control program and its' activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs to ensure that an effective infection control program was maintained at all times. The facility assessment directed that the administrative personnel included one designated Infection Preventionist.

Based on review of facility documentation, facility policies, and interviews, the facility failed to ensure nurse aides received no less than 12 hours of in-services, annually, including dementia management training. The findings include:Review of the facility's 2024 - 2025 nursing staff in-servicing and competency documents failed to identify documentation that nurse aides completed no less than 12 hours, per year, of in-servicing and failed to identify dementia management training was completed.Facility documentation review and interview with the DNS and the Staff Development Nurse (RN #1) on 6/3/25 at 11:45 AM identified that the facility's prior Staff Development Nurse left the facility in August of 2024. RN #1 indicated that the staff development position wasn't filled, and sometime around October or November of 2024, she and the DNS took on the role of educating the nursing staff. The DNS indicated that the facility provided competency evaluations and education, on the following topics upon hire and annually: body mechanics, falls, fear of retaliation, fires safety, HIPPA, infection control, Covid-19, personal protective equipment (PPE), abuse, neglect, misappropriation, resident rights, workplace violence, codes, black out take out, hazardous materials, QAPI, and emergency preparedness. The DNS further indicated that staff in-services and competency evaluations were on-going and completed on an as needed basis, but they did not always document when training was completed; additionally supportive services had also come to the facility to provide staff education. RN #1 identified that she was unaware that nurse aides required no less than 12 hours of in-servicing, per year, and that she would estimate that the nurse aides had completed approximately 8 hours of training, in 2024. The DNS also identified that she was unaware that nurse aides required no less than 12 hours of in-servicing, per year. The DNS further indicated that the prior Staff Development Nurse did not leave a lot of records for in-servicing or competencies that had been completed. RN #1 indicated that while annual in-servicing was completed by approximately 80% of nursing staff, dementia education was not provided, in 2024 or to date in 2025. The DNS identified that she and RN #1 got the majority of the nursing staff caught up with the mandatory annual education, but dementia in-serving had fallen through the cracks. The DNS identified that she would implement a system for tracking nurse aide in-servicing hours and ensure documentation was completed for all in-services and competency evaluations. The DNS further identified that the nursing staff would be provided dementia management training.The facility's In-servicing of Nursing Assistants policy directs that all nurse aides receive regular, structured in-service education that is relevant, competency-based, and compliant with federal and state regulations to promote quality care delivery. The facility shall implement and maintain an in-service education program for nursing assistants that: includes at least 12 hours of in-service training per calendar year, addresses identified knowledge and skills deficit, and includes topics relevant to the nurse aide role and resident care, including areas such as infection control, resident rights, abuse prevention, dementia care, communication techniques, and proper body mechanics.The facility's Dementia Care Management policy directs all staff shall receive dementia-specific training upon hire and annually thereafter. Training shall include techniques for effective communication with cognitively impaired residents, de-escalation, and non-pharmacologic behavior management strategies, and recognition of abuse, neglect, and exploitation.The facility's Dementia Education policy directs that all staff working in long-term care facilities receive comprehensive training on dementia care to provide high quality, person-centered support for residents living with dementia. The training aims to enhance staff knowledge, improve communication skills, and promote a compassionate, safe, and dignified environment for residents. Staff should complete dementia training upon hire, annually, and refresher courses or additional training sessions will be provided as needed.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #19) reviewed for PASARR, the facility failed to ensure the state mental health authority was notified when the resident received a new mental health diagnosis. The findings include: The PASARR dated 9/27/23 indicated a level 2 approval without specialized services. Resident #19 has a diagnosis of major depression, anxiety, and opioid dependance. Resident #19 was admitted to the facility in 10/5/23 with diagnoses that included stoke, fibromyalgia, and chronic pain. The quarterly MDS dated [DATE] identified Resident #19 had moderately impaired cognition, required maximum assistance with toileting and touching assistance with dressing and personal hygiene, had a diagnosis of depression and was receiving antianxiety, antidepressant and opioid medications. a. Review of the census report identified Resident #19 went to the hospital on 8/15/24 to 8/21/24.A physician's order dated 8/21/24 directed to administer Seroquel (antipsychotic medication) 12.5 mg daily at bedtime for delusional disorder. The annual MDS dated [DATE] identified Resident #19 had moderately impaired cognition, had a diagnosis of depression, chronic pain, stroke, and anxiety and was receiving antianxiety, antidepressant, opioid, and antipsychotic medications. Review of the diagnosis page identified Resident #19 received the diagnosis of delusional disorder on 9/19/24.The care plan dated 9/29/24 identified Resident #19 was receiving an antipsychotic medication. Interventions included initiating nonpharmacological interventions and attempting a gradual dose reduction to the lowest possible therapeutic level as indicated by the physician.A psychiatric note, written by APRN #2 dated 10/17/24 identified Resident #19 was on the medication Seroquel for diagnosis of delusional disorder that is moderate in severity. Interview with APRN #2 on 6/3/25 at 8:04 AM indicated Resident #19 had gone to the hospital in August 2024 and returned on Seroquel with a diagnosis of mood and sleep disorder. APRN #2 indicated that Resident #19 started with delusions in the hospital but continues with the delusions now. APRN #2 indicated after her initial reevaluation from the hospital Resident #19 was started on a low dose of Seroquel but due to the delusional symptoms she had increased the Seroquel, and she gave Resident #19 the diagnosis of delusional disorder by 10/17/24. APRN #2 indicated Resident #19 still has periods of delusions and it is still an active diagnosis. b. The quarterly MDS dated [DATE] identified Resident #19 had severely impaired cognition and has a diagnosis of chronic pain. Resident #19 is receiving antidepressant, opioid, and antipsychotic medications. Review of Resident #19's diagnosis report identified a new diagnosis of dementia and paranoia disorder on 12/12/24. A Neurological Consult dated 12/12/24 identified Resident #19 has dementia with hallucinations and paranoia with severe brain atrophy. The nurses note dated 12/12/24 at 12:00 PM noted Resident #19 had returned from the neurological appointment with recommendations to start Donepezil 5 mg at bedtime and Abilify 2mg as needed if Donepezil was not effective for a diagnosis of dementia with hallucinations and paranoia. APRN and resident representative updated. The psychiatric note written by APRN #2 dated 12/19/24 identified Resident #19 had a consultation with a neurological clinic and was started on Donepezil, and Abilify will be added as needed. APRN #2 noted she will add the diagnosis of dementia with hallucinations and paranoia. Interview with the psychiatric APRN, APRN #2, on 6/3/25 at 8:04 AM indicated the resident representative took Resident #19 to a neurological appointment to see if Resident #19 had dementia in mid-December 2024. APRN #2 indicated Resident #19 was given a diagnosis of dementia, hallucinations, and paranoia at that visit. Interview with the Director of social work, SW #1, on 6/3/25 at 8:32 AM indicated that she was responsible for the PASARRs for the residents in the facility. SW #1 indicated she would inform the DNS and MDS of new mental health diagnosis and she would do the new PASARR with the new diagnosis. SW #1 indicates that she took over as the Director earlier this year and did not go back and audit any PASARR's or diagnosis prior to her taking over the position. SW #1 indicates that she has only reviewed PASARR's for the new admissions and for and changes in diagnosis going forward. After clinical record review, SW #1 identified Resident #19 had a level 2 PASARR approval ion 9/27/23 that included the diagnosis of major depression and anxiety. SW #1 indicated when Resident #19 received the new diagnosis of delusional disorder in October 2024 there should have been a new PASARR submitted and when Resident #19 received a new diagnosis of hallucinations, paranoia, and dementia in December of 2024 there should have been another submission to PASARR for re-evaluation. SW #1 indicated that she will submit today to PASARR for a new level 2 re-evaluation with the new diagnosis. Interview with SW #2 on 6/3/25 at 8:38 AM indicated she is a part time social worker now but was the full-time social worker prior to SW #1. SW #2 indicated she was responsible for Level 1 and level 2 PASARR's. SW #2 indicated she was not aware that a PASARR would need to be updated with a new mental health diagnosis until today after discussing it with SW #1. Review of the PASARR Policy identified to ensure compliance with federal and state regulations by identifying residents with mental illness (MI), intellectual disability (ID), or related conditions prior to admission to the facility and providing appropriate care and services. Residents prior to admission will undergo the federal mandated PASARR screening process, consisting of a level 1 and needed then a level 2 screening. Maintain the PASARR documentation in the resident's medical record. Re-screening is required upon a significant change in condition. Notify the PASARR authority if a current resident shows signs of MI or ID not previously identified.

Based on a review of the clinical record, facility documentation, and staff interviews for 1 of 3 residents (Resident #1) reviewed for quality of care, the facility failed to properly transcribe physician wound treatment orders. The findings include: Resident #1 had a diagnosis of Parkinson's, mild cognitive impairment, artificial hip joint, and malignant neoplasm of the thyroid. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and was dependent of care and transfers. The Resident Care Plan (RCP) dated 5/1/25 identified Resident #1 refuses incontinent care and has the potential for skin impairment. Interventions directed to encourage and elevate resident's heels while in bed and to educate resident on the risks of non-compliance. A review of the wound care progress note dated 4/22/25 identified treatment recommendations for the right heel as follows: zinc to the peri-wound (PW), collagen, Hydrofera Blue, and a dry protective dressing to be changed once a day and as needed. The physician's order dated 4/22/25 directed to cleanse the right heel with wound cleanser, apply collagen, Hydrofera Blue, and wrap in kerlix. The record review failed to identify an order to apply zinc to the peri-wound of the right heel. A review of the treatment records failed to identify Zinc was applied to the peri-wound in accordance with physician treatment recommendations. Interview with MD #1 (Wound MD) on 5/27/25 at 2:20 PM identified zinc was a part of the order and was supposed to be applied to the peri-wound of the right heel with wound cleanser, collagen, Hydrofera Blue, and wrapped in a dry dressing like a 4x4 gauze or kerlix. MD # 1 indicated that his treatment recommendations should have been followed. MD # 1 stated that if it was not applied, he could not say the wound would get worse. Interview with the Director of Nursing (DNS), Administrator, and RN #1 on 5/27/25 at 2:42 PM identified the treatment recommendation by MD # 1 on 4/22/25 stated to apply zinc to the peri-wound but, does not know why the physician order placed did not indicate the application of zinc to the peri-wound. The physician order that was placed should have matched the treatment recommendation by the wound MD. Facility Compliance with and Implementation of Physician Orders Policy dated 1/19/18 directed that orders must be entered into the resident's electronic health record promptly and accurately.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure fall risk assessments were conducted in accordance with the standards of practice. The findings include: Resident #1 had diagnoses that included cerebral infarction due to embolism, hemiplegia affecting left non-dominant side, anxiety, and vascular dementia. A care plan dated 7/21/24 identified that the resident had an ADL deficit related to a cerebral infarction with interventions that directed to assist the resident with ADL's as needed and for the resident to transfer and ambulate independently. A physician's order dated 8/18/24 directed to complete quarterly observations (assessments) for falls once day on the 9th of March, June, September, and December. The annual MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of 14 indicative of intact cognition, was occasionally incontinent of bowel, continent of bladder, independent with bed mobility and able to self-propel wheelchair, required set-up for transfers and with personal hygiene, and supervision with ambulation. The MDS identified Resident #1 had no falls since admission. Review of Resident #1's clinical record on 10/29/24 identified Resident #1's most recent fall risk assessment was completed on 12/20/2022. Interview and clinical record review with the DNS on 10/29/24 at 12:35 P.M. was unable to provide documentation to reflect Resident #1 had any fall risk assessments conducted since 12/20/2022. The DNS identified although Resident #1 was independent with transfers, not a fall risk, the quarterly fall risk assessments should have been conducted on Resident #1. The DNS could not explain why Resident #1's fall risk had not been assessed since 12/20/2022. The DNS identified the nurses are responsible for conducting the residents' quarterly fall risk assessments. The DNS indicated it is her expectation all residents have quarterly fall risk assessments conducted. Review of facility admission/quarterly observations policy identified all nursing observations are to be completed on admission and quarterly and nursing is to complete assessments on admission and quarterly.

Based on review of clinical records, interviews, and facility policy for one (1) of three (3) residents reviewed for neglect, (Resident #1), the facility failed to ensure incontinent care was provided to a resident according to the plan of care and facility policy, resulting in a finding of neglect. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable pressure ulcer of the ankle. Review of the admission assessment dated [DATE] identified Resident #1 was oriented, with memory intact, and had clear and organized thinking. The admission Assessment further indicated Resident #1 was unable to transfer and use the toilet, and utilized a bed pan and adult briefs to manage h/her bladder incontinence. Review of the Resident Care Plan dated 6/5/2024 identified Resident #1 had potential for skin impairment as evidenced by occasional incontinence with interventions that directed to apply barrier cream with incontinent care, turn and position resident at least four times per shift, and to educate resident to change positions. Interview with Person #1 (Resident #1's responsible party) on 6/12/24 at 9:53 AM identified Resident #1 was admitted to the facility at approximately 1:45 PM on 6/5/24 and h/she had stayed with Resident #1 until 9:30 AM on 6/6/24. Person #1 had requested incontinent care for Resident #1 at 4:30 PM by ringing the call bell and received no assistance or inquiry. Person #1 indicated utilizing the call bell again at 6:30 PM and 8:30 PM as Resident #1 had still not received incontinent care and again received no response. At approximately 9:00 PM, LPN #1 came into the room and administered pain medication, Person #1 requested incontinent care be provided to Resident #1. LPN #1 stated that h/she would inform NA #1 that incontinent care was needed. Person #1 further indicated that NA #1 did not provide incontinent care, and further identified that incontinent care was not provided until the beginning of the 11:00 PM to 7:00 AM shift. Interview with NA #1 on 6/12/24 at 9:19 AM identified he/she was assigned Resident #1 on 6/5/24 on the 3:00 PM to 11:00 PM shift, she had introduced his/herself to Resident #1 before dinner (he/she was unable to recall the exact time), however, she did not provide incontinent care to Resident #1. NA#1 identified that she provided Resident #1 incontinent care after collecting the dinner trays from Resident #1's room and identified that the resident had been incontinent (unsure of the time, however, dinner is served around 5:30-6:00 PM, further, the family was not in the room at the time incontinent care was provided). NA #1 identified that she provided incontinent care one time on the 3:00 PM to 11:00 PM to Resident #1. NA #1 further identified he/she was not informed of what Resident #1's care needs were and did not know what the facility's incontinent care policy was. Interview with NA #2 on 6/12/24 at 10:17 AM who worked on the 11:00 PM to 7:00 AM shift from 6/5 into 6/6/24 identified he/she checked in on Resident #1 at the start of the 11:00 PM to 7:00 AM shift and identified that Resident #2 had been incontinent and performed incontinent care. Interview with the Director of Nurses on 6/12/24 at 1:25 PM identified residents who required incontinent care should be checked four times per shift and changed if necessary. The undated facility policy for incontinent care dated directed that a resident be checked for incontinence every 2 hours and clean skin when soiled.

Based on review of clinical records, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to notify the physician for a resident who exhibited signs and symptoms and complained of pain and was not due for pain medication administration for several hours. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable vascular ulcer of the Left ankle. Review of the admission assessment dated [DATE] identified Resident #1 as oriented, had clear and organized thinking with a pain score 10 on a 0-10 pain scale (zero (0) being no pain and ten (10) being the worst pain), the pain was described as sharp, and was alleviated by medication and was increased with change of position. The Resident Care Plan dated 6/5/2024 identified Resident #1 had an actual skin impairment/potential for skin impairment as evidenced by a vascular ulcer to the Left ankle with interventions that included to turn and position resident at least four times per shift, and to educate resident to shift body positions. A physician's order dated 6/5/2024 directed oxycodone 5 milligrams (mg) (a narcotic pain medication), 1 tablet by mouth every 6 hours as needed for pain, acetaminophen (an over-the-counter pain medication) 500 mg, 2 tablets by mouth every 8 hours as needed for pain, and pain monitoring every shift. Review of the June 2024 Medication Administration Report (MAR) identified on 6/5/24 Resident #1 was administered two (2) 500 mg tablets of acetaminophen for pain at 7:35 PM on 6/5/24 with good effect and one 5 mg tablet of oxycodone at 9:15 PM on 6/5/24 for complaints of Left leg pain with effect. Further review of the MAR on 6/6/24 at 3:06 AM identified that the resident was medicated with two (2) 500 mg tablets of acetaminophen on 6/5/24 and one 5 mg tablet of oxycodone for a pain level of six (6) with good effect (4 hours after the initial complaints of pain were noted by the nursing staff). Interview with NA #2 on 6/12/24 at 10:17 PM identified Resident #1 was placed on a bedpan on 6/5/24 at approximately 11:45 PM and had groaned when the bedpan was placed and when it was removed. NA #2 had also noted that the dressing to the Left ankle wound had fallen off and needed to be replaced. NA #2 identified that Person #1 (a family member), who was in the resident's room at the time, had asked if Resident #1 could be given his/her pain medication. NA#2 indicated he/she informed LPN #1 of the request for pain medication and the need for the dressing to be replaced. NA #2 was told by LPN #1 that Resident #1 was not scheduled to receive his/her pain medication at the current time. Interview with LPN #1 on 6/12/24 at 11:23 AM identified that she was informed by NA #2 that the resident's family member had requested pain medication for Resident #1, however, it was too early for the resident to receive the pain medication. Further, Resident #1's dressing fell off his/her leg within the first hour of the 11:00 PM to 7:00 AM shift and that he/she had entered Resident #1's room with RN #1 to perform wound care and a dressing change. LPN #1 identified the resident appeared to be in pain during the dressing change because the resident winced during the dressing change. LPN #1 further identified he/she didn't think the physician should have been notified of Resident #1's pain as his/her pain medication(s) were due soon after his/her dressing change, (however, LPN #1 could not specify how long after the dressing change his/her pain medications were due). LPN #1 further indicated that because his/her nursing supervisor (RN #1) was present during the dressing change and Resident #1's expressions of pain, and further, RN #1 had asked the resident during the dressing change if he/she was in pain and the resident replied yes it was the responsibility of the nursing supervisor to contact the physician to report the pain, and the concern that pain medications were not due for administration. Interview with RN #1 the 11:00 PM to 7:00 AM nurse supervisor, on 6/12/24 at 11:06 AM identified he/she was in Resident #1's room when the dressing was changed and identified that the resident was in moaning and appeared to be in pain as he/she and LPN #1 re-dressed the wound. RN #1 indicated he/she was aware Resident #1's pain medications were not due to be administered and believed the resident's next dose of pain medication was going to be given within 30 minutes of performing the dressing change. (However, Resident #1 was not scheduled to receive her scheduled dose of either acetaminophen or oxycodone until approximately 3:00 AM according to the MAR). RN #1 indicated had he/she known her next dose of pain medications was not due until 3:00 AM (approximately 4 hours from the time of the dressing change), he/she would have called the physician to ask if the resident could receive his/her pain medications earlier that the prescribed time frames. Interview with Medical Director on 6/12/24 at 1:07 PM identified he/she would expect staff to contact him/her regarding a resident's pain and pain management options, including the administration of pain medication. Interview with the Director of Nursing Services (DNS) on 6/12/24 at 1:29 PM identified facility practice was to offer Tylenol for breakthrough pain, if it was available. If the order for Tylenol was not scheduled to be offered until a later time, the Advanced Practicing Registered Nurse or Medical Director should be contacted to discuss pain management options. Review of the facility Pain Management Policy dated 1/19/18 directed pain management was a multidisciplinary care process that included assessing the potential for pain, effectively recognizing the presence of pain, developing and implementing approaches to pain management, to conduct a comprehensive pain assessment when there is a new onset of new pain or worsening pain of existing pain. The policy further directs to contact the physician when there are significant changes in the level of the resident's pain and/or for prolonged, unrelieved pain despite care plan interventions.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to activate emergency services and failed to provide basic life support measures including CPR, until emergency services arrived for an alert resident who was a full code in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding includes: Please cross reference F658 Resident #1 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had indicated an advanced directive choice. Interventions directed to obtain a Medical Orders for Life-Sustaining Treatment (MOLST), document accurate advanced directives on the face sheet and obtain a MD order for advanced directives. Advance Directives were signed by Resident #1 dated [DATE] that indicated the resident requested to be a Full Code (resuscitate - CPR) (cardio-pulmonary resuscitation). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the incident report dated [DATE] at 1 AM identified Resident #1 was last seen by staff at 10 PM, and at 12:30 AM staff observed Resident #1 to be non-responsive, face down on the side of the bed. CPR was initiated without success and Resident #1 was pronounced at 12:40 AM. The report further indicated the staff member failed to follow policy and procedures for CPR. The nurses note dated [DATE] at 5:59 AM identified Resident #1 was observed lying on the floor, face down in his/her room with his/her head partially under the bed. Resident #1 was unresponsive, CPR was started immediately and was pronounced at 12:40 AM due to no pulse, no respirations and no heart sounds heard on auscultation, and the APRN was notified. Review of Resident #1's death certificate identified death was pronounced by RN #1 on [DATE] at 12:40 AM. Nurses note, written by the DNS, dated [DATE] at 8:07 AM identified the funeral home was notified of Resident #1's death, and note at 10 AM identified Resident #1's body was released to the funeral home. Review of the clinical record failed to identify emergency medical services (EMS) was activated and failed to identify CPR was continued after two (2) initial rounds were provided, until EMS arrived or until a physician arrived and pronounced Resident #1. Interview, clinical record review, and facility documentation review with the DNS on [DATE] at 1:26 PM identified Resident #1 was a full code, and when Resident #1 was found unresponsive, RN #1 directed LPN #1 not to call 911 and provided two (2) rounds of CPR and then stopped CPR. The DNS further indicated when Resident #1 was found unresponsive, RN #1 should have directed staff to call 911, and CPR should have continued until EMS personnel arrived. Additionally, the DNS identified RN #1 should not have discontinued performing CPR on Resident #1. Interview with RN #1 on [DATE] at 10:58 AM identified when Resident #1 was found unresponsive, he did not activate 911 or call a code blue (the facility code when a resident is unresponsive and requires CPR). RN #1 indicated Resident #1 was a full code and he provided two (2) rounds of CPR and then stopped CPR because Resident #1 had fixed pupils, mouth was fixed open, and he/she was in rigor (stiff). RN #1 identified he started CPR because he wanted to see if there were signs of life, but it was too late because there was no pulse, no blood pressure, no respirations, and he directed staff not to call 911. RN #1 indicated he then went to the supervisor's office, called the physician and the Administrator. Additionally, RN #1 identified prior to this incident, although he worked at the facility since [DATE], he was unaware of the facility policy on providing CPR to a resident who is a full code. RN #1 further indicated it was not within his scope of practice to stop CPR once he started CPR. Interview with LPN #1 on [DATE] at 11:14 AM identified that on [DATE] at approximately 12:30 AM she found Resident #1 unresponsive in his/her room, called for help immediately, and the supervisor (RN #1) came to assist. LPN #1 identified she asked RN #1 if she should call 911 and was directed to not call 911. Interview with APRN #1 on [DATE] at 1:13 PM identified when a resident who is a full code is found unresponsive, staff should start CPR and 911 should be activated. Additionally, APRN #1 identified that it is the expectation that staff would continue CPR until Emergency Medical Services (EMS) personnel arrived. APRN #1 further identified it was not within RN #1's scope of practice to make the decision to stop CPR on a resident who is a full code. Interview with MD #1 on [DATE] at 3:37 PM identified it was not within RN #1's scope of practice to decide to stop CPR on a resident who is a full code. Additionally, MD #1 identified when Resident #1 was found unresponsive, 911/EMS should have been activated and CPR should have been started and continued until EMS arrived. RN #1 failed to direct staff to call 911 when Resident #1 was found unresponsive, and although RN #1 provided two (2) rounds of CPR, RN #1 failed to continue to provide CPR until EMS arrived or a physician arrived and pronounced Resident #1. This resulted in a finding of Immediate Jeopardy. On [DATE] the facility provided the Department with an action plan that included RN #1 was suspended and received education prior to return to work. All nursing staff were educated if a resident is found unresponsive and is a full code, to initiate CPR and to direct a staff member to call 911, and not to stop CPR until a higher authority takes over, or a physician pronounces the resident. All staff were educated regarding Code Blue, the steps to follow, and a staff member is to be designated to meet EMS and direct them in the facility. Code Blue drills were conducted on ,d+[DATE] (1st shift), ,d+[DATE] (2nd shift), and [DATE] (3rd shift) to ensure nurses are following the CPR policy, calling EMS, and providing CPR until EMS arrives. An audit of all residents advance directives and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Audits and drills will continue monthly with review by QAPI. Date of correction was [DATE]. Review of the facility Cardiopulmonary Resuscitation Policy dated [DATE] directed in part, if an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is know that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual or there are obvious signs of irreversible death (e.g. rigor mortis). The policy further defined the emergency procedure for CPR as follows: if an individual is found unresponsive, briefly assess for abnormal or absence of breathing, if sudden [CONDITION(S)] is likely, begin CPR; instruct a staff member to activate the emergency response system (code) and call 911; verify or instruct a staff member to verify the DNR or code status of the individual; initiate the BLS sequence of events and continue with CPR/BLS until emergency medical personnel arrive.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure licensed staff met professional standards for quality of care, to include directing staff to activate 911 and providing basic life support measures including CPR, in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding includes: Please cross reference F678 Resident #1 was admitted to the facility in [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had indicated an advanced directive choice. Interventions directed to obtain a Medical Orders for Life-Sustaining Treatment (MOLST), document accurate advanced directives on the face sheet and obtain a MD order for advanced directives. Advance Directives were signed by Resident #1 dated [DATE] that indicated the resident requested to be a Full Code (resuscitate - CPR) (cardio-pulmonary resuscitation). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of incident report dated [DATE] at 1 AM identified Resident #1 was last seen by staff at 10 PM, and at 12:30 AM staff observed Resident #1 non-responsive, face down on the side of the bed. CPR was initiated without success and Resident #1 was pronounced at 12:40 AM. The report further indicated the staff member failed to follow policy and procedures for CPR. The nurses note dated [DATE] at 5:59 AM identified Resident #1 was observed lying on the floor, face down in his/her room with his/her head partially under the bed. Resident #1 was unresponsive, CPR was started immediately and was pronounced at 12:40 AM due to no pulse, no respirations and no heart sounds heard on auscultation, and the APRN was notified. Review of the clinical record failed to identify EMS was activated and failed to identify Resident #1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Interview, clinical record review, and facility documentation review with the DNS on [DATE] at 1:26 PM identified Resident #1 was a full code, and when Resident #1 was found unresponsive, RN #1 directed LPN #1 not to call 911 and provided two (2) rounds of CPR and then stopped CPR. The DNS further indicated when Resident #1 was found unresponsive, RN #1 should have directed staff to call 911, and CPR should have continued until EMS personnel arrived. Additionally, the DNS identified RN #1 should not have discontinued performing CPR on Resident #1. Interview with RN #1 on [DATE] at 10:58 AM identified when Resident #1 was found unresponsive, he did not activate 911 or call a code blue (the facility code when a resident is unresponsive and requires CPR). RN #1 indicated Resident #1 was a full code and he provided two (2) rounds of CPR and then stopped CPR because Resident #1 had fixed pupils, mouth was fixed open, and he/she was in rigor (stiff). RN #1 identified he started CPR because he wanted to see if there were signs of life, but it was too late because there was no pulse, no blood pressure, no respirations, and he directed staff not to call 911. RN #1 indicated he then went to the supervisor's office, called the physician and the Administrator. Additionally, RN #1 identified prior to this incident, although he worked at the facility since [DATE], he was unaware of the facility policy on providing CPR to a resident who is a full code. RN #1 further indicated it was not within his scope of practice to stop CPR once he started CPR. Review of RN #1's employee file identified a CPR card was issued [DATE] (after his date of hire). Review of the clinical record identified Resident #1's death was pronounced by RN #1 on [DATE] at 12:40 AM. Nurses note, written by the DNS, dated [DATE] at 8:07 AM identified the funeral home was notified of Resident #1's death, and note written by the DNS at 10 AM identified Resident #1's body was released to the funeral home. Interview with LPN #1 on [DATE] at 11:14 AM identified that on [DATE] at approximately 12:30 AM she found Resident #1 unresponsive in his/her room, called for help immediately, and the supervisor (RN #1) came to assist. LPN #1 identified she asked RN #1 if she should call 911 and RN #1 directed her not to call 911. Interview with APRN #1 on [DATE] at 1:13 PM identified when a resident who is a full code is found unresponsive, it is her expectation that CPR would be started and 911 would be activated. Additionally, APRN #1 identified that it is the expectation that staff would continue CPR until Emergency Medical Services (EMS) personnel arrived. APRN #1 further identified it was not within RN #1's scope of practice to make the decision to stop CPR on a resident who is a full code. Interview with MD #1 on [DATE] at 3:37 PM identified it was not within RN #1's scope of practice to decide to stop CPR on a resident who is a full code. Additionally, MD #1 identified when Resident #1 was found unresponsive, 911/EMS should have been activated and CPR should have been started and continued until EMS arrived. RN #1 failed to direct staff to call 911 when Resident #1 was found unresponsive, and although RN #1 provided two (2) rounds of CPR, RN #1 failed to continue to provide CPR until EMS arrived. Review of the facility Cardiopulmonary Resuscitation Policy dated [DATE] directed in part, if an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (cardio-pulmonary resuscitation/basic life support) shall initiate CPR unless it is know that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual or there are obvious signs of irreversible death (e.g. rigor mortis). The policy further defined the emergency procedure for CPR as follows: if an individual is found unresponsive, briefly assess for abnormal or absence of breathing, if sudden [CONDITION(S)] is likely, begin CPR; instruct a staff member to activate the emergency response system (code) and call 911; verify or instruct a staff member to verify the DNR or code status of the individual; initiate the BLS sequence of events and continue with CPR/BLS until emergency medical personnel arrive.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of one resident (Resident #2) reviewed for respiratory assessments the facility failed to ensure a resident with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen, indicative of no cognitive impairment and required limited assistance with transfers, dressing, toileting and personal hygiene and was occasionally incontinent of bladder and always continent of bowels. The Resident Care Plan (RCP) dated 8/4/22 identified antibiotic therapy for pneumonia. Interventions directed to provide medications per medical order, treatment per medical order, monitor for signs and symptoms of infection, monitor for pain and vital signs per medical order. A physician's order dated 11/9/21 directed for Oxygen at 2 liters per minute via nasal cannula for [CONDITION(S)], may remove for brief periods. A nurse's note dated 8/5/22 at 3:11 PM identified Resident #2 was seen and evaluation by APRN and a chest x-ray was ordered. The note further identified the chest x-ray results were received, the APRN was notified and a new order was received to start antibiotics [MEDICATION(S)] 400 mg daily for 10 days and [MEDICATION(S)] 100 mg twice a day for 10 days. Review of the x-ray report dated 8/5/22 identified the x-ray showed Resident #2 had pleural effusion and pneumonia. A physician's order dated 8/5/22 directed to give [MEDICATION(S)] [MEDICATION(S)] (an antibiotic for pneumonia) capsule 100 mg twice a day. An APRN note dated 8/5/22 at 7:05 PM identified Resident #2 was being seen for evaluation of Acute Kidney Injury (AKI) and leukocytosis. The note further identified Resident #2 was positive for cough (chronic) and negative for shortness of breath and wheezing. Additionally, the physical exam identified pulmonary effort was normal, decreased air movement present and rhonchi present with the plan to obtain a chest x-ray 2 views to rule out pneumonia. A physician's order dated 8/6/22 direct to give [MEDICATION(S)] (an antibiotic for pneumonia) capsule 400 mg once a day. A nurse's note dated 8/6/22 at 11:22 PM identified at around 8:35 PM RN #2 was informed that Resident #2 did not feel well. The note indicated RN #2 went to the resident's room to find resident sitting in wheelchair and stated he/she did not feel good and wanted to go to the hospital. Additionally, the note identified Resident #2 had a pulse oximeter reading of 86% (the measurement of oxygen saturation in the blood) with a heart rate of 90 and oxygen on at 3 liters. RN #2 indicated at that time she increased the oxygen to 6 liters and called 911. The note further indicated Resident #2 was alert and talking at the time the emergency personnel arrived and was transferred at approximately 9:00 PM. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review identified Resident #2 received one dose of [MEDICATION(S)] on 8/6/22. Interview with RN #1 on 9/1/22 at 10:56 AM identified he heard one of the NA's stating Resident #2 was not feeling well. RN #1 identified he was not assigned to that unit and he was not the supervisor for the shift, but he did go to the resident's room and attempted to obtain a pulse oximeter reading but the oximeter was not working at which time he went to the other unit to obtain a new oximeter and was able to obtain a reading on Resident #2's ear which was 88-90%. RN #1 indicated at that time he went and informed the supervisor (RN #2) that the resident needed to go to the hospital and went back to his unit. Interview with RN #2 on 9/1/22 at 11:55 AM identified on 8/6/22 the floor nurse from the other unit informed RN #2 that Resident #2 was not feeling well and she would need to go check on the resident. RN #2 identified she immediately went to the resident's room and the resident reported to her that he/she did not feel well and wanted to go to the hospital. RN #2 identified the pulse oximeter reading was 86% at which time she increased the resident's oxygen to 6 liters and called 911. RN #2 indicated when the EMT's arrived, Resident #2 was alert and verbal and remained coherent while the EMT's transported the resident to the ambulance. Additionally, RN #2 identified that her assessment did not consist of listening for lung sounds and just monitored the resident until the EMT's arrived. Interview with the DNS on 9/1/22 at 1:39 PM identified she would expect the RN to listen to lung sounds as part of their assessment of a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy title Change of Condition dated 1/19/18 directed in part all residents with a potential change of condition are identified in a timely manner. Any alteration in a resident's baseline indicates a potential change of condition. Any resident with a change of condition will receive timely and appropriate intervention. The RN will assess and determine if a change of condition has occurred and will make the APRN or MD aware of the resident's current condition.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 of 3 sampled residents reviewed for Abuse (Resident # 33) the facility failed to ensure that the resident was free from Abuse. The findings include: Resident # 33 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified Resident #33 as moderately cognitively impaired, no memory problems, required extensive assistance and one person physical assist with bed mobility, transfer and personal care. A care plan dated 1/10/18 identified Resident #33 had a communication problem related to neurological deficits, weak or absent voice. Interventions included to monitor for and record a decline in mood. A Reportable Event (RE) form dated 2/04/18 identified Resident #33's roommate (R#58 BIMS score 15 on MDS dated [DATE]) reported CNA #2 was being rough, angry and rude towards Resident #33 while providing care. The RE further indicated the Supervisor (RN#1) spoke to Resident #33 and his/her roommate regarding the incident and that an assessment had been completed on R#33 that identified no signs of injury, bruising or complaints of pain. A Social Worker progress note dated 2/04/18 identified that the Social Worker was informed by RN#1 that Resident #33's roommate reported that overnight CNA #2 was very rough with Resident #33. The documentation further identified the resident was making noises that indicated discomfort and/or pain as the resident is non-verbal. Additionally, the documentation indicated that CNA #2 firmly told Resident #33 to stop pressing the call bell. The Social Worker documentation identified that s/he met with Resident #33 and asked if CNA #2 hurt him/her and that Resident #33 nodded his/her head indicating yes. A statement dated 2/05/18 identified the DNS conducted an interview with Resident #33's roommate who reported CNA #2 went into Resident #33 room three (3) times during the night and that Resident #33 was moaning in some type of pain while the CNA#2 was there. The residents roommate stated, She was hurting him. Additionally, the documentation identified that when Resident #33's roommate yelled out what's going on over there, CNA#2 stopped, s/he was fresh to me and left the room. A statement obtained by the DNS on 2/05/18 at 8:30 AM identified that during an interview with R#33 identified that the resident pointed and pushed his hands away from him/her and indicated that he was treated badly by CNA#2. R#33 was noted to cry and couldn't catch his/her breath. A statement dated 2/08/18 written by CNA#2 identified that s/he might have seemed aggravated/irritated during the care of Resident#33 since ten more residents needed care and h/she denied the allegation. A statement dated 2/08/18 written by CNA # 3 identified R#33 had informed him/her on Monday (2/05) what had happened on Sunday (2/04) and that his/her roommate had reported the incident already. CNA #3 indicated h/she observed Resident #33 in the hallway and the resident could not stop crying and screaming because he/she saw CNA #2, the girl who hit him/her on the buttock and arm enter the building on 02/08/18. A statement dated 2/08/18 further identified that LPN #2 heard a gut wrenching cry in the hallway at approximately 11:00 AM and observed staff surrounding Resident #33 who was pointing his/he finger up in the air and began hitting his left thigh over and over again. LPN #2 indicated s/he referred the resident to the psych APRN for evaluation. APRN#2 Psych note dated 2/08/18 identified resident was evaluated because he/she saw the aide (CNA#2) in the hallway s/he had allegations against and the sight of him/her agitated him/her. A statement dated 2/08/18 identified the ADNS witnessed Resident #33 in the hallway at approximately 10:30 - 11:00 AM crying, scared and upset when CNA #2 came in for a meeting with the DNS and Administrator for an allegation of mistreatment towards Resident #33. The statement further identified emotional support was provided and Resident #33 was administered a PRN for anxiety which had good effect after 15 minutes. Additionally an x-ray was ordered for the left hip as Resident #33 was pointing to the area, which was negative for injury and/or fracture. Interview with the DNS on 2/20/18 at 12:30 PM identified that although a RE had been initiated, he/she was unable to provide documentation of immediate notification to DPH and subsequent notification of police, physician and family in accordance with facility policy. A second interview with the DNS on 2/20/18 at 12:45 PM identified that h/she did not consider the matter as abuse, only a customer service concern and therefore did not follow facility policy as the definition of verbal abuse included disparaging remarks and Resident #33 was a mute. Interview with CNA #4 on 2/20/18 at 2:24 PM identified that Resident #33 normally does not moan during care. Interview with CNA#2 on 2/20/18 at 2:30 PM identified that during the night she/he went into the resident's room (3) times and provided incontinent care, provided the bed control, the over bed table and placed the call bell within reach. Interview with RN # 1 in 2/20/18 at 2:34 PM identified that although h/she documented an assessment was completed on the RE, he/she failed to document the assessment in the clinical record. A subsequent interview with the DNS on 2/20/18 at 2:57 PM identified h/she began to question if physical abuse had occurred as Resident #33 became extremely emotional after observing CNA #2 come into the facility for an interview. The DNS indicated R#33's reaction was very remarkable crying, screaming and pointing to his/her thigh. Interview with Psych APRN#2 on 2/27/18 at 8:10 AM identified R#33 is nonverbal and so one would have to rely on other non - verbal cues and staff to determine resident's reliability. Interview with Resident #58 on 3/01/18 at 10:15 AM identified s/he was able to recall the night of the allegation. Resident was consistent in his/her details regarding the allegation. Resident #58 was able to describe NA #2's physical appearance. R#58 identified CNA #2 had been in the room three (3) times during the night shift and was yelling at the resident in a very rude/demanding voice. R#58 identified that although s/he could not see what was going on because the privacy curtain was pulled s/he could clearly hear CNA#2 yelling at Resident #33 and at one point Resident #33 started to cry out. Interview with R#33 on 3/01/18 at 10:30 AM identified the resident was able to clearly communicate by nodding his/her head yes and shaking his/her head no and gesturing thumbs up and thumbs down. Resident #33 identified by nodding his/her head yes that s/he recalled the allegation of abuse. When asked if CNA #2 yelled and/or was rude to him/her the resident nodded yes. When asked if CNA #2 hit him/her the resident nodded yes and with his/her left hand started to slap his/her left upper/outer thigh. During interview R#33 indicated CNA #2 hit him/hers with an open hand, like a hard slap. Resident then pointed to the hallway and then to his/her eyes and used a motion with his/her hand to indicate s/he was crying. When asked if R#33 became visibly upset when s/he saw CNA #2 in the hallway, and if s/he was crying when s/he saw CNA #2 in the hallway, Resident #33 nodded yes and started to cry and again became visibly upset. Resident #33 denied any incidences of mistreatment by CNA #2 prior to the 2/04 incident. During interview R#33 indicated s/he felt safe and was happy CNA #2 was no longer employed at the facility by smiling and gesturing thumbs up. Although interview with APRN # 3 on 3/01/18 at 11:30 AM indicated that R#33 is not a reliable historian due to his organic neurological illness and R#58 due to his history of alcohol/drug dependence and incident of obtaining contraband while in the facility, both R#33 and his roommate (R#58) were able to consistently reiterate the details of the incident on the 11-7 shift on 2/04/18 multiple times to facility staff and state surveyors. In addition R#33's extreme reaction to seeing CNA#2, the alleged perpetrator, in the facility on 2/08/18 was witnessed by multiple facility staff and documented and included in their statements during the investigation. In addition during multiple interviews with the state surveyors R#33 was able to demonstrate through gestures the actions of CNA#2 on 2/04 and reacted with extreme emotions when recounting the incident. Review of R#58's care plan failed to reflect that the resident had behaviors of confabulation or accusatory behaviors towards staff. Facility's Abuse policy defines verbal abuse as any use or oral written, or gestured language that would include disparaging and derogatory terms to residents. Facility policy defines physical abuse as any hitting slapping, pinching, kicking or controlling behavior through corporal punishment. The Abuse policy further directs reporting mechanisms to be reported to DPH within 24 hrs followed by a written report within 72 hours, that the attending physician be contacted by the RN supervisor and that alleged abuser be placed on suspension pending investigation and a complete report would be submitted to DPH within 5 working days.

Based on clinical record review, facility documentation, interviews, and observations, for 2 of 4 residents reviewed for pressure ulcers, (Resident #4 and Resident #14), the facility failed to ensure a pressure ulcer was treated, provided preventative measures to prevent a pressure ulcer, and/or ensure pressure relieving devices were administered in accordance with the physician's orders [REDACTED]. 1. Resident #4 had [DIAGNOSES REDACTED]. A 5 day Minimum Data Set ((MDS) dated [DATE] identified that the resident was alert and oriented, required extensive assistance with Activities of Daily Living (ADL's) and received a pressure reducing device for chair and the bed. Review of a Wound Care Consultant (WCC) report dated 11/10/16 completed by Medical Doctor (MD) #1 identified that the resident had a stage 2 pressure injury to the sacrum, initial measurements were 1.5 Centimeters (cm) in length and 0.5 cm in width, with 76-100% granulation with recommendations to treat the sacral wound with Alginate, cover with bordered gauze and change daily. Review of a Resident Care Plan dated 11/14/16 identified that the resident had an open area to the sacral area with interventions to administer the treatment as ordered. Review of a physician's orders [REDACTED]. Review of the medical record and November Treatment Administration Record (TAR) failed to identify that a treatment was administered to the sacral wound until 11/16/16, (6 days after the wound was identified and a treatment was ordered by MD#1). Interview and review of the medical record with the Director of Nurses (DNS) on 12/14/16 at 10:10 AM identified that although on 11/10/16 the WCC (MD#1) identified a stage 2 area to the sacrum with recommendations to apply alginate, cover with a border gauze and change daily, the physician's order [REDACTED]. Interview with the wound nurse (LPN#4) on 12/15/16 at 12:30 PM identified that he/she does the wound rounds with the WCC (MD#1) weekly and the recommendations for treatment are verbally given to him/her and he/she writes the physician's orders [REDACTED]. 2. Resident #14 had [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, required total dependence with ADL's, was at risk for pressure ulcers and received oxygen. A physician's orders [REDACTED]. A WCC note completed by MD #1 on 12/1/16 identified that there was an abrasion on the posterior left ear, the initial wound measurements were 0.8cm in length, and 0.2 cm in width with 76-100% [MEDICATION NAME], with recommendations for a Xeroform gauze followed by a band aid and apply foam protection from oxygen tubing. a. A physician order [REDACTED]. Review of the TAR for December 2016 identified that ear guards should be applied to Resident #14 ' s oxygen tubing. Review of the medical record failed to identify any pressure relief and/or ear guards had been applied preventatively to the oxygen tubing prior to 12/1/16, when the abrasion was identified. Interview with the WCC (MD#1) on 12/20/16 at 11:00 AM identified that he believed that the abrasion to the left ear was caused by the pressure form the oxygen tubing and that he/she had not coded it as pressure on the wound care flow sheets because he was told by facility staff that it was an abrasion. Additionally, the description of the wound would be indicative of a pressure area, however, had not documented that it was pressure in the notes. Further, he/she would have expected the facility to have placed foam protectors over the oxygen tubing to prevent a pressure area to the ears from occurring. Interview with LPN#4 (the facility wound nurse) on 12/20/16 at 9:30 AM identified that it was facility protocol for residents receiving oxygen to have ear guards, but he/she was unable to find any documentation that foam ear tubing had been applied to the oxygen tubing prior to 12/1/16. Interview with the DNS on 12/19/16 at 11:00 AM identified that it would be his/her expectation for nursing to apply the foam protectors as a preventative measure to the oxygen tubing for a resident who is receiving continuous oxygen. b. Observation of Resident #14 on 12/20/16 at 1:00 PM with LPN#5 identified that the resident had a 4x4 dressing wrapped around the oxygen tubing on both ears. Interview with LPN#4 identified that although the resident should have the foam ear guards applied to the oxygen tubing, was unable to explain why the 4x4 dressings were around the oxygen tubing. Interview with the WCC (MD#1) identified that the 4x4 dressing wrapped around the oxygen tubing would not have adequate pressure relief and the foam ear guards should be used. Subsequent to surveyor inquiry on 12/20/16 the resident had the foam ear guards applied to the oxygen tubing.

Based on review of the clinical record, facility policy, facility documentation and interview for one of three residents reviewed for hydration (Resident #5), the facility failed to conduct consistent intake and output, total intake and output daily and conduct assessments for hydration when the resident was identified at risk for dehydration. The findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Hydration Evaluation dated 8/25/16 identified the resident was at risk and a care plan must be initiated to prevent dehydration. The dietitian nutritional assessment dated [DATE] identified that due to the resident's [DIAGNOSES REDACTED]. The resident's estimated fluid requirement was identified as 1669cc per day. The Minimum Data Set assessment dated [DATE] identified severe cognitive impairment and extensive assistance for personal hygiene. The interim care plan dated 8/25/16 identified potential for dehydration with interventions that included to monitor for symptoms of dehydration, monitor intake and output as indicated, provide and encourage fluids, and dietician consultation as indicated. The Advanced Practice Registered Nurse (APRN) progress note dated 11/18/16 identified it was reported that the resident had a decrease in oral status. The note indicated poor oral intake, fatigue, weakness and chronically ill looking. A [DIAGNOSES REDACTED]. The dietitian progress note dated 12/1/16 identified the resident now required a one to one feed per the nurse aide and charge nurse. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Total Intake and Output Record dated 12/6/16 identified the following fluid intake recorded: 12/6/16, 11-7am- 120cc and 7-3pm -720cc. Documentation was lacking for the 3-11pm shift and that the 24 hour total was calculated. 12/7/16, 11-7am-120cc, 7-3pm-840cc, and 3-11pm, 480 for a total of 1640cc for the 24 hour period. 12/8/16, 7-3pm, 860cc. Documentation was lacking for 11-7am and 3-11pm and that the 24 hour total was calculated. 12/9/16, 11-7am, 120cc and 7-3pm, 620cc. Documentation was lacking for 3-11pm and that the 24 hour total was calculated. 12/10/16, 7-3pm, 920cc. Documentation was lacking for 11-7am and 3-11pm and that the 24 hour total was calculated. 12/11/16, 7-3pm, 920cc. Documentation was lacking for 11-7am and 3-11pm and that the 24 hour total was calculated. Review of the December 2016 Dehydration Assessment Checklist identified the dehydration assessment was not conducted on 12/6/16 on the 7-3pm and 3-11pm shifts, 12/7/16 on the 7-3pm and 3-11pm shifts, 12/8/16 on the 7-3pm and 3-11pm shifts, 12/9/16 no assessments, 12/10/16 on the 7-3pm and 3-11pm shifts, and 12/11/16 on the 7-3pm and 3-11pm shifts. The APRN acute visit progress note dated 12/12/16 identified the resident had a dry tongue and an elevated white blood count and administration of an antibiotic for [MEDICAL CONDITION]. A [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 12/19/16 at 10:30AM identified hydration assessments are completed every night on the 11-7AM shift reviewed in the morning and referred to the APRN if an issue. The DNS did not identify how a comprehensive hydration assessment could be conducted when the intake and output was not completed every shift and was not totaled to ascertain the resident's 24 hour intake. Although the Intake and Output records identified the resident failed to consume the estimated 24 hour fluid intake and failed to consume less than 1000cc per 24 hours, the resident was not reflected on the 24 hour report, and the clinical record failed to identify the physician was notified until 12/12/16. Review of the facility Intake and Output Policy indicated an accurate record of the resident's fluid balance will be kept by nursing personnel. The 11-7am charge nurse will start the new sheets for intake and output and place the dietary recommendations on the intake and output sheet. The reason the resident is on intake and output should be put on the intake and output sheet so all team members are informed. The 11-7am supervisor will monitor this every Sunday to ensure it is completed. The 11-7am charge nurses to perform weekly dehydration assessments on the resident's intake and output. This should be done on Saturday nights for the previous week's intake and output. Place on the 24 hour report and in the dietary communication book any resident taking less than their average weekly intake. The 11-7am Supervisor will ensure the weekly dehydration assessments are completed every Saturday night. The 3-11pm charge nurse is to total the daily intake and output and place on the 24 hour report any resident consuming less than 1000cc in 24 hours for notification of the MD in the AM. A dehydration note and nurse's note should be written.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for three of six residents in the survey sample reviewed for abuse, (R#9, R#35, R#109 ), the facility failed to provide necessary care and services to residents who were dependent on staff for care and/or failed to speak appropriately to the residents. The findings include: 1. Resident #9's [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] identified that the resident was cognitively impaired, required an assist of one for activities of daily living (ADL's) and assist of two with Hoyer lift for transfers. The Resident Care Plan (RCP) dated indicated that perineal care would be provided every (q) 2 hours and as needed. Review of the facility's Perineal Care policy indicated that perineal care would be provided as needed during bathing, at bedtime and after urination and bowel movements. Review of facility documentation and interview with the DNS on 6/3/16 at 12:15 PM identified that on 3/1/16, the resident's family member had indicated that the resident's brief and wheelchair were wet with urine at 4:30 PM. The NA assigned to the resident on the evening shift, NA #1 was removed from the schedule, a body audit was completed and skin was noted to be intact. Review of the facility investigation identified that the resident was incontinent of urine at noon and was cleaned and changed, however interview with the DNS identified that, although the resident was checked at 4:15 PM and was slightly wet, perineal care was not completed at that time. Interview with NA #1 on 6/8/16 at 11:00 AM identified that he/she had checked the resident at 4:15 PM, after recreation and the diaper did not have a line on it (indicating that the diaper was wet). NA #1 indicated that the resident's family did not call nursing personnel to change the resident at 4:30 PM. NA #1 identified that he/she put Resident #9 back to bed at 5:15 PM and changed the resident at that time. 2. Resident #35's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that Resident #35 was cognitively impaired and was totally dependent on staff for bed mobility, transfers, toilet use, hygiene and locomotion. The resident had no mood and/or behavioral issues and was noted to be always incontinent of urine. The care plan dated 8/5/15 identified that the resident had a self care deficit with toileting with interventions that included to assist with toileting needs and provide privacy and dignity during care. Nurse's notes (NN) dated 9/8/15 identified that the resident approached the Administrator yesterday morning (9/7/15) regarding a disrespectful statement made by NA#9 a previous evening. The note indicated that an investigation was initiated, and notifications were made to responsible party, police, the Health Department and APRN. Social Services for emotional support provided today and will follow up. The NA#9 involved in the allegation was not scheduled until outcome of investigation is complete. Review of the facility investigation dated 9/9/15 noted that on 9/7/15 at 10:30 AM, Resident #35 reported that he/she was told to pee in the bed on the 11 PM to 7 AM shift 9/5/15 going into 9/6/15. Resident #35 also reported that the nurse aide had made derogatory comments about the resident's weight. Review of facility investigation conclusion dated 9/11/15 signed by the DNS identified that NA#9 did tell the resident to urinate in his/her brief believing that the time required to perform a mechanical lift transfer would be held up because the other NA and charge nurse were involved with other resident care. The facility disciplined NA#9 for disregarding resident dignity and was re-educated on Resident Rights and Dignity along with Customer Service and Abuse Prohibition. Interview and review of facility documentation with NA#10 on 6/9/16 at 9:45 AM identified that on the morning on 9/6/15, he/she noticed that the resident was not acting like his/herself. NA#10 identified that the resident told him/her that a NA with a head wrap had called him/her a fat ass and told the resident to urinate in his/her diaper. NA#10 identified that he/she went to get LPN#3 because he/she felt bad for the resident and reports something he/she feels is inappropriate. NA#10 identified that, at that time, the resident required a sit to stand lift and that he/she would take the resident to the bathroom because the resident was continent about 50 percent of the time. Review of the ADL flowsheet for September 2015 identified that the resident was, on occasion, continent of urine. Interview and review of facility documentation with LPN#3 on 6/8/16 at 2:05 PM, who worked on 9/6/15 on the 7-3 shift identified that NA#10 had reported an allegation of abuse to him/her and that Resident #35 was crying. LPN# 3 went to see Resident #35 who reported that NA#9 told him/her to pee in the brief and that he/she was fat. LPN#3 identified that the resident stated to him/her that he/she treats everyone with dignity and that they treat me like an animal. LPN#3 told RN #4, the Supervisor, immediately. LPN#3 had his/her med cart outside of Resident #35's room and saw RN#4 go into the room and talk to the resident. LPN#3 identified that the resident was crying like a baby and repeated that NA#9 stated he/she should urinate in the bed because NA#9 couldn't move his/her fat ass. Interview with NA#9 on 6/9/16 at 10:20 AM identified that Resident #35 rang the bell and wanted to go to the bathroom. NA#9 informed the resident that they were working short and offered the bedpan and the resident used the bedpan to urinate around 4 AM. NA#9's statement was read to him/her regarding the events that took place on the 11-7 shift on 9/5/15 going into 9/6/15 which identified that NA#9 had stated I can't use the lift by myself but let me give you the bedpan. The resident stated no, I don't want the bed pan. NA#9's statement indicated that the resident's bottom was red and hurt so he/she told the resident to void in his/her diaper and I will change and wash your bottom. The resident did void and NA#9 waited and changed the resident right away. NA#9 asked are you done? the resident stated not yet and NA#9 waited until he/she was done. After the NA#9's statement was read, NA#9 was then asked again if he/she had told the resident to urinate in his/her brief per the statement as it was read and NA#9 agreed that he/she had. Review of the facility abuse policy on 6/9/16 at 2:15 PM identified that verbal abuse is the any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families or within hearing distance, to describe residents regardless of their age, ability to comprehend or disability and that neglect is any failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness. Additionally, reporting mechanisms: include calling the Administrator or on-call designee and Director of Nursing Services and witnessed or alleged abusive action to a resident will be reported within 24 hours by telephone to the Connecticut Department of Public Health by the Administrator, Director of Nursing Services or designee. 3. Resident #109's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #109 had severe cognitive impairment, was totally dependent on staff for activities of daily living, had functional limitations to both the upper and lower extremities, nephrostomy tubes in place, and was always incontinent of bowel. The nurse's note dated 8/19/15 at 10:00 AM identified when Resident #109 was turned to be washed up, blood was noted on the resident's pillow. The resident was observed to have dried blood and matted down hair. The area was cleansed and a 3 centimeter (cm) by 1 cm laceration was noted to the lower scalp. The physician was notified and the resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The Reportable Event Form dated 8/19/15 at 8:45 AM identified Resident #109 was noted to have a 3 cm by 1 cm laceration to the head/scalp area with soft tissue swelling. The resident was transferred to the hospital. The investigation identified on 8/18/15 when the 3-11 PM Nurse Aide (NA) provided incontinent care to the resident an incident occurred. When the nurse aide had rolled the resident away from him, the side rail the nurse aide was standing next to came down. The report stated the resident rolled face first towards the nurse aide and the nurse aide caught the resident midway as the resident was rolling out of bed and then the nurse aide lifted the resident back into bed. The report identified when the resident was placed back into the bed, blood was noted on the linen and the nurse aide attempted to stop the bleeding using towels and sheets. The conclusion of the incident was the nurse aide failed to report the 8/18/15 incident to the charge nurse, Nursing Supervisor and/or the on-coming shift. Interview with 3-11 PM nurse aide, NA #2, on 6/3/16 at 12:00 PM identified on 8/15/15 while he was providing care to the resident, as he rolled the resident away from him the side rail he was standing next to came down and the resident rolled back towards the him and off the bed. NA #2 stated that he pinned the resident against the side of the bed frame and rail and picked the resident up and placed the resident back onto the bed. NA #2 identified he noticed blood on the linens, so he changed the linens, went back to work and did not report to the nurse what happened because he got scared. Interview with 11-7 AM nurse aide, NA #4, on 6/6/16 at 12:00 PM identified that NA #2 did not inform her of what had happened on the 3-11 PM shift. Interview with 7-3 PM NA #8 on 6/3/16 at 12:46 PM identified that while providing morning care she rolled the resident over onto the side and saw the pillow case stained with blood. NA #8 stated that she looked at the resident's head, saw the hair matted down with blood and reported that to the charge nurse. Interview with the former Director of Nursing (DON) on 6/6/16 at 12:25 PM identified when the laceration on the back of Resident #109's head was discovered an investigation was started. The former DON stated the investigation identified that on 8/18/15 during the 3-11 PM shift while care was provided the resident rolled out of bed. The former DON stated that the nurse aide threw the bloody linens in the laundry basket and did not report the incident to the nurse because he was scared. The former DON stated that the nurse aide was terminated related to not reporting an injury and neglect of a resident.

Based on review of the clinical record, review of facility documentation and interview for one of six sampled resident who alleged mistreatment from staff (R#93), the facility failed to ensure the resident was free from abuse. The findings include; Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified that the resident was alert, confused and required an assist of two for activities of daily living (ADL's) and assist of two with Sara lift transfer. Review of the Resident Care Plan (RCP) dated 2/8/16 identified that the resident had been known to become increasingly combative with care. An intervention directed to leave the resident and re-approach at a later time if the resident refused care. The resident's care card identified that care was with assist of 2. Review of facility documentation and interview with the DNS on 6/3/16 identified that on 2/10/16, Resident #93 sustained two skin tears (1 X 2 cm and 2 x 3 cm) to the right arm while NA #6 was providing care to the resident. An investigation was completed and determined that NA#6 restrained the resident by holding the resident's arms down to keep him/her from hitting the NA. The NA did not believe assist of 2 was on the RCP and/or care card. NA #6 was terminated. NA #6 was not available for interview at the time of the investigation.

Based on review of the clinical record, review of facility documentation and interview for two of four sampled resident's reviewed for accidents ( R# 101, R#109) the facility failed to respond to a residents elopement in a timely manor and/or increase supervision of the resident with numerous elopements from the facility and/or failed provide appropriate care and services resulting in a fall and/or failed to ensure a safe and hazard free environment. The findings include: 1. Resident #109's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #109 had severe cognitive impairment, was totally dependent on staff for activities of daily living, had functional limitations to both the upper and lower extremities, nephrostomy tubes in place, and was always incontinent of bowel. The resident care plan dated 8/4/15 potential for impaired skin integrity related to contracted extremities, incontinence, and dependent on staff for all care and repositioning. Interventions directed to turn and reposition every two (2) hours, low air loss mattress and chair pad and incontinent care every two (2) hours. The care plan under self-care deficits directed the resident required an assist of one (1) with care and a second person may be needed for repositioning and a boost in bed. The nurse's note dated 8/19/15 written at 10:00 AM identified when Resident #109 was turned to be washed up, blood was noted on the resident's pillow. The resident was observed to have dried blood and matted down hair. The area was cleansed and a 3 centimeter (cm) by 1 cm laceration was noted to the lower scalp. The physician was notified and the resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. The Reportable Event Form dated 8/19/15 at 8:45 AM identified Resident #109 was noted to have a 3 cm by 1 cm laceration to the head/scalp area with soft tissue swelling. The resident was transferred to the hospital. The investigation identified on 8/18/15 when the 3-11 PM Nurse Aide (NA) provided incontinent care to the resident, an incident occurred. When the nurse aide had rolled the resident away from him/her, the side rail the nurse aide was standing next to came down. The report stated the resident rolled face first towards the nurse aide and the nurse aide caught the resident midway as the resident was rolling out of bed and then the nurse aide lifted the resident back into bed. The report identified when the resident was placed back into the bed, blood was noted on the linen and the nurse aide attempted to stop the bleeding using towels and sheets. Interview with 3-11 PM nurse aide, NA #2, on 6/3/16 at 12:00 PM identified on 8/15/15 while s/he was providing care to the resident, as s/he rolled the resident away from him/her the side rail he was standing next to came down and while he was looking to see why the rail came down, s/he saw the resident roll back towards the side of bed with no rail and fall off the bed. NA #2 stated he caught and pinned the resident against the side of the bed frame and picked the resident up and placed the resident back onto the bed. NA #2 identified he noticed blood on the linens, so he changed the linens, went back to work and did not report to the nurse what happened because s/he got scared. Interview with 7-3 PM NA #8 on 6/3/16 at 12:46 PM identified that while providing morning care s/he rolled the resident over onto the side and saw the pillow case stained with blood. NA #8 stated that s/he looked at the resident's head, saw the hair matted down with blood and reported that to the charge nurse. NA #8 identified that the resident was quieter then he/she usually was. Interview with the former Director of Nursing (DON) on 6/6/16 at 12:25 PM identified when the laceration on the back of Resident #109's head was discovered an investigation was started. The former DON stated the investigation identified that on 8/18/15 during the 3-11 PM shift while care was provided the resident rolled out of bed. The former DON stated that the nurse aide threw the bloody linens in the laundry basket and did not report the incident to the nurse because s/he was scared. The former DON stated the nurse aide was terminated related to not reporting an injury. 2. Resident # 101's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified moderately impaired cognition, limited assistance for ADL's, and independent ambulation. The RCP dated 4/15/16 identified a potential for wandering/elopement. Interventions directed the staff to redirect as necessary, encourage recreational activities and the application of a wanderquard on the left wrist. The clinical record identified the resident eloped from the facility and/or facility grounds on five occasions between admission on 4/1/16 through 6/10/16. a. Nurse's notes dated 5/1/16 identified the resident was found outside the facility, on the grass at 2:55 PM. The front door alarm sounded. The resident was returned to the facility and revisions of the RCP were not identified. On 5/2/16 a behavioral health consult was conducted and the resident's medications were adjusted b. Nurse's notes dated 5/12/16 identified the front door alarm sounded and the resident was found in the facility parking lot at 6:30 PM. The RCP was updated to include redirect the resident to the lounge A behavioral health consult dated 5/16/16 identified the time of the resident's medications were changed c. Nurse's notes dated 5/25/16 identified the resident eloped from the facility through the main entrance door around 7:10 AM. The resident was found in the woods down the road from the facility by an outsider who stated the resident fell . The resident was transferred to the ED for evaluation and returned to the facility at 8:15 PM with bilateral knee bruises. Facility investigation of the incident on 5/25/16 identified that the third and first shift supervisors heard the main entrance alarm sounding and responded. Interview with the third shift supervisor on 6/9/16 at 11:00 AM identified that when they reached the lobby a resident seated on a sofa pointed to the door. They proceeded outside and the resident was not visible on the grass or the parking lot. All staff proceeded to search for the resident on facility grounds. Some staff utilized their cars to aid in the search. A behavioral health consult dated 5/30/16 identified the resident's Zyprexa was increased due to the worsening of wandering. The RCP was updated and directed the staff to redirect the resident away from exits and engage in activities. d. Nurse's notes dated 6/1/16 at 5:45 AM identified the resident was observed leaving the building from the left side door and proceeded to walk around the building to the front entrance. The resident refused to come back into the building. The police were notified, arrived 20 minutes later and convinced the resident to come in side. Interview with the Administrator on 6/8/16 at 10:30 AM identified that all side doors are alarmed and sound when opened. e. Nurse's notes dated 6/9/16 identified the resident exited the facility at 7:00 AM through his/her room window. Interview on 6/9/16 at 9:00 AM with the administrator, DNS, and RN#2 identified the residents sock was found next to an open window. The resident walked around the building and was found heading towards the parking lot with only one sock on. The resident was returned to the facility. A skin tear on the left hand measuring 10 cm by 5 cm was noted. The resident was placed on 1 to 1 observation until transferred to the ED for evaluation. Interview, review of the clinical record and facility documentation on 6/8/16 at 10:30 AM with the administrator and RN#2 identified that although the resident's care plan was reviewed and the resident's medications were adjusted after each incident, there is no documentation that the facility increased the resident's supervision to prevent additional elopements. 3. Resident #101's [DIAGNOSES REDACTED]. The resident care plan (RCP) dated 4/4/16 identified a problem with wandering. Interventions included to assess for ability to understand inappropriate behavior as needed. Tour of facility on 06/06/2016 at 10:46:19 AM noted facility staff at the nurse's station and R#101 ambulating independently (on east wing) and entering the bathroom adjacent to nurse without the benefit of staff assistance and remained in that room for an extended period of time. Subsequent observation of bath/shower room identified that the sharps container located on the wall had three (3) blue handled shaving razors protruding out of its receptacle. Interview with LPN#3 on 06/06/2016 at 10:58 AM s/he indicated not being aware of who was responsible for maintaining the sharps container in a safe manner. Interview with the assistant nursing director (ADON) on 6/06/2016 at 11:10 AM s/he indicated that it was all staff's responsibility to maintain the sharps container in a safe manner. 4. Observation on 6/6/2016 at 12:32 PM in room #131 identified that the wall behind the bed near the door had a missing/damaged outlet cover. Interview with Director of Maintenance on 6/9/2016 at 1:20 PM indicated that the maintenance department replaces missing outlet covers, and that there is a maintenance log communication book on every unit.

Based on resident interview, clinical record review, staff interview and review of facility policy for two of three residents in the survey sample reviewed for pain management (R # 5, #32), the facility failed to assess a new onset of pain and/or monitor the effect of pain medication. and/or for the only resident in the survey sample reviewed for [MEDICAL TREATMENT] ( R # 6) the facility failed to allocate fluids for a resident on a fluid restriction. The findings include; 1. Resident #5 ' s [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified R #5 had had no cognitive impairment. The Resident Care Plan (RCP) dated 3/23/16 identified an alteration in comfort related to generalized and/or muscle weakness. Interventions directed staff to complete pain assessment sheet, assess pain on a scale of 1-10 and document, reassess after administering pain medications and report ineffective pain medication to the MD. A physician's order [REDACTED]. A physician order [REDACTED]. An APRN note dated 5/3/16 indicated R#5 was being evaluated for leaning to the left side. The Resident stated that symptoms were new onset and acute and the resident was noted with poor posture due to weakness/dementia/cognitive impairment, resident is unable to reposition self. A PT/OT evaluation was ordered at that time. The nurse ' s note dated 5/3/16 at 3 p.m. identified: PT Evaluation for ill-fitting wheelchair. Physical therapy note on 5/6/16 documented that the Resident #5 was to receive a custom wheelchair evaluation assessment with National Seating and Mobility. The nurse ' s note dated 5/3/16 at 3 p.m. identified: PT Evaluation for ill-fitting wheelchair. Physical therapy note on 5/6/16 documented that the Resident #5 was to receive a custom wheelchair evaluation assessment with National Seating and Mobility. An APRN note on 5/16/16 indicated R#5 had complaints of a headache which began one day prior. R#5 reports that residents ' symptoms are acute. APRN impression notes no acute findings - Tylenol. The last Resident pain evaluation was dated 1/22/16 and identified that R#5 had no pain and R#5 did not verbalize pain. Review of the Medication Administration Record for May 2016 did not identify any new areas of pain as indicated by the APRN ' s evaluation of headache on 5/16/16. Only one pain assessment was done as ordered on May 1, 2016 on the 11-7 shift. No other pain assessments were documented from May 1, 2016 (7-3) through May 31, 2016 although APAP was administered as ordered on [DATE], 5/6/16, 5/7/16, 5/10/16, 5/14/16, 5/15/16, 5/16/16, 5/17/16, 5/23/16, 5/24/16, 5/29/16, and 5/31/16. The medication administration record and/or nurse ' s notes lacked any documentation as to why the medication was administered or a re-assessment of the medication effectiveness after the medication was administered. Review of the Medication Administration Record for June 2016 indicated that APAP 650 mg was administered on 6/1/16, 6/2/16, 6/3/16, 6/7/16 and 6/8/16. The reason (headache) for pain medication administration was documented once on 6/7/16 at 6:30 a.m. There were no other reasons for pain medication administration documented and/or reassessment of the effectiveness of medication administered. In an interview with Resident #5 on 6/6/16 at 11:05 AM, he/she noted that he/she has pain in the back and left hip and that Tylenol does not work. Resident #5 reported that s/he keeps telling them and it doesn ' t work. Resident #5 told the nurse and the aide but does not recall the names. An interview with LPN#7 on 6/8/16 noted that Resident #5 has occasional headaches and has old hip pain since s/he was young. LPN# 7 reported that the reason for pain medication administration and effectiveness should be documented on the Medication Administration Record. Interview with ADON on 6/8/16 noted that nurses are to document the reason for pain medication administration and reassess one hour after to determine the effectiveness. The effectiveness is also to be documented on the Medication Administration Record. Review of facility policy on pain assessment and management program identified that an evaluation of a resident ' s pain will be performed upon each new report of pain and the effectiveness of the current medication regime will be monitored and evaluated. 2. Resident #32's [DIAGNOSES REDACTED].# 32 was alert and oriented with no memory problems and had chronic hip pain A resident careplan dated 5/13/16 identified a problem with alteration in comfort related to a history of a right [MEDICAL CONDITION]. A physician's orders [REDACTED]. An APRN note dated 6/1/16 indicated R #32 was complaining of hip pain. The resident indicated the Tylenol was not effective. The plan indicated provide [MEDICATION NAME] as needed as there are no acute changes. Review of a medication record dated 5/13/16 - 5/23/16 noted R #32 received [MEDICATION NAME] 5 mg po seven (7) times. None of the seven administrations indicated where and/or what type of pain the resident was experiencing. Five (5) out of the seven (7) medication administrations did not indicate the effect and/or result of the pain medication. Review of a medication record dated 6/1/16 - 6/9/16 indicated the resident received [MEDICATION NAME] 5 mg po nineteen (19) times. None of the nineteen administrations indicated where and/or what type of pain the resident was experiencing. Sixteen (16) out of the nineteen (19) administrations did not indicate the effect and/or result of the pain medication. An interview on 6/6/16 at 2:34 PM with R # 32 indicated he/she had pain every day and the pain medication he/she was receiving provided only minimal temporary relief. An interview on 6/8/16 at 9:30 AM with LPN # 3 indicated the facility policy was to document on the back of the medication record and/or nurse's notes if the resident received relief from as needed pain medications. Review of a facility policy on pain assessment and management program indicated monitoring and evaluation of the pain management plan of care included effectiveness of the current medication regime and the need for dose changes. 3. Resident # 6 ' s [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] identified Resident # 6 was severely cognitively impaired. The Resident Care Plan (RCP) identified a potential for alteration in fluid status. Interventions included maintaining I& O ' s - update MD prn and maintain fluid restriction. A physician's order [REDACTED]. Nutritional assessment notes identify the fluid restriction of 1200 cc but failed to delineate amount of fluid between dietary and nursing. Interview with LPN #4 on 6/9/16 indicated that nursing does not have specific amounts of fluids ordered to be given with medications per shift. Interview with food service supervisor on 6/9/16 at 10:50 a.m. indicated that the dietician notifies dietary of any fluid restriction for a resident. The food service supervisor printed out a day ' s menu with the amount of fluid to be given at each meal. The meal ticket did not note that the resident had a specific fluid restriction. Review of facility policy on fluid restriction identified the facility will accurately monitor the restricted amount of a resident ' s fluid intake by having nursing and dietary collaboratively determine the amount of fluid restriction to be used by nursing for medication administration with the remaining amount of fluid to be given during daily meals and snacks.

Based on clinical record review, review of facility documentation, observations, and interviews for one of five residents reviewed for pressure ulcers (Resident #113), the facility failed to ensure a pressure ulcer was monitored, assessed and/or treatment provided that resulted in immediate jeopardy and/or for two of five residents in the survey sample reviewed for pressure ulcers (Residents #12 and #109), the facility failed to ensure that the residents' plan of care for the prevention of pressure ulcers was consistently implemented. The findings include: 1. Resident #113 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified fluid filled blisters on bilateral heels and no wounds on the left ankle. The Braden Scale assessment dated [DATE] identified the resident was at a high risk to develop pressure ulcers. The Minimum Data Set ((MDS) dated [DATE] identified cognitive impairment, total assistance for bed mobility, incontinence of bowel and bladder and one (1) stage 2 pressure ulcer. The care plan dated 3/22/12 identified impaired skin integrity with interventions that included monitoring of the areas by the wound nurse weekly. The wound note dated 4/19/12 identified that R#113 had developed a Deep Tissue Injury (DTI) with dry eschar on the left lateral ankle. The wound notes dated 4/19/12 and 4/26/12 identified the left lateral ankle as a DTI with 100 percent eschar, however a measurement of the area was not conducted. The 5/3/12 weekly pressure ulcer worksheet completed by the facility's wound nurse identified the left outer malleolus as a Stage III pressure ulcer that measured 0.5 centimeters (cm.) by 0.6 cm. by 0.2 cm. The wound note dated 5/3/12 by Advanced Practice Registered Nurse #1 (APRN) #1 identified the left ankle wound remained intact with eschar. APRN #1 recommended treating the ankle wound with Alginate and foam dressing daily. The 5/10/12 weekly pressure ulcer worksheet identified the left outer malleolus was a Stage II pressure ulcer that measured 0.5 centimeters (cm.) by 0.6 cm. by 0.2 cm. Review of the clinical record on 7/11/12 at 8:00 AM failed to reflect the treatment recommended by APRN #1 on 5/3/12 was implemented. Additionally, the clinical record failed to reflect wound monitoring and assessment was conducted from 5/10/12 through 7/10/12 (61 days later). On 7/10/12 at 1:35 PM, Person #1 requested that the surveyor observe a wound on R #113's left ankle. Observation at the time identified an open wound with drainage present on the left ankle (malleolus). The resident's sock was also noted with dried drainage and no eschar and/or scab was noted in the sock. Person #1 indicated at the time of the observation that R #113's wound had been there for a while and that there was not any change in the wound. Person #1 reported to the surveyor that this is what the wound had looked like for weeks. Interview with the Director of Nurses (DNS) on 7/10/12 at 3:15 PM indicated R #113 had a history of [REDACTED]. Observation of R #113's left lateral ankle with the DNS on 7/10/12 at 3:30 PM identified a unstageable 1.1 centimeter (cm) by 1.1 cm by 0.3 cm open, cratered area with 90 % slough. The wound was moist with a calloused peri wound. APRN #2 assessed the wound at the time and directed to cleanse the area with Normal Saline followed by the application of Santyl and to cover the area with a dry clean dressing daily for 14 days. Interview with Nurse Aide (NA) #3 on 7/11/12 at 9:20 AM identified she was a regular care giver for the resident and the wound on the left ankle had been present for as long as he/she could remember. Interview with the Wound Nurse (RN #2) on 7/11/12 at 9:30 AM identified she did not implement the treatment to the left ankle wound on 5/3/12 because she/he thought APRN #1 would initiate the treatment. Interview with the DNS on 7/12/11 at 9:00 AM identified the facility weekly wound rounds are conducted by the facility APRN, Wound Nurse and Treatment Nurse. The DNS indicated the Wound Nurse was responsible to implement all recommendations from the APRN. The DNS was unable to identify why the Wound Nurse did not implement the recommended treatment on 5/3/12. APRN #1 was unavailable for interview. Further attempts to interview the Wound Nurse (RN#2) were unsuccessful. Review of facility policy directed that wound assessment documentation will be completed at least weekly and when changes in the wound are apparent. Weekly wound documentation is to include a description of the area including color, size, depth, location, extent of any drainage condition of the wound area and surrounding area and any signs of infections. In addition, the policy directed that treatment of [REDACTED]. The above deficiency resulted in a finding of Immediate Jeopardy. 2. Resident #12 (R #12) had [DIAGNOSES REDACTED].#12 was cognitively impaired and required total assistance for most Activities of Daily Living (ADLs). Physician orders [REDACTED]. The care plan dated 6/19/12 identified R #12's risk for skin impairment with interventions that included to use devices for skin protection as needed although was not specific to the devices to be utilized. On 7/11/12 at 9:15 AM, R #12's nasal cannula was observed to be in place. Upon further observation with the assistance of facility staff, the back of R #12's left ear where the tubing of the nasal cannula rested, appeared to be reddened, non blanchable, and lacked padding/protection of the area. On 7/12/12, a second observation at 11:40 AM with RN #3 identified that although the reddened area behind R #12's left ear was still present, the area was blanchable though still lacked protection of the area from contact with the tubing. Subsequent to surveyor inquiry, ear guards were placed over the nasal cannula tubing to reduce pressure to the area behind R #12's ears. 3. Resident #109 (R #109) was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing note dated 5/4/12 identified that R #109's heels were pink and boggy and that a 2.0 centimeter (cm.) area on the left heel was peeling. The Minimum Data Set ((MDS) dated [DATE] identified that R #109 was totally dependent on staff for all Activities of Daily Living (ADLs). The care plan dated 6/26/12 identified the risk for pressure ulcers with interventions that included to off load heels when in bed. During a body audit conducted on 7/10/12, R #109's right heel was identified as boggy and a physician order [REDACTED]. Observation on 7/11/12 at 10:00 AM in the presence of LPN #3 identified that R #109 was lying in bed without the benefit of heel elevation/offloading. R #109's right heel was observed to remain boggy. Interview with RN #3 at the time of the observation identified that the facility had available equipment to ensure that the resident's heels could be off loaded. A second observation on 7/12/12 at 9:10 AM identified that R #109 was lying in bed but remained without the benefit of off loading of the heels in accordance with the plan of care. Review of facility policy directed that a specific treatment plan to prevent pressure ulcers be developed and implemented.

Based on review clinical records, review of facility policies, review of facility documentation, observations, and interviews for one of five residents reviewed for pressure ulcers (Resident #113), the facility failed to ensure that the resident's pressure ulcer was monitored and/or assessed and/or treated in accordance with professional standards of practice. The findings include: 1a. Resident #113 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified that no wounds were present on the resident's left ankle. The Braden Scale assessment dated [DATE] identified that R #113 was at a high risk to develop pressure ulcers. The Minimum Data Set ((MDS) dated [DATE] identified that R #113 was cognitively impaired, required total assistance for bed mobility, was incontinent of bowel and bladder and one (1) stage 2 pressure ulcer. The care plan dated 3/22/12 identified impaired skin integrity with interventions that included monitoring of the areas by the wound nurse weekly. The wound note dated 4/19/12 identified that R#113 had developed a Deep Tissue Injury (DTI) with dry eschar on the left lateral ankle. The wound notes dated 4/19/12 and 4/26/12 identified the left lateral ankle as a DTI with 100 percent eschar, however a measurement of the area was not conducted. b. The 5/3/12 weekly pressure ulcer worksheet completed by the facility's wound nurse identified the left outer malleolus as a Stage III pressure ulcer that measured 0.5 centimeters (cm.) by 0.6 cm. by 0.2 cm. The wound note dated 5/3/12 by Advanced Practice Registered Nurse #1 (APRN) #1 identified the left ankle wound remained intact with eschar. APRN #1 recommended treating the ankle wound with Alginate and foam dressing daily. The 5/10/12 weekly pressure ulcer worksheet identified the left outer malleolus was a Stage II pressure ulcer that measured 0.5 centimeters (cm.) by 0.6 cm. by 0.2 cm. Review of the clinical record on 7/11/12 at 8:00 AM failed to reflect the treatment recommended by APRN #1 on 5/3/12 was implemented. Additionally, the clinical record failed to reflect wound monitoring and assessment was conducted from 5/10/12 through 7/10/12 (61 days later). On 7/10/12 at 1:35 PM, Person #1 requested that the surveyor observe a wound on R #113's left ankle. Observation at the time identified an open wound with drainage present on the left ankle (malleolus). The resident's sock was also noted with dried drainage and no eschar and/or scab was noted in the sock. Person #1 indicated at the time of the observation that R #113's wound had been there for a while and that there was not any change in the wound. Person #1 reported to the surveyor that this is what the wound had looked like for weeks. Interview with the Director of Nurses (DNS) on 7/10/12 at 3:15 PM indicated R #113 had a history of [REDACTED]. Observation of R #113's left lateral ankle with the DNS on 7/10/12 at 3:30 PM identified a unstageable 1.1 centimeter (cm) by 1.1 cm by 0.3 cm open, cratered area with 90 % slough. The wound was moist with a calloused peri wound. APRN #2 assessed the wound at the time and directed to cleanse the area with Normal Saline followed by the application of Santyl and to cover the area with a dry clean dressing daily for 14 days. Interview with Nursing Assistant #3 (NA #3) on 7/11/12 at 9:20 AM identified she was a regular care giver for the resident and the wound on the left ankle had been present for as long as he/she could remember. Interview with the Wound Nurse (RN #2) on 7/11/12 at 9:30 AM identified she did not implement the treatment to the left ankle wound on 5/3/12 because she/he thought APRN #1 would initiate the treatment. Interview with the DNS on 7/12/11 at 9:00 AM identified the facility weekly wound rounds are conducted by the facility APRN, Wound Nurse and Treatment Nurse. The DNS indicated the Wound Nurse was responsible to implement all recommendations from the APRN and was unable to identify why the Wound Nurse did not implement the recommended treatment on 5/3/12. APRN #1 was unavailable for interview. Further attempts to interview the Wound Nurse (RN#2) were unsuccessful. Review of facility policy directed that wound assessment documentation will be completed at least weekly and when changes in the wound are apparent. Weekly wound documentation is to include a description of the area including color, size, depth, location, extent of any drainage condition of the wound area and surrounding area and any signs of infections. In addition, the policy directed that treatment of [REDACTED]. According to the Government'sPressure Ulcers Treatment Guide http://www.woundheal.com/healing/clinicalPrintVersion.htm, re-assess pressure ulcers at least weekly. If the condition of the patient or wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted.

Based on review of the clinical record and staff interview for one of five residents reviewed for pressure ulcers, Residents #113, the facility failed to ensure that the plan of care related to pressure ulcers was reviewed and/or revised when the resident was identified to have developed a Stage III pressure ulcer on the left malleolous. The findings include: 1. Resident #113 (R #113) was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified no wounds on the left ankle. The Braden Scale assessment dated [DATE] identified that R #113 was at a high risk to develop pressure ulcers. The Minimum Data Set ((MDS) dated [DATE] identified cognitive impairment, total assistance for bed mobility, incontinence of bowel and bladder. The care plan dated 3/22/12 identified impaired skin integrity with interventions that included monitoring of the areas by the wound nurse weekly. The wound note dated 4/19/12 identified that R#113 had developed a Deep Tissue Injury (DTI) with dry eschar on the left lateral ankle. The wound notes dated 4/19/12 and 4/26/12 identified the left lateral ankle as a DTI. Review of the 5/3/12 weekly pressure ulcer worksheet completed by the facility's wound nurse identified that R #113 had a Stage III pressure ulcer on the left outer malleolus that measured 0.5 centimeters (cm.) by 0.6 cm. by 0.2 cm. The wound note dated 5/3/12 by Advanced Practice Registered Nurse #1 (APRN) #1 identified the left ankle wound remained intact with eschar. APRN #1 documented his/her recommendation for treatment of [REDACTED]. Review of the clinical record on 7/11/12 at 8:00 AM failed to reflect the treatment recommended by APRN #1 on 5/3/12 was implemented and/or that the resident's plan of care was revised to include the development of the new pressure ulcer on the left ankle (left outer malleolus). Interview with the Wound Nurse (RN #2) on 7/11/12 at 9:30 AM identified she did not implement the treatment to the left ankle wound on 5/3/12 because she/he thought APRN #1 would initiate the treatment. On 7/10/12 at 1:35 PM, Person #1 requested that the surveyor observe a wound on R #113's left ankle. Observation at the time identified an open wound with drainage present on the left ankle (malleolus). The resident's sock was also noted with dried drainage and no eschar and/or scab was noted in the sock. Person #1 indicated at the time of the observation that R #113's wound had been there for a while and that there was not any change in the wound. Person #1 reported to the surveyor that this is what the wound had looked like for weeks. Interview with the Director of Nurses (DNS) on 7/10/12 at 3:15 PM indicated R #113 had a history of [REDACTED]. Observation of R #113's left lateral ankle with the DNS on 7/10/12 at 3:30 PM identified a unstageable 1.1 centimeter (cm) by 1.1 cm by 0.3 cm open, cratered area with 90 % slough. The wound was moist with a calloused peri wound. APRN #2 assessed the wound at the time and directed to cleanse the area with Normal Saline followed by the application of Santyl and to cover the area with a dry clean dressing daily for 14 days. Interview with the DNS on 7/12/11 at 9:00 AM identified the Wound Nurse was responsible to implement all recommendations from the APRN and was unable to identify why the Wound Nurse did not implement the recommended treatment on 5/3/12. Review of facility policy directed that an individualized comprehensive plan of care be developed for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs.

Based on review of clinical records, review of RE, and interviews for one of four sampled residents reviewed with allegations of abuse (R#108), the facility failed to ensure the resident was free from mistreatment. The findings include: Resident # 108's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident as alert, with short and long-term memory problems, no behaviors, and total care with bed mobility, personal hygiene and toilet use. A RCP dated 10/6/11 identified a problem with the resident's refusal of care and treatments. Interventions included to monitor for times of refusals, leave the resident and re-approach at a later time. A physician's orders [REDACTED]. A nurse's note dated 11/10/11 (3 PM -11 PM) noted the Foley catheter was changed and draining hematuria. Review of a RE investigation dated 11/11/11 on 1/05/12 at 10:30 AM with the Administrator and Nurse Consultant indicated that R#108's roommate reported that R#108 had been slapped during the night. A 1.5 cm x 0.5 cm skin tear was observed on the resident's left wrist during morning care. The investigation indicated that LPN #1 and LPN #2 requested that NA#1 and NA #2 assist with a procedure, by holding R#108's arms/hands while the LPN's inserted a urinary catheter. R#108 was noted to be combative and uncooperative during the procedure. The Administrator indicated although she could not substantiate that the resident was slapped, facility staff did not follow the facility's protocol for providing care in a dignified manner. All four staff members were terminated at the time for substantiated abuse and all employees were educated on resident abuse. Interview with LPN #1 on 1/05/12 at 3:30 PM identified that LPN#2 requested that she insert a Foley catheter into R#108 on 11/11/11 at approximately 1:00 AM because he had been unable to catheterize the resident. At that time she administered [MEDICATION NAME] 0.25 mg by mouth because the resident had been yelling that day. LPN#1 indicated that she requested that NA#1 and NA#2 hold the resident's arms, because the resident was attempting to push her away during the catheter insertion. LPN#1 indicated the resident was yelling and calling the staff foul names. LPN#1 indicated that she would have stopped the procedure, however the resident never made the request. LPN #1 also indicated that at no time did she witness any staff member slap or cover the resident's mouth. Interview with LPN #2 on 1/05/12 at 4:30 PM identified that he worked on 11/10/11 (3:00 PM-11:00 PM shift). LPN#2 indicated that at approximately 12:30 PM while completing his documentation he remembered that he was suppose to replace R #108's Foley catheter. When LPN#2 went into R#108's room to change the Foley catheter, the resident refused at that time. LPN #2 indicated that he notified the (11 PM-7 AM shift ) supervisor who instructed him to tell the LPN#1, the (11 PM-7 AM) nurse. LPN#2 indicated when he told LPN #1, LPN #1 indicated that she could not do it herself and requested assistance with the procedure. LPN#2 indicated he assisted LPN#1 by spreading R#108's legs while NA #1 and NA #2 held the resident's hands. LPN #1 then catherized the resident while the resident was heard yelling and swearing during the procedure. LPN#2 indicated that at no time did he observe any staff member cover the resident's mouth or slap the resident. Interview with NA #1 on 1/06/12 at 6:00 AM identified that on 11/11/11 at approximately 1:00 AM she was asked to hold R#108's hand while LPN #2 catheterized the resident. NA#1 indicated that she held one hand and NA#2 held the other. NA#1 indicated she held R#108's hand loosely because the resident attempted to swing at LPN # 2 who was catheterizing the resident. NA#1 indicated the resident was yelling and swearing and stated, "I am going to get you." At no time did she or any other staff member observe hitting and/or covering the resident's mouth. Interview with NA #2 on 1/06/12 at 6:20 AM identified that on 11/11/11 at approximately 1:00 AM she was asked to calm R#108 while LPN #2 catheterized the resident. NA#2 indicated she was on one side of the resident and NA #1 was on the other side. NA#2 indicated that R#108 was yelling and using curse words. NA#2 indicated that she held the resident's hand because the resident was trying to get at LPN #2 with his/her hands/arms. NA#2 indicated that at no time did she observe any staff slap and/or cover the residents' mouth.