Every finding on record at Whispering Pines Rehabilitation and Nursing Center

East Haven, Connecticut · CCN 075294

26 findings across 12 inspections, in the inspector's own words, 7 of them at actual harm or above.

Data as of September 30, 2026, released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Inspection of March 17, 2026

6 findings

F689J · Immediate jeopardy, isolated

Based on interviews, observations, clinical record review, and review of facility policy for the only sampled resident reviewed for respiratory care (Resident #37), the facility failed to ensure a safe environment for a resident on continuous oxygen by allowing the resident (Resident #37) to self-administer a petroleum-based ointment into the nose without physician orders, proper assessment, or staff interventions. Staff failed to recognize and act on posted safety signage (Oxygen in use-no petroleum lotions), did not remove the flammable material from the room, and did not educate the resident on the danger of using petroleum products with oxygen therapy. These systemic failures exposed the resident to a significant fire risk and potential respiratory complications, resulting in Immediate Jeopardy. The findings include: Resident #37's diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia (abnormally elevated level of carbon dioxide in the blood), and mild persistent asthma. Physician orders dated 2/2/26 and currently in effect directed Oxygen at 2 liters/minute via nasal cannula related to hypoxia for COPD and continuous every shift. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 had intact cognition and was dependent with toileting, transfers, and bed mobility. The MDS further indicated Resident #37 had a diagnosis of COPD and was on oxygen therapy. The Resident Care Plan (RCP) dated 2/8/26 identified Resident #37 had an altered respiratory status and difficulty breathing related to oxygen dependence and COPD. Interventions included to monitor Resident #37 for signs and symptoms of respiratory distress and providing oxygen as ordered. Observation during the initial tour on 2/25/26 at 11:16 AM identified Resident #37 was in bed and on continuous oxygen at 2 liters/minute via nasal cannula with 1 small (1.76 ounce) uncovered tub of VapoRub ointment (petroleum based chest rub) which was 1/2 empty and 1 large (3.53 ounce) uncovered tub of VapoRub ointment which was 1/2 empty on the overbed table (resting over the bed and in front of the resident). A second observation and an interview with Resident #37 on 2/25/26 at 1:45 PM identified his/her family member had brought in the 1 small (1.76 ounce) tub of VapoRub ointment and 1 large (3.53 ounce) tub of VapoRub ointment and the resident had been self-administering the ointment inside of his/her nose (with the oxygen running) several times a day for months. Resident #37 indicated he/she applied the ointment when his/her nose felt dry or congested. Resident #37 stated the nursing staff was aware he/she had the 1 small (1.76 ounce) uncovered tub of VapoRub ointment and 1 large (3.53 ounce) uncovered tub of VapoRub ointment on his/her overbed table and was self-administering the ointment inside of his/her nose while on continuous oxygen. Additionally, Resident #37 identified he/she had been on continuous oxygen for many years at home and also while at the facility. Resident #37 noted he/she was never told and was not aware he/she should not have been using a petroleum-based ointment while receiving oxygen. Observation, interview, and review of the clinical record with LPN #1 on 2/25/26 at 1:48 PM identified she was aware Resident #37 had 1 small (1.76 ounce) uncovered tub of VapoRub ointment and 1 large (3.53 ounce) uncovered tub of VapoRub ointment on the overbed table (which sat over the bed and in front of the resident). LPN #1 indicated she was aware that the resident was self-administering the petroleum-based ointment inside of his/her nose while on continuous oxygen. LPN #1 indicated although there was a sign attached to the doorway of the resident's room which indicated 'Oxygen in use, no petroleum lotions', she was not aware the resident should not have been using the VapoRub ointment and had never noticed the signage outside of the resident's room. Review of the clinical record with LPN #1 identified Resident #37 did not have a current order for the VapoRub and the resident had not had a self-administration of medication assessment completed. LPN #1 indicated she would need to remove the 2 tubs of VapoRub ointment from Resident #37's room. An observation of 2/26/26 at 11:25 AM identified, subsequent to surveyor inquiry, the 1 small (1.76 ounce) uncovered tub of VapoRub ointment and 1 large (3.53 ounce) uncovered tub of VapoRub ointment on Resident #37's overbed table had been removed. Interview and review of the clinical record with the DNS on 3/2/26 at 12:42 PM identified Resident #37 should not have had or been self-administering VapoRub ointment inside of his/her nose while on continuous oxygen. The DNS indicated the nursing staff should have ensured Resident #37 did not have VapoRub ointment in his/her room as indicated on the oxygen in use' sign attached to the resident's doorway, as it was a potentially flammable item. The DNS stated the nursing staff should have educated Resident #37 to not use the VapoRub ointment because it was unsafe, and the resident should not have been self-administering a medication without a physician's order or a completed self-administration of medication assessment. Additionally, the DNS identified although the nursing staff had been educated on oxygen administration, she would need to provide further education. Interview with the Branch Manager of the oxygen company on 3/11/26 at 12:34 PM identified VapoRub ointment was a petroleum-based material which, due to flammability, should not come into direct contact with the flow of oxygen. The Branch Manager indicated oxygen and VapoRub ointment were flammable materials and if Resident #37 was applying VapoRub ointment inside of his/her nose while receiving oxygen via nasal cannula there would be a risk for burns or potential fire. The Branch Manager identified use of petroleum-based products should not be used around oxygen and it would be unsafe to be in a resident's room while oxygen was running. Interview with NA #2 on 3/11/26 at 1:20 PM identified several weeks ago Resident #37 had 1 small (1.76 ounce) uncovered tub of VapoRub ointment and 1 large (3.53 ounce) uncovered tub of VapoRub ointment located on the overbed table. NA #2 indicated she was aware that the resident was self-administering the petroleum-based ointment inside of his/her nose while on continuous oxygen. NA #2 indicated although there was a sign attached to the doorway of the resident's room which indicated Oxygen in use, no petroleum lotions', she was not aware the resident should not have been using the VapoRub ointment and had never noticed the signage outside of the resident's room. Review of the VapoRub ointment ingredients and directions for use indicated it was a petroleum jelly-based ointment, and it should not be applied inside of the nostrils. Review of the VapoRub ointment Safety Data Sheet (SDS) identified it had a moderate flammability hazard rating. Review of the facility policy, Oxygen Therapy, undated, directed oxygen therapy shall be provided for residents in an emergency situation and for long term use oxygen may only be administered by licensed personnel.The above deficiency resulted in the finding of Immediate Jeopardy (IJ). After observations made on 2/25/26 and 2/26/26 (with additional information obtained on 3/11/26), the facility Administrator was provided with the IJ template on 3/11/26 at 2:37 PM and submitted a removal plan which was approved by the State Agency on 3/11/26.The Removal Plan noted in part, that the DNS immediately removed the VapoRub from Resident #37's room, provided education to all staff, resident families and a message was also sent to all staff via a messaging system ensuring that oil or petroleum-based products were not used with residents receiving oxygen therapy. Additionally, staff were educated to immediately remove and notify the resident and nursing supervisor of any petroleum-based products found in resident rooms for residents receiving oxygen therapy. Additionally, the removal plan identified a housewide audit was completed on 2/25/26 (after initial observations were made of VapoRub being used by Resident #37) ensuring that no resident on oxygen was utilizing any petroleum-based products. The facility will implement weekly audits on each unit to ensure no petroleum-based products were in the room of residents receiving oxygen.Observations on 3/13/26 identified that the facility implemented the removal plan and the IJ was removed.

F580E · No harm, potential for more than minimal, pattern

Based on interviews, review of the medical record, facility documentation, observations, and facility policy for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure the Advanced Practice Registered Nurse (APRN) was notified when a medication was unavailable and therefore not administered. The findings include: 1.Resident #7 was admitted to the facility in October 2025 with diagnoses that included dementia, urinary retention with chronic foley use and urinary tract infections (UTI).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was severely cognitively impaired and required set up for meals, moderate assistance for activities of daily living (ADLs) and had a urinary foley catheter.Physician orders dated 2/3/26 directed to administer D-Mannose (supplement used for prevention of UTIs) 1 scoop of powder two times a day.The Resident Care Plan (RCP) dated 2/6/26 identified Resident #7 had Catheter-Associated UTIs related to indwelling urinary catheter use with interventions that included to change catheter tubing as indicated, monitor for evidence of catheter blockage or leakage and flush per physician's orders. Additional interventions included monitoring for signs and symptoms of UTI and perform careful peri-care. The Medication Administration Record (MAR) for February 2026 identified that D-Mannose was not administered on 2/13/26 at 8:30 AM (but at 4:30 PM and on 2/25/26 at 8:30 AM signed as administered despite being unavailable on previous and subsequent days/shifts), 2/25/26 at 4:30 PM, 2/26/26 at 8:30 AM and 4:30 PM and 2/27/26 at 8:30 AM (a total of 5 missed doses) as it was coded as being unavailable. Nursing notes from 2/3/26 through 2/26/26 lacked documentation that the APRN was notified that Resident #7 had 5 missed doses of the D-Mannose.A progress note dated 2/24/26 and written by Advanced Practice Registered Nurse (APRN) indicated that Resident #7 was at high risk for developing UTI due to a chronic urinary foley and poor fluid/ food intake. Additionally, the APRN progress note did not reflect that Resident #7 missed 5 dose(s) of the D-Mannose.Interview with APRN #1 on 3/3/26 at 9:00 AM identified that she was not made aware of the D-Mannose not being available or administered on 2/13/26 at 8:30 AM, 2/25/26 at 4:30 PM, 2/26/26 at 8:30 AM and 4:30 PM until 2/27/26 when she wrote alternative orders to give Cranberry 250 milligrams (mg) tablets if D-Mannose is unavailable. She indicated that the policy was that the practitioner was to be notified when medication was not given due unavailability and that she should have been notified that Resident #7 missed doses. She indicated that although she was trialing the medication on several residents, she would have written alternative orders for Cranberry tabletsSubsequent to surveyor inquiry, alternative orders were obtained from APRN #1 on 2/27/26 for Cranberry tabs 450 milligrams (mg) to be given if D-Mannose was unavailable for Resident #7.2. Resident #14's diagnoses included dementia, diabetes, benign prostatic hyperplasia (BPH) (enlarged prostate) and calculus of ureter (kidney stone).The Resident Care Plan (RCP) dated 12/11/25 identified Resident #14 was incontinent of bowel and bladder related to impaired mobility. Interventions included to offer the urinal every 2 hours and monitor for signs and symptoms of urinary tract infection (UTI): pain, burning, blood-tinged urine, no urinary output, elevated temperature, urinary frequency, foul smelling urine, altered mental status, and change in eating habits.The RCP further identified Resident #14 was at risk for urinary complications related to BPH. Interventions included administering medications as ordered, monitoring dysuria, hematuria, urgency, and frequency of urination, and report changes to the medical doctor.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, had no behavior symptoms, had no rejections of care, had urinary incontinence, was not on a urinary toileting program, required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers.A physician order dated 2/3/26 directed to administer D-Mannose oral powder (supplement used for prevention of UTIs) 1 scoop by mouth, 2 times a day for UTI prevention.The Medication Administration Record (MAR) for February 2026 identified D-Mannose was not administered 26 out of 51 opportunities (50.9%) as follows: on 2/8/26 at 4:30 PM, 2/9/26 at 8:30 AM, 2/10/26 at 8:30 AM, 2/11/26 at 8:30AM and 4:30 PM, 2/12/26 at 8:30 AM and 4:30 PM, 2/13/26 at 8:30 AM and 4:30 PM, 2/20/26 at 8:30 AM and 4:30 PM, 2/21/26 at 8:30 AM, 2/22/26 at 8:30 AM and 4:30 PM, 2/23/26 at 8:30 AM and 4:30 PM, 2/24/26 at 8:30 AM and 4:30 PM, 2/25/26 at 8:30 AM and 4:30 PM, 2/26/26 at 8:30 AM and 4:30 PM 2/27/26 at 8:30 AM and 4:30 PM, and 2/28/26 at 8:30 AM and 4:30 PM and was coded by the nurse in the electronic medical record as being unavailable.Review of the February 2026 MAR and nursing notes dated 2/1/26 through 2/26/26 identified out of the 22 times D-Mannose was coded in the electronic health record (EMR) as not given due to being unavailable, 19 nursing notes were written which indicated D-Mannose was unavailable and/or on order from the pharmacy but failed to identify the physician or Advanced Practice Registered Nurse (APRN) was notified that D-Mannose was unavailable and Resident #14 had missed 22 doses.An APRN progress written by APRN #1 on 2/20/26 at 2:35 PM indicated Resident #14 was seen for a rash on the face. The progress note identified Resident #14 had history of UTIs and had a stent placed in his/her ureter in August of 2023. The progress note failed to reflect that Resident #14 had missed doses of the D-Mannose.A physician progress note dated 2/23/26 at 8:15 AM identified Resident #14 was seen for a 30-day regulatory visit. The progress note identified Resident #14 had a diagnosis of BPH unspecified for whether urinary tract symptoms were present. The note failed to reflect Resident #14 had missed doses of the D-Mannose.An APRN progress written by APRN #1 on 2/25/26 at 3:32 PM indicated Resident #14 was seen for UTI symptoms and follow-up on facial rash. The progress note identified Resident #14 complained of dysuria (pain on urination) on exam, that he/she had a history of UTIs and stent placement, and that Resident #14 was supposed to have the ureteral stent replaced last year but refused the procedure. The progress note identified Resident #14 had suprapubic tenderness with palpation and the treatment plan was to send a urine test, obtain blood work, encourage fluids, monitor output, and monitor for signs and symptoms of UTI. The progress note failed to reflect that Resident #14 had missed doses of the D-Mannose which had been ordered for UTI prevention.Interview with Licensed Practical Nurse (LPN) #2 on 2/27/26 at 1:48 PM identified that D-Mannose was not available on the medication cart and that it had not been available since about 2/20/26. LPN #2 identified the ADNS orders the D-Mannose and when it's available she brings it to LPN #2 to place inside the medication cart. LPN #2 further identified she did not notify the APRN that the D-Mannose was unavailable but indicated she had notified the ADNS.Subsequent to surveyor inquiry, a nursing note dated 2/27/26 at 4:41 PM identified D-Mannose was unavailable, the APRN was notified, and a new order was received to administer Cranberry tablet 450 mg by mouth every 24 hours as needed if D-Mannose was unavailable.Subsequent to surveyor inquiry an APRN order dated 2/27/26 directed to administer D-Mannose oral powder 1 scoop by mouth 2 times a day for UTI prevention with the directive that if unavailable may use cranberry tablet.An APRN order dated 2/27/26 directed to administer Cranberry tablet 250 milligrams (mg) by mouth every 24 hours as needed (PRN) for UTI prophylaxis with the directive to use when D-Mannose was unavailable.Interview with APRN #1 on 3/3/26 at 10:25 AM identified the order for D-Mannose was put in place by herself as a trial to see if adding it into the resident's regimen would have beneficial results. She indicated that she was sure she had overheard the D-Mannose was unavailable, but that she had not felt that the missing doses would be harmful and so hadn't recommended anything further until she was notified by a nurse on 2/27/26 that the D-Mannose was unavailable.3.Resident #20 was admitted to the facility in August 2023 with diagnoses that included dementia with behaviors, sepsis, and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired, required set up for meals and was dependent on staff for all other activities of daily living (ADLS). The Resident Care Plan (RCP) dated 1/26/26 identified Resident #20 had UTIs related to weakness and urosepsis (UTI that spreads to the blood stream) with interventions that included to monitor vitals signs, monitor for signs and symptoms of UTI and notify the practitioner, provide frequent incontinent care as needed, encourage fluids during the day to promote prompt voiding, incontinent care before lunch, and monitor and report to MD any possible medical causes of incontinence.APRN #1's progress note dated 2/3/26 identified Resident #20 was at high risk for UTIs due to dementia, incontinence, use of briefs and limited mobility. Resident #20 to start on D-Mannose for urinary tract health and UTI monitoring once a shift for retention, urgency, frequency, hematuria (blood in urine), dysuria (painful urination) and hesitation, encourage fluids, and follow up with urology as needed. Physician orders dated 2/3/26 directed to administer D-Mannose powder one scoop 2 times a day, urinary tract monitoring (UTI) every shift, document in nursing notes and Advanced Practice Registered Nurse (APRN) book of any signs and symptoms of UTI.The Medication Administration Record (MAR) for February 2026 identified D-Mannose was not administered on 2/8/26 at 4:30 PM, 2/9/26 at 8:30 AM and 4:30 PM, 2/11/26 at 8:30AM and 4:30 PM, 2/12/26 at 8:30 AM, 2/13/26 at 8:30 AM and 4:30 PM, 2/19/26 at 4:30 PM, 2/20/26 at 8:30 AM and 4:30 PM, 2/21/26 at 8:30 AM and 4:30 PM, 2/23/26 at 8:30 AM, 2/25/26 at 8:30 AM and 4:30 PM, 2/26/26 at 8:30 AM and 4:30 PM and 2/27/26 at 8:30 AM (a total of 19 missed doses) as it was coded as being unavailable.Nursing notes from 2/3/26 through 2/26/26 lacked documentation that the APRN was notified that Resident #20 had missed 19 doses of the D-Mannose.Interview, review of medical supplier packing slips (2/4/26 and 2/10/26) with the Central Supply Clerk and observation of over-the counter (OTC) supply closet on 2/2/7/26 at 11:20 AM identified that she was responsible for placing OTC order for the D-Mannose with the medical supply vendor. She indicated that she only places orders for OTC medications from the medical supply vendor and the nurses are responsible for ordering medications including OTCs if needed from the pharmacy. She indicated on 2/4/26 she did not place an order for the D-Mannose (even though physician's orders were initiated on 2/3/26). An order was placed for 1 case of the D-Mannose powder (12 bottles in a case) on 2/10/26 from the medical supply vendor. The order had not yet come in from the vendor as of 2/27/26. The packing slips identified that no order was placed on 2/4/26 and an order was placed on 2/10/26 for one case. She indicated that she had made the Assistant Director of Nursing (ADNS) aware that the medication was on back order. She could not recall the exact date but as soon as she was made aware, she notified the ADNS, which was at least a week or two ago. An inspection of the OTC cabinet identified there was D-Mannose available.An interview with LPN #2 on 2/27/26 at 12:00 PM identified that there was not any D-Mannose in any of the medication carts and she could not administer D-Mannose to any of her residents that were to receive the medication. She could not recall when it was last available, but she had made the ADNS and central supply aware when it was no longer available. Interview with Pharmacy Manager on 3/3/26 at 8:30 AM identified that the pharmacy does have D-Mannose available for order in capsule form but not powder. She indicated that an initial order was received on 2/3/26 for Resident #20 for the D-Mannose. However, when the pharmacy had called back (3 times) they were unable to get a response from the charge nurse or the nursing supervisor regarding sending the D-Mannose. She indicated that a pharmacy technician had spoken to a nurse on 2/3/26 at 12:35 PM but was not sure who it was but believed it was the ADNS and was told not to send D-Mannose as it was an OTC medication.Interview with APRN #1 on 3/3/26 at 9:00 AM identified that she was not made aware of the D-Mannose not being available until 2/27/26 when she wrote alternative orders Cranberry tablets 250 milligrams if D-Mannose unavailable. She indicated that the policy was that the practitioner was to be notified when medication was not given due unavailability and that she should have been notified that Resident #20 had missed several doses. She indicated that although she was trialing the medication on several residents, she would have written alternative orders for Cranberry tablets.Interview with the ADNS on 3/3/26 at 10:00 AM indicated that she was aware that D-Mannose was unavailable and the nurses and central supply had notified her sometime in February 2026, but she could not recall the date. She indicated that she did not contact the pharmacy to inquire if D-Mannose was available as they have a formulary the facility follows. The ADNS also did not recall speaking to someone from the pharmacy on 2/3/26. In addition, she indicated that she had not notified APRN #1 but thought she already knew that the D-Mannose was unavailable. The ADNS indicated that the policy was the practitioner was to be notified if medication was not given due to unavailability. She indicated that she should have contacted the pharmacy to inquire if D-Mannose was available for order. Furthermore, she indicated that the nurses should not have signed off medication as given if it was not available and could not explain why it was signed off on one shift as given and documented on the following shift as being unavailable.Subsequent to surveyor inquiry, alternative orders were obtained from APRN #1 on 2/27/26 for Cranberry tabs 450 milligrams (mg) to be given if D-Mannose was unavailable for Resident #20.Review of the Refill Orders policy (pharmacy policy) directed, in part, to anticipate refill needs and not to wait until a resident is completely out of a medication before reordering.Review of the Medication Administration-General Guidelines policy directed, in part, if a medication with an active order cannot be located within the medication cart, the medication room, and/or other units in the facility should be searched to locate the medication, The policy directed if the medication cannot be located to contact the pharmacy. The policy directed if a regularly scheduled medication is unavailable or refused it is documented within the EMR and an explanatory nursing note is written. The policy further directed if (xx consecutive doses-no number entered) of a vital medication are not administered the physician is notified and the nurse documents the notification and the response.

F684E · No harm, potential for more than minimal, pattern

Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #3) reviewed for hospitalization, the facility failed to perform fingerstick glucose levels for a diabetic resident as indicated by the providers note and for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure medications were administered per physician's orders. Additionally, for 1 of 3 residents (Resident #65) reviewed for non-pressure skin conditions, the facility failed to identify a change in wound status. The findings include: 1.Resident #3's diagnoses included Type 2 diabetes with diabetic neuropathy, history of sepsis related to urinary tract infections, chronic kidney disease, and morbid obesity. An annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #3 was cognitively intact and independent with wheelchair mobility; however, the resident required assistance for transfers into the wheelchair. Physician orders initially dated 11/3/23 and currently in effect directed Metformin twice daily as a hypoglycemic agent for diabetes management, as well as orders to administer Insta Glucose gel if Resident #3's blood glucose level fell below 70 mg/dL with symptoms, or below 60 mg/dL regardless of symptoms, followed by a repeat glucose check in 15 minutes. The orders also directed the administration of intramuscular Glucagon if the resident was unable to swallow, with a subsequent repeat blood glucose check. The provider additionally ordered annual laboratory studies that included a glucose value however, the provider did not issue orders for routine fingerstick blood glucose monitoring. In the absence of such orders, nursing staff did not have the means to obtain timely, real time glucose values necessary to identify and respond to hypoglycemia or hyperglycemia in accordance with the ordered treatment parameters. A progress note written by Advanced Practice Registered Nurse (APRN) #1 and dated 10/24/25 at 5:05 PM directed staff to monitor Resident #3's finger stick blood glucose levels, A1C, B12 levels, and weights in relation to the resident's diabetes diagnosis. Despite the APRN's directive for finger stick glucose monitoring, there were no corresponding physician orders put in place, and nursing staff did not complete routine finger stick blood glucose checks as indicated in the APRN's progress note. The Resident Care Plan (RCP) dated 12/1/25 identified Resident #3's diagnosis of diabetes, with interventions that included obtaining fasting serum blood glucose levels as ordered and monitoring for signs and symptoms of both hypoglycemia and hyperglycemia. On 12/18/25 at 12:07 PM, lab work consisting of a Basic Metabolic Panel (BMP) and a Complete Blood Count (CBC) were collected by a diagnostic laboratory and radiology service, which included a blood glucose level test. A nursing note dated 12/18/25 at 12:41 PM identified Resident #3 exhibited new symptoms, including lethargy, new onset cough, and nausea. Resident #3 was tested for COVID 19 and the result was positive. Additionally, the nursing note indicated the APRN was present in the facility and was made aware of Resident #3's new symptoms and positive diagnosis of COVID-19. The documentation did not indicate that a fingerstick blood glucose level was obtained at that time, although facility policy noted nursing staff were directed to obtain a finger stick blood glucose level on diabetic residents receiving insulin or oral hypoglycemic agents if the resident exhibited any signs or symptoms of hypoglycemia or hyperglycemia, including mental status changes, dizziness, headache, or lethargy (see facility policy below). A nursing note dated 12/18/25 at 3:31 PM identified that the laboratory notified the facility of a critically high blood glucose level of 709 milligrams/deciliter (mg/dL). The APRN was informed, and Resident #3 was subsequently sent to the emergency department for further evaluation. An APRN note dated 12/18/25 at 6:20 PM indicated that nursing staff reported a critically high glucose level of 709 mb/dL following bloodwork obtained in response to Resident #3's symptoms of lethargy, poor appetite, nasal congestion, cough, and a positive COVID 19 diagnosis. The resident was subsequently transferred to the emergency department for a higher level of care due to the risk of hyperosmolar hyperglycemic state and the anticipated need for intravenous insulin, intravenous fluids, and continuous monitoring. Resident #3 returned to the facility from the acute care hospital with a diagnosis of hyperglycemia and having been administered intravenous insulin and fluids. Interview and clinical record review with APRN #1 on 3/2/26 at 10:20 AM noted that the clinical record failed to reflect that she had written orders to monitor Resident #3's finger stick blood glucose levels as noted in her progress notes from 10/24/25. Additionally, APRN #1 identified although she recommended finger-stick blood glucose monitoring from her progress note, she could not identify how often to perform finger sticks. APRN #1 also stated that an order should have been written to obtain a fingerstick glucose and that obtaining orders was a shared responsibility between the providers and the nursing staff. APRN #1 further stated that she would ordinarily review laboratory results that she recommended as part of her assessment but was unsure why she did not identify that fingerstick glucose levels were not being obtained for Resident #3. An interview with the ADNS on 3/2/26 at 11:15 AM identified that nursing reviews new orders every 24 hours but does not currently have a process to identify recommendations from the provider progress notes. The ADNS further indicated that although nursing can help place new orders, they must then be signed by the provider. Review of the facility's undated policy titled, Hypoglycemia Management, indicated that nursing staff were directed to obtain a finger stick blood glucose level on diabetic residents receiving insulin or oral hypoglycemic agents if the resident exhibited any signs or symptoms of hypoglycemia or hyperglycemia, including mental status changes, dizziness, headache, or lethargy. 2.Resident #7 was admitted to the facility in October 2025 with diagnoses that included dementia, urinary retention with chronic foley use and urinary tract infections (UTI). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was severely cognitively impaired and required to be set up for meals, moderate assistance for activities of daily living (ADLs) and had a urinary foley catheter. Physician orders dated 2/3/26 directed to administer D-Mannose (supplement used for prevention of UTIs) 1 scoop of powder two times a day. The Resident Care Plan (RCP) dated 2/6/26 identified Catheter-Associated UTIs related to indwelling urinary catheter use as a concern with interventions that included to change catheter tubing as indicated, monitor for evidence of catheter blockage or leakage, flush per physician's orders, monitor for signs and symptoms of UTI, and perform careful peri-care. The Medication Administration Record (MAR) for February 2026 identified that D-Mannose was not administered on 2/13/26 at 8:30 AM (but at 4:30 PM and on 2/25/26 at 8:30 AM signed as administered despite being unavailable on previous and subsequent days/shifts), 2/25/26 at 4:30 PM, 2/26/26 at 8:30 AM and 4:30 PM and 2/27/26 at 8:30 AM (a total of 5 missed doses) as it was coded as being unavailable. Nursing notes from 2/3/26 through 2/26/26 lacked documentation that the APRN was notified that Resident #7 had missed doses of the D-Mannose. An Advanced Practice Registered Nurse (APRN) #1 progress note dated 2/24/26 indicated that Resident #7 was at high risk for developing UTI due to chronic urinary foley and poor fluid/ food intake. Her progress note did not reflect that Resident #7 missed dose(s) of the D-Mannose. Subsequent to surveyor inquiry, alternative orders were obtained from APRN #1 on 2/27/26 for Cranberry tabs 450 milligrams (mg) to be given if D-Mannose was unavailable for Resident #7. 3. Resident #14's diagnoses included dementia, diabetes, benign prostatic hyperplasia (BPH) (enlarged prostate) and calculus of ureter (kidney stone). The Resident Care Plan (RCP) dated 12/11/25 identified Resident #14 was incontinent of bowel and bladder related to impaired mobility. Interventions included to offer the urinal every 2 hours, encourage fluids during the day to promote prompted voiding responses, monitor intake and output, and monitor for signs and symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, no urinary output, elevated temperature, urinary frequency, foul smelling urine, altered mental status, and change in eating habits. The RCP further identified Resident #14 was at risk for urinary complications related to BPH. Interventions included administering medications as ordered, monitoring for dysuria, hematuria, urgency, and frequency of urination, and report changes to the medical doctor. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, had no behavior symptoms, had no rejections of care, had urinary incontinence, was not on a urinary toileting program, required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers. A physician order dated 2/3/26 directed to monitor every shift (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM) for signs and symptoms of UTI and document any signs or symptoms in a nursing note and Advanced Practice Registered Nurse (APRN) book. a. A physician order dated 2/3/26 directed to administer D-Mannose oral powder (supplement used for prevention of UTIs) 1 scoop by mouth 2 times a day for UTI prevention. The Medication Administration Record (MAR) for February 2026 identified D-Mannose was not administered 22 out of 51 opportunities (43.1%) as follows: on 2/8/26 at 4:30 PM, 2/9/26 at 8:30 AM, 2/10/26 at 8:30 AM, 2/11/26 at 8:30AM and 4:30 PM, 2/12/26 at 8:30 AM and 4:30 PM, 2/13/26 at 8:30 AM and 4:30 PM, 2/20/26 at 8:30 AM and 4:30 PM, 2/21/26 at 8:30 AM, 2/22/26 at 8:30 AM and 4:30 PM, 2/23/26 at 8:30 AM and 4:30 PM, 2/24/26 at 8:30 AM and 4:30 PM, 2/25/26 at 8:30 AM and 4:30 PM, and 2/26/26 at 8:30 AM and 4:30 PM and was coded in the electronic medical record as being unavailable. Nursing notes dated 2/1/26 through 2/26/26 identified 19 nursing notes which indicated D-Mannose was unavailable and/or on order. Interview, review of medical supplier packing slips (2/4/26 & 2/10/26) and observation of over-the counter (OTC) supply closet with the Central Supply Clerk on 2/27/26 at 11:20 AM identified that she was responsible for placing the over the counter (OTC) order for D-Mannose with the medical supply vendor. She indicated that she only placed orders for OTC medications from the medical supply vendor and the nurses were responsible for ordering medications including OTCs if needed from the pharmacy. She indicated on 2/4/26 she did not place an order for the D-Mannose (even though physician's orders were initiated on 2/3/26). An order was placed for 1 case of the D-Mannose powder (12 bottles in a case) on 2/10/26 from the medical supply vendor. The order had not yet come in from the vendor as of 2/27/26. The packing slips identified that no order was placed on 2/4/26 and an order was placed on 2/10/26 for one case. She indicated that she had made the Assistant Director of Nursing (ADNS) aware that the medication was on back order and not available. She could not recall the exact date but as soon as she was made aware, she notified the ADNS, which was at least a week or two ago. On 2/27/26 at 11:20 AM an inspection of the OTC cabinet identified that there currently was D-Mannose available. Interview with Licensed Practical Nurse (LPN) #2 on 2/27/26 at 1:48 PM identified that D-Mannose was not available on the medication cart and that it had not been available since about 2/20/26. LPN #2 identified the ADNS orders D-Mannose and when it's available, she brings it to LPN #2 to place in the medication cart Subsequent to surveyor inquiry, a nursing note dated 2/27/26 at 4:41 PM identified D-Mannose was unavailable, the APRN was notified, and a new order was received to administer Cranberry tablet 450 mg by mouth every 24 hours as needed if D-Mannose was unavailable. Subsequent to surveyor inquiry an APRN order dated 2/27/26 directed to administer D-Mannose oral powder 1 scoop by mouth 2 times a day for UTI prevention with the directive that if unavailable may use cranberry tablet. b. An APRN order dated 2/27/26 directed to administer Cranberry tablet 250 milligrams (mg) by mouth (a discrepancy with the nursing note dated 2/27/26 that identified a new order for Cranberry tablet 450 mg) every 24 hours as needed (PRN) for UTI prophylaxis with the directive to use when D-Mannose was unavailable. Interview and clinical record review with LPN #2 on 3/2/26 at 12:45 PM identified D-Mannose was now available and on the medication cart, but it had not been available at 8:30 AM when she administered Resident #14's medications. LPN #2 identified she had administered a 450 mg cranberry tablet to Resident #14 in substitution for D-Mannose that was unavailable, but she had not signed it out in the electronic medical record (EMR). LPN #2 identified she hadn't realized there was an actual PRN order in place for the cranberry tablet and indicated she had administered the cranberry tablet based on the directions written within the D-Mannose order. Additionally, LPN #2 identified she did not know why the PRN order was for a 250 mg cranberry tablet because the facility did not have that dosage available which was the reason she had given a 450 mg cranberry tablet (despite the APRN order dated 2/27/26 to administer 250 mg cranberry tablet). Interview with the ADNS on 3/2/26 at 1:20 PM identified that the nurses should be signing off the PRN order for a cranberry tablet in the EMR when the D-Mannose was unavailable. She identified the nurses should know to look for a PRN order after reading the direction within the D-Mannose order instructing to give the cranberry tablet if the D-Mannose was unavailable. Additionally, she identified that no medication should be given without a physician order and/or without signing it out in the EMR. The ADNS further identified the order for cranberry tablet 250 mg must have been a data entry error because the facility only had cranberry 450 mg available. Subsequent to surveyor inquiry an APRN order dated 3/2/26 directed to discontinue the order for Cranberry tablet 250 mg every 24 hours PRN and directed to start the order to administer Cranberry tablet 450 mg by mouth every 24 hours PRN for UTI if D-Mannose was unavailable. Review of the MAR for March 2026 identified that D-Mannose was not administered 3 out of 4 opportunities (3/1/26 at 8:30 AM, 3/1/26 at 4:30 PM, and 3/2/26 at 8:30 AM) with 3/1/26 coded as Hold/see nurse note, and 3/1/26 at 4:30 PM and 3/2/26 at 8:30 AM both coded as Other/see nurse note. Additionally, the MAR failed to identify that either dosage of Cranberry tablet was signed out as administered due to D-Mannose being unavailable on 3/1/26 or 3/2/26. Interview with APRN #1 on 3/3/26 at 9:00 AM identified that she was not made aware of the D-Mannose not being available until the facility notified her on 2/27/26 when she wrote alternative orders directing Cranberry tabs 450 milligrams (mg) to be given if D-Mannose was unavailable. (Please refer to F 580). Interview with the ADNS on 3/3/26 at 10:00 AM indicated that she was aware that D-Mannose was unavailable and the nurses and central supply had notified her sometime in February 2026 but could not recall the date. She indicated that she did not contact the pharmacy to inquire if D-Mannose was available as they have a formulary the facility follows. The ADNS also did not recall speaking to someone from the pharmacy on 2/3/26. In addition, she indicated that she had not notified APRN #1 but thought APRN #1 already knew that the D-Mannose was unavailable. 4. Resident #20 was admitted to the facility in August 2023 with diagnoses that included dementia with behaviors, sepsis, and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #20 was severely cognitively impaired, required to be set up for meals and was dependent on staff for all other activities of daily living (ADLS). The Resident Care Plan (RCP) dated 1/26/26 identified Resident #20 had UTIs related to weakness and urosepsis (UTI that spreads to blood stream) with interventions that included monitoring vital signs, monitoring for signs and symptoms of UTIs and notify practitioner, provide frequent incontinent care as needed, encourage fluids during the day to promote prompt voiding, incontinent care before lunch, and monitor and report to MD any possible medical causes of incontinence. A progress note written by APRN #1 and dated 2/3/26 identified Resident #20 was at high risk for UTIs due to dementia, incontinence, use of briefs and limited mobility. Resident #20 to start on D-Mannose for urinary tract health and UTI monitoring once a shift for retention, urgency, frequency, hematuria (blood in urine), dysuria (painful urination) and hesitation, encourage fluids, and follow up with urology as needed. Physician orders dated 2/3/26 directed to administer D-Mannose powder one scoop 2 times a day and urinary tract monitoring (UTI) every shift document in nursing notes and Advanced Practice Registered Nurse (APRN) book of any signs and symptoms of UTI. The Medication Administration Record (MAR) for February 2026 identified D-Mannose was not administered on 2/8/26 at 4:30 PM, 2/9/26 at 8:30 AM and 4:30 PM, 2/11/26 at 8:30 AM and 4:30 PM, 2/12/26 at 8:30 AM, 2/13/26 at 8:30 AM and 4:30 PM, 2/19/26 at 4:30 PM, 2/20/26 at 8:30 AM and 4:30 PM, 2/21/26 at 8:30 AM and 4:30 PM, 2/23/26 at 8:30 AM, 2/25/26 at 8:30 AM and 4:30 PM, 2/26/26 at 8:30 AM and 4:30 PM and 2/27/26 at 8:30 AM ( a total of 19 missed doses) as it was coded as being unavailable. Nursing notes from 2/3/26 through 2/26/26 lacked documentation that the APRN was notified that Resident #7 and Resident #20 had missed doses of the D-Mannose. Interview, review of medical supplier packing slips (2/4/26 & 2/10/26) and observation of over-the counter (OTC) supply closet with the Central Supply Clerk on 2/27/26 at 11:20 AM identified that she was responsible for placing the over the counter (OTC) order for D-Mannose with the medical supply vendor. She indicated that she only placed orders for OTC medications from the medical supply vendor and the nurses were responsible for ordering medications including OTCs if needed from the pharmacy. She indicated on 2/4/26 she did not place an order for the D-Mannose (even though physician's orders were initiated on 2/3/26). An order was placed for 1 case of the D-Mannose powder (12 bottles in a case) on 2/10/26 from the medical supply vendor. The order had not yet come in from the vendor as of 2/27/26. The packing slips identified that no order was placed on 2/4/26 and an order was placed on 2/10/26 for one case. She indicated that she had made the Assistant Director of Nursing (ADNS) aware that the medication was on back order. She could not recall the exact date but as soon as she was made aware, she notified the ADNS, which was at least a week or two ago. On 2/27/26 at 11:20 AM an inspection of the OTC cabinet identified there was D-Mannose available. An interview with LPN #2 on 2/27/26 at 12:00 PM identified that there was not any D-Mannose in the medication carts and she could not administer the D-Mannose to any of her residents that were to receive the medication. She could not recall when it was last available, but she had made the ADNS and central supply aware when it was no longer available. Subsequent to surveyor inquiry, alternative orders were obtained from APRN #1 on 2/27/26 for Cranberry tabs 450 milligrams (mg) to be given if D-Mannose was unavailable for Resident #20. Interview with Pharmacy Manager on 3/3/26 at 8:30 AM identified that the pharmacy does have D-Mannose available for order in capsule form but not powder. She indicated that an initial order was received on 2/3/26 for Resident #7 however, when the pharmacy had called back (3 times) they were unable to get a response from the charge nurse or the supervisor regarding sending the D-Mannose. She indicated that a pharmacy technician had spoken to a nurse on 2/3/26 at 12:35 PM but was not sure who it was and was told not to send D-Mannose as it was an OTC medication. Interview with APRN #1 on 3/3/26 at 9:00 AM identified that she was not made aware of the D-Mannose not being available until the facility notified her on 2/27/26 when she wrote alternative orders directing Cranberry tabs 450 milligrams (mg) to be given if D-Mannose was unavailable. (Please refer to F 580). Interview with the ADNS on 3/3/26 at 10:00 AM indicated that she was aware that D-Mannose was unavailable and the nurses and central supply had notified her sometime in February 2026 but could not recall the date. She indicated that she did not contact the pharmacy to inquire if D-Mannose was available as they have a formulary the facility follows. The ADNS also did not recall speaking to someone from the pharmacy on 2/3/26. In addition, she indicated that she had not notified APRN #1 but thought APRN #1 already knew that the D-Mannose was unavailable. Furthermore, she indicated that the nurses should not have signed off medication as given if it was not available and could not explain why it was signed off on one shift as given and documented on the following shift as being unavailable. A review of Medication Administration Policy (undated) directed, in part, if a dose or regularly scheduled medication is withheld, refused, not available or given at a time other than scheduled time, the space provided on the front of the MAR for that dosage administered is initialed and circled. If electronic MAR is used, documentation of the unadministered dose is done as instructed by the procedure for the use of eMAR system. An explanatory note is entered. If XX consecutive doses of vital medication are withheld, refused or not available the physician is notified. Nursing documents the notification and physician's response. 5. Resident #65 had diagnoses that included senile degeneration of the brain, anxiety, and hypertension. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 was significantly cognitively impaired, was at risk for developing pressure ulcers, had a pressure reducing device for the chair and bed, and had applications of medication/ointment other than to the feet. Additionally, Resident #65 used a wheelchair, required substantial/maximal assistance with eating, and was dependent for bed mobility and transfers. A physician order dated 2/2/26 directed to complete a weekly body audit every Sunday on the 7:00 AM to 3:00 PM shift. The Resident Care Plan (RCP) dated 2/8/26 identified Resident #65 had the potential for pressure injury/skin impairment related to incontinence and impaired mobility. Interventions included a low air loss mattress to the bed with settings according to weight, check mattress placement and settings every shift, perform a weekly skin assessment, and for daily treatment: assess, monitor, record the wound healing/progress and report improvements and decline to the medical doctor (MD)/wound nurse. A physician progress note written by the wound physician and dated 2/11/26 at 10:47 AM identified Resident #65 was seen as a consultation for evaluation of wound(s). The note identified Resident #65 had an area of moisture associated skin damage (MASD) to the bilateral buttocks first evaluated on 2/11/26 that had a cluster of open areas and measured 2.5 centimeters (cm) long by 3.0 cm wide by 0.1 cm deep. Additionally, the wound base was 75-99% granulation tissue (moist bumpy red or pink tissue that forms on the surface of healing wounds) with moist scar tissue (dense fibrous connective tissue that replaces healthy tissue following an injury) noted to the periwound, and a moderate amount of serosanguinous (SS) drainage (thin watery wound drainage that is pink or red in color). The note further identified the treatment recommendation was twice a day cleansing of the wound and apply Calcium Alginate (highly absorbent topical wound dressing) to the base of the wound followed by secure with a dry clean dressing (DCD). A physician order dated 2/18/26 directed to cleanse the bilateral buttocks with Normal Saline, followed by pat dry, followed by application of Collagen (advanced topical wound dressing), followed by applying Hydrogel (cut to fit) (water or glycerin-based sheet that provides moisture to dry wounds), followed by applying a dry clean dressing. Additionally, the order directed for that dressing to be performed two times a day on the day shift (7:00 AM to 3:00 PM) and the evening shift (3:00 PM to 11:00 PM), and then as needed for dislodgement or saturation of the dressing. A physician progress note written by the wound physician and dated 2/25/26 at 8:33 PM identified Resident #65 had an area of MASD to the bilateral buttocks (first evaluated on 2/11/26) that now had 2 open areas that were improved with delayed wound closure and measured 0.5 cm by 0.5 cm by 0.1 cm. Additionally, the wound base was 25-49 % epithelial tissue (light pink regenerated tissue formed during healing), and 50-74% granulation tissue with scar tissue noted to the peri wound, and a small amount of SS drainage. The note further identified the treatment recommendation was twice a day cleansing of the wound and applying Collagen followed by a Hydrogel sheet to the base of the wound followed by securing with a dry clean dressing. A Weekly Non-Pressure Wound Tracking Form completed by the wound nurse (the Assistant Director of Nursing Services) on 2/25/26 at 2:40 PM identified Resident #65 had a partial thickness (superficial) facility acquired wound of MASD to the bilateral buttocks with date of origin 2/11/26 that measured 0.5 cm by 0.5 cm by 0.1 cm, consisted of 2 open areas with 50% granulation tissue and 50% epithelial tissue, a small amount of SS drainage, and scar tissue to the peri wound (skin immediately surrounding a wound). Observation of Resident #65's dressing change and interview with Licensed Practical Nurse (LPN) #2 on 3/3/26 at 11:05 AM identified LPN #2 removed the used dry, clean dressing (DCD) covering the wound and then removed the used Collagen/Hydrogel that was placed over the wound located on the coccyx. Once the dressing was removed a wound was observed to the coccyx that appeared larger in size than the measurements documented on 2/25/26. The wound bed was observed to have greater than 75% slough tissue with remaining granulation tissue less than 25%. The slough tissue was observed to be yellow with brown coloring to the slough located at the center of the wound bed. There was a large amount of scar tissue noted to the entire peri wound. LPN #2 cleansed the wound and prepared the Collagen and Hydrogel to place on the wound. As LPN #2 proceeded to pick up and place the new Collagen and Hydrogel onto the wound she was requested by the surveyor to measure the wound bed. LPN #2 obtained a measuring device for the wound and upon returning she identified the wound had previously been 2 smaller areas located 1 on each buttock but now those were larger and had come together over the coccyx. She identified the wound had looked like this the previous day (3/2/26), but she could not recall what the wound had looked like when she worked on 2/27/26. Additionally, she identified she had not reported to the ADNS (wound nurse) or MD/APRN on 3/2/26 that the wound appeared different and that the wounds had merged into one larger wound because they were going to perform wound rounds on 3/4/26 so they would evaluate the wound at that time. Observation of Resident #65's wound and interview with the wound nurse/ADNS on 3/3/26 at 11:20 AM identified she could not recall if the current presentation of the wound was how it had looked on 2/25/26 during wound rounds without reviewing the documentation from 2/25/26. The ADNS measured the wound and identified the wound measured 2.2 cm by 3.6 cm by 0.1 cm and that 2 separate wounds originally only on the buttocks had merged into one wound that extended from each buttock and merged over the coccyx. She identified she would notify the wound MD. Subsequent to surveyor inquiry a Weekly Non-Pressure Wound Tracking Form completed by wound nurse the ADNS on 3/3/26 at 11:46 AM identified Resident #65 had a full thickness (deeper) facility acquired wound to the bilateral buttocks and coccyx with date of origin 2/11/26 that had worsened and measured 2.2 cm by 3.6 cm by 0.1 cm with 25% granulation tissue and 75% slough tissue, a moderate amount of SS drainage, and maceration (moist wrinkled skin) to the top edge of the peri wound. A new physician order dated 3/3/26 directed to cleanse the bilateral buttocks with Normal Saline, followed by patting dry, followed by applying Alginate, followed by applying a dry clean dressing. Additionally, the order directed for the dressing to be performed two times a day on the day shift and evening shift, and then as needed for dislodgement or saturation of dressing. Interview with the wound nurse/ADNS on 3/3/26 at 12:05 PM identified she had notified the wound MD, and APRN of Resident #65's new wound appearance and a new treatment order had been implemented. The ADNS further identified the nurses should report to her and/or the nursing supervisor when there was a deteriorating change in a wound appearance, and that LPN #2 should have notified her yesterday that Resident #65's wound appearance had changed. The Documentation policy directed, in part, nursing documentation is related to addressing resident needs and problems. The policy directed for treatments a description of the area treated is recorded weekly and when indicated such as a change in appearance, and that significant changes are noted and the physician notified. The Pressure Ulcer Policy directed, in part, risk factors that impact the development of pressure ulcers includes pressure points, moisture exposure of the skin to urinary and fecal incontinence, and impaired mobility. The policy directed the facility should have a system in place that assures changes in skin condition are recognized and reported to the residents' physician and wound nurse. The policy directed the facility shall provide treatment and services to prevent pressure ulcer development, identify and evaluate risk factors and changes in the resident's condition, and monitor the effectiveness of interventions. The policy further directed staff shall remain alert to potential changes in the resident's skin condition and shall evaluate and document identified changes on a daily basis and reported to the physician when applicable.

F810D · No harm, potential for more than minimal, isolated

Based on observations, interviews, review of the clinical record, and facility policy for the only resident reviewed for nutrition (Resident #62), the facility failed to provide adaptive equipment per the physician's order for a resident with dysphagia. The findings include: Resident #62's diagnosis included Type 2 diabetes mellitus, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease.An Occupational Therapy (OT) requisition form for adaptive equipment dated 11/11/25 directed Resident #62 was to have a sippy cup, foam built-up utensils and the beverage cart list (which identified residents' need for adaptive equipment) had been updated. A physician's order dated 2/2/26 directed to provide a sippy cup and foam handle built up utensils for all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #62 was moderately cognitively impaired, dependent with transfers, toileting, and bed mobility. The MDS indicated Resident #62 required setup or clean up assistance when eating and was on a mechanically altered and therapeutic diet. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #62 required assistance with eating, had poor nutritional intake and a potential for a nutritional deficit. Interventions included to assist the resident with meals, to set-up at mealtime as needed and to consult with the dietician for nutritional concerns. Review of the Nurse Aide (NA) care card directed the use of a sippy cup and adaptive equipment with all meals.Observations on 2/25/26 at 12:30 PM and 2/26/26 at 12:42 PM noted Resident #62 in bed eating pasta and mashed potatoes and drinking water and juice without the benefit of foam handle built up utensils and a sippy cup. Resident #62 was observed with a regular utensil/spoon and a large clear cup without a handle for both meals.Review of the unit's beverage cart list (attached to the beverage cart and identified the residents' diets and adaptive equipment orders) dated 2/26/26 indicated Resident #62 required a sippy cup and foam handle utensils for breakfast, lunch, and dinner.Observation and interview with Licensed Practical Nurse (LPN) #1 on 2/27/26 at 12:42 PM identified Resident #62 was dining in his/her room and was in bed feeding him/herself mashed potatoes with regular utensils without the benefit of foam handle built up utensils and a sippy cup for his/her beverage. LPN #1 indicated it would have been the responsibility of the kitchen to send the adaptive equipment up to the unit, the Nurse Aide (NA) should have reviewed the beverage cart list and NA care card and ensured the resident was provided the foam handle built up utensils and sippy cup with his/her lunch. Observation, interview, and review of facility documents with the Director of Dietary on 2/27/26 at 12:46 PM identified Resident #62 was drinking from a Kennedy cup (a tall, lidded cup with a straw) and should have had a sippy cup (a short double handled cup with a sippy lid). The Director of Dietary further indicated Resident #62 should have been eating with foam built up utensils (which were sent from the kitchen and kept on the beverage cart) but the resident was eating with a regular spoon. The Director of Dietary proceeded to point out a clear bin on the beverage cart which contained the foam built up utensils and a sippy cup on top of the beverage cart and instructed NA #2 to provide them to the resident. The Director of Dietary stated it was the responsibility of the NA to provide adaptive equipment for Resident #62 and reviewed the beverage cart list with NA #2 and provided further education.Observation, interview, and review of facility documents with NA #2 on 2/27/26 at 12:48 PM identified she served and set up Resident #62 for lunch without the benefit of foam built up utensils and a sippy cup. NA #2 indicated she was not aware Resident #62 needed the foam built up utensils and sippy cup because she had failed to review the beverage cart list and NA care card prior to serving the residents meal. Review of the beverage cart list with the Director of Dietary and NA #2 indicated Resident #62 was to have a sippy cup and foam handle utensils for breakfast, lunch, and dinner. NA #2 proceeded to locate a sippy cup (on top of the beverage cart) and foam built up utensils (in a clear bin on the beverage cart that had a printed list on the lid which indicated the resident's room number and initials and 'red foam handle utensils') and provided them to Resident #62. Resident #62 began eating chocolate ice cream with the red foam built up utensil/spoon. Review of the residents NA care card with NA #2 directed that Resident #62 was to have a sippy cup and adaptive equipment with all meals. Interview with Occupational Therapist (OT) #1 on 3/2/26 at 12:25 PM identified Resident #62 had difficulty while eating due to bilateral weak hand grip strength and required a sippy cup and foam handle built up utensils for all meals. OT #1 indicated the adaptive equipment was to promote independence for the resident and would ensure Resident #62 had increased meal intake. OT #1 identified it was the responsibility of the NA to ensure the resident was provided the adaptive equipment with each meal. OT #1 also noted if Resident #62 was not provided the foam handle built up utensils that could cause the resident to be unable to feed him/herself and decrease the resident's nutritional intake.Interview with the DNS on 3/2/26 at 12:39 PM identified the NA should have referred to the care card or the list on the beverage cart and provided the adaptive equipment to Resident #62 at mealtime. Additionally, the DNS identified she would need to conduct additional education with the NA's regarding adaptive equipment.Review of the facility policy, Nutrition Supervision of Resident, undated, directed residents were served diets as prescribed and to promote optimal health status. Adaptive, self-help devices are provided to contribute to the resident's independence in eating and the resident's diet card should be checked prior to serving the meal.

F842B · No harm, potential for minimal, pattern

F645B · No harm, potential for minimal, pattern

Based on review of the clinical record, facility documentation, interview, and facility policy for 2 of 5 residents (Resident #31 and Resident #32) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure that a redetermination was submitted to the appropriate state agency when a short-term approval expired. The findings include: 1.Resident #31 was admitted to the facility in [DATE] with diagnoses that included schizophrenia, major depression, and moderate intellectual disabilities. A Level of Care Screening Assessment (determines what type of healthcare facility a person needs) was completed on [DATE] at the hospital prior to admission to the long term care facility with an approval for short-term 60 days (expired in [DATE]). A 5 day admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #31 did not have a serious mental illness that required a level 2 Preadmission Screening and Resident Review (PASRR) (ensures residents with certain conditions are appropriate placed and receive the services needed), was cognitively intact, required supervision and/or moderate assistance with activities of daily living (ADLS) and coded diagnoses of schizophrenia and depression. The Resident Care Plan (RCP) dated [DATE] identified Resident #31 was taking psychotropic drugs secondary to schizophrenia and depression. Interventions included administering medications per orders, monitor for side effects and dose reduction as indicated. In addition, the RCP identified that Resident #31 had been placed for long term care with interventions that included will receive daily opportunities for social contact, encourage to participate in conversations with other residents and provide situations as much as possible for the resident to control environment. Interview with Social Worker (SW) #1 on [DATE] at 11:45 AM identified that she had not submitted a redetermination when the 60-day approval had expired in [DATE]. SW #1 indicated that she was responsible for submitting the redetermination and it was an oversight that it was not completed. Subsequent to surveyor inquiry, SW #1 submitted to the contracted state agency for a new Level of Care Screening on [DATE] at 2:22PM (151 days after the 60-expiration date from the [DATE] submission). 2.Resident #32 was admitted to the facility on [DATE] with diagnoses that included catatonic schizophrenia, major depressive disorder with recurrent severe psychotic symptoms, and obsessive-compulsive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #32 had severe cognitive impairment, was dependent for transfers, and was receiving antianxiety, antidepressant, and anticonvulsant medications. A Notice of PASSR Level I Screen Outcome dated [DATE], issued by the state contracted agency noted Resident #32 had a PASSAR condition and was approved to remain in the facility for up to 30 days from the date of admission without requiring a PASRR Level II screen. The notice also indicated that if Resident #32 required a stay beyond the 30 day period, a nursing facility representative must update the state contracted agency to submit an updated screen along with a completed Level of Care form on or before the 30th day of admission so that a PASRR Level II screen could be completed. The Resident Care Plan (RCP) dated [DATE] identified Resident #32 as having a PASRR positive status related to mental illness, specifically schizophrenia/schizoaffective disorder and major depressive disorder, requiring specialized services including physical therapy, occupational therapy, and psychiatric services. The RCP further indicated Resident #32 may require assistance with reasoning, learning, problem solving, activities of daily living (ADLs), and behavior management. Identified interventions included supportive counseling provided by social services staff, family therapy, and ADL (activities of daily living) training as needed. Interview with Social Worker (SW) #1 on [DATE] at 11:30 AM identified Resident #32 was approved for a 30 day stay in the facility beginning on the date of admission ([DATE]). SW #1 stated that she was responsible for updating PASRR screens as required and acknowledged that Resident #32 should have an updated PASSAR Level I Screen and a Level of Care form submitted on or before [DATE], since the resident remained in the facility beyond the initial 30 day period. Social Worker #1 also indicated that an updated PASSAR Level I and/or Level of Care Screen was not completed by the contracted state agency. Subsequent to surveyor inquiry SW #1 submitted a PASSAR Level I and a Level of Care Screening request to the contracted state agency on [DATE]. A review of the Pre-admission Screening and Resident Review (PASRR) policy (undated) directed, in part, it is the policy of the facility to assure all residents admitted to the facility receive a PASARR in accordance with state and federal regulations. The facility will coordinate assessments with the PASRR program under Medicaid in subpart C to this part to maximum extent practicable to avoid duplicative testing and effort. Coordination includes incorporating the recommendations for the PASRR level 2 determination and the PASRR evaluation report into a resident' assessment, care planning and transitions of care. Referring to all level 2 residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level 2 resident review upon a significant change in resident status assessment.

Inspection of January 29, 2026

1 finding

F600D · No harm, potential for more than minimal, isolated

Based on review of the clinical record, facility documentation, facility policies, and interviews, for one (1) of four (4) residents reviewed for abuse (Resident #2), the facility failed to ensure Resident #2 was free from physical abuse when the resident, who was dependent on staff for bed mobility and transfers, was discovered with multiple injuries of unknown origin including a lip laceration, forehead abrasion with swelling, and bruising to the back of the right hand and wrist, and later indicated a staff member struck him/her. The findings include:Resident #2's diagnoses included hemiplegia and hemiparesis after cerebral infarct affecting the left side, aphasia, depression, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had severely impaired cognitive function (Brief Interview for Mental Status (BIMS) score of 3), impaired movement of one side of the upper and lower extremity and was dependent on staff for bed mobility and transfers in and out of the bed and chair. The Resident Care Plan dated 10/20/25 identified Resident #2 had decreased functional mobility and was at risk of falls due to hemiplegia and hemiparesis of the left side. Interventions directed assistance of one (1) with daily living skills, bed mobility, and transfers in and out of bed and chair. The nurse's note dated 12/26/25 at 12:08 AM identified RN #1 was notified by LPN #1 that upon entering Resident #2's room to administer evening medications LPN #1 discovered Resident #2 was injured. RN #1 identified Resident #2 had a swollen right lip with a laceration approximately 2 cm by 1.5 cm in length, an abrasion to the forehead, a quarter sized bump to the forehead, and bruises to the back of the right wrist and thumb area. Upon interview, Resident #2 nodded his/her head no when asked if he/she fell or bumped his/her head. Resident #2's family member (Person #1), the police, the Advanced Practice Registered Nurse (APRN), and the Administrator were notified and the resident was sent to the hospital for an evaluation. The hospital discharge documents dated 12/26/25 identified a CT scan of the head and neck were performed and resulted negative. The hospital directed the facility to apply ice three (3) times per day and Tylenol or Ibuprofen if needed for pain. The physician's note dated 12/26/25 identified Resident #2 was alert and oriented at baseline and able to answer questions slowly with yes/no format due to aphasia. The facility reported an injury of unknown origin. Resident #2 identified he/she fell but was unable to provide further details. An interview with Person #1 on 1/28/26 at 10:50 AM identified on 12/25/25 he/she spent most of the day visiting Resident #2 and left the facility around 3:30 PM. Prior to leaving, Person #1 took a picture of Resident #2 holding a Merry Christmas sign to send to family. Around 9:00 PM, Person #1 received a call from the facility regarding Resident #2 being injured and immediately returned to the facility. Person #1 identified Resident #2 was able to understand what was said and with difficulty, due to aphasia, was able to answer questions. Person #1 identified Resident #2 would not tell him/her what happened to cause the injury. An interview with the Director of Social Services (DSS) on 1/28/26 at 12:10 PM identified Resident #2 had a BIMS score of 3 but understood more than he/she was able to express due to aphasia. An interview with NA #2 on 1/28/26 at 12:43 PM identified she worked on 12/25/25 from 3 PM to 11 PM and that she did not see or provide care to Resident #2 until after NA #1 left for the evening. After NA #1 left, NA #2 assisted Resident #2 with incontinent care and at that time, observed injuries. She further identified Resident #2 was incontinent of stool, required assistance of two (2) staff to provide personal care, and that stool was found on the floor near the bed. Review of the written statement and interview with LPN #1 on 1/28/26 at 12:49 PM identified on 12/25/25 LPN #1 was passing medications when NA #1 approached him in an upset and erratic manor and stated she should not be working because it was her mother's birthday, NA #1 reported to the supervisor and left for the remainder of the shift. LPN #1 then went into Resident #2's room to administer medications and discovered injuries. Resident #2 was unable to identify what occurred. An interview with Resident #2 (with Person #1 present) on 1/28/26 at 1:10 PM was conducted. Due to Resident #2's aphasia, he/she had difficulty processing questions and answered some questions with a delayed response. Resident #2 was aware NA #1 no longer worked at the facility and was able to indicate satisfaction. Resident #2 verbally identified NA #1 struck him/her causing the injuries identified on 12/25/25 and demonstrated through forming a fist with his/her right hand and then touching hand to forehead. Resident #2 acknowledged through yes/no format that he/she fell but was unable to provide any details. Interview with the DON (Director of Nursing) on 1/28/26 at 2:55 PM identified Resident #2 told her he/she fell but after being asked multiple ways was never able to indicate how the fall occurred or how he/she got back up. The DON further identified Resident #2 would not have had the ability to get up independently and would have likely required the assistance of two (2) staff members. The DON identified there were no residents on the unit who wandered or had a history of aggression and that LPN #1 was in the hallway during the evening and would have seen or heard if a resident wandered into Resident #2's room. When the DON proceeded to inform Resident #2 that NA #1 would no longer work at the facility, Resident #2 became teary eyed and shook his/her head okay. The facility terminated NA #1 due to lack of cooperation with the investigation. Interview with NA #1 on 1/29/26 at 10:20 AM identified she worked from 3 PM to 11 PM on 12/25/26. NA #1 was the NA assigned to provide care for Resident #2 and had worked with Resident #2 several times since she began work at the facility approximately three (3) months prior. NA #1 identified no one else provided care for Resident #2 until she left her shift early due to feeling unwell. NA #1 denied that Resident #2 sustained a fall and identified if he/she fell, at least two (2) people and possibly a Hoyer lift would have been required to transfer Resident #2 off the floor. NA #1 denied harming Resident #2. Although attempted, a call was not returned by RN #1 or by the detective assigned to the case. Review of the facility policy for Resident's Rights directed in part that the Resident had the right to be free from verbal, sexual, physical or mental abuse. Review of the facility policy for Abuse, Neglect, and Exploitation identified residents would not be subjected to abuse by anyone. The policy further identified injuries of unknown origin would be investigated as if they could be a result of abuse if the source of injury was not observed, the source of injury can't be explained, or the injury is suspicious because of the extent of injury, the location of injury, the number of injuries, or the incidence of injuries over time.

Inspection of February 26, 2025

1 finding

F684D · No harm, potential for more than minimal, isolated

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for medication administration, the facility failed to ensure medication orders were transcribed accurately and failed to ensure the resident was free from medication errors. The findings include: Resident #2's diagnoses included conversion disorder with seizures or convulsions. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of no cognitive impairment, and had a seizure disorder. The Resident Care Plan (RCP) dated 1/15/2025 identified a potential for seizure activity related to seizure disorder. Interventions directed to medicate as ordered and monitor for effectiveness. Physician order dated 1/10/2025 directed Lamictal XR (Lamotrigine, used to control seizures) oral tablet Extended Release 24-hour 100 milligram (mg) one (1) time a day. Additional physician order dated 1/10/2025 directed Lamotrigine ER oral tablet Extended Release 24-hour 25 mg (Lamotrigine) Give one (1) tablet by mouth one time a day for ANTICONVULSANTS for 1 week Week 5: (take with 100 mg for a total of 125 mg daily) AND Give 2 tablet by mouth one time a day for ANTICONVULSANTS Week 6: take with 100 mg for a total 150 mg daily and continue this dose. A physician order dated 1/24/2025 directed Lamotrigine ER Oral Tablet Extended Release 24 hour (Lamotrigine) Give 125 mg by mouth one (1) time a day. The manufacturing information review identified Lamictal was the brand name, and the generic medication name was Lamotrigine (same medication/drug). Review of January Medication Administration Record (MAR) directed start date 1/10/2025 Lamictal XR oral tablet extended release 24-hour 100 mg (Lamotrigine) give 1 tablet by mouth one time a day for anticonvulsant, was signed to identify it was administered daily from 1/11 through 1/26/2025. Additional review of January MAR indicated Lamotrigine ER oral tablet extended release 24 hour (Lamotrigine) 125 mg was signed to identify it was administered daily on 1/25 and 1/26/2025. Incident report dated 1/27/2024 identified Resident #1 received Lamotrigine 100 mg and 125 mg on 1/25 and 1/26/2025. The report indicated the 100 mg dose was supposed to be discontinued on 1/24/2025. The APRN was notified, and new orders were obtained to monitor vital signs every shift for three (3) days. Review of nurses note dated 1/27/2025 at 10:46 AM identified a medication error. A new Lamotrigine orders were received and transcribed without full discontinuation of the previous order resulting in administration of both orders on 1/25 and 1/26/2025. The APRN was notified with new orders to monitor vital signs every shift for 3 days, neurology and family notified. Interview, clinical record review, and facility documentation review on 2/26/2025 at 9:30 AM with the ADNS identified Resident #2 had an order for Lamictal XR 100 mg daily and on 1/25 and 1/26/2025 Resident #2 received an additional 125 mg in error. The ADNS stated the 100 mg should have been discontinued and Resident #2 should have been receiving only the 125 mg dose. The ADNS stated although she entered the order on 1/24/2025 that directed to administer 125 mg, she did not discontinue the order for 100 mg, and she should have. Interview, clinical record and facility documentation review with DNS on 2/26/2025 at 1:58 PM identified Resident #2 received an additional 100 mg of Lamictal (Lamotrigine) on 1/25 and 1/26/2025 in error. The DNS stated it was a transcription error, and the ADNS was provided education to ensures she reviewed all of Resident 2's medications when she entered the new order. Resident #2's neurologist and the medical director were notified, labs were ordered to check levels. Interview with the DNS identified the facility did not have a medication order transcription policy. Review of facility Medication Orders Policy directed in part; each medication order should be documented the Medication Administration Record (MAR). When a new order changes the dosage of previously prescribed medication, discontinue previous entry by writing DC'd and the date, or discontinue the order as per the electronic software instructions and re-type the new order.

Inspection of January 8, 2025

1 finding

F626D · No harm, potential for more than minimal, isolated

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had exhibited an inappropriate behavioral symptom and was transferred to the hospital for an evaluation, the facility failed to re-admit the resident after the hospital psychiatric physicians identified Resident #1 was not a risk of harm to self or others. The findings include: Resident #1's diagnoses included alcohol abuse with alcohol-induced Korsakoff's psychosis, depression, and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life and did not exhibit behavioral symptoms during the seven (7) day look back period. The Resident Care Plan dated 7/19/24 identified Resident #1 had a history of inappropriately touching staff back on 5/14/24. Interventions directed to anticipate and meet the resident's needs, provide opportunities for positive interactions, and encourage positive coping skills. The nurse's note dated 7/24/24 at 10:19 PM identified Resident #1 touched a staff member inappropriately. The resident apologized for the behavior and the psychiatric Advanced Practice Registered Nurse was notified. The psychiatric progress note dated 7/25/24 identified Resident #1 was started on Prozac 10 milligrams (mg) daily for depression following the7/24/24 incident. The psychiatric progress note dated 7/29/24 identified Resident #1 refused to take the Prozac after the first dose due to it making him/her too tired the Prozac was discontinued, and Paxil 20 mg daily was ordered. The nurse's note dated 7/30/24 at 8:17 PM identified at approximately 6:30 PM Resident #1 touched a 3-11PM nurse aide, Nurse Aide (NA) #1, in her private area and then Resident #1 slid his/her hand upward to NA #1's breast. The note identified Resident #1 was placed on one (1) to one (1) observation, notifications were made to all appropriate parties, and Resident #1 was transferred to the Emergency Department (ED) for a psychiatric evaluation. The note written by the Administrator dated 7/31/24 at 3:38 PM identified she spoke with Resident #1's Conservator and advised the Conservator the facility was unable to allow Resident #1 to return and the hospital was notified. The hospital record dated 7/30/24 identified Resident #1 had a decline in mental status since April/May. The record identified the facility reported Resident #1 allegedly touched a staff member inappropriately, was referred to the ED and required psych clearance to return. The note dated 7/31/24 indicated the facility was clear that Resident #1 was not allowed to return to the facility therefore Resident #1 was admitted to the medical team waiting for placement at a new Long Term Care (LTC) facility. The note dated 8/26/24 identified Resident #1 was discharged from the hospital to a new LTC facility on 8/24/24. Interview with the hospital Social Worker, Person #2, on 1/8/25 at 12:15 PM identified Resident #1 was admitted to the medical department from the ED. Person #2 indicated she was not aware the ED had attempted to send Resident #1 back to the facility on 7/31/24. Person #2 contacted the facility on 8/14/24 to inquire if they would re-admit the resident and they refused therefore, a referral was made to an alternate facility. Interview with Resident #1's Conservator, Person #1, on 1/8/25 at 12:25 PM identified a meeting was held with the Inter-Disciplinary Team (IDT) on 7/25/24 and there was no discussion at that time regarding discharging Resident #1. Interview with the Administrator on 1/8/25 at 2:45 PM identified the facility decided they were not going to take Resident #1 back following the 7/30/24 transfer to the ED because it was the third offense towards a staff member and the facility did not want to take the chance that it would occur again or that Resident #1 would do something to a resident. The Administrator identified the facility did not initiate a consultative process with the hospital. Review of the Resident's [NAME] of Rights policy identified, in part, the resident has the right to be allowed to stay in the facility and federal and state law permit an involuntary transfer or discharge when the health and safety of individuals in the facility is endangered. Although requested, the Administrator identified the facility did not have a specific policy for emergency discharges.

Inspection of November 21, 2024

2 findings

F689D · No harm, potential for more than minimal, isolated

Based on clinical record review, facility documentation, and interviews for one (1) of three (3) residents reviewed for an injury of unknown origin (Resident #5), the facility failed to ensure that the resident remained free from injury during a Hoyer lift transfer. The findings included: Resident #5 had a diagnoses of Alzheimer's disease. A care plan dated 6/12/24 identified that the resident had a self care deficit related to impaired mobility and cognition with interventions that included to assist the resident out of bed with a Hoyer lift. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that a Brief Interview for Mental Status (BIMS) of three (3) indicative of severe cognitive impairment and was dependent on staff for Activities of Daily Living (ADLs) including transfers. A nurse's note dated 11/15/24 at 12:03 PM identified that the resident had a bruise to the left chest measuring 6.5 in length 10.5 centimeters (cm) in width. An assessment was completed, no facial grimacing was noted and an X-ray of the left ribs was ordered. An X-ray report dated 11/15/24 of the left ribs were negative. Review of a reportable event dated 11/15/24 identified that a bruise of unknown origin was observed to the left upper chest during am care. The summary identified that the facility concluded that the bruise was caused by the Hoyer bar, (holds the Hoyer pad) that had aligned with the bruise. Interviews with staff who cared for the resident 24 hours prior to the identification of the bruise on 11/15/24 on 11/21/24 at various times failed to identify any incidents or issues with care that could have caused the bruising. Interview with the Director of Nurses (DNS) on 11/21/24 at 3:00 PM identified that the facility had performed a Hoyer transfer with the resident to identify potential causes of the bruise. It was identified that the Hoyer bar that attaches the Hoyer pad had aligned with the bruise, the facility believed that while the Hoyer was being pulled away from the resident, the bar was noted to swing and could have possibly hit the resident in the chest causing the bruise. The DNS identified that Resident #5 is now a nurse supervised Hoyer lift transfer. Subsequent to the incident the facility conducted competencies and education on Hoyer lift transfers with Nurse Aides. Review of the safe resident handling and transfers policy identified that residents are handled and transferred safely to prevent or minimize risk for injury.

F580D · No harm, potential for more than minimal, isolated

Based on clinical record review, interviews and facility documentation for one (1) of three (3) residents (Resident #1) reviewed for a change in condition, the facility failed to report a change of condition to the physician timely. The findings included: Resident #1 had diagnoses of Alzheimer's Disease, anxiety disorder, and age-related osteoporosis. Review of the Resident Care Plan dated 10/8/24 identified Resident #1 had osteoporosis with interventions directed to monitor, document, report to the physician, as needed, signs and symptoms of complications related to osteoporosis such as acute fracture, compression fractures, loss of height, kyphosis, and pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of two (2) indicative of severe cognitive impairment, and required maximal assistance with toileting, dressing, and personal hygiene. Review of the Department of Public Health Facility Licensing and Investigations Section Reportable Event Form dated 11/3/24 at 7:15 AM identified Resident #1 had an injury to his/her right pinky finger (bruise) and the right hand. A nurses note dated 11/3/24 at 11:34 AM identified that at 7:15 AM the Nurse Aide (NA) identified a bruise on the right fifth digit, the Advanced Practice Registered Nurse (APRN) was notified and an X-ray was ordered. An X-ray report dated 11/3/24 identified a a displaced transverse fracture at the base of the fifth digit. Interview with RN #1 (11:00 PM to 7:00 AM, Nursing Supervisor) on 11/21/24 at 11:00 AM identified he/she was informed by NA #1 on 11/3/24 at approximately 1:00 AM that something was wrong with Resident #1's right pinky finger. RN #1 indicated he/she checked Resident #1's right hand and saw that the pinky finger had a blue discoloration on it, however, did not appear as a new injury, and that Resident #1's right ring finger, middle finger, and hand were red but not swollen. RN #1 further identified he/she performed passive range of motion to Resident #1's right pinky finger without Resident #1 responding in pain or grimacing. RN #1 indicated he/she wanted to check nursing notes to ensure it was a new condition prior to contacting the physician, however, became distracted with a re-admission to the facility at 2:00 AM that morning and his/her other routine duties. RN #1 identified he/she didn't realize he/she had forgotten about Resident #1's injury until he/she overheard NA #2 reporting it to RN #2 during morning report. RN #1 indicated he/she then updated RN #2 with his/her previous assessment. Interview with NA #2 on 11/21/24 at 12:02 PM identified he/she was informed of the bruise on Resident #1's right hand by NA #1 during morning report on 11/3/24. Upon checking the residents hand around 7:00 AM that morning she identified Resident #1's right hand was swollen and that the right pinky was in an unusual position. NA #2 indicated he/she immediately notified RN #2 of the situation. Interview with RN #2 on 11/18/24 at 12:30 PM identified he/she assessed Resident #1's right hand following notification of the injury on 11/3/24 from NA#2 and that the pinky finger appeared to be dislocated. RN #2 further identified contacting the Advanced Practice Registered Nurse (APRN), was directed to order an x-ray which was positive for a fracture and the resident was sent to the emergency department. Interview with the Director of Nursing Services on 11/18/24 at 2:45 PM identified that the facility conducted an investigation and determined that the resident had osteoporosis and on 11/2/24 it was noted that the resident had h/her glasses in/her hand after having difficulty removing them from h/her face and questioned if this could have been the cause of the injury. The DNS identified that staff was to initiate an investigation of the injury and to notify the physician of the injury/change of condition. The DNS further indicated RN #1 should have ensured that the change in condition was reported upon assessment to the provider ( the injury was identified on 11/3/24 at 1:00 AM and was not reported to the provider until 7:00 AM). Interview with the Medical Director on 11/25/24 at 4:26 PM indicated, at minimum, staff should contact the APRN when a resident's change in condition has been identified. Review of the facility's Change of Condition policy directed the Charge Nurse/Supervisor was responsible for notifying the attending physician/ APRN and the resident's responsible family members or legal representatives when a change occurs in the resident's condition, which included significant changes in physical, mental, or psychosocial status as well as any accident that results in injury and/or hospitalization .

Inspection of May 16, 2024

9 findings

F687E · No harm, potential for more than minimal, pattern

Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #67) reviewed for Activities of Daily Living (ADL's), the facility failed to provide podiatry services to a long-term resident. The findings include: Resident #67's was admitted to the facility in August of 2023 with diagnoses that included type II diabetes mellitus, muscle weakness, difficulty in walking, and repeated falls. An admission physician's order dated 8/29/23 directed that Resident #67 may have podiatry services as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was cognitively intact and required moderate staff assistance with personal hygiene, substantial staff assistance with bed mobility, and was staff dependent with transfers. The Resident Care Plan dated 2/15/24 identified Resident #67 had diabetes mellitus. Interventions included completing a body check for breaks in the skin and treat promptly as ordered by the physician. Observation on 5/10/24 at 12:12 PM, identified Resident #67 with excessively long toenails. Interview and observation with Resident #67 on 5/13/24 at 10:14 AM identified he/she had excessively long toenails. He/she indicated that they were uncomfortable and jagged, getting caught on the sheets, and reported his/her toenails had not been cut since prior to residing at the facility, almost 9 months ago. Resident #67 identified that he/she had complained to the NA's numerous times during care, but the nails still had not been cut. Interview and clinical record review with RN #1 on 5/14/24 at 2:12 PM identified that foot and nail care was completed with daily care and on shower days by the NA's; irregularities were to be reported to the licensed nursing staff. Further, RN #1 indicated that licensed nursing staff was responsible for weekly body checks and excessively long nails should have been identified during the body check. The facility policy for toenail care directed that if a resident was diabetic (as was Resident #67) or had thick nails, the resident would be required to be seen by a podiatrist. During a review of the clinical record, RN #1 indicated that she was unable to find podiatry consent for Resident #67 or that Resident #67 had previously seen a podiatrist. RN #1 stated she was unaware of Resident #67's excessively long toenails. Review of the Treatment Administration Record (TAR) and nursing notes for April and May 2024 identified that LPN #1 signed off the weekly body audit on 4/17/24, 5/1/24, and 5/7/24 but failed to note Resident #67's toenail length. Interview and observation with LPN #1 on 5/14/24 at 2:30 PM identified that on observation, Resident #67's toenails were abnormally long and needed to be cut, he/she required a podiatrist, the resident had recently transferred her unit, and the NA's had not notified her of the resident's toenail length. Although LPN #1 signed off the weekly body audit on 4/17/24, 5/1/24, and 5/7/24, she identified she had not observed the length of Resident #67's toenails prior to surveyor inquiry. Interview with Social Worker #1 on 5/14/24 at 2:47 PM identified that she was the podiatry liaison, she was unsure if podiatry services were offered to Resident #67, and she had not been notified that Resident #67 needed to be seen. Subsequent to surveyor inquiry, a signed podiatry consent was obtained on 5/15/24. Review of the Foot Care policy dated 2023 directed, in part, that the facility would provide foot care and treatment in accordance with professional standards of practice and if necessary, would assist the resident in making appointments with a qualified person.

F656D · No harm, potential for more than minimal, isolated

Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #67) reviewed for an allegation of mistreatment, the facility failed to develop a comprehensive care plan indicating refusal of care, inappropriate behaviors, and accusations towards staff. The findings include: Resident #67's diagnoses included major depressive disorder and alcohol dependence. A nurse's note dated 1/3/24 at 12:50 PM identified Resident #67 was increasingly agitated and cursing at staff and his/her roommate. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was cognitively intact and required moderate assistance with personal hygiene, substantial assistance with bed mobility, and was dependent with transfers. Review of the Resident Care Plan (RCP) failed to include a care plan for behaviors. A nurse's note dated 2/21/24 at 11:26 AM indicated that Resident #67 was sexually inappropriate with staff and he/she was subsequently made an assist of 2 staff at all times. A nurse's note dated 4/25/24 at 11:25 PM identified that Resident # 67 was refusing care from certain staff members and the nursing supervisor was aware. A nurse's note dated 5/10/24 at 3:56 PM identified that Resident #67 made an allegation of staff mistreatment. Interview with Resident #67 on 5/15/24 at 9:48 AM identified that he/she has been refusing to shower for several months due to the facilities water temperature and his/her vertigo condition. Review of wound physician notes dated 5/15/24 identified that Resident #67 refused showers due to vertigo and hasn't washed his/her hair in at least a month. Interview with LPN #3 on 5/15/24 at 1:27 PM identified that a noncompliance and behavior care plan was not initiated because although she had heard staff discussing the behaviors of Resident #67, there was no documentation of the refusals and behaviors towards staff in the clinical record. In an interview and clinical record review with the DNS on 5/16/24 at 11:48 AM, it was identified that the clinical record failed to reflect an RCP regarding Resident #67's refusal of care, inappropriate behavior, and/or accusations towards staff. She indicated that she was aware of Resident #67's behaviors and that the interdisciplinary team talked about them often in morning report. Additionally, the DNS reported that the MDS nurse was responsible for the noncompliance care plan and she was unaware that a RCP for Resident #67's behaviors did not exist. Review of the Comprehensive Care Plan policy directed, in part, that the resident has the right to refuse to participate in the development of his/her care plan and medical nursing treatments. When such refusals were made, appropriate documentation would be entered into the resident's clinical records in accordance with established policies.

F695D · No harm, potential for more than minimal, isolated

Based on observations, review of the clinical record, facility policy, and interview for 1 of 2 residents (Resident #13) reviewed for oxygen, the facility failed to follow the physician's oxygen order. The findings include: Resident #13's diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD), anxiety disorder, and dementia. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was severely cognitively impaired and was dependent on staff for bed mobility, transfers, and personal hygiene and required substantial assistance with eating. Observation on 5/10/24 at 12:20 PM, identified Resident #13 in bed with the nasal cannula on, with the oxygen concentrator set to 3.0 LPM. Review of the Resident Care Plan dated 5/13/24 identified that Resident #13 had emphysema and COPD. Interventions included monitoring for difficulty breathing, monitoring for signs and symptoms of acute respiratory insufficiency and signs of respiratory infection, and to administer oxygen via nasal cannula to keep oxygen greater than 90%. Review of the physician's orders in effect from 5/1/24 through 5/13/24 directed to administer oxygen at 2.0 liters per minute (LPM) via nasal cannula continuously and as needed for shortness of breath. Observation on 5/13/24 at 10:30 AM, identified Resident #13 in bed with the nasal cannula on, with the oxygen concentrator set to 3.0 LPM. Review of the clinical record, observation, and interview with LPN #2 on 5/13/24 at 10:32 AM identified that although Resident #13 had a physician's order to administer 2.0 LPM of oxygen via a nasal cannula, he/she was noted to be receiving oxygen via the concentrator set to 3.0 LPM. LPN #2 indicated that she doesn't normally work on Resident #13's unit, she was unsure why the oxygen concentrator settings didn't match the physician's order, and that normally she would check the oxygen setting on entering Resident #13's room, but she had not seen the resident yet, during her shift. Review of the Oxygen Therapy policy directed, in part, that oxygen administration requires a physician's order, and flow meter is to be turned to the prescribed rate and the rate of flow is to be checked by the licensed staff.

F690D · No harm, potential for more than minimal, isolated

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #53 and Resident #67) reviewed for bowel and bladder, for Resident #53, the facility failed to assess bowel and bladder continence status and failed to implement a plan to restore continence and for Resident #67 the facility failed to ensure the resident maintained bowel and bladder function. The findings include: 1. Resident #53 was admitted to the facility with diagnoses that included fall, aspiration pneumonia, and acute kidney injury. The Nursing Admission assessment dated [DATE] identified Resident #53 was cognitively intact and required a rolling walker with the assistance of 2 staff members to ambulate. The Nursing Admission Assessment failed to address bowel and bladder continence. The Resident Care Plan dated 4/13/24 identified Resident #53 was at risk for a decline in his/her ability to perform activities of daily living (ADLs) and interventions included assisting Resident #53 with toileting, dressing, and ambulating. A physician's order dated 4/14/24 directed to administer 2mg of bumetanide (a diuretic) every other day. Review of the bladder and bowel documentation from 4/13/24 until 4/30/24 indicated Resident #53 was incontinent of bladder 45 out of 49 opportunities and was incontinent of bowel 25 out of 29 opportunities. Interview with Resident #53 on 5/10/24 at 11:25 AM identified he/she used the toilet regularly at home. Resident #53 indicated that he/she would prefer to use a toilet but had only been offered a bedpan, not using the bathroom, since he/she was admitted to the facility. Resident #53 reported experiencing incontinence on several occasions due to extended wait times after requesting a bedpan. Further, Resident #53 noted that he/she suggested to the NA that they bring him/her the bedpan at scheduled intervals on the days the diuretic was administered, but this has not happened. An interview and clinical record review with the DNS on 5/15/24 at 12:25 PM, the clinical record contained a bowel and bladder assessment from Resident #53's previous admission to the facility dated 9/27/23. The evaluation identified Resident #53 as a candidate for a toileting schedule. The clinical record failed to reflect a bowel and bladder evaluation for Resident #53's current admission to the facility. The DNS indicated it was the admitting nurse's responsibility to complete the bowel and bladder assessment on admission, but she was unable to identify why an assessment had not been completed for Resident #53. Additionally, the DNS identified the lack of an assessment should have been identified during the facility's weekly Standards of Care meeting but was unable to explain how this was overlooked. Review of the Bowel and Bladder Assessment policy dated 3/2000 directed, in part, to complete a bowel and bladder assessment within 14 days of admission to assist in determining the most effective and appropriate treatment and management of bowel and bladder function. 2. Resident #67's diagnoses included calculus of ureter and bile duct (formation of stones), presence of urogenital implants, and a history of urinary tract infections. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was cognitively intact and required moderate assistance with personal hygiene, substantial assistance with bed mobility, and was dependent with transfers. The Resident Care Plan dated 3/22/24 identified that Resident #67 was incontinent of both bowel and bladder due to impaired mobility. Interventions included following incontinence protocol, monitor for signs and symptoms of a urinary tract infection, and monitor input and output per facility policy. Review of the MDS data completed since Resident #67's admission indicated: The admission MDS assessment dated [DATE] identified that Resident #67 was frequently incontinent of urine and frequently incontinent of bowel, with no toileting programs in place. The 5-day MDS dated [DATE] identified that Resident #67 was occasionally incontinent of urine and always incontinent of bowel, with no toileting programs in place. The quarterly MDS dated [DATE] identified that Resident #67 was frequently incontinent of urine and frequently incontinent of bowel, with no toileting programs in place. The quarterly MDS dated [DATE] identified that Resident #67 was always incontinent of urine and always incontinent of bowel, with no toileting programs in place. Review of the Bowel and Bladder Evaluations for Resident #67 identified that on 8/8/23, the assessment determined that the resident was a good candidate for individualized retraining. On 1/3/24, the assessment determined that the resident was a candidate for a toileting schedule (timed voiding). On 5/12/24, the assessment determined that the resident was a candidate for a toileting schedule (timed voiding). Review of the clinical record failed to identify that any individualized retraining or any toileting schedules had been completed. Interview with Resident #67 on 5/13/24 at 10:14 AM identified that although he/she was capable of using a urinal, he/she indicated that due to difficulty with bed mobility and not being able to sit on the edge of the bed without staff assistance, the urine would spill out of the urinal consistently into the bed. Additionally, Resident #67 identified that when he/she felt the need to go to the bathroom, he/she would ring the call bell, but would not get the assistance he/she required in time which subsequently led to soiling the bed. Further, Resident #67 reports he/she is no longer aware of the urge to go to the bathroom. Interview with LPN #3 (MDS Coordinator) on 5/14/24 at 11:49 AM identified that she gets the data for section H (bladder and bowel) of the MDS from the Nursing Admission Assessment, documented nurse's notes, NA documentation, and completed Bowel and Bladder Evaluations. She indicated that MDS staff is responsible for completing the Bowel and Bladder Evaluations, but reported she answers no to both the urinary and bowel toileting program questions of the MDS (H0200 and H0500), even if the assessments state the resident is a candidate for individualized retraining or toilet scheduling because it was her understanding that the facility does not have these programs. LPN #3 stated nursing would then be responsible for initiating a 3-day diary of the resident's current bladder and bowel functioning, but reported there was no current process on how to communicate that to the floor nurses. Additionally, she indicated that they have a weekly meeting on Wednesdays to discuss the at risk residents, but she was unsure if Resident #67 had been discussed for his/her declining bowel and bladder functioning. Interview with RN #1 on 5/14/24 at 2:12 PM identified that she was not aware of any resident's past or present on toileting programs and she was also not aware of how to initiate a 3 day toileting diary. Interview with RN #2 (Nursing Supervisor/MDS) on 5/15/24 at 12:01 PM identified that after he completes a bladder and bowel assessment that indicates that a resident is a good candidate for any type of retraining or toileting schedule, he verbally tells the staff on the unit to observe that resident's tendencies. RN #2 reported that he has not seen any bowel and bladder diaries completed on any residents, indicating he would think that the staff would start them on a retraining program if the resident was able to participate, but reported he was not aware of a policy or process. RN #2 identified that he is not able to follow up with the staff on the residents toileting tendencies, as he works weekends only, and reported that in the future he would start requesting the information needed in writing, not verbally. Interview with the DNS on 05/15/24 at 12:25 PM identified that Resident #67 gradually lost bladder and bowel functioning over time from admission to his current status. She indicated the facility did an initial 3-day diary at the beginning of his admission, but she was unable to identify who initiated the diary, was unable to locate the paper copy or any follow up, and was unaware if the physician was notified of the change in functioning. The DNS identified that Resident #67 had a few cancelled urology appointments, but indicated the facility should have followed up and developed a bladder and bowel schedule and added it to the NA's assignment. Further, the DNS identified that MDS staff is responsible for gathering information on the resident's bowel and bladder functioning and should have initiated a 3-day diary and then the interdisciplinary team would have discussed the results in morning report and at their weekly at-risk meeting. Review of the Bowel and Bladder Retraining policy dated 3/2001 directed, in part, that bowel and bladder retraining is the responsibility of all nursing personnel and directs to toilet the resident at the same time daily, every 2 to 3 hours, encourage adequate intake of fruits, vegetables, and roughage, and encourage exercises as tolerated. All outcomes should be documented in the clinical record and inform the physician as needed. 50095

F692D · No harm, potential for more than minimal, isolated

Based on review of the clinical record, interviews, and review of facility policy for two of six residents (Resident #14 and Resident #62) reviewed for nutrition, for Resident #14, the facility failed to ensure a significant weight change was identified in a timely manner, and for Resident #62, the facility failed to obtain weights per the physician's orders. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia, congestive heart failure, and diabetes. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #14 was severely cognitively impaired, required set up assist for eating, moderate assistance with personal hygiene, transferring, and bathing. The Physician orders dated 11/24/23 through 3/12/24 directed for Resident #14 to be weighed daily. Review of Resident #14's weight record identified a weight of 222.2 pounds (lbs.) on 12/20/23 and a weight of 199.0 lbs. on 2/17/24 for a total significant weight loss of 23.2 pounds (10.44 percent) over 2 months. No further weights were identified in the clinical record from 12/21/23 through 2/16/24. Interview and review of the clinical record on 5/16/24 at 10:31AM with the Dietician identified Resident #14's significant weight change of 23.2 lbs. between 12/20/23 and 2/17/24 (approximately 2 months). The Dietician indicated that she was responsible to identify changes in resident weights but had been unavailable for part of the time between 2/17/24 and 3/12/24 and that no staff had been covering in her absence. Additionally, the Dietician was noted to have worked in the building on 2/21/24 and 3/7/24 but had not been notified by facility staff and had not recognized that Resident #14 had a weight loss until her third visit to the facility on [DATE] (24 days after Resident #14's weight loss). Subsequent to determining the resident had sustained a significant weight loss, she recommended Resident #14 be given double portions and requested liquid protein 30 milliliters twice a day. The Dietician was unable to indicate why Resident #14's weight loss was not addressed sooner. 2. Resident #62's diagnoses included heart failure, hypertension, and Chronic Obstructive Pulmonary Disease (COPD). The Quarterly MDS assessment dated [DATE] identified that Resident #62 was moderately cognitively impaired, was independent for transfers, supervised for ambulation, and he/she had a significant weight loss. The Resident Care Plan in effect from February 1, 2024 through February 29, 2024 identified Resident #62 was at risk for nutritional deficit with interventions that included monitoring weights, labs and offering a therapeutic diet with high calorie supplements as directed by the physician. The physician's order in effect from February 1, 2024 through February 29, 2024 directed to weigh Resident #62 every night shift and notify the physician of any increase in weight of 2-3 pounds per day or 5 pounds per week. Review of Resident #62 clinical record from 8/24/23 to 5/14/24 identified that he/she was not weighed for 4 days, on February 4, 5, 6, and 7, 2024. An interview and record review with RN # 6 on 5/15/24 at 10:35 AM identified that Resident #62 had not been weighed on February 4, 5, 6, and 7, 2024 due to a broken scale according to the nursing progress notes. RN #6 was unable to explain why the Resident #62 had not been weighed, but indicated that the resident could have been brought to another unit to obtain his/her weights. Review of the facilty weight policy identified that any weight gain or loss of 5 pounds or more will trigger a re-weight to be obtained with 24 hours to verify the results. Significant weight loss parameters (Per OBRA) are as follows: 5% in 30 days and 10 % in 6 months. Weights will be documented in the electronic medical record. Each resident will be weighed upon admission, monthly, and when indicated, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. 50250

F580D · No harm, potential for more than minimal, isolated

Based on review of the clinical record, facility policy, and interviews for 1 of 6 residents (Resident #62) reviewed for nutrition, the facility failed to notify the provider when weights were not obtained per the physician's order. The findings include: Resident #62's diagnoses included heart failure, hypertension, and Chronic Obstructive Pulmonary Disease (COPD). The Nursing Admission assessment dated [DATE] identified Resident #62 was oriented to time, place, and person, was independent with eating, required one staff assist with ambulation, and the assist of two staff with bathing and grooming. The Resident Care Plan dated 8/23/23 identified Resident #62 was at risk for nutritional deficit. Interventions included monitoring weights, laboratory values, and offering a therapeutic diet with high calorie supplements as directed by the physician. A physician's order dated 8/23/23 directed to weigh Resident #62 every night shift and notify the physician of an increase of 2-3 pounds per day, or 5 pounds per week. Review of Resident #62 clinical record from 8/23/23 to 5/14/24 identified that he/she had not been weighed for 4 days, February 4, 5, 6, and 7, 2024, due to a broken scale. The clinical record failed to indicate that the physician was notified. An interview and record review with RN #6 on 15/5/24 at 10:35 AM failed to identify that the physician was notified when Resident #62 was not weighed for 4 consecutive days. Additionally, RN #6 indicated that Resident #62 could have been brought to a different scale in the facility to be weighed. Interview with Advanced Practice Registered Nurse #1 on 5/16/2024 at 11:00 AM identified that she had not been notified Resident #62 had not been weighed for 4 consecutive days but should have been as the weights were ordered to be taken daily. Review of facility policy identified, in part, that each resident will be weighed upon admission, monthly and when indicated, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident.

F761D · No harm, potential for more than minimal, isolated

Based on observation, review of facility documentation, facility policy, and interviews for 1 of 2 medication rooms reviewed for medication storage and labeling, the facility failed to ensure drugs and biologicals were kept under proper temperature controls. The findings include: Observation and interview with RN #3 (the Infection Preventionist) on 5/16/24 at 12:40 PM identified recorded out-of-range temperatures documented on the Windsor Court medication refrigerator's temperature log. In May 2024 temperatures were noted to be outside of the acceptable range (35 F to 46 F) on 13 out of 16 documented days and ranged between 49 F and 60 F. In April 2024 3 out of 30 readings fell outside the acceptable range and were documented between 47 F and 54 F. Currently observed in the medication refrigerator were the following medications: 1. carboxymethyl cellulose sodium 0.5% 0.5oz 2. 1 full vial of lispro 3. 1 full vial of Levemir 4. 1 Trulicity single dosing pen 5. Aranesp 0.42ml syringes x 2 6. lorazepam oral concentrate full vial 30ml RN #3 indicated that staff should have re-checked the refrigerator temperature, and if it read outside the acceptable range, then update the log accordingly. RN #3 was unable to explain why the refrigerator temperatures weren't rechecked on the days documented with out-of-range readings and was unable to identify how long the refrigerated medications had been exposed to the unacceptable temperatures adding that the refrigerator temperatures fluctuated. Interview with LPN #4 on 5/16/24 12:48 PM identified that the 11:00 PM to 7:00 AM nurse was responsible to check the refrigerator temperature and that if the temperature was out of range, then the issue should be brought to the attention of maintenance. Review of the Medication Storage policy identified all refrigerated medications should be kept between 35 F to 46 F, as stated by the United States Pharmacopeia and by the Centers for Disease Control.

F758D · No harm, potential for more than minimal, isolated

Based on review of the clinical record, facility policy and interviews for the only sampled resident (Resident #67) reviewed for mistreatment, the facility failed to monitor and document targeted behaviors per the physician's order. The findings include: Resident #67's diagnoses included major depressive disorder and alcohol dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was cognitively intact and required moderate assistance with personal hygiene, substantial assistance with bed mobility, and was dependent with transfers. Additionally, the MDS indicated that the resident had not exhibited any behaviors. The Resident Care Plan dated in effect from November 2023 through May 2023 identified that Resident #67 received antidepressant medication related to depression. Interventions included to monitor, document, and report to the physician ongoing signs and symptoms of depression including sadness, irritability, anger, never being satisfied, crying, shame, worthlessness, guilt, suicidal ideation, negative mood and/or comments, slowed movement, fatigue, lethargy, agitation, attention seeking, and anxiety. A physician's order dated 11/28/23 directed to monitor for any increased anxiety, yelling, agitation or any unusual behaviors, document, and report to the psychiatric Advance Practice Registered Nurse (APRN). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from December 2023 through May 2024 identified Resident #67 was receiving psychotropic medications but failed to identify targeted behavior monitoring for psychotropic medication use. Review of the psychiatric APRN notes dated 2/15/24 and 3/19/24 identified diagnoses including adjustment disorder, anxiety disorder, major depressive disorder, and alcohol abuse. Additionally, the notes indicated that Resident #67 had been seen for behaviors including agitation and yelling at staff on 1/5/24 and directed to continue monitoring the resident for changes in mood and behavior. Interview and clinical record review with RN #1 on 5/14/24 at 2:12 PM identified that she was unable to locate behavior monitoring in Resident #67's clinical record. She reported that if a resident had a physician's order for behavior monitoring, it should be documented on in the MAR, and nurses would be responsible to document either a Y for yes behaviors were observed, or N for no behaviors were observed every shift and document any identified behaviors in the nursing progress notes. Review of nursing notes dated 1/3/24 through 5/10/24 indicated 5 nursing progress notes documenting Resident #67's mood/behaviors but no further behavior monitoring documentation was identified. Interview and clinical record review with the ADNS on 5/14/24 at 2:23 PM identified that there were physician's orders directing behavior monitoring that had been incorrectly entered by the previous APRN. The ADNS indicated that due to the incorrect entry, behavior monitoring had not been conducted as directed from November 2023 through May 2024, and that subsequent to surveyor inquiry, she would correct the order to ensure behavior monitoring would occur as directed. Although requested, a policy on physician's orders was not provided. Review of the Psychotropic Medications policy directed, in part, that behavioral monitoring will be completed by nursing to record specified target behaviors, such as biting, kicking, continuous crying, pacing, hitting, scratching, screaming, yelling, etc.

F644B · No harm, potential for minimal, pattern

Based on review of the clinical record and interview for 1 of 5 sampled residents, (Resident #11) reviewed for PASRR, the facility failed to refer the resident to the appropriate state-designated authority for a level II evaluation following a new psychiatric diagnosis. The findings include: Resident #11 was admitted in June 2020 with diagnoses that included chronic obstructive pulmonary disease, anxiety, and lung neoplasm. Review of the clinical record identified a negative PASRR level 1 dated 6/22/20 with no diagnosis of Alzheimer's dementia, or mental illness. The 5 day Minimum Data Set assessment dated [DATE] identified Resident #11 was cognitively intact and required assistance with activities of daily living. An Advanced Practice Registered Nurse progress note dated 9/29/22 identified Resident #11 with an active diagnosis of schizoaffective disorder. Further review of the clinical record failed to identify a PASRR level II was conducted following the new psychiatric diagnosis. The Resident Care Plan dated 6/23/23 identified Resident #11 was receiving psychotropic medications, had mood and behavior disorders. Interventions directed to assist Resident #11 by allowing him/her to express their feelings and to assist to de-escalate. In an interview and review of the clinical record with Social Worker #1 on 5/16/24 at 12:30 PM she identified that following Resident #11's new psychiatric diagnosis of schizoaffective disorder the state agency should have been notified to conduct a level II PASRR assessment.

Inspection of June 21, 2021

1 finding

F678J · Immediate jeopardy, isolated

Based on clinical record review, review of facility documentation and policies and interviews for one sampled resident (Resident #1) who was a recent admission and had acknowledged full Cardio-Pulmonary Resuscitation (CPR) in the advance directive and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a full code. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive assistance of two (2) staff with transfers in and out of the bed and chair and extensive one (1) person assistance with toilet use. The Advanced Practice Registered Nurse's (APRN) progress note dated [DATE] at 6:40 AM identified she spoke with Resident #1's spouse, Person #1, at length today regarding Resident #1's current code status and Person #1 reiterated that Resident #1 was to be a full code. The nurse's note, written by the ,d+[DATE]PM Nursing Supervisor, dated [DATE] at 10:58 PM identified he was summoned to Resident #1's room by the ,d+[DATE]PM charge nurse and upon entering the room Resident #1 was observed slumped over in wheelchair. The nurse's note indicated upon assessment Resident #1 had no palpable carotid pulse, and no heartbeat or breath sounds upon auscultation. The note identified Resident #1 was noted as a full code, therefore Resident #1 was placed in bed with CPR back board underneath the trunk, CPR was initiated by RN #1, when the Emergency Medical Technician (EMT) arrived they relieved RN #1 from performing CPR, all efforts by the EMT's to resuscitate Resident #1 were futile, and Resident #1 was pronounced dead at 5:46 PM. The nurse's note, written by the ,d+[DATE]PM charge nurse, dated [DATE] at 11:11 PM identified she was called to Resident #1's room by a nurse aide around 5:30 PM, Resident #1 was noted to be unresponsive and the Nursing Supervisor was called to assess Resident #1. Interview with the ,d+[DATE]PM Nursing Supervisor, Registered Nurse (RN) #1, on [DATE] at 3:35 PM, RN #1 identified he was passing medication on an adjacent unit when the ,d+[DATE]PM charge nurse, Licensed Practical Nurse (LPN) #2, came to him and stated Resident #1 might be dead. RN #1 identified they went back to Resident #1's unit and first thing he did was verify Resident #1's code status for himself. RN #1 indicated noting that Resident #1 was a full code, he called 911, grabbed the crush cart and went into Resident #1's room. RN #1 identified Resident #1 was observed slumped over in wheelchair and upon assessment Resident #1 presented with no palpable carotid pulse, heartbeat or breath sounds. RN #1 identified Resident #1 was placed in bed with the CPR backboard underneath and CPR was initiated. RN #1 indicated the EMT's arrived, relieved him from performing CPR and at 5:46 PM Resident #1 was pronounced dead. Interview with the Acting Director of Nursing (DON) on [DATE] at 3:47 PM identified LPN #2 should have sent one of the two (2) nurse aides that were in the room to get the supervisor or call a Code Blue to Resident #1's room. The Acting DON identified LPN #2 should have had the other nurse aide assist her with putting Resident #1 on the floor and LPN #2 should have started CPR. Interview with the ,d+[DATE]PM charge nurse, Licensed Practical Nurse (LPN) #2, on [DATE] at 3:55 PM identified she was aware Resident #1 was full code. LPN #2 indicated she was called to Resident #1's room by a nurse aide due to Resident #1 being unresponsive around 5:30 PM. LPN #2 identified she assessed Resident #1, Resident #1 was pulseless and unresponsive to verbal stimuli. LPN #2 indicated although there were two (2) nurse aides with her in the room, she left Resident #1's room to get the Nursing Supervisor who was passing medications on an adjacent unit. LPN #2 indicated she did not initiate CPR when she found Resident #1 unresponsive and pulseless and left the room because she needed the Nursing Supervisor's help. Interview with the ,d+[DATE]PM nurse aide, Nurse Aide (NA) #3, on [DATE] at 4:10 PM identified she went into Resident #1's room to serve Resident #1 a drink for supper. NA #3 indicated as she entered Resident #1's room she thought Resident #1 was sleeping, so she proceeded to touch Resident #1 and Resident #1 did not respond. NA #3 identified she went to the doorway, noticed LPN #2 in the hallway and called LPN #2 into Resident #1's room. NA #3 indicated LPN #2 assessed Resident #1 and left the room to get the Nursing Supervisor and after LPN #2 left the second nurse aide that was in the room left leaving her alone with Resident #1. Interview with the Medical Director on [DATE] at 11:53 AM identified Resident #1 was a full code and if Resident #1 was unresponsive and pulseless, LPN #2 should have started CPR immediately. Review of the facility's Cardiopulmonary Resuscitation policy directed in case of a cardiac and/or pulmonary arrest, CPR was instituted immediately. Two (2) person rescue: one (1) person remains with victim and CPR was instituted, the second person places a call for assistance, calls 911 and pages a Code Blue.

Inspection of June 11, 2018

1 finding

F692G · Actual harm, isolated

Based on review of the clinical record, staff interview, review of facility documentation, and review of facility policies and procedures, for the only resident in the survey sample reviewed for hydration(Resident #424) the facility failed to consistently monitor intake and output and/or ensure a resident was meeting their fluid intake needs and/or conduct an assessment for dehydration and/or implement measures addressing such in a timely manner. The findings include: Resident #424 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nutritional assessment dated [DATE] identified that Resident #424 was receiving a regular diet, had good oral intake, and required an estimate of 1675 cc of fluids daily. The admission MDS assessment dated [DATE] identified Resident #424 had severely impaired cognition and required supervision of one person with transfers, supervision with eating, limited assist with one person for toileting, and extensive assist with one person for personal care. The care plan dated 1/22/18 identified Resident #424 had a self-care deficit related to cognitive and physical functioning. Interventions included total assist with Activites of Daily Living (ADLs) skills and assist with turning and positioning as needed. The care plan further identified Resident #424 was at risk for a fluid volume deficit related to altered intake process, cognitive state, decreased independent access to fluids and uncontrolled health conditions. Interventions included the monitoring of intake and output, monitor and ensure at least 75% of the meal was taken, monitor labs per orders, and monitor for signs of dehydration. A significant change MDS assessment dated [DATE] identified Resident #424 had severely impaired cognition, required extensive assistance with two persons for transfers, and required total care with one person for toileting, eating, and personal care. The fluid intake flow sheets dated 2/7/18 through 2/23/18 identified a marked reduction in fluid intake less than estimated needs of 1675 cc (12 of 16 days) with consistent days beginning 2/16/18 until hospital discharge on 2/23/18. Review of the nursing progress notes dated 2/16/18 through 2/23/18 did not reflect notification to the Physician/APRN regarding the resident's decreased fluid intake. A hospital discharge summary dated 2/26/18 identified Resident #424 was admitted on [DATE] with an admission [DIAGNOSES REDACTED]. Laboratory data collected on admission on 2/23/18 included a sodium level 153 (normal 133-145), BUN 85 (normal 10-24) and creatinine of 4.0 (normal 0.7- 1.5). An interview with LPN #1 on 6/5/18 at 3:05PM stated that notifications for poor oral and fluid intake were made routinely and placed within a book for the APRN to review. He/she was unable to provide documentation that the APRN was notified of Resident #424's poor oral intake. An interview with Dietician #1 on 6/6/18 at 9:08 AM identified while he/she could not recall Resident #424, he/she would review nurses notes and/or be notified by nursing if a resident was not meeting their fluid needs. The dietician further stated that although he/she would make recommendations for a dehydration assessment if needed, the assessment was completed by nursing staff. Review of the clinical record failed to reflect an assessment for dehydration. An interview with the DNS on 6/6/18 at 9:43 AM identified that there had been a problem with monitoring fluids at the facility. He/she indicated a hydration assessment was to be initiated when it was identified that a resident was not meeting fluid needs after three days and that it most likely had not been completed for Resident #424. Interviews with the APRN on 6/6/18 at 12:56 PM and 1:08 PM identified he/she had only been monitoring Resident #424 for dependent [MEDICAL CONDITION] and heart failure and that if there was a decline in functional status including eating and drinking, he/she would have expected to be notified. The APRN further stated that he/she was not notified when Resident #424 was not meeting his/her fluid needs beginning 2/16/18 and that there was a decrease in meal intake beginning 2/20/18, and that had he/she been made aware, he/she would have examined Resident #424 and completed a work-up based on his/her findings. The facility policy for Maintaining Patients Fluid Intake to Prevent Dehydration Protocol directed staff would address fluid needs when levels fall below their levels by monitoring documentation, maintaining a notice of below levels posted on the MAR for two weeks, and leaving a note in a book for the APRN. A hydration assessment was to be completed if fluid intake on the third consecutive day was not met. Additionally, the APRN was to be notified. If fluid goals were not met for the fourth consecutive day the APRN was to be notified for additional orders. The facility failed to ensure Resident #424's fluid intake was consistently monitored and/or that a dehydration assessment was completed in a timely manner.

Inspection of June 22, 2017

1 finding

F323G · Actual harm, isolated

Based on observations, review of the clinical record, and interviews, for 1 of 3 sampled residents (Resident #111), reviewed for accidents and/or for 1 of 3 nursing units, the facility failed to provide care in a safe manner to prevent a fall with injury, and/or failed to ensure the environment was free of accident hazards. The findings include: 1. Resident #111's [DIAGNOSES REDACTED]. The annual MDS dated [DATE] identified that Resident #111 had severely impaired cognition, and required extensive assistance of 2 staff with dressing, personal hygiene, and locomotion on and off the unit. Additionally, an assessment of balance during transitions identified Resident #111 was not steady, and was only able to stabilize with staff assistance for moving from seated to standing, moving on and off the toilet, and surface to surface transfers (transfer between bed and chair or wheelchair). The care plan dated 10/18/16 identified Resident #111 had decreased functional mobility and a cognitive deficit. Interventions included to transfer Resident #111 out of bed with the assistance of 2 staff, to an adapted tilt in space wheelchair. The physician's orders [REDACTED].#111 to and from the bed, and/or to the wheelchair. Accident/incident report dated 12/26/16 at 4:00 PM identified that NA #3 attempted, without assistance, to remove Resident #111's pants while the resident was seated in the wheelchair. Resident #111 slid off the wheelchair to the floor and sustained multiple skin tears, a laceration to the left side of the head, and a fractured left hip. Nurse's note dated 12/26/16 at 4:20 PM written by the nursing supervisor, (RN #2) identified he/she was called to Resident #111's room, where Resident #111was observed in bed. The note identified Resident #111 slid off the wheelchair to the floor and was lifted back to bed by the charge nurse (RN #3) and NA #3. An assessment conducted by RN #2 at that time identified Resident #111 sustained 6 skin tears on the left forearm, complained of pain in the leg and shortening of the leg was observed. RN #2 indicated that based on the assessment, it became apparent that some hip injury was possible. Additionally, a 2.0cm by 2.0cm by 1.5cm laceration was noted on Resident #111's head near the left ear. Subsequent to APRN notification, Resident #111 was sent to the hospital for an evaluation. Hospital documentation dated 12/26/16 identified Resident #111 sustained an impacted subcapital fracture of the left femoral neck (left hip fracture) and a laceration to the left scalp, which required staples to close. A statement by NA #3 dated 12/27/16 indicated that he/she was trying to remove Resident #111's slacks while the resident was seated in the wheelchair. NA #3 pulled on Resident #111's slacks twice, and the resident slid out of the wheelchair. NA #3 indicated that RN #3 assisted to lift Resident #111 back into bed by sitting the resident up on the floor, lifting the resident under the arms and holding the waist of the resident's pants. NA #3 indicated it was a difficult lift and Resident #111's legs buckled and almost fell again. NA #3 indicated that this is when Resident #111 started yelling about his/her leg. NA #3 indicated that when Resident #111 was seated at the edge of the bed, he/she turned the resident's legs to lay him/her down in bed. A statement by RN #3 dated 12/27/16 identified that when he/she entered the room on 12/26/16, Resident #111 was on the floor. RN #3 identified that while Resident #111 was on the floor, he/she assessed the skin tears, which were noted on the left arm. RN #3 indicated that he/she transferred Resident #111 back into the bed because the resident's hand was turning blue. RN #3 indicated Resident #111 was a heavy transfer. Additionally, RN #3 identified that Resident #111 complained of pain to the left hip. The investigation conclusion dated 12/29/16 identified that as NA #3 pulled on Resident #111's pants to remove them, Resident #111 slid off the wheelchair. Although NA #3 attempted to catch Resident #111, the resident landed on his/her left side. RN #3 directed NA #3 to assist him/her to lift Resident #111 into the bed to assess the bleeding areas better. Subsequently, Resident #111 was transferred to the hospital due to his/her injuries. Interview with RN #3 on 6/20/17 at 2:25 PM identified that Resident #111 was bleeding from skin tears and crying about pain in the left lower leg while on the floor. RN #3 indicated he/she decided to move Resident #111 to the bed because Resident #111 was crying to be put back into bed Additionally, Resident #111 was in between the furniture on the floor, and his/her arm was turning blue. RN #3 indicated that although he/she attempted to assess Resident #111's injuries while on the floor, it was hard because there was no room to do a good assessment and he/she was unable to move the bed and/or furniture. Interview with the DNS on 6/20/17 at 2:38 PM identified that NA #3 should not have attempted to remove Resident #111's pants while the resident was still seated in the wheelchair. Additionally, after RN #3 decided to move Resident #111 back into bed, a lift should have been used rather than picking Resident #111 up by the legs and arms. Interview with RN #2 on 06/22/17 8:36 AM identified he/she would have left Resident #111 on the floor, provided comfort, continued assessment, treat bleeding skin tears, and wait for EMS. Interview with PT #1 6/22/17 at 9:19 AM identified that if a resident is totally dependent on staff for transfers, that resident should not be manually lifted off the floor after a fall. Additionally, PT #1 indicated that staff could cause injuries such as shoulder dislocation and additional trauma by lifting under the axilla and by the legs. Interview and demonstration with the DNS on 6/22/17 at 12:43 PM identified that the furniture in Resident #111's room was readily movable. Additionally, the DNS did not identify what his/her expectation of staff was regarding Resident #111 being moved from the floor into the bed while crying with leg pain and prior to EMS arrival. Although multiple calls were placed to NA #3 for an interview, an interview was not obtained. NA #3 is no longer employed at the facility. Observation on 6/19/17 at 10:20 AM identified that the electrical room on the Terrace Garden unit was unlocked. The contents of the room included an electrical floor buffer machine, 2 electrical panels, a bottle of Window and Glass cleaner and a spray can of Crawling Insect Killer. Interview and observation with RN #1 on 6/19/17 at 10:20 AM identified that the electrical room door should always be locked. Additionally, RN #1 indicated that only maintenance has keys to the electrical room. Interview with Housekeeper #1 on 6/19/17 at 10:30 AM identified that he/she had used the floor buffer earlier in the morning and must have forgotten to lock the door after returning the machine to the closet. Additionally, he/she identified that because the electrical room contained hazardous items, it should remained locked. Review of the facility mechanical rooms policy identified that due to the equipment inside mechanical rooms, only authorized maintenance personnel and/or authorized contractors hired by facility shall have access to, or shall enter these rooms. Additionally, all doors entering mechanical rooms are to be secured at all times.

Inspection of July 16, 2014

1 finding

F323G · Actual harm, isolated

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had had sustained an injury during physical therapy treatment, the facility failed to provide adequate supervision when an E-Stim device was used without settings and/or parameters. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #1 had no cognitive or memory impairments, required extensive one person assistance with activities of daily living, had functional limitation in range of motion on one side, the skin was intact and the resident did not participate in physical and/or occupational therapies. The resident care plan dated 1/9/14 identified Resident #1 has [DIAGNOSES REDACTED] related status [REDACTED]. A physician's orders [REDACTED]. The order failed to reflect the stimulation settings. The nurse's note dated 3/11/14 at 12:00 PM identified Resident #1 was noted to have two presented with burn, blister like areas, one on the left shoulder and one just below the shoulder. The blister on the shoulder measured 3 centimeters (cm) by 1.5 cm by 0.5 cm, was painful to touch and the surrounding skin was very pink in color. The area just below the shoulder measured 4 cm by 1.5 cm by 0.5 cm, was yellow in color and approximately 50% of the area was blistering and the surrounding skin was very pink in color. The physician was notified and a directed to cleanse the areas with Normal Saline followed by Silvadene, followed by a coversite dressing times seven day, then re-evaluate and to discontinue the stimulation treatment. The Reportable Event Form dated 3/12/14 identified that on 3/10/14 at 2:00 PM the E-Stim treatment was applied to Resident #1's left upper extremity and left shoulder. The investigation identified Resident #1 had indicated that the machine physical therapy had placed on was getting intense and although the resident had pushed the kill switch the system did not shut off, Resident #1 ripped the probes off. Upon assessment pink marks and white adhesive from the probes were noted on the skin and the resident denied pain. In a written statement the Certified Occupational Therapy Assistant (COTA) identified that the resident had two nickel and one dime size "red and raw" marks where the pads were placed and the Assistant Director of Nurses (ADON) was immediately notified and assessed the marks. Review of the weekly non pressure tracking from dated 3/12/14 identified three wounds. The left front shoulder was identified with a 3cm by 1.5 by 0.5cm partial thickness wound yellow in color with blisters. The surrounding skin was noted as very pink. The left upper arm below the shoulder noted a burn like area measuring 4cm by 1.5cm by 0.5cm partial thickness wound yellow in color with blisters, and the area on the nape of the neck (left side) measuring 0.5cm by 0.5cm yellow in color with surrounding skin pink in color. In an interview with Resident #1 on 7/15/14 at 1:40 PM, the resident stated that the COTA placed the probes on his/her shoulder, set the timer, gave the switch to him/her to shut off the machine if the treatment became uncomfortable and left the room. Resident #1 stated that "the treatment was so painful it felt like someone stuck my finger in a light socket", and he/she tried to use the shut off switch but the switch did not work, so he/she ripped the pads off and called for help. Interview with the ADON on 7/15/14 at 11:00 AM identified that she was called into the resident's room and assessed the shoulder and neck areas. The ADON indicated that the areas appeared to be an irritation, and she did not feel it was an issue; therefore she did not complete an incident report nor notify the family until 3/12/14 at the time the areas had blistered. Review of Vectra Genisys (the E-Stim machine) user's manual identified that skin irritation and burns beneath the electrodes have been reported with the use of powered muscle stimulators and potential adverse effects with the electrodes are skin irritation and electrode burns. Interview with the Physical Therapist (PT) #1 on 7/15/14 at 10:20 AM identified that the E-Stim machine was new to the facility. PT #1 indicated that he had asked the COTA if she had used this particular machine before and the COTA stated yes, therefore he did not observe the COTA during a treatment with the resident. PT #1 stated that he did not review the manufacturer's guidelines prior to implementing the E-Stim machine and/or develop a policy and procedure and the appliance was not checked by the maintenance department. PT #1 identified that after the incident the machine was sent back to the company and the company did not find that the machine had malfunctioned. PT #1 stated that machine had two different areas to place the stop button and felt that the COTA may have utilized the wrong one which is why the kill switch did not work. PT #1 stated that prior to the incident the treatment was set up and the resident was left alone in the resident's room. PT #1 indicated that since the incident no residents are to be left alone when equipment is hooked up to them. Attempts to interview the COTA were unsuccessful.

Inspection of April 25, 2013

1 finding

F223G · Actual harm, isolated

Based on clinical record review, review of facility investigation and interviews for one of three sampled residents reviewed for mistreatment (R#89), the facility failed to ensure that staff interacted appropriately with residents. The findings include: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS dated [DATE] identified the resident as severely cognitively impaired, required extensive to total assistance with activities of daily living and exhibiting inappropriate behaviors. A RCP dated 12/16/12 identified the resident with ineffective coping and frustration at times when needs are not being met. Interventions included to remove the resident from the public area whenever behavior was disruptive; gently redirect whenever the resident made an inappropriate action; and redirect inappropriate behaviors. Facility A&I dated 12/15/12 identified that R#58 reported that he/she witnessed NA#1 grab R#89 by the arm and forcefully slammed her/him back down in her/his chair. Review of the facility investigation identified on 12/17/12 (2 days later) a body audit identified a 0.5 cm by 0.5 cm reddish/purple bruise on the right hand near the elbow. NA#1 was suspended pending investigation. Interview with R#58 on 4/24/13 at 1:45 PM indicated that R#89 was in the dining room on the 3:00 PM to 11:00 PM shift on 12/15/12 and R#89 was loud. R#58 indicated that NA#1 was talking to another nurse aide and R#89 had been interfering. R#58 indicated that NA#1 slammed R#89 into a chair and pushed him/her back. Although attempts to interview RN#6's were unsuccessful, review of RN#6's written statement dated 12/15/12 at 1:15 AM, identified that R#58 reported the incident to her. In a verbal statement obtained by facility staff on 12/16/12 at 1:00 AM, R#58 reported that he/she witnessed NA#1 grab R#89 forcefully and slammed him/her into a chair. R#89 responded by stating, " don't do that again! " NA#3's written statement dated 12/16/12 indicated that R#89 was in the dining room "cursing", and had kicked the table. NA#3 indicated that NA#1 pulled R#89 back into the chair. Review of NA#1's written statement dated 12/16/12, indicated that while in the dining room, R#89 stood up from the chair and she pulled him/her back into the chair from behind. NA#1 indicated that R#89 also tried to kick the table but was pulled away. Facility abuse investigation indicated that NA#1 was terminated secondary to an abusive action. Interview with the DNS on 4/25/13 at 9:33 AM indicated that R#58 reported NA#1's behavior. NA#1 was terminated as a result of the allegation, because the resident had a bruise and NA#1 sat R#89 forcefully. Interview with NA#1 on 4/25/13 at 11:15 AM indicated the resident was wheelchair bound and wanted to stand up. NA#1 also indicted that R#89 was also agitated, did not want to sit down and was yelling and grabbing the table cloth. NA#1 grabbed R#89 quickly so that he/she would not pull the table cloth off. NA#1 indicated R#89 was quick and her actions were reflex.

Inspection of May 14, 2012

1 finding

F323G · Actual harm, isolated

Based on clinical record reviews, observations, review of facility documentation, and interviews for two of six sampled residents (Residents #51 and #12) reviewed for accidents, the facility failed to implement care plan interventions and/or provide appropriate supervision to prevent a fall and/or injury and/or for one of three residents (Resident #75) reviewed for smoking, the facility failed to ensure the environment was free from accidental hazards. The findings include: 1. Resident #51's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] identified that Resident #51 had moderate cognitive impairments and required extensive assistance of one person with activities of daily living including transfers. The Resident Care Plan (RCP) dated 10/5/11 identified the resident was at risk for falls related to a history of falls with injury, impaired balance, unsteady gait and daily use of psychotropic medication. Interventions directed to ensure the environment is clutter free and encourage the resident to use handrails or assistive devices properly. The self-care performance deficit care plan directed to ensure that shoes were comfortable and not slippery. A physician's orders [REDACTED]. The nurse's note dated 11/17/11 identified that at 8:15 AM a Nurse Aide (NA) #1 reported that while assisting the resident off the scale, the resident slipped and hit his/her arm on the hand rail of the scale. The facility's investigation dated 11/17/11 identified that when getting off the scale the resident slipped and hit the left wrist on the bar, two bruises were noted and ice was applied. At 9:00 AM the resident's left wrist was swollen and painful, the Advanced Practice Registered Nurse (APRN) was notified and an x-ray was ordered. The x-ray report dated 11/17/11 identified that Resident #51 had sustained a fracture of the distal radius with dorsal displacement. Resident #51 was transferred to the emergency department for an evaluation and returned to the facility on [DATE] at 1:08 AM with a left hand splint. Interview and review of the clinical record and facility documentation on 5/1/12 at 12:45 PM with the Director of Nurses (DON) identified that NA #1, who was present during the incident, should have ensured the resident was wearing non-skid socks or shoes to prevent slipping. NA #1 received written counseling for failure to ensure the resident was wearing proper foot wear prior to standing him/her to obtain a weight. Numerous attempts to contact NA #1 were unsuccessful. 2. Resident #12's [DIAGNOSES REDACTED]. The 30-day Medicare Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 had no cognitive impairments, some short term memory deficits, and required two person extensive assistance with bed mobility and toileting. The Resident Care Plan (RCP) dated 2/8/12 identified a self-care deficit. Interventions directed to asset up and assist as needed, and two nurse aides with all resident contact. The nurse's note dated 4/27/12 at 4:45 PM identified that the licensed staff was called to Resident #12's room because the resident was face down on the floor, had sustained a large hematoma on the forehead, was bleeding from the mouth and 911 was summoned. Review of the Reportable Event Form dated 4/27/12 identified that the resident fell out of bed secondary to a loose side rail and sustained a hematoma to the forehead. Interview with Nurse Aide (NA) #2 on 5/2/12 at 3:10 PM identified that when she asked Resident #12 to use the side rail to turn, the side rail became loose and the resident fell to the floor. NA #2 stated that she did not have a second person to assist with the provision care. Interview with Registered Nurse (RN) #3 on 5/2/12 at 3:20 PM and with the Director of Nurses on 5/3/12 at 10:45 AM identified that on 4/27/12 NA #2 failed to have a second staff member present when she provided care to Resident #12. 3. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Smoking Evaluation dated 9/26/11 identified that Resident #75 did not smoke. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #75 had severe cognitive impairment in decision making and required limited assistance with activities of daily living. Observations on 5/2/12 at 1:30 PM Nurse Aide (NA) #3 was noted to lead Resident #75 out of the room and indicated to the resident that they could go outside to smoke. Resident #75 was then observed ambulating down the hall with NA #3 and Resident #75 had an unlit cigar. Further observations on 5/2/12 at 1:45 PM identified Resident #75 and NA #3 seated outside, Resident #75 held a lit cigar and there was no smoking apron on. Interview with Registered Nurse (RN) #6 on 5/2/12 at 2:10 PM identified that she was not aware that the resident smoked. Interview with NA #3 on 5/2/12 at 2:40 PM identified that the resident has smoked approximately every two weeks since admission. NA #3 further indicated a family member brings in the cigars which are kept in the resident's room. Review of the facility's Smoking Policy Agreement states residents may not carry lighters, matches, or cigarettes and smoking materials will be kept by the Nursing Staff.

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