Every finding on record at Wolcott Hall Nursing Center, Inc

Based on observation, review of facility documentation, job descriptions, and interviews for 2 of 2 units, the facility failed to ensure the environment was clean, maintained in good repair and homelike manner, and the facility failed to ensure that electrical/television wiring was maintained in a safe and orderly manner. The findings include:Review of the infection control surveillance safety rounds log identified the last infection control quarterly round were completed on 3/31/26 and on 6/30/26.Observation during the initial tour on 8/10/26 at 8:40 AM through 9:30 AM, and on 8/12/26 at 10:40 AM through 11:00 AM with the Maintenance Supervisor/Housekeeping Supervisor and RN #1 (Infection Preventionist) identified the following:a. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bedrooms on Migeon Lane unit in rooms 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 109, 110, 111, 112, 114, 115, 116, 117, and the nourishment area. Forest Court unit in rooms 118, 119, 200, 201, 203, 204, 206, 207, 208, 209, 210, 221, hallway floor, and the nurse station.b. Damaged, chipped, hole, stains and/or marred bedroom walls on Migeon Lane unit in rooms 101, 102, 105, 107, and 111.c. Damaged, missing wall, and hole bedroom wall on Migeon Lane unit in room [ROOM NUMBER].d. Damaged, peeling, torn, and stains on bedroom wallpapers on Migeon Lane unit in rooms 102, 103, 104, and 117.e. Damaged, peeling, torn, and stains on bathroom wallpaper and/or wall on Migeon Lane unit in room [ROOM NUMBER]. Forest Court unit in room [ROOM NUMBER].f. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on Migeon Lane unit in room [ROOM NUMBER] and hallway. Forest Court unit hallway.g. Damaged, peeling, and/or cracked bathroom floor tiles on Migeon Lane unit in room [ROOM NUMBER]. h. Damaged, peeling, and/or cracked bedroom floor tiles on Migeon Lane unit in room [ROOM NUMBER]. Forest Court unit in rooms [ROOM NUMBERS]. i. Damaged, dirty, and (green, black) stain in old soap holder on the bathroom wall on Migeon Lane unit in rooms [ROOM NUMBERS].j. Damaged, torn, and/or peeling bedroom floor mat on Forest Lane unit in room [ROOM NUMBER]. k. Damaged, and/or rusty bedroom radiator on Migeon Lane unit in rooms [ROOM NUMBERS].l. Damaged, and/or rusty bathroom radiator on Migeon Lane unit in rooms [ROOM NUMBER].m. Observed hanging loose and/or dangling multiple wires from the television on Forest Court unit in room [ROOM NUMBER].Interview with RN #1 on 8/12/26 at 10:55 AM identified she was aware of some of the issues identified with the environment during the survey. RN #1 indicated that the housekeeping department is responsible to maintain the resident rooms in a homelike environment at all times. RN #1 indicated she and the Housekeeping Supervisor will be having a meeting with the housekeeping department, maintenance department regarding the environment cleanliness, and repairs. Interview with the Maintenance Supervisor/Housekeeping Supervisor on 8/12/26 at 11:00 AM identified he was aware of some of the issues identified during the survey. The Maintenance Supervisor/Housekeeping Supervisor indicated he was aware of the resident bedroom floors with stains and/or wax build up on the floors. The Maintenance Supervisor/Housekeeping Supervisor indicated that maintenance of the facility is ongoing. The Maintenance Supervisor/Housekeeping Supervisor indicated that staff are responsible to notify the maintenance department with issues or problems that require repair. The Maintenance Supervisor/Housekeeping Supervisor indicated he will be having a meeting with the maintenance department, and the housekeeping department regarding the environment cleanliness, and repairs. The Maintenance Supervisor/Housekeeping Supervisor indicated he will be having a meeting with the Administrator, the DNS, and corporate in regard to the resident bedroom floors. Interview with the Administrator on 8/12/26 at 11:20 AM the Administrator identified she was aware of some of the issues. The Administrator indicated she was aware of the resident bedroom floors with stains and/or wax build up on the floors. The Administrator indicated the maintenance department, and housekeeping department will be working on these issues. The Administrator indicated the maintenance department, and the housekeeping department will be in-service. The Administrator indicated she will be having a meeting with the DNS, the Maintenance Supervisor/Housekeeping Supervisor, and corporate regarding the resident bedroom floors. Interview with the DNS on 8/12/26 at 11:30 AM identified she was not aware of all the issues. The DNS indicated she was aware of the resident bedroom floors with stains and/or wax build up on the floors. The DNS indicated she will be having a meeting with the maintenance department, and the housekeeping department regarding the environment cleanliness, and repairs. The DNS indicated she will be meeting with the Administrator and the Maintenance Supervisor/Housekeeping Supervisor to discuss a plan regarding the resident bedroom floors.Review of the maintenance supervisor job description identified he/she plans, organizes and directs the maintenance and repairs of the physical plant, equipment and all essential building systems. Ensures the facility is safe and secure. Review of the maintenance technician job description identified under direct supervision provides quality maintenance services. Assists in the maintenance and repair of the physical plan and grounds, equipment and various building systems. Provides a clean, orderly and safe environment for all facility residents and staff.Review of the housekeeping supervisor identified plans, organizes and directs the provision of housekeeping services. Monitors the activities of assigned staff ensuring the facility is cleaned on a scheduled basis to maintain high standards and appearance. May be required to perform daily housekeeping functions in absence of staff.Review of the housekeeping assistant identified under the direct supervision provides quality housekeeping services, and a clean, orderly and safe environment for all facility residents and staff.

Based on review of the clinical record, facility policy, and interviews for 3 of 3 residents (Resident #6, 25 and 44) reviewed for care planning, the facility failed to ensure the residents and/or resident representatives were invited to and given the opportunity to participate in their quarterly care plan meetings, and for 1 of 2 residents (Resident #50) reviewed for pain management, the facility failed to ensure the comprehensive care plan was revised following an amputation. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling, and muscle weakness. The care plan dated 10/24/25 identified Resident #6 needed staff assistance with ADLs. Interventions included advanced directives per MD orders. The care plan also identified Resident #6 had impaired cognition and decision-making skills. Interventions included if Resident #6 did not understand what was being said to restate using simpler terms. The admission MDS dated [DATE] identified Resident #6 had severely impaired cognition, was always continent of bowel and bladder, required maximal assistance from staff with toileting, and moderate assistance from staff with bathing and dressing. An APRN order dated 10/26/25 by APRN #1 directed to obtain and document code status. An APRN order dated 11/5/25 by APRN #1 directed Do Not Resuscitate (DNR)/RNP (RN to pronounce). The admission MDS dated [DATE] identified Resident #6 had severely impaired cognition, was always continent of bowel and bladder, required maximal assistance from staff with toileting, and moderate assistance from staff with bathing and dressing. An APRN order dated 10/26/25 by APRN #1 directed to please obtain and document code status. An APRN order dated 11/5/25 by APRN #1 directed for advance directives that included Do Not Resuscitate (DNR)/RNP, (RN to pronounce). Review of the clinical record failed to identify documentation that resident care conferences had been conducted or that Resident #6 and his/her resident representative were invited to participate. Facility documentation review and interview with LPN #2 (MDS Coordinator) on 8/12/26 at 11:25 AM identified she was responsible for initiating and conducting resident care conferences for residents of the facility. LPN #2 identified she did not make any notes in the clinical record regarding any care conferences and identified that she kept the care conference sign in sheets in a binder in her office. LPN #2 further identified that she would invite residents and resident representatives to the care conferences but did not document or track these invites. LPN #2 identified she would mail out all invites to resident representatives, and if a response was mailed back, then the mailed back response paperwork was the only documentation to show that invites were sent. LPN #2 also identified any notes about the care conferences that were written by her on the care conference sign in sheets, and not in the resident's clinical record. Review of a resident care plan conference sign off document identified that resident care conferences were held for Resident #6 on 11/7/25 (initial care conference held 18 days after admission to the facility); 4/9/26; and 5/7/26. The document identified that Resident #6's advance directive choices included DNR, DNI, and RNP. Review of the document failed to identify any invitation or participation by Resident #6 or his/her resident representative for the care conferences held on 11/7/25 and 4/9/26. The care conference held on 5/7/26 identified Resident #6's resident representative was invited to the care conference but was a no show. Further review of the documentation and clinical record failed to identify how Resident #6's resident representative had been notified of the 5/7/26 care conference (as LPN #2 identified all invites were done by mail and the mailed back response paperwork was the only documentation to show that invites were sent). Although requested, the facility failed to provide documentation related to resident care conference invitations to Resident #6's resident representative. The facility policy on care planning directed that a comprehensive, interdisciplinary plan of care would be developed, implemented, reviewed, and updated for each resident in accordance with regulatory requirements and resident specific needs, preferences, strengths, and goals. The policy also directed that residents and/or responsible parties would be encouraged to participate in the care planning process. The policy also directed that care plan conferences would be conducted in accordance with regulatory requirements and as needed for significant changes of condition, and the resident and/or responsible party would be invited to participate in care planning conferences. The policy also directed that care plans, care conferences, participant involvement, revisions, and related interdisciplinary documentation would be maintained in the medical record. 2. Resident #25 was admitted to the facility in August 2025 with diagnoses that included COPD, ileostomy status, and Crohn's disease. The quarterly MDS dated [DATE] identified Resident #25 had intact cognition, was able to make him/herself understood and express ideas and wants, had clear comprehension of verbal content, required substantial/maximal assistance with chair/bed-to chair transfers, and was independent wheeling 150 feet with a motorized wheelchair. The care plan dated 5/31/26 identified Resident #25 was at risk for changes in mood state due to long term placement, with interventions that included encouraging him/her to attend group activities, converse and express feelings, and take an active social role in the facility. Interview with Resident #25 on 8/9/26 at 8:40 AM identified that he/she did not recall having been invited to his/her quarterly care conference meetings, nor had he/she attended a quarterly care plan conference with members of the interdisciplinary team. Resident #25 indicated that he/she had interest in attending his/her care plan conferences. Review of the Resident Care Plan document provided on 8/9/26 identified Resident #25's care plan conferences were completed on 8/21/25, 11/28/25, 2/23/26, and 5/25/26 and were signed off by the MDS Coordinator and representatives from social service, dietary, and activities. The Resident Care Plan document failed to identify a sign-off that Resident #25 and/or a resident representative had attended the care plan conference. Review of Resident #25's medical record dated 8/7/25 through 8/9/26 failed to identify documentation of care plan conferences taking place, including resident and/or resident representative involvement and/or refusals, and interdisciplinary documentation. Interview with the MDS Coordinator (LPN #2) on 8/10/26 at 2:19 PM identified that she was responsible for inviting the interdisciplinary team and the residents and/or resident representatives to the care plan conferences and for conducting the resident care plan conferences. One month prior to a resident's care plan conference, she would provide the resident and/or resident representative with an invitation, that included the care conference date and time, to attend his/her care plan conference. LPN #2 indicated that she did not have documentation to support that Resident #25 had received his/her care plan conference invitation. Resident #25 had expressed an interest in attending his/her care plan meetings and had never declined attending. LPN #2 identified that she would not always circle back to Resident #25 on the day of the care plan conference for participation. LPN #2 further identified that she does not always go down to get the resident at the time of their care plan conference, but she would meet with the resident after the meeting and provide an update. LPN #2 indicated that residents should be attending their care plan conferences, and it was her responsibility to ensure the residents attended the meeting, if that was their preference. LPN #2 further indicated that she does not document in the resident's clinical record updates from the quarterly care plan conferences; she would only document when bigger issues were identified by the resident, but she does have the IDT attendees sign-off the Resident Care Plan document. 3. Resident #44 was admitted to the facility in February 2025 with diagnoses that included Parkinsonism, depression, and anxiety. The quarterly MDS dated [DATE] identified Resident #44 had had intact cognition, was able to make him/herself understood and express ideas and wants, had clear comprehension of verbal content, and required supervision/touching assistance with chair/bed-to chair transfers and with walking 150 feet. The care plan dated 6/25/26 identified Resident #44 was at risk for changes in mood state due to diagnoses of anxiety and depression and long-term placement, with interventions that included encouraging him/her to attend group activities, converse and express feelings, and offer activities of interest. Interview with Resident #44 on 8/9/26 at 8:32 AM identified that he/she did not know what a resident care plan conference was and could not recall having been invited to the care plan conferences, on a quarterly basis, or attending a care plan conference. Resident #44 indicated that a meeting with the interdisciplinary team on a routine basis to discuss his/her concerns, goals, and/or care interventions sounded nice, and that he/she would want to attend a meeting like that. Review of the Resident Care Plan document provided on 8/9/26 identified Resident #44's care plan conferences were completed on 12/15/25, 3/13/26, and 6/11/26 and were signed off by the MDS Coordinator and representatives from social service and activities. The Resident Care Plan document failed to identify a sign-off that Resident #44 or a resident representative had attended the care plan meeting, but identified a review was completed with the resident. Review of Resident #44's medical record dated 2/4/25 through 8/9/26 failed to identify documentation of care plan conferences taking place, including resident and/or resident representative involvement and/or refusals, and interdisciplinary documentation. Interview with the MDS Coordinator (LPN #2) on 8/10/26 at 2:19 PM identified that she did invite Resident #44 to his/her care plan conferences a month prior but did not have documentation to support that he/she had received his/her care plan meeting invitation. LPN #2 indicated that Resident #44 was invited but did not wish to participate in his/her care plan meetings. LPN #2 identified that since Resident #44 did not want to participate, she reviewed information from the meeting with him/her after the meeting, but that there was no documentation in Resident #44's clinical record that the care plan conference details were reviewed with Resident #44. Interview with the DNS on 8/12/26 at 8:32 AM identified that the purpose of the quarterly resident care plan conferences was to review, with the resident and/or resident representative and members of the IDT, the comprehensive care plan, resident code status, and medications; she was not aware that Resident #25 and Resident #44 had indicated that they were not invited to their quarterly care plan meetings. The DNS indicated that she would expect all residents and/or resident representatives to be invited to his/her care plan meeting, although some residents who have resided in the facility for a long time opt out of attending; if the resident would like to attend, the facility staff should be assisting them with getting to the meeting or holding the meeting in the resident's room. The DNS further indicated that she would expect not only the sign-in sheet to be signed by the resident and/or resident representative, when possible, but also a progress note to be written in the medical record documenting what was reviewed during the meeting, any changes or updates to the care plan, and who was in attendance, including the resident and/or resident representative. The Care Planning policy directs that a comprehensive, interdisciplinary plan of care will be developed, implemented, reviewed, and updated for each resident in accordance with regulatory requirements and resident-specific needs, preferences, strengths, and goals. Residents and/or responsible parties will be encouraged to participate in the care planning process. Care plan conferences will be conducted in accordance with regulatory requirements and as needed for significant changes in condition. The resident and/or responsible party will be invited to participate in care plan conferences. Care plans, care conferences, participant involvement, and related interdisciplinary documentation will be maintained in the medical record. 4. Resident #50 was admitted to the facility in July 2026 with diagnoses that included osteomyelitis and bacteremia. The care plan dated 7/10/26 identified Resident #50 was admitted for short term rehabilitation and was receiving antibiotic therapy for Osteomyelitis of the right ankle and foot. Interventions included administering antibiotics per the physician's order. The resident was at risk for pain/discomfort which could may impact mobility, mood (anxiety/depression), behaviors, sleep, ADL functioning, and relationships with others, with interventions that included turning and repositioning and administering pain medications per the physician's orders. The resident was at risk for skin breakdown secondary to a wound vac to the right ankle, with interventions that included following all recommendations from the wound care team, ICN and wound APRN. The admission MDS dated [DATE] identified Resident #50 had intact cognition, had an impairment to one side of the lower extremity, required substantial/maximal assistance with toilet transfers, sitting to standing, and chair/bed-to-chair transfers, and reported frequent pain over the last 5 days. Review of the Census List identified Resident #50 was discharged from the facility to the hospital on 7/27/26. Resident #50 was readmitted to the facility on [DATE] with diagnoses that included a partial amputation at the level between the knee and ankle of the lower right leg. The Nursing admission assessment dated [DATE] identified Resident #50 had a right below the knee amputation (BKA), ambulation status was bedrest, and had 8/10 localized pain to the right leg which was exacerbated by movement and relieved by rest and pain medication. Interview with Resident #50 on 8/9/26 at 8:50 AM identified that he/she had recently underwent a right BKA, following many months on antibiotic therapy, and that overall, his/her pain control was well managed but that phantom pain was very real and that he/she was having a hard time finding relief from it. Resident #50 further indicated that he/she had communicated his/her concerns about the phantom pain to the nursing staff and APRN, and he/she felt that the facility was putting in a lot of effort to find the best treatment regimen Review of the clinical record with the MDS Coordinator (LPN #2) on 8/10/26 at 2:37 PM failed to identify the comprehensive care plan had been reviewed and updated following Resident #50's readmission to the facility on 7/30/26 (11 days). Interview with LPN #2 on 8/10/26 at 2:37 PM identified that both herself and the nursing staff were responsible for reviewing and revising residents' comprehensive care plans. LPN #2 indicated that she was aware of Resident #50's amputation, but she did not update the comprehensive care plan to reflect the BKA post-surgical interventions, phantom pain management, or resolve the wound vac, when he/she returned to the facility. LPN #2 identified that it was an oversight that the care plan was not revised, and that she would update it immediately. Subsequent to surveyor inquiry, Resident #50's care plan was updated to reflect a care plan that identified Resident #50 had a right BKA and was at risk for complications following amputation: infection, hematoma, wound dehiscence, and stump necrosis, with interventions that included watching for surgical complications and pain management, as ordered. Interview with the DNS on 8/12/26 at 8:38 AM identified that she would have expected Resident #50's comprehensive care plan to have been reviewed and revised following his/her readmission to the facility, typically within 24 hours, including a new care plan for his/her BKA with appropriate interventions, as well as updating the discontinued interventions such as the wound vac treatment. The DNS identified that it was usually the responsibility of the MDS Coordinator to revise and update resident care plan following morning report, where the IDT shares and discusses important resident information and updates. The Care Planning policy directs that a comprehensive, interdisciplinary plan of care will be developed, implemented, reviewed, and updated for each resident in accordance with regulatory requirements and resident-specific needs, preferences, strengths, and goals. The care plan will include: identified problems, needs, or focus areas, measurable goals, individualized interventions, and responsible disciplines. Care plans will be reviewed and updated with changes in condition, goals, preferences, and interventions. Resident care summaries, assignment tools, or care cards will be updated as needed to reflect current care plan interventions.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 16 residents (Resident #6) reviewed for advance directives, the facility did not review the residents wish for code status with the resident representative for 10 months following admission to the facility. The findings include:Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling, and muscle weakness. The care plan dated 10/24/25 identified Resident #6 needed staff assistance with ADLs. Interventions included advance directives per MD orders. The care plan also identified Resident #6 had impaired cognition and decision-making skills. Interventions included if Resident #6 did not understand what was being said to please restate using simpler terms.Review of the care plan failed to address advance directive choices. The admission MDS dated [DATE] identified Resident #6 had severely impaired cognition.An APRN order dated 10/26/25 by APRN #1 directed to obtain and document code status.An APRN order dated 11/5/25 by APRN #1 directed Do Not Resuscitate (DNR)/RNP (RN to pronounce death).Review of the clinical record on 8/9/26 failed to reflect documentation that advance directives had been reviewed with Resident #6 and/or his/her resident representative. Following the clinical record review, a request was made to the facility to provide the documentation.Subsequent to surveyor inquiry, interview and review of documentation on 8/10/26 at 9:41 AM a medical interventions consent form was provided by the Administrator for Resident #6. The form identified Resident #6's choices regarding the administration of life support included DNR, DNI (do not intubate), and do not administer any artificial means of nutrition including tube feedings or TPN (total parenteral nutrition). The form also identified Resident #6 wished to have IV fluids and hospitalization for trauma only. The form was signed by RN #1 (IP nurse) and LPN #2 (MDS Coordinator) with a note that the form was reviewed and consented by Resident #6's resident representative. The form was dated 8/9/26, one day prior. The Administrator identified the form was dated 8/9/26 which was when the advance directives were reviewed with Resident #6's resident representative, but the Administrator indicated there was an additional form which was signed by Resident #6. Subsequent to surveyor inquiry, review of documentation and interview with the Administrator on 8/10/26 at 12:00 PM identified an undated medical interventions consent form for Resident #6. The form identified Resident #6's choice regarding the administration of life support included DNR, DNI, RNP (RN to pronounce death), and do not administer any artificial means of nutrition including tube feedings or TPN (total parenteral nutrition). The form also identified Resident #6 wished to have IV fluids and hospitalization. The form identified an undated signature with Resident 6's name, no staff nurse signature, and it was signed by APRN #1 dated 10/30/25. The Administrator identified that APRN #1 reviewed the original advance directives with Resident #6 on 10/30/25 and signed the form with the resident (this is in conflict with the interview with APRN #1 who did not discuss advance directives with Resident #6 or his/her representative). The Administrator further identified that she believed that the facility APRN also typically reviewed advance directive forms with facility residents. The Administrator identified that since the original form was signed with Resident #6 directly and the resident wasn't with it, a new form was reviewed and signed with Resident #6's resident representative on 8/9/26. The Administrator was unable to identify why Resident #6's advance directives were not reviewed with the resident representative when Resident #6 was initially admitted to the facility on [DATE] or any time after, until surveyor inquiry on 8/9/26.Interview with APRN #1 on 8/10/26 at 1:58 PM identified that she did not review any advance directive forms with residents of the facility as a typical part of the admission process. APRN #1 identified that Resident #6 was cognitively impaired and had been since admission to the facility and was also very hard of hearing. APRN #1 identified that both of these issues would make it difficult to review or sign any documentation directly with Resident #6 and that all documentation and discussions regarding Resident #6's care were reviewed with his/her resident representative. APRN #1 also identified that the process at the facility included that the licensed nursing staff, typically the admitting nurse, would review and sign the advance directive form with the resident. APRN #1 identified after the nurse finished his/her portion of the form, the form was then placed in an APRN/MD book at the nurses station along with any others that were obtained since the last time a provider was in the facility. APRN #1 identified that the providers would retrieve the signed forms, sign the provider portion of the form, and return back to the folder to be added to the resident's clinical record. APRN #1 identified the only time she would ever review advance directive choices with a resident, or a resident representative, would be if there were any discussions regarding a change in status to comfort measures or hospice, and that she would document the discussion as goals of care in her provider note. APRN #1 then reviewed her notes and identified she did not have any discussions regarding advance directives with Resident #6 or his/her resident representative. Interview with LPN #1 on 8/11/26 at 7:30 AM identified that while she was not the nurse who admitted Resident #6 to the facility, she was regularly assigned to care for him/her and identified that for residents admitted to the facility, the admission nurse would usually be the nurse who would try and obtain the advance directive form within 48 hours of admission. If the resident was unable to complete the form, the nurse would review with the resident's representative and then following completion of the form, the nurse would date and sign the form on the staff nurse signature line and then place the form in the provider folder for the APRN or MD to review and sign. LPN #1 identified that nursing staff assigned to the resident would be responsible for completing the form, and typically the APRN or MD only signed the form after placed in the folder. The facility policy on advance directives directed that the facility would provide residents or their representative information regarding advance directives and the right to accept or refuse treatment upon admission. The policy further directed that advance directive decisions, including code status and withholding or withdrawing of treatment, would be reviewed with the resident or the appropriate decision maker, documented in the medical record, and supported by physician's orders, and if no advance directive decision had been made, the resident would remain full code until clarified. The policy further outlined the procedure regarding advance directives as follows:1. Advance directives and code status would be reviewed upon admission by licensed nursing staff and or the attending physician.2. Copies of living wills, healthcare proxies, conservatorship paperwork, or other advance directive documents would be maintained in the medical record.3. Advance directive decisions would be documented on the appropriate facility forms and supported by physician's orders.4. The attending physician would document discussions and decisions regarding advance directives in the medical record.5. Advance directive and code status would be reflected in the residence care plan and reviewed quarterly and as needed with any significant change.6. Any change to advance directives or code status must be communicated promptly to the interdisciplinary team.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #48) reviewed for a closed record (death), the facility failed to report, initiate an investigation and implement appropriate mitigation measures after Resident #48 was readmitted to the facility with information on the discharge summary indicating the resident had been treated for Legionella pneumonia. The findings include: Resident #48 was re-admitted to the facility in May 2026 from an acute hospital with diagnoses that included chronic obstructive pulmonary disease (COPD). Nursing admission assessment dated [DATE] identified Resident #48 was cognitively intact with no shortness of breath, cough, nausea or vomiting. The care plan dated 5/26/26 identified Resident #48 was at risk for pain related to a left hip fracture. Interventions included allow activity as tolerated, observe for signs and symptoms associated with pain and allow activity as tolerated. The admission MDS dated [DATE] identified Resident #48 was cognitively intact. The APRN progress note dated 5/28/26 at 8:00 AM identified Resident #48 had a onetime vomiting episode after breakfast. Zofran (medication used to treat nausea and vomiting) was ordered as needed for 48 hours and nursing was instructed to report any reoccurrence. A physician progress note dated 6/2/26 at 1:45 PM identified Resident #48 was evaluated for nausea and vomiting with chest congestion and breathing difficulties. Nursing reported hypoxia (low oxygen) at 89% (normal oxygen saturation levels 95% to 100%) requiring oxygen via nasal canula. Resident #48 had poor air entry in all fields, scattered wheezing (abnormal breath sounds), occasional cough, breathing mildly labored. Vomiting was determined likely secondary to constipation. A stat (as soon as possible) chest x-ray and blood work were ordered. The chest x-ray dated 6/2/26 identified Resident #48 was negative for pneumonia, pulmonary edema and pneumothorax. Nursing staff were to continue to monitor Resident #48's respiratory status and nausea/vomiting. An APRN progress note dated 6/3/26 identified Resident #48 was evaluated for continued cough. Lungs were clear to auscultation, oxygen saturation 94% with oxygen at 2 liters/minute via nasal canula. Resident #48 denied fever and chills, was continuing prednisone and nebulizers as needed, Zofran for nausea with a plan to repeat the chest x-ray in a few days if no improvement. Resident #48 was noted overall to be improving, moving his/her bowels with a plan to continue current treatments and monitor. An APRN progress note dated 6/4/26 at 10:30 AM identified Resident #48 experienced another vomiting episode overnight, reporting no appetite and weakness. Treatment included administering a one-time dose of Rocephin (antibiotic medication used to treat infection), oxygen, nebulizers as needed, repeat chest x-ray, laboratory testing, intravenous (IV) fluids for dehydration and continued monitoring. Chest x-ray dated 6/4/26 identified no evidence of acute disease. Nursing progress note dated 6/5/26 identified Resident #48 vomited brownish liquid, stating he/she did not want to eat. The APRN was made aware. An APRN progress note dated 6/19/26 at 9:15 AM identified Resident #48 had one episode of vomiting. Laboratory testing was ordered and nursing staff were instructed to report any continued vomiting. An APRN progress note dated 6/21/26 identified Resident #48 became hypoxic beginning 6/20/26 and was placed back on oxygen at 2 liters/min via nasal cannula. Oxygen saturation was 90% on oxygen at 2 liters and bilateral lower lobe crackles were noted on exam. Resident #48 reported feeling tired but was eating and hydrating, denied fever, chills, cough, congestion or further nausea. Laboratory results were pending and a chest x-ray was ordered to rule out aspiration pneumonia secondary to vomiting. Chest x-ray dated 6/22/26 identified Resident #48 had modest right lower lobe and slight left lower lobe pneumonia. Physician orders dated 6/22/26 directed to administer Cefpodoxime Proxitil 200mg (antibiotic) orally twice daily for 7 days and Doxycycline 100mg (antibiotic) twice daily for 7 days for treatment of pneumonia. An APRN progress note dated 6/25/26 at 10:45 AM identified resolving pneumonia, stabilizing laboratory levels with IV hydration. Situation, Background, Assessment, Recommendation (SBAR) note dated 6/25/26 at 11:40 AM identified Resident #48 with a change of mentation, uncontrolled pain in the left knee and swelling in the right hand. The physician was notified and orders obtained to be transferred to the hospital for further evaluation. Review of hospital documentation identified a Legionella Antigen IEA and Streptococcal (strep) Antigen urine test result dated 6/27/26 for a specimen collected on 6/26/26 during hospitalization identified Resident #48 with a presumptive positive Legionella result as compared to a presumptive negative result obtained four months earlier (no date). Comments noted a presumptive positive for Legionella pneumophila antigen in urine suggested a current or past infection. Hospital Discharge summary dated [DATE] (transmitted 7/2/26 at 6:01 PM) identified Resident #48 was admitted with a diagnosis of bilateral community acquired pneumonia. Urine strep/Legionella testing was found to be presumptive positive. Due to the Legionella pneumonia, Azithromycin was to continue for a total of 10 days which would also treat presumed strep pneumonia. Discharge medications included Azithromycin 500mg which was to be discontinued on 7/7/26. Resident #48 appeared well, was alert and oriented, and lungs were clear to auscultation. Nurse's note dated 7/4/26 at 8:37 AM identified Resident #48 was found unresponsive with no pulse, no blood pressure or response to verbal/tactile stimuli. Apical pulse was absent after checking one minute. Pupils were fixed and dilated. Time of death was pronounced at 8:05 AM. Death Certificate dated 7/4/26 identified the primary cause of death as Legionella pneumonia. Interview and clinical documentation review with the Administrator on 8/10/26 at 9:00 AM identified she was aware of Resident #48's primary diagnosis of Legionella pneumonia but indicated the resident was treated with antibiotics. The Administrator could not recall what measures were implemented in response to the positive Legionella finding but would have been part of an interdisciplinary discussion to address the issue. Interview with the Medical Director (MD #1), on 8/10/26 at 9:13 AM identified Legionella pneumonia was the primary diagnosis on the death certificate, and that Resident #48 had no prior history of Legionella that he was aware of. MD #1 indicated that any resident with community acquired pneumonia would be treated with antibiotics known to treat Legionella as well. The Medical Director further identified he would expect the facility to follow the water management plan following a resident with documented presumptive positivity to Legionella. Interview with the Director of Maintenance on 8/10/26 at 10:22 AM identified the facility had a water management plan that included procedures to be implemented if the water tested positive for Legionella but he would not know what to do for a resident who tested positive as that scenario had never previously occurred. The Director of Maintenance indicated that the facility utilized an outside water management consulting company to complete an assessment, make recommendations and conduct water sampling which was all negative. The water management plan is followed preventively and was recently reviewed in July 2026 with the consulting company and determined to be adequate. Testing had been performed at that time with pending results. The Director of Maintenance confirmed no changes were made to the water management plan after Resident #48 returned from the hospital for continued treatment for Legionella pneumonia as he was not aware. Subsequent to surveyor inquiry, the Director of Maintenance indicated that he was informed that Resident #48 had a history of Legionella prior to admission. Interview and clinical record review with Infection Preventionist (RN #1) on 8/10/26 at 10:55 AM with the Regional Director of Nursing (RN #3) present identified she vaguely recalled discussing Resident #48's Legionella diagnosis at some point. However, RN #1 indicated that Legionella was transmitted through water, not person to person and Resident #48 was treated with antibiotics therefore, there was no need to take further action. RN #1 identified that maintenance conducts routine flushing of designated water sources and that she really did not play a role in water management. If the need were to arise, RN #1 identified she would notify RN #3 for additional resources and support, restrict drinking and use of the water supply and contact the local health department for additional guidance. RN #1 further identified there was no need to take further action as Resident #48 was presumed positive for Legionella according to labs obtained during hospitalization which were not confirmed and the hospital discharge paperwork did not include recommendations for follow up. RN #1 was unable to state why mitigation measures were not immediately implemented after Resident #48 was readmitted to the facility being treated for Legionella pneumonia and subsequently, when MD #1 documented the primary cause of death as Legionella pneumonia on 7/4/26. Subsequent to surveyor inquiry, the facility reported the presumptive positive finding of Legionella pneumonia to the overseeing state agency, initiated an investigation and implemented mitigation measures. Interview and clinical record review with RN #3 on 8/10/26 at 10:55 AM identified the IP provided water management education prior to and after 7/3/26. RN #3 indicated if she had been made aware that Resident #48 had tested positive for Legionella, she would have implemented bottled water and directed no further use of water. RN #3 further identified the hospital should have done further testing and notified the facility when Resident #48 tested presumptive positive for Legionella during hospitalization. Additionally, RN #3 asserted Resident #48 could have had exposure to Legionella outside of the facility. RN #3 was unable to state why mitigation measures were not immediately implemented after Resident #48 was readmitted to the facility being treated for Legionella pneumonia and subsequently, when MD #1 documented the primary cause of death as Legionella pneumonia on 7/4/26. Interview with the General Manager for the contracted water management services (Water Management Contractor #1) on 8/11/26 at 12:22 PM identified he provides water management consulting services and water testing for the facility. Water Management Contractor #1 indicated that the water management plan was reviewed in July 2026 and was adequate and there was no prior history of positivity. Water Management Contractor #1 further identified he was not notified by the facility until 8/10/26, subsequent to surveyor inquiry, that a resident tested presumptive positive for Legionella. Water Management Contractor #1 made additional recommendations to the facility that included shutting down the sink where Resident #48 resided, restricting showers, conducting focused water testing and continued use of bottled water that the facility had self-initiated separately from his recommendations on 8/10/26. Recommendations may be amended depending on the result of the focused water testing which was conducted on 8/11/26. Water Management Contractor #1 further identified he should be notified immediately for any resident who tests positive for Legionella so he can provide additional guidance and perform water testing. Subsequent interview with the Administrator on 8/11/26 at 6:07 AM identified she was unable to recall when or where staff discussed the Legionella pneumonia diagnosis, and meeting notes were not maintained. Interview with the DNS on 8/11/26 at 6:07 AM identified she was not aware Resident #48 was readmitted to the facility after testing presumptive positive for Legionella. A third facility-initiated interview with the Administrator with the Regional Director of Nursing (RN #3) present on 8/11/26 at 12:24 PM identified she was not aware that Resident #48 returned from the hospital with Legionella pneumonia documented on the discharge summary. The Administrator and RN #3 were unable to state why mitigation measures were not immediately implemented after Resident #48 was readmitted to the facility being treated for Legionella pneumonia and subsequently, when MD #1 documented the primary cause of death as Legionella pneumonia on 7/4/26. Interview with the Infection Preventionist at the community hospital, (IP #5), where Resident #48 was treated, on 8/11/26 at 2:34 PM, identified the resident tested negative for Legionella on 4/3/26 during a past hospitalization and could have been exposed as he/she transferred in and out of facilities since that time but was unable to provide the exposure window of time when a person can become infected. IP #5 indicated that the hospital clinical record lacked documentation of any further action taken during hospitalization following the presumptive positive Legionella finding and was unable to discuss what, if any further action should be taken following a presumptive positive Legionella test or procedures for communication to a facility upon discharge as it was outside of her role. Laboratory Certificate of (water testing) results dated 7/22/26 (Received 8/12/26 subsequent to surveyor inquiry) identified Legionella was not detected in 8 of 8 areas sampled. Subsequent interview with the DNS on 8/12/26 at 7:10 AM identified she reviewed Resident 48's discharge summary but not in its entirety so she was unaware Resident #48 had tested positive for Legionella. The DNS indicated nursing staff were expected to review the hospital W 10 Interagency Patient Referral Form when a resident returns from the hospital. The DNS further identified nursing staff were also responsible for reviewing the discharge summary, but not comprehensively, as it was the physician's responsibility to thoroughly review the discharge summary, and the hospital's responsibility to report clinically significant findings. The DNS further identified she would have reported the positive Legionella result if she had known. Subsequent interview with the MD #1 on 8/12/26 at 10:17 AM identified he could not recall when he first learned that Resident #48 was being treated for Legionella pneumonia during hospitalization but that the information was likely obtained from the discharge summary. MD #1 indicated he completed the death certificate remotely on 7/4/26 and hastily included Legionella pneumonia as a primary diagnosis but should not have as Resident #48 had completed treatment for the infection. Therefore, other comorbidities should have been considered and indicated he would be amending the death certificate to reflect his findings. MD #1 also indicated he was not aware Resident #48 had a previously negative Legionella test on 4/3/26 and that he/she could have had exposure sometime prior to admission on [DATE] as a person could have positive findings for an extended period after testing positive. MD #1 further identified the positive result should have triggered reporting to the overseeing state agency, investigation and mitigation efforts but emphasized no other residents required treatment for Legionella and that the lack of reporting did not result in harm to any other residents. Additionally, although he did not directly discuss the Legionella diagnosis with the facility, he generally relied on nursing staff to review the discharge paperwork for any clinically significant findings. Interview with the Microbiologist at the hospital (Microbiologist #1) on 8/12/26 at 12:12 PM where Resident #48 was treated identified the presumptive positive Legionella antigen urine test dated 6/26/26 was obtained in conjunction with a Streptococcal Antigen urine test which also tested presumptive positive and would be highly suggestive of a false positive. Other interfering factors such as antibiotic therapy or alterations in PH could also result in a false positive reading. In such cases, additional testing is warranted for confirmation of Legionella. The hospital clinical record lacked documentation that any further testing was completed but acknowledged Resident #48 was treated for documented Legionella pneumonia. Interview with the hospitals Infectious Disease Specialist, (MD #3) on 8/18/26 at 3:30 PM identified that while he was not directly involved with Resident #48's care, a chart review indicated that Legionella pneumonia was likely considered based on Resident #48's multiple comorbidities, active treatment of community acquired pneumonia in the facility and presumptive positive Legionella testing. MD #3 indicated no test was 100% conclusive and additional testing would be required which were not completed based on clinical record review. Resident #48 was treated with antibiotics which would have treated Legionella if positive. However, the test itself was not conclusive. Review of the Exposure to Legionnaire's Disease policy directed the facility to monitor and treat residents as appropriate for potential exposure to Legionnaire's disease. When a patient is diagnosed with Legionnaire's disease it is recommended to adhere to the following guidelines to determine if further interventions are needed: 1. An investigation for the source of Legionella should be initiated when: a. > 1 case of definite health care associated Legionella disease is identified. A case requiring further interventions would constitute a patient who spent the entire 10 days prior to the onset of illness in the facility. The CDC supports obtaining confirmation of lab results through a culture of lower respiratory secretions on selective media and the Legionella urinary antigen test concurrently. b. >2 cases of possible health care associated Legionnaires disease a case in which patients spent part of the 10 days before symptoms started at the same facility are identified within 12 months of each other. 2. A Class B outbreak may need to be reported pending the outcome of the above noted criteria. 3. A clinical line list should be initiated to monitor residents. The Centers for Disease Control and Prevention (CDC) fact sheet on Legionnaires to support staff on identifying symptoms. 4. Perform an environmental assessment to evaluate possible environmental exposures. High risk areas may include cooling towers, showers, baths, fountains, respiratory equipment, ice machines, equipment that monitors consistent water temperatures. 5. The facility specific water management plan should be reviewed. A specialist in testing sources for Legionnaires may be consulted for further identification and interventions as needed.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #48) reviewed for a closed record, the facility failed to ensure a comprehensive nursing admission assessment was completed when the resident was readmitted from the hospital. The findings include:Resident #48 was re-admitted to the facility from an outside hospital in May 2026 with diagnoses that included a healing left femoral fracture and Chronic Obstructive pulmonary disease (COPD).The care plan dated 5/26/26 identified Resident #48 was at risk for pain related to a left hip fracture. Interventions included allow activity as tolerated and observe for signs and symptoms associated with pain and allow activity as tolerated.The admission MDS dated [DATE] identified Resident #48 was cognitively intact, required assist of one with bed mobility, transfers, toileting and ambulated with the assist of one using a wheelchair or walker.A nurse's note dated 6/22/26 at 10:05 PM identified a chest x-ray noted left lower lobe pneumonia. Two antibiotics initiated during the shift. No cough was noted, Resident #48 denied shortness of breath, the head of bed elevated receiving oxygen 2liters/min with an oxygen saturation of 95%.An APRN progress note dated 6/23/26 at 8:00 AM identified Resident #48 was receiving antibiotic therapy for treatment of pneumonia further noting abnormal laboratory values indicating AKI, hyponatremia (low sodium) and hypokalemia (low potassium) requiring the initiation if IV therapy the preceding evening and additional electrolyte supplementation with a plan for repeat laboratory testing the following day and renal ultrasound. Resident #48 was in bed, reporting that he/she was feeling better, oxygen saturation 92% on 2 liters via nasal cannula and lung sounds were clear to auscultation. Respiratory management included antibiotics, oxygen and nebulizers as needed. An APRN progress note dated 6/25/26 at 10:45 AM identified resolving pneumonia, stabilizing laboratory levels with IV hydration and a treatment plan to rule out gout related to new right hand pain found negative for fracture. The physician was notified and orders obtained to be transferred to the hospital for further evaluation. A Situation, Background, Assessment, Recommendation (SBAR) note dated 6/25/26 at 11:40 AM identified Resident #48 with a change of mentation, uncontrolled pain in the left knee and swelling in the right hand.Review of Hospital Discharge Summary notes dated 7/2/26 (transmitted 7/2/26 at 6:01 PM) identified Resident #48 was admitted with a principle diagnosis of bilateral community acquired pneumonia. Resident #48 was medically managed in the intensive care unit out of concern for bacterial pneumonia and hypotension (low blood pressure) despite IV resuscitation where he/she received IV antibiotics. Urine strep/Legionella testing was found to be positive. Due to the Legionella pneumonia, Azithromycin was to continue for a total of 10 days which would also treat presumed strep pneumonia. Discharge medications included Azithromycin 500mg which may be discontinued on 7/7/26. Resident #48 also underwent patellar effusion aspiration with recommendations to follow up with orthopedics and primary care physician. Resident #48 appeared well, was alert and oriented, and lungs were clear to auscultation.A nurse's note dated 7/4/26 at 8:37 PM identified Resident #48 was found unresponsive with no pulse, no blood pressure or response to verbal/tactile stimuli. Apical pulse was absent after checking one minute. Pupils were fixed and dilated. Time of death was pronounced at 8:05 AM. The Death Certificate dated 7/4/26 identified the primary cause of death as Legionella pneumonia.An interview with the DNS on 08/12/26 at 7:10 AM identified she reviewed Resident 48's discharge summary but not in its entirety so was unaware Resident #48 tested positive for Legionella. The DNS indicated nursing staff were expected to review the hospital W 10 (inter Agency Patient Referral) Form (provides medical and care needs so receiving facilities can prepare for admission) when a resident returns from the hospital. The DNS further identified nursing staff were also responsible for reviewing the discharge summary but not comprehensively as it was the physician's responsibility to thoroughly review the discharge summary. The DNS further identified she would have reported the positive legionella result if she had known.Nursing progress note dated 8/15/26 at 12:27 PM, entered as a late entry for 7/2/2026 by the DNS and subsequent to surveyor inquiry, identified for resident returned from hospital at 3:00 PM with diagnosis of pneumonia. W10 with admission orders verified by the APRN. Resident welcomed back and settled in bed. Call placed to responsible party to notify them of resident's return. The note lacked documentation that a comprehensive RN admission assessment had been completed when the resident returned from the hospital on 7/2/26.Despite multiple attempts to interview the admitting RN who worked on 7/2/26, an interview could not be obtained.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #6) reviewed for medication administration, the facility failed to ensure medications were administered in a manner that met professional standards of quality.The findings include: Resident #6 was admitted to the facility in October 2025 with diagnoses that included heart failure, dementia, and benign prostatic hyperplasia (BPH). The quarterly MDS dated [DATE] identified Resident #6 had severely impaired cognition, did not have a swallowing disorder, and had taken medications from the following high risk drug classes during the last 7 days: antidepressant and diuretic. The care plan dated 8/12/26 identified Resident #6 needed assistance with ADLs, with interventions that included fluctuations in ability to perform ADLs due to his/her cognitive status and to provide assistance, as needed. Physician's orders dated 8/2/26 directed to administer Escitalopram oral tablet, 10mg, give 1 tablet by mouth in the morning for depression/anxiety, administer Finasteride oral tablet, 5 mg by mouth, once daily for BPH, administer Tamsulosin HCL oral capsule, 0.4 mg by mouth, once daily for BPH, administer Furosemide oral tablet 20 mg, give 1 tablet by mouth, once daily for CHF, administer Memantine HCL oral tablet 10 mg, give 1 tablet by mouth, once daily related to dementia and crush appropriate medications and place in food and /or fluids as needed, every shift. Medication administration observation #1 with LPN #1 on 8/9/26 at 9:45 AM identified the following medications were reconciled with Resident #6's physician's orders, prepared, crushed, and mixed with pudding: Escitalopram oral tablet 10mg, Finasteride oral tablet, 5 mg, Furosemide oral tablet 20 mg, Memantine HCL oral tablet 10 mg, and the Tamsulosin HCL oral capsule, 0.4 mg was opened and the contents were mixed with pudding. The medication administration was stopped by this surveyor prior to administration to the resident. Interview with LPN #1 on 8/9/26 at 9:45 AM identified that all of the medications she prepared were safe to be crushed and the capsule opened prior to administration to the resident. Subsequent to surveyor inquiry, LPN #1 placed a call to the Consultant Pharmacist, and a call back was awaited. During an interview with LPN #1 and RN #1 on 8/9/26 at 9:53 AM, RN #1 identified that the Tamsulosin HCL oral capsule was safe to open and to mix the contents with pudding, and the Finasteride tablet was safe to be crushed because it did not have an enteric coating. Subsequent to surveyor inquiry, both medications were reviewed and determined that they should be administered as whole and not crushed or opened. RN #1 identified that neither medication should be administered as crushed or opened. LPN #1 indicated that Resident #6 previously took his/her medications whole but recently needed them to be crushed, and that she had opened the Tamsulosin capsule, in the past, and administered the contents, but she could not recall if she had crushed the Finasteride tablet during prior medication administrations. Medication administration observation #2 with LPN #1 on 8/9/26 at 10:03 AM identified the following medications were reconciled with Resident #6's physician's order, prepared, crushed, and mixed with pudding: Escitalopram oral tablet 10mg, Furosemide oral tablet 20 mg, Memantine HCL oral tablet 10 mg. The Finasteride oral tablet, 5 mg and the Tamsulosin HCL oral capsule, 0.4 mg were placed in the pudding whole. Resident #6 spit out the Tamsulosin capsule and refused that medication. LPN #1 identified that she would report the refusal to Nursing Supervisor and APRN. Interview with the Consultant Pharmacist (Pharmacist #1) on 8/9/26 at 10:10 AM identified that Tamsulosin capsules cannot be opened and Finasteride tablets cannot be crushed as both medications have an FDA warning not to crush or open the medication. Pharmacist #1 indicated that opening the Tamsulosin capsule and crushing the Finasteride tablet alters the bioavailability of the drugs causing them not to work as they were intended and decreasing the efficacy of the medication. Interview with the DNS on 8/9/26 at 10:20 AM identified that Resident #6 would not take medications unless they were crushed. The DNS indicated that she would expect the APRN or pharmacist to be contacted to confirm if a medication could be crushed or opened. The DNS further indicated that nursing would be contacting the APRN to review Resident #6's medications to ensure all his/her medications could be safely crushed/opened and if they could not be crushed/opened and remained a necessary part of his/her medication regimen then they would look into new formularies, such as a liquid.The Medication Administration policy directs that medications will be administered only upon a valid physician/provider order and in accordance with applicable regulations, professional standards of practice, and facility procedures. Medication administration shall be performed safely and accurately utilizing the principles of medication administration, including the right resident, right medication, right dose, right route, right time, and right documentation. The policy further directs that the administration of medications is to be completed according to the physician/provider orders and accepted standards of practice.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for accidents, the facility failed to ensure facility staff provided adequate supervision to prevent Resident #1 from exiting the facility unattended. The findings include:Resident #1's diagnoses included depression, anxiety, congestive heart failure, pressure ulcer to the heel and a history of falls. The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, required substantial assistance with toileting hygiene, was dependent for bathing, dressing and personal hygiene, and utilized a walker and/or wheelchair for mobility. The Nursing Evaluations dated 11/10/25 identified Resident #1 was not at risk for elopement. A December monthly physician's order identified Resident #1 may go out on a leave of absence with a responsible party. The nurse's note dated 12/28/25 identified at 2:00 PM a passerby from outside the facility came to the facility to notify staff there was an elderly individual in a wheelchair who he/she believed was a resident. Resident #1 was found across the street at a local business in the parking lot sitting in a wheelchair. Resident #1 was assessed and no injuries or signs or symptoms of distress were noted and Resident #1 stated he/she wanted to visit a friend who owned the business. Resident #1 was brought back to the facility. The note indicated Resident #1 was last seen by staff at 12:20 PM and it was not clear the exact time Resident #1 exited the facility. The note identified Resident #1 was transferred to the emergency department at 3:55 PM. The nurse's note dated 12/29/25 at 8:56 AM identified Resident #1 returned from the hospital with a diagnosis question a urinary tract infection. The social services note dated 12/29/25 at 9:15 AM identified Resident #1 was seen post the 12/28/25 event and could not recall who actually let him/her out of the facility and believed the person was a family member. Interview with the Social Worker on 1/7/26 at 11:24 AM identified Resident #1 reported to her that he/she sneaked out between the inside door and the outside door after a delivery driver left the facility. The Social Worker identified Resident #1 was alert and oriented and had not raised any flags regarding an elopement risk and did not verbalize or exhibit any exit seeking behaviors prior to the 12/28/25 incident. Interview with one of the housekeepers, Housekeeper #1, on 1/7/26 at 11:28 AM identified on 12/29/25, she was asked to cover staff and sit with Resident #1, as Resident #1 was on one to one observations. Housekeeper #1 indicated Resident #1 stated to her that he/she had not slept well the night before the elopement and on the day of the incident Resident #1 was in the library (right near the front door). Housekeeper #1 identified Resident #1 explained he/she was watching families coming in and out of the facility and watching the door light counting how long the light stayed green until the door relocked. Resident #1 then stated to Housekeeper #1 that he/she watched a delivery driver being buzzed out of the facility and the person who let the delivery driver out left the area and that was when Resident #1 followed the delivery driver out of the door and waited in the vestibule between the locked door and the main door until the delivery driver left the parking lot and then Resident #1 went out the second main door. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 1/7/26 at 11:39 AM identified on 12/28/25 she was not assigned to Resident #1's unit but she noticed Resident #1 was not in the dining room at lunch and she asked staff members if Resident #1 was coming to the dining room but no one seemed to know. NA #1 identified that at some time after lunchtime she heard the front doorbell ring and went to answer the door with the charge nurse, Licensed Practical Nurse (LPN) #1, behind her as there was nobody scheduled at the front desk on the weekends, and a passerby was at the door stating there was a person who might be a resident across the street and the passerby described Resident #1. NA #1 identified she and LPN #1 immediately went outside and across the street to bring Resident #1 back to the building. NA #1 identified Resident #1 would not tell her how he/she got out of the building. Interview with LPN #1 on 1/7/26 at 11:46 AM identified on 12/28/25 Resident #1 was last seen in the library around 12:20 PM and at approximately 2:00-2:15 PM a passerby came to the building and reported there was a person in a wheelchair outside across the street. LPN #1 identified she and NA #1 immediately went out to bring Resident #1 back to the building. LPN #1 identified Resident #1 stated to her that he/she went to speak with his/her friend who worked at the business across the street. LPN #1 identified Resident #1 stated to her that he/she waited until the delivery person was buzzed out of the building and followed him out of the building. LPN #1 identified Resident #1 had not exhibited exit seeking behaviors in the past. LPN #1 explained on the weekends there was no staff member scheduled to sit at the front desk to let visitors in and out of the building. Interview with the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, on 1/7/26 at 12:38 PM identified on 12/28/25 it was reported to her that Resident #1 was found by a passerby across the street in the parking lot of a business at around 2:00 PM. RN #1 identified staff reported Resident #1 was last seen by facility staff at lunchtime. RN #1 identified a staff member was not assigned to sit at the front lobby reception desk on the weekends, staff must let visitors in and out of the facility, and she was unsure who let the delivery driver out at the time Resident #1 eloped. Interview and clinical record review with the Director of Nursing (DON) on 1/7/26 at 1:02 PM identified on 12/28/25 the supervisor called her to report Resident #1's elopement. The DON identified Resident #1 was last seen by staff at 12:20 PM and approximately forty-five (45) minutes later Resident #1 was found outside. The DON identified on the weekends the front lobby reception desk was not staffed, and facility staff must let visitors in and out. The DON identified she questioned all staff working on 12/28/25 and no staff member admitted to buzzing the delivery driver out of the building, but that someone had to let him/her out as the door requires someone to buzz for the door to open. The DON identified it was the expectation that when a staff member lets a visitor out of the building, they are to watch for any residents near the door, and to stay in the area until the door shuts and relocks. The DON indicated Resident #1 stated to her that he/she put his/her foot in the door when the delivery driver was let out of the building, got into the vestibule between the locked door and the main door, waited for the delivery driver to leave the parking lot, then made his/her way out of the building and across the street. The DON identified she could not state if the staff member did not wait to see the door shut and lock as no staff member admitted to letting the delivery driver out of the building. Interview with the administrator on 1/7/26 at 1:21 PM identified there was no staff member assigned to the front lobby reception desk on weekends and off hours. The administrator identified it was the expectation of the staff that they would let the visitor in and out and stay in the area until the door closed and relocked before leaving the area to ensure no resident was able to exit the building. The administrator explained the door relocks as soon as it closes and there was an alarm that would alert staff if the door was held open too long. The administrator identified no staff member admitted to letting the delivery driver out of the building on 12/28/25, all visitors were interviewed from 12/28/25 and reported not seeing a resident by the door when they exited. The administrator identified she called the delivery company, and she could not get any information regarding who delivered to the building on 12/28/25 as they could not trace it without a shipping number, and she felt that if it was a delivery driver who routinely comes to the facility, that driver may have known where the buzzer was to unlock the door and buzzed themself out and that was when Resident #1 followed without being seen by a staff member. The administrator identified there was no written policy regarding letting visitors in and out of the facility. The facility identified the deficient practice and developed an immediate plan of correction on 12/28/25.Education was initiated regarding the elopement policy.Education was initiated regarding missing resident drills.Education was initiated regarding elopement risk.Random weekly audits will be conducted regarding door checks.Random weekly audits will be conducted regarding traffic exiting the building.Random weekly audits will be conducted regarding elopement risk-wandering.All results will be reviewed at the next QAPI meeting.Compliance date: 12/28/25

Based on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents reviewed for fluid status, the facility failed to complete dehydration evaluations in accordance with facility policy and failed to notify the provider with the results of a dehydration evaluation timely. The findings included: Resident #1 had diagnoses that included adjustment disorder with depressed mood, peripheral vascular disease, and unspecified congestive heart failure. Review of the Nursing admission assessment dated [DATE] identified Resident #1 had a very poor food intake pattern, Resident #1 never ate a complete meal, rarely ate more than one-third of any food offered, ate two (2) servings or less of protein (meat or dairy products) per day, and took fluids poorly. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of five (5) indicative of severely impaired cognition. The MDS further identified Resident #1 required moderate assistance with oral and personal hygiene and set-up assistance with eating. Review of Resident #1's Care Plan dated 12/26/24 identified the Resident #1 was exhibiting signs and symptoms of Corona Virus and had the potential for nutritional decline related to poor appetite interventions directed to encourage fluids up to fluid restriction, if applicable, to prevent dehydration, and to record intake and output as ordered. Review of the Resident #1's Nutritional assessment dated [DATE] identified Resident #1 had an estimated daily fluid need of 1445 milliliters to 1740 milliliters. Review of Resident #1's Fluid Intake Chart dated 12/30/24 through 1/12/25 identified the following: -A fluid intake of 580 milliliters on 12/30/24. -A fluid intake of 720 milliliters on 12/31/24. -A fluid intake of 650 milliliters on 1/1/25. -A fluid intake of 960 milliliters on 1/2/25. -A fluid intake of 980 milliliters on 1/3/25. -A fluid intake of 1080 milliliters on 1/4/25. -A fluid intake of 960 milliliters on 1/5/25. -A fluid intake of 1020 milliliters on 1/6/25. -A fluid intake of 860 milliliters on 1/7/25. -A fluid intake of 760 milliliters on 1/8/25. -A fluid intake of 480 milliliters on 1/9/25. -A fluid intake of 380 milliliters on 1/10/25. -A fluid intake of 600 milliliters on 1/11/25. -A fluid intake of 640 milliliters on 1/12/25. Intake for the 14 days were all below the residents minimum daily fluid needs of 1445 milliliters. a) Review of Resident #1's Dehydration Evaluations identified evaluations were completed on 12/31/24, 1/3/25, 1/6/25, and 1/11/25 which indicated dark urine, decreased skin turgor, dry tongue, and dry mucous membranes. The evaluations identified that the practioner was notified on 12/31/24, 1/3/25, and 1/6/25. Interview with the Director of Nursing Services (DNS) on 3/5/25 at 3:10 PM identified that a Dehydration Evaluation should be completed when a resident's fluid intake was below his/her fluid goal for three (3) consecutive days and that Resident #1 should have had a Dehydration Evaluation. The DNS further identified that although the dehydration assessments were completed in accordance with facility policy on 12/31/24, 1/3/25, and 1/6/25, a Dehydration Assessment should have been completed on 1/9/25 instead of 1/11/25 (2 days late) as his/her fluid intake did not meet the established parameters on 1/6/25, 1/7/25, and 1/8/25. b. Review of the 1/11/25 Dehydration Evaluation identified Resident #1 had dark urine, decreased skin turgor, dry tongue and mucous membranes, and that APRN #1 was notified of the findings. Review of LPN #2's SBAR (Situation, Background, Assessment, Recommendation) dated 1/13/25 at 7:53 PM identified Resident #1 with increased lethargy, had mental status changes, was not eating or drinking, and that the family requested the resident be sent to the emergency room. Review of the hospital paperwork dated 1/13/25 identified that the resident was dehydrated and required Intravenous (IV) fluid resuscitation. Interview with LPN #1 (who performed the 1/11/25 Dehydration Evaluation) on 3/6/25 at 2:55 PM identified she did not call the provider on January 11, 2025 she placed the Dehydration Evaluation into the Advanced Practice Registered Nurse (APRN) binder for review, however, the physician/APRN should have been called regarding Resident #1's 1/11/25 Dehydration Evaluation results and decreased fluid intake because January 11, 2025 was a Saturday and it was not guaranteed that a provider would be at the facility on that day. Interview with APRN #1 on 3/5/25 at 3:00 PM identified that he/she was not made aware of the 1/11/25 Dehydration Evaluation findings until 1/13/25 (Monday) when he/she was at the facility and would expect to have been called on 1/11/25 (Saturday) if the resident was at risk for dehydration. Interview with the DNS on 3/5/25 at 3:10 PM identified it was acceptable practice to place Dehydration Evaluations in the APRN binder during the week (Monday through Friday) as the physician/ APRN were in the facility on a regular basis, however if the evaluation was completed over the week-end (1/11/25 was a Saturday),and the assessment identified signs of dehydration the physician/APRN should have be called regarding findings/concerns on 1/11/25. The DNS further identified at risk residents should be seen within 24 hours of their Dehydration Evaluation if signs of dehydration are identified. The facility did not have a Dehydration Evaluation policy to provide. Review of the Hydration Protocol directed new patients would have a daily fluid goal of 1500 milliliters unless otherwise ordered by the physician. Review of the Intake/Output policy directed to ensure adequate hydration and prevent dehydration to the extent possible based on each resident's individualized care needs and choices. Review of the Hydration Protocol directed all residents will receive sufficient fluids to maintain proper hydration and health.

Based on record review and interviews for one of three sampled residents (Resident #42) reviewed for accidents, the facility failed to ensure the resident was free from injury resulting from an instant hot pack. The findings include: Resident #42's diagnoses included dementia, ulcerative colitis, liver cancer, brain cancer, and colon cancer. The quarterly MDS assessment dated [DATE] identified Resident #42 had intact cognition (BIMS of 15), was totally dependent on staff for transfers, toileting, hygiene, and dressing, and utilized a manual wheelchair for mobility. The Resident Care Plan (RCP) dated 11/15/24 identified Resident #42 had a recall, memory impairment and impaired decision making related to dementia. Care plan interventions directed to use short and simple sentences, allow time to respond when speaking to the resident, when confused or forgetful offer gentle reminders, and if the resident does not understand, please state in simple terms. The physician's orders for the month of November 2024 directed the resident required a two person assist with bed mobility and transfers via a Hoyer lift The nurse's note dated 1/12/25 at 2:52 PM identified Resident #42 sustained a burn to the right outer knee from an instant hot pack. The skin assessment identified the area was dry, red and measured 4.0 cm in length and 1.5 cm in width. The Situation, Background, Assessment, Recommendation (SBAR) nurse's note written by LPN #1 dated 1/12/24 at 3:47 PM identified NA #1 reported Resident #42 was noted to have a hot pack applied directly to the right knee without a barrier between the skin and hot pack. Resident #42 identified that someone entered his/her room and applied the hot pack directly to his/her right knee. The note further identified Resident #42 had a burn to the right outer knee. The note also identified that the family, APRN and nursing supervisor were updated. The initial wound evaluation dated 1/15/25 at 4:48 PM identified Resident #42 had a new first degree burn to the right lateral knee. The wound size was documented as 4.0 cm in length by 2.0 cm in width and 0.1 cm in depth. The wound base was 100 percent epithelization with scant amount of serosanguineous drainage. The treatment plan directed to apply Xeroform (a type of gauze dressing) to the base of the wound and secure with a dry clean dressing, to be changed every other day and as needed. The weekly wound evaluation dated 1/29/25 at 6:10 AM identified that the first degree burn to the right lateral knee had worsened due to the presence of slough (dead tissue) in the wound bed. The wound size was documented as 4.0 cm in length by 1.5 cm in width and 0.1 cm in depth. The wound base was 75 percent epithelization, 25 percent slough and with scant amount of serosanguineous drainage. The treatment plan directed to apply Santyl (chemical debridement) followed by Xeroform to the base of the wound and secure with a dry clean dressing to be completed every other day and as needed. Interview with NA #1 on 2/6/25 at 1:50 PM identified that on the day she found the burn, Resident #42 was lying in bed, and she went in the room to provide incontinent care. She noted that she removed the blanket, and saw a hot pack applied to the right knee without a barrier between the right knee and the instant heat pack. She immediately removed the hot pack and reported to the nurse. She further identified that the hot pack was from the facility's supply and was located opposite the nursing station. She also identified that the nurse aides and nurses have access to the supply closet. Additionally, NA #1 identified that she had not applied the hot pack to Resident #42 and would notify the nurse if a resident requested a hot pack. She identified that she had not received training regarding the use of the hot packs nor was she aware of a protocol regarding the use of instant hot packs. She noted that she knows that she cannot apply a hot pack to a resident. Interview with the DNS on 2/7/25 at 8:00 AM identified that LPN #1 notified her that Resident #42 had a burn to the right knee cause by the instant hot pack. She identified that the nursing staff noticed that the hot pack was directly applied to the resident's skin. She further noted that the nursing staff should follow the manufacturer's instructions related to not applying the hot pack directly to the skin because it could cause an injury. She also identified that she was unable to determine who applied the hot pack to Resident #42's right knee, and noted Resident #42 was total care for transfers and bed mobility and was unable to obtain a hot pack without staff knowledge or self-apply a hot pack. She further identified that the usage of the hot pack was a nursing measure and indicated that only the licensed nurses were allowed to apply the hot pack. Interview with APRN #2 on 2/7/25 at 1:40 PM identified that she was notified of Resident #42's burn to the right knee on 1/12/25. She could not recall whether or not she received a picture from the charge nurse but noted that she did not order a treatment because it was conveyed that the skin was intact, with no redness, or injury noted. She identified that she instructed the nursing staff to monitor the right knee area. She further identified that her expectation of monitoring would include monitoring for redness, warmth, and/or drainage from the right knee burn for three days. Interview with the Wound Specialist (APRN) on 2/7/24 at 2:00 PM identified that her initial encounter with Resident #42's right knee burn was on 1/15/25. She diagnosed the right knee wound as a first degree burn because her initial encounter noted the area was dry and red, so she ordered Xeroform to keep the wound area moist. She further noted the wound had worsened because of the development of slough to the wound bed and changed the treatment to Santyl to remove the dead skin in the wound bed. She further noted that the development of the slough to the wound bed was typically a part of the normal healing process for any type of burn wound. Interview with the DNS on 2/8/24 at 10:45 AM identified that the facility did not have a written protocol or policy related to the use of the hot packs, and that the staff should follow the manufacture's guidance at the back of the hot pack. She further identified that the nursing staff should have been educated regarding who was allowed to apply the hot pack to a resident and education regarding not applying the hot packs directly to the skin. The DNS noted that she did not have documentation of education provided to the staff regarding the use of the hot packs. Review of the Dynarex instant hot pack manufacturer's warning identified that the hot pack should not be applied directly to unprotected skin. The hot pack should be wrapped in a soft cloth before prior to applying the hot pack directly to the skin and that not applying the cloth could result in burn injuries.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation and failed to have a system in place to keep an accurate accounting of controlled medications. The findings include: Observation on [DATE] at 11:35 AM identified the DNS office contained a binder that held the yellow Controlled Substance Disposition Records (CSDR), the CSDR sheets were organized alphabetically. Additionally, some of the yellow CSDR sheets were from 2023 and had not yet been reconciled with the white CSDR nor were the medications identified as having been destructed. The book did not contain audit sheets for 2024 and the last signed off narcotic audit was [DATE] Interview on [DATE] at 11:45 AM with the DNS and RN#8 identified that the DNS is responsible for narcotic reconciliation in the facility and completed an audit on [DATE]. The DNS indicated that she doesn't use the audit sign off sheets to log the audits and signs the yellow Controlled Substance Disposition Record (CSDR) sheet to identify when an audit of that medication was completed. The DNS indicated the audits should be completed twice a month, but she sometimes runs out of time. The DNS was not able to demonstrate that narcotics were reconciled regularly or in some cases, at all. The DNS noted that sometimes when a resident is discharged , they are discharged with the medication, and she does not know what happens to the white CSDR that was with the medication in the med cart. The DNS further identified that the white sheets may go with the chart to the records department. When asked how the medications were reconciled without having the white CSDR sheets match up against the yellow CSDR sheets, the DNS did not answer but indicated that she was trying to implement a better system. Interview on [DATE] at 11:55 AM with RN#4 and RN#8 identified that narcotic audits should be completed two times per month and that the audit signature sheets are provided to keep track of the audits. Interview on [DATE] at 12:13 PM with RN#3 identified that the white CSDR sheets are turned into the DNS if the resident is discharged with the remaining medication after it is zeroed out. RN#3 indicated that the DNS takes the unused narcotics from the unit carts if a resident dies and/or if the medication is discontinued or changed, or the resident leaves without it. Observation and interview on [DATE] at 12:33 PM with the DNS identified she attempted to reconcile 10 CSDR sheets and the audit identified that only two of the ten controlled medications remained in the medication cart. The DNS indicated she was going to check the destruction bin and the records department. She identified that the nurses sometimes discharge residents and place the white copies of the CSDRs into the chart and the records department takes them. The DNS identified she would like to receive the white copies, but nursing doesn't give them to her. Interview on [DATE] at 1:09 PM with the DNS identified that she found the white CSDR sheets, and they were in the records department from discharged residents, two of the residents were deceased residents and the white CSDRs and medications were in the DNS office. The facility policy for medication administration identified narcotics and controlled substances must be double-locked and counted per facility protocol and that medication reconciliation should be done upon resident admission, transfer and discharge.

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #252) reviewed for respiratory care, the facility failed to ensure a physician order was in place for a resident who required oxygen therapy. The findings included: Resident #252 was admitted to the facility on [DATE] with diagnoses included dementia, without behavioral disturbance, psychotic disturbance, mood disturbance anxiety, and dyspnea. The hospital discharge summary dated 1/29/25 identified Resident #252 was administered oxygen via nasal cannula at 2 lpm (liters per minute) while in the hospital. The nursing admission assessment dated [DATE] at 11:05 AM identified Resident #252 was admitted to the facility with diminished lung sounds, exhibited shortness of breath (SOB) with exertion, utilized oxygen, and had diagnoses of asthma, and chronic obstructive pulmonary disease (COPD) The baseline care plan dated 1/29/25 identified Resident #252 received respiratory treatment with interventions that included oxygen and O2 sats as ordered, suction as ordered, head of bed elevated to comfort level, lung sounds as ordered, watch for increased cough, congestion, wheeze, edema, and shortness of breath. Th physician's orders dated 1/29/25 directed to change and label the oxygen (O2) set up every Saturday on the night shift. The nurse's note dated 1/29/25 at 12:25 PM identified Resident #252's O2 saturation was 95% on 5 liters of oxygen. The nurse's note dated 1/30/25 at 3:05 PM identified Resident #252's O2 saturation was 97% on 5 liters of oxygen. The occupational therapy evaluation and plan of treatment dated 1/30/25 identified the short-term goal for care to improve standing tolerance by 2 minutes with no shortness of breath on 2 liters of O2. Review of the clinical record identified nursing notes dated 1/31/25, 2/1/2, 2/2/25 and 2/6/25 that identified Resident #252 had oxygen in place. Observation on 2/6/25 at 11:33 AM identified Resident #252 had oxygen in place via nasal canula and the oxygen level was set at 0.5 liters per minute. Observation on 2/8/25 at 7:37 AM identified Resident #252 sleeping in bed with nasal canula in place and oxygen set and flowing at 2 liters per minute. Interview on 2/8/25 at 8:01 AM with RN#3 identified that residents receiving oxygen therapy should have a physician's order in place directing the use of oxygen and the level the oxygen should be set at. Review of the clinical record with RN #3 failed to identify an oxygen order for Resident #252. Interview on 2/8/25 at 10:00 AM with the DNS, Administrator, RN#4, and RN#8, identified there should be a doctor's order in place directing the use of oxygen. Additionally, the DNS identified there was not a policy related to the monitoring of a resident that utilizes continuous oxygen therapy. Interview with RN #2 on 2/8/25 at 2:33 PM identified that she completed the admission paperwork for Resident #252 and noted orders for oxygen were not noted on the W10, so they were not included on the admission orders for the facility. An unsuccessful attempt was made to interview MD #1 on 2/8/25 at 2:41 PM regarding the lack of oxygen therapy orders for Resident #252. The nasal cannula oxygen administration policy identified that the procedure for oxygen administration contained verification of the physician's order and review of the patient chart to familiarize yourself with the patient history and directed use of a humidifier bottle if flow is greater than 4 LPM. Additionally, the policy directed to record the start of oxygen in the patient's chart.

Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure the medication administration cart was appropriately secured during the medication administration pass while not within the line of sight of the nurse. The findings include: Observations of medication administration on 2/6/25 at 9:31 AM identified LPN #2 was able to access the medications without using a key to unlock the medication cart. She used her fingers to pull the lock out and was able to open the drawers containing the medications. LPN #2 prepared Resident #45's medications and then pushed the lock in on the cart and entered the resident's room and pulled the privacy curtain. The medication cart was not within LPN #2's line of sight. LPN #2 returned to the cart and was able to pull the locking mechanism out and without using a key, was able to access medications. At 9:52 AM, LPN #2 prepared medications for Resident #250, LPN#2 pushed the locking mechanism on the med cart, entered the room, and pulled the privacy curtain closed. The medication cart was not within LPN #2's line of sight. Interview on 2/6/25 at 10:00 AM with LPN#2 identified that if the cart was in the resident's doorway and the nurse was in the room, the cart did not have to be secured with the key. Interview on 2/7/25 at 10:14 AM with the DNS identified that the medication cart must be locked when the nurse walks away from it. The DNS indicated that if the cart was visible, and the nurse was close by, then it may be okay to not use the key. Additionally, the DNS identified that the locks will be checked because they should not be able to be opened when in the locked position without a key. Facility policy on medication storage and administration identified that medication administration carts are locked when not visible to the nurse or qualified staff, and that the nurse or qualified staff should stay with resident until medications have been taken.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of five sampled residents (Resident #4 and Resident #5), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident upon admission. The findings include: 1. Resident #4 was admitted to the facility in September of 2024 with diagnoses that included dementia, type 2 diabetes mellitus, anemia, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #4 had moderately impaired cognition. Review of the Pneumococcal Vaccine Consent form identified Resident #4 responsible party gave the facility permission to administer the pneumococcal based on the guidance provided on current pneumococcal vaccine schedule per the Centers for Disease Control and Prevention (CDC) in collaboration with the provider oversight on 10/9/24. Review of Resident #4 clinical records on 2/6/25 failed to identify that he/she received the vaccination or documentation that the resident refused the vaccine. Interview with the Regional Director of Nursing Services (RN #4) and the Infection Preventionist (IP) Nurse (RN #5) on 2/7/25 at 9:14 AM identified she was responsible for ensuring the resident was administered the pneumococcal vaccine as requested, however she was trying to administer the COVID-19, influenza vaccine, dealing with outbreaks and monitoring vaccine reaction. IP identified COVID-19 outbreak was in September of 2024 and December of 2024, and gastrointestinal outbreak in January of 2024. The IP further indicated the vaccine should be administered when requested but had to check historical immunization prior to administration, however the vaccine was not administered to the resident at the time when it was requested. 2. Resident #5 was admitted to the facility in January of 2024 with diagnoses that included dementia, chronic obstructive pulmonary disease, and pulmonary fibrosis. The admission MDS assessment dated [DATE] identified Resident #5 had moderately impaired cognition. Review of the Pneumococcal Consent Form (PCV 23), (PVC 20) and (PVC 15) identified Resident #5's responsible party gave the facility permission to administer the pneumococcal on 1/30/24. Review of another Pneumococcal Vaccine Consent form identified Resident #4 responsible party gave the facility permission again to administer the pneumococcal based on the guidance provided on current pneumococcal vaccine schedule per the Centers for Disease Control and Prevention (CDC) in collaboration with the provider oversight on 10/8/24. Review of Resident #5 clinical records on 2/6/25 for January and February of 2024 and October of 2024 all failed to identify that he/she was administered the vaccination. Interview with Person #2 on 2/8/24 at 10:57 AM identified he/she had given the facility permission to administer the pneumococcal vaccine to Resident #5 in quite a while now and had assumed it was automatic administered after the consent is signed, but it seem as it was not administered as the facility called him/her on 2/7/25 stating Resident #5 was not feeling well hence they were unable to administer the pneumococcal vaccine on 2/7/25. Interview with the Regional Director of Nursing Services (RN #4) and the Infection Preventionist (IP) Nurse (RN #5) on 2/7/25 at 9:14 AM identified she was responsible for ensuring the resident had received the pneumococcal vaccine as required, however indicated she was not the IP at the time when the Resident #5's pneumococcal consent was first signed in January of 2024. Interview with the RN #4 and RN #5 on 2/7/25 at 10:42 AM identified that on admission residents are assessed and offered the pneumococcal vaccination. RN #5 identified the process for administering vaccine to the resident, a consent is received from the resident/the resident responsible party to administer the vaccine, then a physician's order is obtained, and the vaccine is administered by the IP nurse or the nurse on the unit. Both RN #4 and RN #5 identified that the pneumococcal vaccine should have been administered when requested by the resident/resident representative and currently in the process to ensure all residents are updated with their pneumococcal vaccination. They further identified that Resident #4 and Resident #5 are eligible for PCV 20 and will be receiving the vaccine. Review of the Pneumococcal policy identified residents, or their responsible party will be offered the pneumococcal vaccine according to their specific eligibility that aligns with the current Center for Disease Control (CDC) Adult immunization schedule upon admission. The facility should obtain historical pneumococcal vaccination history and collaborate with the MD to determines appropriate vaccine needs. The policy further identified the facility would document date and location of injection site, refusal and re-offer and historical pneumococcal vaccine administration in the medical record if given in the community.

Based on review of the clinical record, review of facility policy/procedures and interviews for 1 of 5 sampled residents (Resident #18) reviewed for unnecessary medication, the facility failed to ensure monthly pharmacy medication regimen review recommendations were part of the clinical record. The findings include: Resident #1's diagnoses included anxiety disorder, bipolar disorder, and dementia. The annual MDS assessment dated [DATE] identified Resident #18 was severely cognitively impaired, had no behaviors, was independent with bed mobility, transfers, dressings and personal hygiene. The care plan dated 10/28/23 identified Resident #18 utilized antipsychotic medication and antidepressant medication for management of bipolar disorder and dementia w/behavioral disturbance with interventions that included be aware of movements of the mouth, trunk or extremities, and be aware of medication changes. The consultant pharmacist's monthly regiment review dated 12/14/23 identified there were recommendations made. Interview with the DNS on 2/8/25 at 12:30 PM identified that Consultant Pharmacist's recommendation could not be located. Interview with the Staff Development RN on 2/8/25 at 1:00 PM identified she could print the Consultant Pharmacist's report of the recommendations made. Review of the Pharmacist's recommendation dated 12/14/23 identified Resident #18's as needed order for Melatonin had not been used within the previous 90 days with a recommendation to discontinue the Melatonin due to lack of use. Interview with the DNS and the Administrator on 2/8/25 at 8:42 AM identified that the Pharmacist's recommendations are faxed to the facility, then placed in the provider book to be reviewed and a decision noted to accept or decline the recommendation. Once the recommendations are reviewed and a decision made a copy is given to the DNS and a copy is placed in the resident's physical clinical record. The DNS could not explain why the recommendation was not placed in Resident #18's clinical record. Review of the Medication Regimen Review policy identified the facility should maintain readily available copies of the consultant pharmacists reports on file in the facility and as a part of the resident's permanent record.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to initiate a grievance concern for a missing item. The findings include: Resident #1 had diagnoses that included dementia, anxiety, agitation, and depression. A progress note dated 1/10/2023 at 12:07 P.M. written by the Administrator identified she was notified of Resident #1's misplaced wedding ring. The Administrator identified a concern form would be initiated, she spoke with Resident #1's family member regarding Resident #1's misplaced wedding ring and will initiate a search. A progress note dated 1/11/2023 at 8:25 P.M. written by the Administrator identified she followed up with Resident #1's family member in person today regarding Resident #1's misplaced ring and a search was still in progress. Review of the facility's Grievance Log from 1/1/2023 to 12/31/2023 failed to provide documentation to reflect a grievance concern form was completed on 1/10/2023 for Resident #1's missing wedding ring. Interview and clinical record review with Administrator on 7/3/2024 at 1:35 P.M. she was unable to provide documentation to reflect that on 1/10/2023 when Resident #1's wedding ring was misplaced that a grievance concern form was completed nor documentation to identify the outcome of the grievance. The Administrator identified the social worker is responsible for completing a grievance concern form when a resident reports a missing item and once the investigation is completed the summary is documented on the concern form to indicate the findings. The Administrator identified on 1/10/2023 the facility was without a social worker and that a grievance concern form was not completed when Resident #1's wedding ring was reported to be misplaced. The Administrator indicated that Resident #1's wedding ring was found to be in possession by h/her family member, however, she was unable to provide documentation to reflect Resident #1's misplaced wedding ring was found. Upon surveyor inquiry the Administrator provided this surveyor with a progress note dated 7/3/2024 at 10:24 A.M. (the day of the survey) that indicated she had discussed with the former therapeutic recreation director who confirmed Resident #1's ring was with h/her family member and that the former infection preventionist had confirmed that Resident #1's family member had the ring. Review of facility grievance policy, in part, identified it is the right of a resident and/or responsible party to have a prompt and reasonable resolution of a complaint or concern. Each concern form will contain the concern, the resolution, and the person responsible for resolving the concern. The grievance policy directs a complaint or concern should be put in writing using the concern form, the concern form shall be completed as soon as possible, and the resident/responsible party shall be informed of the resolution.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for medication errors, the facility failed to ensure medication was administered in accordance with physician orders and failed to ensure the resident received the correct dose of a cancer treatment medication. The findings include: Resident #2's diagnoses included malignant neoplasm of the prostate and malignant neoplasm of the bone. A physician order dated 10/3/2022 directed to administer Abiraterone Acetate (used to treat cancer) 250 milligrams (mg), four (4) tablets once a day for a total dose of 1000 mg for prostate cancer. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had moderately impaired cognition, had a diagnosis of cancer, benign prostatic hyperplasia (BPH) and obstructive uropathy. The facility medication error report dated 11/2/2022 identified after counting the Abiraterone Acetate for planned discharge, the facility staff identified a discrepancy in the number of tablets, and indicted the correct dose of the medication was not administered. The facility incident report dated 11/4/2022 identified Resident #2 was alert and oriented and included statements from LPN #1 and LPN #2 (11:00 PM to 7:00 AM charge nurses) that indicated both LPN #1 and LPN #2 stated they gave the Abiraterone Acetate medication as ordered, 4 tablets once a day. The incident report further identified upon discharging Resident #2, when staff counted the medication tablets, it was identified staff failed to administer 51 tablets. Facility investigation identified Resident #2 was administered 29 tablets, and Resident #2 should have received 80 tablets (51 tablets were not administered in accordance with physician orders). Facility investigation did not identify the dates of the errors. The investigation further identified Resident #2 was seen by his/her oncologist on 11/3/2022 and the physician identified no immediate side effects were present (the error was not significant), and Resident #2 was to continue on the Abiraterone Acetate with no change in the dosage ordered. Interview and documentation review with the Administrator on 5/24/2024 at 1:44 PM identified Resident #2's Abiraterone Acetate was brought into the facility by the resident's family member. The Administrator identified it was her recollection the family member counted the tablets upon discharge and the DNS did a recount of the tablets, which identified the discrepancy in the number of tablets that should have been administered. The Administrator identified an additional recount was completed which confirmed the medication error. The Administrator identified it was facility policy to always ensure the right route, right resident, right dose, right time, and right documentation was followed, and that for Resident #2, facility staff did not follow the facility policy and the medication error occurred. The Administrator stated the medication should have been administered as ordered by the physician and was unable to explain why it was not given as ordered. Although requested, a policy regarding medication administration was not provided for surveyor review.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #1) reviewed for advanced directives, the facility failed to ensure staff addressed Resident #1's Advanced Directive choices (full code vs. do not resuscitate) upon readmission in accordance with facility policy. This resulted in contradictory information in the medical record which cause confusion when R #1 was found without a pulse and respirations and staff did not initiate Cardiopulmonary Resuscitation (CPR) timely resulting in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included diabetes, gangrene, major depressive disorder, anxiety, and acquired absence of left leg above knee. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, required extensive assistance with personal care, and was receiving hospice services. The Resident Care Plan (RCP) dated [DATE] identified in part, Hospice Care, advanced directives as ordered, and registered nurse pronouncement (RNP). A physician's order dated [DATE] directed, Do Not Resuscitate (DNR), Do Not Intubate (DNI) and RNP. Review of the clinical record identified Resident #1 chose to stop Hospice services effective [DATE], was transferred to the hospital for elective surgery, and was readmitted to the facility on [DATE]. The W-10 (an Interagency Patient Referral Report from the hospital) dated [DATE] identified Resident #1 was a Full Code (provide CPR, chest compressions and mechanical respirations) for Resident #1. A physician's order written by APRN #1, dated [DATE] directed to provide Cardiopulmonary Resuscitation (CPR). An APRN note dated [DATE] at 1:01 PM identified Resident #1 had revoked Hospice benefits and APRN #1 reviewed/discussed Resident #1's advanced directives with Resident #1 and his/her family, all questions were answered, reviewed Resident #1's diagnosis and current health status and the decision was made for Full Code status to include all life saving measures such as CPR, chest compressions and intubation with mechanical ventilation. Review of the clinical record identified Resident #1 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE] with a new diagnosis of a Deep Vein Thrombosis (DVT). The W-10 dated [DATE] at 1:48 PM identified a code status of Full Code for Resident #1. Record review identified Resident #1 was re-hospitalized on [DATE] with readmission to the facility on [DATE]. The W-10 dated [DATE] identified Resident #1 had a code status of DNR. Nurse's note dated [DATE] at 7:30 PM identified Resident #1 was readmitted to the facility and orders were verified with on call APRN #2. The nurse's note identified the facility failed to address Resident #1's code status upon readmission. Review of the nurse's notes dated [DATE] from 5:45 AM through 7:20 AM identified Resident #1 was found unresponsive and review of documentation by facility staff identified the W-10 directed DNR. The facility incident report dated [DATE] at 7 AM identified the facility had contradictory code status listed for Resident #1 (listed as both DNR and Full Code) and there was a delay in providing CPR due to the contradictory information contained in the medical record. Review of the EMS run sheet dated [DATE] identified dispatch was notified at 7:10 AM and arrived at the bedside of Resident #1 at 7:15 AM. The run sheet further identified after 20 minutes of CPR Resident #1 remained in asystole (without a heartbeat) with no changes at any point during the resuscitation efforts. Additionally, the run sheet identified with all crew members and parties involved in agreement, efforts were discontinued at that time and resuscitation was discontinued with time of death of 7:33 AM. Review of the clinical record failed to identify staff reviewed Resident #1's advance directives with Resident #1 upon readmission on [DATE] in accordance with facility policy and failed to address code status when verifying orders with APRN #2. Interview with RN #1 on [DATE] at 12:02 PM identified she went into Resident #1's room at 5:45 AM on [DATE] and found Resident #1 did not look good. Resident #1's hands were cold, his/her body was warm and RN #1 could not find a radial (wrist) or carotid (neck) pulse, and Resident #1 had a blood sugar of 155. RN #1 further identified at that time she called for help from LPN #1 (working on another unit) and went to Resident #1's paper chart and found hospital paperwork dated [DATE] that directed CPR and hospital paperwork dated [DATE] that directed DNR, and she was unsure what to do. RN #1 indicated at that time she called the DNS and left a message. RN #1 did not receive a call back, so she then called another nurse (RN #3) and asked her to come to the facility because RN #1 was not sure what to do since the code status listed in the chart were contradictory. RN #1 stated RN #3 did come in, they decided Resident #1 was a Full Code, and 911 was called and a code was paged. Additionally, RN #1 identified she looked for Resident #1's code status in the paper chart only, she did not check the electronic medical record (EMR) when she identified Resident #1 had no pulse or respirations at 5:45 AM. RN #1 identified CPR was started on Resident #1 at approximately 6:50 AM (one hour and 5 minutes after Resident #1 was first found without a pulse or respirations). RN #1 further identified she was unaware of the facility policy on CPR until after the incident, but now knows that when there are conflicting code status orders in the medical record, she must initiate CPR until clarification of the code status is obtained and that she should have started CPR immediately on Resident #1; RN #1 indicated she should have started CPR at 5:45 AM when she found Resident #1 without a pulse. Interview with RN #3 on [DATE] at 12:18 PM identified she received a call from RN #1 in a panic on [DATE] at approximately 6:15 AM stating Resident #1 had expired and asked RN #3 to come to the facility. RN #3 identified she arrived at the facility approximately 25 minutes later, looked in Resident #1's paper chart and found the hands up form that directed for DNR, she went into Resident #1's room and found Resident #1 expired, and RN #1 began post-mortem care. Additionally, RN #3 identified at approximately 6:50 AM the day Supervisor (RN #2) came in and asked both RN #1 and RN #3 if they had checked the orders in the EMR, at which time RN #3 went to the EMR and found the order which directed for Full Code. RN #3 identified at that time RN #2 directed to call 911, get the emergency cart and the Automatic External Defibrillator (AED) and call a code. RN #3 identified she went into Resident #1's room and began CPR, applied the AED, and continued CPR after the AED directed for no shock. RN #3 indicated LPN #2 assisted with CPR until EMS arrived. RN #3 identified the facility policy directed to check the EMR for the orders for code status, but that prior to this incident, it was her practice to look in the paper chart for the most recent date and not look at the EMR. RN #3 further indicated she had since been in-serviced and now knows to look at the EMR. RN #3 identified she did not know what she should do when there is conflicting documentation, but she followed the supervisor's (RN #2) direction. RN #3 further identified CPR should have been started immediately upon finding Resident #1 unresponsive. Interview with RN #2 (Day Supervisor) on [DATE] at 12:30 PM identified when he clocked in on [DATE] the night nurse informed him Resident #1 had stopped breathing at approximately 6:00 AM and she was unsure of the code status of Resident #1. RN #2 identified he directed the nurse to call the DNS, but if they do not know the code status, they should initiate a code. RN #2 further identified he had asked RN #1 and RN #3 if they had checked the EMR for the code status, which they then checked at that time and the EMR directed for Full Code. RN #2 indicated that CPR was initiated, 911 was called and a code was called at that time. RN #2 identified he was not involved in the actual code. Additionally, RN #2 identified the facility policy on code status directed if there are conflicting ordered in the medical record, you would follow the most recent orders. Review of facility documentation identified RN #2 punched into work on [DATE] at 6:56 AM (one hour and 11 minutes after Resident #1 was found without a pulse or respirations). Interview with the DNS and RN #4 (corporate nurse) on [DATE] at 1:20 PM identified it is the responsibility of the admitting nurse to verify the orders for code status upon a resident admission or readmission and staff should look in both the EMR and the paper chart when looking for a resident's code status. Further the DNS and RN #4 were unable to provide documentation that staff addressed Resident #1's advance directives with Resident #1 and with the physician/APRN upon readmission to the facility on [DATE]. Staff should have addressed the code status with Resident #1's readmission, and the DNS and RN #4 were unable to explain why it was not addressed. The advance directives should be clearly identified in the clinical record, and if there is contradictory information, staff should follow the directives with the most recent date. Interview with APRN #1 on [DATE] at 1:55 PM identified when Resident #1 was readmitted on [DATE], she did not review Resident #1's advance directives with staff, and she did not see Resident #1 to review the advance directives. Interview with RN #6 on [DATE] at 4:14 PM identified she was the admitting nurse when Resident #1 returned to the facility on [DATE]. RN #6 indicated although she verified orders with APRN #2, she did not review Resident #1's advance directives with Resident #1 or with the APRN and passed the information to the Supervisor be addressed on [DATE]. Review of the facility Advanced Directives Policy dated [DATE] directed in part, upon admission advance directives with be reviewed with the resident and/or their decision makers.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of five residents (Resident #1) reviewed for advance directives, the facility failed to ensure physician orders were in place when an RN pronounced a death. The findings include: Resident #1's diagnoses included diabetes, gangrene, major depressive disorder, anxiety, and acquired absence of left leg above knee. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, required extensive assistance with personal care, and was receiving hospice services. The Resident Care Plan (RCP) dated [DATE] identified in part, Hospice Care, advanced directives as ordered, and registered nurse pronouncement (RNP). An APRN note dated [DATE] at 1:01 PM identified APRN #1 reviewed/discussed Resident #1's advanced directives with Resident #1 and his/her family, all questions were answered, reviewed Resident #1's diagnosis and current health status and the decision was made for Full Code status to include all life saving measures such as CPR, chest compressions and intubation with mechanical ventilation. Review of the clinical record identified Resident #1 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE], and the Inter-Agency Form (W-10) dated [DATE] identified Resident #1's code status was Full Code. Record review identified Resident #1 was hospitalized on [DATE] with readmission to the facility on [DATE]. The W-10 dated [DATE] identified Resident #1 had a code status of DNR. Nurse's note dated [DATE] at 7:30 PM identified Resident #1 was readmitted to the facility and orders were verified with on call APRN #2. The nurse's note identified the facility failed to address Resident #1's code status upon readmission. Review of the clinical record failed to identify an RN May Pronounce (RNP) order for Resident #1. Review of the nurse's notes dated [DATE] from 5:45 AM through 7:20 AM identified Resident #1 was found unresponsive and review of documentation by facility staff identified the W-10 directed DNR. Additionally, the notes identified RN #1 summoned RN #3 to come to the facility to assist with Resident #1, Emergency Medical Services (EMS) responded to the facility and took over CPR. Review of the EMS run sheet dated [DATE] identified dispatch was notified at 7:10 AM and arrived at the bedside of Resident #1 at 7:15 AM. The run sheet further identified after 20 minutes of CPR Resident #1 remained in asystole (without a heartbeat) with no changes at any point during the resuscitation efforts. Additionally, the run sheet identified with all crew members and parties involved in agreement, efforts were discontinued at that time and resuscitation was discontinued with time of death of 7:33 AM. The death certificate dated [DATE] identified Resident #1's death was pronounced by RN #3 on [DATE] at 7:20 AM. Additional clinical record review failed to identify a death certificate signed by a physician. Interview with RN #1 on [DATE] at 12:02 PM identified she went into Resident #1's room at 5:45 AM on [DATE] and found Resident #1 did not look good, his/her hand was cold, his/her body was warm and she could not find a radial (the wrist) or carotid (the neck) pulse. Although the record failed to identify an RNP order was in place for Resident #1, interview failed to identify why RN #1 signed Resident #1's death certificate. Interview with RN #4 on [DATE] at 6:14 PM identified RN #3 pronounced Resident #1 on the death certificate and there was no order for an RNP. Additionally, RN #4 identified it was the EMS personnel who called the emergency department physician who directed them to discontinue CPR and they called for the discontinuation/resident death at 7:33 AM. RN #4 further identified RN #3 should not have pronounced Resident #1 without a physician order and could not give a reason as to why RN #3 did pronounce the resident without an order. Review of the facility undated Death of Resident, Pronouncement by a Registered Nurse Policy, directed in part, RNs may pronounce a resident's death if a MD order and progress notes are present. Additionally, the policy directed the physician will write an order stating RN may pronounce death, and a progress note explaining that death is anticipated. This order must be renewed every 120 days, the registered nurse will make the determination of death by means of observation and assessment including, but not limited to, pulse, respiration, heartbeat, and pupil reaction, and when the criteria in #2 are met, the nurse will call the physician to notify him of the pronouncement of death.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #1) reviewed for advanced directives, the facility failed to ensure staff acted timely when a resident was unresponsive, and staff were unable to identify a resident's code status. The findings include: Resident #1's diagnoses included diabetes, gangrene, major depressive disorder, anxiety, and acquired absence of left leg above knee. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, required extensive assistance with personal care, and was receiving hospice services. The Resident Care Plan (RCP) dated [DATE] identified in part, Hospice Care, advanced directives as ordered, and registered nurse pronouncement (RNP). An APRN note dated [DATE] at 1:01 PM identified APRN #1 reviewed/discussed Resident #1's advanced directives with Resident #1 and his/her family, all questions were answered, reviewed Resident #1's diagnosis and current health status and the decision was made for Full Code status to include all life saving measures such as CPR, chest compressions and intubation with mechanical ventilation. Review of the clinical record identified Resident #1 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE], and the Inter-Agency Form (W-10) dated [DATE] identified Resident #1's code status was Full Code. Record review identified Resident #1 was hospitalized on [DATE] with readmission to the facility on [DATE]. The W-10 dated [DATE] identified Resident #1 had a code status of DNR. Nurse's note dated [DATE] at 7:30 PM identified Resident #1 was readmitted to the facility and orders were verified with on call APRN #2. The nurse's note identified the facility failed to address Resident #1's code status upon readmission. Review of the nurse's notes dated [DATE] from 5:45 AM through 7:20 AM identified Resident #1 was found unresponsive and review of documentation by facility staff identified the W-10 directed DNR. Additionally, the notes identified RN #1 summoned RN #3 to come to the facility to assist with Resident #1, Emergency Medical Services (EMS) responded to the facility and took over CPR. The facility incident report dated [DATE] at 7 AM identified the facility had contradictory code status listed for Resident #1 (listed as both DNR and Full Code) and there was a delay in providing CPR due to the contradictory information contained in the medical record. Review of the EMS run sheet dated [DATE] identified dispatch was notified at 7:10 AM and arrived at the bedside of Resident #1 at 7:15 AM. The run sheet further identified after 20 minutes of CPR Resident #1 remained in asystole (without a heartbeat) with no changes at any point during the resuscitation efforts. Additionally, the run sheet identified with all crew members and parties involved in agreement, efforts were discontinued at that time and resuscitation was discontinued with time of death of 7:33 AM. Review of the clinical record failed to identify staff acted timely when Resident #1 was identified to have no pulse or respirations, and staff were unable to identify Resident #1's code status. Interview with RN #1 on [DATE] at 12:02 PM identified she went into Resident #1's room at 5:45 AM on [DATE] and found Resident #1 did not look good. Resident #1's hands were cold, his/her body was warm and RN #1 could not find a radial (wrist) or carotid (neck) pulse, and Resident #1 had a blood sugar of 155. RN #1 further identified at that time she called for help from LPN #1 (working on another unit) and went to Resident #1's paper chart and found hospital paperwork dated [DATE] that directed CPR and hospital paperwork dated [DATE] that directed DNR, and she was unsure what to do. RN #1 indicated at that time she called the DNS and left a message. RN #1 did not receive a call back, so she then called another nurse (RN #3) and asked her to come to the facility because RN #1 was not sure what to do since the code status listed in the chart were contradictory. RN #1 stated RN #3 did come in, they decided Resident #1 was a Full Code, and 911 was called and a code was paged. Additionally, RN #1 identified she looked for Resident #1's code status in the paper chart only, she did not check the electronic medical record (EMR) when she identified Resident #1 had no pulse or respirations at 5:45 AM. RN #1 identified CPR was started on Resident #1 at approximately 6:50 AM (one hour and 5 minutes after Resident #1 was first found without a pulse or respirations). RN #1 further identified she was unaware of the facility policy on CPR until after the incident, but now knows that when there are conflicting code status orders in the medical record, she must initiate CPR until clarification of the code status is obtained and that she should have started CPR immediately on Resident #1; RN #1 indicated she should have started CPR at 5:45 AM when she found Resident #1 without a pulse. Interview with RN #3 on [DATE] at 12:18 PM identified she received a call from RN #1 on [DATE] at approximately 6:15 AM stating Resident #1 had expired and asked RN #3 to come to the facility. RN #3 identified she arrived at the facility approximately 25 minutes later, looked in Resident #1's paper chart and found the hands up form that directed for DNR, she went into Resident #1's room and found Resident #1 expired, and RN #1 began post-mortem care. Additionally, RN #3 identified at approximately 6:50 AM the day Supervisor (RN #2) came in and asked both RN #1 and RN #3 if they had checked the orders in the EMR, at which time RN #3 went to the EMR and found the order which directed for Full Code. RN #3 identified at that time RN #2 directed to call 911, get the emergency cart and the Automatic External Defibrillator (AED) and call a code. RN #3 identified she went into Resident #1's room and began CPR, applied the AED, and continued CPR after the AED directed for no shock. RN #3 indicated LPN #2 assisted with CPR until EMS arrived. RN #3 identified she did not know what she should do when there is conflicting code status documentation, but she followed the supervisor's (RN #2) direction. RN #3 further identified CPR should have been started immediately upon finding Resident #1 unresponsive. Interview with RN #2 (Day Supervisor) on [DATE] at 12:30 PM identified the facility policy on code status directed if there are conflicting ordered in the medical record, staff should follow the most recent orders. Interview with the DNS and RN #4 (corporate RN) on [DATE] at 1:20 PM identified RN #1 should have started CPR on Resident #1 immediately when she could not verify the code status of the resident. Interview with APRN #1 on [DATE] at 1:55 PM identified when Resident #1's code status could not be determined, CPR should have been started immediately when Resident #1 was found unresponsive, without a pulse and without respirations. The facility policy titled Cardiopulmonary Resuscitation dated [DATE] directed in part, if a resident or substitute decision maker does not execute an advance directive, the resident will be a full code until a decision is made by the resident or substitute decision maker.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of five residents (Resident #1) reviewed for advance directives, the facility failed to ensure the clinical record was complete and accurate to include events that occurred when the resident was found without respirations or a pulse. The findings include: Resident #1's diagnoses included diabetes, gangrene, major depressive disorder, anxiety, and acquired absence of left leg above knee. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had no cognitive impairment, required extensive assistance with personal care, and was receiving hospice services. The Resident Care Plan (RCP) dated [DATE] identified in part, Hospice Care, advanced directives as ordered, and registered nurse pronouncement (RNP). An APRN note dated [DATE] at 1:01 PM identified APRN #1 reviewed/discussed Resident #1's advanced directives with Resident #1 and his/her family, all questions were answered, reviewed Resident #1's diagnosis and current health status and the decision was made for Full Code status to include all life saving measures such as CPR, chest compressions and intubation with mechanical ventilation. The nurse's note dated [DATE] at 6:00 AM, written by RN #1, identified Resident #1 was found unresponsive with skin warm to touch and the W-10 (hospital inter-agency form) read DNR. The nurse's note dated [DATE] at 6:10 AM, written by RN #2, identified RN #2 had been called to come in by RN #1 to assist with Resident #1. Additionally, the note identified Emergency Medical Technicians (EMT) arrived and took over CPR. The nurse's note dated [DATE] at 6:55 AM, written by RN #2, identified a code was called for Resident #1, 911 was called by RN #1, CPR was started and awaiting EMT arrival. The nurse's note dated [DATE] at 6:55 AM, written by RN #1, identified 911 was called, EMT's on their way and code in progress. The nurse's note dated [DATE] at 7:20 AM identified Resident #1 was pronounced deceased by the EMT's. Review of the EMS run sheet dated [DATE] identified dispatch was notified at 7:10 AM and arrived at the bedside of Resident #1 at 7:15 AM. The run sheet further identified after 20 minutes of CPR Resident #1 remained in asystole (without a heartbeat) with no changes at any point during the resuscitation efforts. Additionally, the run sheet identified with all crew members and parties involved in agreement, efforts were discontinued at that time and resuscitation was discontinued with time of death of 7:33 AM. The facility incident report dated [DATE] at 7 AM identified the facility was reviewing and investigating an incident surrounding the recent code of Resident #1. Additionally, the report identified it was unclear if CPR was provided in a timely manner due to contradictory code statuses listed in the medical record. The incident report investigation indicated at 5:45 AM when RN #1 entered the room perform a finger stick (FS), Resident #1's hands were cold, and it was difficult to palpate pulses. Lung sounds were assessed, and it was determined that Resident #1 had expired. RN #1 checked the chart and saw the hospital record dated [DATE] that directed DNR. At 6:50 AM (one hour and five minutes after Resident #1 was identified by staff to have expired), RN #1 identified the facility electronic medical record (EMR) chart listed Resident #1's code status as Full Code and activated EMS. Additionally, the summary identified RN #1 failed to open her computer to look in the EMR to see that the active code status in the EMR dated [DATE] directed for CPR. The report further identified RN #1 failed to discover conflicting code status orders until approximately 6:50 AM and realizing there was, in fact, an order for CPR, a code was called, EMS was activated, and the emergency procedures were followed. RN #1 was subsequently suspended, and additional education was provided prior to RN #1 returning to work. Interview with RN #1 on [DATE] at 12:02 PM identified she went into Resident #1's room at 5:45 AM on [DATE] and found Resident #1 did not look good. Resident #1's hands were cold, his/her body was warm and RN #1 could not find a radial (wrist) or carotid (neck) pulse, and Resident #1 had a blood sugar of 155. RN #1 further identified at that time she called for help from LPN #1 (working on another unit) and went to Resident #1's paper chart and found hospital paperwork dated [DATE] that directed CPR and hospital paperwork dated [DATE] that directed DNR, and she was unsure what to do. RN #1 indicated at that time she called the DNS and left a message. RN #1 did not receive a call back, so she then called another nurse (RN #3) and asked her to come to the facility because RN #1 was not sure what to do since the code status listed in the chart were contradictory. RN #1 stated RN #3 did come in, they decided Resident #1 was a Full Code, and 911 was called and a code was paged. Additionally, RN #1 identified she looked for Resident #1's code status in the paper chart only, she did not check the electronic medical record (EMR) when she identified Resident #1 had no pulse or respirations at 5:45 AM. RN #1 identified CPR was started on Resident #1 at approximately 6:50 AM (one hour and 5 minutes after Resident #1 was first found without a pulse or respirations). Interview with RN #3 on [DATE] at 12:18 PM identified she received a call from RN #1 on [DATE] at approximately 6:15 AM stating Resident #1 had expired and asked RN #3 to come to the facility. RN #3 identified she arrived at the facility approximately 25 minutes later, looked in Resident #1's paper chart and found the hands up form that directed for DNR, she went into Resident #1's room and found Resident #1 expired, and RN #1 began post-mortem care. Additionally, RN #3 identified at approximately 6:50 AM the day Supervisor (RN #2) came in and asked both RN #1 and RN #3 if they had checked the orders in the EMR, at which time RN #3 went to the EMR and found the order which directed for Full Code. RN #3 identified at that time RN #2 directed to call 911, get the emergency cart and the Automatic External Defibrillator (AED) and call a code. RN #3 identified she went into Resident #1's room and began CPR, applied the AED, and continued CPR after the AED directed for no shock. RN #3 indicated LPN #2 assisted with CPR until EMS arrived. Interview with RN #2 (Day Supervisor) on [DATE] at 12:30 PM identified when he clocked in on [DATE] the night nurse informed him Resident #1 had stopped breathing at approximately 6:00 AM and she was unsure of the code status of Resident #1. RN #2 identified he directed the nurse to call the DNS, but if they do not know the code status, they should initiate a code. RN #2 further identified he had asked RN #1 and RN #3 if they had checked the EMR for the code status, which they then checked at that time and the EMR directed for Full Code. RN #2 indicated that CPR was initiated, 911 was called and a code was called at that time. Review of the clinical record failed to identify the nurse's notes accurately reflected the events identified as reported in the facility documentation and staff interviews of events that occurred. Interview with the DNS and RN #4 (Corporate RN) on [DATE] at 1:20 PM identified both RN #1 and RN #2 were directed to write detailed nurses notes regarding the incident with Resident #1 on [DATE], but both failed to write a detailed note. Additionally, the DNS and RN #4 identified RN #1 and RN #2 should have written a detailed note regarding the timeline and events that occurred with Resident #1 on [DATE], and they were unable to explain why the notes were not written. Review of the facility undated Cardiopulmonary Resuscitation Policy, directed in part, to document events in the resident's medical record. Review of the facility undated Nursing Documentation Policy directed in part, nursing documentation provides an account of information about the resident's health care status, it provides an account of any change in condition, current assessments, and any concerns that alter the resident's plan of care. This documentation may be in the form of a handwritten note or entered electronically and will be stored in the resident's medical record.

Based on clinical record review, facility documentation, review of facility policies and staff interview for one of three sampled residents reviewed for mistreatment (Resident #58), the facility failed to ensure the resident was free from physical abuse. The findings include: Resident #58's [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] did not identify the residents mental status but identified the resident required extensive assistance of two for bed mobility, transfers, dressing and toileting. The MDS further identified the resident required extensive assistance of one for eating and personal hygiene. A care plan dated 4/07/17 identified the resident required assistance with daily hygiene, bathing, dressing, incontinent of bowel/bladder, non-ambulatory, refuses care and sometimes spit at staff during meals or may try to pinch the staff. Interventions include to not argue with the resident, requires maximum assistance with daily washing, if she/he refuses care, please remind her/him of the importance but honor rights to refuse. Interventions further identify that staff may wear protective equipment when feeding the resident related to the resident spitting. Facility Accident/Incident report dated 6/12/17 identified that on 6/07/17 and 6/08/17 during the evening meal, a NA (NA#6) reported witnessing abusive behavior to the resident by another NA (NA#5). Facility identified that on 6/12/17 a statement from NA#6 identified that on 6/07/17, NA#6 was being trained by NA#5, and NA#5 was providing care to R#58 (undressing) and R#58 began spitting. NA#6's statement further identified that NA#5 became very frustrated and, took a towel and aggressively put it around the resident's mouth, tucking both sides of the towel behind the resident's neck and stated, You don't spit at me. NA#6 further identified the resident moved her/his head back and forth to remove the towel and stated, I'm scared. R#58 attempted to pinch NA#5 and NA#5 slapped her hand and said, You don't pinch me. NA#6's statement of 6/12/17 further identified that on 6/08/17 she/he was also training with NA#5 and the, same thing happened when they were undressing the resident NA#5 tried putting a towel around the resident's mouth, tucking both sides behind the resident's neck. Interview with NA#6 on 10/3/17 at 2:50 PM identified that she/he was training with NA#5 for the first time as a NA. When they began rendering care on the resident, NA#5 did not explain anything to R#58 and the resident started spitting and trying to scratch NA#5. NA#5 was then observed to take a towel and wrap it around the outside of the resident's mouth to stop the resident from spitting. The resident attempted to move her/his head back and forth but the towel did not move. NA#5 was seen by NA#6 to smack the resident's hand when R#58 attempted to pinch her/him. NA#6 identified that she/he did not report the incident to the DNS until 6/12/17 (5 days after the initial event). NA#6 further identified that she/he was trained to report an incident when it occurs, but did not want to be one of those people that is new and reports something. NA#6 further identified that she/he was scared of NA#5 because she/he was rough, but after the 6/08/17 occurrence, decided to report it. Attempts to interview NA#5 were unsuccessful. Facility's Abuse Policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Subsequent to facility investigation, the allegation of abuse was substantiated and NA#6 was terminated.

Based on clinical record review and interview for 1 of 3 sampled residents reviewed for hydration (R#11) the facility failed to identify a resident's failure to meet fluid needs to prevent further decline. The findings include: Resident #11's [DIAGNOSES REDACTED]. Review of the Annual Nutritional assessment dated [DATE] identified estimated fluid needs of 1180 cc. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status score of 5 (0-7 severe impairment), requiring limited assistance with transfers and ambulation and independent with eating. Review of the care plan dated 11/22/11 identified that R#11 ate well and had stable weights with interventions to provide supplements as ordered. Review of the nutritional quarterly note date 11/11/11 identified that R#1's fluid intake was good, averaging for seven days 1676 cc and meeting goal. Review of the Intake and Output (I + O) records dated 2/9/11 through 2/14/12 failed to identify that for five days, R#11 had not met estimated fluid needs. Record of I+O for 2/10/12 was not completed, although the nurse's notes reflect that this was the day the resident had vomited and had diarrhea. On 2/11/12 the I+O was incomplete and nurse's notes reflect that the resident only took in small amounts. On 2/12/12 input was 300 cc plus sips and 1020 cc for 2/13/12. Review of a speech evaluation dated 2/13/12 identified R#11 with moderate orophangeal dysphagia with a subsequent diet change to puree/nectar and a good prognosis. Review of the Nurse's Progress notes dated 2/9/12 identified that R#11 was tolerating the new diet well and was without cough or congestion. Nurse's notes dated 2/10/12 identified that R#11 vomited at 6:30 PM and had four episodes of diarrhea. On 2/11/12 there was no further episodes of vomiting and R#11 took small amounts of fluids. Further review of the nurse's notes identified that on 2/11/12, R#1 was spoon fed but demonstrated no attempts to swallow. On 2/12/12 R#11 took 300 cc with much encourage and poor appetite was identified for 2/13/12. Review of the Nurse's notes dated 2/14/12 at 4:00 AM identified that R#11 was actively resistive to thick fluids, pushing liquids out of mouth and pale but arousable. Nurse's notes dated 2/14/12 2:00 PM identified resident took only sips and at 5:30 PM was weak and lethargic. The facility failed to ensure that R#11 consumed adequate fluids to prevent dehydration and at the family's request the physician was notified and the resident transferred to the emergency room . Review of the hospital history and physical dated 2/14/12 identified that on physical examination R#11 had sunken eyes, dry oral mucosa and reduced turgor. A review of laboratory results were as follows: BUN :85, (baseline 22), Creatinine of 1.8, (baseline 1.0) and sodium 164. Assessment identified R#11 with severe dehydration, [MEDICAL CONDITION] secondary to diarrhea and dangerously elevated [MEDICAL CONDITION] with a calculated water deficit of four liters. Interview with MD#1 on 2/15/12 at 12:30 PM (the physician in both settings) identified that he/she was aware that residents in the facility (including R#11) had been experiencing gastro-intestinal disturbances, but was not alerted to R#11's change of condition and fluid status until 2/14/12. Interview and review of the facility policy with the Director of Nursing on 2/15/12 at 3:30 PM identified that if a resident does not meet fluid goals for three consecutive days the resident is assessed for dehydration and the physician, dietician and family will be notified to determine changes in the plan of care.

Based on clinical record review for one of three sampled residents reviewed for respiratory status, (R#1) the facility failed to implement a Bilevel Positive Air Pressure ([MEDICAL CONDITION]) machine on admission. The findings include: Resident #1's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status Score (BIMS) of 12 (8-12 moderately impaired). Review of the acute care Inter-Agency patient Report (W10) dated 2/6/12 identified that R#1 was discharged to the facility directing the utilization of [MEDICAL CONDITION] at night and when sleeping during the day. Review of the Nurse' Progress Notes dated 2/7/12 at 6:15 AM, identified that R#1 became diaphoretic, complained of severe abdominal pain and was returned to the hospital. Review of the hospital admission history and physical dated 2/7/12 identified that R#1 was admitted with difficulty breathing and complaints of abdominal pain. R#1 was found to be tachypneic, hypoxic and hypertensive. The history and physical further stated that R#1 did not receive the [MEDICAL CONDITION] at the nursing home. Interview with RN#1 on 2/14/12 at 12:30 PM identified that he/she did not ordered the [MEDICAL CONDITION] equipment because he/she had incorrectly assumed that R#1 already had the appropriate equipment and never checked the room to confirm it was there. Interview with RN#2 on 12/14/12 at 12:45 PM identified that he/she was not aware that R#1 needed [MEDICAL CONDITION] until late into the night and was unaware that the equipment could be ordered twenty-four hours a day. Interview with LPN#1 on 2/14/12 at 2:40 PM identified that it is the Supervisor's responsibility to review and verify the orders and order the necessary equipment. He/she further stated that he/she did not receive any paperwork on the resident until very late and was not aware of the need for [MEDICAL CONDITION] until he/she over heard the supervisor talking to the night nurse. Interview with the Director of Nursing on 2/15/12 at 10:30 am identified that the [MEDICAL CONDITION] should have been ordered and the provider is available twenty-hours/day. Interview with MD#2 on 2/22/12 at 3:30 PM identified that on admission to the hospital, R#1 was in respiratory distress and arterial blood gases demonstrated that R#1 was both hypoventilated and acidotic. MD#2 identified that the [MEDICAL CONDITION] was not elective but was of utmost importance and significant to this resident.

Based on clinical record review and interviews for one of five new admissions reviewed for the administration of medication (R#1) the facility failed to administer medications in a timely manner. The findings include: Resident #1's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified a Brief Interview for Mental Status Score (BIMS) of 12 (8-12 moderately impaired). Review of the acute care Inter-Agency patient Report (W10) dated 2/6/12 directed that the following medications be administered on the 3-11 shift: Rifadin 300 milligrams (mg) every 12 hours, [MEDICATION NAME] 500 mg every 12 hours, [MEDICATION NAME] 10 mg. twice daily,[MEDICATION NAME] 50 mg twice daily with meals, [MEDICATION NAME] 75 mg at bedtime, Sodium [MEDICATION NAME] 650 mg three times a day, [MEDICATION NAME] 80 mg every 12 hours, [MEDICATION NAME] Kids 250 mg twice daily, Amphogel suspension 360 millimeters three times a day, and [MEDICATION NAME] Opthalmic drops twice a day. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Nurse's Progress notes dated 2/7/12 at 6:45 AM identified that R#1 complained of abdominal pain, was diaphoretic with a blood pressure of 224/98. The physician was called and R#1 was sent to the emergency department and was admitted . Review of the hospital admission history and physical dated 2/7/12 identified that R#1 was admitted to the hospital with [REDACTED]. R#1 was found to be tachypneic, hypoxic, hypertensive with a blood pressure of 209/72, a had a brain natriuretic peptide (BNP) of 1060 with a recent prior level of 300 (BNP is helpful in diagnosing heart failure). The admission history and physical further stated that it appeared that R#1 did not receive [MEDICAL CONDITION] or any medications at the long term care facility. Interview with RN#1 identified that he/she had three admissions that evening and the order transcription was not completed until late and then the medications were not received until late. Interview with LPN#1 on 2/14/12 at 2:40 PM identified that he/she was not given the Kardexes until late and did not give any medications that evening. He/She continued to say that it is the Supervisor's responsibility and should have known that the medications were not administered. Interview with MD#2 on 2/22/12 at 3:30 PM ( the physician in both settings) identified that after reviewing the Medication Kardex in the emergency room , it was noted that the previously ordered medications were not signed off as administered. MD#2 stated that on admission R#1 was hypoventilated and acidotic and the fact that he/she hadn't received his/her medications, especially [MEDICATION NAME], was significant. After the resident received both the [MEDICAL CONDITION] and [MEDICATION NAME] in the acute care facility R#1 returned to baseline.

Based on review of the clinical record, review of the facility policy and interviews for one of three sampled residents, (R#2), the facility failed to ensure that sufficient fluid intake was maintained to prevent dehydration. The findings include: R#2 was admitted to the facility on [DATE] from an acute care hospital emergency room (ER) with [DIAGNOSES REDACTED]. R #2's Blood Urea Nitrogen (BUN), on 5/4/10 was 20mg/dl (normal 7-18 mg/dl) and the serum Creatinine was 1.1 mg/dl (normal 0.8-1.3 mg/dl). The admission Minimum Data Set ((MDS) dated [DATE] identified that R #2 had a short term memory deficit, moderate cognitive impairments, and required extensive assistance for eating. Physician's orders dated 5/14/10 directed a regular mechanical soft diet with thin liquids and supplements that included powered cereal once daily, a house supplement of 120 milliliters by mouth, two times a day, and cold blend twice a day. Nurse aide flow sheets dated 5/14/10-5/21/10 identified that R #2 consumed less then 50% of meals on eleven occasions. On 5/21/10 dietary notes indicated that R #2 is at risk for weight loss secondary to advanced age and dementia. Dietary notes dated 5/21/10 indicated that R #2's fluid requirements were 1515 cubic centimeters (cc). Nurse aides' flow sheets dated 5/22/10-5/31/10 identified that R #2 consumed less then 50% of meals on nine occasions. Nurse aides' flow sheets dated 6/1/10-6/30/10 identified that R #2 consumed less that 50% of meals on nineteen occasions. Additional nurse aides' flow sheets dated 7/1/10-7/8/10 identified that R #2 consumed less than 50% of meals on twelve occassions. On 7/8/10 the monthly weight sheet identified a seventeen pound weight loss from the previous month. On 7/9/10 the nurse's notes indicated that both the physician and dietician were notified of R #2's weight loss. On 7/9/10-7/16/10 the nurse aide flow sheets identified that R #2 consumed less than 50% of meals on eleven occasions. On 7/16/10 the dietician recommended to continue all increased calorie and protein supplements, and monitor weights weekly. The nurse aide flow sheets identified that on 7/17/10 and 7/18/10 R #2 did not eat for five out of six meals. On 7/18/10 the nurse's notes identified that R #2 was listless, refusing meals, only taking small amounts of fluids, skin turgor was poor and mucous membranes were dry. Although the nurse's note indicated that the nursing supervisor was notified on 7/18/10, the clinical record lacked dehydration assessments, intake and output (I&0) until 7/21/10 when R #2 was refusing food. Interview with the Assistant Director of Nursing on 5/11/11 at 2:15 PM indicated that R #2 should have been placed on I&0 and a dehydration assessment should have been initiated on 7/18/10 when R #2 experienced a change in condition. R #2's intake was 660 cc on 7/21/10, and 480 cc on 7/22/10. The physician was not notified until 7/21/11 and at that time a basic metabolic panel was ordered for 7/22/10. R #2's BUN was 41 mg/dl, the serum Creatinine was 1.44 mg/dl and the Sodium level was greater then 165 mmol/L (normal 136-145). R #2 was admitted to the hospital on [DATE] with dehydration. Interview with MD #1 on 5/23/10 at 11:00 AM identified that he/she should have been notified on 7/18/10 of R #2's lack of oral intake and clinical symptoms. MD #1 indicated that he/she would have obtained bloodwork on 7/18/10 to check for dehydration and would have expected R #2 to be placed on I&0 at that time. MD #1 identified that on 7/23/10 when R #2 was hospitalized the BUN was 52mg/dl, the serum Creatinine was 2.5mg/dl and the Sodium level was 163 mmol/L. The facility policy for hydration directs that one of the conditions that necessitates the need for intake and output is a change in condtion which may alter the hydration status. Intake and output should be completed for a minimum of three days or until the condition stabilizes.

Based on review of the clinical record, facility documentation and interviews for one of three residents reviewed for pressure ulcers, (R#1), the facility failed to implement interventions to prevent the development of a pressure ulcer. The findings include: R#1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that R #1 had impaired short term memory, but intact long term memory, required extensive assistance for bed mobility, but ambulated independently on the unit with a rolling walker, and had no pressure ulcers. The Braden scale pressure sore risk assessment dated [DATE] indicated a mild risk for pressure sore development.The nursing care plan dated 7/13/10 identified a risk for skin breakdown with interventions that included encouragement to change position approximately every two hours, weekly body audits, pressure redistributing mattress on the bed and a pressure redistributing cushion on the chair. Nurse aide flow sheets dated 7/13/10-7/18/10 identified that R #1 was independent with bed mobility on both the day and eveining shifts and extensive assistance on the night shift. Nurse aide flow sheets dated 7/21/10-7/31/10 identified that R #1 now required extensive assistance for bed mobility on all shifts. Nurse aide flow sheets dated 8/1/10 to 8/24/10 identified that R #1 required extensive assistance/total dependence for bed mobility and extensive assistance for locomotion on all shifts. Although R #1 had a decline in his/her ability to reposition himself/herself beginning on 7/21/10, a review of the clinical record and/or interview with the Assistant Director of Nursing on 5/17/10 at 10:15 AM failed to reflect that a subsequent Braden scale pressure sore risk reassessment and/or an interim care plan for the prevention of pressure ulcers with interventions that were implemented when a decline in mobility was noted. The skin tracking record dated 8/24/10 identified that R #1 developed a new 4.0 centimeter (cm) round, intact, stage two pressure ulcer on the right heel. Although revisions to R #1 ' s care plan were developed and implemented as of 8/24/10, the nurse's note dated 8/30/10 identified that the right heel blister had a 0.5cm by 3.5 cm open area. Interview and review of the clinical record with the MDS nurse on 5/17/11 at 10:15 AM identified that when R #1's bed mobility and ambulation declined beginning on 7/21/10 it was the responsibility of both the RN and/or MDS nurse to reassess and change the nursing care plan to reflect the resident's current nursing care needs. Facility policy directed that a Braden scale pressure sore risk assessment would be completed whenever a resident had a change in condition. Facility policy further directed that the care plan is updated as necessary, to reflect changes in the resident's status.