Every finding on record at Woodlake at Tolland

Based on observations, clinical record reviews, review of facility documentation, review of facility policy and interviews for one of two sampled residents (Resident #94) reviewed for skin condition (skin tears), the facility failed to ensure Geri-sleeves were implemented to prevent recurrence of skin tears and for one sampled resident (Residents #54) with wandering and exit seeking behaviors, the facility failed to ensure the care plan addressed the resident's exit seeking and wandering behaviors. The findings include: Resident #94 had diagnoses that included dementia and anemia. The annual MDS assessment dated [DATE] identified Resident #94 had severe cognitive impairment and required total assistance with personal hygiene and dressing. The assessment further identified Resident #94 did not have the presence of skin tears. The accident and incident report dated 10/7/25 at 8:00 AM identified Resident #94 was noted with a skin tear to the left hand that measured 0.6 centimeters (cm) in length by 0.8 cm in width with no active bleeding. The note further noted Resident #94 self-propelled in the wheelchair, was combative at times, and had fragile and thin skin. Additionally, the APRN and family were notified, and Geri-sleeves were added to the resident's plan of care to protect the resident's skin. The Resident Care Plan (RCP) dated 10/7/25 identified Resident #94 sustained a skin tear on 10/7/25. Care plan interventions included assess resident for pain and/or discomfort, obtain treatment, monitor for signs and symptoms of infection, and re-approach resident when combative during care. Although, the accident and incident report noted the intervention of Geri-sleeves, the care plan was not updated to reflect the use of Geri-sleeves. The nurse's note dated 10/25/25 at 11:38 AM identified Resident #94 became combative during morning care, started swinging his arms and hit his/her right hand on the side rail resulting in a skin tear that measured 1.5 cm in length and 0.5 cm in width with a scant amount of serosanguineous drainage. The nurse's note dated 1/8/26 at 8:41AM identified Resident #94 became combative during care and hit his/her left forearm on the side rail that resulted in a skin tear that measured 1.8 cm in length. The care plan for skin tears dated 1/8/26 identified that the intervention for the application of Geri-sleeves to the bilateral upper extremities was not added to the care plan until 1/8/26 after the resident sustained a third skin tear. Observations on 2/4/26 at 11:00 AM and 2/10/26 at 9:55 AM identified Resident #94 lying in bed, wearing a hospital gown without the Geri-sleeves in place and not found in the bed. Interview with NA #3 on 2/10/26 at 11:25 AM identified Resident #94 required assistance for dressing and personal hygiene. She identified Resident #94 can become combative when he/she is not ready to get up in the morning. She further identified Resident #94 is supposed to have Geri-sleeves applied to the upper extremities at all time that can be removed for care. After surveyor inquiry NA #3 found one Geri-sleeve in the bedside drawer. She further identified that Resident #94 was on her assignment, but she had not provided morning care because they had extra help and another nursing aide provided the morning care. Interview with the DNS on 2/11/26 at 9:50 AM identified that the charge nurses are responsible for updating the resident care plan after an incident of skin tears. He identified that Resident #94 had a skin tear on 10/7/25 and the nursing intervention was to wear Geri-sleeves at all time to prevent further skin tears. He identified that Resident #94 should be wearing the Geri-sleeves to the bilateral upper extremities at all times and only removed for care. He could not provide a reason why the care plan was not implemented on 10/7/25 when the accident and incident report indicated that Geri-sleeves were added to the resident care plan. The Care Plans policy identified that the interdisciplinary care plan would be developed to maintain resident optimal status to each resident. The RCP would identify for the care and services required and the date of the expected achievement of the goals. Resident #54 was admitted to the facility in August of 2025 with diagnoses that included anemia, chronic kidney disease and dementia. The quarterly MDS assessment dated [DATE] identified Resident #54 had moderately impaired cognition, required maximal assistance with toileting hygiene, personal hygiene, could self-propel in the wheelchair, required moderate assistance with transfers and bed mobility. The assessment further identified Resident #54 was ambulatory with supervision. Review of the Psychiatry evaluation and progress note dated 1/5/26 identified Resident #54 was seen by the provider for a follow-up for increased behaviors. The note further identified staff reports that Resident #54 had increased periods of confusion, yelling, exit seeking, refusing care, and was not always redirectable. The note further identified Resident#54 had an order for Trazodone (anti-depressant medication) as needed and to continue with current medication and monitoring. Review of the Psychiatry evaluation and progress note dated 1/26/26 identified Resident #54 was seen by the provider for a follow-up for increased behaviors. The note further identified staff reported that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and was not always redirectable. The note further identified that Trazadone (medication) was effective and the order for Trazadone was renewed. Review of the Psychiatry evaluation and progress note dated 1/29/26 identified Resident #54 was seen by the provider for a follow-up on increased behaviors. The note identified staff reported that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and were not always redirectable. The staff also reports resident is up during the night with increased behaviors and the provider will increase the Trazadone dosing at bedtime to 50 milligrams (mg). The nurse's progress note dated 1/29/26 at 11:40 PM identified Resident #54 was confused and wandered into other residents' room and was redirected several times. The nurse's progress note dated 2/1/26 at 12:06 AM identified resident wandered on the unit and was assisted to bed at around 10:00 PM. The nurse worked on 1/31/26 but charted at midnight, hence this occurred on 1/31/26. The nurse's progress note dated 2/1/26 at 10:00 PM written by RN #5 identified Resident was agitated for most of the shift, going from room to room and was found in the kitchen on the unit by dietary. The note further identified Resident #54 attempted to open the door to the stairs and was redirected several times. The resident then managed to pull the fire alarm at 8:15 PM and the fire department responded. Resident #54 was assisted to bed and provided with 9:00 PM medications. The note further indicated that the resident's responsible party was notified regarding the incident. Review of the Psychiatric evaluation and progress note dated 2/2/26 identified Resident #54 was alert, oriented and somewhat irritable and staff reports that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and were not always redirectable. The note further identified Resident #54 has a physician's order to administer Trazadone medication as needed and the medication was used for 2 months and reports to be effective, and the at bedtime dose was recently increase. The notes further dictate to continue to monitor Resident #54. Review of the clinical record from November 2025 to February 2, 2026, failed to reflect that an elopement risk assessment was completed nor any interventions implemented for the resident's wandering and exit seeking behavior as identified in the nurse's progress notes and the psychiatry evaluation and progress notes. Review of Resident #54's care plan dated 1/26/26 identified Resident #54 exhibits and is at risk for exhibiting non-compliance with the treatment plan as evidenced by refusing care, non-compliant with transfer status with interventions that included reapproach resident, monitor behaviors and determine the underlining cause and divert attention. However, the care plan failed to reflect a risk for elopement/wandering and exit seeking behaviors with the appropriate interventions that were individualized to the resident such as elopement risk assessment and the placement of a wander guard device. Interview with the Care Plan Coordinator (LPN #4) on 2/11/26 at 12:30 PM identified he was responsible for updating and revising the residents who reside on the long-term care unit plan of care. He identified that he was aware of the resident's exit seeking behavior, wandering and pulling of the fire alarm, however he did not update the resident's care plan and implement the appropriate interventions. He identified at the time of the incident when the resident exhibited the wandering behaviors and exit seeking the supervisor on the 3-11 PM shift should have updated the care plan so that it would be reviewed by the ADNS and himself and then discussed in the morning meeting. Interview with the DNS on 2/11/26 at 10:25 AM identified at the time of the incident involving the pulling of the fire alarm, wandering on the unit and exit seeking the resident's care plan should have been updated with the appropriate interventions implemented. Review of the Care Plans policy identifies the interdisciplinary care plan would be developed to maintain resident's optimal status to each resident. The RCP would identify for the care and services required and the date of the expected achievement of the goals. The policy further identifies the care plan can also be revised as needed at any time on an interim basis and will address the residents' needs on an individualized basis.

Based on clinical record, review of facility documentation, review of facility policy, and interviews for 3 sample residents (Resident #90, Resident #92, and Resident #94) reviewed for infection surveillance, the facility failed to maintain a system to track a Multi-Drug Resistant Organism (MDRO) infection to the other healthcare provider upon transfer. The findings include: Review of facility MDRO line listing tracking form identified Resident #90 had a history of Methicillin Resistant Staphylococcus Aureus (MRSA) to a wound that was identified on 12/10/21. Resident #90's diagnoses included multiple sclerosis, dementia, and anxiety. The resident medical diagnoses failed to identify the MRSA to a wound. The quarterly MDS assessment dated [DATE] identified Resident #94 identified severe cognitive impairment and required extensive assist with toileting, personal hygiene, dressing, and transfer. Review of facility MDRO line listing tracking form identified Resident #92 had a history of Extended Spectrum Beta-Lactamase (ESBL) in the urine that was identified on 12/17/25. Resident #92 diagnoses included Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, anxiety, and depression. The resident medical diagnoses failed to identify the ESBL in the urine. The quarterly MDS assessment dated [DATE] identified Resident #92 identified intact cognition and required extensive assist with toileting, personal hygiene, dressing, and transfer. Review of facility MDRO line listing tracking form identified Resident #94 had a history of ESBL in the urine that was identified on 10/11/24. Resident #94 diagnoses included COPD, dementia, and anemia. The resident medical diagnoses failed to identify the ESBL in the urine. The quarterly MDS assessment dated [DATE] identified Resident #92 identified severe cognitive impairment and required extensive assist with toileting, personal hygiene, dressing, and transfer. Interview with RN #2 (infection control nurse) on 2/9/26 at 2:00 PM identified that all residents with history of MDRO would be included in the resident medical diagnoses so other provider would be aware of the residents history of MDRO. She identified that the MDS person is the responsible for adding the MDRO diagnosis in the resident clinical record. She identified that she would add any resident with history of MDRO to her tracking form and remove the resident from the tracking form when discharge from the facility. She also identified that the MDRO tracking form was only available in her office and the nursing unit did have a copy of the MDRO tracking form. Review of Resident # 90, Resident #92, and Resident #94 with RN#2 the history of MDRO were not added to the medical diagnosis. She further identified that she could not recall whether she communicated to the MDS coordinator that Resident #90, Resident #92, and Resident #94 had history of MDRO. Interview with LPN #3 (MDS Coordinator nurse) on 2/11/26 at 12:15 PM identified that she was responsible for adding the medical diagnoses in the clinical record. She identified that she would add the MDRO to the resident's medical diagnosis when she was made aware. She could not recalled whether she was aware of the history of MDRO for Resident #90, Resident #92, and Resident #94. Review of the Multidrug-Resistant Organisms policy identified that the appropriate precautions will be taken when caring for residents with known or suspected to have a MDRO. The policy further identified that when single rooms are not available, cohort residents with the same MDRO in the same room, and if not possible cohort with a resident who was at low risk for acquisition of MDRO's and are likely to have a short length of stay.

Based on review of facility documentation, facility policy/procedure, and interviews for 2 of 3 nurse aides (NA #12 and #13), the facility failed to complete the required annual in-service training. Review of NA#12's personnel file identified that she was hired on 2/9/09 and failed to identify documentation that Abuse Neglect and Exploitation, Resident Rights, Dementia Care, and Infection Control training was completed for 2024. The two trainings able to view for 2024 were Communication and Behavioral Health. Review of NA#13's personnel file identified that she was hired on 11/7/24 and failed to identify documentation that Dementia Care, Behavioral Health, and Communication training was completed for 2025. The training completed for 2025 was Abuse Neglect and Exploitation, Resident Rights, and Infection control. Review of the training schedule identified each month there are scheduled training that should be completed for the facility. Interview on 2/13/26 at 3:52PM with the Staff Development Nurse (RN #11) identified she was recently hired as the staff development nurse at the facility. She identifies it is the responsibility of the staff development nurse to ensure staff receives the mandatory annual education training and track when the training was completed. The staff development nurse identified that there is mandatory education scheduled throughout the year and a skill fair is done annually. Interview on 2/13/26 at 3:55PM with the Administrator identified that the staff development nurse and other department heads would host a skill fair event which included majority of the required mandatory education and training, where staff would be able to complete the required education/training. The Administrator further identified that there had been a great deal of turnover in the staff development nurse role and that she was unable to locate the training materials requested. Although a facility policy was requested one was not received.

Based on observations, clinical record reviews, facility policy review, and interviews for two of six sampled residents (Resident #8 & #90) reviewed for nutrition, the facility failed to ensure the adaptive equipment (two handled cup) was implemented in accordance with the physician's orders. The findings include: Resident #90's with diagnoses that included dementia, multiple sclerosis, and primary generalized osteoarthritis. The occupational therapy evaluation and plan of treatment from 3/14/25 to 6/11/25 identified Resident #90 was evaluated for difficulties with the regular cup related to fine motor deficit. The resident goal identified Resident #90 would be able to utilize a two handled mug for all liquid to increase performance and independence with self-feeding and increase fluid intake. The physician's order dated 3/21/25 identified Resident #90 directed to use two handled mug with straw during all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 had severe cognitive impairment and independent with eating, total assist for toileting, personal hygiene, dressing, and transfer. Further review of the resident assessment identified Resident #90 was on mechanically altered diet. The Resident Care Plan (RCP) dated 1/16/25 identified Resident #90 care card. Care plan interventions directed to provide diet per physician's order, use scoop dish at all meal, and use two handled mug with straw during all meals. Observation on 2/4/26 at 12:30 PM identified Resident #90 sitting in bed eating his/her lunch and noted with scoop dish plate and one plastic container cup of cranberry juice and one plastic container cup of orange juice on the bedside table. The meal ticket on the resident tray identified a scoop dish for adaptive equipment but the 2 handled mug was not listed in the adaptive equipment. Observation on 2/10/26 at 12:10 PM identified Resident #90 sitting in bed eating his/her lunch and noted with scoop dish plate and one plastic container cup of cranberry juice and one plastic container cup of orange juice on the bedside table. The meal ticket on the resident tray identified a scoop dish for adaptive equipment but the 2 handled mug was not listed in the adaptive equipment. Interview with the Food Service Director (FSD) on 2/10/26 at 12:45 PM identified that all residents that need adaptive equipment would be coming from therapy and/or nursing. He identified that the nursing and/or the therapy would send out a notification ticket to the dietary department, and the adaptive equipment would be added to the resident ticket to identify the adaptive equipment needed for the resident. He identified that Resident #90 used a scoop dish plate for all meals, but he was not aware of the two handled mug for all liquid. He further identified that he might not receive the notification that Resident #90 need to use the two handled mug that why it was not listed in the resident meal ticket. Interview with OTR #1 (rehab director) on 2/10/26 at 1:35 PM identified that the rehab department would evaluate a resident whether an adaptive equipment is needed for meal. She identified that either her rehab department and/or nursing would notify the dietary when there is an order to use adaptive equipment. She identified that she received a concern from the nursing department regarding Resident #90 fluid intake. She identified that Resident #90 had a fine motor deficit to his/her hands and was evaluated to use a two handled mug for all liquid to increase and/or promote the resident fluid intake. She could not identify why the two handled mug was not reflected in the resident meal ticket. The Resident Adaptive Feeding Equipment Changes policy identified that the facility would ensure all residents have appropriate and updated feeding equipment per physician's orders. The resident adaptive feeding equipment would be found in the facility electronic medical record system, and all feeding equipment changes must be the result of an evaluation by therapy, nursing, and physician. Resident #8 was admitted to the facility February 2025 with diagnoses that included Adult failure to thrive, cancer, arthritis, cataracts, muscle weakness and other lack of coordination. Occupational Therapy assessment dated [DATE] identified Resident #8 was referred for assessment after spilling hot liquids with a goal that indicated Resident #8 would safely perform self-feeding tasks with independence with use of 2 handled mug for proper positioning during meals and for grasp/release of items in order to increase independence in self-feeding and increase nutritional intake. Resident #8 was discharged from OT services 6/16/25. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #8 had intact cognition, required set up or clean up assistance with eating, required supervision or touching assistance with oral hygiene, received a therapeutic diet and parenteral/IV feeding, receiving 500 cc/day or leg of fluid intake by IV, while a resident at the facility. The care plan dated 12/29/26 identified Resident #8 required a right-hand orthotic to prevent contracture and OT adaptive equipment provided a 2 handled mug for liquids with all meals and feeding set up. Treatment Administration Record (TAR) dated February 2026 documented on days and evenings identified total fluid intake: 2/1/26 total 1160 ml 2/2/26 total 1240 ml 2/3/26 total 1100 ml 2/4/26 total 720 ml 2/5/26 total 1480ml 2/6/26 total 1580 ml 2/7/26 total 960 ml 2/8/26 total 1200 ml 2/9/26 total 840 ml 2/10/26 total 1000 ml 2/11/26 total 580 ml 2/12/26 total 1220 ml Physician's orders dated 2/2/26 directed to encourage oral hydration for 24 hours, increase PO fluids every day and evening shift for increased creatinine, OT adaptive equipment PT to provide 2 handled mug for all liquids (originated 5/12/25) with a duplicate order added 2/13/26 after surveyor inquiry. Observation of Resident #8's overbed tray table on 2/4/26 at 2:34 PM identified 4 clear plastic cups with straws, one containing a tan colored liquid half full, one half full of clear liquid, one half full with a whitish colored liquid and one half full with an orange color liquid. There was not a cup with any handle in the room. Interview with Resident #8 on 2/4/26 at 2:34 PM identified Resident #8 was experiencing side effects from either medications or chemotherapy and indicated Resident #8 experienced loose stools and abdominal pain which limited Resident #8's desire for food or fluid intake. Resident #8 identified that this day was a chemotherapy day and indicated that he/she did not feel well and had not and would not be consuming the items on the overbed tray. Interview with Person #1, Resident #8's son, on 2/5/26 at 2:15 PM identified Resident #8 as a picky eater who sometimes doesn't eat and indicated this was a side effect of chemotherapy. Review of the clinical chart on 2/5/26 at 2:34 PM identified Resident #8 had and 18.67% weight loss since 11/13/25. Observation of Resident #8 on 2/9/26 at 10:16 AM identified Resident #8 seated in the wheelchair and 4 plastic cups on the overbed tray table, one half full of clear liquid, one half full of orange colored liquid, one half full of red liquid and one half full of oatmeal. Resident #8 indicated that he/she could not recall eating breakfast and identified he/she was not feeling well but was not able to elaborate and identified he/she would not be consuming the items on the overbed tray table. There was not a cup with a handle in the room. Resident #8's hands were in the resident's lap and the fingers appeared knobby with pronounced knuckles, as fingers with arthritis would appear Interview with RN#7 on 2/9/26 at 10:27 AM identified Resident #8 has refusals of intake after chemo treatments but has fluids provided in the room. RN #7 indicated that Resident #8 likes applesauce, pudding, ginger ale and cookies and was able to eat and drink independently and did not need any assistive devices. Observation of Resident #8 on 2/10/26 at 7:12 AM identified the overbed tray table had a plastic cup with reddish colored liquid with a straw but was not within reach of the resident. There is not a cup with a handle in the room. The meal ticket identified Resident #8 had a special diet with notes to cut up all foods but did not list any adaptive equipment. Interview with Person#1, Resident #8's son, on 2/13/26 at 10:40 AM identified that staff had left a container of applesauce not opened and without a spoon on the bedside table and indicated he was going to feed Resident #8. Person #1 identified that Resident #8 had arthritis in the hands which made it difficult to grasp at times. Observation at this time identified Resident #8 had 1 liter of normal saline that had finished infusing into an IV placed in the left arm of Resident #8. Interview with RN#2, RN currently caring for Resident #8 on 2/13/26 at 10:49 AM identified Resident #8 fell on 2/9/26 and was found to be dehydrated and had received 2 liters of IV fluid since 2/9/26. Interview with the dietician on 2/13/26 at 11:52 AM identified Resident #8 was followed by the APRN but misses and/or refuses meals due to chemotherapy treatments and indicated Resident #8 was able to use utensils per the dietician's observations, identified Resident #8 was ordered a two handled cup for liquids, but could not confirm if the cup was being used. Observation of Resident #8 on 2/13/26 at 12:10 PM identified Resident #8 consumed less than 25% of the lunch meal and identified on the overbed tray table 2 plastic cups, one containing a pink colored liquid and another with a chocolate nutritional shake in the cup without a straw. There was not a two handled cup present. Interview with the dietician on 2/13/26 at 12:17 PM identified Resident #8 had a fluid goal of 1900 to 2300 ml/daily but indicated there was no order to monitor fluid intake. The dietician identified that she does not review the fluid intake unless the resident was on a fluid restriction and indicated that Resident #8 was not receiving enough fluid orally according to the documentation and identified it should be reviewed more consistently. Interview with NA#5 on 2/13/26 at 1:20 PM identified she was not sure if Resident #8 had a special cup as she had not seen the resident with one. Additionally, NA#5 was collecting lunch dishes from the rooms and there was not a handled cup on the dishware cart. NA #5 indicated that Resident #8 holds cups independently and drinks well and identified Resident #8 would not need a handled cup. Interview with RN#7 on 2/13/26 at 1:25 PM identified Resident #8 was receiving IV fluids for dehydration and indicated she had never seen Resident #8 with a handled cup. Interview with APRN#1 on 2/13/26 at 1:47 PM identified that intake and output should be monitored for all residents and should be in the resident chart notes. APRN#1 indicated that Resident #8 had received IV fluids in the past related to dehydration and that Resident #8 was not great with PO intake but could not identify if Resident #8 required any assistive devices but indicated that if it had been ordered by therapy, she would expect it to be implemented. Interview with the Therapy Director (Occupational Therapist) on 2/13/26 at 2:43 PM identified Resident #8 was assessed and ordered a dual handled cup for spilling a hot beverage. The therapy director indicated the process was that after the assessment, therapy was responsible for putting the order for the assistive device into the electronic health record (EHR) and identified the kitchen and nursing are notified when an assistive device is ordered. The therapy director indicated that she was not certain the communication was relayed to the kitchen, but identified the assistive device is located in Resident #8's care plan. Interview with the Food Service Director (FSD) and the Dietician on 2/13/26 at 2:55 PM identified the kitchen had no knowledge of the dual handled cup prior to this day. The FSD indicated the assistive device was added to the meal ticket and would be implemented on the resident floor and produced the meal ticket which identified Resident #8 had adaptive equipment of a 2 handled mug with lid. Interview with the DNS on 2/13/26 at 3:02 PM identified Resident #8 was being followed by the APRN and the dietician and that the expectation for facility monitoring of a resident included complying with ordered adaptive equipment and collaboration between departments. All observations only showed drinks present in Resident #8's room. There were no observations of Resident #8 drinking anything provided and when asked, Resident #8 refused to drink. Resident #8 was never observed with a 2 handled cup nor an orthotic device. Resident #8 had multiple issues including chemotherapy (side effect of diarrhea), 2 diuretics, 2 stool softeners, history of dehydration, minimal fluid and food intake, assistive device ordered and not implemented, and intake refusals. Resident #8 was monitored by each discipline (Therapy, dietician, APRN) although the assessments were being done, the interventions were more reactive than proactive, and it did not appear that the individual disciplines were collaborating. Definitively, the assistive device that was ordered was never implemented and could have contributed to the dehydration was could not be solely responsible for the dehydration. Facility policy for hydration identified dehydration risk factors to include history of refusing fluids and use of diuretics and indicated if the resident had consumed less than their estimated fluid goal for 3 consecutive days, evaluate the resident for signs and symptoms of dehydration. Facility policy for nutritional intake identified the purpose of the policy was to ensure all residents receive the appropriate diet, are provided with assistance and adaptive equipment as indicated, and have food and fluid intake observed and recorded. Additionally, the policy indicated that adaptive self-help devices are provided to assist the residents' independence in eating and that nursing personnel will observe the food and fluid intake of residents and report any situations of concern to the physician.

Based on clinical record review, facility documentation/policies, and interviews, for one (1) of three (3) residents (Resident #117) reviewed for a change in condition, the facility failed to ensure timely provider notification of a significant change in condition, which resulted in a delay in medical intervention and subsequent transfer to the hospital. The findings include:Resident #117 was admitted to the facility on [DATE] with diagnoses that included acute on chronic heart failure (CHF), protein calorie malnutrition and malignant cancer of the colon.The Nursing admission assessment dated [DATE] identified Resident #117 was alert to person, place, time and situation and required supervision for eating.The Resident Care Plan (RCP) dated 1/16/25 identified Resident #117 had nutritional problems related to advanced age, altered nutrition labs, impaired skin, protein-calorie malnutrition and CHF. Interventions included to monitor/document/report any signs of dysphagia; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat.The admission Nutrition assessment dated [DATE] identified Resident #117's feeding ability was independent with supervision. Resident #117 had no problems with chewing and/or swallowing.Physician's order dated 1/16/25 directed a regular diet, regular texture and thin liquids.The Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified a score of 15 indicating intact cognition.A progress note by APRN #2 dated 1/18/25 identified Resident #117 had ongoing nausea and was on aspiration precautions. A progress note by APRN #1 dated 1/20/25 identified Resident #117 was having nausea two days prior and Zofran was ordered with good effect. She identified to continue to monitor for nausea and vomiting symptoms.A nursing note dated 1/21/25 at 6:35 AM identified Resident #117's vital signs were stable, Resident #1 was alert and able to make his/her needs known and no signs or symptoms of distress were noted.A pulse obtained by LPN #1 on 1/21/25 at 11:16 AM was 47 beats per minute (BPM) manual (normal range 60-100 BPM).Review of the clinical record failed to identify provider notification of the pulse obtained outside of normal ranges. A nursing note by LPN #1 dated 1/21/25 at 1:10 PM identified Resident #117 was alert, had some forgetfulness, denied pain and discomfort, had no respiratory or cardiac distress, vital signs were stable, had no cough or congestion, denied nausea and appetite remained fair.A Situation Background Assessment and Recommendation (SBAR) note by RN #1 dated 1/21/25 at 5:28 PM identified Resident #117 was lethargic, confused, not responding and had low blood pressure (BP). Vital signs obtained at 5:35 PM identified a BP of 90/50, pulse of 52, respiratory rate of 18, temperature of 97.4 degrees Fahrenheit and an oxygen saturation of 95%. The APRN and Resident #117's family member were notified at 5:00 PM. A progress note by APRN #1 dated 1/21/25 identified Resident #117's BP was low (80s over 40s) with a recheck of 90/50. Resident #117 reported feeling unwell but was unable to explain what he/she was feeling. Resident #117's heart rate was 52 BPM and he/she was pale with cool skin. The note identified Resident #117 could be septic due to vital signs and mental status in the setting of chronic wounds. Resident #117 was sent to the ED for further evaluation.An EMS (emergency medical services) Care Record by EMT #1 dated 1/21/25 identified dispatch was called at 5:27 PM and arrived at the facility at 5:34 PM. A blood pressure (BP) could not be obtained and Resident #117's SP02 (oxygen level in the blood) was 55 on room air (normal range is 95-100). EMT #1 applied 4 Liters (L) of oxygen and at 5:50 PM applied 15 L of oxygen via a non-rebreather mask (high flow oxygen device used to deliver oxygen to a person with severe hypoxia).The hospital chest x-ray dated 1/21/25 identified bilateral small-to-moderate pleural effusions (fluid buildup around both lungs) and bilateral lower lobe consolidation/atelectasis (areas of lung inflammation or partial collapse in the lower parts of both lungs).Review of hospital records identified Resident #117 expired on 1/21/25.Interview with Person #1 on 2/5/26 at 1:55 PM identified he went to visit Resident #117 on 1/21/25 around 4:45 PM. He identified when he walked into Resident #117s' room, Resident #117 was lying on his/her side, with the head of the bed flat, and NA #1 was spooning liquid into Resident #117's mouth. He identified the day prior, Resident #117 had no issues with eating independently. He identified Resident #117 was observed breathing heavily and dribbling liquid out of his/her mouth but NA #1 continued inserting more liquid into Resident #117's mouth. He identified he panicked, told NA #1 to stop, and left the room to find the nursing supervisor. He identified he told the nursing supervisor that Resident #117 was gasping for air and needed to go to the hospital. He identified the nursing supervisor assessed Resident #117 and called 911. He identified he was told he needed to leave the facility so staff could prepare Resident #117 transfer. Interview with LPN #1 on 2/6/25 at 11:57 AM identified she did not remember Resident #117. She identified if she obtained a pulse that was abnormal (47 BPM) she would have notified the APRN who is frequently in the building and would document that they were notified.Interview with LPN #2 on 2/6/25 at 12:17 PM identified 1/21/25 was the first time she provided care for Resident #117 and at around 5:00 PM NA #1 notified her that Resident #117 was not eating. She identified she evaluated Resident #117 and NA #1 reported Resident #117 normally ate independently. LPN #2 directed NA #1 to assist Resident #117 with eating. LPN #2 identified she reported Resident #117 was not eating, required assistance to eat and had an altered mental status (AMS) to RN #1. She identified Resident #117 then had a low BP and she notified RN #1, who notified the APRN. The APRN ordered Resident #117 be transferred to the ED. Interview with RN #1 on 2/6/25 at 12:36 PM identified LPN #1 reported Resident #117 was lethargic. She identified she assessed Resident #1 and identified he/she was alert and breathing but lethargic. She identified Resident #117's BP was low, but Resident #117's BP usually trended low. RN #1 called 911. She further identified she was not notified that Resident #117 was not eating and was unaware LPN #2 instructed NA #1 to feed Resident #117.Interview with NA #1 on 2/6/25 at 12:50 PM identified she could not remember Resident #117.Interview with APRN #1 on 2/6/25 at 1:10 PM identified she did not recall the specific details regarding Resident #117. She identified she would expect to be notified of an abnormal pulse and that nursing staff typically document provider notification in the medical record. She further identified that if she had been notified of the abnormal pulse, she would have included it in her 1/21/25 progress note. APRN #1 identified that if a resident who was previously independent with eating was no longer eating, she would expect to be notified and would initiate a speech therapy referral for a swallowing evaluation.Interview with the DNS on 2/6/26 at 2:00 PM identified that when an abnormal vital sign is obtained, it should be repeated to confirm accuracy and if confirmed, the physician should be notified. He identified if staff have concerns such as a change in mentation, the nursing supervisor should be notified. Once notified, the nursing supervisor should conduct a change in condition assessment and notify the physician. Review of the Change of Condition in a Resident Status policy directed for the nurse to notify the resident's attending physician when there had been a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medications and a need to transfer the resident to a hospital. The RN will assess the resident's change of condition and document their findings in the medical record.Review of the Vital Signs policy directed that any time a resident's vital signs significantly deviate from their normal baseline, the attending provider is to be informed. Such notification must be documented in the resident's medical record.

Based on observation, facility policy and interviews for 2 of 3 sampled medication rooms and observation of medication administration, the facility failed to store medications appropriately. The findings include: Observation on [DATE] at 9:18AM identified a bottle of Fluticasone 50mcg nasal spray approximately 1/3 full for Resident #39 and a Tresiba Flex Touch Insulin degludec injection with 100 units remaining on top of a medication cart with 12 units dialed into the pen for Resident #31 in the Rehab unit. No nurse was attending the cart at the time and later it was identified the nurse was down the hall in a resident's room without eyes on the medication. This medication was observed to be unattended for approximately 4 minutes before the nurse returned to the cart. Interview on [DATE] at 9:10AM with LPN#5 identified she was nurse assigned to this medication cart and she was down in a resident's room and had left these two medications out on top of the cart because they were the last two medications to be given in her medication pass. LPN#5 identified the medications should not have left them on top of the cart due to the fact a resident could have picked it up and it would be dangerous. Interview on [DATE] at 11:44AM with the DNS identified medication should be locked and not left out on top of a medication cart. A nurse should not leave medication unattended. Observation on [DATE] at 2:29PM of the second-floor medication room identified 5 IV dressing change trays expired on [DATE] and 12 IV start kits expired [DATE]. Interview on [DATE] at 2:30PM with RN#7 identified there is a company that starts IV's and the kits would only be utilized by the company that starts IV's as they do not start IV's in the facility. They make complete dressing changes however they should not be utilizing expired trays and that there was not anyone currently on an IV on the second floor, expired items should be thrown out. The facility also utilized a stock person. Interview on [DATE] at 2:47PM with Stock Person #1 identified she did not order or receive IV supplied and that expired supplies should be thrown out. Review of the medication storage policy directed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is only accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews for the facility reviewed for medication storage the facility failed to ensure there was a system of receipt and disposition to accurately ensure reconciliation of controlled substances received into the facility. The findings included:Interview with the nursing supervisor, RN #3 on 2/10/26 at 5:26 AM identified that when controlled substances come into the facility they are inventoried by the receiving nurse, verified and signed by a second nurse, and the controlled substance disposition record (CSDR) gets photocopied and the copy goes to the ADNS and the original goes with the medication on the medication cart.Interview with the ADNS on 2/11/26 at 10:37 AM identified she had been the ADNS for a year at this facility. The ADNS indicated that when the copies of the CSDR comes into her office they are placed in a binder. The ADNS identified that once a medication is zeroed out the original sign off CSDR is brought to the ADNS office and placed in the binder and the copy is thrown away. The ADNS identified that there was a binder that she kept all the outstanding CSDR copies in. The ADNS indicated that when she completes the bi-weekly audits she does not take the binder with her and the audits consist of counting the controlled substances with the nurse responsible for the med cart. The ADNS identified that she does keep the delivery slips but does not review them.Observation of the ADNS office on 2/11/26 at 10:40 AM identified two large binders with completed CSDR signature sheets, one binder with copies of CSDR sheets, and several piles around the office of CSDR originals and copies. Additionally, the ADNS produced a file with complete CSDRs and identified that those were medications that had been destroyed. When asked to produce all the CSDR copies that had not been reconciled, the ADNS indicated they were in the binder and there were several around her office and asked for time to get them together.Interview with the ADNS on 2/11/26 at 1:13 PM identified she had not been trained on a process for audit and reconciliation and had dismantled the binder with all of the copies of the CSDRs and indicated that she went around the facility to identify controlled substances in use in the facility so that she could make a binder with all of the controlled substances in use in the facility. The ADNS identified that she took out all the CSDR copies that were not in use in the facility and not yet reconciled and placed them into a different binder to be reconciled at a later time.Review of all of the outstanding CSDR copies on 2/11/26 at 1:20 PM, those in use in the facility and the non-reconciled not in use in the facility, identified two hundred fifty three (253) CSDR copies that were not reconciled, meaning the medication was not in use in the facility and it was unknown if the medication had been destroyed, returned, completed, discontinued or sent home with a discharged resident. 66 of these CSDR copies were flagged for the facility to reconcile.Interview with the DNS and ADM on 2/11/26 at 3:00 PM identified they were not aware that the ADNS did not have a reconciliation process for the controlled substances. The DNS indicated that he did oversee the ADNS, designated the DNS responsible for the audits and reconciliation, but identified although the ADNS was not trained on how to complete the process, he thought she was familiar with the process of audit and reconciliation.Interview with the ADM on 2/13/26 at 8:40 AM identified the facility had completed a full audit of the outstanding CSDRs and streamlined the process and indicated that the destruction and reconciliation process was being revamped. The ADM provided proof that the 66 flagged CSDRs were able to be reconciled and indicated that all controlled substances were able to be located.The facility policy for Medication distribution and control identified the DNS is responsible for all control drugs in the facility and she/he will maintain complete accounting of the distribution of all control drugs in the facility.Although requested, a pharmacy contract, nor a policy for controlled substance audit and reconciliation, was not provided by the facility.

Based on review of the clinical record, review of facility policy/procedures and interviews for 1 of 8 sampled residents (Resident #95) reviewed for nutrition, the facility failed to ensure quarterly nutrition assessments were completed. The findings included: Resident #95's diagnoses included Type II diabetes, Gastro-esophageal reflux disease (GERD) with esophagitis, Barretts esophagus without dysplasia. The care plan dated 4/10/25 identified Resident #95 was at risk for a nutrition problem related to Type 2 Diabetes, GERD, intestinal malabsorption, prostate cancer, hypertension, coronary artery disease, Barretts esophagus with interventions that included diet consult as needed, honor food preferences as they arise, monitor weights monthly, registered dietician to evaluate and make diet changes and recommendations as needed. The quarterly MDS assessment dated [DATE] identified Resident #95 was moderately cognitively impaired, was independent for bed mobility, transfers, dressing, eating and personal hygiene. Physician order review for May 2025 identified an order directing Monthly weights. Review of the monthly weight for June 2025 identified a monthly weight of 136.8lbs on 6/5/25. Review of the monthly weight for July 2025 identified a monthly weight of 130.4lbs on 7/4/25. Review of the quarterly nutritional assessments identified a quarterly assessment was done by the Dietician on 3/28/25. The next quarterly assessment was not completed until 11/26/25. Interview on 2/10/26 at 1:14PM with the Dietician identified that if a resident has a greater than 5lb weight loss or gain during a monthly weight there should be a re-weight completed. When Resident #95 was weighed on 7/4/25 there should have been a re-weight completed as the weight loss was greater than 5lbs. The Dietician identified that although she reviews the monthly weights completed, she does not always notice the weight loss unless it triggers significant weight loss in her computer. When she does notice the weight losses, she makes a list a give them to the units of who need a re-weight. However, the dietician identified she did not notice the weight loss or request a reweight that she could recall. Furthermore, the Dietician identified that she is responsible for completing quarterly nutritional assessments on residents and each resident should have an evaluation every quarter. These evaluations are synonymous with MDS date. The process she follows would be to go into the computer and see who is triggering for an MDS to be completed that month. However, she had now learned that more people can be added to the MDS list as the month goes on so she has had to do several more checks to ensure someone is not missed. The Dietician identified she did in fact miss completing Resident #95's quarterly nutrition assessment that should have been completed for the MDS in August of 2025. Interview on 2/11/26 at 11:44AM with the DNS identified he would expect the quarterly nutrition assessments to be completed by the dietician, and the weights to be identified by the nurse or dietician when a re-weight needs to be completed. Review of the Weight Measurement Policy directed residents with a weight variance of 5lbs more or less than the previous month will be re-weighed. The dietician will review the resident weight and make recommendations accordingly. Review of the Nutrition Documentation Policy directed nutrition documentation should include nutrition assessments- initial, annual, or significant change. Quarterly assessments or progress notes- identifying dietary changes as they occur and monitoring if interventions are working and goals are being met.

Based on observations, review of clinical records, review of facility documentation, review of facility policy and procedure, and interviews, for two of eight sampled residents (Residents #54 and Resident #110) reviewed for accidents, the facility failed to ensure an elopement risk assessment was completed per facility policy and facility failed to ensure a resident wearing a wander guard device was functioning and transmitting to alert staff when triggered and for one of three sample residents (Resident #11) reviewed for accidents, the facility failed to ensure the staff follow the resident care plan to prevent a fall. The findings include:Resident #54 was admitted to the facility in August of 2025 with diagnoses that included anemia, chronic kidney disease and dementia. The quarterly MDS assessment dated [DATE] identified Resident #54 had moderately impaired cognition, had behaviors, required maximal assistance with toileting hygiene, personal hygiene, wheeling of the manual wheelchair 50 feet and make two turns and at 150 feet in the corridor and moderate assistance with transfers and bed mobility. The assessment further identified Resident #54 ambulates 10 feet and 50 feet with supervision or touch assistance. The care plan initiated on [DATE] identified Resident #54 at risk for exhibiting non-compliance with the treatment plan as evidenced by refusing care, non-complaint with transfer status with interventions that included reapproach resident, monitor behaviors and determine the underlining cause and divert the resident's attention. The physician's order dated [DATE] directed to offer seating near the nurse's station with stimulating activity when the resident is awake during the late-night shift. Review of the clinical records identified Resident #54 had an elopement risk assessment completed on [DATE] given the resident a score of zero which indicates low risk/not applicable for risk of wandering. Review of the Psychiatry evaluation and progress note dated [DATE] identified Resident #54 was seen by the provider for a follow-up on increased behaviors. The note further identified staff reports that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and were not always redirectable. The note identified resident has an order for Trazodone (anti-depressant medication) as needed and to continue with current medication and monitoring. Review of the Psychiatry evaluation and progress note dated [DATE] identified Resident #54 was seen by the provider for a follow-up on increased behaviors. The notes further identified staff report that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and were not always redirectable. The note further identified that Trazadone (medication) was effective and the order for Trazadone use was renewed, with a schedule Trazadone order for bedtime which was agreed by the resident's Power of Attorney (POA). Review of the Psychiatry evaluation and progress note dated [DATE] identified Resident #54 was seen by the provider for a follow-up on increased behaviors. The note identified staff reports that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and were not always redirectable. The staff also reports resident is up during the night with increased behaviors and the provider will increase the Trazadone dosing at bedtime to 50 milligrams (mg). The nurse's progress note dated [DATE] at 11:40 PM identified Resident #54 was confused and wandered in the unit going into other residents' room and was redirected several times. The nurse's progress note dated [DATE] at 12:06 AM identified resident wandered on the unit and was assisted to bed at around 10:00 PM. The nurse worked on [DATE] but charted at midnight, hence this occurred on [DATE]. The nurse's progress note dated [DATE] at 10:00 PM written by RN #5 identified Resident was agitated for most of the shift, going from room to room and was found in the kitchen on the unit by dietary. The note further identified Resident #54 attempted to open the door to the stairs and was redirected several times. The resident then managed to pull the fire alarm at 8:15 PM and the fire department responded. Resident #54 was assisted to bed and provided with 9:00 PM medications. The note further indicated the resident responsible party was notified regarding the incident. Review of the Psychiatric evaluation and progress note dated [DATE] identified Resident #54 was alert, oriented and somewhat irritable. The note identified staff reports that Resident #54 had increased periods of confusion, yelling, exit seeking and refusing care, and were not always redirectable. The note further identified Resident #54 has a physician's order to administer Trazadone medication as needed and the medication was used for 2 months and reports to be effective, and the at bedtime dose was recently increase. The notes further dictate to continue to monitor Resident #54. Review of the clinical records from [DATE] to February 2, 2026, failed to reflect that an elopement risk assessment was completed nor any interventions implemented for the resident's wandering and exit seeking behavior as identified in the nurse's progress notes and the Psychiatry evaluation and progress notes. Interview with the DNS on [DATE] at 3:00 PM identified he was aware of the incident that occurred on [DATE] with Resident #54 regarding the pulling of the fire alarm and wandering behavior. He further identified the incident was discussed at morning meeting and the interdisciplinary team decided the resident was not at risk for elopement as the resident was just anxious. The DNS identified the staff offered as needed medication for the behavior, offered the resident snack, psychiatric follow-up and social service follow-up for support were completed. The DNS identified an elopement risk assessment is completed on admission, quarterly and after any incident of elopement. The DNS then reviewed the resident's clinical records and identified the resident should have had an elopement risk assessment completed in November of 2025 at the time of the quarterly MDS assessment. The DNS further identified after looking back at the incident which occurred on [DATE], that another elopement risk assessment should have been complete then to determine if the resident was at risk for elopement and wandering. Interview with Nursing Supervisor (RN #5) on [DATE] at 1:58 PM identified her notes dated on [DATE] was her documentation of what the staff had reported to her. RN #5 was asked after the incident with the resident pulling the fire alarm, opening exit doors what interventions were put in place when she responded that the resident was checked on frequently as the nurse's aides know to do that as it is common sense and there were 5 staff schedule on the unit so they were able to manage the resident. RN #5 further identified she was not sure if the physician was updated but the maintenance staff came in when the fire alarm was pulled. Interview with the Charge Nurse (LPN #7) on [DATE] at 8:33 AM identified at the beginning of the shift, Resident #54 displayed behaviors such as opening doors, trying to open exit doors and was redirected several times. LPN #7 identified Resident #54 wanted to leave the facility and wanted to call the police because other residents were taking his/her stuff. LPN #7 identified while she was doing her medication pass, she heard the fire alarm went off and it was Resident #54 who had pulled the fire alarm as he wanted to leave. LPN #7 identified she had reported the incident to the supervisor (RN #5) and could not recall the supervisor telling her to do anything, the staff did frequent checks on the resident, and the supervisor had written a note and notified the family. LPN #7 identified that looking back at the incident an elopement risk assessment should have been completed as the resident wanted to leave. Interview with the Unit Manager (RN #8) on [DATE] at 1:13 PM identified she was unaware that it was her responsibility to complete the quarterly assessment that was due in November of 2025 which included the elopement risk assessment. RN #8 identified she was just made aware yesterday that she was responsible for completing the assessments for the residents residing on the rehabilitation unit. Subsequent to surveyor's inquiry Resident #54 had an elopement risk assessment on [DATE] which indicated a score of 9 (medium risk to wander) and a wander guard device was placed on the resident's right ankle. Review of the Wandering Risk Assessment policy identifies a wandering risk assessment will be utilized and complete on all residents to determine their risk level. The assessment will be done upon admission and quarterly. Review of the Elopement Prevention policy identifies the facility shall complete a wandering/elopement risk assessment on every resident upon admission, quarterly and after elopement incidents. The policy further identifies the quarterly assessment will be conducted while the quarterly MDS's are completed. Resident #110's diagnoses included type 1 diabetes mellitus, anxiety, and metabolic encephalopathy. The admission MDS assessment dated [DATE] identified Resident #110 had severely impaired cognition, required maximal assistance with personal hygiene, dressing, bed mobility, wheeling of the manual wheelchair 50 feet and make two turns and at 150 feet in the corridor and dependent with transfers. The care plan dated [DATE] identified Resident #110 was at risk for elopement related to confusion with interventions that included the resident is triggered for wandering/eloping and the behavior will be deescalated. The physician's order dated [DATE] directed for a wander guard bracelet to the right ankle and to check for placement of the bracelet on each shift and to check wander guard for function every night on the 11:00PM to 7:00AM shift. Observation on [DATE] at 11:34 AM with NA #8 identified Resident #110 is located on the second floor of the building. Resident #110 was in his/her room seated in his/her wheelchair and a wander guard bracelet was noted on the resident's right ankle. The nurse aide then wheeled the resident to the exit door of the unit, and the alarm did not sound. The nurse aide proceeded to take the resident on the elevator to the first floor and after leaving the elevator and upon entering the first-floor entry doorway the alarm sounded. NA #8 identified that the wander guard alarm should have been alarmed by the second-floor exit doorway to signal staff that the resident was attempting to leave the unit. The expiration and serial number on the device were checked and noted to have an expiration date of 7/2024 and serial number of F06645, which was over a year expired. Interview with the Nursing Supervisor (RN #9) on [DATE] at 12:03 PM identified the function of the wander guard bracelet is checked on the 11:00PM to 7:00AM shift using a device. RN #9 use the device called the pocket tag reader to check the functioning of the wander guard and it read ok. RN #9 then read the back of the wander guard bracelet and noted the wander guard was expired. RN #9 identifies the facility has a binder on the unit which identifies residents who use a wander guard, the location of the wander guard and the picture of the resident. Review of the elopement/wander guard binder failed to identify the expiration date and the serial number of each of the wander guard in use for each resident. Observation and interview with the Director of Maintenance on [DATE] at 1:55 PM identified the wander guard did not alarm on the second-floor exit door. The Director of Maintenance identifies that he checks the ground field for transmission of the signal monthly using the pocket tag reader and selects four random residents who wears a wander guard and brings the resident to the exit door on their unit to check if the wander guard sounded to alert the staff. Review of the check operation of doors and patient wandering system for the month of [DATE] completed by Director of Maintenance documentation failed to identify that Resident #110 was selected for his/her wander guard to be checked. The Director of Maintenance identified Resident #116 was newly added to the wander guard list in [DATE], so he did not check that resident. Interview with the Technical Support who supplies the facility its wander guard device and system (Person #3) on [DATE] at 10:51 AM identified the pocket tag reader checks the battery strength of the wander guard and not the transmitting of the wander guard. Person #3 identifies the wander guard should be tested at the exit to check if it reads and the alarms sound to alert others. Person #3 further identifies a wander guard may have a 1 year or a 3-year warranty on the back along with the expiration date, which is the date the warranty expires. Person #3 identifies the warranty date means the device should function effectively and if not, the company will fix any issues with the device within the timeframe and after the expiration date the company will not cover any issues with the device. Person #3 identifies that the device may not work after the expiration date, as the integrity of the device can be affected so they recommend changing the device or test frequently than normal for function and at the exit doors to check if the alarms sounds when the expiration date has passed. Interview with the DNS on [DATE] at 10:25 AM identified the facility was not checking or documenting the expiration dates and the serial number of the wander guards being used in the facility. The DNS identifies that the device should alarm on the second floor as to alert staff the resident is leaving the unit. Review of the Wanderguard Security System policy identifies Wanderguard Security device will be placed on any resident that the resident care team decides is at risk for wandering away from the facility and the 11:00PM-7:00AM nurse will check for function and replace non-functional devices. The procedures for applying and activating the Wanderguard Security devices included checking the active date on the signaling device to be sure it has not expired. Resident # 11 's diagnoses included schizoaffective disorder, wedge compression fracture of first lumbar vertebra, right knee osteoarthritis, and morbid obesity. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had intact cognition, required total assistance for personal hygiene, dressing, bed mobility, transfers, and was non-ambulatory. The physician's order dated [DATE] with origination date of [DATE] directed to provide toileting at bed level with assistance of 2 people, dressing at bed level with assistance of 2 people, and use a mechanical lift with 2 people. The morse fall scale (used to predict risk for fall) dated [DATE] identified Resident #11 score 55 which indicates a high risk for fall. The Resident Care Plan (RCP) dated [DATE] identified interventions that directed bed mobility with assistance of 2 people, dressing at bed level with assist of 2 people, and personal hygiene with assistance of 2 people. The accident and incident report dated [DATE] at 1:50 PM identified Resident #11 was transferred back to bed to provide incontinent care, and he/she was asked to turn to the side, and he/she rolled out of bed onto the floor. The nurse's note dated [DATE] at 4:26 PM identified Resident #11 was observed between 2 beds with his/her knees facing the wall and he/she was noted hanging onto the bed rails. NA #2 was providing his/her care alone. Resident #11 was turned onto his/her right side, and he/she rolled off the bed. Resident #11 was assessed for injuries and/or pain, and he/she was transferred back to the bed using a mechanical lift. Resident #11 was observed with pink area measured 6.5 centimeters (cm) by 4.5 cm to the left knee and 5 cm by 6cm redness with bruising to the right knee. Resident #11 complained of 8 out of 10 on the pain scale. The physician was notified of the fall and new physician's order was obtained to administer oxycodone 5 milligrams (mg) for one dose, apply ice pack three times daily for 3 days and obtain 3 views of right knee x-ray. Family was also notified of the fall. The right knee x-ray report dated [DATE] identified Resident #11 did not have an acute fracture and/or dislocation. The nurse's note dated [DATE] at 4:53 AM identified Resident #11 was alert, verbal, and status post fall. Resident #11 had slight redness to the bilateral knee and no complaint of pain and discomfort. Interview with OTR #1 (rehab director) on [DATE] at 9:50 AM identified Resident #11 was receiving Physical Therapy (PT) services when the resident had an accident. She identified Resident #11 had a trunk weakness and required 2 people assist at bed level for personal hygiene, toileting, and dressing when he/she rolled out of the bed. She further identified that the staff were re-educated to follow the resident care plan when providing care. Interview with NA #2 on [DATE] at 10:20 AM identified she asked Resident #11 to turn to the right side to provide an incontinent care when he/she rolled off out of bed. She identified that she was alone at that time providing incontinent care and she was not aware that he/she required 2 people for bed mobility. She identified that she was a new employee at that time of the accident and she just went off the orientation when Resident #11 had an accident. She identified that she did not check the resident care plan because nobody knew where to find the resident care card. She identified that she did not ask the nurse whether Resident #11 required 2 people to provide for incontinent care. She further identified that she was educated to ask for another person to provide incontinent after the accident. Interview with the Director of Nursing Services (DNS) on [DATE] at 10:35 AM identified that Resident #11 was in his/her bed and rolled off from the bed when NA # 2 was providing incontinent care. He identified that NA #2 was alone providing incontinent for Resident #11 when he/she rolled out of bed. He identified that Resident #11 care plan was updated to have 2 people assist at bed level and staffs were educated after the accident happened. The Fall Prevention Program policy identified that all resident falls would have a focus review by interdisciplinary team for causes, risk factors and to provide preventive measures and interventions. The facility would develop an individualized care plan to meet the residents' needs and implement the plan to prevent a fall.

Based on observations, review of the clinical record, review of facility policy and procedures and interviews for one sampled resident (Resident #29) reviewed for limited range of motion, the facility failed to ensure splints were applied according to the wearing schedule as ordered by the physician. The findings include: Resident #29 was admitted to the facility in 2019 with diagnoses that included unspecified dementia, unspecified severity, with agitation, non-pressure chronic ulcer of other part of left foot limited to breakdown of skin, hydrocephalus and poly-osteoarthritis. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #29 had severely impaired cognition, exhibited bilateral upper extremity impairment, no impairment of the lower extremities, was dependent with all self-care and mobility and was not receiving therapy services. Physician's orders dated 1/27/26 directed the following splinting devices:Bilateral upper extremity palm guards to maintain skin integrity and contracture management, Bilateral elbow extension splints ON during AM care; OFF during PM care with directions to store device in the bedside drawer between uses and direction to document changes in skin condition or concerns, notify therapy via screen as necessary every day shift to check splint cleanliness/condition, check skin integrity pre/post application, perform range of motion as needed, fasten straps, if applicable and monitor device during use as needed.Bilateral knee splints ON in the evening and OFF in the AM with directions to store device in the closet between uses, document changes in skin condition or concerns and notify therapy via screen as necessary. The care plan dated 1/15/26 directs the care card that includes directions for splint to include:Bilateral elbow extension splints on during am care; off during PM care, remove splints prior to transfers via mechanical lift. Apply splints again once transfer completed and stored in the bedside drawer. Document changes in skin condition or concerns. check splint cleanliness/condition, check skin integrity pre/post application, perform ROM as needed, fasten straps, if applicable, monitor device during use as needed notify nursing/rehab/MD with any unusual findingsResident to have bilateral upper extremity palm guard to maintain skin integrity and contracture management.Bilateral knee extension splints On in evening; off in am. Between uses store device in the closet and document changes in skin condition or concerns. Notify therapy via screen as necessary. check splint cleanliness/condition, check skin integrity pre/post application, perform ROM as needed, fasten straps, if applicable, monitor device during use as needed notify nursing/rehab/MD with any unusual findingsThe care plan indicated the NA, LPN and RN were responsible for the splint care. Occupational therapy note dated 1/23/26 identified a therapy goal of caregivers will demonstrate competence in performing passive range of motion to the patient's bilateral upper extremities, including the hand, and will safely don and doff the prescribed palm guard to reduce the risk of contracture. The treatment administration record dated January and February 2026 identified that splint donning (putting on) and doffing (taking off) was completed daily for the bilateral elbow splints, bilateral knee splints, and every shift, every day for the bilateral palm guard monitoring. Occupational Therapy note dated 2/3/26 identified caregivers were able to follow the plan of care for an orthotic device on bilateral hands but did not identify who the caregivers were. Occupational Therapy note dated 2/4/26 identified caregiver education was provided on donning/doffing an orthotic device for the hands to prevent a risk for contractures and that care givers were provided hands on training but does not identify who the care givers were. Observation of Resident #29 on 2/4/2026 at 11:41 AM identified several splints on the dresser in the resident room. Resident #29 was lying in bed with no upper extremity splints in place. There were no palm guards or elbow splints in place. Resident #29 was covered by a blanket, and the lower extremity is not visible. Resident #29's upper extremities are very bent at the elbows and appear contracted. Resident #29's hands are contracted with fingers bent in and not extended at all with fingertips/nails that look like they are pushing into the resident's palm and appearing stiff. Resident #29 is in a hospital johnny, eyes were closed with crusted residue, and it does not appear that morning care had been completed. Observation of Resident #29 on 2/9/2026 at 10:07 AM identified Resident #29 in bed with upper extremity splints, elbow splints, nor palm guards, in place on the resident. Signage on the door identified Resident #29's room is droplet/contact precautions. Observation of Resident #29 on 2/10/2026 at 6:45 AM identified upper extremity splints, elbows and palm guards, were not in place on the resident but present on the resident dresser. Resident#29 was observed still sleeping under the covers with the right knee splint outline visible under the blanket. Occupational Therapy note dated 2/11/26 identified caregiver education was provided for how to measure orthotic device for proper fitting. Observation of Resident #29 on 2/11/2026 at 1:45 PM identified Resident #29 in bed without bilateral upper elbow or palm guard splints not in place on resident. One elbow splint observed on the resident dresser and one elbow splint observed on the chair in the corner of the resident room. Resident #29 is sleeping and covered with blankets so lower extremity splints are not observed. Observation of Resident #29 on 2/13/2026 at 9:40 AM identified Resident #29 in bed asleep without bilateral upper elbow or palm guard splints in place. Resident #29 was covered in blankets and knee splints were not visible. Interview with NA#5 on 2/13/2026 at 9:48 AM identified she was going to perform morning care with Resident #29. Observation of Resident #29 care performed by NA#5 and an orientee and interview with NA#5 on 2/13/26 at 9:55 AM identified a right knee brace in place on Resident #29. NA#5 indicated that Resident #29 only had the right knee brace and had never seen one on the left leg. Observation of Resident #29's room failed to locate a second knee brace. When morning care was completed, NA#5 put the knee brace back in place on the right knee. NA#5 placed the palms guard with the grey pillow splint on the right hand and the velcro palm guard splint on the left hand with the thumb hole on the pinky side. NA#5 did not put on the bilateral elbow splints are not placed back on Resident #29. NA#5 identified that she does not put them on until Resident #29 is moved via Hoyer lift into the wheelchair. When NA#5 was asked how the splinting was ordered, NA #5 then points to a sign on the wall that says please remove elbow splints prior to moving in the Hoyer lift. NA#5 indicated that Resident #29 does not wear the elbow splints when in bed and that Resident #29 is always moved to the wheelchair before 11:00 AM. NA#5 identified that nursing ensures Resident #29 is out of bed early but NA#5 could not identify what happens if NA#5 is not assigned to the resident and NA#5 indicated she could not identify when she was last assigned to Resident #29. Interview with the Rehab Director, who is the Occupational Therapist on 2/13/2026 at 10:28 AM identified the bilateral hand splints were placed incorrectly and were placed on the wrong hands. The Rehab Director indicated therapy is responsible for educating the nurse aides and other staff on splint placement. The Therapy Director identified Resident #29 should have the bilateral leg splints off during the day and the elbow splints should be on when the residentis getting up for the day. The Therapy Director indicated she needed to review the orders but identified if the resident stays in bed during the day, the splints might be uncomfortable but if they are ordered then they should be on. Additionally, the Therapy Director indicated she would have to double check on the second knee splint as she was not aware of what was ordered and that Physical therapy (PT) was responsible for managing the knee splints. Interview with the Therapy Director on 2/13/2026 at 11:23 AM identified Resident #29 is supposed to have bilateral knee splints, bilateral elbow splints and bilateral hand splints currently. The bilateral hand splints were most recently ordered 1/23/26 after a quarterly assessment which found worsening contracture. The Therapy Director indicated that OT short term goals for the start of care indicated that new caregivers need education for the orthotic device related to the elbow splints and palm guards. The Therapy Director could not identify if staff or which staff had received education on donning and doffing the splints. Interview with NA#5 on 2/13/2026 at 10:40 AM identified that although she is familiar with Resident #29 and has the resident often, she had never been trained to place splints and had not placed them prior to today. Interview with the Therapy Director on 2/13/2026 at 12:44 PM identified palm guards are supposed to be on all the time, elbow splints should be applied as the order states, with AM care. The Therapy Director indicated that even if Resident #29 did not get out of bed, the elbow splints should be put in place with AM care. The Therapy Director identified that subsequent to surveyor inquiry, new knee and elbow assessments were being completed due to not knowing if the resident splinting was consistently completed appropriately and staff education would be completed regarding wearing schedule and proper placement of the splints. Interview with APRN #1 on 2/13/2026 at 1:52 PM identified splinting orders are dependent on therapy assessment and recommendations and the expectation is that splinting is completed as ordered. Interview with PT #1 on 2/13/2026 at 2:18 PM identified Resident #29 was supposed to have bilateral knee splints in place with PM care and removed with AM care. PT #1 indicated that a second knee splint had been located and implemented in Resident #29's care and that the assessment showed improvement to the bilateral lower extremity contractures. PT#1 identified Resident #29 would be picked up for care and staff would be educated on the donning and doffing of the splints and could not identify when both splints were last used. After surveyor inquiry, physical therapy note dated 2/13/26 identified Resident #29 was being picked up for therapy services with goal that caregiver will be able to don bilateral knee brace without assistance of therapy when patient is back to bed at night and off early in the morning as per order.Facility policy for adaptive devices to include orthotics, prosthetics, wheelchairs and positioning devices identified that a picture of the patient wearing the device should be taken and kept where the facility designates for staff reference. The policy indicated that in-service sessions for the patient's primary nurse and CNA to ensure they understand how to don and doff the splint and are familiar with the recommended wearing schedule. The policy identified this training should be documented using the paper in-service form and that training could be documented in the daily treatment note. The policy indicated that therapy issued devices required auditing every six months to assess the need for modifications.

Based on review of the clinical record, facility documentation/policies, Emergency Medical Services (EMS) records, and interviews, for one (1) of three (3) residents (Resident #117) reviewed for a change in condition, the facility failed to recognize and respond appropriately to an acute change in condition and failed to ensure staff remained with the resident during a medical emergency until EMS assumed care. Resident #117 was found by EMS in respiratory distress without staff present, with severe hypoxia (dangerously low oxygen levels in the body), and was subsequently hospitalized . The findings include:Resident #117 was admitted to the facility on [DATE] with diagnoses that included acute on chronic heart failure (CHF), protein calorie malnutrition and malignant cancer of the colon.The Nursing admission assessment dated [DATE] identified Resident #117 was alert to person, place, time and situation and required supervision for eating.The Resident Care Plan (RCP) dated 1/16/25 identified Resident #117 had nutritional problems related to advanced age, altered nutrition labs, impaired skin, protein-calorie malnutrition and CHF. Interventions included to monitor/document/report any signs of dysphagia; pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat.The admission Nutrition assessment dated [DATE] identified Resident #117's feeding ability was independent with supervision. Resident #117 had no problems with chewing and/or swallowing.A Physician's order dated 1/16/25 directed a regular diet, regular texture and thin liquids.The Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified a score of 15 indicating intact cognition.A progress note by APRN #2 dated 1/18/25 identified Resident #117 had ongoing nausea and was on aspiration precautions. A progress note by APRN #1 dated 1/20/25 identified Resident #117 was having nausea two days prior and Zofran was ordered with good effect. She identified to continue to monitor for nausea and vomiting symptoms.A nursing note dated 1/21/25 at 6:35 AM identified Resident #117's vital signs were stable, Resident #1 was alert and able to make his/her needs known and no signs or symptoms of distress were noted.A pulse obtained by LPN #1 on 1/21/25 at 11:16 AM was 47 beats per minute (BPM) manual (normal range 60-100 BPM).Review of the clinical record failed to identify provider notification of the pulse obtained outside of normal ranges.A nursing note by LPN #1 dated 1/21/25 at 1:10 PM identified Resident #117 was alert, had some forgetfulness, denied pain and discomfort, had no respiratory or cardiac distress, vital signs were stable, had no cough or congestion, denied nausea and appetite remained fair.A Situation Background Assessment and Recommendation (SBAR) note by RN #1 dated 1/21/25 at 5:28 PM identified Resident #117 was lethargic, confused, not responding and had low blood pressure (BP). Vital signs obtained at 5:35 PM identified a BP of 90/50, pulse of 52, respiratory rate of 18, temperature of 97.4 degrees Fahrenheit and an oxygen saturation of 95%. The APRN and Resident #117's family member were notified at 5:00 PM. A progress note by APRN #1 dated 1/21/25 identified Resident #117's BP was low 80s over 40s with a recheck of 90/50. Resident #117 reported feeling unwell but was unable to explain what he/she was feeling. Resident #117's heart rate was 52 BPM and he/she was pale with cool skin. The note identified Resident #117 could be septic due to vital signs and mental status in the setting of chronic wounds. Resident #117 was sent to the ED for further evaluation.An EMS Care Record by EMT #1 dated 1/21/25 identified dispatch was called at 5:27 PM and arrived at the facility at 5:34 PM. EMT #1 identified Resident #117's room door was closed and when opened, there was no nurse or provider in the room or nearby. Resident #117 was observed lying in bed, hunched to his/her side, drooling, had labored breathing and lips were slightly purple. A BP could not be obtained and Resident #117's SP02 (oxygen level in the blood) was 55 on room air (normal range is 95-100). EMT #1 applied 4 Liters (L) of oxygen. The care record identified EM.; #1's partner arrived on scene at 5:50 PM (16 minutes after EMS #1 arrived) and located Resident #117's nurse. Resident #117's nurse identified at 5:00 PM a nurse aid (NA) spoon-fed Resident #117 liquid food and then staff shortly after found Resident #117 to be hypotensive with severely altered mental status. No interventions were provided prior to EMS arrival. Resident #117 was transferred into the ambulance and became unresponsive with a fixed gaze. Resident #117 was placed on a non-rebreather oxygen mask (high flow oxygen device used to deliver oxygen to a person with severe hypoxia) at 15 L and a blood pressure could not be obtained. Resident #117 was breathing at an adequate rate but labored.The hospital chest x-ray dated 1/21/25 identified bilateral small-to-moderate pleural effusions (fluid buildup around both lungs) and bilateral lower lobe consolidation/atelectasis (areas of lung inflammation or partial collapse in the lower parts of both lungs).Review of hospital records identified Resident #117 expired on 1/21/25.Interview with EMT #1 on 2/3/26 at 3:00 PM identified she arrived at the facility at 5:34 PM on 1/21/25 and entered the building without being met by or encountering any facility staff. She located Resident #117's room, observed the door was closed, and upon entering found Resident #117 alone with no staff present. Resident #117 did not have a roommate. EMT #1 observed Resident #117 lying on his/her right side, drooling, with liquid noted on his/her clothing, and exhibiting labored breathing consistent with respiratory distress. Resident #117 was not receiving supplemental oxygen and was semi-responsive with severe hypoxia. EMT #1 initiated oxygen at 4 liters via nasal cannula. She stated she did not leave the resident's room to locate staff because it was unsafe to leave Resident #117 unattended. EMT #1 further indicated her partner arrived at approximately 5:50 PM, and she directed him to locate facility staff, as no staff had presented to the room and staff were unaware EMS had arrived in the building.Interview with Person #1 on 2/5/26 at 1:55 PM identified he went to visit Resident #117 on 1/21/25 around 4:45 PM. He identified when he walked into Resident #117s' room, Resident #117 was lying on his/her side, with the head of the bed flat, and NA #1 was spooning liquid into Resident #117's mouth. He identified the day prior, Resident #117 had no issues with eating independently. He identified Resident #117 was observed breathing heavily and dribbling liquid out of his/her mouth but NA #1 continued inserting more liquid into Resident #117's mouth. He identified he panicked, told NA #1 to stop, and left the room to find the nursing supervisor. He identified he told the nursing supervisor that Resident #117 was gasping for air and needed to go to the hospital. He identified the nursing supervisor assessed Resident #117 and called 911. He identified he was told he needed to leave the facility so staff could prepare Resident #117 transfer.Interview with LPN #1 on 2/6/25 at 11:57 AM identified she did not remember Resident #117. She identified if she obtained a pulse that was abnormal (47 BPM) she would have notified the APRN who is frequently in the building and would document that they were notified.Interview with LPN #2 on 2/6/25 at 12:17 PM identified 1/21/25 was the first time she provided care for Resident #117 and at around 5:00 PM NA #1 notified her that Resident #117 was not eating. She identified she evaluated Resident #117 and NA #1 reported Resident #117 normally ate independently. LPN #2 directed NA #1 to assist Resident #117 with eating. LPN #2 identified she reported Resident #117 was not eating, required assistance to eat and had an altered mental status (AMS) to RN #1. She identified Resident #117 then had a low BP and she notified RN #1, who notified the APRN. The APRN ordered Resident #117 be transferred to the ED. LPN #2 identified she did not stay in the room with Resident #117 until EMS arrived because she had another Resident to care for. She identified she thought NA #1 stayed with Resident #117.Interview with RN #1 on 2/6/25 at 12:36 PM identified LPN #1 reported Resident #117 was lethargic. She identified she assessed Resident #1 and identified he/she was alert and breathing but lethargic. She identified Resident #117's BP was low, but Resident #117's BP usually trended low. RN #1 called 911. She identified that after her assessment she left Resident #117's room to do paperwork for the transfer. She identified someone should have stayed in the room with Resident #117 until EMS arrived. She further identified she was not notified that Resident #117 was not eating and was unaware LPN #2 instructed NA #1 to feed Resident #117.Interview with NA #1 on 2/6/25 at 12:50 PM identified she could not remember Resident #117.Interview with APRN #1 on 2/6/25 at 1:10 PM identified she did not recall the specific details regarding Resident #117. She identified she would expect to be notified of an abnormal pulse and that nursing staff typically document provider notification in the medical record. She further identified that if she had been notified of the abnormal pulse, she would have included it in her 1/21/25 progress note. APRN #1 identified that if a resident who was previously independent with eating was no longer eating, she would expect to be notified and would initiate a speech therapy referral for a swallowing evaluation. She identified a staff member should have stayed in the room with Resident #117 until EMS arrived.Interview with the DNS on 2/6/26 at 2:00 PM identified that when an abnormal vital sign is obtained, it should be repeated to confirm accuracy and if confirmed, the physician should be notified. He identified if staff have concerns such as a change in mentation, the nursing supervisor should be notified. Once notified, the nursing supervisor should conduct a change in condition assessment and notify the physician. He further identified a staff member should remain with the resident, if a medical emergency is identified, until EMS arrives and assumes care.Review of the Change of Condition in a Resident Status policy directed for the nurse to notify the resident's attending physician of a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, refusal of treatment or medications and a need to transfer the resident to a hospital. The RN will assess the resident's change of condition and document their findings in the medical record.Review of the Vital Signs policy directed that any time a resident's vital signs significantly deviate from their normal baseline, the attending provider is to be informed. Such notification must be documented in the resident's medical record.Review of the Aspiration Precautions policy directed that resident's needing aspiration precautions will be; positioned so that the resident's head is at 90 degrees upright or as close as possible given the resident's physical condition for meals, snack and ingestion of medication, the resident must be assessed by the Speech Language Pathologist for the aspiration precautions to be discontinued and develop a plan of care with feeding strategies and place feeding strategies on the NA care card.

Based on observations, review of clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #116) observed with medication at the bedside, the facility failed to ensure that medications were not left at the resident's bedside for a resident who is without an order or assessment for self-administration of medication and the nursing supervisor (RN #3) observed sleeping on shift in view of the resident unit. The findings include:. The findings include: Observation on 2/10/26 at 4:55 AM identified RN #3 (Nursing Supervisor) in the supervisor's office on the 1st floor seated in a chair with his head bent down to his chest with his eyes closed. The office has two walls that are windows, and a door with windows, so that people outside of the office can see into the office. The lights were off and the door was slightly ajar. The laundry staff person (Laundry #1) pushed the door open and entered the room. Laundry Staff #1 called RN #3's name twice and announced the state was there. At that time, RN #3 opened his eyes and lifted his head to look at the Surveyor. Laundry Staff #1 left the office and RN #3 stood up and rubbed his eyes at which time the Surveyor requested a staffing schedule for the night shift and asked if he had a busy night and his reply was inaudibly mumbled and then he indicated he was resting his eyes. Interview with RN #10 on 2/10/26 at 5:10 AM identified she was responsible for the rehabilitation unit on the overnight shift and indicated RN #3 was the RN supervisor. Interview with Laundry Staff #1 on 2/10/26 at 6:04 AM identified RN #3 was asleep when we entered the supervisor's office and indicated that sometimes the staff sleep on shift when they are on a lunch break. Interview with the ADM on 2/10/26 at 12:05 PM identified that if staff have their assignments covered, they sometimes sleep on their lunch break. The payroll automatically deducts a half hour for lunch but staff do not punch out for the lunches. The ADM indicated the facility had a staff break room and staff should not be asleep in view of the residents. The ADM identified she would have to get the employee handbook and facility policy for guidance on this situation. Review of RN #3 employee timecard report identified RN #3 punched in for work on 2/9/26 at 11:19 PM and punched out on 2/10/26 at 8:06 AM. The facility employee handbook, page 11, identified that all hourly employees will receive a 30-minute unpaid meal break for shifts consisting of over six hours. The policy indicated that if an employee was unable to take a meal break, they should fill out the appropriate form and submit it to HR/payroll coordinator. The facility employee handbook further outlines standards of conduct and corrective action. Page 36 identified the expectation of all employees to use good judgement and maintain the highest standards of professionalism at all time and identified conduct for which discipline may be imposed included sleeping on duty. Facility RN shift supervisor job description identified the nursing supervisor oversees the facility in the absence of higher-ranking management officials, demonstrates measures to promote a safe environment for residents and others. The purpose of the RN shift supervisor position includes to coordinate or manage nursing care, nursing services in accordance with current federal, state, local standards, HIPPA regulations, guidelines and regulations that govern our facility to ensure that the highest degree of quality care is always maintained. The RN supervisor works under the Director of Nursing and/or the Administrator. Resident #116's diagnoses included acute kidney failure, bacteremia, and nontraumatic subdural hemorrhage. The admission MDS assessment dated [DATE] identified Resident #116 had intact cognition, required maximal assistance with toileting hygiene, lower body dressing, transfers and ambulation. Observation on 2/5/26 at 10:19 AM identified Resident #116 was lying in his/her bed with the overbed table positioned on the right side of the bed. Further observation identified on the top of the over bed table a clear plastic bag containing an opened bottle of Latanoprost ophthalmic solution 0.005 % dispensed by an outside pharmacy with approximately a quarter of the solution remained, which the resident indicated he/she uses this medication nightly for his/her recent diagnosis of glaucoma. Resident #116 identified the eye drops were brought in from home, and he/she instill one drop into each eye at bedtime. Resident #116 further identified the staff should be aware that he/she has eye drops in the room as he/she keeps them in plain sight on the over-bed table and he/she needs to have this medication. The monthly physician's order for February 2026 directed Latanoprost ophthalmic solution 0.005 percent (%) to instill one drop into both eyes at bedtime. However, the orders failed to reflect a physician order for self-administration or storage of medication at the resident's bedside. Observation and interview with the Charge Nurse (LPN #8) and the Unit Manager (RN #8) on 2/5/26 at 10:26 AM identified Resident #116 was lying in his/her bed and on the top of the over bed table located on the right side of the bed, a plastic bag containing an opened Latanoprost solution 0.005% eye drop. LPN #8 identified she did not see this medication when she administered the resident his/her medication this morning and RN #8 identified she did not see the medication on the overbed table. LPN #8 removed the medication from the room and placed it in the medication cart. Observation of the medication cart with LPN #8 on 2/5/26 at 10:32 AM failed to identify a facility supply of Latanoprost ophthalmic solution 0.005 % eye drops for Resident #116. Observation of the medication storage room located on the unit with RN #8 on 2/5/26 at 10:33 AM identified in the fridge an unopened bottle Latanoprost ophthalmic solution 0.005 % eye drops for Resident #116 with a pharmacy dispense date of 2/1/26. Interview with RN #8 on 2/5/26 at 10:33 AM identified Resident #116 had signed a self-administration of medication consent form indicating that he/she voluntarily chose not to self-administer medication and does not wish to be assessed by the interdisciplinary team, hence the resident should not be administering any medication to him/herself. RN #8 further identified that the medication should not be kept in the resident's room on the overbed table unless there is a physician's or order directing the storage of medication in the resident's room within the lock box. RN #8 identified the resident can change his/her mind regarding self-administration and if this occurs a self-administration assessment and consent form would need to be completed and the medication to be stored appropriately. Review of the electronic Medication Administration Record (MAR) with the Charge Nurse LPN #9 on 2/10/26 at 3:45 PM identified Latanoprost solution 0.005 % eye drops are scheduled for 8:00 PM and were signed off as administered from 2/2/26 through 2/8/26 by LPN #9. Interview with the Charge Nurse LPN #9 on 2/10/26 at 3:45 PM identified whenever a resident brings in medication from home it is reported to the supervisor and the medication is removed. LPN #9 further identified the facility at times will use the medication supply brought in by the resident until the facility pharmacy sends the resident's supply and the supervisor will keep the resident's supply until returned to the resident. LPN #9 identified he was aware that Resident #116 had eye drops at his/her bedside which he uses to administer to the resident but stores the eye drops in the medication cart. LPN #9 further identified he did not inform the supervisor that he had found the eye drops in the resident's room nor did he bring the eye drops to the supervisor. LPN #9 identified he found a Latanoprost solution 0.005 % eye drops in the fridge that was not opened and it skipped his mind on using the dispensed medication from the facility pharmacy and continued to use the resident's supply. A review of the medication cart with LPN #9 identified the Latanoprost solution 0.005 % eye drops dispended on 2/1/26 by the facility pharmacy was opened on 2/9/26 and the supply brought in by the resident was discarded on 2/8/26 by LPN #8. Interview with the DNS on 2/11/26 at 10:25AM identified medications cannot be left at the bedside unless there is a care plan, a self-administration assessment and a physician order in place. The DNS further identified staff can use medication brought in from home after it is checked for expiration date, notifying the provider but the facility would store the medication in the cart. Review of the Medications Self Administration policy identified patient who request to self -administer medications will be assessed for capability and if it is determined that the patient is able to self-administer: a physician/mid-level provider order is required, self-administration must be care planned, patients must be provided with a secure, locked area to maintain medications, patients must be instructed in a self-administration and periodic evaluation of capability must be performed. Review of the Medication Administration policy identifies a resident may be allowed to self-administer medication only when specifically ordered to do so by an attending physician.

Based on observation, review of clinical records, review of facility policy, review of facility documentation, and interviews for one of three sampled residents (Resident #116), reviewed for activities of daily living (ADL), the facility failed to ensure a resident who requested assistance with ADL care received the care in a timely manner. The findings include: Resident #116 was admitted to facility in January of 2026 with diagnoses that included acute kidney failure, bacteremia, and nontraumatic subdural hemorrhage.The admission MDS assessment dated [DATE] identified Resident #116 had intact cognition, required maximal assistance with toileting hygiene, bathing, taking off footwear, lower body dressing, transfers and ambulation. The assessment further identified Resident #116 was frequently incontinent of bladder and always incontinent of bowel.The care plan dated 1/31/26 identified Resident #116 had potential for alteration in skin integrity relate to decrease mobility, activity in tolerance with interventions that included protect skin with incontinent care and toileting assistance on toileting schedule or routine.Resident #116 care card dated 1/31/26 identified the resident required assistance of one staff member with dressing, personal hygiene, toileting, transfers, provide incontinent care every two hours, and out of bed daily to tolerated wheelchair.Observation on 2/5/26 at 10:19 AM identified Resident #116 was still lying in bed, wearing a Johnny (hospital gown). Resident #116 identified he/she had called for assistance using the call light early in the morning and was told the nurse aide is with another resident and nobody yet to come to provide him/her with assistance to get dressed and washed for the day. During an observation and interview with the Charge Nurse (LPN #8) and the Unit Manager (RN #8) on 2/5/26 at 10:26 AM for medication found at the bedside Resident #116 was still lying in bed, wearing a Johnny (hospital gown). Resident #116 then expressed that he/she had called earlier to get washed up and out of bed and nobody had come to provide him/her with assistance.Interview with RN #8 on 2/5/26 at 10:30 AM identified she did not answer Resident #116's call light and they are down one aide currently as the aide is coming in late. RN #8 identified they were getting residents up who had appointments, therapy and any residents who requested to get out of bed. On leaving the room NA #9 was assisting the roommate of Resident #116 and NA#14 was outside of the room when they were asked if the resident had rung in which they replied no and that they did not answer a call light from the resident.Interview with the LPN #8 on 2/5/26 at 10:45 AM identified Resident #116 rang his/her call light before breakfast, which breakfast comes at 8:30 AM, when she answered Resident #116 call light and he/she requested to get washed and out of bed. LPN #8 identified she was doing her medication pass and told the resident that the nurse aide is with another resident and she when across the hallway to NA #9 and told her the resident needed to wash up for the day.Interview with Resident #116 on 2/5/26 at 2:35 PM identified he/she was last provided with incontinent care sometime after 5:00AM by the 11:00PM to 7:00 AM shift. Resident #116 identified he/she had rung the call light before breakfast and NA #9 indicated she was with another resident. Resident #116 further identified he/she was incontinent with bladder. The resident indicated he/she then received care after the surveyor intervened.Therefore, Resident #116 was last provided with personal hygiene care after 5:00AM and then care was provided again minutes after 11:00 AM, hence resident did not receive assistance with ADL's for over 5 hours. The unit had a census of 21 residents and staff with 3 licensed staff and 2 nurse aides with another nurse aide scheduled to arrive at 8:00AM.Interview with NA #10 on 2/5/26 at 2:11PM identified she is usually scheduled for 8:00 AM but she usually comes in at 8:30 AM or 9:00 AM. NA #10 identified she had overslept this morning and called the facility to let them know she was coming late. She then arrived at the unit after 10:00 AM and immediately went to NA #14 in the hallway to ask her which resident she should see first, when they told her NA #9 would complete care on Resident #116, so she went to another resident. NA #10 further identified her assignment had included Resident #116Interview with NA #9 on 2/5/26 at 2:46 PM identified her interaction with Resident #116 prior to breakfast was to ask him/her what he/she would like for breakfast and what drink she needs and at that time the resident did not let her know he/she needed to get washed up and out of bed. NA #9 identified she did not hear Resident #116 rang his/her call light nor did she answer the resident's call light. NA #9 identified RN #8 informed her that NA #10 was here yet, so she then started to work on her assignment went she started with Resident #116 roommate first, then she provided care to Resident #116 minutes after 11:00 AM. NA #9 further identified LPN #8 did not inform her during their interaction that Resident #116 requested to be washed up. NA #9 identified usually all the residents on her assignment would be provided with personal hygiene care before 10:00 AM. Interview with NA #14 on 2/9/26 at 1:35 PM identified she knew one of the nurse aides would be late, however when 8:00 AM came and the nurse aide did not arrive they called the scheduler who indicated she was going to check. NA #14 cannot recall what time the scheduler got back to them, but when they heard NA #10 was coming later than schedule, they started working on her assignment. NA #14 identified she did not hear Resident #116 rang his/her call light nor did she answer the resident's call light. NA #14 identified when NA #10 arrived, she asked who was left to provide care on her assignment and she informed her about the residents she provided care.Interview with the DNS on 2/9/26 at 3:16 PM identified a call light when rang and answered, the request of the resident should be addressed as soon as possible, within a few minutes. The DNS identified that the facility does not have a system to track when a call light was rung, however if the resident call light was answered prior to 8:30 AM the request should not be answered until 10:45 AM, that was unacceptable. The DNS identified they were aware that the nurse aide was coming late, and the unit manager indicated she would work as the nurse aide until the nurse came in, hence the unit manager did come to the morning meeting. The DNS further identified that if a nurse is in the middle of their medication pass and a resident rang their call light and request to be provided with AM care that the nurse delegate the task but should complete simply task when requested by the resident during medication pass.Review of the Call Light policy and procedure identifies each resident is provided with a working call light. The procedure identifies to answer the call light as quickly as possible and if you cannot give the resident the item or service asked for to do the following: explain to the resident you will ask someone else, get assistance from the charge nurse and return to the resident quickly with a reply.Review of the Activities of Daily Living policy identified appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care including support and assistance with hygiene, mobility, elimination, dining, and communication.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff did not move a resident with identified changes in mental status after a witnessed a fall with a head injury. The findings include: Physician order dated [DATE] directed independent with mobility in the room and hallways using a rollator (rolling walker). The Nurse Aide (NA) Kardex/care card directed as of [DATE], Resident #1 was independent with transfers and ambulation with a rolling walker. Resident #1's diagnoses included dementia, heart failure and insomnia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment and ambulated with partial assistance. The Resident Care Plan (RCP) dated [DATE] identified a risk for falls. Interventions directed to encourage call bell use for assistance, ensure resident is wearing appropriate footwear/non-skid socking when ambulating, follow facility fall protocol and Resident #1 was independent ambulation with a rolling walker. Record review identified Resident #1 had code status Do Not Resuscitate (DNR), and was diagnosed with Norovirus (virus that causes vomiting and diarrhea) APRN note dated [DATE] identified the Norovirus was resolved. Review identified Resident #1 continued with diarrhea on ,d+[DATE] and had a large bowel movement on [DATE] with a stool specimen sent for Norovirus. Review failed to identify any elevated temperatures. Review of reportable event dated [DATE] at 11 PM indicated Resident #1 had an unwitnessed fall; staff witnessed Resident #1 turn around in the middle of the hall and fall. Resident #1 was noted to be weak after the fall, was not responding as usual and was unable to ambulate. The APRN was notified, resident sent via 911 to ED, family notified, and investigation was initiated. Review of nursing note dated [DATE] identified RN #1 was called to assess Resident #1 who had a witnessed fall while self-ambulating in the hallway with a rollator. The Nurse Aide (NA) indicated Resident #1 hit his/her head on the floor. Resident #1 had altered mental status, was unable to follow commands, blood pressure was ,d+[DATE], heart rate 38, respirations 16, and unable to determine (blood) oxygen saturation level. Resident #1 was transferred to bed and placed on oxygen two (2) liters, the on-call provider was notified and ordered to send Resident #1 to the hospital and 911 was called. Emergency Medical Services (EMS) run sheet dated [DATE] identified EMS was called at 11:14 PM. The run sheet identified Resident #1 had non-reactive pupils, arms and legs were mottled. Vital signs obtained were: blood pressure ,d+[DATE], pulse 85, respirations 30. Review of facility SBAR (Situation Background Assessment Request) Communication Form and progress note dated [DATE] at 11:36 PM identified Resident #1 had a fall with change in condition. Increased confusion, new/worsening behavioral symptoms and decreased consciousness, weakness or hemiparesis, and shortness of breath were noted. Resident #1 was transferred to the hospital. Review of Taber's Medical Dictionary directed in part, when a resident falls with a head strike, to assess the severity of the head impact and evaluate for injuries. Observe for mental status changes, neurological abnormalities or bleeding. Residents with signs of neurological compromise should be immediately referred to the emergency department. Review of NA #1 written witness statement dated [DATE] identified NA #1 witnessed Resident #1 slumped over his/her walker in the hall. Before NA #1 could reach the resident he/she spun in a circle as if dizzy, fell on to his/her side and hit his/her head on the ground. The statement indicated the charge nurse and supervisor arrived and were unable to obtain vital signs. The nurse and two (2) NAs then transferred Resident #1 into a wheelchair, with the supervisor present. Staff were still unable to obtain vital signs, and the statement indicated Resident #1 seemed to have trouble breathing and Resident #1 was transferred into bed. Oxygen was applied and then 911 arrived. Review of hospital Emergency Department report dated [DATE] indicated diagnoses of acute encephalopathy (sudden brain dysfunction resulting in changes in mental status), hematemesis (vomiting blood) and syncope (temporary loss of consciousness caused by a sudden, temporary drop in blood flow to the brain) and further indicated resident expired [DATE] at 1:33 AM (2 hours and 33 minutes after the fall). Death certificate dated [DATE] identified Resident #1's cause of death was shock, respiratory failure and hematemesis. Interview and record review with NA #1 on [DATE] at 10:29 AM identified she last observed Resident #1 at 10:40 PM in the bathroom, wearing slippers and she assisted the resident back to bed. About 11 PM she observed Resident #1 walking in the hall wearing slipper socks and then observed him/her hunch over the walker. NA #1 stated she tried to get to Resident #1 to provide assistance, but before she could reach Resident #1, he/she spun in a circle and fell . Resident #1 fell on to his/her side and hit his/her head on the floor. Interview, review of clinical record and facility documentation on [DATE] at 12:22 PM with APRN #1 identified that when a resident has a fall, the resident is typically assessed on the floor, and if there is an injury or change then EMS should be called right away. APRN #1 stated staff should not attempt to move a resident with a possible injury due to a fall and if they hit their head. APRN #1 stated a resident with a change in mentation and head injury should not be moved due to a possible spinal or head injury. Interview and facility documentation review on [DATE] at 12:44 PM with LPN #1 indicated she heard the fall, she heard a very loud sound when Resident #1 hit the floor. LPN #1 stated RN #1/supervisor assessed Resident #1 and directed staff to move Resident #1 into a wheelchair and back to bed. LPN #1 stated she had never seen a resident be moved after a fall with a head injury, and she thought they should have left Resident #1 on the floor and called 911, but RN #1 directed to move Resident #1 off the floor. LPN #1 further stated she should have questioned RN #1's decision to move the resident, but she did not say anything. Interview, clinical record review and facility documentation review on [DATE] at 1:10 PM with RN #1 identified she assessed Resident #1 while he/she on the floor after the fall on [DATE]. RN #1 stated Resident #1 had hit his/her head during the fall, had signs of altered mental status, could not answer questions, showed no expressions of pain, and RN #1 was unable to obtain a blood pressure. RN #1 stated staff lifted Resident #1 into a wheelchair and then transferred him/her into bed. Resident #1 had a low blood pressure, oxygen was started, and 911 was called. RN #1 stated it was her decision to move Resident #1 off the floor, and stated she should not have moved the resident. RN #1 stated she should have made Resident #1 comfortable on the floor and waited for EMS to arrive. Interview, clinical record and facility documentation review with the DNS on [DATE] at 2:15 PM identified Resident #1 ambulated independently and on [DATE] at 11 PM staff witnessed a fall with a head strike. Resident #1 was assessed by RN #1/supervisor and was identified to have mental status changes. Staff then transferred Resident #1 off the floor into a wheelchair and then into bed. The DNS stated Resident #1 should have remained on the floor pending EMS arrival for transfer to the hospital; staff should not have moved Resident #1 off the floor. Review of facility Accident and Incident Investigation Policy directed in part, any resident who sustains an injury to the head can be moved to a safe and comfortable place if no injury is noted.

Based on observation, review of facility documentation, and interviews, the facility failed to ensure opened refrigerator items were dated and discarded, per the facility policy, spoiled food products were discarded, frozen food items were covered, and beverage items were stored in a sanitary manner. The findings include: 1. During an initial tour of the facility kitchen on 3/24/24 at 7:10 AM with the Dietary Director, the following were identified: a. Observation of the reach-in refrigerator identified 4 opened Lactaid cartons without the benefit of an open date label and 1 carton of tomato juice, with an open date of 3/9/24. Interview during the tour with the Dietary Director identified that all opened containers should be labeled with an open date to ensure there is no guessing when the containers were opened or when they should be discarded. The Dietary Director indicated that it is the responsibility of the person who opened the container to create an open date label. The Dietary Director further indicated that the kitchen staff are expected to utilize the Date Marking Quick Reference Guide to determine when food items should be used or discarded by, and based on the reference guide the open carton of tomato juice should have been used or discarded after 7 days (3/16/24). b. Observation of the walk-in refrigerator identified a box of iceberg lettuce with a delivery date of 3/12/24 containing 6 heads of lettuce that had spoiled and further observation of the dry storage identified an undated bag of round buns that had blue-black discoloration on the bottom slices. The Dietary Director disposed of the iceberg lettuce and buns. Interview the Dietary Director identified that the box of iceberg lettuce was a recent delivery, and it should not be spoiled; it is his expectation that fresh produce and perishable food items be inspected upon delivery and daily. The Dietary Directory indicated that it is the cook's responsibility to ensure the food is fresh and to notify him of any perishable food items that were delivered spoiled. The Dietary Director further indicated that all bags of bread should be delivered from the vendor with an expiration date stamped on the bag or printed on the clip. The Dietary Director identified that he would call the vendor to notify them that some bread bags were delivered without an expiration date, and he will ensure the kitchen staff date any undated bags of bread upon delivery. c. Observation of the pantry identified an opened, unsealed bag of rice and further observation of the walk-in freezer identified the following un-wrapped items: chicken tenders, beef patties, pie shells, breaded [NAME], tortellini, and hash browns. Interview with the Dietary Director identified that it is his expectation that all food items stored in the refrigerator, freezer, and pantry must be wrapped up after opening. The Dietary Director further identified that if food is not properly sealed it will be exposed to the surrounding environment and it will not taste fresh. d. Observation of 1 of 6 refreshment carts set with fresh juices, coffee, creamers, water, and cups for breakfast service identified the bottom shelf containing the following used or soiled items: a cup partially filled with juice, 2 towels, and a coffee cup containing old coffee and a spoon. Interview with the Dietary Director identified that there should be no dirty items on the service carts, the carts are only for new drinks and snacks; there are designated carts specifically for dirty items. The Dietary Director directed the dietary aide to clean, sanitize, and restock the cart. The Date Marking Woodlake [NAME] policy ensures the proper rotation of ready-to-eat foods and potentially hazardous foods to prevent or reduce foodborne illness and directs that foods will be date marked with the name of the product, the date of the production or opening. Refer to Quick Reference List for discard date. A designated employee(s) will be assigned to monitor products within department refrigerators/freezers within their responsibility. Processes will be monitored by the food service director. The Dry Food Storage policy directs opened boxes of food shall be re-wrapped, dated, and used as soon as possible. The Cold Food Storage directs all prepared foods in the refrigerator shall be kept covered, labeled, and dated. The Sanitation Policy directs that the sanitation of the facility complies with all state, local, and federal guidelines. Kitchen surfaces and equipment will be maintained in a manner to promote clean and sanitary conditions for food preparation and service.

Based on review of the clinical record, review of facility documentation and interviews for 1 sampled resident (Resident #75) reviewed for edema, the facility failed to ensure APRN or physician were notified that weights were not obtained per physician order. The findings include: Resident #75 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses which included edema, congestive heart failure, and dementia. A physician's order dated 9/22/23 directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week. The care plan dated 9/22/23 identified congestive heart failure. Interventions directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week and give medications per physician order. The Admission MDS assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. A physician's order dated 10/13/23 directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week. A physician's order dated 10/16/23 directed to administer Furosemide( a diuretic medication ) 40 mg 2 times a day for CHF (chronic heart failure). Review of the TAR (treatment administration records) for the months of November 2023 though March 24, 2024 identified the following : 11/1/23-11/30/23 identified 6 missed opportunities out of 30 for daily weights. 12/1/23-12/31/23 identified 10 missed opportunities out of 31 for daily weights. 1/1/24-1/31/24 identified 10 missed opportunities out of 31 for daily weights. 2/1/24- 2/29/24 identified 15 missed opportunities out of 29 for daily weights 3/1/24- 3/31/24 identified 12 missed opportunities out of 24 for daily weights. Review of the TAR indicated Resident #75 had refused on 7 occasions dated 3/4, 3/13, 3/14, 3/20, 3/21, 3/22, 3/24/24. Review of the progress notes dated November 1, 2023-March 24, 2024 did not reflect any refusals and/or explanation of why the weights were not documented . Additionally,the clinical record did not reflect that the APRN or physician were notified of the weights not obtained or refused. Interview with the DNS on 3/25/24 at 10:45 AM indicated the charge nurse was responsible for making sure the nursing assistants obtain the daily weights for Resident #75. The DNS indicated the expectation was if a resident refuses the daily weight the nurse must educate the resident and then try again. The DNS indicated if the resident still refuses the nurse must write a progress note explaining why the weight was not obtained and why the resident refused. Additionally, the DNS indicated if the weight is not obtained or refused the APRN or physician must be notified and documented in the progress notes. After clinical record review, the DNS indicated that the progress notes did not reflect that the APRN or physician had been notified of the missing weights or the refusals of weights in the last 5 months. Review of the facility Weight Management Policy identified to ensure all residents weights are routinely checked, to assess any variations, and implement appropriate interventions for significant weight loss or gain. Although requested the policy for notification of a change in condition it was not provided. Review of the facility Change of Condition Policy identified the facility shall notify the resident, his/her physician, and residnet representative of changes in the residents medical condition. The nurse will notify the physician if there was a refusal of treatment or medications. The nurse will record in the residnet's medical record information relative to changes in the residents medical condition or status.

Based on observations, clinical record review, review of facility documentation, and interviews for one of two sampled residents (Resident #68) reviewed for dignity, the facility failed to ensure that the resident's rights were honored during a meal. The findings include: Resident # 68 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, hypothermia, and congestive heart failure. The care card dated 3/16/24 identified Resident #68 was independent with feeding. The care plan dated 3/18/23 identified Resident #68 was newly admitted to the facility. Interventions included involving the resident in decision making regarding care. The admission MDS assessment dated [DATE] identified Resident # 68 had intact cognition, was occasionally incontinent of bowel, frequently incontinent of bladder, required partial assistance with toileting and bathing, and was independent with eating. Interview and observation on 3/24/24 at 8:25 AM identified Resident #68's breakfast meal tray set up at his/her bedside table by NA #2. Following the tray delivery and set up, NA #2 was observed applying a large clothing protector to Resident #68's chest area and then securing the protector in place at the back of Resident #68's neck area. During this observation, NA #2 did not speak to Resident #68 prior to applying the clothing protector. NA #2 was then observed exiting Resident #68's room. Immediately following this observation, Resident #68 identified that this was the first time a clothing protector had been applied to him/her during a meal. Resident #68 identified that he/she would have liked to have been asked and given the option to choose to use a clothing protector by NA #2. Interview with NA #2 on 3/24/24 at 8:50 AM identified she could not remember if Resident #68 had ever asked for a clothing protector, but that she should have asked Resident #68 if he/she wanted to wear the clothing protector before applying it. Interview with the DNS on 3/26/24 at 11:25 AM identified Resident #68 should have been asked if he/she needed a clothing protector by NA #2. The DNS identified Resident #68 had the right to decide if he/she wanted a clothing protector while eating. The facility policy on resident rights directed that all residents of the facility had the right to be treated with consideration, respect, and full recognition of their dignity and individuality. The policy further directed that residents of the facility had the right to make choices about aspects of their lives that were significant to them.

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #161) reviewed for discharge, the facility failed to ensure the final summary of the resident's stay included the resident's skin integrity, including consultation by the wound physician, and the facility failed to ensure the respiratory equipment was delivered to the resident's home prior to discharge. The findings include: Resident #161 was admitted to the facility in December 2023 with diagnoses which included acute respiratory failure with hypoxia, diabetes, and atrial fibrillation. The physician's order dated 12/27/23 directed to administer oxygen at 2 Liters via nasal cannula continuously every shift The nursing evaluation dated 12/27/23 at 10:51 PM identified Resident #161 was admitted with bruising to top of scalp, bruising to upper middle back, bruising to right elbow, bruising to left hip area, skin tear to left elbow and the use of Oxygen at 1.5 Liters. The care plan dated 12/27/23 identified Resident #161 has altered respiratory status related to acute hypoxic respiratory failure. Intervention included to administer oxygen via nasal cannula as ordered. The care plan dated 12/27/23 identified Resident #161 has a community acquired pressure ulcer stage II to the thoracic spine. Intervention included to administer treatment as ordered and to apply an air mattress. The wound progress note dated 12/28/23 identified Resident #161 was seen for initial evaluation and treatment for right upper extremity skin tear measuring 5.6 cm x 3.8 cm x 0.1 cm with small serosanguinous. Pressure ulcer to thoracic spine stage II measuring 3 cm x 1.6 cm x 0.2 cm with small serosanguinous. Diagnoses laceration to right upper arm and pressure ulcer stage II thoracic spine. Treatment recommendations: Right upper extremity skin tear apply bacitracin and xeroform, cover with dry clean dressing, change every day, and as needed. Thoracic spine pressure ulcer apply bacitracin, cover with foam dressing, change every day and as needed. The wound progress note dated 1/15/24 identified Resident #161 was seen for follow up evaluation and treatment regarding a right upper extremity skin tear, a pressure ulcer to thoracic spine, and a malignancy to the left ear. Resident #161 was also seen for Moisture Associated Skin Damage (MASD) to the sacrum. The case was discussed with the resident representative at bedside in detail. The nurse's note dated 1/20/24 at 11:55 AM identified Resident #161 was discharged home at 10:54 AM with all active medications and discharge instructions. All medications were reviewed with Resident #161 and resident representatives at bedside. The social service note dated 1/20/24 at 12:18 PM identified Resident #161 was discharged back to the assisted living facility with visiting nurses. Resident #161 was provided medications and a copy of the discharge paperwork. Review of the Transfer/Discharge Report and the interagency referral ( W-10) dated 1/20/24 included a list of the resident's current active medications and did not include the use of oxygen at 2 Liters via nasal cannula. Further, the Transfer/Discharge Report failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. The Discharge instruction forms dated 1/20/24 with resident representative signature failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. Further, the Discharge instruction form failed to identify oxygen at 2 Liters via nasal cannula. Interview with the SW #1 on 3/26/24 at 8:29 AM identified she was responsible for Resident #161 discharge. SW #1 indicated she had emailed the physician's order to the oxygen company on 1/18/24 and they were supposed to deliver the oxygen to Resident #161 home. SW #1 indicated she was not aware that the oxygen was not delivered. SW #1 indicated she was not aware that the oxygen company did not call the resident representative. SW #1 indicated she was responsible for making sure the oxygen was delivered to Resident #161 home prior to discharge. SW #1 indicated she acknowledged that this was not a safe discharge. SW #1 indicated she had submitted a physician's order to another oxygen company on 1/20/24 at 12:15 PM and that oxygen company did not accept the order until 1/22/24. SW #1 indicated she was not aware that the discharge paperwork failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. Further, the Discharge instruction form failed to identify oxygen at 2 Liters via nasal cannula. Interview with the DNS on 3/26/24 at 11:00 AM identified SW #1 is responsible for discharging residents and ordering equipment. The DNS indicated he was not aware of the discharge paperwork failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. Further, the Discharge instruction form failed to identify oxygen at 2 Liters via nasal cannula. Interview with Person #3 on 4/2/24 at 12:22 PM identified Resident #161 was discharged from the facility to the assisted living facility without oxygen on 1/20/24 in the early afternoon. Person #3 indicated that he/she had notified the resident representative that Resident #161 will need oxygen prior to admission and if there was no oxygen Resident #161 would have to go back to the nursing home or the hospital. Person #3 indicated Resident #161 needed oxygen before going to bed because the resident's oxygen desaturates with sleep. Person #3 indicated he/she called the nursing home regarding the oxygen order and the person stated they did not know anything about an oxygen order. Person #3 indicated she finally spoke to the discharge person at the nursing home and told her this was not a safe discharge as the resident was discharged without an oxygen being in place. Person #3 indicated she called an oxygen company emergency number and inquired about oxygen for Resident #161 to be delivered before 8:00 PM on 1/20/24. Person #3 indicated an oxygen company responded and had delivered the oxygen around 8:00 PM. Person #3 indicated Resident #161 representative was very upset about the discharge procedure from the nursing home. Person #3 indicated she did not receive a phone call from the nursing home, she was the one that called the nursing home regarding the oxygen equipment not being delivered to the assisted living facility prior to Resident #161 discharge. Review of the facility discharge policy identified resident being discharged from the facility shall have a planned discharge when possible. Residents should only be discharged upon written order of the attending physician.

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #75) reviewed for respiratory care, the facility failed to ensure a comprehensive care plan was developed related to the use of respiratory equipment. The findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The admission MDS assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Additionally, the MDS assessment did not indicate the use of a C-pap. The baseline care plan dated 10/4/23 did not identify the use of a C-pap. The comprehensive care plan dated 10/10/23 did not identify diagnosis of sleep apnea or the use of the CPAP. The physician's orders dated 1/20/24 (120 days after admission) directed the use the CPAP with medium full face mask oxygen flow rate at 2 liters per minute. On every night, off every morning and as needed when napping. Cleanse CPAP tubing with 1/2 water, 1/2 white vinegar (place tubing into a basin) remove the tubing from the basin and allow tubing to be air dry every Sunday on 11:00 PM-7:00 AM shift. (scheduled while resident is using the CPAP). Observation on 3/24/24 at 7:00 AM Resident #75 was lying in bed wearing a CPAP mask with tubing connected to a machine on a rolling cart on the left side of the bed. Interview with the DNS on 3/25/24 at 10:23 AM indicated the MDS coordinator was responsible to include the use of the CPAP in the baseline care plan and the comprehensive care plan since admission. The DNS indicated the MDS coordinator( RN #8 )works remotely and completes the MDS assessments based on physician orders. The DNS indicated that he would have expected a care plan since admission regarding the CPAP. Interview with MDS coordinator (LPN #3), on 3/25/24 at 11:10 AM indicated she was responsible or MDS coordinator RN #8 to include the use of the CPAP on the care plan. LPN #3 indicates that they do the care plan based off the admission physician's orders. LPN #3 indicated that the CPAP was not in the initial admission orders, so it got missed. After surveyor inquiry, the comprehensive care plan dated 3/25/24 included alteration in respiratory status and resident uses a C-pap. Interventions included cleaning the c-pap mask daily per policy, fill humidifier with sterile water per physician order, change the mask and tubing per physician order. Review of the facility Care Plan Policy identified the facility will have an interdisciplinary care plan to achieve and maintain optimal status for each resident. The resident care plan will include the residents needs, realistic goals, and the care and services needed to meet these goals. The MDS coordinator is responsible for ascertaining that all MDS triggered items have been addressed.

Based on review of facility documentation, and interviews, for one sampled resident( Resident #69) reviewed for an allegation of staff to resident abuse, the facility failed to implement policies to protect the resident's from abuse. The finding includes: Resident #69 was admitted [DATE] with diagnosis which included unspecified dementia with psychotic disturbances, emphysema/COPD, and depression. Facility documentation dated 8/22/22 identified Resident #69 believed NA #1 was making a joke about the resident being moved off of the unit by singing the song Celebration. Resident #69 notified his/her spouse of the situation, stated NA #1 was rude, sang Celebration and was delighted about the move. The spouse was visibly upset and expressed concerns to management regarding the treatment. NA #1 was sent home immediately pending investigation. Interview and review of the incident with NA #1 on 03/25/24 at 11:10AM identified her recall of the incident was Resident #69 was either being discharged or moved to another floor. She identified Resident #69 had a history of being mean toward her and was combative with staff. Resident #69's spouse would often yell at staff at times, and Resident #69 was also noted to be accusatory and required an assist of 2 NAs due to behaviors. NA #1 denied singing or disrespecting Resident #69 however stated she was impolite to the spouse and walked away as the spouse was conversing with her. NA #1 stated she could have kept her job had she apologized to Resident #69's spouse however she refused to apologize and at this point was remorseful about that decision. Interview and review of the incident on 03/25/24 at 03:05 PM with then interim DNS RN #9 identified she was unable to substantiate the allegation of abuse as all of the staff supported NA #1 and there no resident heard the dialogue exchange. Review of the facility incident report identified substantiated and when asked did the abuse occur with the resident, the spouse or both, RN #9 identified it was with the spouse and could not substantiate abuse with the resident. RN #9 further stated NA #1 was placed on final warning and called back to the facility to advise her that she would be placed on final warning, however NA #1 encountered the spouse in the parking lot and told the spouse that she was untouchable and proceeded to insult the family member. RN #9 indicated she spoke to her Administrator and in the absence of HR Generalist they terminated NA#1's employment Review of NA #1 personnel file failed to identify the documentation of the incident, the final warning of 8/11/22, or a background check. Although NA #1 completed the application for fingerprinting, her personnel file failed to identify a returned fingerprint verification. Interview with HR Director on 3/25/24 at 1:20 PM identified NA #1 was hired 4/22. The HR Director was unable to locate any preliminary screening associated with NA #1's employment application. Interview with the DNS on 3/25/24 at 3:25PM identified neither he nor the Administrator were employed by the facility in 2022. It would be his expectation that employees are screened, and background checks are done prior to an offer for hire and that personnel files are complete. Although attempted a call to the Administrator of the facility in 2022 was not returned. Although requested a policy for hiring and screening was not provided.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #42) reviewed for activities of daily living, the facility failed ensure a dependent resident was provided with supervision to prevent an injury, and for one of five residents reviewed for pressure ulcer/injury (Resident #61) the facility failed to ensure provided wound care timely in accordance with physician orders. The findings include: a. Resident #42's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] identified Resident #42 had severe cognitive impairment, rarely or never made decisions regarding tasks of daily life, required total assistance of two (2) staff with transferring in and out of the bed and chair, one (1) person assistance with movement to and from off-unit locations, was non-ambulatory and utilized a wheelchair (manual or electric) as a mobility device. The Resident Care Plan dated 5/13/2021 identified Resident #42 was at risk for skin breakdown related to depression, history of falling, cervical spondylosis, [CONDITION(S)]. Interventions directed to monitor skin integrity during care. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note dated 6/18/2021 identified Resident #42 was seen in the morning for an acute visit, Resident #42 had been sitting outside in the direct sunlight for an undetermined amount of time (nursing and recreation stated possibly less than one hour), and Resident #42 was found to be flushed and diaphoretic. The note identified Resident #42 was immediately taken inside, a cool cloth was applied, and water administered. Resident #42 was awake, but his/her eyes were not tracking, just staring, Resident #42 was unable to swallow the water provided, and was not verbally responding or following commands. The note identified Resident #42 did give a yelp of pain with the lifting of the legs. The note indicated Resident #42 progressed to keeping his/her eyes closed, had an acute mental status change. Further, the note indicated that Resident #42's face was flushed, his/her upper chest and abdomen were noted with reddened scattered patches, both arms and the bottom of the legs were reddened, had increased warmth to touch and was sweaty. The note identified vital signs were as followed: blood pressure 86/56, temperature 98.6F, pulse 101, respirations 16, and oxygen saturation was 90% on room air. The note further indicated that Resident #42's presentation with acute mental status change, [CONDITION(S)], and sunburn were most likely from possible dehydration from being in the sun, 911 was immediately called and Resident #42 was sent to the hospital for further evaluation. Review of the Treatment Administration Record for June 2021 identified as needed sunscreen was not applied on 6/18/2021. The Hospital Discharge Summary dated 6/20/21 identified Resident #42 presented with altered mental status after sitting in the sun for a long period of time. As per the emergency room notes, Resident #42 had been sitting outside in the sun, when staff tried to interact, Resident #42 was unresponsive for a period of time with a low blood pressure, [CONDITION(S)] and was transferred to the hospital. The summary identified Resident #42 was in no acute distress, a rash was noted on the torso with some blisters, some raptured abdominal blisters, likely due to sun exposure and Resident #42 was admitted to the hospital. Resident #42 received intravenous fluids for acute kidney injury, and lab results on admission were: Blood Urea [MEDICATION(S)] was 24 (normal range 8-21), Creatinine was 1.5 (normal range 0.40-1.0), Sodium level was 142 (normal range 136-145) which resolved after receiving the intravenous fluids. The facility Admission/Readmission nursing assessment dated [DATE] identified a sunburn with superficial open blisters to right and left shoulders, and a red area to right thigh and left knee. The facility Admission/Annual History and Physical progress note dated 6/21/2021 identified bilateral shoulders supraclavicular sunburn areas with open blisters on each side and erythematous area to the upper right thigh and left knee. Review of past weather reports for the local town on 6/18/2021 identified the weather was sunny with the daytime temperature range from 78 to 84 degrees Fahrenheit and winds 10 miles per hour. Interview with Advanced Practice Registered Nurse (APRN) #1 on 10/5/2021 at 11:00 AM identified she saw Resident #42 who was seated outside in the sun and was informed by nursing and recreation staff that Resident #42 had been outside for less than an hour. APRN #1 indicated she assessed Resident #42 after he/she was in the sun. She indicated that Resident #42 experienced a change in condition from being out in the sun and Resident #42 was sent to the hospital for an evaluation. APRN #1 identified it was not unusual for residents to sit outside on the patio, however the best practice would be to place residents under some shade and to apply sunscreen or protective clothing so the residents would not experience dehydration or a sunburn. Interview with the former Director of Nursing (DON) #2 on 10/5/2021 at 11:20 AM identified the 7 AM to3 PM charge nurse was the staff member who brought Resident #42 outside. The DON #2 indicated Resident #42 was not wearing any sunscreen and was left outside in the sun for approximately thirty (30) minutes. DON #2 further indicated that residents need to have sunscreen applied prior to going outside and the charge nurse should have applied sunscreen on Resident #42 prior to taking the resident outside. Interview, clinical record review, and facility documentation review with the LPN #3 (7 AM to 3 PM charge nurse) on 10/5/2021 at 12:10 PM identified she brought Resident #42 outside because Resident #42 complained of being cold and there were other residents sitting outside at that time. LPN #3 indicated she did not remember the day being super sunny but remembered that it was warm. LPN #3 identified she did not put Resident #42 in the shaded area under the gazebo because she thought the sun would be good for Resident #42. LPN #3 indicated Resident #42 was wearing a long sleeve shirt and long pants and she did not apply any sunscreen to Resident #42 prior to taking him/her outside. LPN #3 identified she retuned inside the building and continued with her assigned tasks. LPN #3 indicated it was probably thirty (30) to forty (40) minutes after she left Resident #42 outside when one of the staff members alerted her that Resident #42 was unresponsive, and Resident #42 was subsequently transferred to the hospital for an evaluation. LPN #3 identified Resident #42 had a sunburn where his/her shirt slide down off the shoulders. LPN #3 indicated that she thought recreation staff would monitor Resident #42 while he/she was outside, however the recreation staff were not responsible to monitor residents outside and if she knew they were not monitoring Resident #42 she would have checked on Resident #42. She indicated that she should have applied the sunscreen, she should have put Resident #42 in the shade, and she should have monitored Resident #42. Facility did not provide a policy for surveyor review. b. Resident # 61's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #61 was alert and oriented, required one person assist for mobility, and had no pressure ulcers or skin issues. The Resident Care Plan (RCP) dated 8/26/2021, identified Resident #61 a venous stasis ulcer on his/her left shin tear with [CONDITION(S)] related to PVD. Interventions directed to document location of wound, amount of drainage, per-wound area, pain [CONDITION(S)] and circumference measurements and to document wound healing. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations and interview with Resident #61 on 10/4/2021 at 8:46 AM, identified Resident #61 ' s left leg was red above the dressing. The dressing was observed to have a tan, light brown color drainage visible on the dressing and the date on the dressing written in black marker read 9/30/2021. Resident #61 indicated that the leg dressing had not been changed since September 30, 2021 and it should be changed every evening. Interview and clinical record review with LPN #10 on October 8, 2021 at 4:15 PM identified she did not change the dressing on 10/1 or 10/2/2021; she had missed completing the dressing change for Resident #61. Interview and clinical record review with LPN #11 on October 8.2021 at 4:50 PM identified she worked on 10/1/2021 during the 3 to 11 PM shift she could not recall if she changed the dressing. Review of facility Nursing Policy and Procedures policy, directed in part, that documentation is recorded only after care is given.

Based on review of the clinical record, facility documentation, facility policy, observations and interviews for 1 of 5 residents (Resident #263) reviewed for accidents, the facility failed to ensure that a resident who required extensive assistance with bed mobility was provided adequate supervision and assistance during incontinent care to prevent a fall out of bed with resulting injury, and for 1 of 3 residents (Resident #10) reviewed for wandering, the facility failed to ensure identified interventions were implemented to prevent an elopement. The findings include. 1. Resident #263 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #263 had severely impaired cognition and required extensive assistance of 2 or more staff with bed mobility. The care plan dated 2/26/18 identified Resident #263 required assistance with activities of daily living and mobility related to generalized weakness, history of a stroke, and advanced [MEDICAL CONDITION] with behavioral disturbances. Interventions included to provide the assistance of 1 staff with bed mobility, toileting, and personal hygiene, and transfer the resident with a mechanical lift. Additionally, the care plan identified Resident #263 was at risk for falling related to a history of a stroke, [MEDICAL CONDITION] medication use and decreased safety awareness related to advanced [MEDICAL CONDITION] with behavioral disturbances. Interventions included to anticipate Resident #263's needs. A fall risk assessment dated [DATE] identified Resident #263 was a high fall risk. A reportable event form dated 4/7/18 at 2:00 AM identified that during incontinent care, Resident #263 slid off the bed and was assisted by a nurse aide, NA #1, to the floor. A statement by NA #1 dated 4/7/18 identified that while changing Resident #263, NA #1 rolled Resident #263 on his/her left side and tucked the clean brief and linen underneath the resident. As NA #1 walked around to the right side of the bed, Resident #263's feet went over the edge of the bed, and although NA #1 attempted to grab Resident #263's legs to push them back up, NA #1 was unable, and Resident #263 slid off the bed onto the floor. A nurse's note dated 4/7/18 at 2:00 AM identified that Resident #263 was observed kneeling next the right side of the bed facing the head of the bed. The note indicated NA #1 lowered Resident #263 from the bed to the floor, and no injuries were noted. A nurse's note dated 4/7/18 10:30 AM, 8 ½ hours later, identified Resident #263 was having pain in the right leg with repositioning onto his/her right side. Resident #263 was unable to straighten the right leg without moaning and grimacing. Additionally, the note indicated Resident #263 had a 4.0cm by 4.0cm ecchymotic area on the upper abdomen, and an abrasion on the left knee that measured 0.5cm. Resident #263 only took liquids for breakfast and Tylenol was administered as ordered. Resident #263 was to be evaluated by the APRN. An APRN note dated 4/6/18 (incident occurred on 4/7/18) identified Resident #263 fell and/or was lowered to floor at approximately 2:00 AM with no apparent injury. Staff requested APRN evaluation because Resident #263 had right leg pain and swelling, and a bruise on the abdomen. The APRN assessment identified +2 [MEDICAL CONDITION] of the right leg including the knee and foot. The resident's abdomen was noted with a hematoma that measured 15cm by 5.0cm with petechiae surrounding the hematoma that measured 15cm by 12cm. Resident #263 winces in pain with right leg palpation. Recommendations included to discontinue the aspirin, obtain stat CBC, stat abdominal x-ray, stat right knee, right tibia/fibula and right foot x -ray, and ultrasound to the right leg. An addendum nurse's note, written by the charge nurse, LPN #1, dated 4/7/18 identified 2 nurse aides came to the nurse's desk to report Resident #263 fell out of bed during turning and incontinent care. Resident #263 was sitting on the floor holding onto the left side rail facing the wall. The nurse aide indicated Resident #263 had put his/her feet over the side of the bed and was assisted to the floor. Resident #263 was assisted back into bed by the RN Supervisor, RN #1, and 2 nurse aides. A medical imaging report dated 4/7/18 identified Resident #263 had acute [MEDICATION NAME] knee trauma of the right leg. Additionally, the report identified a displaced distal periprosthetic femoral fracture. A nurse's note dated 4/7/18 at 10:30 PM identified Resident #263's right leg was swollen and slightly displaced. Upon repositioning, Resident #263 exhibited pain, and Tylenol was administered with no effect. Additionally, the x-ray noted an acute displaced fracture involving the distal femur of the right leg. Subsequent to physician notification, Resident #263 was sent to the hospital for evaluation. A nurse's note dated 4/7/18 at 11:15 PM identified Resident would be returning to the facility with an immobilizer in place and orders for follow up with orthopedics. A nurse's note dated 4/8/18 at 1:00 PM identified the physician ordered [MEDICATION NAME] 2.5mg every 6 hours for 3 days for pain control. Interview with OT #1 on 11/7/18 at 9:35 AM identified that Resident #263 required total assistance with bed mobility and incontinent care. OT #1 indicated that he/she had not assessed Resident #263 to determine the number of staff required to assist the resident with bed mobility, and was unsure if the resident required 1 or 2 staff for assistance with bed mobility and incontinent care. Interview and review of the clinical record with the ADNS on 11/7/18 at 11:10 AM identified that Resident #263 required the assistance of 2 staff with bed mobility and incontinent care. The ADNS indicated he/she thought that 2 staff were present on 4/7/18 at the time of the fall, but upon review of the clinical record, there was only 1 nurse aide present. In a subsequent interview with ADNS on 11/7/18 at 1:00 PM the ADNS identified that Resident #263 was combative at times and staff would use the assistance of 2 staff with care, however Resident #263 required only the assistance of 1 staff for bed mobility at the time of the fall. The ADNS was unsure who was responsible to determine if a resident required assistance of 1 or 2 staff for bed mobility and incontinent care and/or how often a resident should be reassessed to determine the necessary required assistance with activities of daily living. Additionally, the ADNS was unsure if there was a physician's orders [REDACTED]. In another interview with the ADNS on 11/7/18 at 2:30 PM, the ADNS indicated because Resident #263 had been incontinent of bowel, and feces covered Resident #263's lower extremities, NA #1 was unable to get a good grip on Resident #263's legs, and that's what caused Resident #263's legs go over the edge of the bed, because the feces on the legs made the legs slippery. Multiple attempts to interview NA #1 during the standard survey were unsuccessful. Review of the facility fall prevention policy did not reflect direction on who was responsible to determine the required number of staff for a resident's bed mobility. The facility failed to ensure that Resident #263, who required extensive assistance with bed mobility, was provided adequate supervision and assistance during incontinent care on 4/7/18 at 2:00 AM when NA #1 rolled Resident #263 on his/her side, tucked the clean brief and linens underneath the resident (while the resident was on his/her side), and the resident's feet went over the edge of the bed. Subsequently, Resident #263 slid off the bed onto the floor and sustained a displaced distal periprosthetic femoral fracture which required a hospital evaluation, immobilization and pain control. Additionally, the facility investigation failed to identify the resident's position in the bed prior to the fall and/or failed to document a conclusion as to what caused the resident, (who requires extensive assistance to move in bed), to fall out of bed onto the floor. 2. Resident #10's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified Resident #10 had short and long term memory problems, moderately impaired decision making ability, required limited assistance with bed mobility and transfers, extensive assistance with toileting, and exhibited the behavior of wandering. The care plan dated 2/28/18 identified Resident #10 was at risk for elopement due to wandering on the unit, entering other resident rooms and confusion. Additionally, the resident was found attempting to leave the facility looking for his/her car saying let's go. Interventions included the application of a wanderguard, to monitor wanderguard placement each shift, and test wanderguard weekly, provide diversified activity, monitor attempts to leave the unit, and redirect as needed. physician's orders [REDACTED].#10's wheelchair, and check placement and function every shift. A reportable event form dated 4/15/18 identified Resident #10 was observed by a visitor exiting out of the front entrance into the parking lot in a wheelchair. A statement by NA #3 dated 4/15/18 identified while staff were cleaning the dining room, a visitor reported that Resident #10 was outside. NA #3 indicated he/she ran toward the front entrance and although there was no alarm sounding, NA #3 spotted Resident #10 under the archway in the parking lot. Subsequently, Resident #10 was returned to the building. The facility investigation dated 4/16/18 identified that Resident #10's has a wanderguard on his/her wheelchair, but the resident was in a different wheelchair because the regular wheelchair was being repaired. Attempts to interview NA #3 was unsuccessful. Interview with the DNS on 11/9/18 at 1:00 PM indicated the wanderguard can be placed on the resident's wrist, ankle or wheelchair, but in this case, it was on the wheelchair which was not in use at the time. Review of the wanderguard usage policy indicates the bracelets may be attached to the resident's wrist, ankle, wheelchair, etc. and the charge nurse is responsible for checking placement of each wandering bracelet every shift and document on the treatment record.

Based on clinical record review, review of facility documentation and interview for one of three sampled residents reviewed for nutrition (Resident #260) the facility failed to monitor I&O's for a resident at risk for dehydration and/or notify the MD when a resident was not meeting estimated fluid needs as per facility policy. The findings include: Resident #260 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Dehydration Risk assessment dated [DATE] identified the resident scored a 5 (total score of 8 or > represents high risk). The physician's orders [REDACTED]. The Admission Nutrition assessment dated [DATE] identified that the resident's estimated fluid need (EFN) was in the amount of 1875 cc per 24 hours. The resident's documented intake was as follows: 10/11/16 - 1080 cc, 10/12/16 - 1240 cc, 10/13/16 - 1020 cc, 10/14/16 - 1440 cc. laboratory results dated [DATE] identified the resident with a BUN of 18 mg/dl (7-18 mg/dl normal range) and a Creatinine level of .62 mg/dl (0.550-1.300 mg/dl normal range.) Intake on 10/15/16 - 1620 cc and 10/16/16-1440 cc. The Resident Care Plan dated 10/16/16 identified the resident at risk for dehydration/fluid/electrolyte imbalance due to decreased fluid intake, recent history of dehydration and impaired cognitive status. Interventions included to monitor intake and output per orders and notify MD of fluid intake less than resident's individual fluid goals for three consecutive days. A APRN progress note dated 10/16/16 identified the APRN was made aware by nursing that Resident #260 had not met his/her estimated fluid needs for five days and urine was tea colored. The progress note identified the resident showed no signs and symptoms of dehydration and labs will be rechecked if the resident continued to be below fluid goal. The admission MDS dated [DATE] identified the resident with moderately impaired cognition and required set up assistance for feeding. Intake on 10/17/16 - 1200 cc and 10/18/16 - 840 cc. There is no documentation of intake from 10/19/16 through 10/21/16 (3 days). A physician's orders [REDACTED]. The nurse ' s progress note by RN #1 dated 10/26/16 identified the resident was day three under fluid goal and lips were beginning to look red and dry. The note failed to identify MD/APRN was notified of the resident not meeting his/her estimated fluid needs and the clinical record lacked documentation of resident being assessed for dehydration. The nutrition progress note dated 10/27/16 identified resident had a significant weight loss. Admission weight 166 lbs., 10/19/16 162.5 lbs. and on 10/26/16 resident weighed 155 lbs. Note indicated the weight loss was most likely fluid weight loss. A review of resident's intake from 10/22/16 through 11/03/16 identified the resident consumed between 500 and 1380 cc, (for 13 days the resident did not meet his estimated fluid goals once). Nurse ' s progress note dated 11/12/16 identified the resident was lethargic and wanted to stay in bed for most of the day. APRN progress note dated 11/13/16 identified Resident #260 with mental status changes and increased confusion. Note indicated the plan was for the facility to obtain a urine specimen for culture and sensitivity and ordered blood work to be done on 11/14/16. APRN progress note dated 11/14/16 identified APRN was asked to see the resident emergently for significant mental status changes. Note indicated the APRN identified the resident in bed, restless, having periods of apnea, non - verbal, unable to take anything by mouth and unable to follow commands. Resident was transferred to an acute care facility on 11/14/16. The acute care facility history and physical dated 11/14/16 identified the resident presented with dry mucous membranes and hematology performed in the ED showed a BUN of 70 (norm 7-18) and Creatinine of 2.4 (norm 0.550-1.300.) Per the history and physical the resident received IV hydration for a [DIAGNOSES REDACTED]. Acute care facility progress note dated 11/21/16 identified resident ' s BUN as 22 (norm 7-18) and Creatinine was .99 (within normal range.) Interview and medical record review with the Director of Nursing Services (DNS) on 12/09/16 at 1:00 PM identified the MD should have been notified when the resident did not meet his/her estimated needs for three consecutive days as per facility policy. The DNS further identified that there was no documentation in the medical record to identify the facility staff notified the APRN/MD that the resident was not meeting his/her estimated fluid needs. The DNS further indicated that subsequent to surveyor inquiry the facility initiated an I&O audit to review if residents are meeting estimated fluid needs at day 3 and day 10 and if not, what follow up occurred. Interview with MD #1 on 12/9/16 at 1:25 PM identified that review of the APRN progress note dated 10/16/16 the APRN did the appropriate thing based on the lab work from 10/14/16 and the resident was not showing signs and symptoms of dehydration. However, MD #1 further indicated that after reviewing the resident's intake and output, had the facility reported the intake (not meeting estimated needs) he/she would definitely would have ordered lab work and if it showed dehydration, would have initiated IV fluids. Interview with RN #1 on 12/9/16 at 2:00 PM regarding the progress note he/she had written on 10/16/16 referring to Resident #260 not meeting estimated fluid needs for three consecutive days and lips appeared red and dry. RN #1 indicated that although there is no documentation that the MD/APRN was notified he/she may have reported the information in passing to an APRN. The facility's I&O/Hydration Policy identified that any new admission will have a standing order of 1500 ml per day minimum fluid intake until the dietician sees the patient and a fluid goal is calculated. During those 10 days, if the resident does not meet fluid goal times three consecutive days, the MD/APRN will be called. Policy further identified if a resident consumes less than their fluid goal in 24 hours x 3 consecutive days, this will be noted and the MD/APRN will be notified of the decreased intake. The MD/APRN will determine if an assessment is warranted and document his/her findings and plan related to fluid intake.

Based on clinical record review and interview for three of six residents reviewed for accidents, (Resident #2, #118, and #222), the facility failed to provide adequate supervision during a transfer and/or for a resident who had a history of [REDACTED]. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2's cognitive status as intact, had required extensive two person assistance with transfers in and/or out of the bed and chair, had functional limitation of a lower extremity on one side and impairment on both sides of the upper extremities, utilized a wheelchair for mobility, and had a history of [REDACTED]. The Reportable Event Form dated 12/27/14 at 8:00 AM identified that Resident #2 slid out of the wheelchair during a transfer from the bed. The resident was assessed, no injuries were noted and the plan of care was changed on 12/27/14 to utilize a Hoyer lift for all transfers secondary to increased weakness of the left leg cellulitis wound. A physician's orders [REDACTED]. The Reportable Event Form dated 1/9/15 at 9:15 PM identified that Resident #2 was lowered to the floor in the bathroom after a one person assist transfer was attempted by Nurse Aide (NA) #11. Registered Nurse (RN) #9 assessed Resident #2 who complained of right ankle pain. Subsequent to physician notification the resident was transferred to the hospital for an evaluation. The resident was diagnosed with [REDACTED]. In an interview on 10/28/15 at 9:30 AM, Resident #2 identified that he/she had persuaded NA #11 to transfer him/her without the benefit of a Hoyer on 1/9/15. Resident #2 believed that he/she was progressing in physical therapy and could transfer with the assist of one person but unfortunately fell during the transfer and sustained a fractured ankle. In an interview and clinical record review on 10/28/15 at 2:15 PM, the Director of Nursing (DON) identified that the incident occurred because NA #11 did not follow the plan of care for transferring the resident. The DON indicated that it is the expectation for nurse aides to follow the information on the resident's care card for directions on the resident's mobility. Following the incident, the facility implemented a plan of correction which included nurse aide education on following the plan of care and NA #11 was terminated on 1/16/15. Attempts to contact NA #11 and RN #9 were unsuccessful. 2. Resident (R #118) [DIAGNOSES REDACTED]. A quarterly minimum data set (MDS) assessment dated [DATE] indicated R #118 had severely impaired cognition with short and long term memory deficits. The assessment identified R#118 was nonambulatory requiring extensive assistance for locomotion and hygiene. A resident care plan (RCP) dated 7/6/15 indicated R #118 required a wheelchair for locomotion and was dependent on staff for wheelchair mobility. According to a facility investigation on 6/24/15 R#118's family brought in R #118's personal noncustom wheelchair from home. On 7/7/15 at 6:55 PM R #118 was noted to have been sitting in his/her wheelchair and when placed in bed an approximately 4 inch bleeding laceration to his/her right anterior lower leg was noted. In review of the incident the investigation determined that R #118's right anterior lower leg laceration was in the same proximity of contact with a sharp metal piece attached to the wheelchair foot pedal. The investigation indicated the wheelchair was immediately removed from use and R #118 was provided with a facility noncustom wheelchair. R #118 was evaluated by the Advanced Practice Registered Nurse (APRN) and transferred to the hospital Emergency Department (ED) where he/she received fourteen sutures to the laceration on his/her right lower leg. During an interview with Nursing Assistant (NA) #8 on 10/28/15 at 12:00 PM, NA#8 indicated on 7/7/15 at approximately 6:55 PM, NA #7 and NA #8 entered R #118's room and at that time P#118 was complaining he/she had right leg pain. NA#7 and NA#8 placed R #118 into bed from the wheelchair and when R #118's pants and socks were removed the laceration to R #118's right lower leg was identified. During an interview with Occupational Therapist (OT) #1 on 10/27/15 at 2:30 PM OT#1 indicated he/she was not aware that R #118's family had brought in R #118's personal wheelchair and he/she would evaluate a custom wheelchair brought to the facility but would not routinely check a standard wheelchair unless a positioning problem were identified. During an interview with the Director of Nursing (DNS) on 10/28/15 at 1:45 PM he/she indicated P#118's family had brought the wheelchair in and labeled it with R #118's name on 6/24/15 during the 3:00 PM to 11:00 PM shift however the medical record lacked documentation of such. In addition the medical record and/or facility documentation did not indicate the wheelchair had been checked for safety prior to use. b. The quarterly MDS dated [DATE] further indicated R #118 had periods of agitation and restlessness in which he/she was resistive to care. physician's orders [REDACTED].#118 was to be within direct observation of staff from 5:00 PM to bedtime. During an interview with Nursing Assistant (NA) #8 on 10/28/15 at 12:00 PM, NA#8 indicated that upon entering R #118's room on 7/7/15, R #118 was identified as having a right lower leg laceration. R #118 was unattended by staff at that time. Upon surveyor inquiry NA #8 indicated he/she was not aware R #118 required direct observation from 5:00 PM to bedtime. During an interview with the Director of Nursing (DON) on 10/28/15 12:50 PM the DON indicated he/she was not aware R #118 had an order for [REDACTED].#118 within direct observation as per the physician order. Upon surveyor inquiry the DON indicated the facility did not have a policy for direct observation. c. A nurse's note dated 9/9/15 at 11:00 AM indicated R #118 was noted to have a 1 inch skin tear on his/her right lower leg requiring cleansing and a dressing. A requisition dated 9/10/15 by OT#1 requested maintenance to check a rough patch on R #118's wheelchair or pad the area and no adjustments to the chair were needed related to positioning concerns. During a review of the medical record and facility documentation with the DON on 10/28/15 at 1:45 PM, he/she indicated upon surveyor inquiry and subsequent follow up he/she determined that according to OT#1 he/she had received the requisition however RN #3 (Unit Manager) was not available at the time. OT #1 then placed the requisition in R #118's chart and forgot to follow up with RN #3 and/or notify the Director of Maintenance of the need for an evaluation of the chair for safety. The medical record and/or facility documentation failed to identify the wheelchair had been evaluated for safety. 3. Resident #222 (R #222) had [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that R #222 had moderate cognitive impairment, required supervision/oversite with locomotion on and off the unit, and extensive assistance with transfers and ambulation. A fall risk assessment dated [DATE] identified R #222 with a score of thirteen, indicative of a high risk for falls. The care plan dated 10/6/15 identified that R #222 was at risk for falls secondary to a history of falls, unsteady gait, impaired balance, use of psychotropic meds, noncompliance with directions/poor safety awareness and cognitive impairment. In addition, the care plan identified that R #222 had an ADL deficit with interventions that included to anticipate needs, direct supervision in the bathroom (do not leave unattended), an alarmed self-release seat belt, and to supervise wheelchair mobility. Review of the facility accident and incident report dated 10/6/15 identified that R #222 was sitting outside in his/her wheelchair in the presence of staff when the resident's wheelchair began to roll down the sidewalk. The incident resulted in R #222's wheelchair falling forward and the resident falling out of the wheelchair, onto the pavement, hitting the front side of his/her body. The documentation identified that R #222's fall resulted in eye swelling, multiple bruising, and a laceration over the left eye. Review of facility documentation, observation, and subsequent interview with NA #1 on 10/23/15 at 10:10 AM identified that on 10/6/15, R #222 was taken outside by a family member to the patio area where six or seven other residents were already seated. NA #1 indicated that he/she and NA #2 were initially in attendance. NA #1 identified that the door to the outside patio was propped open with a stick which was placed through the opening where the door was attached by the hinges. NA #1 identified that he/she saw the family member lock the resident's wheelchair brakes. NA #1 stated that he/she observed R #222 unlock his/her brakes while he/she was distributing drinks to all the residents and that he/she then relocked the wheelchair brakes. NA #1 identified that after he/she picked up empty drink cups from the residents, he/she went back into the building to place the empty cups on a table near the door. NA #1 stated that he/she did not see NA #2 on the patio or inside the open doorway. NA #1 stated that when he/she turned back around, he/she saw R #222 rolling down the sidewalk. Observation of the sidewalk where R #222 rolled down identified that it was located adjacent to the patio and inclined down a hill. NA #1 identified that he/she immediately began screaming out the resident's name and was running down the hill, trying to catch up with R #222 but that resident's wheelchair flipped over face first. NA #1 stated that he/she was yelling for help, ran back to the door, then back outside was yelling for help through the window when he/she saw then NA #2 come to the doorway. NA #1 stated that he/she told NA #2 to go for help. Interview with NA #2 on 10/23/15 at 11:00 AM identified that on 10/6/15, he/she and NA #1 were outside with residents when R #222's family brought the resident outside. NA #2 identified he/she saw R #222 come out though could not remember who locked the resident's wheelchair brakes but stated we always make sure the wheels are locked. NA #2 identified he/she went inside to wash his/her hands and the first time he/she knew that an incident had occurred was when he/she heard NA #1 yell his/her name and saw R #222 on the ground. NA #2 stated that he/she had not heard NA #1 yelling for help because the sink water was running. Interview with NA #3 on 10/23/15 at 12:00 PM identified that R #222 was known to unlock his/her wheelchair brakes all the time and that the resident had just recently done so to go to the bathroom. Interview with NA #4 on 10/23/15 at 2:00 PM identified he/she has worked at the facility for six years and R #222 had been able to unlock the wheelchair brakes ever since admission to the facility. NA #4 believed that all the nursing staff including the licensed staff were well aware Resident #222 had this capability. Interview and review of facility policy with the DNS on 10/23/15 at 3:00 PM indicated that it would be his/her expectation that the NAs stay with residents while outdoors on the patio. R #222 was transferred to the Emergency Department (ED) for evaluation. Review of the acute care record dated 10/6/15 identified that R #222 was evaluated for acute facial swelling, acute cervical pain, and acute head trauma. R #222 returned from the hospital on [DATE]. Review of the body assessment tracking form dated 10/6/15 at 8:15 PM identified that R #222 returned from the hospital after the fall and had sustained a left eye laceration, two skin tears to the upper cheek, a left thumb skin tear, left knee skin tear, right knee scratch/bruise, complaints of left thumb pain and that the resident's left eye was swollen shut. The wound tracking log identified that the right knee wound measured 1 centimeter (cm) by 0.2 cm, the left knee skin tear measured 1.5 cm by 2.5 cm, the left upper cheek wounds (two) measured 1 cm by 0.2 cm and 1 cm by 0.2 cm and the left eye laceration measured 2 cm by 2 cm. Treatments to the areas included cleansing with normal saline followed by the application of Bacitracin and clean dressings. Review of R #222's September 2015 MAR through prior to the incident on 10/6/15 identified that R #222 had not complained of pain, had not required pain medication, though complained of insomnia one time. Review of facility documentation including R #222's October 2015 Medication Administration Record (MAR) dated10/7/15 through 10/17/15 (subsequent to the resident's fall on 10/6/15), identified that R #222 complained of pain related to his/her injuries and received Tramadol one time, complained of discomfort/pain and received Tylenol ten times, complained of pain and received hydrocodone twice and had insomnia and received Melatonin eight times. Review of the APRN progress note dated 10/7/15 identified that the APRN ordered hydrocodone as needed on 10/7/15 secondary to trauma, fall with pain, and that the resident tolerated hydrocodone better than Tramadol and had been effective in the emergency room . Subsequent to R #222's fall from the wheelchair, the resident's plan of care was revised to include that the resident be kept in view at all times and to be one of the last residents to be taken outdoors.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #1) who had difficulty with chewing and/or swallowing chewing, the facility failed to ensure that the diet recommendation by the speech therapist was reviewed with the physician and/or Advanced Practice Registered Nurse (APRN) . The findings include: Resident #1's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that Resident #1 was oriented to person, place and time, cooperative, alert, able to feed self and had no chewing and/or swallowing difficulties. The interim care plan dated 11/10/13 identified Resident #1 at risk for nutritional defect, dehydration, and/or fluid electrolyte balance. Interventions directed a consistent carbohydrate diet and the fluids were not thickened. A physician's orders [REDACTED]. The speech therapy evaluation dated 11/11/13 identified that Resident #1 was referred to ST due to complaint of coughing during meals, question diet modifications. The assessment identified that Resident #1 had mildly reduced dysphagia characterized by sensation of food in the pharynx and throat clearing with cough during intake of regular solids and the resident required skilled ST services. The diet recommendations were mechanical soft textures, thin liquids in a cup, strategies were to alternate solids with liquids, slow rate and stay seated upright ninety degrees during meals. The ST note after treatment dated 11/11/13 identified that the nursing staff were updated on the diet change to mechanical soft solids. The nurse's notes dated 11/13/13 identified Resident #1 experienced a coughing episode at breakfast with a subsequent increase in temperature and upon respiratory assessment crackles were identified bilaterally in the upper lobes. At that time it was noted that the downgraded diet recommended by the speech therapist had not been implemented for 11/11/13, 11/12/13 and 11/13/14. The nurse's note dated 11/14/13 identified that Resident #1 continued to be congested, had an elevated temperature of 102.5 degrees and a question of aspiration pneumonia was noted. Subsequent to physician notification Resident #1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED].#1 was observed to have an elevated temperature of 102.5 degrees despite a dose of Tylenol, a heart rate of 128, decreased oxygen saturation, very lethargic and fatigued, the resident was thought to have aspirated on 11/13/13 and questioned aspiration and urosepsis. Review of the current policy identifies that if speech therapy makes any diet changes, the therapist will notify the charge nurse and if the charge nurse is not available, will notify the APRN and/or physician and ask them to sign the order as soon as possible and dietary will be called. Interview with the Director of Nurses (DON) on 1/13/14 at 10:30 AM identified that there had been a change in the process of ordering a diet change therefore the speech therapist's recommendation to downgrade Resident #1's diet was not processed. Interview with the Speech Therapist on 1/13/13 at 11:10 AM identified that Resident #1 had complained of a feeling of fullness, difficulty swallowing and had experienced frequent coughing episodes which had precipitated the diet change. The speech therapist had entered the new diet in the computer system (Sigmacare) however the order remained pending approval and was not confirmed by the physician and/or APRN. Interview with the APRN on 1/13/14 at 11:30 AM identified that Resident #1 was a high risk of aspiration secondary to the [DIAGNOSES REDACTED].

Based on clinical record reviews, review of facility documentation and interviews for one of two sampled residents (Resident #3) who received a diuretic medication, the facility failed to ensure that a medication was administered in accordance with the physician's order for one of two sampled residents (Resident #2) who were newly admitted and/or a re-admission, the facility failed to ensure that a discrepancy with a medication was reviewed with the physician prior to transcribing and implementing the medication. The findings include: 1. Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #3 had poor decision making cognitive skills, was totally dependent on staff for activities of daily living and received a diuretic medication daily. A physician's order dated 9/6/13 directed [MEDICATION NAME] 40 milligrams (mg) daily, oxygen therapy at two liters as needed for oxygen saturation less than 90 or shortness of breath and [MEDICATION NAME] 0.5 mg-3 mg/3 milliliters Nebulizer solution every four hours as needed. The nurse's note dated 10/25/13 identified that Resident #3 was noted to cough during the breakfast meal and audible wheezes were heard. A physician's order dated 10/25/13 directed [MEDICATION NAME] treatments twice a day. Review of the nurse's notes from 10/25/13 through 10/28/13 identified diminished lung sounds bilaterally, audible wheezes were heard, Resident #3's oxygen saturation levels ranged from 92-95% and facial swelling was observed. On 10/28/13 Resident #3's blood pressure was 226/97 (normal range 110-120's/60-70's), pulse was 86, respirations 24 and oxygen saturation 94% on room air. Subsequent to physician notification [MEDICATION NAME] 20 mg Intramuscular (IM) was administered immediately, an antibiotic and [MEDICATION NAME] were ordered and oxygen at two liters was applied. From 10/28/13, the 3-11 PM shift through 10/29/13 the 7-3 PM shift, crackles were noted bilaterally at the bases and an audible wheeze. The physician's progress note dated 10/28/13 identified that Resident #3 had been seen by the attending physician for the wheezes (on 10/22/13 when seen the lungs were clear and the resident's medical status was stable). The 10/29/13 note indicated that Resident #3 was seen by the APRN in follow up. The note identified decompensated [MEDICAL CONDITION] off [MEDICATION NAME], resident was given [MEDICATION NAME] 20 mg intramuscular yesterday, still showing signs of volume overload, possible developing pleural effusions. The plan indicated a chest x-ray, blood work, an additional dose of [MEDICATION NAME] 20 mg IM depending on blood work results, daily weights and intake and output monitoring. Review of the Medication Administration Record (MAR) identified that the following were administered: on 10/28/13 [MEDICATION NAME] 20 mg IM times one dose and [MEDICATION NAME] 40 mg daily times five days, on 10/29/13 [MEDICATION NAME] 30 mg IM times one dose and on 10/30/13 [MEDICATION NAME] 40 mg daily was initiated. The Reportable Event Form dated 10/29/13 identified [MEDICATION NAME] 40 mg was scheduled daily at 9:00 AM, the order was discontinued on the MAR. The facility's investigation identified that there was no physician's order to discontinue the [MEDICATION NAME] 40 mg on 10/10/10 therefore Resident #3 did not receive the [MEDICATION NAME] 40 mg for fourteen days. Interview and review of the incident with the Director of Nurses (DON) on 1/13/14 at 12:45 PM identified that there was a glitch in the Sigmacare program. The DON indicated that for Resident #3 both the active and history orders were showing up on the screen, normally to access the history another program is opened. The DON identified that Resident #3 was the only resident in the facility that this happened with and the staff did not question why the screen was different. The DON indicated that LPN #2 thought the [MEDICATION NAME] was a duplicate order so she discontinued one of the [MEDICATION NAME] orders. The DON explained that the 11-7 AM Nursing Supervisor prints out a physician order detail report nightly and reconciles the new and/or changed orders with the paper MAR and treatment records. On 10/10/13 when the Nursing Supervisor, Registered Nurse (RN) #3, saw the discontinued order on the twenty-four hour detail report she discontinued the order on the MAR. 2. Resident #2's [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] identified that Resident #2 was alert and oriented to person, place and time. The hospital discharge instructions dated 11/21/13 directed [MEDICATION NAME] 50 milligrams (mg) daily. A physician's admission order dated 11/21/13 directed [MEDICATION NAME] 50 mg tablet one daily for hypertension. The nurse's note dated 11/25/13, 7-3 PM shift, identified that Resident #2 had an episode of [MEDICAL CONDITION] with flutter in the morning. The resident's heart rate was up to 145 beats per minute and the resident was seen by the cardiac nurse and the Advanced Practice Registered Nurse (APRN). The physician's progress note dated 11/25/13 identified that Resident #2 had rapid [MEDICAL CONDITION] this morning with symptoms, the tele-strip indicated [MEDICAL CONDITION] with a rate in the 140's and the systolic blood pressure was 92. The note indicated that the [MEDICATION NAME] was discontinued until the blood pressure was stable, a twelve lead electrocardiogram (EKG) was ordered, and the [MEDICATION NAME] was changed from [MEDICATION NAME] to [MEDICATION NAME]. A physician's order dated 11/25/13 directed to discontinue the [MEDICATION NAME] and [MEDICATION NAME] and start [MEDICATION NAME] Extended Release 50 mg daily. Review of the EKG dated 11/25/13 at 7:10 PM identified Resident #2 was in normal sinus rhythm with a heart rate of 81 beats per minute. Review of the clinical record from 11/25/13 through discharge on 12/4/13 identified that Resident #2 did not experience any further episodes of rapid [MEDICAL CONDITION] with flutter. Interview with APRN #1 on 1/13/14 at 10:45 AM identified that [MEDICATION NAME] was a short acting form of [MEDICATION NAME] and was usually administered twice a day, where as [MEDICATION NAME] Extended Release was a long acting and taken daily. Interview and review of the incident with the Director of Nurses (DON) on 1/13/14 at 12:45 PM identified that when Licensed Practice Nurse (LPN) #1 and the Nursing Supervisor Registered Nurse (RN) #2 were interviewed both had conflicting statements to the event and the facility failed to identify that the medication discrepancy had been reviewed with the physician. In a written statement sent 1/13/14 at 1:09 PM the charge nurse LPN #1 indicated that there were two different options/medications listed and she asked the Nursing Supervisor Registered Nurse (RN) #2 which was the correct medication. LPN #1 identified that RN #2 directed her to enter the [MEDICATION NAME]. A written statement by RN #2 dated 1/14/14 identified that she was unfamiliar with the interchange between the types of [MEDICATION NAME] medications and she did not utilize the drug reference book prior to inputting the medication order into the Sigmacare system.

Based on clinical record review, observations, staff interview, and resident interview for one of three sampled residents, (Resident #259), reviewed for misappropriation of resident belongings, the facility failed to ensure the resident's items were secure. The findings include: Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident with intact cognition. Accident/incident report documentation dated 8/25/12 at 11:45AM identified the resident's ATM card and $10.00 were missing from his/her wallet when he/she was attempting to balance his/her checking account, and the resident was very upset related to the situation. Additionally, the police were notified and an investigation initiated. Review of a banking document, reviewed by the resident, identified four transactions were made on the account fraudulently from 8/22/12 through 8/24/12 for $5.52-$36.14. Review of facility documentation dated 8/28/12 identified that during the police investigation, NA #3 was observed on video camera at one of the above establishments, using the resident's ATM card to make a purchace. Interview with the DNS on 8/29/12 at 10:00AM identified that they have suspended NA #2 and have been advised by the police that the police will follow up with the interview of NA#2 as part of their investigation. In an interview with Resident #259 on 8/27/12 at 1:00 PM, he/she stated that his/her ATM card and $10.00 were stolen while he/she was a resident at the facility. Additionally, the resident identified that the police are investigating the robbery.