Every finding on record at Apple Rehab Cromwell

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from inappropriate physical contact. The findings include: Resident #1 was admitted with diagnoses that included dementia, anxiety, and depression. Record review identified Resident #1 had a court appointed Conservator. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had Brief Interview for Mental Status (BIMS) of eight (8), indicated moderate cognitive impairment, required needed moderate assistance for transfers and used a wheelchair. The resident care plan (RCP) dated 3/25/2026 identified impaired memory, wandering behaviors, and a history of inappropriately touching a female resident and touching females on their arms. Interventions directed no contact boundaries, redirect if near an exit, approach in a calm manner, notify physician of changes, and protect other residents if unable. 2. Resident #2 was admitted with diagnoses that included dementia, traumatic brain injury, spastic hemiplegia (complete or severe loss of function on one entire side of the body), anxiety and depression. Record review identified Resident #2 had an identified Power of Attorney listed as the responsible party. The quarterly MDS assessment dated [DATE] identified Resident #2 had Brief Interview for Mental Status (BIMS) of six (6), indicated severe cognitive impairment, required substantial assistance for transfers, and used a wheelchair. The RCP dated 5/9/2026 identified poor memory/recall, fluctuations in mood, had wandering behaviors into other resident's rooms, and was touched inappropriately by another resident (Resident #1). Interventions directed to approach slowly and from the front, use short simple sentences, report changes in mental status, social work follow up and support. Facility Reportable Event dated 6/25/2026 at 9:30 AM identified NA #1 observed Resident #1 with his/her hand on Resident #2's genital area attempting to get into the top of Resident #2's pants; NA #1 reported Resident #1 had his/her hand down Resident #2's pants but over the brief. Staff separated the residents, a body check was completed for Resident #2 with no concerns noted, and Resident #1 was moved to another unit. Additional RE information dated 6/25/2026 identified Resident #1 had a prior history of inappropriately touching other residents. Both residents were independent with wheelchair mobility and had last been seen in separate locations in the hallway. Further, the residents did not have a prior relationship/friendship, and Resident #2 did not recall the incident. The facility RE summary dated 6/30/2026 identified the facility investigation indicated Resident # 1's hand was on or near Resident #2's lower abdominal/waist area and although the RE indicated Resident #2 did not recall the incident, the summary indicated Resident #2 denied inappropriate touch. Resident #1 denied the incident occurred. Both resident care plans were updated to direct no contact and Resident #1 was followed by psychiatric services. Interview and record review with LPN #1 on 7/20/2026 at 10:54 AM identified NA #1 called for help on 6/25/2026 around 9:30 AM, and reported Resident #1 had a hand on Resident #2's waist. LPN #1 responded and observed both residents to be fully clothed and clothing was intact. Resident #2 appeared upset, she escorted Resident #2 back to his/her room and when she questioned Resident #2, Resident #2 could not recall the incident. LPN #1 stated Resident #2 frequently wandered the hallway and Resident #1 usually stayed to him/herself, usually in his/her room. Further, LPN #1 stated she was aware of a prior incident between Resident #1 and Resident #2. On 3/25/2026 she had heard Resident #2 say stop it, stop it and LPN #1 pulled Resident #1's wheelchair away from Resident #2. LPN #1 stated at that time, Resident #2 alleged Resident #1 had touched his/her breasts, and when she had moved Resident #1's wheelchair she did not observe any physical contact between the residents. Both care plans were updated to direct no contact between the residents. Since 3/25/2026, she had observed Resident #1 see Resident #2 exit his/her room and Resident #1 would attempt to approach Resident #2. Staff would redirect as able, but LPN #1 stated several times Resident #1 had made physical contact by touching Resident #2's hand. Interview with NA #1 on 7/20/2026 at 2:30 PM identified she was assigned both Resident #1 and Resident #2 on 6/25/2026. She was in the hallway at 9:30 AM when she observed Resident #2 nervously rocking back in his/her wheelchair in the hallway. NA #1 explained when Resident #1, was upset, he/she would rock back and forth in his/her wheelchair. NA #1 described she observed Resident #1 and Resident #2 sitting next to each other, both facing forward, and Resident #1 had his/her hand on Resident #2's wheelchair arm rest and the other hand was between Resident #2's thighs underneath the pants, but over the brief. As Resident #1 began to move his/her hand upwards toward Resident #2's waist attempting to get under the brief she was able to separate the residents. NA #1 stated both residents could self-propel in the wheelchair, Resident #2 was slow to self-propel and Resident #1 was faster because he/she used both his/her hands and feet. NA #1 stated she was aware Resident #1 had a prior history of inappropriately touching other residents, and had a prior incident with Resident #2. Interview with the DON on 7/21/2026 at 1:00 PM identified she was aware Resident #1 had a history of inappropriately touching other residents, and specifically a history of touching Resident #2 inappropriately, and Resident #2 had stated he/she did not want to be touched by Resident #1. The DON stated she did not want Resident #1 to be able to touch Resident #2. The DON concluded NA #1 had observed Resident #1's hand on Resident #2's stomach attempting to get into the top of Resident #2's brief on 6/25/2026, both residents were fully clothed, and she stated staff responded appropriately and both residents could not recall the incident. The incident on 6/25/2026 was inappropriate, should not have occurred, and Resident #1 was moved to another nursing unit/wing. The DON stated on the new unit, Resident #1 had an incident with an alert and oriented resident (Resident #3) when Resident #1 entered Resident #3's room three (3) times and touched his/her hand (unsolicited) and Resident #3 called for staff to remove Resident #1 from the room. Resident #1 was then placed on one-to-one (1:1) observation and subsequently the observation frequency was changed to every 30 minutes with no additional incidents. The facility Abuse policy directed in part, abuse or mistreatment of any kind toward a resident is strictly prohibited. Sexual abuse is defined as any form of sexual harassment, coercion or assault, including unwanted touching between residents. The facility's Resident Rights policy directed in part residents have the right to be free from verbal, sexual, physical, or mental abuse.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include that an ordered medication was not administered for five (5) days and why it was not administered, and that attempts were made to clarify a physician order when requested by the pharmacy prior to filling a prescription. The findings include: Resident #1 was admitted with diagnoses that included dementia, anxiety, and depression. Record review identified Resident #1 had a court appointed Conservator. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had Brief Interview for Mental Status (BIMS) of eight (8), indicated moderate cognitive impairment, required needed moderate assistance for transfers and used a wheelchair. The resident care plan (RCP) dated 3/25/2026 identified impaired memory, wandering behaviors, and a history of inappropriately touching a female resident and touching females on their arms. Interventions directed no contact boundaries, redirect if near an exit, approach in a calm manner, notify physician of changes, and protect other residents if unable. Record review identified staff observed Resident #1 inappropriately touching a resident of the opposite sex on the following dates:3/28/2026 touching the upper chest area.4/9/2026 attempting to pull a resident into a room.4/10/2026 observed in the hallway with a resident and redirected.4/12/2026 observed touching a resident on the arms.4/20/2026 in the hallway close to a resident, redirected.4/21/2026 in the hallway close to a resident, redirected.4/22/2026 touching a resident on the arms.5/29/2026 rubbing a resident's bilateral thighs. Psychiatric APRN note dated 6/5/2026 (late entry) identified Resident #1 was seen for persistent inappropriate sexual behaviors. Behaviors reviewed included lack of motivation, impulsiveness, intrusiveness, attention-seeking, isolating and inappropriate sexual behaviors. Associated symptoms included ongoing intermittent sexual behavior becoming difficult to redirect. Recommendations included medical follow up to rule out any medical etiology. Receiving Citalopram SE (Celexa, used to treat depression) 20 mg for anxiety/agitation continued. Will initiate a gradual drug reduction today (of Celexa) and trail Medroxyprogesterone (drug that lowers testosterone) for compulsions and to continue to monitor. A physician order dated 6/4/2026 directed Medroxyprogesterone Acetate (Medroxyprogesterone; a hormonal treatment used to reduce sexually inappropriate behavior) 100 milligrams (mg) daily for compulsions. Record review identified that the Medroxyprogesterone was not administered as ordered; the doses scheduled for 9 AM were documented with a code 12 on the MAR on 6/4, 6/5, 6/6, 6/7 and 6/8/2026. Review of the MAR identified code 12 identified had no identified definition. Record review failed to identify a nursing note for 6/4, 6/5, 6/6, 6/7 and 6/8/2026 that identified if the Medroxyprogesterone was administered as order, what the #12 code on the MAR referred to, or that the psychiatric APRN was contacted. Additional record review identified a physician order dated 6/9/2026 directed to discontinue the Medroxyprogesterone, and a new order was obtained on 6/9/2026 that directed to administer Medroxyprogesterone 10 mg two (2) tablets daily. Record review and interview with LPN #1 on 7/20/2026 at 10:50 AM identified Resident #1's Medication Administration Record (MAR) directed the Medroxyprogesterone 100 mg was ordered on 6/4/2026 and scheduled to be administered daily at 9 AM. The Medroxyprogesterone 100 mg doses scheduled for 6/4 to 6/8/2026 (5 doses) were not administered; LPN #1 stated the code #12 indicated the medication was not administered. Interview failed to identify why the medication was not administered as ordered, why there were no nursing notes that identified the medication was not administered, and LPN #1 stated the medication was not available to administer. Interview with Pharmacy Consultant #1 on 7/20/2026 at 1:12 PM identified when the pharmacy received the order for the Medroxyprogesterone 100 mg, the pharmacy had asked the facility staff for a clarification of the dosage prior to filling the order because 100 mg was an unusual dosage. Pharmacy Consultant #1 stated the pharmacy contacted the facility supervisor's line daily for clarification without any response received. The order was discontinued on 6/9/2026 when a new order was received for Medroxyprogesterone 10 mg two (2) tablets daily (the original order was for 100 mg). Record review and interview with the DON on 7/21/2026 at 1:08 PM identified although Medroxyprogesterone 100 mg was ordered on 6/4/2026, the MAR indicated it was not administered to Resident #1. The DON stated the pharmacy had contacted the facility to request a clarification of the dosage when filling the order on 6/4/2026, and she contacted psychiatric APRN #1 on 6/4/2026 who indicated she would complete additional research and contact the facility. The DON stated additional attempts were made by the facility to contact psychiatric APRN #1 daily from 6/5/2026 to 6/7/2026 without response from the prescriber. On 6/9/2026 psychiatric APRN #1 provided clarification of the Medroxyprogesterone and ordered to change the dosage from 100 mg to 10 mg, two (2) tablets daily. Although the DON stated it took a while to do the research, interview failed to identify why the record did not clearly identify the Medroxyprogesterone 100 mg was not administered as ordered, and did not include nursing notes to identify the facility attempted to contact the prescribing APRN. Interview failed to identify why the information was not included in the clinical record. Interview with the Medical Director on 7/21/2026 at 12:26 PM identified if the psychiatric APRN was not available, the nursing staff should contact the overseeing psychiatrist or covering psychiatric provider to obtain the necessary information so the medication was not unnecessarily delayed. The Medical Director stated although she was aware the Medroxyprogesterone 100 mg was not administered as ordered by psychiatric APRN #1, she was unable to identify whey she became aware; she did not know why the this was not done to address the 5-day gap from initial order until clarification was obtained from the ordering APRN on 6/8/2026. The facility Medication Administration Policy directed in part, that if the medication was not available attempt to obtain the medication promptly. A documentation policy was not provided for surveyor review during the survey.

Based on record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for wounds, the facility failed to ensure the State Agency was notified timely after the facility was notified of a threat of harm to a resident. The findings include: Resident #1 was admitted with diagnoses that included diabetes, autism, and acquired absence of right toes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), indicative of severe cognitive impairment, and was independent for transfers and mobility. A resident care plan (RCP) dated 1/28/2026 identified a risk for skin issues due to picking and scratching and can be verbally and/or physically aggressive. Interventions directed family members (Person #1) liked to keep door closed (when visiting) to decrease distractions and noise. Record review identified Person #1, Person #2 and Person #4 were co-conservators for Resident #1. A nursing note dated 4/10/2026 at 2:12 PM, written by the DON, identified Person #1 was no longer allowed in the building. A body audit was done without any changes noted to the skin. Resident #1 appeared relaxed and following simple commands. The door to the room was open at this time. Medical Director also saw Resident #1 on 4/10/2026. Staff were notified Person #1 was not allowed on the premises. A physician progress note, written by the Medical Director dated 5/8/2026 (29 days after the email was received) at 7:35 PM identified she was informed Person #4 (a co- conservator) requested to bring Resident #1 to Person's #1 home (for a leave of absence). The note indicated the DON and the Medical Director were concerned for Resident #1's safety, given Person #1's threat to kill Resident #1 and him/herself several weeks ago, warranting police intervention. The external State protective agency and corporate legal were updated. The Medical Director made the decision to deny Person #4's request, based on a priority for Resident #1's safety. A virtual visit was provided with Person #4, and Person #4 expressed understanding. A facility email addressed to SW #1 and the Administrator sent from the external State protective agency case worker (Person #3), dated 4/10/2026 at 11:14 AM, identified that Person #2/co-conservator had concerns that if Person #1/co-conservator took Resident #1 out on a leave of absence (LOA), the resident would not return. The case worker identified the abuse/neglect division of her agency had recommended no unsupervised contact between Person #1 and Resident #1. A facility email addressed to the Administrator and SW #1 from the case worker dated 4/10/2026 at 11:31 AM identified Person #2 was worried about a murder/suicide with Person #1 and Resident #1. The case worker indicated she was working to have Person #1 removed from the co-conservator. A facility email by the DON sent by the Administrator to the case worker dated 4/10/2025 at 1:51 PM identified APRN #2 (facility psychiatric APRN) had spoken to the case worker and Person #2. APRN #2 had reported to the DON that Person #1 had the means and a plan (for the murder/suicide). The facility had contacted the local police who had advised that Person #1 was not allowed on the facility property anymore. A police case report dated 4/10/2026 identified at approximately 1:01 PM, they were dispatched to Resident #1's facility for a report of a suspicious incident. Upon arrival, the officer was met by the DON, the Administrator and Person #1. Person #1 was about to leave the facility and the officer requested he/she to standby. The report indicated that Person #2 had reported that Person #1 had verbalized wanting to end Resident #1's misery by injecting Resident #1 with Insulin the next time Person #1 visited the facility. After the facility was notified, Person #1 arrived at the facility. The officer questioned Person #1 why the facility would be concerned about his/her visitation. Person #1 stated he/she did not want to explain, did not want to speak to the officer and wanted to exercise his/her fifth amendment rights, and was uncooperative. The Officer informed Person #1 that he/she was trespassed from the facility and surrounding premises, would be arrested if he/she returned and requested Person #1 to leave and Person #1 left the premises without incident. Review of the State Agency FLIS reportable event on-line website failed to identify the State Agency was notified of the alleged threat when they became aware on 4/10/2026. Review failed to identify the State Agency had been notified on or after 4/10/2026. Interview with the DON on 5/11/2026 at 11:30 AM identified she was notified on 4/10/2026 via an email from the case worker that Person #2/co-conservator had expressed concern regarding Person #1 may harm, commit a murder/suicide with Resident #1. Person #1 had requested to take Resident #1 on a LOA to visit his/her father and there was a possibility that Person #1 would attempt to harm Resident #1 and then kill him/herself. The facility psychiatric APRN (APRN #2) followed up regarding the concern and identified Person #1 was stockpiling Insulin for an alleged planned murder/suicide. APRN #2 indicated Person #1 had the means and a credible plan, and the DON contacted the police. The DON stated she did not notify the State Agency because it was an unsubstantiated threat made by a third party. Although the DON stated an allegation of abuse should be reported the State Agency, and APRN #2 had advised the threat was credible, and local police were involved, the DON stated she investigated the allegation and she should have notified the State Agency first and then completed the investigation. Interview with APRN #2 on 5/11/2026 at 12:12 PM identified the facility was notified of a possible murder/suicide plan. APRN #2 contacted the case worker and the case worker indicated that about two (2) weeks prior to the 4/10/2026 email, Person #2 had notified the case worker that Person #1 had access to insulin and expressed concern about Resident #1's safety when on an LOA for a possible murder/suicide, and Person #2 requested Resident #1 not be allowed to be alone with Person #1. APRN #2 stated Person #1 had access to Insulin, and had a stockpile of Insulin. APRN #2 stated she also spoke with Person #2 who made the allegation to the case worker, and Person #2 indicated Person #1 had access to Insulin. APRN #2 identified she had a conference call with the DON to discuss the issue on 4/10/2026 and the DON agreed that there was a concern for potential physical harm to Resident #1 and the DON was going to contact the police. Subsequent to the surveyor's inquiry, the facility submitted a reportable event (RE) form to the State Agency on 5/11/2026 (32 days after the email with the threat was received by the facility) regarding the threat received on 4/10/2026. The facility Abuse Policy directed in part, that Abuse was defined as the willful infliction of injury or punishment resulting in physical harm. The Policy further directed, to submit an online report to DPH (State Agency) within two (2) hours of notification.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for wounds, the facility failed to ensure a thorough investigation was completed for an allegation of abuse as per facility policy. The findings include: Resident #1 was admitted with diagnoses that included diabetes, autism, and acquired absence of right toes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), indicative of severe cognitive impairment, and was independent for transfers and mobility. A resident care plan (RCP) dated 1/28/2026 identified a risk for skin issues due to picking and scratching and can be verbally and/or physically aggressive. Interventions directed family members (Person #1) liked to keep door closed (when visiting) to decrease distractions and noise. Record review identified Person #1, Person #2 and Person #4 were co-conservators for Resident #1. A nursing note dated 4/10/2026 at 2:12 PM, written by the DON, identified Person #1 was no longer allowed in the building. A body audit was done without any changes noted to the skin. Resident #1 appeared relaxed and following simple commands. The door to the room was open at this time. Medical Director also saw Resident #1 on 4/10/2026. Staff were notified Person #1 was not allowed on the premises. A physician progress note, written by the Medical Director dated 5/8/2026 (29 days after the email was received) at 7:35 PM identified she was informed Person #4 (a co- conservator) requested to bring Resident #1 to Person's #1 home (for a leave of absence). The note indicated the DON and the Medical Director were concerned for Resident #1's safety, given Person #1's threat to kill Resident #1 and him/herself several weeks ago, warranting police intervention. The external State protective agency and corporate legal were updated. The Medical Director made the decision to deny Person #4's request, based on a priority for Resident #1's safety. A virtual visit was provided with Person #4, and Person #4 expressed understanding. A facility email addressed to SW #1 and the Administrator sent from the external State protective agency case worker (Person #3), dated 4/10/2026 at 11:14 AM, identified that Person #2/co-conservator had concerns that if Person #1/co-conservator took Resident #1 out on a leave of absence (LOA), the resident would not return. The case worker identified the abuse/neglect division of her agency had recommended no unsupervised contact between Person #1 and Resident #1. A facility email addressed to the Administrator and SW #1 from the case worker dated 4/10/2026 at 11:31 AM identified Person #2 was worried about a murder/suicide with Person #1 and Resident #1. The case worker indicated she was working to have Person #1 removed from the co-conservator. A facility email by the DON sent by the Administrator to the case worker dated 4/10/2025 at 1:51 PM identified APRN #2 (facility psychiatric APRN) had spoken to the case worker and Person #2. APRN #2 had reported to the DON that Person #1 had the means and a plan (for the murder/suicide). The facility had contacted the local police who had advised that Person #1 was not allowed on the facility property anymore. Interview with APRN #2 on 5/11/2026 at 12:12 PM identified the facility was notified of a possible murder/suicide plan. APRN #2 contacted the case worker and the case worker indicated that about two (2) weeks prior to the 4/10/2026 email, Person #2 had notified the case worker that Person #1 had access to insulin and expressed concern about Resident #1's safety when on an LOA for a possible murder/suicide, and Person #2 requested Resident #1 not be allowed to be alone with Person #1. APRN #2 stated Person #1 had access to Insulin, and had a stockpile of Insulin. APRN #2 stated she also spoke with Person #2 who made the allegation to the case worker, and Person #2 indicated Person #1 had access to Insulin. APRN #2 identified she had a conference call with the DON to discuss the issue on 4/10/2026 and the DON agreed that there was a concern for potential physical harm to Resident #1 and the DON was going to contact the police. Interview with the DON on 5/11/2026 (32 days after the threat was made) at 11:30 AM identified the facility did not have a local police report regarding the allegation made on 4/10/2026. Interview identified although the DON was aware of the allegation of a threat of harm to Resident #1, the DON indicated she did not complete an incident report, or have any documentation of an investigation completed. The DON stated she had the email dated 4/10/2026 and had discussions with the Administrator, SW and APRN #2, but did not have any additional staff interviews or investigation completed. Additional interview with the DON on 5/13/2026 at 9:00 AM identified that on 4/10/2026, the corporate office had told her to obtain the police report, but she had forgotten to do so. Subsequent to surveyor request, the facility obtained the police report. A police case report dated 4/10/2026 identified at approximately 1:01 PM, they were dispatched to Resident #1's facility for a report of a suspicious incident. Upon arrival, the officer was met by the DON, the Administrator and Person #1. Person #1 was about to leave the facility and the officer requested he/she to standby. The report indicated that Person #2 had reported that Person #1 had verbalized wanting to end Resident #1's misery by injecting Resident #1 with Insulin the next time Person #1 visited the facility. After the facility was notified, Person #1 arrived at the facility. The officer questioned Person #1 why the facility would be concerned about his/her visitation. Person #1 stated he/she did not want to explain, did not want to speak to the officer and wanted to exercise his/her fifth amendment rights, and was uncooperative. The Officer informed Person #1 that he/she was trespassed from the facility and surrounding premises, would be arrested if he/she returned and requested Person #1 to leave and Person #1 left the premises without incident. Review of the State Agency FLIS reportable event on-line website failed to identify a reportable event was submitted to the State Agency. Interview with the DON on 5/11/2026 at 11:30 AM failed to identify the facility completed an investigation, to include staff interviews with signed staff statements. Additionally, the DON could not produce a facility accident and incident report, any involved party statements besides the email chain or any other documented information in regard to the allegation in facility documentation or the resident's medical record. Review of facility Abuse Policy, directed in part, an allegation of abuse by a staff member, visitor, family member or resident must be reported immediately to a facility supervisor who reports it to the Administrator and DON. Further, the Administrator or DON initiate an investigation.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for wounds, the facility failed to ensure the clinical record was complete and accurate to include documentation of a threat of harm to a resident. The findings include: Resident #1 was admitted with diagnoses that included diabetes, autism, and acquired absence of right toes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), indicative of severe cognitive impairment, and was independent for transfers and mobility. A resident care plan (RCP) dated 1/28/2026 identified a risk for skin issues due to picking and scratching and can be verbally and/or physically aggressive. Interventions directed family members (Person #1) liked to keep door closed (when visiting) to decrease distractions and noise. Record review identified Person #1, Person #2 and Person #4 were co-conservators for Resident #1. A nursing note dated 4/10/2026 at 2:12 PM, written by the DON, identified Person #1 was no longer allowed in the building. A body audit was done without any changes noted to the skin. Resident #1 appeared relaxed and following simple commands. The door to the room was open at this time. Medical Director also saw Resident #1 on 4/10/2026. Staff were notified Person #1 was not allowed on the premises. Additional record review failed to identify why Person #1 was not allowed to visit. A physician progress note, written by the Medical Director dated 5/8/2026 (29 days after the email was received) at 7:35 PM identified she was informed Person #4 (a co- conservator) requested to bring Resident #1 to Person's #1 home (for a leave of absence). The note indicated the DON and the Medical Director were concerned for Resident #1's safety, given Person #1's threat to kill Resident #1 and him/herself several weeks ago, warranting police intervention. The external State protective agency and corporate legal were updated. The Medical Director made the decision to deny Person #4's request, based on a priority for Resident #1's safety. A virtual visit was provided with Person #4, and Person #4 expressed understanding. A facility email addressed to SW #1 and the Administrator sent from the external State protective agency case worker (Person #3), dated 4/10/2026 at 11:14 AM, identified that Person #2/co-conservator had concerns that if Person #1/co-conservator took Resident #1 out on a leave of absence (LOA), the resident would not return. The case worker identified the abuse/neglect division of her agency had recommended no unsupervised contact between Person #1 and Resident #1. A facility email addressed to the Administrator and SW #1 from the case worker dated 4/10/2026 at 11:31 AM identified Person #2 was worried about a murder/suicide with Person #1 and Resident #1. The case worker indicated she was working to have Person #1 removed from the co-conservator. A facility email by the DON sent by the Administrator to the case worker dated 4/10/2025 at 1:51 PM identified APRN #2 (facility psychiatric APRN) had spoken to the case worker and Person #2. APRN #2 had reported to the DON that Person #1 had the means and a plan (for the murder/suicide). The facility had contacted the local police who had advised that Person #1 was not allowed on the facility property anymore. A police case report dated 4/10/2026 identified at approximately 1:01 PM, they were dispatched to Resident #1's facility for a report of a suspicious incident. Upon arrival, the officer was met by the DON, the Administrator and Person #1. Person #1 was about to leave the facility and the officer requested he/she to standby. The report indicated that Person #2 had reported that Person #1 had verbalized wanting to end Resident #1's misery by injecting Resident #1 with Insulin the next time Person #1 visited the facility. After the facility was notified, Person #1 arrived at the facility. The officer questioned Person #1 why the facility would be concerned about his/her visitation. Person #1 stated he/she did not want to explain, did not want to speak to the officer and wanted to exercise his/her fifth amendment rights, and was uncooperative. The Officer informed Person #1 that he/she was trespassed from the facility and surrounding premises, would be arrested if he/she returned and requested Person #1 to leave and Person #1 left the premises without incident. Record review failed to identify any documentation on 4/10/2026 of the circumstances surrounding the prohibition of Person #1's to be allowed in the facility. Additional review failed to identify any documentation regarding the threat by Person #1 to kill Resident #1 and him/herself. Interview with APRN #2 on 5/11/2026 at 12:12 PM identified the facility was notified of a possible murder/suicide plan. APRN #2 contacted the case worker and the case worker indicated that about two (2) weeks prior to the 4/10/2026 email, Person #2 had notified the case worker that Person #1 had access to insulin and expressed concern about Resident #1's safety when on an LOA for a possible murder/suicide, and Person #2 requested Resident #1 not be allowed to be alone with Person #1. APRN #2 stated Person #1 had access to Insulin, and had a stockpile of Insulin. APRN #2 stated she also spoke with Person #2 who made the allegation to the case worker, and Person #2 indicated Person #1 had access to Insulin. APRN #2 identified she had a conference call with the DON to discuss the issue on 4/10/2026 and the DON agreed that there was a concern for potential physical harm to Resident #1 and the DON was going to contact the police. Interview with the DON on 5/11/2026 at 11:30 AM identified she was unable to provide documentation in the medical record regarding the allegation of a threat of harm to Resident #1 made on 4/10/2026. Interview identified the record should have included documentation of the threat and why Person #1 was not allowed to visit. Interview failed to identify why the record did not include the documentation. The facility Abuse Policy directed in part, an allegation of abuse by a staff member, visitor, family member or resident must be reported immediately to a facility supervisor who then reports it to the DON and Administrator. The Policy further directed, nursing staff to document a description of the incident in the resident's record. The facility policy Nursing Documentation directed in part that documentation should be completed as soon as possible after a significant event occurs ideally on the same shift.

Based on observations, interviews, review of clinical records, facility documentation, and facility policy for 3 of 5 sampled residents (Resident #11, #48, and #71) reviewed for infection control practices, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn, and during a review of the water management plan, failed to follow consultant recommendations following positive Legionella testing. The findings include: 1. Resident #11's diagnosis included moderate dementia with mood disturbance, weakness, and pressure ulcer of sacral region stage 3. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment, and required extensive assistance with bed mobility, transferring to or from bed, chair, wheelchair, eating, toileting and personal hygiene. Additionally, Resident #11 was actively being treated for a stage 3 pressure ulcer to his/her sacral region (base of the spine above the tailbone). The Resident Care Plan dated 10/25/25 identified Resident #11 had a re-opened stage III pressure ulcer to the coccyx area. Interventions included placing him/her on Enhanced Barrier Precautions (EBP) identified by an orange sticker next to his/her name on the nameplate and ensuring appropriate Personal Protective Equipment (PPE) was readily available/accessible for staff prior to entering the room. Observation and interview on 12/2/25 at 12:00 PM of Resident #11's room identified an orange sticker next to his/her name on the nameplate outside of his/her room. Nurse Aid (NA) #2 was observed to enter Resident #11's room without the benefit of placing on appropriate PPE (a gown) and then provided incontinence care (direct care) to the resident. NA #2 identified that Resident #11's pressure ulcer dressing was wet and requested Licensed Practical Nurse (LPN) #2 to replace the soiled dressing. LPN #2 was observed to enter Resident #11's room without the benefit of placing appropriate PPE (a gown) and then provided a dressing change (direct care) to the resident's open wound. After removing Resident #11's soiled dressing, she cleansed the wound, removed her soiled gloves, and without the benefit of washing or sanitizing her hands, placed on a new pair of clean gloves, and completed the resident's dressing. LPN #2 identified she was unaware of which resident in the room was on EBP stating that the resident closest to the door (resident's roommate) was on EBP for something in the urine, I believe. LPN #2 noted that it was her responsibility to inform staff which residents on the unit required EBP. Interview, observation, and review of facility policy with the Regional Nurse Registered Nurse (RN) #1 on 12/2/25 at 12:40 PM identified EBP was required for resident who were at a higher risk of infection. The facility used a two-step process to identify residents who required EBP which included placing the orange sticker outside the door of the resident's room on the nameplate next to their name and documenting the EBP requirement on the NA Care Kardex located at the nurse's station. Observation of Resident #11's nameplate identified an orange sticker and review of the Care Kardex directed EBP for him/her and not his/her roommate. The RN #1 indicated that staff should have definitely gowned and gloved when providing care for Resident #11. An interview on 12/2/25 at 2:05 PM with NA #2 identified that in order to specify which resident was on EBP, the facility would place the PPE cart on the right side of the doorway if the resident by the window required EBP, or if the resident closest to the door required EBP, the PPE cart would be placed on the left side of the doorway. Although there was a PPE cart outside of Resident #11's room, NA #2 was uncertain which resident was on EBP requiring the use of a gown and gloves during incontinent care. 2. Resident #48 had a history of anxiety, congestive heart failure and cancer. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #48 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment and was dependent on staff for transfers and required substantial/maximal assistance with bed mobility. Observation and interview with NA #4 on 12/2/25 at 8:50 AM identified a sign reading contact precautions (wear a gown and gloves to prevent the spread of infection) and a cart containing Personal Protective Equipment (PPE) outside of Resident #48's room. NA #4 was observed in the room without the benefit of wearing a gown or gloves with her hands resting on the edge of the bedside table. NA #4 was noted to pick up breakfast plates and a mug, exited the room, and placed the items onto a dish cart. NA #4 indicated that she was not required to wear PPE (gloves or a gown) as she had not provided any direct care to Resident #48. Interview and review of facility policy with the Infection Preventionist Registered Nurse (RN) #3 and Regional Nurse, RN #1 on 12/3/25 at 9:43 AM identified that residents who were on contact precautions required the use of a gown and gloves upon entering the room. RN #3 indicated that Resident #48 had a history of clostridium difficile (a contagious multidrug resistant organism) for which he/she had been symptomatic so contact precautions were implemented. Resident #48 had not yet been cleared to discontinue the contact precautions or the use of PPE. 3. Resident #71's diagnoses included Covid-19, metabolic encephalopathy, and weakness. The Nursing admission assessment dated [DATE] identified Resident #71 sometimes had difficulty recalling names and faces, required one person assistance with transfers and ambulation, and needed the head of his/her bed elevated to prevent shortness of breath when lying flat. A Physician order dated 11/25/25 directed Contact/Droplet precautions for Resident #71. The Resident Care Plan (RCP) dated 11/26/2025 identified Resident #71 had Covid-19 and was exhibiting signs and symptoms of the coronavirus including fever, tiredness, and cough and/or difficulty breathing. Interventions included encourage social distancing as able, maintain contact/droplet/airborne precautions per policy, and keep bedroom door closed as able to prevent spread of infection. An observation and interview on 12/2/25 at 12:46 PM with the Director of Maintenance identified signage posted on Resident #71's door which was visible prior to entry, indicating Droplet and Contact Precautions with directions that providers and staff must wear gloves, a gown, a mask, and eye protection for high contact activities. The Director of Maintenance was not observed to be wearing any PPE while kneeling next to Resident #71 and performing repairs on his/her bed, and the door to Resident #71's room was not closed. He stated that he had not worn PPE because Nurse Aide #1 told him he did not need to wear PPE if he was not performing direct patient care. Interview with NA #1 on 12/2/25 at 12:53 PM stated she did not tell the Maintenance Director he did not need to wear PPE in Resident #71's room. Interview with Registered Nurse (RN) #1 (Regional Clinical Director) on 12/2/25 at 12:58 PM identified that the Director of Maintenance had received education on using PPE when entering a room with precautions and should have placed on PPE prior to entering Resident #71's room. Review of the facility's Transmission Based Precautions policy identified in part that transmission-based precautions are utilized to minimize the risk of transmission of infectious agents within a healthcare setting. Appropriate signage will be placed outside of resident rooms indicating Transmission-based precautions. The Enhanced Barrier Precautions Policy dated 5/5/24 directed, in part, that the facility will implement enhanced barrier precautions to include any resident with a pressure injury, regardless of their MDRO (Multi-Drug-Resistant Organisms) colonization or infection status. Staff will perform hand hygiene and don (place) PPE before providing high-contact care to the resident and perform hand hygiene after providing high-contact care. 4. Interview, review of the Water Management Program, and review of facility documentation with the Administrator and Maintenance Director identified that prior to 9/17/25, the facility had tested positive for Legionella. The Maintenance Director indicated that per an email, the water consultant company recommended flushing of the Legionella positive areas 3 times per day. A review of the Water Management Plan Flushing Location (daily) Logs identified that the facility had been flushing 4 areas, the [NAME] Clean utility room sink, the [NAME] soiled utility pot sink, room [ROOM NUMBER], and room [ROOM NUMBER]. A notation on each sheet indicated to flush 3 times a day, 5 minutes each, hot then cold. A review of documented flushing for the [NAME] Clean Utility Room from 8/22/25 through 9/18/25, room [ROOM NUMBER] from 8/22/25 through 9/18/25, and room [ROOM NUMBER] from 8/6/25 to 9/18/25, failed to indicate flushing had taken place over weekends (Saturdays and Sundays), adding this documentation was located elsewhere. Review of the West Soiled Utility Room pot sink documentation of the Flushing Location (daily) Log from 5/29/25 through 7/18/25 (excluding weekends) identified following a 7/18/25 at 8:30 AM entry, a notation at the bottom of the page indicated No more/new water sample results with a second notation indicating no more. Review of a water consultant company email dated 7/18/25 identified official Certificate of Lab Results were included. The lab certificate identified that results were negative (not detected) in the areas tested (faucet and hopper) of the [NAME] Soiled Utility Room. The last recorded entry for this area was dated 7/18/25 at 8:30 AM and the 12:00 PM and had been dashed out (not conducted). Review of a water consultant company email dated 9/18/25 and Laboratory Certificate of Results, identified all areas tested within the facility were negative for Legionella. During a review of the Clean Utility Room and rooms [ROOM NUMBERS] Water Management Plan Flushing Location (daily) Logs there were no entries subsequent to 9/18/25. A notation no more had been written and a pink line drawn across the page after 9/18/25. Although there were 4 additional areas available, in which to document that flushing occurred, (9/19 to 9/22/25, 8 opportunities) the areas were left blank. The Maintenance Director stated that when the facility received the negative Legionella water testing results (9/18/25), the water management consultant had recommended to stop flushing positive locations, so he resumed flushing areas not previously positive, per the Water Management Prevention Plan, and no testing was necessary in October due to the negative results. Review of the Laboratory Certificate of Results dated 11/17/25 identified that the [NAME] Clean Utility faucet, room [ROOM NUMBER], 39, and 42 faucets, and the [NAME] soiled hopper hot pot were identified as Legionella positive. An email dated 11/20/25 from the water management company identified we have seen a huge jump in these numbers and want to be sure there has been no change to water quality. Review of the November Water Management Meeting Minutes indicated that although flushing had continued from 9/17/25 through 11/17/25 per the Water Management Plan, there was no evidence of flushing to the previously identified Legionella positive areas. The Maintenance Director stated he had resumed flushing Legionella positive areas 3 times daily during the week of November 20th. Flushing Location (daily) Logs to positive areas, 3 times daily, were provided that began on 11/20/25. The Administrator indicated he would be reaching out to the water management consultant. An interview with the Administrator on 12/5/25 at 9:00 AM and review of an email 12/3/25 from the water management consultant identified that we (the facility) were flushing daily in September after the results were negative instead of 3 times a day. My understanding is that this is what we should be doing when we see negative. Right? An email response dated 12/4/25 identified per our conversation with maintenance and leadership post those positive results (September) yes. The facility was directed to reduce flushing from 3 times daily back to 1 time daily. The Administrator indicated he would check the water testing logs and consult with corporate staff regarding the Water Management Plan to see if the previously positive water locations were flushed daily per the recommendation and logged elsewhere. An interview with the water management consultant on 12/4/25 at 9:16 AM indicated the water management plan had basic locations that needed to be flushed per an established routine, after that, when water testing was completed, any further recommendations were made on an ongoing basis through emails. The water management consultant indicated the September 2025 water testing results came back negative and the recommendations at that time were to reduce flushing of the previously positive locations to once daily. S/he indicated it would be up to the facility to act on the recommendations, and to reach out with any concerns or necessary clarifications. Re-interview with the Administrator on 12/4/25 at 2:50 PM failed to identify documentation that areas previously identified as Legionella positive were being flushed daily from 9/19/25 through 11/20/25. On 11/20/25 per the water management consultant recommendation, the facility received positive Legionella results and resumed flushing 3 times per day to positive Legionella areas. Although requested, weekend flushing documents prior to 9/17/25, flushing of the [NAME] Soiled Utility Room after 7/18/25, and daily flushing documentation logs to flush the previously positive areas following the 9/17/25 negative result were not provided.

Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 sampled residents, (Resident #52) reviewed for abuse, the facility failed to suspend the accused staff member according to their abuse policy. The findings include: Resident #52's diagnoses included Multiple Sclerosis (MS), depression, anxiety, age-related osteoporosis, and hereditary and idiopathic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status score of 15, indicating intact cognition, required substantial/maximal assistance with bed mobility and upper body dressing, and was fully dependent on staff for transfers, lower body dressing, and toileting hygiene. The Resident Care Plan (RCP) in effect from 4/21/25 through 12/2/25 identified Resident #52 had a fracture of the right tibia (shin) subsequent to a fall and was at a risk for falls due to paraplegia. Interventions included the assistance of 2 with a mechanical lift for all transfers. An interview with Resident #52 on 12/2/25 at 11:10 AM, identified that approximately 5-6 months ago; while speaking to Person #2 he/she (the resident) began to cry while describing a situation that had occurred with a Nurse Aide (NA) who had demonstrated aggressive care towards him/her and his/her roommate. Resident #52 described the NA as loud, rude, and verbally abusive, and acted in an aggressive manner slamming items and doors in the room while providing direct care. Resident #52 indicated that following their conversation, Person #2 went to speak with the Director of Nursing Services (DNS) and that subsequently the DNS removed the NA from his/her assignment.An interview with the Director of Nursing Services (DNS) on 12/3/25 at 9:49 AM identified she had spoken with Person #2 regarding Resident #52's allegations but did not recall Person #2 or Resident #52 stating the NA yelled at the resident, only that she was more to the point and stern. The DNS indicated she had not documented any of the details from their conversation and could only provide information based on memory. The DNS indicated she had not removed the NA from the schedule pending the investigation, did not move the NA off the unit, and did not change the NA's assignment, but directed the NA and charge nurse that the NA was not to care for Resident #52 going forward. Subsequent to surveyor inquiry the DNS wrote up a grievance dating it was received on 9/12/25 and had the document signed on 12/3/25 by the Administrator and Social Worker. An interview with Person #2 on 12/3/25 at 11:43 AM, identified he/she did speak with the DNS in her office regarding this incident about 4-5 months ago and was certain that he/she told the DNS the NA was being verbally abusive to Resident #52 and that her actions were uncalled for. Person #2 also identified the DNS prohibited the NA from going into Resident #52's room following their conversation. A review of the facility policy for abuse identified, in part, that verbal abuse is defined as the use of oral, written, or gestured language that includes derogatory or threatening terms directed at a resident or within their hearing distance. And abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Additionally, nursing staff will document the incident in the clinical record, and the accused will be immediately suspended without pay pending the findings of the investigation.

Based on observation, interviews, review of clinical records, facility documentation, and facility policy for 1 of 3 residents, (Resident #52) reviewed for abuse, the facility failed to conduct an investigation per the abuse policy. The findings include:Resident #52's diagnoses included Multiple Sclerosis (MS), depression, anxiety, age-related osteoporosis, and hereditary and idiopathic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status score of 15, indicating intact cognition, required substantial/maximal assistance with bed mobility and upper body dressing, and was fully dependent on staff for transfers, lower body dressing, and toileting hygiene. The Resident Care Plan (RCP) in effect from 4/21/25 through 12/2/25 identified Resident #52 had a fracture of the right tibia (shin) subsequent to a fall and was at a risk for falls due to paraplegia. Interventions included the assistance of 2 with a mechanical lift for all transfers. An interview with Resident #52 on 12/2/25 at 11:10 AM, identified that approximately 5-6 months ago; while speaking to Person #2 he/she (the resident) began to cry while describing a situation that had occurred with a Nurse Aide (NA) who had demonstrated aggressive care towards him/her and his/her roommate. Resident #52 described the NA as loud, rude, and verbally abusive, and acted in an aggressive manner slamming items and doors in the room while providing direct care. Resident #52 indicated that following their conversation, Person #2 went to speak with the Director of Nursing Services (DNS) and that subsequently the DNS removed the NA from his/her assignment.An interview with the Director of Nursing Services (DNS) on 12/3/25 at 9:49 AM identified she had spoken with Person #2 regarding Resident #52's allegations but did not recall Person #2 or Resident #52 stating the NA yelled at the resident, only that she was more to the point and stern, and that was why she had not documented any of the details from their conversation and could only provide information based on memory. She indicated customer care education was provided to the NA following the allegation and that she had conducted an investigation consisting of speaking with a staff member and Resident #52, however, she was unable to provide documentation of either the education or an investigation. Although the DNS had a copy of a customer care education given to the NA, this occurred months after speaking to Person #2, was dated 10/15/25, and was given in relation to a separate incident not involving Resident #52. Subsequent to surveyor inquiry the DNS wrote up a grievance dating it was received on 9/12/25 and had the document signed on 12/3/25 by the Administrator and Social Worker. An interview with Person #2 on 12/3/25 at 11:43 AM, identified he/she did speak with the DNS in her office regarding this incident about 4-5 months ago and was certain that he/she told the DNS the NA was being verbally abusive to Resident #52 and that her actions were uncalled for. Person #2 also identified the DNS prohibited the NA from going into Resident #52's room following their conversation. A review of the facility policy for abuse identified, in part, verbal abuse is defined as the use of oral, written, or gestured language that includes derogatory or threatening terms directed at a resident or within their hearing distance. And abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Nursing staff would document a description of the incident in the resident record. The Administrator/DNS or designee will initiate an investigation. The investigation will include interviews with all witnesses including the accused, interviews with any individuals with relevant information, and obtain signed and dated statements from all parties. The outcome of the investigation and any corrective actions will be documented in the internal investigation report. An RN will assess the resident involved and document in the nursing notes.

Based on interviews, record review and policy review for the only sampled resident (Resident # 7), reviewed for pain, the facility failed to transcribe and implement new physician's orders for medications. The findings include:Resident #7's diagnoses included paranoid schizophrenia, insomnia, and anxiety.The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was independent with eating, and required partial/moderate assistance with dressing and toileting hygiene. The Resident Care Plan dated 10/25/25 identified Resident #7 had a positive Preadmission Screening and Resident Review (PASRR), (a federal requirement ensuring people with serious mental illness aren't inappropriately placed in a nursing home). Interventions included a minimum of a yearly comprehensive psychiatric evaluation to clarify the current psychiatric diagnosis and appropriate treatment, and the ongoing evaluation for the effectiveness of current psychotropic medication on target behavioral symptoms.Review of Resident #7's paper clinical record identified a physician's order signed on 11/25/25 by psychiatric APRN #2 to discontinue Zyprexa (an antipsychotic), discontinue Melatonin (medication for insomnia) 6 milligrams (mg), and start Melatonin 10 mg every night. Interview and record review with Licensed Practical Nurse (LPN) #1 on 12/2/25 at 12:40 PM identified that although the paper physician's order sheets were not usually utilized, the facility policy directed nurses to transcribe any written paper orders into the electronic medical record. The 11:00 PM to 7:00 AM shift was responsible to review the paper record every 24 hours ensuring any orders written were transcribed to the electronic health record. A review of Resident #7's orders in the electronic health record failed to identify Zyprexa was discontinued and failed to identify Melatonin had been changed from 6 mg to 10 mg since written on 11/25/25 (7 days prior). Although she could not identify why the orders were not transcribed, LPN #1 identified they should have been. Subsequent to surveyor inquiry LPN #1 transcribed the physician's orders dated 11/25/25 into the electronic medical record.Interview with the Director of Nurses (DNS) on 12/3/25 at 11:15 AM identified the facility policy directed nurses scheduled on the shift that the paper order was written were responsible for transcribing the orders to the electronic medical record. The 11:00 PM to 7:00 AM shift nurse was responsible to review the paper record every 24 hours to ensure any physician orders which had been written were not missed and that the orders were accurately transcribed. Although she could not identify why the orders had not been transcribed, the DNS indicated that Resident #7's new orders from 11/25/25 should have been transcribed into the electronic health record on the date written.Interview with psychiatric APRN #2 on 12/3/25 at 11:39 AM identified she saw Resident #7 on 11/25/25 to complete a comprehensive evaluation to address his/her psychiatric status. Additionally, although she would expect the orders to be followed up on by nursing, the delay did not cause any ill effects to Resident #7.Review of the Physician's Orders policy directed, in part, that the purpose was to ensure physician's orders were complete and accurate.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 4 sampled residents (Resident #5) reviewed for accidents, the facility failed to obtain and document orthostatic (positional) blood pressures per the physician's order, failed to ensure the resident's condition was documented for 72 hours following a fall per the facility practice, and for 1 of 3 sampled residents (Resident #44) reviewed for pressure ulcers, the facility failed to set an alternating pressure mattress at the correct setting, per the physician order and Resident Care Plan. The findings include. The findings include: 1.Resident #5's diagnosis included fracture of the neck of the femur with subsequent encounter for closed fracture with routine healing (hip fracture). The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and had no history of falls. The Resident Care Plan dated 6/17/25 indicated Resident #5 was at risk for falls due to psychotropic drug use, impaired safety awareness and not always calling for assistance. Interventions included ensuring the walker was within reach, and to place his/her favorite items and the call bell within reach. A Reportable Event dated 7/5/25 indicated Resident #5 was observed, by the charge nurse, losing his/her balance and falling to the floor with no complaints of pain or apparent injuries. The physician was notified and directed to follow the facility policy and to obtain orthostatic blood pressures every evening for 3 days. A physician order dated 7/6/25 directed to obtain orthostatic blood pressures (lying, sitting, and standing) at bedtime for 3 days beginning on 7/6/25 for a fall related to the loss of balance. An interview and clinical record review on 12/4/25 at 11:23 AM with the nursing supervisor, Registered Nurse (RN) #2, identified a physician order on the Medication Administration Record (MAR) to obtain orthostatic blood pressures (lying, sitting, and standing) every evening for 3 days beginning on 7/6/25. Although the first and third days (7/6/25 and 7/8/25) were signed as being completed, RN #2 was unable to locate documentation of the results in the clinical record or in the Director of Nurses office, and paper documentation of orthostatic blood pressures would only be used if the resident hit their head, which RN #2 indicated Resident #5 had not. Additionally, RN #2 was unable to locate post fall documentation of the resident's condition anywhere in the clinical record, that should have occurred every shift for 72 hours, indicating this was the facility practice following a resident fall. The facility policy labeled Falls indicated in part after a fall an incident report would be completed and in the event a resident hit their head a neurological sheet would be completed for 72 hours post fall. 2.Resident #44's diagnoses included dementia, heart failure, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #44 had a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment, required substantial/maximal assistance rolling left and right in bed and was dependent on staff for toileting hygiene and transfers and a pressure reducing device for the bed was used. The Resident Care Plan (RCP) dated 10/15/25 identified Resident #44 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included providing incontinent care, inspecting skin when providing care for signs/symptoms of breakdown, and checking the function of the air mattress every shift, set to 150 pounds (lbs.). A physician's order in effect from 10/15/25 through 12/2/25 directed to set the alternating pressure mattress at 150 lbs. and to check the mattress function and setting every shift. Observations on 12/1/25 at 10:11 AM, 12/1/25 at 1:45 PM, 12/2/25 at 10:54 AM, and 12/2/2025 at 12:30 PM, identified Resident #7 in bed with the pressure-relieving mattress set at 100 lbs. Observation, interview, and review of physician orders with Licensed Practical Nurse (LPN) #1 on 12/2/25 at 12:35 PM identified Resident #44 was lying in bed, covered by a blanket, with the head of the bed slightly elevated. The alternating pressure mattress was observed to be set at 100 lbs. The current physician order directed the alternating pressure mattress to be set at 150 lbs. and to check the function and setting every shift. LPN #1 identified that the alternating air mattress was incorrectly set according to the physician's order, on 12/1/25 and 12/2/25. LPN #1 stated that the facility policy directed to set the alternating air mattress per the physician order and that it was her responsibility as the unit nurse to check and ensure the correct setting. LPN #1 indicated that she had not checked the setting on Resident #44's alternating air mattress that shift but should have. Subsequent to surveyor inquiry, LPN #1 changed the setting on Resident #44's alternating air mattress from 100 lbs. to 150 lbs. per the physician's order. Interview with the Director of Nursing (DNS) 12/2/25 at 12:55 PM indicated that the facility policy directed setting pressure relieving mattresses per the physician order and the unit nurse was responsible to check mattresses for the correct physician ordered setting every shift. The DNS indicated Resident #44's mattress should have been set according to the physician's order, at 150 lbs., and not at 100 lbs. as observed. Review of the undated Wound and Skin Care policy directed, in part, that the interdisciplinary plan of care will address problems, goals and interventions directed toward the prevention and/or treatment of impaired skin integrity and/or pressure ulcers.

Based on observation, interview and review of facility policy for 1 of 3 sampled residents (Resident #2), reviewed for activities of daily living, the facility failed to follow their policy for ostomy care. The findings include:Resident #2's diagnoses included ileostomy, chronic kidney disease, and chronic atrial fibrillation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required extensive assistance for toilet use and bed mobility, and was dependent on staff for transfers.A skills competency evaluation dated 8/7/25 for Nurse Aide (NA) #5 identified that ostomy care was successfully completed. Additionally, the evaluation identified the evaluator of competency completion as the Staff Development nurse.The Resident Care Plan (RCP) dated 8/20/25 identified Resident #2 had an ileostomy. Interventions included assisting with ileostomy and stoma care as ordered and as needed.A physician's order dated 9/13/25 for Resident #2 directed colostomy care every shift. Observation of NA #5 on 12/2/25 at 12:46 PM emptying the contents of Resident #2's ostomy bag, identified she opened the clamp at the bottom of the ostomy collection bag and emptied the contents into an appropriate trash receptable. Once the ostomy collection bag was empty, NA #5 wiped the opening of the bag to clean then rolled up and clamped to prevent leakage. NA #5 then disposed of trash appropriately, removed her PPE, and completed hand hygiene. The observation failed to identify the colostomy collection bag was washed out with a soap solution and rinsed with water.Interview with NA #5 on 12/2/25 at 1:45 PM identified that she could not remember the policy or procedure for ostomy care and emptying of the collection bag. NA #5 indicated that she received yearly education and competencies from the facility but could not identify the last time she was evaluated. NA #5 indicated that she used to rinse ostomy bags with soap and water but stopped about nine (9) months prior because a nurse directed to stop doing so to prevent infection. NA #5 was unable to identify the nurse who had given her the directive. Interview, facility documentation review, and policy review with the Staff Development Registered Nurse (RN) #3 on 12/3/25 at 9:21 AM identified that staff received training and were evaluated upon hire and annually for ostomy care. RN #3 indicated that staff should follow the facility policy for ostomy care which directed staff to wash the ostomy bag with a soap solution and rinse with water during ostomy care and RN #3 was unable to identify why ostomy care was completed incorrectly. Interview with the Director of Nursing (DNS) on 12/3/25 at 12:16 PM identified that staff were evaluated annually for ostomy care, the policy directed staff to rinse the ostomy bag NA #5 and should have followed the policy, and it was the responsibility of the staff performing the care to know the policy and procedure. The interview failed to identify why ostomy care for Resident #2 was completed incorrectly. Review of the undated ostomy care policy directed, in part, that after emptying the contents of the ostomy bag, wash out the bag with soap solution and rinse with water.

Based on review of the clinical record, interviews, and facility policy for 2 of 3 sampled residents (Resident #12 and Resident #38) reviewed for Intravenous (IV) therapy, the facility failed to ensure staff obtained physician orders for routine care and maintenance of peripherally inserted IV sites and failed to consistently document observations of the IV site and the presence or absence of adverse reactions per the facility policy. The findings include. 1. Resident #12's diagnosis included chronic renal disease and urinary tract infection.The quarterly Minimum Data Set (MDS) dated [DATE] indicted Resident #12 had moderate cognitive impairment.A physician order dated 11/13/25 directed to provide Dextrose-Sodium chloride Intravenous Solution 5-0.45% 75 milliliters per hour (ml/hr.) every shift for fever/hydration for 3 days for a total of 3 liters.The Resident Care Plan dated 11/14/25 indicated Resident #12 was receiving IV hydration via a peripherally inserted catheter in the left upper extremity due to fever, decreased fluid and food intake, and was started on an IV antibiotic for a urinary tract infection (UTI). The interventions included observing the insertion site every shift for redness, swelling drainage or tenderness, observe for signs of an infiltration, and provide care to the IV site per the facility policy.A clinical record review and interview with the Infection Preventionist, Registered Nurse (RN) #3, and the regional nurse, RN #1 on 12/3/25 at 9:43 AM identified Resident #12 had received IV hydration and an antibiotic through a peripherally inserted IV line according to the physician orders. After an adverse reaction, phlebitis (vein inflammation), was observed and reported to the provider on 11/17/25, the IV was discontinued. Review of nursing note documentation for the IV site condition and presence or lack of adverse reactions during IV therapy between 11/13/25 and 11/17/25 (4 days) was inconsistently documented. RN #3 indicated the unit nurse who had documented the original physician IV orders in the electronic medical record failed to check off the standing orders which would have directed nurses to appropriately monitor and document the condition and status of Resident #12's IV therapy each shift. RN #1 indicated she had made the Administrator aware of the missing orders and the facility was currently working with the pharmacy to ensure standing IV orders would automatically populate. Resident #12's standing orders should have included monitoring for adverse reactions, observing the IV site every shift, IV tubing changes, and site rotation.2. Resident # 38's diagnosis included mild protein calorie malnutrition.The quarterly Minimum Data Set, dated [DATE] indicated Resident #38 had mild cognitive impairment.The Resident Care Plan dated 11/21/25 identified Resident #38 was receiving IV hydration therapy via a peripherally inserted IV site due to poor intake of fluids with interventions including observing the IV site for symptoms of infiltration or signs of redness swelling drainage or tenderness.A physician order dated 11/21/25 directed to provide Dextrose-sodium Chloride Intravenous solution 5-0.45% at 60 milliliters per hour (ml/hr.) to provide 2 liters over 4 days.An interview and clinical record review with the Infection Preventionist, RN #3 on 12/3/25 at 2:15 PM identified Resident #38 had provider orders for IV hydration in November 2025, but had no standing orders for monitoring adverse reactions, observing the IV site every shift, IV tubing changes and site rotation per the facility policy.The policy on Intravenous (IV) Physician Orders directed, in part, a valid physician's order is required before initiating IV therapy which includes the IV fluid or fluids, type, rate and volume, IV medications (drug, dose frequency, route duration) IV site specifications and special instructions that include, but not limited to flushing protocols and frequency of monitoring and nurses must document the initiation, monitoring, and discontinuation of IV therapy as well as any resident response or complications. The policy indicated that the director of Nursing (DON) is responsible for auditing compliance with IV order policies.The policy labeled Intravenous (IV) Therapy: Safe Administration, Monitoring, Documentation and Termination Policy indicated the policy establishes procedures to ensure the safe administration, ongoing monitoring, and accurate documentation. The policy indicated ongoing monitoring of the IV site for infiltration, phlebitis, infection or dislodgment per the facility policy and to document the condition of the site observed during monitoring rounds.The policy labeled Policy on Recognition of Signs and Symptoms of Complications, including Sepsis, During IV Therapy, indicated nursing staff must monitor residents receiving IV therapy for potential complications including local reactions systemic reactions including assessing the IV site at least every shift and documentation of the IV site and residents' status with each shift and as needed.

Based on interviews, and record and policy reviews for the only sampled resident (Resident # 7) reviewed for pain, the facility failed to review the clinical record to ensure appropriate management of pain. The findings include:Resident #7's diagnoses included displaced fracture of the right femur, polyneuropathy, and anxiety.The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was independent with eating, required partial/moderate assistance with dressing and toileting hygiene, and received scheduled and as needed pain medications. The Pain Assessment interview identified Resident #7 had pain or was hurting frequently in the 5 days prior to the assessment, the pain frequently made it hard to sleep at night, and he/she frequently limited day to day activities due to pain.The Resident Care Plan dated 10/25/25 identified Resident #7 was at risk for pain/discomfort related to a hip fracture. Interventions included emotional support, medications as ordered, and a skilled assessment of pain symptoms.Review of the clinical record identified a hospital progress note dated 5/24/25 indicating Resident #7 had a large, engorged tick on his/her right knee with surrounding erythema (redness) and cellulitis (infection of the skin) extending from the right medial knee to the right shin. There was a concern and question of an acute neurologic abnormality possibly related to Lyme disease or similar cause; Resident #7 refused all levels of care and treatment. Further review identified a hospital inpatient History and Physical dated 10/24/25 identifying Resident #7 reported a tick bite around 8 months ago for which he/she remembered having a targetoid (bullseye) rash and migrating joint pain. He/she denied rash or joint pain at the time but believed sensory changes from the bite and treatment during a prior inpatient psychiatric admission were contributory to the most recent fall and endorsed intense generalized pruritus (irritating sensation to the skin).A nurse note dated 10/27/25 at 3:46 PM identified Resident #7 was at the hospital for a tick bite around 8 months ago, was never formally diagnosed with Lyme disease, but was currently experiencing night sweats, joint pain, and fatigue.A review of Physician #1's History and Physical dated 10/28/25 at 11:16 AM identified Resident #7 asked if he/she had Lyme disease. Physician #1 noted a negative Lyme disease test (A negative Lyme disease tests meant antibodies were not detected, and a false negative could occur due to the body not producing enough antibodies) and noted bilateral shoulder pain (Lyme disease can cause bilateral shoulder pain often as part of joint inflammation or nerve involvement.)A nurses note dated 11/4/25 at 1:50 PM identified Resident #7 stated I have been telling the APRN that I think I have Lyme disease and requesting Advil (ibuprofen) instead of Dilaudid (a narcotic pain medication) due to better pain management. APRN #1 was updated on Resident #7's condition and directed new orders to discontinue the Dilaudid and start Advil 600 milligrams (mg) as needed every 6 hours for pain.A review of APRN #1's progress note dated 11/5/25 at 1:36 PM identified Resident #7 was seen for a pain management follow up visit, stating the Dilaudid was not working, and felt the Advil worked better. It was also identified that he/she continued with sweats while lying in bed and chills at nighttime.Review of a nurses note dated 11/6/25 at 2:33 PM identified Resident #7 reported sweating/flu symptoms, and the APRN was updated.Interview with Resident #7 on 12/1/25 at 12:36 PM identified that he/she was admitted to the facility following a hip fracture and continued with pain which he/she had reported to the nurses who directed him/her to tell the physician during a follow up. Resident #7 indicated he/she had joint pain that hurt all over, in the same manner as it did when he/she had Lyme disease. Additionally Resident #7 identified he/she had a tick bite a couple months ago and although the laboratory work came out negative, he/she felt doxycycline (an antibiotic) had helped in the past and was needed now for the joint pain to go away. Resident #7 identified he/she was only 54 and should not be feeling this way, referring to being down due to being in pain all the time.Interview and record review with Licensed Practical Nurse (LPN) #1 on 12/2/25 at 12:40 PM identified that she was frequently the charge nurse for Resident #7 who, although he/she had utilized Advil for pain, the Advil was sometimes ineffective and had most recently occurred on 12/1/25. Additionally, LPN #1 identified that she verbally reported the ineffective pain management to APRN #1 on 12/1/25.Interview and record review with APRN #1 on 12/2/25 at 1:08 PM identified she been seeing Resident #7 due to ineffective pain management post a hip fracture and that Dilaudid, naproxen, and Robaxin failed to provide the resident with pain relief. APRN #1 indicated that although Resident #7 had reported joint pain, she didn't feel like she got the full story because she could not locate documentation supporting a tick bite anywhere in Resident #7's health record. A review of the discharge hospital History and Physical paperwork dated 10/24/25 with APRN #1 identified Patient also reports a tick bite 8 months ago for which he/she remembers having a targetoid rash and migrating joint pain. He/she denies rash or joint pain currently but believed sensory changes from the bite and treatment during a prior inpatient psychiatric admission were contributory to his/her most recent fall. APRN #1 identified she was not aware of that information. Additionally, if she had been aware of the tick bite she identified she would have investigated a little deeper, conferred with the MD and geared pain management toward rheumatoid arthritis.Observation of Resident #7 on 12/3/25 at 11:57 AM identified him/her having a conversation with a nurse regarding feeling like he/she was hit with a bat all over due to the joint pain he/she was having. The nurse stated the APRN would be in later.Subsequent to surveyor inquiry APRN #1 evaluated Resident #7, the progress note dated 12/3/25 at 1:38 PM identified Resident #7 was seen for continued ongoing issues with pain management, and that he/she was convinced of having Lyme disease, but there was no documentation of testing or initiation of doxycycline with Resident #7 insisting he/she received doxycycline for a tick bite with no record of such. Initiation of Celebrex (an anti-inflammatory drug) 200 mg twice a day, was ordered and Resident #7 agreed to start the medication.Review of the Pain Management Policy directed in part to ensure the effective assessment, management, and documentation of pain. Additionally, develop an individualized pain management plan in collaboration with the residents, the family and the interdisciplinary team.

Based on interviews, clinical record review, and facility policy for 1 of 3 sampled residents (Resident #2) reviewed for activities of daily living (ADL), the facility failed to accommodate a resident's choice for bathing. The findings include: Resident #2's diagnoses included chronic kidney disease, chronic atrial fibrillation, and hypotension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required extensive assistance for toilet use and bed mobility, and was dependent on staff for transfers.The Resident Care Plan (RCP) dated 8/20/25 identified Resident #2 needed assistance with ADLs. Interventions included assisting with set up at the bedside or in the bathroom and assisting with tasks he/she was unable to perform.Interview with Resident #2 on 12/1/25 at 10:43 AM identified that although he/she received bed baths, a morning shower was preferred, and it had been a long time since receiving one. Resident #2 indicated he/she notified the staff of the preference to receive a shower but was told that a bed bath was easier for the staff to perform. Resident #2 was unable to recall how long it had been since receiving a shower, stated he/she would say yes if offered, but staff never asked if he/she wanted one.Review of the nurse aid East Wing assignment sheet for Tuesday, 12/2/25 identified that Resident #2's shower day was scheduled for Tuesday on the 7:00 AM to 3:00 PM shift.Review of Resident #2's Nurse Aid (NA) Resident Care Card (directs care) identified that his/her scheduled shower day was on Tuesday on the 3:00 to 11:00 PM shift. Additionally, the Resident Care Card indicated that Resident #2 was dependent on staff assistance with bathing and preferred showers.Re-interview with Resident #2 on 12/3/25 at 10:25 AM identified that he/she was supposed to get a shower the day prior, Tuesday 12/2/25, but had not. Resident #2 stated he/she was told that staff did not have the correct mechanical lift pad size until right before the change of shift and gave him/her a bed bath instead. Additionally, Resident #2 indicated he/she was never offered an alternative time to receive a shower. Interview, review of the Resident Care Card, and nurse aid assignment sheet with NA #3 on 12/3/25 at 10:08 AM identified NAs were responsible for assisting residents with showers on their assigned bath day. The assignment sheet for Resident #2 indicated showers were to be given on Tuesday's between 7:00 AM and 3:00 PM but the Resident Care Card indicated the shower day was on Tuesdays between 3:00 PM and 11:00 PM. NA #3 stated that she was unaware Resident #2 had not received his/her weekly shower and if she knew, she would have offered one to him/her.Interview, review of the Resident Care Card and review of nurse aid assignment sheet with Licensed Practical Nurse (LPN) #1 on 12/3/25 at 11:07 AM identified that NAs were responsible for assisting residents with showers on the assigned day. If the resident refused, she would speak to the resident to see if they would like it at a different time, and if not, document the refusal in the electronic health record. LPN #1 stated Resident #2 was supposed to receive a shower on Tuesday, 12/2/25 (the previous day) but did not due to trouble finding the correct mechanical lift pad to assist him/her out of bed. She indicated she had become sidetracked during shift change and should have followed up with Resident #2 to offer a later time. Additionally, LPN #1 identified she should have informed the nurse on the oncoming shift of the missed shower indicating that she would now go ask Resident #2 if he/she would like to take a shower.Interview with the Director of Nursing (DNS) on 12/3/2025 at 12:16 PM identified that NAs were responsible for providing showers to residents according to the Resident's Care Card. The DNS indicated that if a resident refused a shower the nurse should be notified. Additionally, the DNS indicated that if a resident preferred showering on a different day or time, the facility would do what they could to accommodate the request.Review of the Activities of Daily Living policy dated 12/9/14 directed, in part, for staff to provide individualized assistance to residents according to their wishes and plan of care.Review of the undated Resident Rights policy directed, in part, that residents have the right to choose activities, schedules and health care consistent with their interests and their plan of care and have the right to make choices about aspects of their life that are significant to them.

Based on interviews, review of the clinical record and facility policy, for 2 of 5 sampled residents (Resident #5 and Resident #54) reviewed for unnecessary medications, for Resident #5 the facility failed to ensure a Monthly Medication Regimen review was completed, and for Resident #54, the facility failed to ensure a timely response to a pharmacist recommendation. The findings include:1.Resident #5's diagnosis included Parkinson's disease, schizoaffective disorder, bipolar disorder, anxiety disorder and epilepsy. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #5 had mild cognitive impairment and was receiving antipsychotic, antidepressant, anticoagulant and anticonvulsant medications. The Resident Care Plan dated 9/30/25 identified Resident #5 was at risk for seizures, changes in mood and behavior, and at risk for potential adverse effects from the use of psychotropic medications and anticoagulation therapy. Interventions included evaluating the effectiveness, side effects, and results of laboratory tests for ordered medications. Interview and review of Resident #5's medical record on 12/2/25 at 11:59 AM with the Director of Nursing Services identified the facility contracted with a new pharmacy and began service in June 2025. Although the DNS was able to locate electronic monthly pharmacy reports for June, July, August, and September 2025, she was unable to locate a pharmacy MMR review completed for Resident #5 in September 2025. 2. Resident #54's diagnoses included atherosclerotic heart disease without angina pectoris, hypertension and hyperlipidemia. The annual Minimum Data Set assessment (MDS) dated [DATE] identified Resident #54 had a Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment and required partial/moderate assistance with dressing, toileting, and transfers. The Resident Care Plan dated 9/11/25 identified Resident #54 was at risk for cardiac issues related to cardiovascular disease. Interventions included medications and vital signs as ordered, per policy, and to watch signs/symptoms associated with cardiorespiratory issues. A Nursing Summary Report from the pharmacy dated 7/11/25 identified Resident #54 required hypertension management due to the daily blood pressure medication regimen consisting of Amlodipine Besylate 10 milligrams (mg) once a day and Carvedilol 12.5 mg twice a day (medications for hypertension). The recommendation identified Resident #54 had 1 blood pressure reading (154/78) documented in the last 30 days prior to the regimen review. The pharmacist recommended an order for routine blood pressure checks, which was signed by APRN #3 on 10/14/25. Review of Resident #54's blood pressures identified readings as follows: 6 in July; 3 in August; and 1 in September with 2 instances of a systolic blood pressure exceeding 139 mmHg, (normal 120/80) Interview and review of the Medication Regimen Review (MRR) on 12/3/25 at 1:56 PM with the Director of Nurses (DNS) identified that the pharmacy recommendations for hypertension management by ordering routine blood pressure checks was dated 7/11/25 but not signed by APRN #3 until 10/14/25. A new physician's order effective 10/15/25 directed blood pressures be taken every 15 days. The DNS indicated that MRR recommendations were to be given to the APRN within 3 days. She identified there should have been a physician's order for the routine blood pressures checks in July and was unable to identify why there was a 3-month delay for Resident #54's recommendation approval stating she handed the MRR's to the APRN right away and maybe it was in her bag. Interview and clinical record review with APRN #3 on 12/3/25 at 3:06 PM identified the protocol for MRR was for the DNS to provide her with the recommendations from the pharmacy, which she reviewed, if approved she entered the physician's order into the electronic health record, then gave the MRR paper back to the DNS within a time frame of a week. A review of Resident #54's MRR from 7/11/25 with APRN #3 identified recommendations for routine blood pressure checks with an approval date and signature of 10/14/25. APRN #3 could not identify why it took 3 months for her to approve the recommendation, adding she gets a lot of paperwork. Review of the Consultant Pharmacy Services Requirements Policy directed in part that a written report of findings and recommendations resulting from review of medication regimen, medical record and nursing documentation records to the Director of Nursing. Additionally, it directed the facility to establish policies and procedures that address response timeframes for monthly drug regimen review. (Although requested a policy on Medication Regimen Review time frames was not provided).

Based on observations, facility policy, and interviews during a review of medication storage and labeling, for 1 of 2 medication rooms observed, the facility failed to ensure that expired medications were discarded, failed to ensure medications were labeled appropriately, and failed to ensure medications requiring refrigeration for 5 residents (Resident #3, 10, 14, 39 and 55) were stored at the appropriate temperature. The findings include:1.Observation of the North Wing medication storage room on 12/3/25 at 11:58 AM identified the following: One bottle of Gastrografin incorrectly labeled (the bottle had a partial name tag; however, the residents name was torn off). One Normal saline flush with an expiration date of 8/13/24. Four Heparin Lock Flushes, 50 unit/5ml expired on 3/31/24. One IV Start kit and one IV clamp that expired 4/3/23. Ice buildup was noted in the refrigerator. A temperature log dated 12/1/25 identified a medication refrigerator temperature of 22.1 degrees F (normal to 46 degrees Fahrenheit (F). A temperature log dated 12/2/25 identified a medication refrigerator temperature of 21.2 degrees F. Observation with LPN #3 on 12/3/25 at 1:54 PM identified a medication refrigerator temperature of 20.1 degrees F. 2. Medications observed being stored in the medication refrigerator at an inappropriate temperature of 20.1 degrees F were as follows: Three Mounjaro (tirzepatide) injections. One Fluorouracil 1% PF Ophthalmic solution. Two 100 ml Lantus Injection. One Novolog Injection. Five 650 mg Acetaminophen suppositories.Additionally, residents who had medications stored in the refrigerator at an inappropriate temperature included:a. Resident #3 's diagnoses included Type 2 diabetes mellitus, chronic obstructive pulmonary disease and anxiety. A physician's order dated 9/11/25 directed to administer Mounjaro, inject 0.5ml units subcutaneously one time a day, every Wednesday for Diabetes Mellitus.A container of Mounjaro labeled with Resident #3's name was observed to be stored in the refrigerator at an inappropriate temperature of 20.1 degrees F.Review of Medication Administration Records (MAR) from 12/1/25 through 12/3/25 indicated that resident was given their medication per physician's order.b. Resident #10 's diagnoses included type 2 diabetes mellitus, hypertensive heart disease with heart failure and gastro- esophageal reflux disease.A physician's order dated 7/14/25 directed to inject 18 units of Lantus subcutaneously in the morning for diabetes mellitus.One container of Lantus solos 100 ml injection labeled with Resident #10's name was observed to be stored in the refrigerator at an inappropriate temperature of 20.1.Review of MAR from 11/1/25 through 12/4/25, identified that 18 units of Lantus subcutaneously was administered daily.c. Resident #14's diagnoses included type 2 diabetes mellitus, chronic obstructive pulmonary disease and gastro- esophageal reflux disease without esophagitis.A physician's order dated 12/7/22 directed to insert 1 Acetaminophen 650 mg suppository rectally every 4 hours as needed.One container of 5 Acetaminophen 650 mg suppositories labeled with Resident #14's name was observed to be stored in the refrigerator at an inappropriate temperature of 20.1.Review of Resident 14's MAR from 12/1/25 through 12/4/25 failed to indicate administration of a Acetaminophen suppository. d. Resident # 39's diagnoses included type 2 diabetes mellitus, stage 3 chronic kidney disease and hyperlipemia. A Novolog Inject Flex Pen labeled with Resident #39's name directed to inject per a sliding scale: If 150-200+ 2 units; 201-250 = 4units; 251-300 =6 units; 301-350 =8 units greater than 350 call the provider was observed to be stored in the refrigerator at an inappropriate temperature of 20.1. Requested orders were not provided prior to exiting the facility. e. Resident #55 's diagnoses included glaucoma, hypertension, and osteoarthritis. A physician's order dated 4/14/25 directed to instill 1 drop of Latanoprost Ophthalmic Solution 0.005% in both eyes at bedtime for glaucoma.One Latanoprost Ophthalmic Solution labeled with Resident #55's name was observed to be stored in the refrigerator at an inappropriate temperature of 20.1.Review of Residents #55's MAR from 11/1/25 through 11/30/15 identified that Latanoprost Ophthalmic Solution was administered daily. Interview with Registered Nurse (RN) #2 on 12/3/25 at 12:10 PM identified that all medications should be labeled with the resident's name, dose, and directions, and that all nursing staff were responsible for ensuring medications were properly labeled. Additionally, the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts were responsible for ensuring the refrigerator was maintained at an appropriate temperature. She identified she was unsure how long the ice build-up had been present in the medication refrigerator and stated she had not been notified of the refrigerator's condition.Interview with Person #3 from the pharmacy on 12/3/25 at 1:35 PM identified that the medications observed to have been stored in the medication room refrigerator, at temperatures outside the acceptable parameters (36 to 46 degrees F) would affect the stability of each of the medications. Further, any medication that was not stored at the appropriate temperature would need to be replaced.Interview with Licensed Practical Nurse (LPN) #2 on 12/3/25 at 1:54 PM identified the ice build-up has been there for a few weeks. She reported noticing the refrigerator temperature was below the acceptable parameter of 36 to 46 degrees F and adjusted the temperature to 36 degrees F.Interview with RN #3 12/3/25 at 1:58 PM identified that she was unable to locate a temperature log for November 2025 for the North Wing, all temperature logs should be given to her monthly, and she was unable to explain why there was no temperature log for the month of November. Interview with RN #1 on 12/3/25 at 2:05 PM indicated that she believed staff were writing down the temperature in Celsius and not Fahrenheits (21.2 degrees Celsius is equivalent to 69.98 degrees Fahrenheit).Re-interview with RN #3 on 12/4/25 at 9:02 AM indicated that the facility recently received a new digital monitor last week and stated that they would be educating staff how to write down the medication refrigerator temperatures (Celsius vs Fahrenheit) Although several requests were made for Novembers temperature log for North Wing, the facility was unable to locate the log.The Medication Storage policy directed, in part, medications requiring refrigeration or temperatures between 36 degrees F (2 Celsius (C) and 46 degrees F (8 C) are kept in a refrigerator with a thermometer to allow daily temperature monitoring. Facilities medication orders policy indicates in part Complete medication orders specify the following components: Clients full name, date of order, name of medication, dosage and administration information Route.

Based on observation, interviews, review of the clinical record and facility policy for the only sampled resident, (Resident #6), reviewed for dental services, the facility failed to assist with obtaining routine dental services upon request. The findings include:Resident #6's diagnoses included Turner's syndrome, type 2 diabetes, and gastroparesis.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required touching assistance with chair/bed-to-chair transfers, required set-up assistance with oral hygiene, and had a problem with vomiting.The Resident Care Plan (RCP) in effect from 9/22/25 through 12/3/25 identified Resident #6 had gastroparesis but failed to include an oral intervention for vomiting due to gastroparesis, failed to include the risk for tooth erosion from stomach acids, and failed to identify that Resident #6 was at risk for various dental issues related to his/her diagnosis of Turner's syndrome (a genetic condition resulting in skeletal and dental anomalies).An observation and interview with Resident #6 on 12/1/25 at 10:12 AM identified a missing front tooth and discoloration to visible teeth. Resident #6 identified he/she told the nurse he/she wanted to see a dentist, but staff had never offered an appointment, and he/she still has not been seen by a dentist.Interview and review of the clinical record on 12/3/25 at 10:05 AM with Licensed Practical Nurse (LPN) #3 identified that when a resident requested to see the dentist, the nurse would reach out to the Advanced Practical Registered Nurse (APRN) to obtain an order for a dentist visit. She indicated she was unable to recall if Resident #6 had asked her to see the dentist and was unable to locate a dental visit in the medical record. LPN #3 identified that the Nursing admission Assessment in July of 2025, incorrectly identified that the resident had all his/her own teeth and she was aware that Resident #6 was missing 1 or 2 teeth in the front. An interview and review of the clinical record on 12/3/25 at 10:55 AM with the Director of Nursing Services (DNS) identified that nursing should have noted Resident #6's missing tooth when performing the Nursing admission Assessment in July 2025, but failed to do so, and Resident #6 has not seen a dentist since admission to the facility. The DNS indicated she had not been made aware that Resident #6 requested dental services, and subsequent to surveyor inquiry, the DNS stated she would contact the APRN for an order to obtain dental services.Review of the Ancillary Services policy identified, in part, that residents' ancillary service needs will be evaluated during admission and as part of ongoing assessments by the interdisciplinary care team. Residents and/or their legal representatives will be informed of available services and assisted in scheduling appointments as needed.

Based on interviews, facility documentation and policy review, the facility failed to develop, monitor and implement an effective Quality Assurance Performance Improvement plan. The findings include:Review of the Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 1/22/25, 4/23/25, and 7/23/25 identified quality measures were reviewed without the benefit of any identified plan, education, or audits to ensure compliance. Additional review of QAPI documentation failed to identify an annual performance improvement plan.Interview and review of the facility QAPI/Performance improvement information with the Director of Nursing (DNS) on 12/4/25 at 11:35 AM identified she was in charge of Quality Assurance and Performance Improvement program in the facility. She stated that the policy directed the facility to identify areas of concern and take actions to improve those areas. Review of the quarterly meetings with the DNS identified that formal meetings were held quarterly, but the only quarter that included a QAPI was dated 10/29/25 and was based on a family suggestion for a more pleasant dining experience. Review of the prior 3 quarters (meeting minutes dated 1/22/25, 4/23/25 and 7/23/25) failed to include any quality performance improvement plans in place reflecting quality measures. Although the DNS identified that quality measures were reviewed regularly, there was no improvement plan based on those areas with the DNS stating that she did not have any other audits or projects for the outliers in the quality measures.Interview and facility documentation review with the Administrator on 12/4/25 at 12:02 PM identified the policy for conducting a QAPI plan was based on areas that had been identified as needing improvement through the Certification and Survey Provider Enhanced Reports (CASPER), quality measures, and weekly meetings with facility staff. The Administrator indicated that the DNS was in charge of overseeing the quality improvement program. Additionally, he identified that the facility did not have an annual performance improvement plan because both himself and the DNS had just started this past January (11 months prior). A review of the facility quality measures for 2025 with the Administrator identified multiple areas to be triggering above 20%, and although he stated those areas were being worked on, he could not provide a plan, education, or audits indicating any measures undertaken by the facility, adding the facility was just not taking credit in the form of documentation. Review of the Administrator job description identified, in part, that he/she develops, implements and maintains the Quality Assurance Performance Improvement Program. Additionally, he/she helps the facility meet the company's commitment to quality by participating in quality improvement teams.Review of the Quality Assurance Program directed, in part, that it is established to ensure high quality resident care by focusing on identifying areas of concern, objective assessment of the cause, implementation of a mechanism to eliminate or reduce the problems and monitoring to ensure continued effectiveness.

Based on interviews, review of the clinical record, and facility policy for 1 of 3 residents (Resident #8), reviewed for the environment, the facility failed to notify the physician when a physician order directing the use of a bed cradle could not be implemented. The findings include: Resident #8's diagnoses included dementia, peripheral vascular disease, and purpura (spontaneous capillary rupture).A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status (BIMS) score of 3 indicating severely impaired cognition, was dependent with chair/bed to chair transfers, required maximal assistance with rolling left and right, and was at risk for developing pressure injuries.The Resident Care Plan (RCP) dated 9/26/25 identified Resident #8 was at risk for skin breakdown and skin tears. Interventions included gentle handling during all transfers and care procedures, inspecting skin when providing care, and offloading heels while in bed.A physician order dated 10/2/25 directed Resident #8 to have a bed cradle applied to the bed and check (placement) each shift for prevention/protection.Observation and interview on 12/3/25 at 5:25 AM with Licensed Practical Nurse (LPN) #4 identified Resident #8 did not have a bed cradle applied to his/her bed. LPN #4 stated the bed cradle was broken and had not been used since 11/30/25. Further, she stated the broken bed cradle was reported by her to the day shift on 12/1/25 and she should have followed up on the status of repair but failed to do so. LPN #4 indicated she did not enter the broken bed cradle into the maintenance log and she did not notify the Medical Doctor or Advanced Practice Registered Nurse (APRN) that the bed cradle could not be used for Resident #8 as ordered.Interview on 12/3/25 at 10:23 AM with the Director of Maintenance identified he had not been notified of the broken bed cradle until 12/3/25 at 10:13 AM, and the repair of the bed cradle was scheduled to occur on 12/3/25.Interview on 12/3/25 at 10:42 AM with the Director of Nursing Services (DNS) identified that nursing should have notified the APRN of the inability to apply Resident #8's bed cradle and failed to do so.Interview on 12/4/25 at 10:47 AM with APRN #1 identified she was not made aware that Resident #8's bed cradle could not be used as ordered and she would have wanted to be notified. APRN #1 stated Resident #8 was prone to skin tears when experiencing periods of restlessness, as he/she would get tangled up in his/her sheets resulting in skin tears when he/she tried to get out of bed. She further stated the bed cradle helped ensure Resident #8 was protected from developing a skin tear. APRN #1 identified had she known the bed cradle was broken she would have placed a hold on the order and ordered a different skin intervention for Resident #8.A review of the Physician Orders policy identified, in part, that written and/or verbal/telephone orders may be obtained to prescribe medications and treatments. The facility's policy failed to include that an order to hold a treatment or medication should be obtained if a written order could not be followed.

Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents, (Resident #52) reviewed for abuse, the facility failed to report an allegation of abuse to the State Agency. The findings include: Resident #52's diagnoses included Multiple Sclerosis (MS), depression, anxiety, age-related osteoporosis, and hereditary and idiopathic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status score of 15, indicating intact cognition, required substantial/maximal assistance with bed mobility and upper body dressing, and was fully dependent on staff for transfers, lower body dressing, and toileting hygiene. The Resident Care Plan (RCP) in effect from 4/21/25 through 12/2/25 identified Resident #52 had a fracture of the right tibia (shin) subsequent to a fall and was at a risk for falls due to paraplegia. Interventions included the assistance of 2 with a mechanical lift for all transfers. An interview with Resident #52 on 12/2/25 at 11:10 AM, identified that approximately 5-6 months ago; while speaking to Person #2 he/she (the resident) began to cry while describing a situation that had occurred with a Nurse Aide (NA) who had demonstrated aggressive care towards him/her and his/her roommate. Resident #52 described the NA as loud, rude, and verbally abusive, and acted in an aggressive manner slamming items and doors in the room while providing direct care. Resident #52 indicated that following their conversation, Person #2 went to speak with the Director of Nursing Services (DNS) and that subsequently the DNS removed the NA from his/her assignment.An interview with the Director of Nursing Services (DNS) on 12/3/25 at 9:49 AM identified she had spoken with Person #2 regarding Resident #52's allegations but did not recall Person #2 or Resident #52 stating the NA yelled at the resident, only that she was more to the point and stern, and that was why she had never reported the allegation to the State Agency. The DNS indicated she had not documented any of the details from their conversation and could only provide information based on memory. Although the DNS indicated she had conducted an investigation and had provided the NA with customer care education, she was unable to provide any documentation related to the allegation. Subsequent to surveyor inquiry the DNS wrote up a grievance dating it was received on 9/12/25 and had the document signed on 12/3/25 by the Administrator and Social Worker. An interview with Person #2 on 12/3/25 at 11:43 AM, identified he/she did speak with the DNS in her office regarding this incident about 4-5 months ago and was certain that he/she told the DNS the NA was being verbally abusive to Resident #52 and that her actions were uncalled for. Person #2 also identified the DNS prohibited the NA from going into Resident #52's room following their conversation and was never notified that the facility determined that the event had been deemed a customer service matter.Review of the Abuse Policy identified, in part, that verbal abuse is defined as the use of oral, written, or gestured language that includes derogatory or threatening terms directed at a resident or within their hearing distance. And abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Nursing Staff will document a description of the incident in the resident record, an Accident and Incident (Reportable Event) report will be completed for each resident involved, documentation of the conclusion of the investigation and actions taken on the internal investigation form will occur, and a follow up report including conclusions and any action taken will be submitted online to FLIS within 5 days of the alleged incident.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for personal hygiene and incontinent care, the facility failed to follow the physician's orders for two (2) staff to assist the resident when being turned from side to side during care which resulted in a fall off the bed and the resident sustaining a laceration to the head. The findings include: Resident #1's diagnoses included hemiplegia and hemiparesis affecting the right side after a stroke, atrial fibrillation, morbid obesity, aphasia, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS) indicating Resident #1 rarely or never made decisions, was dependent on staff for all activities of daily living, required maximum assistance for turning and repositioning when in bed, was incontinent of bowel and bladder, and received an anticoagulant ( a blood thinning medication). The Resident Care Plan dated 10/10/24 identified Resident #1 had a self-care deficit due to a history of a stroke with a right sided deficit, was always incontinent of bowel and bladder, and at risk for falls. Interventions directed side rails per physician's orders to assist with bed mobility, call bell in reach, incontinent care per policy, and assistance with turning and repositioning. The nursing admission assessment dated [DATE] identified Resident #1 was re-admitted to the facility after a hospitalization. The assessment indicated Resident #1 was an assist of two (2) with positioning and incontinent of bowel and bladder. A physician's order dated 12/9/24 directed total mechanical lift for transfers, and assistance of two (2) staff for bed level activities of daily living and incontinent care. The nurse's note dated 12/14/24 at 6:20 AM identified the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1, responded to a 11PM-7AM nurse aide, Nurse Aide (NA) #1, calling for help. Upon entering Resident #1's room, RN #1 noted Resident #1 laying on his/her right side with the head was up against the nightstand and blood was coming from the right side of the head. Emergency Medical Service (EMS) was called and Resident #1 was transferred to the hospital for further evaluation. The nurse's note dated 12/14/24 at 7:32 AM identified the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #2, was called to Resident #1's room. The note indicated Resident #1 was observed on the floor after falling off the bed during incontinent care. The Resident Care Card prior to the 12/14/24 incident, last updated on 3/11/24, failed to identify the number of staff needed for assistance with turning and repositioning and incontinent care. The December 2024 Treatment Administration Record identified staff documented Resident #1 was an assist of two (2) with bed level activities of daily living and incontinent care. The hospital record dated 12/14/24 identified Resident #1 sustained a scalp laceration. The nurse's note dated 12/14/24 at 1:19 PM identified Resident #1 returned from the hospital with five (5) staples to the right side of the scalp. Interview with the Director of Nursing (DON) on 1/6/25 at 11:50 AM identified on 12/9/24 when Resident #1 returned from a short hospital stay the physical therapist, (PT) #1 assessed Resident #1 and obtained an order for Resident #1 to be a two (2) person assist for incontinent care. The DON identified PT #1 should have updated the nurse aide Resident Care Card. The DON identified at the time of the fall on 12/14/24, two (2) staff should have been assisting Resident #1. Interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 1/6/25 at 12:10 PM identified she worked with Resident #1 on a regular basis and the resident had been a two (2) person assist for as long as she could recall due to Resident #1's body size and right sided weakness. LPN #1 identified she had assisted NA #1 with Resident #1's incontinent care in the past when she worked the 11PM-7AM shift. Interview with the physical therapist, PT #1, on 1/6/25 at 12:25 PM identified upon return from the hospital on [DATE] she assessed Resident #1 and noted Resident #1 continued to require assistance of two (2) for all bed level care due to the resident's body size and non-functional right side. PT #1 explained an assist of one (1) staff during care would not have been safe. PT #1 identified she wrote the order on 12/9/24 because all orders need to be rewritten when a resident returns from the hospital. PT #1 also identified that she updated the Resident Care Card, however she was unable to locate a copy. Interview with the 7AM-3PM nurse aide, NA #2, on 1/6/25 at 12:45 PM identified she worked with Resident #1 on a regular basis, and someone always helped her when providing incontinent care. NA #2 explained a staff member would stand on either side of the bed acting as a barrier when rolling the resident from side to side and Resident #1 was an assist of two (2) during care for as far back as she could recall. Interview with NA #1 on 1/6/25 at 1:00 PM identified she had provided care for Resident #1 for the past eighteen (18) months, the only time she requested assistance when providing incontinent care was if Resident #1 was exhibiting an increase in behaviors, otherwise she provided care alone because the Resident Care Card did not say assist of two (2). NA #1 indicated on 12/14/24 she assisted Resident #1 with incontinent care. NA #1 explained she turned Resident #1 onto the right side, had the resident hold the bed rail with the left hand, stood behind the resident and washed the resident's back, she then placed Resident #1 on his/her back, walked to the other side of the bed, positioned Resident #1's right leg over the left leg, had the resident hold the bed rail with the left hand and as she pulled the pad towards her to turn Resident #1 onto the resident's left side, Resident #1's right leg swung forward and propelled Resident #1 feet first onto the floor and Resident #1 sustained a laceration to the right side of the head. The facility policy, Positioning, identified residents who are unable to position themselves are repositioned in accordance with his/her individual needs and that the Resident Care Card would indicate that the resident needs assistance with positioning. The facility policy, care Planning, identified the Resident Care Card would be updated as needed to reflect changes made to the resident's plan of care.

Based on observation, clinical record review, review of facility policy, and interview for the only sampled resident (Resident #71) reviewed for a death record, the facility failed to ensure that liquids were not accessible to a resident who was on aspiration (choking) precautions. The findings include: Resident #71's diagnoses included cerebrovascular accident (stroke) with left sided paralysis, Barrett's esophagus (narrowed esophagus), and dysphagia (difficulty swallowing). The Nursing Admission assessment dated [DATE] identified Resident #71 was cognitively impaired, dependent on staff for eating, and required the assistance of 2 staff for bed mobility and transfers. The Resident Care Plan (RCP) dated 11/29/23 identified Resident #71 was at risk for aspiration (food or fluids going into the lungs) with interventions that included assisting with feeding, watching for signs/symptoms of aspiration, alternating solids and liquids, encouraging small sips of fluid and small bites of food, encouraging the resident to remain in an upright position, at 90 degrees, for all intake, and to remain upright for 30 minutes to 1 hour after eating. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 was severely cognitively impaired, required maximum assistance with eating, and was dependent for oral hygiene. Additionally, Resident #71 experienced loss of liquids and solids from his/her mouth when eating or drinking, held food in their mouth, coughed or choked during meals, and required a mechanically altered diet of pureed food with thickened liquids. A physician's order dated 12/1/23 directed 1 to 1 supervision for Resident #71 with feeding/eating, and that his/her diet was to be puree textured food, honey thickened liquid consistency, and that Resident #71 required aspiration precautions. A nurse's note (written by RN #6) dated 12/6/23 at 2:39 PM identified Resident #71 had consumed fluid at the bed side and was seen by another staff coughing. Resident #71 was assessed, s/he was afebrile (without fever), his/her oxygen saturation (blood oxygen level) was 68% (normal range is 90% to 100%), and the remainder of the residents vital signs were stable. Oxygen was applied, the Advanced Practice Registered Nurse (APRN) was notified, and a chest x-ray was ordered. Review of Person #2's written report dated 12/7/23 at 11:39 AM identified on 12/6/23 s/he was on a facetime call with Resident #71 and noted that the resident appeared different. Person #2 indicated that while s/he was asking Resident #71's visitor about Resident #71's condition, a male nurse came in and told him/her (Person #2) that a cup of water had been left within Resident #71's reach, the resident had chugged the liquid and aspirated, and was then placed on oxygen. The written report from Person #2 further identified that Resident #71 was recovering from a stroke and required 1 to 1 assistance with feeding prior to this incident. A nurse supervisor note (written by RN #7) dated 12/6/23 at 11:20 AM identified she had been notified that Resident #71 was hypoxic (low oxygen in body tissues). RN #7 indicated Resident #71 had a normal temperature, an elevated heart rate of 110 beats per minute (normal range 60-80), blood pressure of 122/68 (within normal range), and fine crackles in bases of the lungs upon auscultation (listening). RN #7 increased Resident #71's oxygen level to 4 liters per minute through a nasal cannula (tubing). The APRN was notified and directed an immediate chest x-ray and vital signs every hour for 3 hours. A Speech Language Pathologist (SLP) note dated 12/6/23 at 4:57 PM identified that she was asked to see Resident #71 after the resident was found by Physical Therapy (PT) and Occupational Therapy (OT) trying to drink by his/herself which resulted in Resident #71 coughing and having chest congestion. RN #6 was notified immediately. The SLP note further indicated that she encouraged Resident #71 to perform strong coughs, however Resident #71 had difficulty following directions. The SLP attempted to facilitate swallowing with downward lingual pressure (tongue pressure) using an empty spoon, however this was not effective. The SLP subsequently educated staff not to leave food or drink within Resident #71's reach due to his/her required 1 to 1 supervision with food and eating assistance. The SLP noted that Resident #71 was attempting to self-feed, however s/he was not safe to self-feed and that RN #6 then resumed care. An APRN note dated 12/7/23 at 2:51 PM identified Resident #71 was transferred to the hospital with diagnoses of aspiration pneumonia, leukocytosis (elevated white cell count), and acute kidney injury (AKI) due to Resident #71's inability to meet fluid goals, poor oral intake, and an increased oxygen demand. A hospital discharge summary dated 1/9/24 identified Resident #71 was admitted to the hospital's Intermediate Care Unit (IMCU) and required high flow oxygen treatment due acute respiratory failure with hypoxia, aspiration pneumonia of the left lower lobe, and pneumonia due to the COVID-19 virus which had been diagnosed upon arrival to the hospital (12/7/23). Resident #71 had a Percutaneous endoscopic gastrostomy tube (PEG Tube/feeding tube) placed due to severe dysphagia, had a non-ST elevation myocardial infarction (heart attack), and required close telemetry monitoring (heart monitoring). Additionally, it was noted that Resident # 71's hospital stay was complicated by aspiration pneumonia. Interview with RN #6 on 4/9/24 at 12:28 PM, who responded to the incident on 12/6/23, identified that PT notified him that she saw Resident #71 guzzle water from a cup and began to cough. RN #6 ran to Resident #71's room, obtained vital signs, and started Resident #71 on oxygen due to the low oxygen saturation levels. RN #6 was unable to recall the actual oxygen saturation level stating he thought it was 58% or 68%. RN #6 notified both the nursing supervisor and the APRN of the incident. Interview with the SLP on 4/9/24 at 1:26 PM indicated that PT #3 and COTA #1 were walking by Resident #71's room and that from the hallway they observed Resident #71 in bed, alone, in the upright position, with a cup in his/her hand. PT #3/COTA #1 reported that Resident #71 had consumed the fluid, was coughing, and had spilled some liquid on his/her clothing. Additionally, Resident #71 was noted to be congested when breathing and that she was asked to evaluate the resident. The SLP stated that she had tried to get Resident #71 to clear his/her airway by swallowing, but her attempts had been ineffective. The SLP identified that the hospital discharge summary, on Resident #71's arrival to the facility, indicated that Resident #71 required 1 to 1 supervision with meals and that this was continued at the facility on Resident #71's admission orders due to his/her risk for aspiration. Subsequent to assessing Resident #71 after the 12/6/23 incident, the SLP instituted orders for feeding in a few places, not to leave a tray or fluids at the bedside, and to continue the 1 to 1 supervision. Interview with the Occupational Therapy Assistant (COTA #1) on 4/9/24 at 1:57 PM identified that she had helped to reposition and bathe Resident #71 after the resident was noted to have consumed the liquid. COTA #1 noted that the front of Resident #71's [NAME] had been soaked with a thickened liquid. COTA #1 indicated that Resident #71 was not aware that s/he had a deficit following the stroke and lacked initiation and self-awareness. Additionally, COTA #1 identified that she saw liquids and/or food left at bedside, across the room previously and did not believe Resident #71 had the ability to reach over. Interview with PT #3 on 4/9/24 at 2:30 PM identified that on 12/6/23 she had seen Resident #71 from the hallway, in bed, upright, and that the resident was holding a cup in his/her hand. PT #3 noted that Resident #71 was found with fluid down the front of his/her [NAME], and she notified the SLP. PT #3 stated that Resident #71 had a dense stroke, was flaccid on the left side, and had a right sided gaze. PT #3 indicated that Resident #71 was on aspiration precautions, required assistance with eating and drinking and required cues to swallow. Further, PT #3 identified that she had not seen Resident #71 with any visitors in the morning, on the day she discovered him/her holding the cup, only staff were present and upon discovery Resident #71 had been alone in the room with the cup in his/her hand. Interview and observation with Nurse Aide (NA) #4 on 4/9/24 at 3:04 PM identified that she assisted feeding Resident #71 with breakfast on 12/6/23. An observation of Resident #71's previous room identified that the overbed table was on the left side of the bed (as it was currently located) adjacent to the bed with the corner of the overbed table (approximately 6 inches) overlapping the mattress and touching Resident #71's half side rail (as it was currently positioned). Additionally, NA #4 identified that Resident #71 had been sitting upright following breakfast. NA #4 identified she had left Resident #71's thickened drink to the left of Resident #71 thinking that it would be out of his/her reach. NA #4 indicated that Resident #71 did not have visitors in his/her room around the time of and following breakfast, that only staff were present, that dietary staff had passed out the meal and that NA were responsible to distribute fluids. Interview with PT #3, COTA #1 and the SLP on 4/9/24 at 3:17 PM identified that it was unlikely but not impossible for Resident # 71 to reach over to his/her left side while in the upright position and pick up a cup if it had been located on the overbed table (where NA #4 indicated the overbed table had been located and where she had left the resident's beverage). Attempts to reach RN #7 and Person #2 were unsuccessful. Review of the facility Dysphagia policy identified, in part, that residents with dysphagia have difficulty swallowing liquids and/or solids that might pose a safety issue/risk for aspiration. Aspiration precautions may be instituted on residents who have dysphagia, and who have orders from a physician, nurse, or speech/language pathologist. Further, the Dysphagia policy procedure indicated that aspiration precautions included the head of the bed be elevated to a minimum of 30 degrees, supervision of meals may be identified, and positioning needs may be assessed. Interventions would be resident specific.

Based on review of the clinical, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #1) reviewed for accidents, the facility failed to provide adequate supervision during the provision of personal care resulting in fall with injuries. The findings include: Resident #1's diagnoses include dementia, [CONDITION(S)], anxiety disorder, depression, [CONDITION(S)], [CONDITION(S)] and spinal stenosis. A quarterly MDS assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive assistance of one for bed mobility, dressing, toilet use and personal hygiene. The assessment further identified that the resident had not history of falls in the past three months. The resident care plan dated 12/6/21 identified Resident #1 was at risk for falls with interventions that included; utilize two half side rails as an enabler, alternating pressure mattress to the bed and redirect and reposition if resident noted with legs hanging off of the bed or leaning to one side. The care plan further identified that the resident was at risk for osteopenia and [CONDITION(S)] with an intervention to minimize the risk for falls. Monthly physician's orders for the month of December/2021 identified that the resident required the assistance of one staff for activities of daily living and resident required a mechanical lift for transfers. The Interdisciplinary Team (IDT) fall assessment dated [DATE] identified that NA #1 left the resident's room to retrieve lotion and the resident fell out of bed. The fall assessment noted as a resolution/intervention that the resident should not be left in bed unattended with the bed in the high position. The Reportable Event Report 1/1/22 identified that on 12/31/21 at 11:30 AM, NA #1 was providing personal care to the resident during which the resident fell out of bed. The resident was subsequently sent to the hospital and diagnoses with a fracture of the femur and a [CONDITION(S)] that required sutures. The Reportable Event Report's summary dated 1/4/22 identified that NA #1 conveyed that Resident #1's bed was positioned at waist level for care and that the resident was positioned on his/her side when NA #1 left the room to gather supplies and upon reentry to the resident's room, NA #1 heard a loud noise and found Resident #1 on the floor. The report further noted that the corrective action plan to prevent reoccurrence included staff education regarding bringing all supplies into the room prior to care and when the bed is positioned in the raised position or the resident is positioned on his/her side, the resident should not be left alone. Interview on 1/10/22 at 11:25 AM with NA #1 identified that she left the resident to retrieve a specific lotion that she wanted to use on the resident that she'd left in the adjacent room and upon returning to Resident #1'room heard a thump and entered the room to observe the resident on the floor. Interview on 1/10/22 at 11:40 AM with the DNS identified she would have expected NA #1 to have gathered all supplies prior to the start of incontinent care per facility policy and to utilize facility products or those provided by the family for care. The DNS further identified that NA #1 should have contacted another NA to assist in securing lotion to maintain safety and lower the bed if necessary when exiting the room. Interview on 1/10/22 at 12:05 PM with the RN #1 identified that the resident was on the floor face down after the fall and noted that Physician #1 was in the building and rushed to the room with the distress call for possible emergent care. Resident #1 was sent to the hospital for an evaluation where he/she was diagnosed with a fracture to the femur and a laceration to the head requiring staples. RN #1 further noted that the resident remained hospitalized at the current time. Interview on 1/10/22 at 12:20 PM with RN #2 (the nursing supervisor on duty at the time of the incident) identified that Resident #1was found in a semi prone position on the floor due to weight shifting. Although Physician #1 was in the room RN #2 indicated the resident was lying close to the wall and could not be moved because the resident was lying between the bed and the wall. She further noted that there was bleeding resulting from the [CONDITION(S)]. Further interview with RN #2 identified that Resident #1's bed was in the high position and the resident does not move without maximum assistance. A second interview on 1/10/22 at 1:20 PM with NA #1 identified the resident did not have bed rails, but an observation with the Administrator at approximately 1:30 PM identified that Resident #1's bed had immovable rails on both sides of the bed that measured approximately twenty inches long from the top of the bed. A new bed was assigned to Resident #1 that had a winged air mattress to provide protection for possible [CONDITION(S)] activity. The facility's bathing/bed bath policy identified that supplies need to be assembled prior to the provision of a bed bath/provision of care and noted the necessary equipment consists of a basin, soap, washcloth, towels, bath blanket and gloves. The facility failed to ensure that the resident was left in a safe position in bed, which resulted in a fall with serious injuries inclusive of a femur fracture and a laceration to the head that required sutures.

Based on clinical record reviews, review of facility documentation and interviews for one sampled resident (Resident #1) who was reviewed for a self-inflicted injury, the facility failed to ensure a sharp tool was secured and not easily accessible to a resident to prevent an injury. The findings include: Resident #1's diagnoses included [CONDITION(S)] of left upper limb, depression and heart failure. A physician's order dated 9/18/21 directed to monitor Resident #1 for [CONDITION(S)] behaviors which included itching, picking at skin, restlessness, hitting, stealing, delusions, hallucinations, [CONDITION(S)], aggression and refusing care. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made consistent and reasonable decision regarding tasks of daily life, received pain medication daily and as needed, participated in physical and occupational therapy, and received an antidepressant daily. The nurse's notes dated 9/27/21 indicated at approximately 8:00 AM a charge nurse received a call from Resident #1's family member, Person #1, who reported Resident #1 had sent a picture from his/her cell phone of a box cutter lying on Resident #1's leg and Resident #1 expressed he/she was going to use the box cutter to kill him/herself. The note identified Resident #1 was noted to have several slits to the right wrist and Resident #1 stated I took the box cutter to cut myself during the night. The note identified on assessment Resident #1 had approximately eight (8) to ten (10) superficial cuts/slits to the right wrist that were scabbed over and there was no active bleeding, Resident #1 had good range of motion to the right wrist and denied any pain or discomfort. The note indicated Resident #1 was immediately placed on one to one (1:1) observation, seen by the physician at 8:30 AM, and a new order was given to send Resident #1 to the emergency room for evaluation. In an interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #1, on 10/12/21 at 11:15 AM, she indicated Resident #1 sustained eight (8) to ten (10) superficial lacerations on the right hand that were self-inflicted with a box cutter Resident #1 had taken from the therapy gym. RN #1 identified Resident #1 did not express feelings of sadness prior to the incident. In an interview with the Certified Occupational Therapy Assistant (COTA) #1 on 10/12/21 at 11:59 AM she indicated a therapy staff member observed a box cutter unattended on a mat in the therapy gym and the box cutter was placed in a plastic container in a closet. COTA #1 identified the following day a box cutter was again found on a mat in therapy room and was placed in the closet. COTA #1 indicated although there were residents were in the gym on both days when the box cutters were observed on the mat, she was unable to recall if Resident #1 was one (1) of the residents. In an interview with the Rehab Director on 10/12/21 at 12:10 PM she indicated tools including the box cutters were kept in a plastic container in the therapy gym, and the box cutters were utilized by staff to cut the tennis balls to place on walkers. The Rehab Director identified the closet containing the plastic container of tools was not locked. In an interview with the Rehab Tech on 10/12/21 at 1:06 PM she indicated on 9/23/21 she found a box cutter unattended on a mat inside the rehab gym and the box cutter was placed in a plastic container in the gym. The Rebab Tech identified residents were in the gym at the time she placed box cutter in the closet. In an interview with the 7AM-3PM charge nurse from the North Unit, RN #3, on 10/12/21 at 12:07 PM she indicated she had received a phone call from Resident #1's family member regarding the cell phone photo with the box cutter and she informed Resident #1's charge nurse, RN #1. RN #3 identified Resident #1 explained the box cutter was on a counter in the rehab gym, so he/she took the cutter and used the cutter to cut his/her wrist. The facility did not have a policy for safeguarding tool and ensuring tools were not easily accessible to residents.

Based on clinical record review and staff interview for the only resident in the survey sample reviewed for accidents (R # 91), the facility failed to supervise the resident during care resulting in a fall with injury and/or failed to ensure that residents were free from hazards that may cause harm. The findings include: 1. Resident# 91's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident had severely impaired cognition, required extensive assist with bed mobility, transfer, and walking in the room; and was not steady moving from a seated to standing position. A resident care plan dated 1/29/17 indicated the resident was at risk for falls secondary to dementia and needing assistance for transfers. The resident had a history of [REDACTED]. On 1/29/17 the resident was found on the floor next to the bed with no injury. Interventions included encourage the resident to keep the resident in highly visible areas, bed alarm, dycem to wheelchair, anti-rollback back to wheelchair, and call bell in reach. A nurse's note dated 2/19/17 at 11:08 AM indicated R #91 was found on the bathroom floor lying face down. The resident was screaming loudly and a large amount of blood was noted. The resident complained of severe pain in the face and right arm. A large open area was noted on the forehead. The ambulance was called and the resident was transferred to the emergency room . A review of a reportable event and investigation dated 2/19/17 indicated R # 91 fell in the bathroom. He/she was found facing down with large amounts of blood noted. The resident was screaming out loud. The resident had a large open area on the forehead that was bleeding. The resident indicated he/she was in severe pain. The investigation indicated R # 91 was assisted to the bathroom by NA # 1. The nurse aide went into the room to obtain a face cloth off the bed. Nurse aide # 1 heard a noise and found him/her on the floor. The resident sustained [REDACTED]. Nurse aide # 1 was placed on suspension pending the investigation. A hospital discharge summary dated 2/20/17 indicated R # 91 was left alone on the toilet and fell . He/she had a repaired facial laceration with suture removal to be done in 5 days, and a fractured right humerus with a sling to be used for comfort. The resident's pain was well-controlled with oral analgesics. The note indicated that there was a question if the fall was related to syncope, noted the resident's troponins were negative, and the EKG was unremarkable for ischemia and/or infarct. An interview on 6/28/17 at 10:00 AM with NA #1 indicated that he/she had assisted R # 91 to the bathroom on 2/19/17. He/she assisted the resident on the toilet and was going to provide care to the resident, but could not find the washcloths. He/she turned his/her back to the resident and went back into the room to look for the washcloths when he/she heard a bang. He/she looked back and the resident was on the floor. He/she did not see how the resident fell from the toilet. Nurse aide # 1 indicated he/she was aware that R # 91 was a fall risk and had many falls in the past. Nurse aide # 1 indicated he/she had never left the resident on the toilet alone before and should have put the call light on to request someone to get him/her the washcloths. An interview on 6/28/17 at 11:40 AM with the RN # 3 indicated he/she would have expected NA #1 to stay with the resident in the bathroom and put the bathroom call light on to request the washcloths. He/she further indicated after this incident all the nurse aides in the facility were in-serviced. 2. Observations on 6/27/17 during a tour of the facility noted the following resident safety concerns: a. A Velcro strip was attached to room #6 door frame with multiple large metal staples that were unattached and sticking out with exposed sharp edges. b. East Wing shower room has cracked, jagged tiles at ankle length. c. Door frame to East Wing bathroom had cracked broken plastic floor molding with jagged edges. d. The supply closet door was found on unlocked on two occasions - 06/27/17 with the Director of Maintenance and again on 6/29/17 with the Administrator. Items accessible to residents included: mouthwash, lotion, shaving cream, razors, toothpaste and other toiletries. The key was located on a nail on the upper left side of the door on the wall. e. The laundry room was found to be unlocked and unattended on multiple occasions on 6/27/17. The lock to the back door on the East Wing side was found to be broken and staff were unable to secure the door. The multiple caustic and hazardous chemicals were accessible to residents including: microtech liquid laundry suds, sour/soft, break detergent. The dryer machines were accessible to residents and they become extremely hot to the touch when the are in operation. In an interview with the Director of Maintenance, Director of Housekeeping and RN#1 on 6/27/17 at 1 PM, they indicated that the door to the East Wing had a broken lock and that the laundry room doors are left open. The doors remain unlocked on the off-shifts for staff to bring in dirty laundry. On 6/29/17, the laundry room doors remained unlocked until subsequent to surveyor inquiry. Review of the MSDS for the chemicals used in the laundry identified that the chemicals used in the laundry room are dangerous, corrosive, causes eye and skin burns and can be harmful or fatal if swallowed.

Based on clinical record review and staff interviews for one of three sampled residents (Resident 19) reviewed for change in condition, the facility failed to notify the physician in a timely manner regarding a change in the resident ' s mental status. The findings include: Resident #19's was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that the resident was severely cognitively impaired, had memory problems and required limited assistance for toileting. The (interim) Resident Care Plan (RCP) dated 8/23/13 identified a risk for falls with interventions that included providing the resident with non-skid socks, to redirect the resident when needed and to provide the resident with a call bell. The physician's order [REDACTED]. 25 Milligrams ( MG0 twice a bid when needed for agitation, [MEDICATION NAME] Sodium ( Mood Stabilizer) 250 MG every am , [MEDICATION NAME] Sodium 125 MG at hour of sleep and [MEDICATION NAME] Sodium 250 MG now. The nurses ' notes dated 8/24/13 through 8/26/13 identified that the resident exhibited combative and aggressive behaviors, resistance to care, agitation, yelling, delusional behavior, made attempts to self-transfer and was placed on one to one observations. The nurse ' s note dated 8/26/13 for the 3-11:00 P.M. shift identified Resident # 19 was found on the floor in the hallway on the East Wing. The resident was found on her/his back with their head against the wall. The resident was assessed and no apparent injuries were noted. A subsequent nurse ' s note dated 8/26/13 at 11:00 P.M. identified Resident #19 was observed standing up in his/her room and lost his/her balance, landed on the floor and indicated that no injuries were noted from the fall. The nurses ' note dated 8/27/13 through 8/28/13 identified Resident #19 was noted with increased lethargy, sleeping most of the shift, was unsteady and confused. The psychiatric Advanced Practical Nurse ( APRN) consultant was notified of the need to evaluate the resident ' s medications. The psychiatric Advance Practical Nurse ( APRN) consultant progress notes dated 8/30/13 identified that Resident #19 exhibited aggressive, delusional and paranoia behaviors and recommended no changes to the resident ' s antipsychotic medications. The nurse ' s note dated 9/3/13 identified that Person #1 reported to facility staff that Resident #19 was lethargic, had slurred speech and was drooling and was not at his/her baseline. The clinical record failed to reflect the attending physician was notified of the resident ' s change in condition. The routine physician ' s progress note dated 9/4/13 identified that Resident #19 was more lethargic, and the [MEDICATION NAME] was discontinued and the resident would remain on [MEDICATION NAME] . The nurses ' notes dated 9/4/13 through 9/6/13 identified that Resident # 19 was lethargic and indicated that the [MEDICATION NAME] was held due to the resident ' s increased lethargy. The nurse ' s notes dated 9/5/13 through 9/6/13 (48 Hours) lacked documentation that the resident ' s physician had been notified of the change in Resident # 19 ' s mental status and that Resident #19 had reported hitting her/ his head during a fall . The nurses notes dated 9/7/13 identified that Resident # 19 ' s was sluggish to respond, that the resident ' s right pupil was not responsive to light , the left hand grasp was strong but the right hand grasp was absent, that the resident was not following commands and was noted with a right lip drop. Additionally, noted that the resident was sent to emergency room for an evaluation and noted that the resident was admitted to the hospital with [REDACTED].# 19 had multiple left cerebral emboli due a new onset of [MEDICAL CONDITION] and that due to the resident ' s [DIAGNOSES REDACTED]. Interview with Medical Doctor (MD) # 1 on 11/21/13 at 2:43 P. M. identified that he/she was not aware that Resident #19 reported to staff that she/ he hit her/ his head during the fall on 8/26/13 and that if he/ she had been made aware of the resident hitting her/ his head he/ she would have visited Resident # 19 and conduct an examination.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to provide supervision and/or assistance to prevent an accident. The findings include: Resident #1's [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified that Resident #1 had moderate cognitive impairment, disorganized thinking, required extensive one person assistance for transfers in and out of the bed and/or chair and toileting use, was non-ambulatory, utilized a wheelchair for mobility and the resident's balance during transitions was not steady and only able to stabilize with staff assistance. The resident care plan dated 3/28/13 identified that Resident #1 required assistance with activities with daily living. Interventions directed to provide assistance with bathing, toileting and bed mobility. a. Review of progress note dated 5/20/13 at 8:50 AM identified that at 6:45 AM the charge nurse was called to the room and Resident #1 was on the floor face down with a large laceration to the bridge of the nose. The resident was transferred to the emergency department, was identified with a fractured nose and sutures to the laceration and steri strips were applied to the right hand. Review of the radiology report dated 5/20/13 identified that Resident #1 had sustained displaced and somewhat comminuted fractures of the nasal bones with nasal septal deviation towards the left, the septum was fractured and there was soft tissue density in the nasal cavity suggestive of a hemorrhage. Review of facility documentation dated 5/20/13 identified that Resident #1 fell forward out of the wheelchair while Nurse Aide (NA) #1 was taking Resident #1 to the bathroom. Interview with NA #1 on 10/28/13 at 3:00 PM identified that she had transferred Resident #1 out of bed and into the wheelchair without the leg rests because she customarily applied the leg rests after morning care was completed. NA #1 stated that she turned, reached back to get gloves, turned back around and took one and one-half step when Resident #1 fell forward onto the floor. NA #1 identified that she has received direction to always use leg rests with Resident #1. Interview with the Director of Rehabilitation on 10/28/13 at 3:10 PM identified that after the fall a therapy screen was completed and the front wheels were raised on the wheelchair. The Director indicated that if a resident was being pushed in the wheelchair, leg rests should be utilized. Review of facility policy directs that residents will be provided appropriate seating to maintain comfort, body alignment and promote maximum level functioning. b. Review of the progress note dated 8/14/13 identified that Resident #1 was transferred to the toilet in the shower room and left with the call bell. Resident #1 proceeded to attempt to self-transfer and fell . Review of facility documentation dated 8/14/13 identified NA #1 had transferred Resident #1 onto the toilet in the shower room bathroom, left to answer a call bell and when she responded to the bathroom call bell Resident #1 was found on the floor on his/her knees, hanging on to the side bars with no injury. Interview with the Assistant Director of Nursing (ADON) on 10/28/13 at 12:05 PM identified that Resident #1 shouldn't have been left alone on the toilet and subsequent to the incident the care plan was revised.

Based on record review, staff interview and review of facility documentation for one of three sampled residents reviewed for accidents (Resident # 21), the facility failed to transfer with two assist and a mechanical lift per the physician orders [REDACTED]. The findings include: Resident # 21's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] severe cognitive impairment and required extensive assistance of two staff members for bed mobility, transfers and assistance of one staff member with dressing, and personal hygiene. The care plan dated 6/26/12 identified assistance with activities of daily living with interventions which included to provide extensive assistance with activities of daily living and to transfer with a mechanical stand lift and assistance of two staff members. The physician orders [REDACTED]. The nurse's note dated 9/6/12 at 2:00 PM identified scattered bruising on the right knee measuring 8 centimeters by 6.5 centimeters. The Physician Assistant note dated 9/6/12 identified the resident had right knee pain and bruising. The resident complained of more pain in the left knee but stated pain was in both the knees. The Physician Assistant further identified that staff stated there was not any reported trauma. Tramadol was ordered and administered and if there was no relief, the Physician Assistant recommended to administer Naproxen 25 mg every 12 hours for 2 days. The nurse's note dated 9/7/12 at 5:00 PM noted new ecchymotic areas to the lateral right knee and right great toe. The physician's orders [REDACTED]. The x-ray report dated 9/7/12 at 8:15 PM identified a recent fracture to the right knee and the resident was transferred to the emergency room for an evaluation. The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The nurse's note dated 9/9/12 at 3:55 PM noted bruising to the residents left lateral knee and upper calf with increased pain with movement. The physician was notified and directed an x-ray to the left knee, fibula, tibia and femur. X-ray results dated 9/9/12 noted a possible subtle metaphyseal fracture of the distal femur. The nurse's note dated 9/9/12 at 11:30 PM noted inconclusive results from the knee/femur x-ray; physician was notified and ordered to repeat the x-ray. The resident was also noted to have a bruise on the left side of the breast and rib and complained of pain upon touch. The left wrist was also noted to be swollen and "distorted." The nurse's note further identified when the resident was asked how she/he sustained the injuries, the resident states "falling a few days ago." The physician was updated and directed to send resident to the hospital for an evaluation. The nurses note dated 9/10/12 at 7:00 AM noted the resident returned from the hospital and diagnosed with [REDACTED]. The nurses note dated 9/10/12 at 4:00 PM noted the hospital called and the left leg was negative for a fracture but to continue with the immobilizer and contact the orthopedic physician. Facility investigation dated 9/10/12 identified on 9/5/12 R#21 was in the shower room to receive a shower. NA#1 was standing in front of the resident placing the Hoyer pad below the resident (a Hoyer split pad) when the resident began to slide forward. NA#1 further indicated that she grabbed the resident around the resident's waist to lift her/him back into the shower chair. The nurses notes dated 9/17/12 at 3:25 PM identified the resident was seen by the orthopedic physician and diagnosed with [REDACTED]. The immobilizer was discontinued to the right leg but continued on the left leg. On 10/3/12 at 11:40 AM interview with NA#1 identified on 9/5/12 she gave the resident a shower and while placing the Hoyer pad under the resident without assistance, Resident #21 began to slide out of the shower chair, her/his buttocks leaving the seat of the chair but did not hit the floor. NA#1 stated she "bear hugged" the resident from the front because the resident is larger and lifted her/him back into the shower chair as he/she did not have time to call for help due to the resident sliding out of the shower chair. The facility investigation conclusion from the DNS identified that the physician and physician assistant concur that the type of movement caused by flexing bilateral knees could cause an injury. On 10/5/12 at 11:41 AM an interview with the Orthopedic Physician Assistant noted due to the resident's age, being on Coumadin and probable osteoporosis, the act of placing the resident in a bear hug and lifting her/him in a shower chair caused the torso bruising and probably the knee fracture.