Every finding on record at Apple Rehab West Haven

Based on clinical record review, facility documentation review, and interviews for three of three residents (Resident #1, #4 and #5) reviewed for quality of care, the facility failed to ensure the physician/designee orders were reviewed and renewed at least once every 60 days. The findings included: Resident #1's diagnoses included dementia, and delusional disorders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment and required assistance with ADLs and ambulated independently. The Resident Care Plan (RCP) dated 12/18/2025 identified and alteration in ADL function. Interventions directed to assist as needed. Record review identified Resident #1 was on a 60-day schedule for review and renew of physician orders. Additional review identified the last signed orders were dated September 2025; physician orders were not signed by MD #1 beginning October 2025 through February 2026. Although requested facility failed to provide any additional signed physician orders (paper or electronic) for Resident #1. Resident #4's diagnoses included severe protein calorie malnutrition, chronic pulmonary disease and history of transient ischemic attack (mini-stroke). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and required assistance for ADLs. The Resident Care Plan (RCP) dated 1/18/2026 identified Resident #4 needed assistance with ADLs. Interventions directed to assist as indicated and transfer per MD orders. Record review identified Resident #4 was on a 60-day schedule for review and renew of physician orders. Additional review identified the last signed orders were dated September 2025; physician orders were not signed by MD #1 beginning October 2025 through February 2026. Although requested facility failed to provide any additional signed physician orders (paper or electronic) for Resident #4. Resident #5's diagnoses included dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #5 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment and was dependent ADLs. The Resident Care Plan (RCP) dated 3/6/2026 identified an alteration in ADLs, and interventions directed to assist as needed and transfer per MD orders. Record review identified Resident #5 was on a 60-day schedule for review and renew of physician orders. Additional review identified the last signed orders were dated September 2025; physician orders were not signed by MD #1 beginning October 2025 through February 2026. Although requested facility failed to provide any additional signed physician orders (paper or electronic) for Resident #5. Interview and record review with the DNS and Corporate RN #1 on 4/20/2026 at 2:30 PM identified physician orders should be signed at least every 60-days. MD #1 was new to signing electronic orders and had been educated how to sign them, but indicated the orders for Resident #1, #4 and #5 were not signed. Resident #1 and Resident #4's orders were last signed in September 2025. RN #1 further stated she was unable to identify when Resident #5's orders were last signed (they were not signed during September 2025). Interview failed to identify why the facility did not identify the orders were not signed timely and failed to identify a facility process to ensure orders were signed timely. Subsequent to surveyor inquiry, interview and record review with the DNS and RN #1 on 4/21/2026 at 12:32 PM, identified the orders were now signed. Although requested, the facility did not provide a policy for surveyor review related to physician orders, or electronic signatures.

Based on clinical record reviews, facility documentation, facility policies, and interviews for four of four residents (Resident #7, #8, #9, and #10) reviewed for quality of care, the facility failed to ensure elopement risk assessments were performed at appropriate intervals, and/or the facility failed to ensure an elopement risk assessment was completed accurately/completely. The findings include: Resident #7's diagnoses included mild cognitive impairment and anxiety. The Resident Care Plan dated 2/15/25 identified Resident #7 had impaired memory, recall, and decision-making skills. Interventions directed reminders when confused. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of three out of fifteen (3/15), indicating severe cognitive impairment, had no wandering behaviors and ambulated independently with a wheelchair. Clinical record review identified no elopement risk assessments were completed since admission to the facility on 5/19/25 (two years). Review of a nursing re-admission assessment dated [DATE] identified an elopement risk assessment was initiated; however, the assessment was not completed. 2. Resident #8's diagnoses included depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicating resident was cognitively intact. and ambulated independently with a wheelchair. The Resident Care Plan dated 3/3/26 identified Resident #8 an alteration in ADL function (activities of daily living). Interventions directed to assist with ADL's as needed due to resident may fluctuate in his/her ability to perform ADL's due to cognitive status. Clinical record review identified the most recent completed elopement risk assessment for Resident #8 was dated 11/5/2022, with no evidence of a reassessment since that time (3 years and 4 months). A nursing re-admission assessment dated [DATE] referenced a prior elopement risk assessment identifying Resident #8 as not at risk for elopement. Record review failed to identify an elopement risk assessment was completed upon re-admission on [DATE]. 3. Resident #9's diagnoses included adjustment disorder, and anxiety. A nursing assessment dated [DATE] identified Resident #9 had cognitive impairment. An elopement risk assessment was initiated; however, the assessment was not completed, including the final risk determination section. The Resident Care Plan dated 3/25/26 identified Resident #9 is at risk for elopement from the building due to tendency to wander. Interventions directed placement on the secured unit, wander guard per physician orders, and check wander guard placement each shift and functioning per facility policy. Record review failed to identify any elopement assessment was completed since admission on [DATE] (68 days prior). 4. Resident #10's diagnoses included dementia and adjustment disorder. A Nursing admission assessment dated [DATE] identified cognitive impairment. The Resident Care Plan dated 2/28/26 identified Resident #10 at risk for wandering and can be confused and forgetful, at risk for elopement from the building. Interventions directed to apply wander guard per physician orders, orders, and check wander guard placement each shift and functioning per facility policy, and to offer to escort resident if seen heading toward or lingering near an exit door. Clinical record review identified the most recent completed Elopement Risk Assessment for Resident #10 was dated 11/25/2024 (1 year and 5 months prior), with no evidence of a reassessment since that time. Interview and record reviews with RN #1 (Corporate Regional Nurse) on 4/28/26 at 12:15 PM identified nursing staff are responsible for completing elopement risk assessments for residents, and the electronic medical record (PCC) generates alerts when assessments are due. RN #1 stated she expected elopement risk assessments to be completed on admission, readmission, quarterly, and with a change in condition; however, she confirmed the facility policy only requires completion on admission and readmission and does not include a requirement for ongoing or periodic reassessment. RN #1 further stated that elopement risk assessments for Resident #7 and Resident #9 were not completed in full, including the final risk determination section was not completed, and was unable to provide a rationale for the incomplete assessments. RN #1 was also unable to explain how the facility monitors compliance with completion or reassessment of elopement risk assessments. Review of the facility undated Elopement Risk Policy directed in part, all residents are evaluated for risk of elopement on admission and readmission; every resident admitted to the facility will be evaluated for elopement risk. A care plan will be developed and individualized interventions implemented if the resident is identified to be an elopement risk per the Elopement Risk Evaluation. An activated elopement bracelet (wander guard) will be placed on the resident and documented in the medical record if deemed appropriate. Each shift, placement of the elopement bracelet will be verified and documented in the medical record. Functioning of the elopement bracelet will be tested on ce a day by utilizing a tester unit and documented in the medical record.

Based on review of the clinical record, facility documentation and facility policy, and interviews for one of two residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was assessed timely upon readmission for special needs and adaptive devices for a resident with a known history of requiring a specialized drinking cup. The failure resulted in a second-degree burn measuring seventeen (17) centimeters (cm) by nine-point-five (9.5) cm. The findings include:Resident #1 was admitted to the facility with diagnoses that included stroke, diabetes mellitus, peripheral vascular disease, congestive heart failure and chronic obstructive pulmonary disease with dependance on supplemental oxygen. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated moderate cognitive impairment, required staff to set up for meals. The Resident Care Plan (RCP) dated 9/24/2025 identified an alteration in activities of daily living, and was at risk for aspiration. Interventions directed to set up meals, and to keep head of bed at 90 degrees while eating. Physician orders dated 9/13/2025 directed use of a Kennedy cup (adaptive drinking cup with a screw on lid that prevents spills even when turned upside down) for all hot and cold liquids. Facility discharge/transfer documentation dated 10/9/2025 identified Resident #1 was transferred to the hospital due to a change in respiratory status. The documentation directed Resident #1 required use of a Kennedy cup for all hot and cold liquids. A nursing re-admission assessment form completed by RN #1 dated 10/23/2025 at 1:30 PM identified Resident #1 was readmitted to the facility without any changes in functional status. A nursing SBAR (change in condition) note dated 10/23/2025 at 7:29 PM identified Resident #1 had spilled coffee, noted discoloration on the right thigh with reports of pain level of four (4) out of ten (10) where 10 was the worst possible pain. Review of the NA documentation of Activities of Daily Living (ADL) for October 2025 identified that it included an intervention to provide Resident #1 with a [NAME] Cup with all meals for all fluids. A facility reportable event (RE) form dated 10/23/2025 at 5:00 PM (the day of readmission to the facility) identified Resident #1 removed a coffee lid from the cup and spilled the coffee on her/his right thigh. An RN assessment was completed with redness noted initially to the site then a blister formation. Physician order dated 10/24/2025 (the day after the incident) directed use of a Kennedy cup for all hot and cold liquids. The RE summary dated 10/27/2025 identified Resident #1 called for NA #3 to report that she/he had spilled coffee on her/his right thigh. Resident #1 identified he/she removed the coffee lid and while attempting to remove the lid some of the coffee spilled on him/her. Initial redness was noted followed by blistering later in the shift. The area measured seventeen (17) cm by nine-point-five (9.5) cm. The temperature of the coffee served from the coffee dispenser was tested at 171 degrees Fahrenheit. Upon report of the spill, an RN assessment was performed and a cool compress was applied. The APRN and responsible party were notified. Bacitracin was initially ordered then the order was changed to Silvadene (cream used to prevent and treat wound infections in residents with burns) daily. A therapy screen was ordered, and Resident #1 was given a Kennedy cup to prevent future occurrences. A wound care MD specialist note dated 10/28/2025 identified the wound was a right lateral hip burn, full thickness (of the skin) measuring twelve (12) cm in length by eight-point-five (8.5) cm in width and zero (0) depth with a calculated area of one-hundred and two (102) square cm. The wound base was seventy-five (75) percent (%) slough (yellowish stringy dead tissue). Resident #1 reported pain at five (5) on a scale of ten (10). Interview with OT #1 on 11/17/2025 at 10:40 AM identified she evaluated Resident #1 on 10/24/2025 due to his/her readmission to the facility on [DATE]. OT #1 stated she was unaware of the burn at the time of her evaluation, and based on her knowledge of Resident #1's previous status, she immediately re-ordered the Kennedy cup for all liquids. OT #1 stated Resident #1 had a long history with spilling drinks prior to the transfer to the hospital on [DATE]. OT #1 stated Resident #1 had required use of a Kennedy cup since August 2024. She identified that the order for the Kennedy cup had been discontinued when Resident #1 was transferred to the hospital on [DATE] and the order was not re-activated when Resident #1 returned to the facility (from the hospital) on 10/23/2025. She did not assess Resident on 10/23/2025 when he/she returned to the facility due to the time of day when Resident #1 was readmitted . OT #1 stated she did not know why the nursing staff did not identify that Resident #1 needed the Kennedy cup for safety upon her/his readmission, and why they did not re-order the use of the Kennedy cup. Interview with NA #3 on 11/17/1015 at 1:00 PM identified she was the Nurse Aide (NA) assigned to Resident #1 on 10/23/2025 and Resident #1 was in bed and was using a regular coffee cup. About 5:00 PM she answered the call light and Resident #1 reported that he/she had taken the lid off the cup and spilled the coffee on his/her right thigh. NA #3 stated she did not know Resident #1 needed a special cup for liquids as she was not assigned to distribute drinks before dinner that day. She identified that there is a list attached to the drink cart that identified residents who need special equipment such as a Kennedy cup and the NA providing the drinks would be responsible to address that need. NA #3 stated she did not recall if Resident #1 used a Kennedy cup prior to the hospital transfer on 10/9/2025. Interview and facility documentation review with NA #2 on 11/17/2025 at 1:46 PM identified she was assigned to the drink cart on 10/23/2025, and identified Resident #1 was not listed as needing a Kennedy cup for liquids. NA #2 stated she had provided the coffee in a regular coffee cup with a lid when serving drinks prior to dinner on 10/23/2025. NA #2 stated she did not recall Resident #1 had used a Kennedy cup prior to her/his hospital transfer on 10/9/2025. Interview and record review with the DON on 11/27/2025 at 2:20 PM identified Resident #1 had an active order in effect on 10/9/2024 that directed to provide Resident #1 with a Kennedy cup for all hot and cold liquids. The order was automatically discontinued in the electronic medical record (EMR) when Resident #1 was transferred to the hospital. Upon Resident #1's return to the facility, orders were obtained based on the hospital transfer documents, and the hospital documents did not list an order for a Kennedy cup for all hot and cold liquids. The DON stated the admitting nurse was not familiar with Resident #1's previous care needs and did not re-enter the order for the Kennedy cup. The DON stated the facility did not have a process in place to reconcile previous orders or interventions for any resident upon readmission, and indicated unique needs could be missed. Review of the NA October 2025 ADL documentation identified the Kennedy cup ws documented as provided through 10/9/2025. Additional review identified the documentation was marked to indicated the activity did not occur through 10/22/2025 (the day before readmission to the facility). The DON was unable to explain why the Kennedy cup continued to appear on the ADL documentation sheet when Resident #1's previous order was discontinued with the 10/9/2025 discharge and why the NAs were unaware that Resident #1 needed a Kennedy cup for all liquids. Interview identified the Kennedy cup should have been re-ordered upon Resident #1's return to the facility. The DON was unable to explain why an assessment for use of the Kennedy cup that was ordered prior to hospital transfer was not completed prior to being served a meal. The Facility Policy Adaptive Equipment, directed in part, that adaptive equipment is provided to residents based on evaluation and recommendations by the care team with a goal to help the residents eat independently.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to notify a provider when an antibiotic used to treat a Urinary Tract Infection was omitted five (5) times for various reasons. The findings include:Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to notify a provider when an antibiotic used to treat a Urinary Tract Infection was omitted five (5) times for various reasons. The findings include: Resident #1's diagnoses included Alzheimer's disease and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating Resident #1 had some memory recall deficits, was dependent on staff for personal hygiene and toileting and incontinent of bowel and bladder. The Resident Care Plan dated 5/21/25 identified that Resident #1 was often incontinent of bowel and bladder and at risk for. Interventions directed to offer and encourage fluids often throughout the day, encourage and offer toileting as needed and if the resident reports burning on urination, has an elevated temperature or reported flank pain, notify a provider, as the resident may have a urinary tract infection. The nurse's note dated 8/13/25 at 4:11 AM identified Resident #1 returned from the hospital and was diagnosed with a urinary tract infection and started on cefuroxime (an antibiotic) and the Advanced Practice Registered Nurse (APRN) was notified. A physician's order dated 8/13/25 directed to administer the antibiotic cefuroxime axetil 500 milligrams (mg) tablet, give one (1) tablet two (2) times a day for a urinary tract infection for ten (10) days. Review of the August 2025 Medication Administration Record (MAR) identified the cefuroxime axetil was not administered five (5) times to Resident #1 on: -8/13/25 at 9:00 AM reporting the medication was unavailable and to see the nurse's note.-8/15/25 at 9:00 AM reporting the antibiotic was held and to see nurse's note.-8/15/25 at 5:00 PM reporting Resident #1 was on a Leave of Absence (LOA).-8/21/25 at 9:00 AM reporting the antibiotic was held and to see nurse's note.-8/22/25 at 9:00 Am reporting the antibiotic was held and to see nurses note. Review of the nurse's notes dated 8/13/25, 8/15/25 and 8/21/25 identified Resident #1 had refused the 9:00 AM doses of cefuroxime and there were no notes documented regarding the 8/15/25 dose at 5:00 PM or the 8/22/25 dose at 9:00 AM. Upon further review from 8/13/25 through 8/22/25 the nurse's notes failed to reflect documentation the charge nurses informed the nursing supervisors or the provider was notified of the missed administrations. Interviews with LPN #1 and LPN #2 on 9/17/25 identified they were unaware the provider had to be notified for each missed dose of a medication. The nurses explained they had not notified the nursing supervisor or the provider when they did not administer the cefuroxime axetil on 8/13/25, 8/15/25, 8/21/25 or 8/22/25. LPN #2 identified she could not recall why on 8/22/25 she did not document Resident #1's refusal to take the cefuroxime axetil in the nurse's notes reporting she should have. Interview with the APRN on 9/17/25 at 1:28 PM identified she was unaware and had not been notified Resident #1 missed five (5) doses of the cefuroxime axetil due to refusal and going on an LOA, stating had she known, she could have changed the time of the administrations to allow the staff to reapproach Resident #1 at a later time and/or extended the duration of the cefuroxime axetil treatment. The APRN identified t a provider should have been notified for each missed medication dose. Interview with the Director of Nursing (DON) on 9/17/25 at 2:37 PM identified the provider should have been notified for each missed dose medication and each missed dose was documented to include why the medication was not administered and who was notified following the omission of each medication and any new orders obtained. The DON reported when a resident refuses a medication, nursing should be educating the resident on its importance and then reapproaching the resident if they continue to refuse and documenting each reapproach and interaction and identified that she was unsure why that had not been done. Review of the Medication Administration policy (undated) directed, in part, that all medications shall be administered safely and accurately in accordance with physician's orders, facility protocols and applicable state and federal regulations. Document the administration in the MAR immediately after giving the medication. Monitor residents for therapeutic side effects and potential side effects of medications. All resident refusals of medication must be documented in the medical record, including the reason for refusal if provided, and the provider must be notified as appropriate. If medication is not available at the time of administration: notify the physician immediately and request guidance or an alternative order, inform he resident or their responsible party, check with the pharmacy to expedite delivery of the medication and document all actions taken in the resident's medical record and notify the supervisor.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for admission orders, the facility failed to ensure an appointment was scheduled with an outside specialty provider per admission orders. The findings include:Resident #1's diagnoses included Alzheimer's disease, type 2 diabetes mellitus and myotonic muscular dystrophy (a genetic disorder affecting the muscles and causing progressive weakness and muscle stiffness). The Nursing admission assessment dated [DATE] at 7:33 PM identified that Resident #1 was alert with good memory recall and required staff assistance with positioning and transfers. The Resident Care Plan (RCP) dated 5/7/25 identified that Resident #1 has a diagnosis of diabetes and is at risk for hypo/hyperglycemia. Interventions included watching for any acute signs/symptoms of hypo/hyperglycemia and reporting to the provider, checking the resident's blood sugar with any diabetic signs and symptoms including sweating, confusion or changes in mental status. A nurse's note dated 5/7/25 at 8:58 PM identified that Resident #1 was newly admitted to the facility at 4:00 PM and required an Endocrinology appointment within one (1) to two (2) weeks. A physician's order dated 5/7/25 directed that Resident #1 required a follow-up appointment with Endocrinology within 1 to 2 weeks and directed to discontinue the order when the appointment was obtained. Review of the clinical record from 5/8/25 through 8/23/25 failed to identify that an endocrinology appointment was ever scheduled or that the resident was seen by endocrinology. Review of the Medication Administration Records from May 2025 through August 2025 identified that nursing continued to sign off the 5/7/25 order identifying that Resident #1 required an endocrinology appointment daily at 9:00 AM until 8/22/25 (3.5 months later). Interview with Person #1 (Endocrinology office) on 9/17/25 at 11:18 AM identified that Resident #1 had not been seen in their office from May to August 2025 and reported that no one from the facility had ever called them to set up an appointment. Interview with Registered Nurse (RN) #5 (3:00 PM to 11:00 PM Nursing Supervisor) on 9/17/25 at 3:13 PM identified that when a resident is admitted to the facility with hospital paperwork stating they require an appointment with an outside provider, she notifies the provider, notates it on the facility's 24-hour report and then enters an order that shows up on the MAR so that the charge nurse is aware that they need to schedule the appointment. RN #5 identified that the charge nurse is responsible for scheduling the appointment within 72-hours and reported that if they don't have time, it's their responsibility to notify the nursing supervisor for assistance. She identified that the endocrinology appointment should have been scheduled by the facility, and she was unsure why it had not been. Interview with the Director of Nursing (DON) on 9/17/25 at 2:41 PM identified that the facility doesn't utilize secretaries or unit managers, so the charge nurses and nursing supervisors are responsible for making appointments and setting up transportation for residents who require appointments outside of the facility. She reported that although she was not the DON at the time of Resident #1's admission and she was unaware that the resident required an endocrinology appointment, nursing staff should have followed the physician's order and ensured that the appointment was scheduled as directed and that coordination of medical care was preserved for the resident. The DON identified that staff should have scheduled the appointment within 48 to 72 hours, and she was unsure why staff continued signing off the order daily for three (3) months without scheduling the appointment. Although requested, policies on following physician's orders and scheduling offsite provider appointments were not provided.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for a change in condition, the facility failed to ensure a complete and accurate clinical record to include medical care provided prior to a transfer to the hospital. The findings include:Resident #1's diagnoses included Alzheimer's disease, type 2 diabetes mellitus and myotonic muscular dystrophy (a genetic disorder affecting the muscles and causing progressive weakness and muscle stiffness). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition and required substantial assistance for bed mobility and was dependent on staff for personal hygiene and toileting. The Resident Care Plan (RCP) dated 8/18/25 identified that Resident #1 has a diagnosis of diabetes and is at risk for hypo/hyperglycemia. Interventions included watching for any acute signs/symptoms of hypo/hyperglycemia and reporting to the provider, checking the resident's blood sugar with any diabetic signs and symptoms including sweating, confusion or changes in mental status. A nurse's Situation Background Assessment and Recommendation (SBAR) dated 8/23/25 at 9:38 AM identified that the resident was observed laying in his/her bed only responsive to a chest rub which produced slight facial grimacing. It reported that the resident's breathing was labored and the heart rate was tachycardiac (abnormally fast) at 125 beats per minute, skin was pale and cold to touch and appears very weak and cachectic (muscle wasting) with decreased endurance and sharp bony prominences. It identified that the family was notified, the provider was notified and an order was obtained to transfer the resident to the Emergency Department (ED) for evaluation. Although the SBAR identified that the resident was barely responsive, skin was pale and cold to touch, and the resident had a diagnosis of diabetes, neither a body temperature nor a blood sugar were documented as obtained or communicated to the provider. Review of the clinical record failed to identify a body temperature or a blood sugar documented for Resident #1 on 8/23/25. Review of hospital ED notes dated 8/23/25 identified that the resident was found to be febrile (having a fever) of 102.2 degrees Fahrenheit (moderate grade fever) and a blood glucose level of 503 (high blood sugar that requires immediate medical care). Interview with RN #2 on 9/17/25 at 1:41 PM identified that on 8/23/25, she was the nurse assigned to Resident #1 when the Nurse Aide (NA #2) notified her that the resident was unresponsive. RN #2 reported that she did a brief assessment on the resident and then notified RN #1 (Nursing Supervisor), who called the provider and then started the paperwork to transfer the resident to the ED as she (RN #5) did a more thorough assessment and obtained vital signs and a blood sugar on the resident. RN #2 identified that although she didn't document the blood sugar or the body temperature, reporting that she should of before she left for her shift that day, stated that due to Resident #1's condition, she forgot to fully document, stating she left out important documentation that were important to communicate in the resident's medical care to the hospital. RN #2 identified that she could not recall the resident having a fever and reported that she believed the resident's blood sugar was 110 (within normal range) prior to sending the resident to the ED. Interview with the Advanced Practice Registered Nurse (APRN) on 9/17/25 at 1:28 PM identified that for Resident #1 who was known to be diabetic and on insulin and for a resident who was currently being treated with antibiotics for a UTI, when the resident was observed to be unresponsive, nursing should have immediately taken a full set of vital signs, including a body temperature and a blood glucose level and communicated it to the provider and the Emergency Medical Staff (EMS) upon transport to the hospital and then documented it so that facility providers could review. Interview with the Director of Nursing (DON) on 9/17/25 at 2:41 PM identified that nursing staff is responsible for documenting in the clinical record for a resident as close to the event that the care takes place but no later than the end of the shift. The DON reported that RN #2 should have documented Resident #1's body temperature and blood sugar in the clinical record on 8/23/25 and she was unaware that it had not been done. Review of the Nursing Documentation policy (undated) directed, in part, that documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift. In extenuating circumstances, documentation may be entered at a later time, but it must be clearly indicated as such to maintain transparency and accuracy. All entries must be factual, complete, and reflect the resident's current condition and care provided. Document any changes in the resident's condition, new symptoms, or reactions to treatments immediately and include any actions taken (e.g., physician notification) and resident/family communication.

Number of residents sampled:0Number of residents cited:0 Based on observations, reviews of facility documents, and staff interviews, the facility failed to ensure that staff responsible for maintaining water temperatures were knowledgeable regarding acceptable hot water temperature ranges to ensure residents were free from potential burns. The facility failed to ensure water temperatures were monitored in residents' rooms / bathrooms prevent potential scalding of residents resulting in a finding of Immediate Jeopardy. The findings include: An observation on 8/7/2025 at 9:00 AM of the water temperature checked at the bathroom faucet shared by Residents #1 and #31 rooms initially read 130 degrees Fahrenheit(F) (Normal Range 110 to 120) then dropped down to 128 degrees F. The Administrator on the unit was asked to observe the temperature reading which identified the water temperature at the resident sink to be 128/127 degrees F. Further observation by the Administrator identified the water felt hot to touch. After the surveyor inquiry, the Administrator indicated he would inform Maintenance Director #1 immediately of the hot water temperatures. A request by the surveyor was made for the Administrator to obtain the facility's daily water temperature logs. An observation on 8/7/2025 at 9:10 AM in Resident #25 and #35's bathroom identified the water temperature was initially 128 degrees F then dropped down to 127 degrees F. An interview was conducted on 8/7/2025 at 10:00 AM with the Administrator, Maintenance Director #1 and the Director of Operations after surveyor inquiry, regarding the facility plan to safeguard residents, staff and visitors from using hot water until water temperature was within acceptable ranges to prevent potential burns. The Administrator indicated the Maintenance Director would immediately adjust the mixing valve and recheck temperatures. The Administrator indicated temperatures were within acceptable range having responded to the adjustment of the mixing valve. When the surveyor inquired about a copy of the temperatures taken, Maintenance Director #1 indicated she/he was unable to provide a copy as s/he did not write them down. Further inquiry into the facility's plan to ensure water temperatures remain in an acceptable range, ruling out a failure of the mixing valve, including staff awareness of the high-water temperatures as they provide care to residents in the facility identified no response. After a period of silence, the Director of Operations spoke up indicating an instant message would be sent to all staff immediately to inform them of the situation. At this time the surveyor again requested the daily water temperature logs to be provided. An interview and document review on 8/07/2025 at 12:50 PM with the Administrator identified logs labeled Water Management Plan, Hot Water Temps and Flushing in various locations throughout the facility taken monthly (one day) with the only resident locations being the 2nd and 3rd floor shower and tub rooms. The monthly temperature logs for January through April 2025 identified the resident areas the facility sampled for water temperatures were the 2nd and 3rd floor shower and tub rooms finding those and other non-resident locations requiring temperature monitoring and flushing for the water management plan were within acceptable temperature range (110-120 degrees F). The monthly logs dated 5/22/2025 through 7/18/2025 exceeded the acceptable water temperature limit which consisted of the following: temperatures on 5/22/2025 ranged from 127 to 130 degrees F, the temperatures on 6/19/2025 ranged from 126 to 132 degrees F, and on 7/18/2025 the temperatures ranged from 126 to 133 degrees F for 4 months without evidence of adjustment of the temperature and documentation of subsequent temperatures taken to indicate the effectiveness of adjustments to ensure water temperatures were safe for use to prevent scalding. The Administrator indicated in addition to instant messaging all staff, the staff on duty were in-serviced, water temperatures were taken of random resident bathrooms on 8/7/2025 at 9:55 AM subject to surveyor high water temperature readings. Further review of water temperatures identified the temperatures were all above 120 degrees F at 11:15 AM. However, after the mixing valve adjustment, water temperatures were identified within acceptable range (none above 120 or below 110 degrees F) After surveyor inquiry as to the facility's plan to monitor the ongoing effectiveness of the adjustment of the mixing valve in providing water at an acceptable temperature to prevent scalding, the administrator read the plan put in place which indicated checking random resident room water temperatures were to be taken each shift at a minimum of 5 times per week then 2 random resident rooms in each hallway to be monitored daily going forward. On 8/11/2025 at 8:40 AM an interview and facility document review of the facility water management plan with the Administrator and Maintenance Director #1 identified the Water Management Plan stated to prevent scalding, the temperature of the water was to be tested where the flow valve regulates the temperature. Review of the monthly water temperature flushing logs dated 5/2025 through 7/2025 with the Administrator and review of surveyor water temperatures taken on 8/7/2025 identified water temperature above 120 F. Further review identified no documentation of the temperature of outgoing water was taken at the mixing valve location as indicated in the plan to prevent scalding. On 8/12/2025 at 11:30 AM an interview and facility document review with the Administrator indicated s/he investigated the current facility water/boiler mechanics and identified the boiler had a mixing valve and a part attached to it which provided the ability to check the temperature of the water before going out to the facility and resident care areas. Upon request, copies of the facility random water temperature monitoring per the facility plan in resident rooms, were provided and identified water temperatures taken every shift were within acceptable range. A facility policy and procedure for monitoring water temperatures was again requested. On 8/12/2025 12:28 PM an interview with the Administrator indicated the facility did not have a policy and procedure for checking the water temperature. On 8/12/25 at 2:00 PM to 2:30 PM temperatures were checked by the survey team, which identified high temperatures in 5 resident's bathroom sinks on the first and second floors which identified the following temperatures: ranging from 121 to 124.An interview with Nurse Aide (NA#1) on 8/12/25 at 2:42 PM indicated When you turn the hot water dial all the way hot, it is too hot, I have felt it with my hand. Additionally, NA#1 reported that when the water is too hot, she would turn the dial to the middle.On 8/12/2025 an interview and review of facility documents at 3:05 PM with the Administrator and Maintenance Director #1 (Physical Plant Manager) indicated Maintenance Director #1 was responsible for monitoring the water temperatures that reach the locations of the resident care areas to ensure the temperature was in the acceptable range (110-120 degrees F). Maintenance Director #1 indicated after surveyor inquiry, s/he believed the water temperature limit to be 130 degrees F and the monthly elevated water temperatures documented in the water management plan logs from April- July 2025 raised a bit of concern resulting in him/her reaching out to Maintenance Director #2, 4 months after water temperatures were out of range. Maintenance Director #1 indicated Maintenance Director #2 informed him/her the water temperature limit was 120 degrees F and advised to adjust the water temperature. Maintenance Director #1 indicated s/he took some temperatures after the adjustment, but none were documented. Maintenance Director #1 and the Administrator indicated in summary prior to surveyor inquiry; no temperatures were taken in the resident bathrooms to prevent the potential for scalding and the facility had no policy related to monitoring water temperatures. Additionally, no interventions were implemented during the months May 2025 through July 2025 to adjust the water temperatures to ensure safe hot water temperatures.The lack of knowledge of Maintenance Director #1 related to water temperature management including acceptable water temperature limits, lack of water temperature monitoring in the resident bathrooms and no facility policy and procedure to prevent scalding from water provided to the resident care areas including the bathrooms of residents resulted in a finding of Immediate Jeopardy. On 8/12/2025 at 4:05 PM, the survey team explained in detail about the Immediate Jeopardy (IJ) to the Administrator and the Administrative team which the Administrator acknowledged. On 4/12/2025 at 4:35 PM the IJ Template was provided via email to the Administrator. On 8/12/2025 5:40 PM with revision at 6:41 PM the facility submitted the Plan of Correction to the survey team, to remove the IJ immediacy.See the plan of correction below:1.The mixing valve that controls the domestic hot water temperature of the facility has been adjusted on 8/12/25 to ensure more cold water enters the domestic system so that water temperatures that reach fixtures are no more than 120 degrees Fahrenheit. A licensed facility contractor will be onsite to review the mixing valve and other adjustments to the domestic hot water system to ensure the system mechanicals and settings are in good working order and set accordingly to ensure safe water temperature below 120 degrees. This licensed contractor will be on site by 7:00 PM 8/12/25. Maintenance and management staff will remain onsite when the facility contractor is present. Current hot water temperatures from fixtures in the domestic hot water system are currently reading below 120 degrees. 2. All residents have the potential to be affected by the alleged deficient practice.3. Inservice education will be completed for the Director of Maintenance on safe operating of the facility domestic hot water system, associated mixing valves, maximum temperature for safe water per the Connecticut Public Health Code and the facility procedures for taking hot water temperatures as part of the facility preventative maintenance program. Education will be completed by August 13th, 2025. Additionally, facility nursing staff will be educated on the facility monitoring process of hot water temperatures, and how to report a concern if a fixture of the domestic hot water system appears to be outside of the range of safe temperatures. This Inservice will be completed with written communication and in the form of a posting for both staff and visitors. 4. Audits of hot water temperature will commence on each shift starting on 8/12/25 and will be conducted on each floor of the facility in alternating locations. Temperatures will be monitored one time each shift at these varying locations with any abnormal temperatures being reported to the Director of Maintenance and Administrator. These shift audits will be completed for 8/20/25 or until substantial compliance is achieved. 5.These audits will be reviewed by the facility committee with additional reviews of the facility Accident and Incident logs for burns or other associated injuries related to domestic hot water.6. The Administrator is responsible for this entire plan of corrective actions The Immediate Jeopardy was removed on 8-13-25 at 9:30 AM

Based on a review of the facility water management program, review of policy and interviews, the facility failed to ensure a policy and procedure for monitoring water temperatures to ensure temperatures are in acceptable ranges and process to follow with temperatures are out of range. The findings included: An observation on 8/7/2025 at 9:00 AM during checking water temperature in the bathroom faucet shared by Residents #1 and #31 initially read 130 degrees Fahrenheit(F) then down to 128 degrees F. The administrator on the unit was asked to observe the temperature reading, finding the water temperature at the resident sink to be 128/127 degrees F and it felt hot to touch. After surveyor inquiry, the Administrator indicated s/he would inform Maintenance Director #1 immediately. A request for the facility daily water temperature log was requested by the Administrator. An observation on 8/07/2025 at 9:10 AM in Resident #25 and #35's bathroom sink identified the water temperature was initially 128 degrees F then down to 127 degrees F. The surveyor requested several times for the facility policy and procedure for monitoring hot water temperature. However, the facility was only able to provide verbal instructions how they would follow up on the hot water temperature to ensure residents were free from scalding. Interview with the administrator at the time of the incident identified he would notify the Director of Maintenance who would notify staff the water was hot and maintenance would monitor hot water temperatures frequently until hot water temperatures are within normal range.

Based on clinical record review and staff interviews for 1 of 3 employee files reviewed for Nurse Aide (NA # 8), the facility failed to conduct a thorough investigation on the history of prospective staff, including required background checks, prior to the hire date. The findings include: On 8/14/2025 at 12:55 PM, an interview and review of employee files with the Human Resources Director identified NA#8 was hired on 4/12/2024. She was certified as a nursing aide since 3/07/2023. Although NA#8's employee file contained signed employee consents for background checks, the file did not contain documentation of a completed state or federal background check, including fingerprint-based screening through the Applicant Background Check Management System (ABCMS). The Human Resources Director indicated she was unable to retrieve evidence of an ABCMS screening on the online portal. The Human Resource Director indicated background checks, including the ABCMS screening, are done by the facility prior to employing staff and could not identify a reason for NA#8 not having one. Furthermore, the Human Resource Director indicated NA#8 would be removed from the schedule until NA#8 completes an ABCMS screening. On an interview on 8/14/2025 at 1:35 PM, the Administrator could not explain why NA # 8 did not have a background check or an ABCMS screening prior to being hired. The Administrator indicated that when the Human Resource Director began working at the facility, she had been auditing employee records, and the facility would ensure employee records are audited for background checks. Although requested, the facility was unable to produce a policy for pre-employment screening. However, the facilities abuse policy given during the survey identified a section for pre-hire screening, which indicated the facility would ensure an active license or certification and would review regulatory action reports. The abuse policy did not identify a process for ensuring background checks and ABCMS screenings were completed.

Based on review of facility employee education training records and staff interview for 5 of 5 training records reviewed (NA#9, NA#10, NA#11, NA#12, and NA#13), the facility failed to ensure that nurse aides received at least 12 hours of in-service training annually. The findings include:On 8/14/2025 at 2:13 PM, an interview and record review with RN#3 identified staff members participate in an annual skills day that takes 2 hours. RN#3 indicated there are also modules that staff take to add additional training time. Five nurse aide training records were reviewed with RN #3, and the following were identified: NA#9 (date of hire: 3/28/2024) had 3 hours of in-service training documented, including 2 hours for yearly skills day and 1 hour of dementia training. NA#10 (date of hire: 9/18/2024) had 4 hours of in-service training documented, including 2 hours of skills day and 2 hours of dementia training. NA#11 (date of hire: 1/30/2024) had 2 hours of in-service training documented for skills day. NA#12 (date of hire: 8/2/2024) had 2 hours of in-service training documented for skills day. NA#13 had zero hours of in-service training documented.During the interview, RN#3 indicated the training records reviewed were complete and acknowledged that none of the five nurse aides had documentation of the required 12 hours of annual in-service training.RN#3 indicated the training was made available, but not all staff completed it.

Based on observations of the kitchen, review of policy and staff interviews, the facility failed to ensure staff obtained ice in a sanitary manner in the kitchenette where the ice machine was not operational and the facility failed to ensure items in the kitchen were dated and labeled, dented cans were discarded, temperatures were consistently taken/ documented, and cleaning schedules were signed off on. The findings include: 1. On 8/7/2025 at 9:14 AM an observation of the kitchen identified the ice machine in the right corner of the room was pad locked and the wall mounted scoop holder was empty in the presence of the federal surveyor in attendance. LPN #2 entered the nourishment room and opened the freezer took out an ice cube tray (1 of four), with non-gloved hands, filled the tray with tap water and placed the ice cube tray into the freezer portion of the nourishment room refrigerator) further observation identified none of the ice cube trays had covers. Food items in a cloth bag were on the freezer shelf above the open ice cube trays and were labeled with a resident name and dated. An interview on 8/07/2025 at 9:15 AM with LPN #2 indicated the ice machine was broken for about 1-2 months but she/he was not exactly sure. The Administrator indicated the freezer had been broken for a few months, one was ordered and was scheduled to be delivered in a day or two. An observation of the freezer was again completed with the administrator and LPN #2 and the\ federal surveyor which identified ice cube trays noted and no other process for ice delivery. A facility policy was requested regarding use of ice cube trays in the nourishment room, but none was provided. 2. The tour of the Dietary Department on 8/6/25 with the Director of Dietary and cook #1 identified the following: The following items were identified with no dates or labels: Freezer 1 had a bag of brown dough like substances. Refrigerator #3 had 4 containers of red paste like substance, 2 containers of white substance, 1 container of meat, 5 containers of 3oz pureed substance. 3 sandwiches with brown and purple jellylike substance. Interview with cook #1 on 8/6/25 at 9:34AM indicated all items in the freezer and Fridges should be labeled with the date it was opened and the name of the items. He reported that all kitchen staff are responsible for ensuring this is done. [NAME] #1 is unsure why the aforementioned items are not labeled. Interview with the Dietary Director on 8/6/25 at 11:20 am indicated that all items in the fridge, freezer and storage areas should be labeled and dated. He reported that all kitchen staff are responsible for ensuring this is done. Facilities stock rotation policy indicates in part that All items need to be individually dated when removed from original containers. B. Walk through of the dry storage area on 8/6/25 at 9:40AM revealed the following can had a dent: 1 (6 pounds 9 ounces), Hunts Tomato sauce. Interview with cook #1 on 8/6/25 at 9:41 AM reported, all dented cans should be placed in a separate area and return to vendor. He reported that staff who are assigned stocking the dry storage are responsible for ensuring this is done. Facilities Damaged food containers policy indicated in part indicates angular dent with acute crimping of the body, wall or end seam should not be used . item should be removed from the storeroom and return to the vendor. C. Review of the food temperature log revealed that no temperatures were taken or documented for 7/16/25, 7/17/25 and 7/18/25. Interview with cook #1 on 8/6/25 at 9:58 AM indicated all cooks are responsible for entering temperature logs daily for food items. He is unsure why on the aforementioned dates has no temperatures recorded. Facilities Procedure for taking serving temperatures indicated temperatures should be taken when the food is placed in the steam table, no longer than 15 minutes before surveying. D. The weekly cleaning schedules that were provided do not indicate who is responsible for each task nor signatures indicating the task were done. Interview with the Director of Dietary on 8/6/25 at 11:38 AM indicated that he was not aware the cleaning logs needed to be signed.

Based on review of the clinical record reviews, resident interviews, review of facility policy and staff interviews for 4 of 10 residents (Resident # 13, # 39, # 45 and # 81), the facility failed to ensure meals were served within 14 hours. The findings include:Resident #13 's diagnoses included anxiety, adjustment disorder and epilepsy. he quarterly Minimum Data Set assessment dated [DATE] identified Resident #13 was moderately cognitively impaired and requires set up assistance for eating.2. Resident # 39's diagnoses included Type 2 diabetes mellitus, hypertension and dysphagia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #39 was cognitively intact and required set up assistance for eating.3.Resident # 45 's diagnoses included Type 2 diabetes mellitus, Gastro-Esophageal Reflux Disease without esophagitis and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was cognitively intact and required set up assistance for eating.4, Resident # 81 's diagnoses included anemia, localized edema and orthostatic hypotension.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #81 was cognitively intact and required set up assistance for eating.Review of facilities mealtimes indicated that dinner is served at 4:45 and Breakfast is served at 7:45am (15 hours apart).Interview with Residents #13, # 39, 45 and #81 on 8/11/25 at 10:43 AM indicated they do not receive a substantial snack between dinner and breakfast. Resident #13 reported the third floor does not get a snack cart daily. Resident #45 indicated if they do get a snack cart snack it only has crackers. He/she reported if he/she requests a sandwich he/she often gets push back from staff. Resident #39 reported that there is no peanut butter and jelly provided on the carts.Observation of the second-floor nourishment room on 8/11/25 at 1:23 PM identified juices, apple sauce and meals for other residents in the fridge. A snack box on the second floor had an assortment of crackers.Interview with Dietary Director Food Services on 8/14/25 at 11:21 AM indicated snacks go out to the units 3 times per day (after each meal). He reports the cart contains crackers, apple sauce and oatmeal cookies.

Based on clinical record review and staff interviews, the facility failed to ensure that annual performance evaluations were completed for 1 of 3 nurses' aides (NA # 8) reviewed for performance evaluations and failed to provide regular in-service education based on the outcome of a performance evaluation. The findings include: Review of the personnel file for Nurse Aide #8 identified a hire date of 4/12/2024. As of the date of the survey (8/14/2025), there was no documented annual or earlier performance evaluation on file for Nurse Aide # 8. On 8/13/2025 at 2:13 PM, an interview and record review with RN#3 identified NA#8 had completed the required education on core competencies on 10/15/2024, which totaled 2 hours of training. However, RN#3 indicated NA#8 had not completed at least 12 hours per year of in-service education or education that addressed areas of weakness as determined in any performance review. On 8/14/2025 at 9:56 AM, an interview with the Human Resources Director identified NA#8 should have received an annual performance evaluation based on the hire date. The HR Director was unable to locate any documentation for a performance evaluation. An interview with the DNS on 8/14/2025 at 1:30 PM identified the DNS is responsible for completing performance evaluations for nursing aides. The DNS indicated that she was not in the DNS role at the time NA#8's performance evaluation was due and could not explain why it had not been completed.

Based on a review of Payroll-Based Journal (PBJ) staffing data and staff interviews, the facility failed to ensure sufficient nursing staff were available on weekends. The findings include: Review of PBJ data submitted by the facility identified weekend staffing levels were lower than weekday staffing during the following fiscal quarters: FY Quarter 4 of 2024 (July 1 -September 30, 2024) and FY Quarter 2 of 2025 (January 1-March 31, 2025). On 8/14/2025 at 11:07 AM, an interview with the facility scheduler identified the facility staffs appropriately but indicated that callouts may have made staff run short. The scheduler indicated when callouts occur, she will call staff to help cover. The scheduler further indicated that for a census of 83 residents (the facility census on the first day of survey), the facility schedules 3 LPNs for the 7-3 PM shift, 3 LPNs for the 3-11 PM shift, and 2 LPNs for the 11-7 AM shift. The facility also schedules one RN supervisor on each shift. For nursing aides, the scheduler indicated there are 10 nurse aides scheduled for the 7-3 PM shift, 8 aides for 3-11 PM, and 5 aides for the 11-7 AM shift. A review of staffing schedules for Sunday, 2/9/2025, with the scheduler, identified 11 nursing aides were scheduled for the 7-3 PM shift. However, for the 7-3 shift, there were 6 callouts from nursing aides, and the facility was able to call in one nursing aide. The 7-3 PM shift had a total of 6 nursing aides instead of 10. For the 3-11 PM shift on 2/9/2025, the facility had 8 nursing aides scheduled, but 5 nursing aides called out. The facility was able to call in 3 nurse aides, and one additional aide arrived at 9:30 PM. From 3:00 PM to 9:30 PM, the facility had only 5 nursing aides instead of 8. An interview with the scheduler indicated 2/9/2025 a snow day, and so the number of callouts was unusual. The facility did not provide documentation to demonstrate that resident care needs were being met despite the reduced staffing levels. A review of the staffing schedules for Saturday, 3/8/2025, and Sunday, 3/9/2025, identified on 3/8/2025, the census was 81 residents, and on the 7-3 PM shift, there were 11 nursing aides scheduled, but only 10 worked due to callouts. On 3/9/2025, the census was 83 residents, and there were 11 nursing aides scheduled, but only 10 worked due to callouts. A review of the Facility assessment dated [DATE] identified that the average daily census was 83 residents and the staffing plan called for 11 nursing aides for the 7-3 PM shift. The Facility Assessment further identified the weakness in the facility-based risk assessment was staffing, including a unionized workforce and limited per-diem/temporary licensed and unlicensed staff. On 8/14/2025 at 1:35 PM, an interview with the Administrator identified he was not aware the facility had been triggered for low weekend staffing in the PBJ report for FY Quarter 4 of 2024 and FY Quarter 2 of 2025. The Administrator indicated there can be call-outs, but the facility calls in staff to help when that occurs. The Administrator further indicated the facility is enforcing disciplinary actions related to callouts when appropriate. Additionally, the ADNS and DNS have worked to fill in as the RN supervisor; however, the Administrator indicated the DNS and ADNS would not have punched in when picking up shifts as direct-care staff. The Administrator also indicated that although the facility has contracted with a staffing agency in the past, it is not currently utilizing temporary/contract staff and had not utilized them in FY Quarter 4 of 2024 and FY Quarter 2 of 2025.

Based on interviews, clinical records and policy review for 1 of 1 resident (Resident #17) reviewed for edema, the facility failed to obtain weekly weights per physician's order and for 1 of 2 residents (Resident #8) reviewed for medication administration the facility failed to ensure a resident's medication was made available and for 3 of 3 residents (Resident #1, Resident #31, Resident #38) reviewed for physician orders, the facility failed to ensure medications were administered timely and in accordance to physician orders and 1 of 5 residents reviewed for Unnecessary Medication (Resident # 29), facility failed to ensure that medications were administered per physician's orders. The findings included: 1.Resident #17's diagnoses included dysphagia, gastroesophageal reflux disease and rhabdomyolysis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 had a Brief Interview of Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and was a setup for eating and partial/moderate assistance for dressing and transfers. The physician's order dated 7/15/25 directed for weekly weights to be obtained every Monday. The Resident Care Plan dated 7/22/25 identified Resident #17 had potential for a nutritional decline related to multiple medical problems, need for a therapeutic diet and need for altered consistency diet. Interventions included providing supplements as ordered and to weigh as ordered. A review of the weight report identified Resident #17 had a weight obtained on 8/7/25, without the benefit of weekly weights since the physician's order was initiated on 7/15/25. A review of the nurse's notes dated 7/15/25 through 8/13/25 failed to identify Resident #17's refusal of getting a weight. Interview and record review with Nursing Assistant (NA) #2 on 8/13/25 at 9:22 AM identified the nursing assistants are responsible for obtaining resident weights, which are done monthly. Additionally, any resident who gets a weigh more frequently is identified on the Weights List posted at the nurse's station. A review of the posted Weights List with NA #2 directed for Resident #17 to be weighed monthly. Interview and clinical record review with RN Supervisor (RN) #1 on 8/13/25 at 9:54 AM identified the facility policy on weights was for NA's to obtain them on admission, then weekly for four weeks and then per physician's order. A review of Resident #17's clinical record identified she/he had a physician's order for weekly weights starting 7/15/25, with the only weight obtained on 8/7/25. RN #1 could not identify why the weights were not obtained weekly per physician's order. Subsequent to surveyor inquiry RN #1 obtained a weight for Resident #17, who was witnessed to be cooperative with the weight request. Review of the Weight Monitoring Policy directed in part that accurate and timely measurement of weight change in all residents is an important tool in assessing their nutritional status. 2. a. Resident #8's diagnoses included spina bifida, paraplegia, and stage 4 pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was cognitively intact and required the assistance of 2 or more people with bed mobility, toilet hygiene, and transfers. Observations of medication administration on 8/6/25 at 9:38 AM with Licensed Practical Nurse (LPN #1) for Resident #8 identified the clotrimazole-betamethasone cream was not available in the facility. Interview with LPN#1 on 8/6/25 at 10:29 AM identified Resident #8's clotrimazole-betamethasone cream was not located in the medication cart or in the medication room, and she would fill out a paper pharmacy re-order form and fax to pharmacy, and the cream should be delivered the next day. Interview on 8/7/25 at 9:35 AM with LPN #2 identified she was taking care of Resident #8 and administered her/his morning medications but could not locate the clotrimazole-betamethasone cream. LPN #2 placed a second pharmacy re-order request electronically through via computer. It was further identified the paper pharmacy re-order form for the cream was faxed to the pharmacy on 8/6/25 at 10:56 PM and would not be delivered until later in the afternoon on 8/7/25. Interview on 8/7/25 at 10:36 AM with the DNS identified residents' medications should be re-ordered by the nurse when the quantity gets down to approximately a seven-day supply, and the medication would get delivered the same day if it was re-ordered or the next day, depending on the time of day requested. The DNS further identified, the physician should be notified when medications are not available or given to a resident. Review of Resident #8's Medication Administration Record (MAR) on 8/11/25 at 12:15 PM identified Resident #8 did not receive the clotrimazole-betamethasone cream and missed applications scheduled for 8/6/25 in the morning and in the evening and missed on 8/7/25 in the morning. Interview on 8/11/25 at 12:36 PM with LPN #1 identified that she filled out a paper medication re-order form for Resident #8's clotrimazole-betamethasone cream on 8/6/25 in the morning but did not fax it to the pharmacy until 10:56 PM on 8/6/25 at the end of her double shift. LPN #1 did not recall if the physician was notified. Interview on 8/13/25 at 2:05 PM with Person #3 identified the pharmacy received a paper re-order on 8/6/25 at 10:56 PM and another electronic re-order request on 8/7/25 at 9:38 AM and Resident #8's clotrimazole-betamethasone cream was delivered on 8/7/25 at 4:26 PM. Review of the Medication Administration Policy V1 dated 2025 directed, in part, the physician must be notified when a dose of medication has not been given, and an explanatory note is entered on the reverse side of the record provided when needed documentation. b. Resident #1's diagnoses included non-Hodgkin lymphoma, anxiety disorder, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required maximal assistance (helper does more than half the effort) with oral hygiene, showers, personal hygiene, upper and lower body dressing and required the assistance of 2 or more helpers with transfers. The physician's orders; dated 4/15/25 directed to administer escitalopram oxalate oral 10 milligram (MG) tablet one time a day for depression, trazodone HCI 50 MG tablet two times a day for agitation, and polyethylene glycol powder 17 gram (G) two times a day for constipation, dated 4/18/25 directed to administer oxycodone HCI 5 MG tablet two times a day for pain, dated 6/25/25 directed to administer Dulcolax 5 MG tablet one time a day for constipation, and dated 8/4/25 directed to administer lactulose 15 milliliters (ML) two times a day for constipation. Scheduled medication administration times in Resident #1's MAR was 9:00 AM. c. Resident #31's diagnoses included diabetes mellitus, congestive heart failure, anxiety disorder, and depression. The quarterly MDS assessment dated [DATE] identified Resident #31 was moderately cognitively impaired and required maximal assistance with toileting hygiene, personal hygiene, lower body dressing, and transfers. The physician's orders; dated 1/18/24 directed to offer dairy or cola with meals related to low phosphorus level, scheduled at 8 :00AM daily, dated 9/30/24 directed to instill 1 drop of refresh plus ophthalmic solution in both eyes two times a day for dry eyes scheduled for 9:00 AM, dated 10/1/24 directed to give 1 scoop of MiraLAX oral powder in the morning for constipation scheduled for 9:00 AM. The physician's orders dated 10/2/24 directed to give losartan potassium I tablet in the morning for hypertension scheduled for 9 :00AM, dated 10/2/24 directed to give metoprolol tartrate 12.5 mg two times a day for hypertension scheduled for 9:00 AM, dated 11/17/24 directed to give Norvasc 1 tablet in the morning for hypertension scheduled for 9:00 AM, dated 12/24/24 directed to give Nepro 240 ml in the morning scheduled for 8:00 AM, dated 4/11/25 directed to give linagliptin 5 MG one time a day for diabetes scheduled for 9:00 AM, dated 6/18/25 directed to give sevelamer carbonate 1 tablet three times a day for specialized treatment scheduled for 9 AM, dated 6/30/25 directed to give Eliquis 5 MG tablet two times a day related to cerebral infarction (stroke) scheduled for 9:00 AM. The physician's orders dated 7/1/25 directed to give protonix 1 tablet one time a day for gastroesophageal reflux (heartburn) prior to breakfast scheduled at 8:00 AM, give clopidogrel bisulfate 75 MG in the morning for prophylaxis (prevention) scheduled for 9:00 AM, dated 7/15/25 directed to give cinacalcet HCI 90 MG one time a day scheduled at 9:00 AM, dated 7/16/25 directed to give gabapentin 1 capsule two times a day scheduled for 9:00 AM, and dated 7/21/25 directed to give doxycycline hyclate 100 MG two times a day for foot wound scheduled at 9:00 AM. Scheduled medication administration times in Resident #31's MAR was 8:00 AM and 9:00 AM. d. Resident #38's diagnoses included hepatic (liver) failure, malignant neoplasm (cancer) of prostate, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #38 was cognitively intact and required setup or clean-up assistance for eating, toileting hygiene, personal hygiene, and transfers. The physician's orders dated 3/31/22 directed to give magnesium oxide one time a day for supplement. The physician's orders dated 4/6/22 directed to give B-1 100 MG tablet one time a day for nutrition, cyanocobalamin 1000 microgram (MCG) tablet one time a day for vitamin, and folic acid 1 MG tablet one time a day for anemia. The physician's 7/29/22 directed to give Lasix 40 MG tablet one time a day for diuretic, dated 10/3/24 directed to give Norvasc 2.5 MG tablet in the morning for hypertension (high blood pressure). The physician's orders 1/14/25 directed to give tamsulosin HCI 0.4 MG two times a day for prostate. Scheduled medication administration times in Resident #38's MAR was 9:00AM. Observation on 8/12/25 at 11:04 AM identified LPN #8 at her medication cart administering medications in the third-floor hallway to Resident #1, Resident #31, and Resident #38. Interview with LPN #8 on 8/12/25 at 11:09 AM identified she administered medications that were scheduled for 8:00 AM and 9:00 AM to Resident #1, Resident #31, and Resident #38 at 11:04 AM. LPN #8 identified she administered the medications past the scheduled time because she came into work at 8:00 AM to help and she did not notify the physician the medications were late. Review of Resident #1, Resident #31, and Resident #38's MAR on 8/13/25 at 10:00 AM, identified medications administered on 8/12/25 at 11:04 AM were signed off in the computer given by LPN #8 at 8:00 AM and 9:00 AM timeframes. Interview with DNS on 8/13/25 at 10:30 AM identified per the facility's medication administration policy, medications can be administered one hour before scheduled time and one hour after scheduled time, and the clinician should be notified. The DNS also indicated a nurse should not have given 8:00 AM and 9 :00AM scheduled medications at 11:04 AM but should have an order for that time given. Review of the Medication Administration and General Guidelines Policy dated 2025 directed, in part, medications are administered within one hour of the scheduled time, unless the physician specifies a specific time, before and after meal orders are administered precisely as ordered. 3. Resident #29 's diagnoses included Unspecified dementia, Type 2 diabetes mellitus, chronic kidney disease. A physician's order dated 4/16/25 directed Resident #29 requires assistance of one staff for transfers The quarterly Minimum Data Set assessment (MDS) assessment dated [DATE] identified Resident #29 was cognitively impaired and required maximal assistance with toilet transfers and hygiene and supervision assistance with eating. The care plan dated 7/5/25 identified Activities of daily living (ADL). Interventions included to assist with preforming ADL as needed. Review of the August 2025 Medication Administration Record (MAR) indicated the following medications were missed on 8/8/25: DM Supplement 8oz once a day in the morning, Risperidone ( anti-psychotic) to be given 1 mg by mouth in the morning, Eliquis ( blood thinner) Oral Tablet 5 MG(Apixaban) to be given 1 tablet mouth two times a Day(this was not given in the morning), Metformin ( anti-diabetic agent) HCl to be given 1 tablet by mouth two times a day, Tamsulosin HCl ( treat prostate )Oral Capsule 0.4 MG (Tamsulosin HCl) to be given 1 capsule by mouth two times a day (this was not given in the morning), to give 240 ml clear liquids during medication pass every shift for hydration, pain assessment and behaviors were also not documented. Review of Nursing notes for 8/8/25 did not indicate Resident # 29 refused medications. Interview with DNS on 08/13/2025 1:08 PM indicated that medications are administered as prescribed. She further indicated if a resident were to refuse her/his medication, then it should be documented in notes or on the MAR. The DNS reported the charge nurse is responsible for ensuring that the MAR is completed and is unsure why the MAR is blank.

Based on clinical record review, observations, facility policy review and staff interviews for the only resident reviewed for accidents (Resident #17) and 1 of 2 residents (Resident #17) reviewed for Activities of Daily Living, the facility failed to ensure staff updated the resident care plan after a fall and revise the care plan to reflect the resident's oral care needs and preferences and for 1 of 3 residents ( Resident #82) reviewed for respiratory care, the facility failed to revise and update care plan to reflect oxygen use and interventions. The findings included: 1.Resident #17's diagnoses included schizophrenia and dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was moderately cognitive impaired. The care plan dated 6/12 2025 with updated 7/22/2025 indicated Resident #17was at risk for falls due to newly admitted to the facility indicating Resident #17 fell on 5/24/2024, 2/7/2025, 4/19/2025 and 7/22/2025. Interventions included in part to offer toileting after each meal, encouraging asking and waiting for assistance and staff to conduct frequent checks. The care plan further indicated Resident #17 required assistance with activities of daily living. Interventions included in part to provide dental services as ordered and needed. The care plan further indicated Resident #17 can be resistive to washing hands, showering, refusal of care and following physician's orders. Interventions included, in part, if Resident #17 refuses care to leave and return in 5-10 minutes and to praise desired behavior. A facility Reportable Event form dated 6/21/2025 indicated Resident #17 was found on the floor(fall) unconscious with a hematoma to the right cheekbone, regained consciousness before being sent to the hospital for an evaluation. The Fall Scene investigation page 3 of the report was noted to have a complete brief description of the residents' state prior to the fall and the resident/room check after the fall. The Fall Huddle/Root Cause of Fall, intervention to prevent future falls, update of the care plan and care card were not completed and the area for the supervisor's name and signature who completed the fall scene investigation remained blank. A dental exam note dated 7/07/2025 indicated, in part, Resident #17 was missing some teeth had moderate plaque/food debris buildup, moderate gingivitis/swollen bleeding gums and moderate hard calcium deposits condition of teeth were fair with no symptoms. Nursing home staff action requirements was to continue with oral care. An observation on 8/6/2025 at 11:33 AM identified Resident #17 at 9:50 AM was noted sitting in a chair outside the nurse's station, confused but smiling. Resident #17's teeth were noted to have a build up along gumlines with white material. An observation on 8/7/2025 at 10:07 AM Resident #17 was noted to have the same white buildup on upper and lower gumline/teeth. On 8/12/2025 at 9:33 AM attempts to reach RN #6, the nursing supervisor on duty at the time of the fall were unsuccessful. On 8/12/2025 at 10:22 AM an interview, record and facility document review with the Director of Nursing Services (DNS) indicated during the time of the fall management changes that happened administrative staff was behind in revieing incident reports leading to not seeing incomplete areas on the document. The DNS further indicated she/he was unable to provide revision of the care to address the residents fall or after return from the hospital to meet resident needs post fall. Additionally, there are no revisions for interventions to prevent further falls. The DNS indicated the nursing supervisor was responsible for revising the care plan. An observation on 8/12/2025 at 10:55 AM identified Resident #17 with white build up on the top and bottom gumline still noted. On 8/12/2025 at 11:00AM an interview and observation with Resident #17's regular nurse aide. (NA #6) indicated Resident #17 has dementia She gets up before breakfast in the AM but still wants to do oral care by him/ herself but NA # 6 assist with setting up the resident with the supplies needed and assist when needed. The buildup of white debris at the gumline NA#6 indicated possibly could be the oral tablet she gets from the nurse that dissolves in the resident's mouth. An interview and record review with the Nursing Supervisor, RN # 4 on 8/12/2025 at 11:05 AM indicated the care plan directed to see a dentist as needed and resident was seen by the hygienist recently. RN #4 further indicated the care plan should have been updated with the resident's oral care needs and preferences regarding wanting to provide own care. RN #6 further indicated s/he would update the care plan based on the dental evaluation and with the resident preferences. The facility policy labeled Care Planning indicated in part, a comprehensive care plan will be developed based on identified needs, strengths, and preferences of the resident and developed by the interdisciplinary team. The care plan is reviewed and updated at least quarterly and necessary to reflect changes in the residents' status. 2. Resident # 82's diagnoses included Acute Respiratory Failure with Hypoxia, acute respiratory failure with hypercapnia and anxiety. Review of the W10 (Intra-Agency Discharge Summary) indicated Resident #82 was admitted to hospital 4/20/25 due to (Principal) hypoxia Acute hypoxic respiratory failure. Resident #82 W10 physician's orders indicated the resident requires oxygen due to diagnosis of severe lung disease or hypoxia liter flow of 2L continuous. A physician's order dated 5/16/25 directed to taper off oxygen gradually, maintaining oxygen saturation of >90 and to monitor every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #82 was cognitively intact and required supervision /set up assistance for personal hygiene, oral hygiene and partial assistance for bed mobility. The MDS did not indicate Resident #82 was receiving oxygen. The resident care plan dated 6/10/25 identified Cardiovascular Disease Interventions included to check oxygen saturation as ordered/as needed/per policy (created 1/14/22). The care plan does not identify intervention for oxygen specifically. Observations on 8/6/2025 at 12:43 PM of Resident #82 identified the resident in room with nasal canula flowing at 1.5 L. while making the observation Resident #82 reported it supposed to be on 2. Observation on 8/7/2025 at 9:28 AM of Resident #82 on nasal cannula at a 1.5 L flow. Resident #82 reported he/she has been on oxygen since returning to the facility from the hospital (4/30/25). Interview with DNS on 8/14/25 at 1:50 PM indicated that if a resident is on oxygen, the care plan should be updated to include interventions for that care. She also indicated the nursing team is responsible for ensuring this process is done. The DNS was unable to explain why the care plan did not reflect interventions for oxygen utilization. Facilities care planning policy (revised 10/30/20) indicates in part The care plan is revised and updated at least quarterly and as necessary to reflect changes in the resident status.

Based on clinical record review, observation, facility documentation, facility policy and interviews for 1 resident (Resident #57) reviewed for pain, the facility failed to ensure a comprehensive assessment was completed timely. The findings include: Resident #57 's diagnoses included Unilateral Primary Osteoarthritis, presence of artificial right knee and lower back pain. The clinical record identified Resident #57 as cognitively intact.The care plan dated 7/21/25 identified pain. Interventions included providing medications as ordered A physician's order dated 8/8/25 directed to ice packs to right knee every 3 hours for 20 minutes at a time to reduce swelling. Interview with MDS Coordinator #1 on 8/13/2025 at 10:46 AM reported for newly admitted residents the MDS should be completed on or before 14 days after admission. She further indicated the MDS coordinator is responsible for doing so and as of 8/1/25 the MDS was identified as late. She was unsure why the MDS was not completed. Facilities [NAME] Planning policy indicates in part that A comprehensive and individualized plan of care will be developed for each resident. The policy did not speak to the MDS completion process.

Based on clinical record review, facility documents, policy review and staff interviews for 1 of 6 residents reviewed for abuse (Resident # 2), the facility failed to conduct a thorough investigation regarding an allegation of mistreatment. The findings include: Resident #2's diagnoses included quadriplegia (paralysis of all four extremities), anxiety, and depression. The Medicare 5-day MDS assessment dated [DATE] identified Resident #2 was cognitively intact and had not exhibited behavioral symptoms towards self or others. The MDS assessment further indicated Resident #2 was dependent for toileting and bathing and always incontinent of bowel. A care plan dated 7/9/2025 identified Resident #2 required total assistance for activities of daily living (ADL). Interventions included the assistance of one staff member with incontinence care and using a hands-free system to use the call light. 0n 8/6/2025 at 3:20 PM during a screening interview, Resident #2 indicated that 3 to 4 months ago, a nursing aide whose name she/he did not recall came in during a morning shift around 11:00 AM to provide a bath. Resident #2 indicated he/she refused care, but the nursing aide proceeded to wash him/her anyway. Resident #2 indicated she/he complained to his/her nurse that day (LPN#1) and to the DNS at the time (RN#5). Resident #2 indicated she/he had not seen the nurse aide again since the incident and indicated she/he did not know what LPN#1 and RN#5 had done about the incident. On 8/11/2025 at 11:00 AM, an interview with LPN #2, who was taking care of Resident #2, indicated she had heard about the incident but could not recall from where. LPN # 2 further indicated she did not know any details. However, LPN#2 indicated she thought it had occurred on a weekend when she was off. On 8/11/2025 at 11:44 AM, an interview with LPN#1 identified that sometime in the end of March 2025 or April 2025 (LPN#1 could not recall the exact date), NA#8 came to her to inform her that Resident #2 was refusing care from NA#8. LPN#1 indicated she spoke to Resident #2, who indicated NA#8 was trying to change him/her against his/her will. Additionally, LPN#1 indicated Resident #1 had informed her that NA#8 had changed him/her against his/her will during the night therefore she/he want NA#8 taking care of him/her anymore. LPN#1 indicated she had the nursing aides switch assignments so NA#8 would not be assigned to Resident #2 and then informed RN#5 about the resident's concern. LPN#1 did not recall which nursing aide took over Resident #2's care. LPN#1 indicated that when there is an allegation of abuse, staff are supposed to contact the DNS, and the DNS handles things from there. LPN#1 further indicated that she did not follow up with the resident afterwards and did not recall if the DNS had spoken to Resident #2 after being informed. LPN#1 indicated she did not tell the supervisor of the shift because she had already told the DNS. On 8/11/2025 at 12:23 PM, an interview with the Administrator indicated he was not aware of an incident between NA#8 and Resident #2. The Administrator also identified RN#5's last day working as a DNS was on 6/30/2025 and the current DNS served as Assistant Director of Nursing Services (ADNS) from 5/15/2025 to 7/21/2025 and then assumed DNS role on 7/22/2025. On 8/11/2025 at 2:18 PM, an interview with RN#5 identified RN#5 did not recall an incident between NA#8 and Resident #2 and indicated that had there been an incident, she would have written an incident report. The written report would been left on her desk after she left the facility. RN#5 indicated that when there was an allegation of staff-to-resident abuse, the process included: staff write statements, notifying the social worker, and removing the staff member from the schedule pending investigation. On 8/13/2025 at 10:30 AM, an interview with the DNS indicated she was not aware of an incident between Resident #2 and NA#8, but indicated that if a resident refuses care, staff should document it and reapproach later. Additionally, the DNS indicated there were no other incident and accident reports for Resident #2 from 1/1/2025 to 8/6/2025 other than what was already provided. On 8/14/2025 at 9:13 AM, an interview with NA#8 identified NA#8 denied providing care to Resident #2 without his/her consent. NA#8 did indicate that there was an incident a few months prior (NA#8 could not recall the exact day or month) where she was providing incontinence care to Resident #2 after Resident #2 had agreed to peri care, but Resident #2 complained that NA#8 was taking too long and yelled at her to stop and leave. NA#8 indicated she stopped and reported to LPN#1 the resident did not want her/him (NA #8) taking care of him/her anymore. NA#8 indicated she could not recall which nursing aide switched assignments with her that day. The facility policy for Abuse notes any staff suspecting abuse should immediately report it to the supervisor, who would then report it to the DNS and the Administrator. Additionally, the policy directed the Administrator, DNS, or designee would initiate an investigation. The Abuse policy further indicated that an investigation would include interviews of all witnesses, including the accused, interviews with any individual with relevant information, signed and dated statements for all involved parties, and a review of the accused staff member's employment record.

Based on clinical record review, facility documents, policy review and staff interviews for 1 of 6 residents reviewed for abuse (Resident # 2), the facility failed to follow up on and report a potential allegation of abuse. The findings include: Resident #2's diagnoses included quadriplegia (paralysis of all four extremities), anxiety, and depression. The Medicare 5-day MDS assessment dated [DATE] identified Resident #2 was cognitively intact and had not exhibited behavioral symptoms towards self or others. The MDS assessment further indicated Resident #2 was dependent for toileting and bathing and always incontinent of bowel. A care plan dated 7/9/2025 identified Resident #2 required total assistance for activities of daily living (ADL). Interventions included the assistance of one staff member with incontinence care and using a hands-free system to use the call light. 0n 8/6/2025 at 3:20 PM during a screening interview, Resident #2 indicated that 3 to 4 months ago, a nursing aide whose name she/he did not recall came in during a morning shift around 11:00 AM to provide a bath. Resident #2 indicated he/she refused care, but the nursing aide proceeded to wash him/her anyway. Resident #2 indicated she/he complained to his/her nurse that day (LPN#1) and to the DNS at the time (RN#5). Resident #2 indicated she/he had not seen the nurse aide again since the incident and indicated she/he did not know what LPN#1 and RN#5 had done about the incident. On 8/11/2025 at 11:00 AM, an interview with LPN #2, who was taking care of Resident #2, indicated she had heard about the incident but could not recall from where. LPN # 2 further indicated she did not know any details. However, LPN#2 indicated she thought it had occurred on a weekend when she was off. On 8/11/2025 at 11:44 AM, an interview with LPN#1 identified that sometime in the end of March 2025 or April 2025 (LPN#1 could not recall the exact date), NA#8 came to her to inform her that Resident #2 was refusing care from NA#8. LPN#1 indicated she spoke to Resident #2, who indicated NA#8 was trying to change him/her against his/her will. Additionally, LPN#1 indicated Resident #1 had informed her that NA#8 had changed him/her against his/her will during the night therefore she/he want NA#8 taking care of him/her anymore. LPN#1 indicated she had the nursing aides switch assignments so NA#8 would not be assigned to Resident #2 and then informed RN#5 about the resident's concern. LPN#1 did not recall which nursing aide took over Resident #2's care. LPN#1 indicated that when there is an allegation of abuse, staff are supposed to contact the DNS, and the DNS handles things from there. LPN#1 further indicated that she did not follow up with the resident afterwards and did not recall if the DNS had spoken to Resident #2 after being informed. LPN#1 indicated she did not tell the supervisor of the shift because she had already told the DNS. On 8/11/2025 at 12:23 PM, an interview with the Administrator indicated he was not aware of an incident between NA#8 and Resident #2. The Administrator also identified RN#5's last day working as a DNS was on 6/30/2025 and the current DNS served as Assistant Director of Nursing Services (ADNS) from 5/15/2025 to 7/21/2025 and then assumed DNS role on 7/22/2025. On 8/11/2025 at 2:18 PM, an interview with RN#5 identified RN#5 did not recall an incident between NA#8 and Resident #2 and indicated that had there been an incident, she would have written an incident report. The written report would been left on her desk after she left the facility. RN#5 indicated that when there was an allegation of staff-to-resident abuse, the process included: staff write statements, notifying the social worker, and removing the staff member from the schedule pending investigation. A review of nursing notes and social work notes from 3/15/2025 to 5/30/2025 failed to identify an incident where Resident#2 refused care and complained of being provided peri care against his/her will. A review of facility accident and incident reports from 1/1/2025 to 8/6/2025 for Resident #2 failed to identify an incident between NA#8 and Resident #2 or any other incident of potential abuse. A review of the facility's state's reportable events data since the last recertification survey on 12/21/2023 failed to identify an allegation of abuse for Resident #2. On 8/13/2025 at 10:30 AM, an interview with the DNS indicated she was not aware of an incident between Resident #2 and NA#8, but indicated that if a resident refuses care, staff should document it and reapproach later. Additionally, the DNS indicated there were no other incident and accident reports for Resident #2 from 1/1/2025 to 8/6/2025 other than what was already provided. On 8/14/2025 at 9:13 AM, an interview with NA#8 identified NA#8 denied providing care to Resident #2 without his/her consent. NA#8 did indicate that there was an incident a few months prior (NA#8 could not recall the exact day or month) where she was providing incontinence care to Resident #2 after Resident #2 had agreed to be peri care, but Resident #2 complained that NA#8 was taking too long and yelled at her to stop and leave. NA#8 indicated she stopped and reported to LPN#1 the resident did not want her/him (NA #8) taking care of him/her anymore. NA#8 indicated she could not recall which nursing aide switched assignments with her that day. The facility policy for abuse notes any staff suspecting abuse should immediately report it to the supervisor, who would then report it to the DNS and the Administrator. An Accident and Incident report would be completed, and nursing staff would document a description of the incident in the resident's record. Additionally, the Abuse policy indicated the Administrator, DNS, or designee would initiate an investigation and submit an online report to the Facilities Licensing and Investigation Section.

Based on clinical record reviews, review of facility policy and staff interviews for 2 of 5 residents (Resident #21 and Resident #29) reviewed for unnecessary medications, the facility failed to obtain consent from the resident's representative for psychotropic medications and informed the resident's representative in advance of risk and benefits of psychotropic medication usage. The findings included: 1.Resident # 21's diagnoses included anxiety disorder, dementia, and borderline personality disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and required assistance of 2 or more helpers with showering, personal hygiene, upper and lower body dressing, and transfers. The MDS further identified Resident #21 had verbal behavioral symptoms directed toward others, and noted antipsychotics received on a routine basis. The Resident Care Plan (RCP) dated 6/13/25 identified psychiatric drug use and at risk for potential adverse effects of psychotropic drug use. Interventions included: to be aware of any signs of tremors or shaking, drowsiness, agitation, nausea, mood, behavior, dizziness, and have the medical doctor evaluate effectiveness and to identify side effects of medications for possible decrease/elimination of psychotropic drugs. A physician's order dated 7/22/25 directed to give Risperdal 1.0 Milligram (MG) two times a day for agitation and to notify the Advanced Practice Registered Nurse (APRN) or Psychiatric APRN for medication being held due to sedation. On 8/13/25 at 1:15 PM first request for psychotropic medication signed consent form for Resident #21 from Registered Nurse (RN#8). Consent was not provided. On 8/14/25 at 2:14 PM second request for psychotropic medication signed consent form for Resident #21 from RN #8. Consent was not provided. Interview with RN #8 on 8/14/25 at 2:14 PM identified signed consent forms for psychotropic medications were in the psychiatric consultant company notes. Resident #21 consent form was not available despite several requests for the form. Review of the Psychotropic Medication Use Policy revised on 3/1/25 directed, in part, facility should involve the resident or the resident's representative in discussion of potential non-pharmacologic and medication interventions to address the management of behaviors. The involvement should be documented in the resident's medical record. Facility staff should inform the residents and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications. 2. Resident #29's diagnoses included unspecified dementia, Type 2 diabetes mellitus, chronic kidney disease. The quarterly Minimum Data Set assessment (MDS) assessment dated [DATE] identified Resident #29 was cognitively impaired and required maximal assistance with toilet transfers and hygiene and supervision assistance with eating. The MDS additionally noted the utilization of antipsychotic and antidepressant medications. A physician's order dated 6/24/25 directed to give 1.0 MG of Risperidone by mouth in the morning. The care plan dated 7/5/25 identified Activities of daily living (ADL). Interventions included to assist with preforming ADL as needed. Review of Residents #29's clinical record failed to reflect a consent form notifying the resident's representatives of risk and benefits of the utilization of psychotropic medications. Interview with 8/14/2025 2:14 PM with Medical Doctor # 2 indicated the consent was not available. She reported consents in the psychiatric notes but was unable to locate. Interview with RN#3 identified she/he was able to locate a psychiatric note dated 8/5/25 indicating Resident #29 consented (resident has impaired cognition, diagnosis of dementia and is conserved). After inquiry of Resident # 29's ability to give consent, RN 3 indicates she/he could not provide evidence Resident # 29's conservator consented to the medication and could not explain why the resident was given a consent form.

Based on clinical record reviews, facility documentation, facility policy, and interviews for two of three residents (Resident # 6 ) reviewed for abuse, the facility failed to ensure a resident with known psychosocial behaviors was free from physical mistreatment which resulted in injury following an alleged staff to resident incident and for ( Resident # 123) the facility failed to ensure the resident was free from verbal and physical abuse. The findings included: 1.Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was without cognitive impairment and was independent with locomotion on and off the unit with the utilization of a wheelchair. The Resident Care Plan (RCP) dated 7/30/21 identified Resident #6 could be physically and verbally aggressive with impulsiveness. Interventions included: to not express anger or impatience verbally or with physical movements which would likely increase confusion and agitation, to be cognizant of not approaching the resident's personal space and to not make unrealistic demands. The nursing progress notes dated 9/27/21 at1:27 P.M. identified the Registered Nurse (RN) met with the resident, secondary to allegation of staff causing injury to the resident's left thumb. Upon assessment the left thumb appeared to be swollen, no discoloration was noted at time of the incident. Resident # 6 stated that his/her left thumb was painful. The Advanced Practice Registered Nurse (APRN) was made aware of the incident and pain. Resident #6 was medicated for pain by the charge nurse and ice was applied to the left thumb. Resident #6 continued to self-propel in the hallway on the unit. All aspects of safety maintained. Additionally, the nursing progress note indicated staff would continue to assess the resident's pain level and swelling to left thumb. A Reportable Event Summary dated 9/30/21 identified on 9/27/2021 at approximately 1:00 P.M. Resident #6 alleged that a staff member whom s/he identified, caused injury to his/her left thumb after the staff member pulled his/her wheelchair backwards, hurting his/her left thumb. The alleged staff member was escorted from the unit, interviewed, and removed from the schedule pending investigation. An assessment was completed, APRN, conservator and the police were notified, and an investigation was conducted. The facility was unable to substantiate the alleged allegation because it was determined to be unintentional, therefore the incident was deemed an accident. The nursing progress notes dated 9/27/21- through 10/5/21 identified an X-ray of the left hand was obtained for Resident #6 on 9/28/21 following complaints of discomfort. The X ray results were negative for fractures. The left thumb presented with signs of discoloration and swelling and with no increased pain. A second x-ray dated 10/4/21 of the left hand noted avulsion fracture to the left thumb with moderate displacement. An interview on 10/12/21 at 11:14 A.M. and 10/15/21 at 10:00 A.M. with Resident #65 identified s/he observed Nurse Aide (NA #7) yell at Resident #6 because she thought Resident #6 was talking about her and then pushed the resident's wheelchair towards her/him and said, You're going upstairs! Resident #6 said Leave me alone! Resident # 65 further indicated NA #7 hurt Resident #6's left thumb, and nothing was done about the incident. Resident #65 stated s/he reported the incident to the Director of Nursing Services (DNS) who indicated she would return with a written statement for Resident #65 to sign but never returned. An interview on 10/14/21 at 12:11 P.M. with the Director of Recreation identified on 9/27/21, residents were eating in the dining room during lunch. NA #7 was serving and assisting with meals. The Director of Recreation observed Resident #6 yelling to NA #7 to get tea for another resident. NA #7 was overheard saying, I can't believe this and then stated, You can't speak to me that way. The tone was described as less then professional and made others in the room uncomfortable. The Director of Recreation obtained the tea for the other resident which he/she felt diffused the situation and left to transport another resident requesting go back to a resident unit. While on the unit, The Director of Recreation observed NA #7 wheeling Resident #6 past the nurse's station backwards. Although, the Director of Recreation did not see Resident #6's hands go near the wheels of the wheelchair, any attempt to lock the wheelchair or place his/her foot down to stop, he did hear NA #7 state You are going back to your room with Resident #6 repeatedly remarking, Leave me alone! The Director of Recreation indicated the most effective way to manage Resident #6 when having behaviors was to redirect the resident. The Director of Recreation also indicated had he known Resident #6 was going to be removed from the dining area, he would have stayed and intervened. An interview on 10/14/21 at 12:28 P.M. with NA #7 in the presence of NA #8 identified she was in the dining room assisting other residents when she overheard Resident #6 making a personal comment about her in relation to getting another resident tea. NA #7 went to the table where Resident #6 was sitting to remove dishes when Resident #6 hit her arm. NA #7 told Resident #6 You can't hit me. Resident #6 yelled profanity at NA #7 for which she responded Stop. You cannot speak to me that way, you need to leave the dining area. NA #7 indicated she should have asked the Director of Recreation for assistance but wanted it to stop so instead, she moved quickly to remove Resident #6 out of the dining area and upstairs to her/his room knowing that this was a place where Resident #6 could calm down. Resident #6 was yelling the whole way. Once upstairs on the nursing unit, NA #7 wheeled Resident #6 backwards off the elevator. According to NA #7 Resident #6 repeatedly put her/his foot down and locked the wheels of the wheelchair at least twice that she could recall and yelled Stop! I am not going to my room! NA #7 further indicated each time Resident #6 locked her/his wheelchair, she would unlock to further move down the hall. NA #7 briefly stopped at the nurse's station to report that Resident #6 had to be removed from the dining area due to behaviors. With the chair locked, NA #7 continued down the hallway backwards with Resident #6 continuing to yell Stop! NA #7 left Resident #6 in the doorway of his/her room. NA #7 sat down to rest after having to pull Resident #6 with the locked wheelchair. The police came and took a statement and NA #7 was relieved from duty during the investigation. NA #7 indicated she had not known Resident #6 to have resistive behaviors, she also did not ask other staff for assistance, or implement any other measure according to the RCP, but stated she should have asked the Director of Recreation for assistance. An interview on 10/14/21 at 3:26 P.M. with Licensed Practice Nurse (LPN #3) indicated she and another nurse, LPN #2 were at the nurse's station when she looked up to see NA #7 wheeling backwards past the nursing station with Resident #6. LPN #3 indicated it was clear Resident #6 was trying to stop as s/he was putting his/her hands on the wheels to try to stop from moving. LPN #3 indicated she could not recall if Resident #6 was yelling as s/he often did. NA #7 reported Resident #6 was removed from the dining room due to behaviors. LPN #3 later told NA #7 Resident #6 should not be wheeled backwards and to stop when the resident say stop. An interview on 10/15/21 at 8:04 A.M. with the DNS and Administrator indicated that although the resident was wheeled backwards in the wheelchair and was trying to stop, the incident was viewed as an accident as the actual injury was not willful and instead happened by accident as a result of Resident #6 attempting to stop while being wheeled backwards. Staff were provided education on the proper way to transport a resident and the appropriate response to a resident who was resistive. Although, the DNS indicated she recalled having a conversation with Resident #65 who reported s/he witnessed the event, she was unable to produce a documented statement or notes from what was described as a 'soft file' related to the alleged incident. An interview on 10/15/21 at 10:06 A.M. with Housekeeping #1 identified she observed Resident #6 yelling at NA #7. NA #7 pulled the wheelchair away from the table and observed Resident #6 holding the wheels and holding her/his foot down to prevent movement. NA #7 then wheeled Resident #6 forward out of the dining area and indicated she/he observed nothing else. An interview on 10/15/21 at 10:22 A.M. with Recreation Assistant #1 (Recreational AST #1) identified she was on the other end of the building when she heard Resident #6 yelling and speaking profanity. Recreational AST #1 looked down the hallway and observed NA #7 pulling Resident #6 backwards and then into the elevator. Recreational AST #1 came close and heard NA #7 say to Resident #6 they were going upstairs in a loud and stern tone. Recreational AST #1 observed Resident #6 trying to stop, yelling no, I'm not going upstairs before the elevator closed. Recreational AST #1 went to the dining are to check on the other residents and then reported the incident to the Administrator. An interview on 10/15/21 at 10:37 A.M. with LPN #2 identified she was upstairs when she observed NA #7 pushing Resident #6 down the hallway. LPN #2 observed Resident #6 placing his/her hands-on top of the wheels trying to stop. LPN #2 recalled Resident #6 was yelling and swearing but could not recall what was said. NA #7 reported NA #6 was removed from the dining area due to behaviors. An interview on 10/15/21 11:00 A.M. with APRN #1 identified although Resident #6 could be impulsive, she would expect transports to be completed in a safe manner to prevent injury. An interview on 10/15/21 at 11:35A.M. with Resident #6 identified NA #7 pushed him/her backwards out of the dining room causing injury to the left thumb. According to Resident #6, s/he did not want to leave the dining room and repeatedly told NA #7 to leave his/her chair alone and to leave him/her alone. Resident #6 tried to lock the wheelchair so NA #7 could not pull the wheelchair backwards. Resident #6 indicated s/he told NA #7 that his /her thumb was in the wheelchair, but that NA #7 kept pushing backwards. The policy for Abuse directs abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Abuse meaning the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. The facility failed to ensure a resident was free from physical mistreatment which resulted in injury. 2.Resident #123 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual MDS assessment dated [DATE] identified Resident #123 had severely impaired cognition and required total dependence with two persons physical assistance. The care plan dated 12/13/19 identified Resident #123 was sometimes confused and forgetful due to dementia diagnosis. Interventions included: to allow time for me to respond when speaking to me and noted if I am confused or forgetful, offer gentle reminders. The care plan dated 12/13/19 identified Resident #123 was at risk for falls. Resident #123 has multiple risk factors such as: [CONDITION(S)] medications and non-ambulatory. Interventions included to provide total mechanical lift transfer with the assistance of two people. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . To provide self-care with assist of 1 at bed level. The Reportable Event report dated 1/24/20 at 4:45 P.M. identified NA #3 reported that she witnessed NA #2 verbally and physically abused Resident # 123. No injury and no distress were noted. No bumps, no swelling, and no bruise noted. Resident #123 is alert, verbal, and confused. Resident #123 transfers with the assist of two persons via mechanical lift. Assist of one with personal hygiene. The APRN was notified with no new order. NA #2 was taken off the schedule pending investigation. Abuse policy and procedure followed, police department was called, physician and family were notified. A statement by NA #3 dated 1/24/20 identified she asked NA #2 to assist her with a Hoyer lift transfer with Resident #123. As Resident #123 was being lowered to the bed h/she complained h/she was in pain. NA #3 indicated as she raised the Hoyer lift bars Resident #123 screamed that he/she was in pain. NA #2 told Resident #123 to shut the [OBSCENITY] -up, don't start your mess. NA #3 indicated she looked at NA #2 with surprise and she told NA #2 don't say that, s/he is [AGE] years old. NA #3 indicated she said to NA #2 girl watch what you are doing, you hit her/him. NA #3 indicated when she finished giving care to Resident #123, she reported the incident to the nurse on duty. A statement by NA #2 dated 1/24/20 at 3:00 P.M. to11:00 P.M. shift identified she was helping NA #3 Hoyer lift Resident #123 into bed. NA #2 indicated they both unhooked Resident #123 from the Hoyer lift and then she left the room with the Hoyer lift. NA #2 indicated she never cursed or did any harm to Resident #123. The care plan dated 1/24/20 identified Resident #123 had an allegation of verbal and physical abuse. Interventions included investigation per house policy. Reported incident to family and physician. Social service and psychiatrist follow up as needed. A nurse's note dated 1/24/20 at 8:53 P.M. identified LPN #1 reported NA #3 witnessed NA #2 verbally and physically abusing Resident #123. RN assessment completed. Resident #123 was safe, and comfort maintained. The DNS, family, and APRN were updated. Incident was reported to the police department for further investigation. A social service note dated 1/27/20 at 10:02 A.M. identified social worker was informed of verbal and physical abuse allegation involving Resident #123. Resident #123 was alert and confused. NA #3 witnessed another NA #2 verbally and physically abuse Resident #123 during a transfer. Resident #123 has no recall of an incident taken place and reported he/she feels alright. Social worker will continue ongoing support. A statement by LPN #1 dated 1/27/20 at 10:51 A.M. identified NA #3 reported to her that she was assisted by NA #2 to place Resident #123 into bed via Hoyer lift. Resident showed some resistance verbally and physically and NA #2 said to Resident #123 shut the [OBSCENITY] up and swatted her/him on the extremity. NA #3 told NA #2 not to say or do that. LPN #1 indicated she reported the incident to the supervisor and Resident #123 was examined to ensures there were no injuries. There were no injuries. A statement by RN #1 dated 1/27/20 at 1:05 P.M. identified LPN #1 reported NA #3 witnessed NA #2 say the F to a [AGE] year-old resident while being transferred to bed. NA #3 cautioned NA #2 to refrain. Upon releasing the Hoyer pad NA #2 swatted Resident #123 hands and shoved the Hoyer bar towards NA #3 hitting Resident #123's arm. Review of the psychiatry note dated 1/31/20 identified she was asked to see Resident #123 post verbal abuse incident last week. Resident #123 denies any pain or sad mood. He/she is doing well at this interview and did not remember any recent incident reports. The Investigation Summary Report dated 2/7/20 identified Resident #123 was [AGE] years old. Resident #123 requires two persons assist with all transfers. According to RN #1, LPN #1 reported to him that NA #3 witnessed NA #2 verbally abused Resident #123 by swearing/cursing and NA #3 cautioned her to refrain and NA #2 swatted Resident #123 hand hitting the resident's arm with the Hoyer lift bar. Abuse policy and procedure was followed. Resident #123 had no ill effects from the incident and is being followed by the social worker and the psychiatric services. care plan has been updated. NA #2 was terminated. Interview with NA #2 on 10/14/21 at 9:55 A.M. identified she did not abuse Resident #123 and the incident did not happen the way NA #3 said it happened. NA #2 indicated she assisted NA #3 with a Hoyer lift transfer and left out of the room. Interview with DNS # 2 on 10/14/21 at 10:14 A.M. identified she does not remember the incident to please reference the written statement. Interview with RN #1 on 10/14/21 at 10:25 A.M. identified he cannot remember the incident and whatever his written statement says he stands by it. Interview with NA #3 on 10/14/21 at 10:35 AM identified she does not want to speak about the incident. NA #3 indicated read my written statement. Although attempted, an interview with previous Administrator and LPN #1 were not obtained. Attempts were made to interview Medical Doctor #1 were unsuccessful. Review of the facility abuse policy dated 12/17 directed to ensure each resident is treated with kindness, compassion and in a dignified manner. To ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws. Abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Allegations of abuse, by any individual (staff, family, visitor, resident) toward a resident must be reported immediately to a facility supervisor. All allegations will be thoroughly investigated and acted upon according to the steps of this policy. Additionally, the abuse policy noted verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm; saying things to frighten a resident/patient, such as telling a resident/patient that he/she will never see their family again. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The facility failed to ensure the resident was free from verbal and physical abuse.

Based on clinical record reviews, review of facility documentation, review of policy and interviews for one of three sampled residents (Resident #132) reviewed for an allegation of abuse, the facility failed to ensure the resident was free from verbal abuse.The findings included: 1. Resident #132's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #132 had memory recall deficits, hallucinations, and delusions, required extensive assistance of two (2) staff for transfers in and/or out of the bed and chair, extensive assistance of one (1) person for locomotion on the unit and utilized a wheelchair for mobility. The resident care plan dated through 12/14/18 identified the resident had altered cognition, the resident talks to self, becomes fixated on situations and frequently thinks staff and others are talking about and/or are upset with the resident. Interventions directed to offer gentle reminders when confused, offer support and reassurance if appears anxious and use short simple sentences. The nurse's note dated 12/14/18 at 11:40 AM indicated that two (2) charge nurses witnessed a nurse aide verbally abuse a resident. The note identified the nurse aide involved stated while she was on her personal phone I'm on the phone, I'm not talking to you and then stated to the person on the phone that was Resident #132, the retarded ass. The note indicated Resident #132 was alert, knows his/her name, was confused and restless at times, and there were no signs and/or symptoms of any form of distress. The Reportable Event Form dated 12/14/18 at 11:00 AM indicated Resident #132 was called a retarded ass by a nurse aide while the aide was on her phone. The incident report identified the incident was witnessed by two (2) charge nurses and the nurse aide was talking on her phone when Resident #132 asked a question and the nurse aide stated to the resident I'm on the phone I'm not talking to you and continued with conservation on the phone then stated to the person on telephone that was Resident #132 the retarded ass. The report identified the nurse aide involved was sent home and all parties were notified. The investigation identified the nurse aide admitted she told Resident #132 to stop acting retarded and the nurse aide was terminated on 12/17/18. The social service note dated 12/14/18 at 4:18 PM identified the social worker spoke to Resident #132 regarding the recent allegation. The note indicated the resident reported the nurse aide yelled at him/her and Resident #132 appeared upset with the situation. The note identified the Social Worker will continue one (1) on one (1) visits and ongoing support. Review of the clinical record from 12/14/18 at 10:59 PM through 12/17/18 at 3:53 PM failed to reflect documentation Resident #132 was monitored for three (3) days after the 12/14/18 incident. The social service note dated 12/17/18 at 3:53PM identified the social worker followed up with Resident #132 regarding the allegation and the resident had no additional information and the resident appeared content. In an interview with the nurse aide, Nurse Aide (NA) #1, on 5/21/19 at 10:17 AM she indicated she was assisting another resident to the dining room, Resident #132 was in the hallway removing his/her clothes and at that time she told Resident #132 to stop been a retard. In an interview with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 5/21/19 at 10:47AM she indicated that on 12/14/18 NA #1 was assisting a resident to the dining room while having a conservation on her telephone and at that time NA#1 stated to Resident #132 can't you see I'm on the phone and continued with her conservation. LPN #1 stated that while referring to Resident #132, NA #1 stated yeah the retarded ass, always bothering me. In an interview with the Assistant Director of Nursing (ADON) on 5/22/19 at 3:30 PM she indicated that NA #1 was talking on her personal phone in the resident care area and when Resident #132 tried to get her attention, NA#1 used inappropriate language which was directed towards the resident. The ADON stated NA #1 was suspended on 12/14/18 pending the investigation and on 12/17/18, NA #1 was terminated secondary to verbal abuse. Review of the facility abuse policy identified verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families within their hearing distance, regardless of their age, ability to comprehend, or disability. The abuse policy also indicated that examples of verbal abuse include, but are not limited to threats of harm, saying things to frighten a resident/patient, such as telling a resident/patient that he/she will never see their family again.

Based on clinical record reviews , review of facility policy, review of facilty documentation and interviews for one of six sampled residents at risk for falls ( Residents # 99), the facility failed to ensure resident equipment was maintained to prevent an injury and /or for two of six sampled residents at risk for falls (Residents # 136 and # 40), the facility failed to provide the necessary supervision to prevent an accident . The findings included: Resident #99's [DIAGNOSES REDACTED]. An admission RCP dated 1/9/17 indicated the resident require assistance with transfer. The physician's orders [REDACTED]. An admission MDS assessment dated [DATE] identified the resident with moderate cognitive impairment and indicated the resident required the physical assistance of two people for transfer and bed mobility. The nurse's notes dated 1/19/17 at 2:30 P.M. identified at 2.00 P.M. when Resident # 99 was ready to be transported to physical therapy, the Physical Therapist (PT) notified the nurse at the nursing station he/she noticed some blood under the resident's left leg. The resident was assessed and noted with a crescent shape skin tear measuring 1.8 CM x 2.3 CM with skin flapping and a heavy drainage on the resident's posterior/lateral left leg above left ankle. The resident was evaluated by the APRN and an order was obtained to cleanse the left leg with Normal Saline, to apply steri-strips, to cover the wound with an ABD, to change the wound every three days for 14 days, and to re-evaluate. The nurse's notes dated 1/19/17 at 10:07 P.M. identified the nurse was called to assess Resident # 99 at 4:30 P.M. when the resident was in the bed. Upon assessment the resident was noted with an elongated open area to left lower extremity that was draining sanguineous drainage. The left leg was cleansed with NS followed by ABD pads. The APRN was notified and staff was directed to transport the resident to an acute care facility for an evaluation. The nurse's note dated 1/19/17 at 10:25 P.M. identified when the nurse aides walked into the resident's room to prepare the resident for bed. NA # 3 and NA# 4 upon removal of the resident's leg rest observed blood on the floor, NA # 3 and NA # 4 lifted Resident # 99's pants leg and noticed a large skin tear and notified the nurse immediately. The resident was assessed by the nurse and noted with a large skin tear with a large amount of blood draining from the area. The area was cleansed with NS followed by a pressure dressing. 911 was summoned to transport the resident to an acute care facility and the APRN was updated. A review of the facility Reportable Event/ Investigation dated 1/20/17 identified NA # 3 and NA # 4 went into to get Resident # 99 ready for bed secondary to the resident sloughing down in the wheelchair. NA # 3 and NA # 4 upon removing the wheelchair leg rest observed blood on the floor. NA # 3 and NA # 4 lifted the resident's left pants leg and observed a large skin tear to the left lower extremity and immediately notified the charge nurse. An RN assessment was conducted and the resident was noted with an 8.5 CM laceration to the left lateral lower extremity and denied any pain or discomfort. The resident was transferred to the hospital for an evaluation. The facility investigation further noted Resident # 99 returned to the facility on [DATE] at 11:15 P.M. in stable condition. The investigation also identified the resident required thirteen sutures to approximate the left lateral lower extremity skin tear and indicated the resident was placed on Keflex (Antibiotic) 250 MG by mouth four times a day for seven days. In an interview and review of Resident #99's clinical record with ADNS on 4/19/17 at 11:35 A.M. identified the resident had two skin tears on 1/19/17 at 1:45 P.M. The ADNS on 4/19/17 at 4:30 P.M. also indicated upon inspection of the wheelchair after, the incident the facility identified that the left calf pad bracket on left leg rest was broken and had a sharp edge which could have caused the injury. During an interview and review of facility Accident Incident Report with RN# 3 on 4/20/17 at 1:39 P.M. identified upon inspection of Resident #99's wheelchair a sharp edge was identified on the left calf bracket of the wheelchair which resulted in the laceration to the resident's left leg. 2. Resident #136's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident with severe cognitive impairment, required extensive assistance with ADL including locomotion on the unit. The physician's orders [REDACTED]. The Reportable Event dated 4/20/16 identified Resident # 136 was slumped in the wheelchair, positioned upright in the wheelchair by staff and indicated when staff started down 3 West hallway, the resident's gown got caught in the wheelchair causing the resident to fall and hit his/her forehead. Additionally, the report noted the resident sustained [REDACTED]. Review of the facilities investigation of the incident dated 4/20/1/6 identified at 8:30 P.M. the resident was observed slumped down in the wheelchair. LPN# 2 repositioned the resident and then proceeded to transport the resident down the hall. During the transport the resident's gown became lodged in the wheelchair. The wheelchair malfunctioned related to the resident posture and attire The nurse's note dated 4/21/16 at 1:41 A.M. identified Resident # 136 at 8:00 P.M. was sleeping in the wheelchair, slouched down, positioned correctly by staff, and indicated while the licensed staff was attempting to transport the resident to bed via wheelchair Resident # 136's gown got caught in the wheelchair causing the resident to fall frontward. Additionally, the nurse's note dated 4/21/16 noted the resident at the time of the incident sustained a 1.5 CM by 2.0 CM abrasion to his/her left side of the forehead. The physician was notified an order was obtain to cleanse with Normal Saline and apply a dry clean dressing every three days and when necessary to the forehead. Interview, review of the clinical record and facility documentation on 4/20/17 at 1:00 PM with the Administrator identified a safety check should be done prior to transporting the resident down the hall. Numerous attempts to interview LPN #2 were unsuccessful. 3. Resident # 40's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident # 40 had a Brief Interview for Mental Status (BIMS) score of seven out of fifteen, indicative of severe cognitive impairment and required extensive assistance of two with transfers; extensive assistance of one person for bed mobility; supervision with set up help for eating, received a mechanical altered diet and noted no signs/symptoms of a swallowing disorder. The Resident Care Plan (RCP) dated 1/12/17 identified the resident has dysphagia and required a mechanically altered diet. Interventions directed to set up meals, encourage resident to eat as much of the meal independently as possible, and to assist the resident when needed with completing the meal. A physician's orders [REDACTED]. The nurse's note dated 1/25/17 at 12:57 P.M. and 5:11P.M. identified while the licensed staff and the APRN was in the resident's room Resident #40 was heard coughing, the resident was assisted to an upright position , noted with stridor, and her/his color turned blue. The Heimlich maneuver was performed and the resident was able to cough out a piece of potato patty she/he was eating. Additionally, the nurse's note dated 1/25/17 at 12:57 P.M. identified the APRN assessed Resident # 40 and was able to remove food particles from the resident's throat with the help of the licensed staff and indicated the resident was able to speak. The nurse's note also identified Resident # 40's oxygen saturation was normal, the resident was started on a puree diet and a speech evaluation was ordered. The Reportable Event and facility investigation dated 1/25/17 identified Resident # 40 was observed coughing while lying in bed with food in her/his mouth. The resident was placed 90 degrees upright, developed a stridor, turned blue and the Heimlich maneuver was performed with success. In an interview with SLP on 4/9/17 at 11:00 A.M. identified that although a potato patty was appropriate on the resident's prescribed diet, it was not appropriate for Resident 40 to be positioned at a 30 degree angle while eating, and all residents should be upright, as close to 90 degrees as possible while eating. Interview and with LPN#5 on 4/9/17 at 11:20.A.M. identified on 1/25/17 just before lunchtime she/he walked by the Resident #40's bed on her/his way to provide care to the resident's roommate, partially pulled the curtain to provide privacy and indicated she/he did not notice any food at Resident #40's bedside. LPN # 5 further identified that while she/he was in the bathroom completing a task for the roommate with the APRN, they heard Resident #40 coughing. LPN#5 indicated she/he exited the bathroom and observed the resident with her/his meal on the over bed table, the resident was lying at a 30 degree angle and indicated the APRN assisted the resident to an upright positron. LPN # 5 also indicated the resident was responsive, could not clear her/his throat and turned blue. The Heimlich maneuver was performed, the resident expelled a piece of potato, and then returned to baseline. LPN#5 further identified Resident #40 should have been upright at 90 degrees for eating, and the tray should have been set up for her/him including cutting the food and opening the containers, but the resident helped him/herself to the tray before the staff could set up the meal tray, or reposition the resident. Interview with Dietary Aide #1 on 4/19/17 at 12:00 P.M. identified it is the dietary department practice to deliver the residents meals to them within the resident's reach, unless notified by nursing not to deliver within reach. He/she further identified that prior to 1/25/17 she/he was delivering Resident 40's meal at the resident's bedside within reach, but has since been educated not to leave the resident's meals within reach. Interview with the ADNS on 4/20/17 at 1:15 P.M. identified that all residents should be positioned at 45 degrees or higher while eating. Review of facility Feeding Policy notes residents should be assisted to a position as upright as possible, and meals should be prepared as needed i.e. cut meat, prepare beverages, etc.

Based on review of the clinical record, and staff interview for one of three sampled residents (Resident #10) the facility failed to ensure the resident was free from neglect when staff did not provided incontinent care for several hours. The findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The care plan dated 7/3/15 directed the assistance of two staff via mechanical lift for all transfers and assistance with toileting needs. The nurse aide assignment, in place on 7/5/15, directed to provide incontinent care to Resident #10 every two hours. On Sunday, 7/5/15 at 9:30PM Person #1 reported to the nursing supervisor, RN#1, that Resident #10's brief was wet and the resident had reported that he/she had been put to bed in the afternoon with a wet diaper. A written statement by RN#1 dated 7/5/15 identified Person #1 was very upset because Resident #10 had been put in bed at approximately 4:00PM with a wet brief and was still wet. Additionally, on observation, RN#1 documented the resident's bottom was red and stool was noted in the vaginal area. Accident/incident report dated 7/6/15 identified that during the 3-11 shift on 7/5/15, incontinent care was not performed on the resident in a timely manner and according to the policy. A written statement by NA #1, (the 7-3 shift NA on 7/5/15) dated 7/6/15 identified that Resident #10 was provided incontinent care at 10:00AM and placed into the recliner chair. Although the resident was periodocally checked and asked if he/she needed anything, no other incontinent care was provided during the day shift on 7/5/15. At 3:00PM the resident rang the call bell and requested to be provided incontinent care. NA #1 reported this information to the oncoming NA, NA #3. At 3:30PM NA #3, NA #2 and NA #1 transferred the resident into bed. At about 7:00PM Resident #10 reported to NA #1 that he/she had not been provided incontinent care yet and that he/she needed to be changed. NA #1 again reported this information to NA #3. At approximately 9:00PM - 9:30PM Person #1 reported to NA #1 that Resident #10 had not been provided incontinent care all day. A written statement by NA #2 dated 7/6/15 identified that when he/she assisted NA #1 and NA #3 get Resident #10 back to bed at approximately 3:30PM the resident was soaking wet. A statement by Person #1 dated 7/6/15 identified that he/she came into the facility at approximately 9:45PM and Resident #10 was upset. Person #1 opened the brief and it was bad, under the brief was saturated in stool and urine. The stool was between the creases in the skin and down the resident's legs. A statement by Resident #10 indicated that staff left him/her in the chair all day without care being provided. A written statement by NA #3 dated 7/5/15 documented that Resident #10 was put to bed at 3:30PM and was was dry. At 8:30PM NA #1 notified him/her that the resident wanted to get changed. NA #3 documented that he/she went in the room at that time and washed up the resident. The admission MDS dated [DATE] identified the resident had no impairment in cognition, required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, bathing, and required total care with assist of two staff with transfers. The accident/incident report conclusion dated 7/17/15 reflected that NA #3 did not provide Resident #10 with incontinent care at 3:30PM or at 7:00PM and was not truthful in his/her statement that he/she had provided incontinent care to Resident #10. NA #3 was terminated. A call was placed to NA #3 on 3/31/16 at 10:00AM and 10:05AM however, an interview could not be obtained. Interview with NA #2 on 3/31/16 at 12:15PM identified that Resident #10 was wet when they put him/her back to bed at approximately 3:30PM. NA #2 offered to help NA #3 provide incontinent care at that time, but NA #3 refused the help. By 8:00PM Person #1 was upset that Resident #10 had not received care and NA#2 documented that he/she provided Person #1 with wet washcloths because Person #1 wanted to provide the care at that time. NA #2 was not able to find NA #3 on the unit at that time. Interview and review of the accident/incident report with RN #2 on 3/31/16 at 12:30PM identified that Resident #10 was not provided with incontinent care from 10:00AM - until after 8:00PM when Person #1 provided it after 8:00PM. RN #2 indicated that based on the interviews from NA #1 and NA #2, Person #1, and Resident #10, it was determined that NA #3 was not truthful in his/her statement and did not provide care to Resident #10 on her shift. Subsequently, NA#3 was terminated. The facility failed to ensure the implementation of the policy that prohibits the neglect of a resident.

Based on review of the clinical record and staff interview for one of three sampled residents (Resident # 1) reviewed for accidents, the facility failed to ensure the necessary care and assistive devices were in place to prevent an injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified short term memory deficits, required limited assistance with bed mobility, extensive assistance of two staff members for transfers, total dependence on staff for toilet use, always incontinent of bowel and bladder and the absence of behaviors. The care plan dated 9/8/14 identified the resident was confused due to dementia and utilized half padded side rails for skin protection and bed mobility. Additionally, the care plan identified the resident occasionally may be resistive to care and at times has kicked care givers. Interventions included assisting the resident to a safe position if resistive/combative, leaving and reapproaching later. The accident/incident report dated 9/27/14 at 2:00 PM identified Resident #1 was found with a bruise to the bottom of his/her left eye. Additionally, at 7:30 PM that night, the resident was observed with a bloody nose that was deviated to one side. The physician was notified and directed to send the resident to the hospital for an evaluation. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Interview with NA#3 (who cared for the resident on 9/27/14 during the 7:00AM-3:00PM shift) on 5/29/15 at 10:15 AM identified the resident did not get out of bed that day because he/she was combative, fighting, scratching, kicking and punching. NA#3 further identified that he/she did leave the resident and reapproached at a later time to complete care without the benefit of an additional staff member. NA #3 identified in the afternoon, he/she removed the padding from the side rails during care, which was the usual practice, but forgot to replace the pads after care was complete. At 1:30 PM NA#3 found the resident on his/her side with his/her face near the side rail and a bruise under the left eye. The side rail padding was not in place at that time. After reporting the bruise to the nurse, NA#3 replaced the side rail pads back onto Resident #1's bed. Observation of the residents ' bed with NA#3 on 5/29/15 at 10:30 AM identified the side rails are metal, which were the same rails that were in place on 9/27/14. Interview with the DNS on 5/29/15 at 11:30 AM identified Resident #1 could move about in the bed and that the facility investigation concluded the resident may have hit his/her face on the side rail. Additionally, the DNS identified that if a resident is combative, after leaving and reapproaching the resident, there should be two staff members present to provide care. Interview with MD#1 on 5/29/15 at 12:40 PM identified the resident was deconditioned and fragile and he/she does believe that it is plausible that the resident hit his/her face on the side rail and caused the fractures. Additionally, he/she believes that the initial bruise under the left eye and the bloody deviated nose later that day originated from the same trauma and that it is highly doubtful that there was a secondary injury. The facility conclusion identified NA#3 did not apply the side rail pads on the bed following care and the resident may have struck his/her face against the side rail.

Based on review of the clinical record, review of facility policies, observations, and interviews, the facility failed to consistently implement measures to prevent and/or reduce the risk of pressure ulcers and/or failed to ensure that an appropriate pressure reduction/pressure relieving devices were in place for four of six sampled resident reviewed for pressure ulcers Residents #61, #93, #164, and169 who developed and/or who were at risk to develop a pressure ulcer. The findings include: 1. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. The documentation further identified that the resident had no open areas upon admission but had a history of [REDACTED]. R #61's admission care plan dated 1/9/14 identified that the resident was at risk for pressure ulcers with interventions that included repositioning every two hours and to supply a pressure redistributing mattress. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified that R #60 had a Brief Interview for Mental status score (BIMs) of four, indicative of cognitive impairment, and required extensive assistance for bed mobility and personal hygiene. Review of the nursing notes dated 1/18/14 on the 11:00 PM to 7:00 AM identified that R #61 had developed a Stage II decubitus at the left buttocks/coccyx region that measured 2.0 centimeters (cm) by 0.5 cm. Orders obtained by APRN #1 dated 1/20/14 directed that the area be cleansed with Normal Saline followed by an Alginate dressing although the treatment kardex identified that the treatment as prescribed by APRN #1 on 1/20/14 began on 1/18/14. Review of the progress notes by APRN #1 dated 1/23/14 identified that R #61 had an unstageable left buttocks pressure ulcer that had increased in measurements to 1.40 cm by 2.5 cm. Physician orders [REDACTED]. Review of the resident's Skin/Wound tracking record dated 2/27/14 identified that R #61's pressure ulcer now measured 2.4 cm by 2.0 cm, yellow in color, and had a moderate amount of serosanguiness drainage. Review of the clinical record that included a review of nursing notes, the care plan and the Medication and Treatment Records (MAR and TAR) from 1/23/14 through 2/28/14 lacked documentation to reflect that the APM mattress was placed on R #60's bed and/or checked for function as directed by the APRN. Review of R #61's March 2014 TAR identified that the APM was in use and checked every shift as of 3/1/14. Interview with LPN #2 on 4/24/14 at 12:00 PM identified that he/she could not recall when the APM mattress was place on R #61's bed. LPN #2 stated that check of the mattress function was usually documented on the TAR. 2a. Resident #93 had [DIAGNOSES REDACTED].#93 had severe cognitive impairment, required limited assistance for be mobility, total assistance for transfers, and was non ambulatory. Review of the care plan last updated on 2/20/14 identified that R #93 had experienced a decline in his/her ability to move about on his/her own, and had a history of [REDACTED]. In addition, the care plan identified that the resident was chairfast. Interventions included that the resident's heels be elevated when in bed. Review of a Skin/Wound tracking record dated 4/4/14 identified that R #93 had developed a new facility acquired 4.0 centimeter (cm) by 4.0 cm Deep Tissue Injury (DTI) on the right heel. Physician orders [REDACTED]. Review of the clinical record dated 4/10/14 identified that the treatment to the resident's right heel was changed to a [MEDICATION NAME] wipe twice daily and direction for staff to offload the resident's heels. Review of the clinical record that included the Treatment Administration Records (TAR) from January through April 2014 lacked documentation to reflect that R #93's heels were offloaded prior to the discovery of the right heel DTI and/or when the DTI was identified on 4/4/14. Review of the TAR for April 1014 identified that staff began to offload the resident's heels as of 4/10/14. b. Observation on 4/25/14 at 1:20 PM identified that R #93 was sitting up in a wheelchair in the doorway of his/her room. A blue, "bunny boot" was observed on the resident's right heel which rested on the foot pedal of the wheelchair. A second observation on 4/25/14 at 2:05 PM in the presence of the Corporate Nurse identified that R #93 was laying on his/her left side with a pillow between his/her legs. The blue, "bunny boot" was still in place on the right foot but the resident's left foot was resting directly on the mattress. Interview with the Corporate Nurse at the time of the observation identified that the blue boot was for comfort, was not pressure reducing/relieving, and would not be used for offloading. Subsequent to surveyor inquiry, the Corporate Nurse provided immediate education to staff present regarding the theory behind offloading and product use to ensure true offloading of residents' heels. 3a. Resident #164 was admitted to the acute care facility on 5/27/14 for complications related to his/her recent [MEDICAL CONDITION]. R #164 returned to the facility on [DATE]. Review of the readmission nursing assessment dated [DATE] identified that R #164 returned to the facility with a reddened but intact area on the buttocks. The documentation identified that R #164's skin was clean, dry, and intact except for staples to the left hip. Review of the interim care plan dated 5/31/13 identified R #164's risk for the development of pressure ulcers with interventions that included to turn and reposition the resident but lacked documentation to reflect an intervention to offload the resident's heels. In addition, review of the record of resident care dated 6/1/13 through 6/5/13 identified that R #164 required extensive assistance for bed mobility and transfers. Review of the clinical record that included R #164's TAR for 5/31/13 and June 2013, the clinical record and TAR lacked documentation to reflect that R #164's heels were offloaded. Review of the nursing note dated 6/4/13 identified that R #164 had developed blisters on his/her bilateral heels. The note further identified that "blue boots" were put in place and that a "note (was placed) in APRN book." Interview with the Corporate Nurse on 4/25/14 at 1:20 PM identified that the blue boots used by the facility were for comfort, were not pressure reducing/relieving, and would not be used for offloading. b. Review of the wound tracking record dated 6/4/13 identified that R #164 had developed a new intact blister on the right heel and a new blister on the left heel. The wound tracking record dated 6/4/13 lacked documentation to reflect any further assessment of the areas to include the size, odor, and/or condition of the periphery. In addition, the tracking record identified both areas as Stage II. Review of facility policy directed in part that a Stage II pressure ulcer would include a partial thickness disruption of intact skin. On 6/5/13, the wound tracking record identified that R #164 had developed a Stage II intact blister on the left heel that measured 5.0 centimeters (cm) by 5.0 cm with no drainage and the periphery was noted as clear. In addition, R #164 had developed a Stage II pressure ulcer on the right heel that measured 9.0 cm by 10.0 cm with a small amount of drainage. On 6/6/13, R #164's right heel was now identified as a Stage II pressure ulcer measuring 9.5 cm x 10 cm x 0.1cm in depth with serosanguineous drainage and pink periphery. Review of the clinical record identified that R #164 was again admitted to the acute care setting on 6/13/13 when he/she was found by facility staff to be unresponsive and breathing heavily. R #164 had recently been [DIAGNOSES REDACTED]. Review of the operative record from the acute care facility dated 6/25/13 identified that during the hospital admission, R #164 underwent bilateral heel debridement down to the bone on the right side and wide debridement to the calcaneum on the right and debridement down to the muscle on the left side. Facility policies directed in part that wound prevention interventions be directed toward minimizing and/or eliminating any negative effects of the causal/contributing factors for pressure ulcer development such as pressure, friction, or shear. The policy directed that interventions be implemented to provide a systematic approach and monitoring process for promoting healthy skin integrity and providing pressure ulcer care. In addition, the policy directed that the interdisciplinary team address problems, goals, and interventions directed toward the preventions/treatment of [REDACTED]. 4. Resident #169 (R #169) had [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] identified that the resident was at risk to develop pressure ulcers and had a reddened, but blanchable area on the coccyx upon admission that measured 0.75 centimeters (cm). Review of the admission care plan dated 4/23/14 identified that R #169 had a pressure ulcer with interventions that included a pressure redistribution mattress and treatment as ordered. Although there was an option to include a pressure redistribution chair cushion, the care plan lacked documentation to reflect that this option was chosen. Observation on 4/24/14 at 10:10 AM, 11:30 AM and at 1:25 PM identified that R #169 was seated in a wheelchair on a blue air cushion that was flattened. Observation and subsequent interview with the facility's Wound Care Nurse on 4/24/14 at 1:25 PM identified that the cushion had likely been sent with the resident from the hospital and that it was not an appropriate seating device for the resident. R #169's pressure ulcer was measured by the Wound Care Nurse at the 1:25 PM and was observed to be 1.1 by 1.1 cm with dry, peeling edges and that the total surface area affected measured 2.6 by 2.0 cm and remained blanchable. Subsequent to surveyor inquiry, R #169 was provided with a pressure relieving cushion for the wheelchair. Review of the facility's wound care protocols directed in part that the purpose of the protocol was to prevent pressure ulcers by identifying residents at risk and to develop appropriate interventions. The protocol further identified interventions for a DTI that included to protect the area and to remove the cause of the pressure. In addition, facility polices directed in part, that a plan of care would be developed and consistently implemented.

Based on review of clinical records, review of facility policies, review of facility documentation, observations, and interviews, the facility failed to provide adequate supervision, assistance and/or assistaive devices in accordance with the plan of care and or instructions to prevent an injury for two of three residents, Residents #164 and #168, who both had a recent total hip replacement and/or failed to ensure that potentially hazardous items were not accessible to one resident, Resident #58, who had a history of [REDACTED].#3, who had a behavior of being combative, the facility failed to implement padded side rails to prevent an injury. The findings include: 1. Resident #164 (R#164) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] identified that R #164 had no cognitive impairment, required one person assistance with positioning and transfers. The interim care plan dated 5/20/13 identified that R #164 had a recent fracture repair with interventions that included to provide incision care and to turn and reposition per facility policy. In addition, the interim care plan directed staff to transfer the resident with the assistance of one or two persons. Nursing notes dated 5/23/13 on the 11:00 PM to 7:00 PM shift identified that R #164 complained of hip pain. The resident was medicated twice during the shift with fair effect. Nursing notes dated 5/23/13 on the 7:00 AM to 3:00 PM shift identified that the physician was notified of the resident's complaints of increased pain and that an x-ray of the left hip was ordered. Review of the clinical record identified that the x-ray results showed a dislocation of the left hip, superior and posterior. The physician was notified and directed to send the resident to the acute care hospital for evaluation. Review of the acute care hospital discharge summary and Inter-Agency Patient Referral Report dated 5/24/13 identified that R #164 reported that he/she was attempting to move self in bed when he/she heard a "pop." The documentation identified that R #164 was admitted for a closed reduction repair of the left hip. Discharge recommendations were to ensure R#164 remained in the abduction brace at all times. Interview with Physical Therapist #1 (PT #1) on 4/24/14 at 8:30 AM indicated that when R #164 was identified with a dislocated left hip on 5/23/13, the recommendations were to ensure that an abduction brace be worn at all times. On 5/27/13, R #164 was again transferred to the acute care hospital with complaints of severe left hip pain. X-rays showed that R #164 had an anterior, superior lateral dislocation of the left hip. Review of the admission record from the acute care hospital identified that R #164's abduction brace had been placed incorrectly. The documentation by the physician identified that the way that the brace was placed, the abductor brace did not provide adequate support or prevention of hip extension or adduction which likely caused the patient's dislocation. R #164 was given conscious sedation and underwent another closed reduction of the left hip. 2. R #168 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 4/11/14 identified that R #168 required two persons to assist with transfers, sit to supine, and from supine to sit as the resident provided "only 50% patient effort" In addition, the hospital referral documentation to the skilled nursing facility identified that R #168 was at risk for falls and was to maintain hip precautions. Review of the admission care plan dated 4/12/14 identified that R #168 required the assistance of one staff member for hygiene and dressing and assistance of two staff persons for transfers and ambulation. Review of facility documentation identified that on 4/19/14, R #168 reported that he/she felt something "pop" after being assisted from sitting on the edge of the bed to a supine position and now had excruciating pain. In addition, review of an undated statement by Nursing Assistant #5 (NA #5) identified that NA #5 assisted R #168 on 4/19/14, to put her legs onto the bed at the resident's request. NA #5's written statement identified that subsequent to the repositioning, R #168 began to scream and NA #5 notified the nurse. Interview with Nursing Assistant # 5 (NA #5) on 4/25/14 at 11:50 AM identified that he/she was assigned to provide care to R #168 on 4/19/14. NA #5 stated that he/she had been told by other caregivers that the resident required transfers via Hoyer lift but that he/she had not yet gotten the resident out of bed that morning. NA #5 stated that as he/she walked by the resident's room, he/she saw R #168 sitting at the side of the bed. NA #5 stated that the resident reported that Physical Therapy (PT) had walked with him/her and took him/her to the bathroom and that he/she only needed NA #5 to lift both his/her legs onto the bed. NA #5 demonstrated to the surveyor in the presence of the Director of PT, how he/she lifted the resident's legs and was observed to lift both legs simultaneously up and onto the bed. NA #5 stated that as he/she repositioned the resident, R #168 stated "ow, it hurts" but that he/she didn't feel it was anything "drastic" as the resident often complained of pain, and proceeded to position the resident's legs even further onto the bed. NA #5 stated that the resident continued complain of pain and asked NA #5 to "push on it." NA #5 demonstrated to the surveyor how he/she used his/her two hands to push down on the upper thigh of the resident's affected leg but stated that he/she "did not do it too hard". As the resident continued to complain of pain, NA #5 reported the resident's complaints to the charge nurse. The Advanced Practice Registered Nurse (APRN) was notified, an x-ray was obtained, and R #168 was subsequently transferred to the Emergency Department (ED) and admitted for dislocation of the femoral portion of the prosthesis. Interview with Director of Physical Therapy (PT) on 4/25/14 at 10:20 AM identified that R #168 was a large woman and required two persons to assist him/her even with placing legs back onto the bed. The Director of PT further identified that residents with recent hip replacements would never be transferred via a Hoyer lift as the action could lead to hip dislocation. The Director of PT stated that if a dislocation occurred during a Hoyer transfer, the symptoms associated with the dislocation would have happened at the time of the transfer so that it was unlikely that use of the Hoyer lift caused the dislocation. Review of R #168's operative report from the acute care hospital dated 4/21/14 identified that R #168 underwent an open reduction internal fixation of the periprosthetic femur after a [DIAGNOSES REDACTED]. 3. Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #3 had severe cognitive impairment, behavioral symptoms that include delusions and of rejection of care, was frequent incontinence of bowel and always incontinent of bladder and required extensive assistance with personal hygiene and bed mobility. The resident care plan dated 3/13/14 directed that Resident #3 was confused, forgetful and could become belligerent and swing his/her arms wildly and at times not easily redirected. Interventions directed to use short simple sentences, offer one at a time directions, allow time for me to respond and if the resident became angry and/or was not redirected then leave the resident in safety and reapproach later. The care plan also identified a risk for skin breakdown. Interventions directed to encourage long sleeves whenever possible, jobst stockings, pressure redistributing mattress on the bed and keep nails trimmed. Review of nurse's notes dated 4/20/14 at 8:00 AM identified that a nurse aide noted a bruise on Resident #3's left hand. When asked how the bruise occurred, Resident #3 stated that they "were tossing me around". Subsequent to notification an Advanced Practice Registered Nurse (APRN) directed for an x-ray of the left hand and wrist. Review of the left hand and wrist x-ray obtained on 4/21/14 identified mild to moderate degenerative joint changes without overt fracture. Observations of Resident #3's left hand on 4/24/14 at 10:00 AM identified a dark bruise over the fingers and extending over the top of the hand up to the wrist with swelling. Review of the Reportable Event Form and investigative report dated 4/20/14 identified that Resident #3 reported to nursing, family as well as social service that staff were rough in caring for him/her. Interview with Resident #3 on 4/24/14 at 10:00 AM indicated that two women came in and "whacked he/she around". I told them to stop that I hadn't done anything to them. When asked how the bruise occurred, Resident #3 replied that he/she may have hit the hand on the side rail during the incident. Interview with Nurse Aide (NA) #3 on 4/24/14 at 9:15 AM identified that Resident #3 was on her assignment. On first rounds Resident #3 was fighting and NA #2 assisted NA #3 in removing the three soaker pads which were underneath Resident #3. NA #3 recalled that full rails which were elevated however she did not recall Resident #3 hitting his/her hand and did not report the incident to the nurse. Review of the resident plan subsequent to the incident, a revision on 4/21/14 directed for bumper pads on bed rails while in bed. The facility's conclusion to the incident identified that Resident #3 may have sustained the injury when the resident became combative, the resident will now have padded side rails and the nurse aides were educated to leave combative residents, report the behaviors to the nurse and return later. 4. Resident #58 (R #58) had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that R #58 had no cognitive impairment, was independent for ambulation in his/her room and independent with eating and hygiene. During the initial tour of the facility on 4/22/14 at 10:00 AM, a large pair of scissors were observed on the resident's bed. R #58 was seated in the bedside chair the resident was seated in the bedside chair. Subsequent to inquiry , the scissors were removed by a nursing assistant. Interview with RN #1 at the time of the observation identified that she/he had left the scissors in the room by mistake after she trimmed the residents name band.

Based on review of the clinical record, review of facility policies, and interviews, the facility failed to implement interventions in accordance with the plan of care for one of three residents, Resident #32, who required assistance with toilet use and/or failed to ensure that staff followed the plan of care for one resident, Resident #168, who had a recent total hip replacement The findings include: 1. Resident #32's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #32 had some cognitive impairments, exhibited behavioral symptoms i.e. screaming, hitting and or scratching and did not exhibit behavioral symptoms of rejection of care, requiring limited one person assistance with toilet use and was occasionally incontinent of bowel and bladder. The resident care plan dated 3/28/14 identified that Resident #32 was often incontinent of bowel and bladder. Interventions directed to offer incontinent care every two hours and as needed. Review of the individualized resident assignment identified Resident #32 as continent and incontinent and the Nurse Aide assignment sheet identified Resident #32 as continent. The nurse's note dated 4/21/14, the 7-3 PM shift indicated that an allegation of abuse was reported at 8:15 AM and the incident occurred on 4/19/14 during the 11-7 AM shift. The Reportable Event Form and the investigative report indicated that when NA #2 had attempted to toilet Resident #32 at around 2:00 AM, the resident refused, so NA #2 left the room. NA #2 identified that she did not return to check Resident #32 until the Nursing Supervisor directed to remove one of the two soaker pads and change the soiled sheet. Review of facility policy directs that incontinent care is performed by nursing staff on all residents who are incontinent. Interview with Registered Nurse (RN) #5 (the 11-7 AM shift Nursing Supervisor) on 4/23/14 at 3:00 PM identified that the morning of 4/20/14 at approximately 5:00 AM she went to complete a treatment on Resident #32 and noted that the resident had two soaker pads on the bed and the sheet was soiled with blood. RN #5 asked NA #2, who was assigned to Resident #32 and NA #2, stated that she did not check the resident during the night. Interview with Licensed Practical Nurse (LPN) #4 on 4/24/14 at 1:30 PM identified that at approximately 5:00-5:15 AM the supervisor approached her and stated that Resident #32 was observed to have two soaker pads and a soiled top. LPN #4 continued to say that Resident #32 was usually continent but needs to be checked during the night and if a resident refused the nurse aide was expected to return later. Attempts to interview NA #2 were unsuccessful. 2, Resident #168 (R #168) was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 4/11/14 identified that R #168 required two persons to assist with transfers, sit to supine, and from supine to sit as the resident provided "only 50% patient effort" In addition, the hospital referral documentation to the skilled nursing facility identified that R #168 was at risk for falls and was to maintain hip precautions. Review of the admission care plan dated 4/12/14 identified that R #168 required the assistance of one staff member for hygiene and dressing and assistance of two staff persons for transfers and ambulation. The care plan further identified that the resident was to be transferred via mechanical lift. Interview with Nursing Assistant # 5 (NA #5) on 4/25/14 at 11:50 AM identified that he/she was assigned to provide care to R #168 on 4/19/14. NA #5 stated that he/she had been told by other caregivers that the resident required transfers via Hoyer lift but that he/she had not yet gotten the resident out of bed that morning. NA #5 stated that as he/she walked by the resident's room, he/she saw R #168 sitting at the side of the bed. NA #5 stated that the resident reported that Physical Therapy (PT) had walked with him/her and took him/her to the bathroom and that he/she only needed NA #5 to lift both his/her legs onto the bed. NA #5 demonstrated to the surveyor in the presence of the Director of PT, how he/she lifted the resident's legs and was observed to lift both legs simultaneously up and onto the bed. NA #5 stated that as he/she repositioned the resident, R #168 stated "ow, it hurts" but that he/she didn't feel it was anything "drastic" as the resident often complained of pain, and proceeded to position the resident's legs even further onto the bed. NA #5 stated that the resident continued complain of pain and asked NA #5 to "push on it." NA #5 demonstrated to the surveyor how he/she used his/her two hands to push down on the upper thigh of the resident's affected leg but stated that he/she "did not do it too hard". As the resident continued to complain of pain, NA #5 reported the resident's complaints to the charge nurse. The Advanced Practice Registered Nurse (APRN) was notified, an x-ray was obtained, and R #168 was subsequently transferred to the Emergency Department (ED) and admitted for dislocation of the femoral portion of the prosthesis. Interview with Director of Physical Therapy (PT) on 4/25/14 at 10:20 AM identified that R#168 was a large woman and required two persons to assist him/her even with placing legs back onto the bed. The Director of PT further identified that residents with recent hip replacements would never be transferred via a Hoyer lift as the action could lead to hip dislocation. The Director of PT stated that if a dislocation occurred during a Hoyer transfer, the symptoms associated with the dislocation would have happened at the time of the transfer so that it was unlikely that use of the Hoyer lift caused the dislocation. Review of R #168's operative report from the acute care hospital dated 4/21/14 identified that R #168 underwent an open reduction internal fixation of the periprosthetic femur after a [DIAGNOSES REDACTED]. Review of facility documentation identified that on 4/19/14, R #168 reported that he/she felt something "pop" after being assisted from sitting on the edge of the bed to a supine position and now had excruciating pain. In addition, review of an undated statement by Nursing Assistant #5 (NA #5) identified that NA #5 assisted R #168 on 4/19/14, to put her legs onto the bed at the resident's request. NA #5's written statement identified that subsequent to the repositioning, R #168 began to scream and NA #5 notified the nurse.

Based on clinical record review, review of the reportable event forms, review of the hospital clinical record, and interviews for one sampled resident (Resident #3) who had a [DIAGNOSES REDACTED]. Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #3 had no memory deficits, some difficulty in cognitive skills for daily decision making and was independent with activities of daily living. A physician's orders [REDACTED]. The nurse's note dated 10/13/10 identified that the wrong dose of [MEDICATION NAME] Insulin was administered at 8:30 AM and Resident #3's blood sugar was 27. After the administration of [MEDICATION NAME] and juice, the blood sugar increased to 61 and the resident was transferred to the emergency department for evaluation. Review of the Hospital History and Physical dated 10/13/10 identified Resident #3 was accidentally given 100 units of [MEDICATION NAME] Insulin instead of 5 units at approximately 8:00 AM. Three hours later the resident was acutely diaphoretic and the blood glucose level was 29. Upon arrival Resident #3's blood glucose was 50 and the resident complained of some dizziness and was diaphoretic. Initially [MEDICATION NAME] 5% intravenous fluids at 250 milliliters (ml) per hour was administered then changed to [MEDICATION NAME] 5% Normal Saline at 50 ml per hour. The Discharge Summary identified that the final [DIAGNOSES REDACTED]. Interview and review of the clinical record and facility documentation with Licensed Practical Nurse (LPN) #1 on 10/27/10 at 2:30 PM identified that she had administered 100 units of [MEDICATION NAME] Insulin to Resident #3 instead of the 5 units that was ordered. LPN #1 identified that the resident complained of feeling dizzy and was diaphoretic. LPN #1 stated that she must not have read the entire order and did not question the large amount of insulin. Interview and review of the clinical and facility documentation with the Director of Nurses on 10/27/10 at 1:00 PM identified that subsequent to the 10/3/10 incident, all licensed staff were in-serviced on the "Five Rights of Medication Administration" and the insulin dosage is now underlined in red on the Medication Administration Records.

Based on clinical record review, review of reportable event reports, and interviews for one sampled resident (Resident #2) who required assistance with transfers and wheelchair mobility, the facility failed to transfer the resident in accordance with the plan of care. The findings include: Resident #2's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #2 had moderate cognitive impairment, required extensive assistance with transfers and bathing, and was totally dependent on staff for locomotion on and off the unit. The Resident Care Plan dated 6/17/10 identified that the resident was at risk for falls and skin tears. Interventions directed to transfer the resident with the assistance of two persons, do not try to get up alone and to utilize of a custom wheelchair for positioning when out of bed. Review of the reportable event dated 8/6/10 identified that at 7:15 PM on 8/5/10 while Nurse Aide (NA) #1 was transferring Resident #2 down the hall in a custom wheelchair to the shower room the resident yelled out in pain. NA #1 stopped the wheelchair immediately and noted the resident was crying. Licensed Practical Nurse (LPN) #2, who was in the hall, heard Resident #2 yell. While LPN #2 examined the resident, Resident #2 complained of pain in the left big toe and at that time there was no evidence of injury. NA #1 proceeded to transport the resident to the shower room, shower the resident and transfer Resident #2 back to bed. The nurse's note dated 8/6/10 at 6:30 AM identified that at 2:30 AM Resident #2's left ankle was noted to be edematous, tender to touch, an area of discoloration that measured 6.0 centimeters (cm) by 3.0 cm was noted at the mid ankle and the resident complained of pain on movement. Subsequent to physician notification an x-ray of the left foot was ordered. The medical progress note dated 8/6/10 identified that Resident #2's left ankle was extremely tender to palpation and movement, warm to touch, swelling was present at the lateral malleolus and the area was ecchymotic. The plan was to obtain a left ankle x-ray to rule out a fracture, no weight bearing and elevate the leg. An addendum note at 3:00 PM identified the left lateral malleolus fracture and osteopenia and per the radiologist not much force was required to cause this fracture due to the poor bone condition. The progress note also identified that Resident #2 had stated the ankle was caught on the foot of the wheelchair on 8/5/10. The x-ray report dated 8/6/10 identified soft tissue swelling over the lateral malleolus with suspicion of underlying acute fracture, there may be a small avulsion fracture at the tip of the lateral malleolus, and diffuse osteopenia. Resident #2 was transferred to the emergency department and returned with a left leg splint. Further review of facility documentation identified that prior to transporting the resident down the hall, NA#1 removed the leg rests from the custom wheelchair. Additionally, the resident stated to the staff that when she/he was transferred to bed on 8/5/10, his/her leg was caught on the wheelchair. Interview, review of the clinical record and observation of the resident's wheelchair on 10/26/10 at 12:00 PM with the Physical Therapist (PT) #1 identified that when the wheelchair leg rests were off, Resident #2's feet did not touch the floor and the resident was able to bear weight during transfers with the assistance of two. PT #1 indicated that the leg rest should not have been removed from the wheelchair prior to propelling it down the hall. Interview and review of NA #1's written statement regarding the injury of unknown origin identified that on 8/5/10, NA #1 transferred Resident #2 from the wheelchair to the shower chair, from the shower chair back into the wheelchair, and from the wheelchair into bed (three times), without the assistance from another staff member. NA #1 indicated that she had removed the wheelchair leg rests prior to transporting the resident. Interview and review of the clinical record with the Director of Nurses on 10/28/10 at 10:00 AM identified that per the plan of care, Resident #2 should have been transferred with the assistance of two.