Every finding on record at Chelsea Place Care Center LLC

Based on observations and interviews, the facility failed to ensure the facility had adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. The findings include:Observations of the facility on all days of the survey 8/11, 8/12, 8/13, 8/17 and 8/18/26 identified 4 floors to the facility. Entry to the facility on the 1st floor containing administration and nursing offices and a large recreation room. Resident rooms were present on the 2nd, 3rd and 4th floors of the facility. All resident rooms on the 2nd, 3rd and 4th floors of the facility had screws in the windows that prevented them from being opened at all. Some of the windows did not have screens in them. The 2nd floor consisted of two secured units (a dementia unit consisting of 2 units and containing 52 resident beds and a behavioral unit consisting of 30 resident beds). The 2nd floor unit (rooms 232-247) were muggy and inside temperatures reached 81 degrees in some rooms on 8/11 and 8/12/26 (which was within the range for regulatory expectations for internal temperature). External temperatures on 8/11 and 8/12/26 reached a high of 84 degrees. The 3rd and 4th floor temperatures reached up to 79 degrees and each of these floors had a portable air conditioner unit in the hallways containing rooms 332-347 and rooms 432-447. There were air conditioner vents in the hallway ceilings that were blowing cool air. Some, but not all of the resident rooms had window air conditioners, and most rooms also had portable fans in them.Interview with LPN#4 on 8/13/26 at 1:50 PM identified that although she did not notice the status of the resident room windows, she confirmed with the administrator that all of the resident room windows in the facility were screwed shut.Interview with a resident who did not want to be identified but was alert and oriented on 8/13/26 at 1:57 PM identified that all of the resident room windows were screwed shut because someone jumped out of a window a few years ago.Interview with LPN #5 on 8/17/26 at 5:48 AM identified that although she has not checked every resident room, there are many windows that she has observed with screws in them, so they are not able to be opened.Interview with Maintenance Assistants #1 and #2 on 8/18/26 at 11:57 AM identified 30 years of employment at the facility and indicated that a couple of years back (not a specific date) all of the resident windows could be opened a small amount (3 inches or so) and a resident was able to get the window open all of the way and jump from the 4th floor. At that time, we were directed to shut all of the windows so they couldn't be opened. Maintenance Assistant #1 identified the facility HVAC system consisting of 3 roof top units that pump cold air to the hallways. Maintenance Assistant #1 indicated the facility got a lot of complaints that the residents were still hot and so the two portable units were put in on the upper floors. Maintenance Assistants identified some rooms have window air conditioners and they place them in the rooms if directed to do so by staff indicating that residents with respiratory concerns usually get one. The maintenance assistants identified that they do not keep a log of temperatures in the building and were aware that the building can get hot at times.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 4 of 9 sampled residents (Residents #9, #87, #162 and #216)) reviewed for medication administration, the facility failed to ensure that the methadone orders in the clinical record matched the orders from the methadone clinic who supplies the bottled methadone being administered to the residents, and failed to ensure suboxone administration was conducted according to professional standards. The findings include:Observation on 8/12/26 at 12:17 PM of Methadone administration for Resident #162 identified LPN #6 provided Resident #162 with a methadone bottle, with a label that identified the resident was receiving 70mg with a concentration of 10mg/ml which equals 7ml. The active physician's order in the clinical record identified a methadone concentration of 10mg/5ml for a dose of 70mg which would be 35ml and not 7ml. The physician's orders did not match the concentration indicated on the methadone bottle that was administered.Resident #162 was admitted to the facility with diagnoses including opioid dependence in remission and moderate protein calorie malnutrition.The quarterly MDS assessment dated [DATE] identified Resident #162 had intact cognition and required setup or cleanup assistance with eating and oral hygiene. Review of the care plan dated 7/2/26 identified Resident #162 has a diagnosis of substance use disorder with interventions including education on facility rules and offered the opportunity to receive behavioral health services to address substance use.The physician's order dated 5/19/26 and active through 8/13/26 directed the administration of Methadone HCL oral solution 10mg/5ml at a dose of 70mg one time a day for current long-term drug therapy.Review of the Methadone Chain of Custody Record (this is a form that is from the community methadone maintenance clinic that identifies the dose and the number of bottled doses sent to the facility for the resident) dated 7/28/26 identified Resident #162 was supplied 14 doses of Methadone 10mg/ml at a dose of 70mg to be administered daily from 7/28/26 through 8/10/26. Administrations were initialed (signed for) by the nurse and the resident daily from 7/28/26 through 8/10/26. The record of administration did not accurately reflect the physician's order or the MAR that the nurses sign to indicate the methadone dose given. Review of Resident #162's Methadone Chain of Custody Record dated 8/11/26 identified Resident #162 was supplied 14 doses of Methadone 10mg/ml at a dose of 70mg to be administered daily from 8/11/26 through 8/24/26. Administrations were initialed by staff and the resident on 8/11/26 and 8/12/26. The record of administration did not accurately reflect the physician's order or the MAR that the nurses sign to indicate the methadone dose given. Review of the MAR for August 2026 identified Resident #162 was administered Methadone HCL oral solution 10mg/5ml 70mg by mouth one time a day for current long-term drug therapy every day from 8/1/26 through 8/12/26. This administration record did not accurately reflect the concentration of the Methadone that was actually administered.Interview with LPN#6 and RN#3 on 8/12/26 at 12:23 PM identified the physician's orders should reflect the medication and the proper concentration that is being administered in the methadone bottle. LPN#6 indicated that the bottles were dated with administration dates and RN#3 identified that the physician's order was correct and noted the dose should taper as indicated in the physician's order. LPN#6 nor RN#3 identified the discrepancy in the methadone concentration. Interview with the Regional Clinical Director of Nursing Services (RN #5) on 8/12/26 at 2:00 PM identified that all methadone orders are reviewed and confirmed when the process at a sister facility was found to have the same problems with the physician's orders accurately reflecting the concentration that was supplied by the methadone clinic and administered to the residents. RN#5 identified that the physician's order should accurately reflect what is actually being administered.The facility's Methadone Protocol identified that when the methadone is brought to the care center, the methadone dose identified on the Chain of Custody Form will be compared to the current physician orders for methadone and any discrepancies must be verified by the methadone clinic followed by a clarification order from the resident's attending physician. The physician's orders are transcribed to the MAR. The facility policy further indicates that the RN Supervisor and/or charge nurse is responsible for the storage and counting of the Methadone as well as distributing it to the residents to administer and prior to administration , the LPN/RN will verify the correct name, date, and dose on the Methadone bottle to the MAR and the Chain of custody proof of administration sheetThe facility policy for Medication Administration and Documentation identified the licensed nurse assures the 5 rights of medication administration including comparing the medication name, strength, route and dosage schedule on the medication administration record against the prescription label with directions to always check three times prior to administration of medication. The policy additionally identifies the licensed nurse administers full dose of medication to resident via correct route and offers resident a drink and observes resident to ensure medication consumption. Observation on 8/12/26 at 12:22 PM of methadone administration for Resident #9 identified LPN#6 provided Resident #9 with a methadone bottle, with a label that identified the resident was receiving 165mg with a concentration of 10mg/ml which equals 16.5ml. The active physician's order in the clinical record identified a methadone concentration of 10mg/5ml for a dose of 165mg which would be 82.5ml and not 16.5ml. The physician's orders did not match the concentration indicated on the methadone bottle.Resident #9 was admitted to the facility with diagnoses including opioid abuse with opioid induced mood disorder, anxiety, depression and post-traumatic stress disorder (PTSD)The care plan dated 4/13/26 identified a diagnosis of substance use disorder with recent substance use. Interventions directed to provide assistance with resident access to administration of MAT (medication assisted treatment for substance use disorder).The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition and was independent with self-care and mobility.Review of Resident #9's Methadone Chain of Custody Record dated 8/11/26 identified Resident #9 was supplied 14 doses of Methadone 165mg with a concentration of 10mg/ml (7 doses) and 160mg (7 doses). The record indicated the dates that the medication should be administered (8/12/26 through 8/25/26).The physician's order dated 8/11/26 directed the administration of Methadone 165mg by mouth with a concentration of 10mg/5ml. Review of the Medication Administration Record (MAR) for August 2026 reflected Resident #9 was administered Methadone HCL oral solution 170mg mouth once a day with a concentration of 10mg/5ml on 8/12/26. The administration record did not accurately reflect eh concentration of methadone identified on the methadone chain of custody record. Additionally, the physician's orders directed the administration of 165 mg by mouth once a day until 8/17/26 then give 160mg by mouth once a day. The chain of custody paperwork from the community methadone program identified a dose of 160mg beginning on 8/11/26. LPN #6 returned the methadone to the cart to clarify the methadone dose the resident should be taking. Interview with LPN#6 and RN#3 on 8/12/26 at 12:23 PM identified that the physician's orders should reflect the medication that is being administered. LPN#6 indicated that the bottles are dated with the expected administration date. RN#3 identified the physician's order is the correct taper order but noted that the discrepancy between orders and the provided methadone bottle should be clarified before being administered. LPN#6 nor RN#3 identified the discrepancy in methadone concentration.Interview with the Regional Clinical Director of Nursing Services (RN #5) on 8/12/26 at 2:00 PM identified that all methadone orders are reviewed and confirmed when the process at a sister facility was found to have the same problems with the physician's orders accurately reflecting the concentration that was supplied by the methadone clinic and administered to the residents. RN#5 identified that the physician's order should accurately reflect what is actually being administered.The facility's Methadone Protocol identified that when the methadone is brought to the care center, the methadone dose identified on the Chain of Custody Form will be compared to the current physician orders for methadone and any discrepancies must be verified by the methadone clinic followed by a clarification order from the resident's attending physician. The physician's orders are transcribed to the MAR. The facility policy further indicates that the RN Supervisor and/or charge nurse is responsible for the storage and counting of the Methadone as well as distributing it to the residents to administer and prior to administration , the LPN/RN will verify the correct name, date, and dose on the Methadone bottle to the MAR and the Chain of custody proof of administration sheetThe facility policy for Medication Administration and Documentation identified the licensed nurse assures the 5 rights of medication administration including comparing the medication name, strength, route and dosage schedule on the medication administration record against the prescription label with directions to always check three times prior to administration of medication. The policy additionally identifies the licensed nurse administers full dose of medication to resident via correct route and offers resident a drink and observes resident to ensure medication consumption. Observation on 8/12/26 at 12:33 PM of Methadone administration for Resident #87 identified LPN#6 provided Resident #87 with a methadone bottle, with a label that identified the resident was receiving 60mg with a concentration of 10mg/ml which equaled 6ml. The physician's order identified a methadone concentration of 10mg/5ml for a dose of 60mg which would be 30mls not 6ml. The physician's order did not match the concentration and amount of medication indicated on the methadone bottle.Resident #87 was admitted to the facility with diagnoses including opioid dependence, anxiety disorder and conversion disorder with seizures or convulsions.The quarterly MDS assessment dated [DATE] identified Resident #87 had intact cognition, was independent with oral hygiene, toileting hygiene and mobility but required setup or cleanup assistance with eating and was taking antianxiety and anticonvulsant medications.Review of the care plan dated 7/30/26 identified Resident #87 was at risk for substance use related to a history of addiction and currently receiving MAT with interventions to evaluate the need for psych/behavioral health consults and communicate facility rules to resident that use of alcohol and non-prescribed drugs are not permitted while in the facility.Review of the Methadone Chain of Custody Record dated 7/28/26 identified Resident #87 received 14 doses of Methadone 10mg/ml at a dose of 60mg to be administered daily from 7/28/26 through 8/10/26. Administrations were initialized by staff and Resident #87 daily. Review of the Methadone Chain of Custody Record dated 8/11/26 identified Resident #87 was supplied 14 doses of Methadone 10mg/ml at a dose of 60mg to be administered daily from 8/11/26 through 8/24/26. Administrations were initialed by staff and resident daily from 8/11/26 through 8/12/26. The record of administration did not accurately reflect the physician's order or what was documented on the MAR.Physician's order dated 5/19/26 and active through 8/12/26 directed administration of Methadone 10mg/5ml oral solution at a dose of 60mg by mouth one time a day for long-term drug therapy related to opioid dependence. The order did not match the methadone concentration identified on the Methadone Chain of Custody Record. Review of the MAR for August 2026 identified Resident #87 was administered Methadone HCL oral solution 10mg/5ml oral solution at a dose of 60 mg by mouth one time a day for long-term drug therapy related to opioid dependence every day from 8/1/26 through 8/12/26. This administration record does not accurately reflect the concentration of the Methadone that was actually administered.Interview with LPN#6 and RN#3 on 8/12/26 at 12:23 PM identified that the physician's orders should reflect the medication that is being administered. LPN#6 indicated that the bottles are dated with the expected administration date. RN#3 identified the physician's order is the correct taper order but noted that the discrepancy between orders and the provided methadone bottle should be clarified before being administered. LPN#6 nor RN#3 identified the discrepancy in methadone concentration.Interview with the Regional Clinical Director of Nursing Services (RN #5) on 8/12/26 at 2:00 PM identified that all methadone orders are reviewed and confirmed when the process at a sister facility was found to have the same problems with the physician's orders accurately reflecting the concentration that was supplied by the methadone clinic and administered to the residents. RN#5 identified that the physician's order should accurately reflect what is actually being administered.The facility's Methadone Protocol identified that when the methadone is brought to the care center, the methadone dose identified on the Chain of Custody Form will be compared to the current physician orders for methadone and any discrepancies must be verified by the methadone clinic followed by a clarification order from the resident's attending physician. The physician's orders are transcribed to the MAR. The facility policy further indicates that the RN Supervisor and/or charge nurse is responsible for the storage and counting of the Methadone as well as distributing it to the residents to administer and prior to administration , the LPN/RN will verify the correct name, date, and dose on the Methadone bottle to the MAR and the Chain of custody proof of administration sheetThe facility policy for Medication Administration and Documentation identified the licensed nurse assures the 5 rights of medication administration including comparing the medication name, strength, route and dosage schedule on the medication administration record against the prescription label with directions to always check three times prior to administration of medication. The policy additionally identifies the licensed nurse administers full dose of medication to resident via correct route and offers resident a drink and observes resident to ensure medication consumption. Observation on 8/12/26 at 12:59 PM of suboxone administration for Resident #216 with LPN #3 identified Resident #216 took 3 acetaminophen tablets with water and then removed the buprenorphine 8mg/naloxone 2mg sublingual film from the packaging and placed the film into his/her mouth. LPN#3 turned and walked out of the room. Resident #216 closed the door to the resident room as LPN#3 and this surveyor left the resident room.Interview with LPN#3 on 8/12/26 at 1:01 PM identified there was not a need to watch the administration of the suboxone and indicated that Resident #216 received the medication multiple times a day.Resident #216 was admitted to the facility with diagnoses including alcohol use, opioid dependence, sedative, hypnotic or anxiolytic dependence and cocaine dependence.Review of the care plan dated 8/2/26 identified Resident #216 had a diagnosis of substance use disorder and recent substance use with interventions including administer meds as ordered, offer the opportunity to receive behavioral health services to address substance abuse.Physician's order dated 8/3/26 directed administration of Buprenorphine HCL-Naloxone HCL sublingual film 8-2mg at a dose of 1 film sublingually every 8 hours for opioid use disorder.Review of the August 2026 MAR identified Resident #216 was administered Buprenorphine HCL-Naloxone HCL 8-2mg sublingual film 3 times daily from 8/3/26 through 8/17/26.Interview with the ADNS and RN#5 on 8/18/26 at 12:00 PM identified suboxone administration should be observed until the film has completely dissolved.Interview with APRN #1 on 8/18/26 at 12:52 PM identified that suboxone administration should be observed until the medication has been completely absorbed. APRN#1 indicated that all medications administered should be observed to make sure the resident consumes the entire dose as prescribed.The facility policy for Medication Administration and Documentation identified the licensed nurse assures the 5 rights of medication administration including comparing the medication name, strength, route and dosage schedule on the medication administration record against the prescription label with directions to always check three times prior to administration of medication. The policy additionally identifies the licensed nurse administers full dose of medication to resident via correct route and offers resident a drink and observes resident to ensure medication consumption.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews for the facility reviewed for medication storage and labeling, the facility failed to ensure all expired medications were removed from the in-use medication storage carts and medication rooms and failed to ensure the storage of controlled substances was double locked. The findings include:Based on observations, review of facility documentation, review of facility policy/procedures and interviews for the facility reviewed for medication storage and labeling, the facility failed to ensure all expired medications were removed from the in-use medication storage carts and medication rooms and failed to ensure the storage of controlled substances was double locked. The findings include: Observation in the 4A medication room with LPN #1 and RN #4 on 8/12/26 at 11:03 AM identified expired medications in the overflow storage for active medication including:Olanzapine 5mg 3 full cards (90 pills) expiration date of 8/4/26 Risperidone 3mg full card (30 pills) expired 7/16/26Probiotic 250 mg (6 capsules remaining) expired 7/14/26 Cefadroxil (22 pills remaining) expired 8/7/26 Observation of the 4A/B Medication Cart with LPN#1 on 8/12/26 at 11:25 AM identified expired patient specific medications in resident specific active medications including: Risperidone 3mg tablet (30 tablets) Use by 3/17/26Prednisone 20 mg tab (10 pills remaining) use by 7/9/25Allopurinol 100mg tabs (30 pills) use by 8/5/26Gabapentin 100mg capsules 3 cards (90 caps) use by 7/18/26 Additional observation of the 4A/B Medication Cart with LPN#1 on 8/12/26 at 11:30 AM Identified patient specific Methadone bottles (used for substance use disorder) kept stored in the top lock box in the medication cart with all of the other controlled substances. According to the controlled substance storage guidelines, Methadone for SUD should be stored separately from other controlled substances. Observation of the 4B/C medication cart with LPN#6 on 8/12/26 at 11:46 AM identified expired medications in the resident active medication area including: Furosemide 20 mg tab (PRN) (7 tablets remaining) use by 7/8/26Minocycline 100 mg capsule (4 capsules remaining) use by 7/19/26Levothyroxine 75 mcg tab (15 tablets remaining) use by 7/28/26 Observation of the controlled substance white CSDR sign off sheet with LPN #6 on 8/12/26 at 12:12 PM identified the sign off log for resident specific Tramadol 50 mg signed off as administered 8/12/26 at 9:26 AM and indicated there were 21 remaining did not accurately reflect the 22-remaining Tramadol in the corresponding bubble pack. Interview with LPN #6, at this time identified she had marked off the administration because the resident had requested it but had not had an opportunity to administer. Observation of 3R medication cart with LPN#3 on 8/12/2026 at 1:22 PM identified expired medications in the over-the-counter medication area and resident specific active medication area including: Melatonin 1mg expired 2/26 Loperamide 2 mg capsule (21 remaining) use 7/16/26Dicyclomine 10 mg capsule (30 remaining) use by 7/16/26clonidine 0.1 mg tablet (90 remaining) use by 7/16/26Methocarbamol 500mg use by 7/13/26 (28 remaining) and a 2nd card of 25 remaining tablets. Additional observation of the 3R medication cart with LPN#3 identified Patient specific methadone bottles in the top of the medication cart with the over-the-counter medications. Two bottles had not been administered. Observation of the chain of custody records identified LPN#3 had signed off and written what would have been the new remaining amount on the administration for 8/12/26. The residents had not received the methadone administration. Interview with LPN#3 on 8/12/26 at 1:25 PM identified that because residents were very busy this day she found it easier to put the methadone to be administered in the top drawer. LPN#3 indicated she had signed off on the administration, so she only had to get the resident's signature. LPN#3 identified that signing off on the medication should occur when the medication was actually administered. Interview with RN#3, RN supervisor on 8/12/2026 at 1:27 PM identified expired medication should be removed by the nurses and indicated Methadone should be stored in the Methadone lock box and not removed until administered and should not be kept in the top drawer of the medication cart. RN#3 indicated no medication should be signed off until administered to the resident. Interview with the ADNS on 8/18/2026 at 11:30 AM identified Methadone should be stored in its own lock box and that all medication carts were fitted with 2 controlled substance lock boxes. Interview with the ADNS who has the controlled substance on point. Confirmed that the methadone should not be stored in the same compartment as the other controlled items. Interview with APRN#1 on 8/18/26 at 12:52 PM identified expired medications should not be in active medication areas and suboxone should be observed for administration until the medication is completely dissolved/consumed. The facility Methadone Protocol identified the RN supervisor and/or charge nurse is responsible for the storage and counting of the Methadone.The facility policy for Medication Storage identified Schedule II-V medications must be maintained in a separately locked, permanently affixed compartments or cabinets and the access system used to lock these medications cannot be the same access system used to lock other non-scheduled medications. The policy additionally indicated that all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. The policy indicated that outdated/expired medications are immediately removed from inventory, disposed of according to procedures for medication disposal.The facility policy for Medication Administration and Documentation identified Medication administration and documentation occurs in a timely and accurate manner.

Based on review of the clinical record, review of facility documentation and interviews, for one sampled resident (Resident #77) reviewed for activities, the facility failed to provide documentation that the resident was provided with activities based on the interest identified on his/her activities assessment. The findings include: Resident #77's diagnoses included type 2 diabetes mellitus, cirrhosis of liver and alcohol dependence with alcohol induced mood disorder. The quarterly MDS assessment dated [DATE] identified Resident #77 had intact cognition, had no behaviors, independent with dressing, transfers and ambulation using a walker. The care plan dated 6/22/26 identified Resident #77 had a psychosocial well-being problem related to depression and anxiety with interventions that included determining what the resident likes to do and offer activities that interest them. Observation on 8/11/26 at 11:15 AM, identified Resident #77 resided on a secured unit, and was noted to be lying in bed. Interview at the time of the observation identified the resident complained that there were no activities available on the unit for him/her to attend. Resident #77 identified that the only activity offered on the unit was watching television in the dining room area with other residents who often complained. Review of Resident #77's activity assessment dated [DATE] identified Resident #77 wished to participate in activities at the facility, and enjoyed reading, listening to music, playing bingo and other cognitive games. The assessment further identified Resident #77 preferred group activities, one-to-one visits with staff and preferred activities such as cards/games, music, radio, reading/writing, religion/spiritual, news/current events, television/movies. Review of Resident #77 activity attendance on 8/13/26 for the last 30 days identified resident attended activities on 8/7/26 and on 8/11/26 a bingo game. Interview on 8/13/26 at 1:22 PM with the Behavioral Health Director/Social Worker (SW #2) for the unit identified she was the former full-time therapeutic recreation staff for the unit until her role changed to the Behavioral Health Director and Social Worker for the unit in June/2026. She further identified she continued to provide recreational activities for the residents on the unit, but the activity schedule was reduced due to her new role. She further identified that Resident #77 attends activities such as current events, bingo and music on the unit. She identified that the Therapeutic Recreational Director (TRD) would document the activity attendance as she is no longer in that role and could not document. Interview with Resident #77 on 8/13/26 at 2:42 PM identified he/she likes reading books and music but there is not a library on the unit for him/her to obtain a book to read, which he/she told the facility on admission his/her preferred activities. The resident continues to identify the activities offered to him/her were current affairs which he/she does not care about, nor does he/she want to watch soap operas on the television in the common area.Interview with the Director of Recreation on 8/13/26 at 2:48 PM identified attendance is taken and documented when resident attends an activity program in the activity section of the electronic record system. She further identified that SW #2 on the unit was covering as the therapeutic recreation staff until the position is filled. She further identified SW #2 is responsible for documenting when residents attend the activities on the unit. In addition, she identified that programs are reduced on the unit because they are without a full-time therapeutic recreation staff for that unit, but between herself and SW #2 they provide activities for the residents. The Director of Recreation further identified residents should receive activities based on their preference identified on the activities assessment, and Resident #77 receives the chronicles daily as reading material but there is no library on the unit, and she is currently working on an outside library to bring books to the facility. The Director of Recreation further identified she is aware that the unit has only minimum activities, but she is short staffed and prior to this the residents had more activities. Interview with the Administrator on 8/13/26 at 3:30 PM identified the behavior unit is without a therapeutic recreation staff and she was of the understanding that the Director of Recreation was covering the activities in the evening, and the behavior health director would cover the morning activities as she was the previous TRD for the unit. She further identified that she would expect them to document the resident's attendance, however, she was just notified today (8/13/26) that SW #2 was unable to chart, hence currently she is having a regional staff addressing the issue and if she had known prior of this, she would have been addressed the issue. Subsequent to the surveyor's inquiry, recreation activities attendance for Resident #77 was completed. SW #2 identified she is currently documenting the resident's attendance for activities. A request for a recreation activity policy was made but was not provided. The Director of Recreation identified activities should be offered to residents based on preference and document whenever the resident attends or participates in activities and further indicated she would provide a policy, but none was provided.

Based on observation, review of the clinical record, review of facility policy/procedures and interviews for 1 sampled resident (Resident #176) reviewed for skin, the facility failed to ensure the skin checks were completed appropriately on a resident that developed an injury of unknown origin. The findings include: Resident #176's diagnoses included schizoaffective disorder bipolar type, acquired absence of left toe, type II diabetes, The quarterly MDS assessment dated [DATE] identified Resident #176 was severely cognitively impaired, had behaviors, was dependent with bed mobility, transfers, dressing and personal hygiene. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 6/17/26 identified Resident #176 had thin fragile skin and was at risk for skin tears with a history of purpura and discoloration. Intervention directed to encourage good nutrition and hydration, monitor size, location of skin tear, and treatment, report abnormalities to MD. Physician's orders for the month of August 2026 directed skin check weekly on Wednesday on the 7-3 shift. Observation of the resident on 8/11/26 at 2:30PM identified a reddened area on the right shin.The skin check dated 8/12/26 identified no new skin areas noted by LPN#2. Observation of the resident on 8/13/26 at 1:15PM identified a reddened area still present on the right shin measuring approximately 5cm in length with dried red substance along the length of the area. Interview with LPN#1 on 8/13/26 at 1:20PM identified although she had been in the room earlier to pass the resident medications, she did not notice the area on the right shin, however, would now alert the supervisor. Interview with NA#1 on 8/13/26 at 2:00PM identified she was the aide who had Resident #176 that day and had provided care earlier to the resident. Although NA#1 had seen the area on Resident #176 she didn't think it looked fresh so therefore did not report it to anyone. Interview with LPN#2 on 8/13/26 at 3:01PM identified she did in fact complete the skin check the night before and although she saw the area on the shin, she did not think that it looked new and there was no current treatment so she did not mark it on the skin check as a new area nor did she notify the supervisor.Interview with the DNS on 8/13/26 at 3:30PM identified she had been informed of the area on Resident #145, and the wound nurse was going to be looking at it. The DNS further identified that skin checks were completed weekly and new areas should be brought to the supervisor's attention and potentially the APRN or MD if an order is needed for treatment. Review of the Personal Care policy directed at reporting any changes to the residents to the nurse and to document according to facility guidelines. Review of the Wound Documentation policy directed the facility will perform weekly wound assessments and document findings on each area; weekly wound assessments will be performed and documented until healed. Although a skin check policy/procedure was requested the DNS stated there was not one.

Based on observations, review of clinical records, review of facility policy/procedure and interviews for 2 of 14 residents (Resident #87 and #162) observed during medication administration (2 of 25 medications administered) resulting in an error rate of 8%, the facility failed to ensure a medication error rate below 5%. The findings include:Observation on 8/12/26 at 12:17 PM of methadone administration for Resident #162 identified LPN #6 provided Resident #162 with a methadone bottle, with a label that identified the resident was receiving 70mg with a concentration of 10mg/ml which equals 7ml, which the resident consumed. The current physician's order identified a methadone concentration of 10mg/5ml for a dose of 70mg which would be 35ml and not 7ml. The physician's orders did not match the dose indicated on the methadone bottle that was administered. Observation on 8/12/26 at 12:33 PM of methadone administration for Resident #87 identified LPN#6 provided Resident #87 with a methadone bottle, with a label that identified the resident was receiving 60mg with a concentration of 10mg/ml which equals 6ml, which the resident consumed. The current physician's order identified a methadone concentration of 10mg/5ml for a dose of 60mg which would be 30mls not 6ml. The physician's order did not match the dose indicated on the methadone bottle that was administered. Interview with LPN#6 and RN#3 on 8/12/26 at 12:23 PM identified the physician's orders should reflect the medication that is being administered. LPN#6 indicated that the bottles were dated with administration dates and RN#2 identified the EHR order is the correct order indicated that Resident #9 was supposed to taper the dose but the discrepancy between the chain of custody and the HER dose should be verified. Neither LPN#6 nor RN#3 identified the concentration discrepancy. The facility's medication error rate was calculated as follows:Medication error rate = number of errors divided by the number of opportunities multiplied by 100. So, 2/25 x 100 = 8%. The facility Methadone Protocol identified that upon return to the care center with the methadone, the Methadone dose identified on the Chain of Custody Form will be compared to the current Physician Orders for Methadone and any discrepancies must be verified by the Methadone clinic followed by a clarification order from the resident's attending physician. The protocol directs that the physician's orders are transcribed to the MAR. The protocol identified that prior to administration, the LPN/RN will verify the correct name, date, and dose on the Methadone bottle to the MAR and the chain of custody proof of administration sheet.The facility policy for Medication Administration identified the Medication Administration Record (MAR) is the form onto which all medication orders are transcribed, from which medications are poured and administered and on which medication doses are charted. The policy indicated that the responsibility or the licensed nurse was to review physician orders and compare against medication administration record and assures the 5 rights of administration including comparing the medication name, strength, route and dosage schedule on the MAR against the prescription label and directed to always check three times prior to administration of medication.

Based on clinical record reviews, review of facility documentation, review of policy and procedures for 2 of 5 sampled residents (Residents #10 and #20) reviewed for influenza vaccine administration and for 1 of 5 sampled residents (Resident #144) reviewed for pneumococcal vaccine administration, the facility failed to ensure the vaccines were administered. The findings include: Resident #10 was admitted to the facility in January of 2024 with diagnoses that included schizoaffective disorder, chronic kidney disease, unspecified intercranial injury, and weakness. The significant change MDS dated [DATE] identified Resident #10 have severely impaired cognition. The assessment further identified that Resident #10 had not received the influenza vaccine in the facility for this year's influenza vaccination season. Review of Resident #10's immunization report and clinical record identified Resident #10 requested to receive the annual influenza vaccine on 10/8/25 by signing a vaccine consent. The immunization report identified Resident #10 received the requested vaccine on 3/4/26 almost 5 months following the consent. Resident #20 was admitted to the facility in July 2025 with diagnoses that included unspecified protein calorie malnutrition, weakness, and dementia. The quarterly MDS dated [DATE] identified Resident #20 was severely cognitively impaired. The assessment further identified Resident #20 did not receive the influenza vaccine in the facility for this year's influenza vaccination season. Interview with the Infection Preventionist (RN#1) on 8/12/26 at 1:34PM identified that she did not have any documentation of refusal for the resident from that date and time. RN#1 further identified that there was a flu clinic in the facility in October of 2025 and that the resident should have received the vaccine and it should not have been delayed. RN#1 identified that if a resident did not get the vaccine in the flu clinic, she would administer the vaccine after the clinic and that it must have been missed. RN#1 identified vaccines are offered to residents on admission by the admitting nurse and during the various seasons when certain vaccines are offered such as influenza. A vaccine history is obtained on admission. RN#1 further identified she did not have a tracking such as a spreadsheet or system beyond looking into the clinical record to see if someone has had a vaccine or is due for a vaccine. RN #1 identified that if a resident refuses a vaccine, it should be documented in the resident's chart. Interview with Corporate Infection Preventionist (RN#2) on 8/12/26 at 1:50PM and on 8/17/26 at 10:30AM identified that the best practice would be to give the vaccine earlier in the flu season. If the resident did not receive the vaccine during the flu clinic time the resident would be followed up on by RN#1 to be given the vaccine. RN#2 further identified that the Infection Preventionist should have a system although it is not dictated as to what that system should be to monitor who has had vaccines and who is due for vaccines. The corporate Infection Preventionist does complete tracking received by the surveyor of who has active consents in the facility. The tracking provided did not list who is due to have vaccines. Interview on with APRN#1 on 8/17/26 at 1:00PM identified residents are given a standing order for influenza vaccine on admission, and she would expect a vaccine such as flu to be given during the start of the flu season in or around September to October. If it was declined it would be offered again by the facility timely. Review of the Immunization Policy directed to identify eligible residents by reviewing immunization history, allergies, and contraindications. Each resident is offered an influenza annually during influenza season as defined by CDC or CMS guidelines unless contraindicated. The residents medical record includes documentation that indicated at a minimum the following, that the resident or resident representative was provided education, that the resident either received or did not receive, or refused, and the date of administration. Resident #144 was admitted to the facility in September of 2024 with diagnoses that included moderate protein malnutrition, muscle weakness, and latent tuberculosis. The quarterly MDS assessment dated [DATE] identified Resident #144 and had moderately cognitively impaired cognition. The assessment further identified that Resident #144 was not up to date on the Pneumococcal vaccine. Review of Resident #144's immunization report and clinical record identified the resident's representative signed a vaccine consent form on 10/17/2025. The vaccine record failed to identify the resident had received the Pneumonia vaccine. Subsequent to surveyor inquiry the vaccine consent was received for Resident #144 stating that the PPV23 was received on 6/4/21. Interview with the Infection Preventionist (IP) (RN #1) on 8/12/26 at 1:34 PM identified Resident#144 was not offered the Pneumonia vaccine at the facility due to the fact she thought the resident was up to date on the Pneumonia vaccine and that it should be offered every 5-10 years. RN#1 further identified that she would verify in CT Wiz (an online portal of vaccinations) if the resident had any pneumonia vaccines. RN#1 could not identify a tracking system she utilized to identify when vaccines are due to be offered or completed. There was no record of offering or refusing the vaccine received. Interview with the Corporate IP (RN#2) on 8/12/26 at 1:50PM identified the vaccine should be offered every 5 years if the resident has not had the PCV 20 vaccine. Resident #144 would be due to be offered the vaccine in June of 2026. Interview with the APRN#1 on 8/17/26 at 1:00PM identified that residents who are eligible which would be over age [AGE] or have chronic disease such as respiratory issues can receive the pneumonia vaccine at age [AGE]-50. The booster can be received every 6 months by CDC guidance. If they have not received PCV 20 then that should be offered. Review of the Immunization Policy directed to identify eligible residents by reviewing immunization history, allergies, and contraindication. Each resident is offered the COVID 19 vaccine unless the immunization is medically contraindicated, the resident does not meet clinical, or eligibility criteria as outlines by regulatory or public health authorities.

Based on review of clinical record, review of facility policy, and interviews for 1 of 5 sampled residents (Resident #45) reviewed for pre-admission screening and resident review (PASARR), the facility failed to ensure a referral to the entity responsible for conducting level II PASARR screening was made for a resident with a new qualifying psychiatric diagnosis. The findings include:Resident #45's diagnoses included bipolar disorder, anxiety disorder, mood disorder, and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #45 was moderately cognitively impaired with no identified behaviors, required maximal assistance with transfers and utilized a wheelchair for mobility. The care plan dated 12/3/25 identified Resident #45 had a behavior problem consisting of restlessness, and weepiness due to an anxiety disorder, depression, bipolar disorder, and dementia. Interventions directed to administer medications as ordered, assist the resident to develop more appropriate methods of coping, and caregivers to provide opportunities for positive interactions. A review of the clinical record identified Resident #45 had a level I PASARR assessment completed on 1/3/20 that did not identify a diagnosis of bipolar disorder. The assessment identified the resident was appropriate for long-term care and a level II screening was not recommended. Review of the clinical record identified the diagnosis of bipolar disorder was added to the resident's list of diagnoses on 1/21/25Interview with SW#1 and Corporate SW#3 on 8/12/26 at 10:10AM identified Resident #45 had a Level I PASARR assessment completed on 1/3/20, and the assessment did not include the diagnosis of bipolar disorder. The bipolar disorder diagnosis was added on 1/21/25. They further noted that bipolarism would be a qualifying diagnosis that would trigger for a level II PASARR assessment to be completed. SW #1 further identified that when there is a new psychiatric diagnosis identified for a resident, the social work team is made aware, which would then alert them to submit a request for a level II PASARR to be completed. SW#1 further acknowledged that when this resident received the new diagnosis of bipolar disorder, it must have been overlooked. In addition, SW#3 noted that a level II PASARR assessment should be completed. SW#3 identified that a referral for the Level II assessment would be done immediately. A policy for PASRR assessments was requested but the facility did not have a policy.

Based on a review of the Facility Assessment, staffing documentation, and staff interviews, the facility failed to ensure the Facility Assessment accurately reflected the facility's current staffing resources and staffing needs. Findings include:A review of the Facility assessment dated [DATE], indicated that the facility had a capacity of 216 residents and a census of 202 residents at that time. The Facility Assessment further indicated that the facility was a four-story building that included a 30-bed behavioral unit on the second floor, a 52-bed secured unit on the second floor, a 33-bed short-term rehabilitation unit on the third floor, a 33-bed short-term subacute unit on the third floor, and a 15-bed substance use disorder unit, in addition to the remaining long-term care resident beds.The Facility Assessment Staffing Plan section indicated that the Administrator and Director of Nursing set staffing for each shift based on the facility's census and current acuity levels of the resident population on each unit, with monthly reviews conducted with the Medical Director and staffing managed by the Scheduler.A review of facility staffing documentation for 7/15/26, 7/18/26, 8/1/26, and 8/3/26 found that the facility did not meet required staffing levels at censuses of 207, 203, 202, and 202 residents, respectively. Review of the Facility Assessment failed to identify the overall number and type of nursing staff needed for each shift and resident unit to provide care and services to the resident population. The Facility Assessment specified only registered nurse staffing, indicating that at least one (1) registered nurse would be present for each shift daily (7A-3P; 3P-11P; 11P-7A).During the facility tour, Residents #19, #45, and #77 expressed concerns about extended delays in receiving assistance and care from staff related to perceived insufficient staffing. An interview with the Scheduler on 8/13/26 at 1:30 PM and again at 2:10 PM indicated that she was responsible for staffing the facility and used a predetermined staffing template that assigned a set number of staff to each unit. The Scheduler indicated that she was not routinely provided with the facility's daily census and did not routinely adjust staffing based on it. The Scheduler further indicated that staffing was adjusted based on census only when the Administrator or ADNS informed her that an increase in the resident population necessitated a change.An interview with the Administrator on 8/13/26 at 2:39 PM indicated that the facility had previously used a staffing ladder, whereby staff could be sent home when staffing exceeded the facility's needs as determined by the census. The Administrator indicated that since the changes to the Connecticut state staffing regulations, version 3.0, the facility had consistently been below the staffing levels required by the regulation; therefore, the staffing ladder was no longer in use. The Administrator acknowledged that she was aware that the facility's staffing levels remained below those required under the revised regulation. She further reported that the Scheduler consistently informed both her and the DNS when staff callouts occurred that could not be covered, so they could make additional calls, in conjunction with the staff blasts, to replace staff and fill identified gaps.Further review of the Facility Assessment identified that a full-time Therapeutic Recreation Director (TRD) was assigned to the behavioral unit.An interview with the Administrator on 8/13/26 identified that the TRD position assigned to the behavioral unit was vacant at the time of the survey.An interview with the Director of Recreation on 8/13/26 indicated that the vacant recreation position on the behavioral unit was being filled, at least in part, by the social worker assigned to that unit, who had previously served in that role. The Director of Recreation further indicated that the vacant position was under recruitment at the time of the survey.The Facility Assessment failed to accurately reflect the facility's current staffing resources and actual staffing methodology and failed to demonstrate that the facility had evaluated the overall number and type of staff needed for each shift and resident unit based on its current resident population, resident acuity, and resources necessary to provide required care and services.

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for Resident Rights, the facility failed to allow Resident #2 to go on a leave of absence (LOA) with a family member and failed to trial unsupervised visitation. The findings include:Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for Resident Rights, the facility failed to ensure Resident #2's right to go on a leave of absence (LOA) with a family member was granted and failed to trial unsupervised visitation. The findings include: Resident #2's diagnoses included cellulitis of the left lower extremity, psychoactive substance abuse, anxiety, and adjustment disorder. The Resident Care Plan dated 11/4/25 identified Resident #2 was at risk for substance use related to a history of addiction and receiving medication assisted treatment. Interventions directed to allow time for expression of feelings, provide empathy, encouragement and reassures, evaluate the need for psych/behavioral health consults, offer the opportunity to receive behavioral health services to address substance use, if determined to be at risk for illegal drug use while in the facility place on supervised visits and the interdisciplinary team (IDT) will re-evaluate weekly, if suspected of using illegal substances, the resident will be asked to provide a urine sample for urine toxicology screen (a test that measures illegal substances in the urine), the resident may be asked to have possessions or room searched if at risk of harmful items is suspected, monitor medications for potential contribution to substance use and/or drug interactions, observe after LOA for evidence of substance use and observe for signs/symptoms of withdrawal for detoxification. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place, and time and was independent with activities of daily living. The Situation, Background, Assessment and Recommendation (SBAR) note dated 12/1/25 at 10:00 AM identified Resident #2 had a person deliver bags of Fentanyl (an opioid pain medication) to the facility that morning. The note indicated the drugs were intercepted at the front desk at which time Resident #2 jumped at the receptionist to recover the drugs. The note identified Resident #2 reported to Emergency Medical Services (EMS) personnel he/she had used Fentanyl the day prior (11/30/25). The note identified Resident #2 was transferred to the Emergency Department (ED) at 12:00 PM. The nurse's note dated 12/1/25 at 10:51 PM identified Resident #2 returned to the facility at 10:00 PM, Resident #2 was to have no visitors, and was placed on one (1) to one (1) (1:1) observation for the next twenty-four (24) hours. The nurse's note dated 12/2/25 at 1:26 AM identified a room search was done at 5:05 PM per security with a nurse aide present, negative results and Resident #2 returned from the ED at 9:41 PM. The note indicated orders upon return: no visitors, no parcels or deliveries, and 1:1 every shift for twenty-four hours. Review of the clinical record from 12/2/25 through discharge on [DATE] identified Resident #2 remained on supervised visitation. The Travel Pass Request Form dated 4/30/26 identified Resident #2 requested a LOA on 5/2/26 from 10:00 AM to 3:00 PM. The Resident LOA Approval form dated 5/2/26 identified Resident #2's LOA request for 5/2/26 was denied, there was no reason documented for the denial, and there was only one (1) signature of the Inter Disciplinary Team (IDT) Committee Review noted. The Travel Pass Request form dated 5/15/26 identified Resident #2 again requested a LOA from 10:00 AM to 3:00 PM. The Resident LOA Approval form dated5/15/26 identified Resident #2's LOA request for 5/16/26 was denied there was no reason documented for the denial, and there was only one (1) signature of the Inter Disciplinary Team (IDT) Committee Review noted. Review of the electronic medical record (EMR) failed to identify documentation regarding approval or denial of the LOA's. Interview with the Director of Nursing (DON) and administrator on 5/22/26 at 2:19 PM identified when a resident was admitted and has a history of substance abuse, the resident was placed on supervised visits. The DON and administrator indicated Resident #2 had been on supervised visits since the time of admission and requested LOA twice since admission and both requests were denied. The DON and administrator explained Resident #2 had a long history of substance use and shortly after admission Resident #2 had a visitor attempt to pass a candy box that contained a large amount of Fentanyl, with the intent to use and sell, and this was confiscated by the receptionist prior to the drugs being in Resident #2's possession. The DON and administrator identified Resident #2 has had no further incidents of visitors attempting to bring in drugs secondary to Resident #2 having supervised visits. The DON and administrator identified when a resident requests a LOA, the request was reviewed by the IDT team to determine approval or denial. The administrator and DON identified the IDT team was made up of the administrator, the DON, the Assistant Director of Nursing, the Minimum Data Set Coordinator, the security specialist, the social workers and if applicable the therapy team. The administrator identified Resident #2 requested a LOA on 5/2/26 as well as 5/16/26 and both visits were denied after the IDT team met and discussed the requests. The DON and the administrator identified they believe Resident #2's rights were followed as the LOA's were denied for the safety of all residents and staff. Interview with the Social Worker (SW) #1 on 5/28/26 at 9:52 AM identified Resident #2 lost his/her unsupervised visit privilege as well as his/her LOA privilege after a visitor attempted to bring in Fentanyl in a candy box last year. SW #1 indicated the rationale for these decisions was due to Resident #2's attempt to have illicit substances brought in with an intent to use and sell. SW #1 identified Resident #2 did not request any LOA's until 5/2/26, and 5/16/26. SW #1 identified Resident #2 did not have a trial of any unsupervised visits from the time of the initial incident on 12/1/25 up until his/her discharge from the facility on 5/27/26. SW #1 identified the IDT team felt that the safety of all residents outweighed the risk of granting unsupervised visits or LOA's from the facility. A second interview with the administrator and DON on 5/28/26 at 12:51 PM identified during Resident #2's time at the facility, Resident #2 had no other requests for LOA's except the two (2) for 5/2/26 and 5/16/26 and Resident #2 had not made any requests for unsupervised visits. The administrator explained the facility did not attempt a trial of unsupervised visits to evaluate if Resident #2 would pass or fail and the facility could not know if Resident #2 would pass or fail without a trial. The administrator identified Resident #2's LOA requests were denied due to his/her history of bringing in large amounts of Fentanyl, enough to sell. The administrator identified that although Resident #2's LOA requests were denied, he/she did have the option of leaving Against Medical Advice (AMA). Review of the facility policy titled Resident Rights and Responsibilities, last revised dated 7/2015, directed, in part, the facility will protect and promote the rights of each resident as set forth in the attached Residents [NAME] of Rights. Additionally, the policy directed, in part, the resident has the right to participate in community activities both inside and outside the facility, the right to be treated with consideration, respect and full recognition of dignity and individuality, the right to exercise rights as a resident and as a citizen, the facility must protect and promote resident rights and support, encourage and assist the resident in exercising those rights, the right to be treated equally with other residents and these residents rights cannot be reduced, rescinded or abrogated (cancel/revoke) by contract. Review of the facility policy titled Authorized leave of Absence, last reviewed 2/18/26, directed, in part, if a resident's health allows, and the resident's doctor agrees, a resident can spend time away from the facility visiting family or friends during the day or overnight, called a leave of absence or a travel pass. The policy further directed, in part, a physician's order is required for all non-medical LOA's, the resident or their responsible persons are asked to provide sufficient notice in requesting a travel pass if medications or other medically necessary arrangements must be ordered in advance, the IDT will review each request in accordance with the resident's individual care needs and special recommendations and safety needs will be documented by the team on the travel pass request form.

Based on clinical record review, facility documentation/policy, and staff/security interviews for two of two residents reviewed for opioid overdose risk (Residents #2 and #6), the facility failed to identify and control accident hazards and provide adequate supervision and safety interventions for residents with known opioid use disorder-by admitting Resident #6 with recent fentanyl use without establishing a completed, risk based plan of care with specific controls (e.g., supervised visits, random room searches, visitor log management, random urine toxicology, and documented substance use disorder (SUD) support/refusal handling), by lacking an overdose/Narcan protocol, by failing to contact law enforcement when illegal drugs were suspected or observed, and by failing to maintain chain of custody for contraband-resulting in Resident #6 requiring two Narcan doses for suspected fentanyl overdose and Resident #2's death due to acute intoxication (fentanyl, gabapentin, sertraline). These failures resulted in a noncompliance finding of Immediate Jeopardy. The findings include:1.Resident #6 was admitted to the facility on [DATE] with diagnoses that included psychoactive substance abuse and opioid dependence with withdrawal. The nursing assessment dated [DATE] identified Resident #6 was alert and oriented to person, time, place and situation and further identified Resident #6 used fentanyl within the past thirty (30) days.The Resident Care Plan (RCP) dated [DATE] identified Resident #6 was at risk for substance use related to a history of addiction and was receiving Medication Assisted Treatment (MAT). The RCP failed to identify interventions for the risk of substance use and MAT.Physician's orders dated [DATE] directed Naloxone (Narcan) 4 mg/0.1 ml (medication used to rapidly reverse an opioid overdose) 1 spray in nostril as needed for suspected overdose and 1 ml intramuscular as needed for suspected overdose.The Social Worker (SW) Initial assessment dated [DATE] identified Resident #6 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15).A Physician's order dated [DATE] directed Methadone (opioid medication used to treat opioid use disorder) 50 mg by mouth once a day for opioid use.The Medication Administration Record (MAR) identified Resident #6 was administered Methadone on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE].Review of the clinical record failed to identify psychiatric/psychology services or contracted SUD program services were offered, were provided or were refused.A note by RN #1 dated [DATE] at 2:13 PM identified Resident #6 was lethargic, drowsy, difficult to arouse, and fell back to sleep easily. A sternal rub was administered, and Resident #6 opened his/her eyes then immediately closed them. Resident #6 had bilateral pinpoint pupils and was administered a first dose of Narcan at 1:30 PM with no response. A second dose of Narcan was administered at 1:31 PM with a positive response and Resident #6 began to speak. Resident #6 admitted to using illegal stuff and security was called.A note by SW #1 dated [DATE] at 5:59 PM identified she was called to Resident #6's room by security to conduct a room search. Five (5) bags of a suspicious substance were found.An APRN note dated [DATE] identified she was asked to see Resident #6 due to lethargy, drowsiness, difficulty waking up with sternal rub, and receiving two (2) doses of Narcan. Resident #6 admitted to using fentanyl that he/she reported bringing into the facility at the time of admission. She ordered Resident #6 be transferred to the emergency department (ED) for further evaluation. The Narcan Administration Report dated [DATE] identified at 1:30 PM Resident #6 was administered Narcan due to lethargy, drowsiness, difficulty arousing and pinpoint pupils. Narcan was administered at 1:30 PM, was ineffective, and administered at 1:31 PM, which was effective. Five (5) empty packets were found by security and flushed down the toilet.The Hospital report dated [DATE] identified Resident #1 presented to the ED due to altered mental status. The toxicology screen drawn [DATE] resulted positive for opiates and fentanyl on [DATE]. Interview with Security #1 on [DATE] at 10:00 AM identified Resident #6 was visited by his/her family member on the morning of [DATE] in his/her private room. He identified he stayed in the room during the visit and did not see any objects being passed from the family member to Resident #6. He identified Resident #6's family member did not use Resident #6's bathroom and was escorted to the lobby after the visit. Although requested, Resident #6's visitor log was not provided. He further identified that after the overdose event on [DATE], he was called into Resident #6's room to perform a room search. He identified that he searched Resident #6 and asked him/her to take his/her hat off. He identified five (5) empty bags tucked into his/her hat. He identified that he flushed the bags down the toilet and Resident #6 told him that the bags were brought with him/her on admission to the facility. Security #1 further identified a room search was conducted on admission to the facility but no further room searches were conducted until the [DATE] overdose event. Interview with RN #1 on [DATE] at 1:30 PM identified she was the RN supervisor on [DATE]. She identified she was notified by the Charge Nurse of Resident #6's change in condition and that she administered the Narcan. RN #1 identified Resident #6 admitted to using illegal substances that day. Interview with the DNS on [DATE] at 10:00 AM identified Resident #6's risk for substance use and MAT plan of care was initiated but not completed. She identified that due to the known history of SUD, the RCP should have included specific interventions including supervised visits, random room searches, random urine toxicology screens and support services. She further identified Resident #6 had no prior room searches. She identified that room searches would be conducted if there was suspicion or observed contraband. She identified the police were not notified if the incident and suspected contraband found because the bags were empty. Although requested, the DNS identified the facility does not have a policy or procedure for suspected drug overdose. Interview with SW #1 on [DATE] at 1:50 PM identified on [DATE] she was called to Resident #6's room to assist with a room search. She identified she observed five (5) dime bags which contained white residue. She identified the bags were discovered tucked into the folded rim of Resident #6's hat. She further identified she ran the recovery program in the facility and the services offered were through an outside vendor who visited the facility one (1) to two (2) times per week to offer support for residents with SUD. SW #1 indicated Resident #6 was offered support for his/her SUD but refused. SW #1 could not identify why the refusal of services from a high-risk resident was not documented in the clinical record and could not identify alternative interventions offered post refusal. Review of the clinical record failed to identify refusal of treatment. Review of the Notification of Hazardous or Precautionary Items form identified hazardous items, which the resident may not have in their possession while on facility property, include intoxicating substances and illegal drugs. If illegal drugs or dangerous/illegally maintained weapons are suspected or detected, the facility will contact the local law enforcement agency for assistance. The IJ template was presented to the Administrator on [DATE] at 3:28 PM for F689 failure to provide adequate supervision and implement necessary safety interventions for a resident with a known history of opioid use disorder and recent fentanyl use.The facility submitted a removal plan, which included ensuring new admissions with a known recent history of substance use would be evaluated for appropriate supervision based on a person-centered risk evaluation and with interventions initiated based on the level of risk. Nursing supervisors would be educated to ensure the RCP on admission, for residents with SUD, contained interventions to provide adequate support. Audits of RCPs for new admissions with a history of SUD would be conducted to ensure appropriate interventions and adequate supervision. The removal plan was accepted by the State Agency on [DATE] at 6:34 PM. 2. Resident #2 was admitted to the facility in February of 2025 with diagnoses that included opioid dependence, cocaine dependence and adjustment disorder.The physician's orders dated [DATE] directed Naloxone (Narcan) 4 mg/0.1 ml 1 spray in nostril as needed for suspected overdose and Naloxone (Narcan) 4 mg/0.1 ml 1 ml intramuscular as needed for suspected overdose. The physician's order dated [DATE] directed Gabapentin 800 mg three times a day for pain. The Social Services quarterly note dated [DATE] identified Resident #2 was seen monthly and/or as needed for psychiatric services. The physician's order dated [DATE] directed room searches every shift daily. The quarterly MDS assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was independent with bed mobility and transfers, required an assist of one staff for toilet use, and was always continent of bowel and bladder. The Resident Care Plan (RCP) dated [DATE] identified Resident #2 was at risk for substance use related to a history of addiction. Interventions included to observe signs/symptoms of withdrawal. The physician's order dated [DATE] directed Sertraline 50 mg once a day for anxiety. A nursing note by RN #3 dated [DATE] at 8:28 AM identified Resident #2 was observed sitting in a wheelchair with slightly slurred speech and dilated pupils. Resident #2 was able to follow finger movement with his/her eyes, had strong hand grasps, was able to follow directions and was alert and oriented to person, place and time. Resident #2 refused to give a toxicology sample because he/she did not need to use the bathroom. A room check was performed by staff, and no contraband was found. Resident #2 refused to go to the hospital. The RCP dated [DATE] identified Resident #2 was discovered with pupils dilated and slumped in wheelchair but was arousable. Interventions included 15 min checks, monitor laboratory tests, evaluate need for psych and reinforce recovery plan.The Room Search dated [DATE] identified no contraband found.Review of the 15 Minute Monitoring Resident Flowsheet dated [DATE] at 10:00 AM identified 15-minute checks were performed through [DATE] at 11:00 PM.A note by SW #1 dated [DATE] at 3:36 PM identified Resident #2 attended Recovery Group.A Psychotherapy note dated [DATE] identified Resident #2 was seen for mood support. Resident #2 appeared to maintain stable mood and coping with psychosocial stressors. Encouraged continued use of thought re-framing, social and independent activities for coping and relapse prevention. A DNS note dated [DATE] at 5:17 PM identified the DNS responded to a STAT (now) page on the unit at 12:50 PM. Resident #2 was on the floor in the bathroom, had a formed BM and did not respond to verbal or tactile stimuli. No pulse was found, CPR was initiated and 911 was called. Narcan was administered twice with no response. Resident #2 was transferred to the ED at 2:00 PM and the hospital called at 2:20 PM to report Resident #2 expired. Review of the hospital ED visit document dated [DATE] identified Resident #2 presented to the ED for cardiac arrest and suspected drug overdose. There was no toxicology reports identified. The document identified the physician spoke with facility staff who identified Resident #2 had a history of drug use and was noted to be hanging out with other residents who were known to use drugs. The document identified the Medical Examiner (ME) was contacted and took the case due to suspected drug use.Interview with the DNS on [DATE] at 12:00 PM identified she questioned whether to report Resident #2's unanticipated death to the State Agency. She identified the hospital record indicated the case would be picked up by the ME and she was awaiting the report. The DNS identified the facility did not contact the ME office for the cause of death. She further identified Resident #2 had no visitors the day he/she expired and no prior leaves from the facility. Review of the ME report on [DATE] identified the report was dated [DATE] and Resident #2's cause of death was acute intoxication due to the combined effects of Fentanyl, Gabapentin, and Sertraline.Re-Interview with the DNS (after review of the ME report) on [DATE] at 11:00 AM identified the RCP dated [DATE] for a risk of substance use included only one intervention which was to observe for signs and symptoms of withdrawal. The DNS identified RCPs are based on individual resident needs and additional interventions would only have been added after suspected substance use. She identified minute 15-minute checks were performed for 72 hours after the suspected overdose on [DATE] and there was no additional monitoring thereafter. She identified there was documentation of Resident #2 attending group therapy once after [DATE], which was on [DATE], and further identified that neither the facility nor the group therapy vendor took attendance for group therapy sessions. The DNS identified that the SW was working on having an attendance list completed for each group therapy session moving forward. She identified Resident #2 had no medical reason for a decline, so when discovered unresponsive on [DATE], Narcan was administered due to a history of opioid dependence. She further identified that the facility provided annual staff education related to signs of opioid overdose and administration of Narcan, however there was no facility policy, procedure, or protocol for suspected drug overdose and Narcan administration.

Based on review of the clinical record, facility documentation, facility policy, and interviews for four (4) of nineteen (19) residents (Residents #7, #8, #9 and #10) reviewed for physician's visits, the facility failed to ensure physician orders were signed and dated with each physician visit per the minimum requirements of the Connecticut General Statute 19-13-D8t. The findings include:1. Resident #7 was admitted to the facility with diagnoses that included dementia and bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 00) and received antipsychotics on a routine basis.The Resident Care Plan dated 10/16/25 identified Resident #7 was at risk for complications related to the use of psychotropic drugs. Interventions included gradual dose reduction as ordered, monitor for continued need of medication related to behavior and mood and monitor for side effects.Provider orders identified monthly orders were signed by the APRN on 6/12/25. Review of Provider orders failed to identify orders signed for July 2025, August 2025, November 2025 and December 2025.2. Resident #8 was admitted to the facility with diagnoses that included dementia and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 00) and received antipsychotics on a routine basis.The Resident Care Plan dated 12/11/25 identified Resident #8 had hypertension with interventions that included to administer medications as ordered.Provider orders identified monthly orders were signed by the APRN on 10/14/25. Review of Provider orders failed to identify orders signed for November 2025 and December 2025.3. Resident #9 was admitted to the facility with diagnoses that included type II diabetes and schizophrenia.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 11), received antipsychotics on a routine basis and received insulin injections for the past seven (7) days.The Resident Care Plan dated 12/29/25 identified Resident #9 had diabetes and interventions included to administer medication as ordered by the Doctor.Provider orders identified monthly orders were signed by the Physician on 9/24/25. Review of Provider orders failed to identify orders signed for October 2025, November 2025 and December 2025.4. Resident #10 was admitted to the facility with diagnoses that included schizophrenia and hyperlipidemia.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) scored of12) and received antipsychotics on a routine basis.The Resident Care Plan dated 12/11/25 identified Resident #10 had a diagnosis of schizophrenia with interventions that included to explain the importance of taking medication and the risks of not taking it. Provider orders identified monthly orders were signed by the Physician on 9/24/25. Review of Provider orders failed to identify orders signed for October 2025, November 2025 and December 2025.Interview with the DNS on 1/5/26 at 1:00 PM identified monthly orders are reviewed and signed in the medical records. She identified the practitioners, or the physician can sign off on resident orders. She further identified there is no policy for timeliness of signing off orders and that the facility follows the Connecticut Public Health Code of signing orders every sixty (60) days.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of five (5) residents (Resident #3) reviewed for opioid medication administration, the facility failed to ensure the resident was treated with dignity by changing the form of a prescribed opioid medication to crushed tablets without individualized assessment or honoring the resident's expressed preference. The findings include:Resident #3 was admitted to the facility with diagnoses that included osteomyelitis of vertebra, post-traumatic stress disorder and opioid dependence. A Provider's order dated 9/17/25 directed regular diet, regular consistency.A Provider's order dated 9/17/25 directed Naloxone (Narcan) 4 mg/0.1 1 spray in nostril as needed for suspected overdose and 1 ml intramuscular as needed for suspected overdose.A Provider's order dated 9/17/25 through 9/24/25 directed Hydromorphone two (2) mg give tablets by mouth every four (4) hours as needed for pain.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), ate independently and did not hold food in mouth and/or cheeks.The Resident Care Plan dated 9/24/25 identified Resident #3 was at risk for substance use related to a history of addiction and was receiving Medication Assisted Therapy (MAT). Interventions included to evaluate the need for psych/behavioral health consults, monitor laboratory test results, suboxone as ordered daily, and communicate the facility rules that the use of alcohol and non-prescribed drugs were not permitted while in the facility.A Provider's order dated 9/24/25 through 12/5/25 directed Hydromorphone two (2) mg three tablets by mouth every six (6) hours as needed for pain.A Provider's order dated 11/29/25 through 12/5/25 directed Hydromorphone four (4) mg one tablet by mouth every six (6) hours as needed for pain.A Provider's order dated 12/3/25 directed all narcotic medication be crushed prior to administration and given in residents choice of apple sauce or pudding.A Provider's order dated 12/5/25 through 12/12/25 directed Hydromorphone four (4) mg one tablet by mouth every eight (8) hours as needed for pain.A Provider's order dated 12/13/25 through 12/15/25 directed Hydromorphone four (4) mg one tablet by mouth every eight (8) hours as needed for pain.Interview with Resident #3 on 12/19/25 at 10:30 AM identified in December of 2025 there were controlled substances being used inappropriately by other residents within the facility. Resident #3 identified his/her Hydromorphone order was changed from whole tablets to crushed tablets. Resident #3 indicated the APRN changed the order to crushed tablets to avoid misuse of the tablets. Resident #3 identified other resident's had orders that were changed to crushed tablets but were changed back to whole tablets. Resident #3 identified he/she did not want his/her medication to be crushed and confirmed the nursing staff, DNS, and APRN were aware of this preference, but the order remained to crush the tablets.Interview with APRN #1 on 12/17/25 at 1:50 PM identified that toward the beginning of December there were concerns of controlled substances being misused in the facility so she changed Resident #3's Hydromorphone to crushed tablets to ensure he/she would not pocket the medication or give the medication to other residents. APRN #1 identified any resident who had an order for Hydromorphone and a diagnosis of opioid use disorder had an order change from whole tablet form to crushed.Interview with the DNS on 12/19/25 at 9:36 AM identified some residents with a history of substance use disorder have controlled substances administered in a crushed form. She identified mouth checks were regularly performed after administration of controlled substances, but controlled substances were crushed to ensure they were not pocketed (the act of holding a medication in the mouth (such as in the cheek or under the tongue) instead of swallowing it as directed). She identified the facility does not have a policy for crushed medication practice. The DNS identified that she was aware Resident #3 had concerns regarding receiving Hydromorphone tablets crushed but the orders were changed to crushed form based on the APRNs discretion. She identified if a Provider's orders stated crushed tablets and a resident refused to take the medication crushed, the medication would be documented as refused.Review of the Residents [NAME] of Rights identified residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #5) reviewed for a change in condition, the facility failed to notify the physician and licensed nursing staff of a significant change in the resident's condition and failed to notify the physician when ordered interventions were ineffective. Specifically, the resident experienced ongoing vomiting, dry heaving, abdominal pain, and non-verbal signs of distress despite administration of PRN medications, and these changes were not timely reported or escalated. The findings include:Resident #5 was admitted to the facility with diagnoses that included chronic respiratory failure, sepsis, and heart failure.Physician's orders dated [DATE] directed Milk of Magnesia (MOM) 30 ml by mouth as needed for constipation and Bisacodyl 10 mg rectally as needed if MOM was ineffective.The Nursing admission assessment dated [DATE] identified Resident #5 was alert and oriented to time, place, person, and situation, had an indwelling Foley catheter, and was always incontinent of bowel.The Resident Care Plan dated [DATE] identified Resident #5 had bowel and bladder incontinence. Interventions included encouraging fluids during the day to promote prompted voided response, check every two hours for incontinence, use of disposable briefs and to change as needed. The RCP further identified Resident #5 was at risk for substance use related to a history of addiction. Interventions included diversion with alternative activities and evaluation of the need for psych and/or behavioral health consults.A physician's order dated [DATE] at 7:39 PM directed Ondansetron 4 mg by mouth every six (6) hours as needed for nausea and vomiting.Review of the Medication Administration Record (MAR) dated [DATE] identified Ondansetron was administered to Resident #5 at 9:00 PM for nausea and vomiting.An abdominal scan dated [DATE] at 9:11 PM identified diffuse constipation with no large or small bowel obstruction.Review of the MAR dated [DATE] identified Bisacodyl was administered to Resident #5 at 10:45 PM; however, the MAR failed to identify administration of MOM and failed to document the effectiveness of either intervention.Interview with NA #1 on [DATE] at 1:26 PM identified she was assigned to provide care for Resident #5 from 11:00 PM through 7:00 AM on [DATE] into [DATE]. She identified at the start of the shift she was notified Resident #5 vomited and she cleaned up Resident #5 and then he/she vomited again. NA #1 identified she reported the vomiting to LPN #1. NA #1 further identified that at approximately 3:00 AM Resident #5 was dry heaving and vomiting, and at approximately 6:45 AM Resident #5 was groaning and moaning with eyes closed. NA #1 identified she did not notify licensed nursing staff of the dry heaving, vomiting or groaning and moaning (non-verbal signs of pain).Interview with RN #2 on [DATE] at 1:56 PM identified she was the nursing supervisor from 8:00 AM to 8:00 PM on [DATE]. RN #2 identified she was notified by LPN #1 that Resident #5 had vomited and complained of abdominal pain. RN #2 assessed Resident #5, contacted the APRN, and received orders for a kidney, ureter, and bladder (KUB) x-ray and Ondansetron for nausea. RN #2 identified she provided shift report to RN #3 and informed her that Resident #5 had vomited, vital signs were stable, and to follow up on the KUB results.Interview with RN #3 on [DATE] at 12:15 PM identified she was the nursing supervisor from 8:00 PM to 8:00 AM on [DATE] into [DATE]. RN #3 identified that around 10:30 PM she was notified by LPN #1 that Resident #5 vomited. RN #3 assessed Resident #5, reviewed KUB results which identified constipation, and notified the APRN. The APRN ordered MOM in prune juice and a suppository, which RN #3 indicated were administered by LPN #1. RN #3 identified Resident #5 refused transfer to the hospital. RN #3 further identified she checked on Resident #5 at approximately 4:00 to 4:30 AM and observed no apparent distress. RN #3 identified that at approximately 7:30 AM she directed NA #3 to determine whether Resident #5 had a bowel movement following administration of the ordered medications (approximately seven and a half hours after MOM was administered). NA #3 reported Resident #5 was not responding and at approximately 7:35 AM, RN #3 called a code and CPR was initiated. Emergency Medical Services (EMS) arrived and continued the code until Resident #5 was pronounced deceased .Interview with LPN #1 on [DATE] at 2:11 PM identified she was assigned to provide care for Resident #5 during the 3:00 PM to 11:00 PM shift on [DATE] and continued care into the 11:00 PM to 7:00 AM shift on [DATE] into [DATE]. LPN #1 identified she administered Ondansetron to Resident #5 at approximately 7:30 PM and noted improvement. She identified that at approximately 10:30 PM Resident #5 vomited multiple times and she believed Resident #5 should be transferred to the hospital. LPN #1 identified she administered MOM at approximately 12:00 AM; however, the administration and outcome were not documented. LPN #1 stated she last observed Resident #5 at approximately 6:00 AM resting and requesting water. She identified she would have checked on Resident #5 if she were made aware Resident #5 was groaning and moaning at 6:45 AM.Interview with APRN #1 on [DATE] at 1:40 PM identified if PRN medications were ineffective or symptoms persisted, the physician or APRN should have been contacted for additional evaluation and orders. APRN #1 further identified Resident #5 had standing orders for Tylenol which could have been administered if Resident #5 was experiencing pain.Interview with the DNS on [DATE] at 12:00 PM identified the need for follow up assessment after the administration of MOM depends on the resident and could range anywhere from an hour to a few hours after administration. She further identified a new onset of moaning/groaning could be a sign or symptom of pain and a nurse should be notified for further assessment.Review of the Physician Notification - Change of Condition policy identified a change in condition is a significant clinical symptom(s) or development, which requires assessment and intervention. If a resident is evaluated by a charge nurse to have a change in condition, the change nurse will notify the RN supervisor. The RN supervisor will do a follow up assessment to ensure that the assessment is documented and reported to the physician. The physician will be contacted to report findings. The nurse will obtain new orders as warranted from the physician. The nurse will document in the nurses notes regarding assessments, findings, changes, physician notified and resident and/or responsible party notification.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #6) reviewed for opioid use disorder, the facility failed to develop and implement a person-centered care plan with appropriate interventions to address the resident's identified risk for substance use disorder (SUD) and receipt of Medication Assisted Treatment (MAT). The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that included psychoactive substance abuse and opioid dependence with withdrawal. The nursing assessment dated [DATE] identified Resident #6 was alert and oriented to person, time, place and situation and further identified Resident #6 used fentanyl within the past thirty (30) days.The Resident Care Plan (RCP) dated 9/23/25 identified Resident #6 was at risk for substance use related to a history of addiction and was receiving MAT. The RCP failed to identify interventions for the risk of substance use and MAT.Physician's orders dated 9/23/25 directed Naloxone (Narcan) 4 mg/0.1 ml (medication used to rapidly reverse an opioid overdose) 1 spray in nostril as needed for suspected overdose and 1 ml intramuscular as needed for suspected overdose.The Social Worker (SW) Initial assessment dated [DATE] identified Resident #6 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15).A Physician's order dated 9/24/25 directed Methadone (opioid medication used to treat opioid use disorder) 50 mg by mouth once a day for opioid use.The Medication Administration Record (MAR) identified Resident #6 was administered Methadone on 9/24/25, 9/25/25, 9/26/25, 9/27/25, 9/28/25 and 9/30/25.Review of the clinical record failed to identify psychiatric/psychology services or contracted SUD program services were offered, were provided or were refused.A note by RN #1 dated 9/30/25 at 2:13 PM identified Resident #6 was lethargic, drowsy, difficult to arouse, and fell back to sleep easily. A sternal rub was administered, and Resident #6 opened his/her eyes then immediately closed them. Resident #6 had bilateral pinpoint pupils and was administered a first dose of Narcan at 1:30 PM with no response. A second dose of Narcan was administered at 1:31 PM with a positive response and Resident #6 began to speak. Resident #6 admitted to using illegal stuff and security was called.A note by SW #1 dated 9/30/25 at 5:59 PM identified she was called to Resident #6's room by security to conduct a room search. Five (5) bags of a suspicious substance were found.An APRN note dated 9/30/25 identified she was asked to see Resident #6 due to lethargy, drowsiness, difficulty waking up with sternal rub, and receiving two (2) doses of Narcan. Resident #6 admitted to using fentanyl that he/she reported bringing into the facility at the time of admission. She ordered Resident #6 be transferred to the emergency department (ED) for further evaluation. The Narcan Administration Report dated 9/30/25 identified at 1:30 PM Resident #6 was administered Narcan due to lethargy, drowsiness, difficulty arousing and pinpoint pupils. Narcan was administered at 1:30 PM, was ineffective, and administered at 1:31 PM, which was effective. Five (5) empty packets were found by security and flushed down the toilet.The Hospital report dated 9/30/25 identified Resident #1 presented to the ED due to altered mental status. The toxicology screen drawn 9/30/25 resulted positive for opiates and fentanyl on 10/1/25. Interview with Security #1 on 12/19/25 at 10:00 AM identified Resident #6 was visited by his/her family member on the morning of 9/30/25 in his/her private room. He identified he stayed in the room during the visit and did not see any objects being passed from the family member to Resident #6. He identified Resident #6's family member did not use Resident #6's bathroom and was escorted to the lobby after the visit. Although requested, Resident #6's visitor log was not provided. He further identified that after the overdose event on 9/30/25, he was called into Resident #6's room to perform a room search. He identified that he searched Resident #6 and asked him/her to take his/her hat off. He identified five (5) empty bags tucked into his/her hat. He identified that he flushed the bags down the toilet and Resident #6 told him that the bags were brought with him/her on admission to the facility. Security #1 further identified a room search was conducted on admission to the facility but no further room searches were conducted until the 9/30/25 overdose event. Interview with RN #1 on 12/19/25 at 1:30 PM identified she was the RN supervisor on 9/30/25. She identified she was notified by the Charge Nurse of Resident #6's change in condition and that she administered the Narcan. RN #1 identified Resident #6 admitted to using illegal substances that day. Interview with the DNS on 12/19/25 at 10:00 AM identified Resident #6's risk for substance use and MAT plan of care was initiated but not completed. She identified that due to his/her known history of SUD, the RCP should have included specific interventions including supervised visits, random room searches, random urine toxicology screens and support services. She further identified Resident #6 had no prior room searches. She identified that room searches would be conducted if there was suspicion or observed contraband. She identified the police were not notified if the incident and suspected contraband found because the bags were empty. Although requested, the DNS identified the facility does not have a policy or procedure for suspected drug overdose. Interview with SW #1 on 12/19/25 at 1:50 PM identified on 9/30/25 she was called to Resident #6's room to assist with a room search. She identified she observed five (5) dime bags which contained white residue. She identified the bags were discovered tucked into the folded rim of Resident #6's hat. She further identified she ran the recovery program in the facility and the services offered were through an outside vendor who visited the facility one (1) to two (2) times per week to offer support for residents with SUD. SW #1 indicated Resident #6 was offered support for his/her SUD but refused. SW #1 could not identify why the refusal of services from a high-risk resident was not documented in the clinical record and could not identify alternative interventions offered post refusal. Review of the clinical record failed to identify refusal of treatment. Review of the Care Plan Policy directed for the care plan to contain resident's goals, resident's strengths, resident's preferences, identified problems, measurable realistic goals and the interventions to be utilized to reach the goals.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents (Resident #2 and Resident #5) reviewed for medication administration, the facility failed to maintain complete and accurate medical records by failing to document the administration of as-needed (PRN) medications and the resident's response to those medications in the medication administration record, in accordance with physician orders and facility policy. The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included opioid dependance and cocaine dependence. The quarterly MDS assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with bed mobility and transfers. The Resident Care Plan dated [DATE] identified Resident #2 was at risk for substance use related to a history of addiction. Interventions included to observe for signs and symptoms of withdrawal for detox, monitor laboratory test results, evaluate the need for psych/behavioral consults and reinforce the need for a plan for recovery and sobriety as a means of improving judgement and behavioral self-control to reduce probability of relapse.Physician's orders dated [DATE] directed Naloxone (Narcan) 4 mg/0.1 ml 1ml intramuscular as needed for suspected overdose and Naloxone (Narcan) 4 mg/0.1 ml 1 spray in nostril as needed for suspected overdose.A DNS note dated [DATE] at 5:17 PM identified the DNS responded to a STAT (now) page on the unit at 12:50 PM. Resident #2 was on the floor in the bathroom, had a formed BM and did not respond to verbal or tactile stimuli. No pulse was found, CPR was initiated and 911 was called. Narcan was administered twice with no response. Resident #2 was transferred to the ED at 2:00 PM and the hospital called at 2:20 PM to report Resident #2 expired. The Narcan Administration Report dated [DATE] identified at 12:50 PM Resident #2 was administered Narcan due to being unresponsive. Narcan was administered at 12:53 PM, was not effective, and a second dose was administered at 12:55 PM, and was not effective. A room search was conducted at 2:05 PM and no contraband was found.Review of the Medication Administration Record (MAR) for [DATE] failed to identify Narcan administration was documented as administered and its effectiveness.Interview with the DNS on [DATE] at 2:00 PM identified medications that are administered should be signed off in the MAR.2. Resident #5 was admitted to the facility with diagnoses that included chronic respiratory failure, sepsis and heart failure.Physician's order dated [DATE] directed Milk of Magnesia (MOM) 30 ml by mouth as needed for constipation.Physician's order dated [DATE] directed Bisacodyl Laxative 10 mg rectally as needed for constipation if MOM is ineffective.The Nursing admission assessment dated [DATE] identified Resident #5 was alert and oriented to time, place, person, and situation, had an indwelling Foley catheter, and was always incontinent of bowel.The Resident Care Plan dated [DATE] identified Resident #5 had bowel and bladder incontinence. Interventions included encouraging fluids during the day to promote prompted voided response, check every two hours for incontinence, use of disposable briefs and to change as needed. The RCP further identified Resident #5 was at risk for substance use related to a history of addiction. Interventions included diversion with alternative activities and evaluation of the need for psych and/or behavioral health consults.A physician's order dated [DATE] at 7:39 PM directed Ondansetron 4 mg by mouth every six (6) hours as needed for nausea and vomiting.Review of the Medication Administration Record (MAR) dated [DATE] identified Ondansetron was administered to Resident #5 at 9:00 PM for nausea and vomiting.An abdominal scan dated [DATE] at 9:11 PM identified diffuse constipation with no large or small bowel obstruction.Review of the MAR dated [DATE] identified Bisacodyl was administered to Resident #5 at 10:45 PM; however, the MAR failed to identify administration of MOM and failed to document the effectiveness of either intervention.Interview with RN #2 on [DATE] at 1:56 PM identified she was the nursing supervisor from 8:00 AM to 8:00 PM on [DATE]. RN #2 identified she was notified by LPN #1 that Resident #5 had vomited and complained of abdominal pain. RN #2 assessed Resident #5, contacted the APRN, and received orders for a kidney, ureter, and bladder (KUB) x-ray and Ondansetron for nausea. RN #2 identified she provided shift report to RN #3 and informed her that Resident #5 had vomited, vital signs were stable, and to follow up on the KUB results.Interview with RN #3 on [DATE] at 12:15 PM identified she was the nursing supervisor from 8:00 PM to 8:00 AM on [DATE] into [DATE]. RN #3 identified that around 10:30 PM she was notified by LPN #1 that Resident #5 vomited. RN #3 assessed Resident #5, reviewed KUB results which identified constipation, and notified the APRN. The APRN ordered MOM in prune juice and a suppository, which RN #3 indicated were administered by LPN #1. RN #3 identified Resident #5 refused transfer to the hospital. RN #3 further identified she checked on Resident #5 at approximately 4:00 to 4:30 AM and observed no apparent distress. RN #3 identified that at approximately 7:30 AM she directed NA #3 to determine whether Resident #5 had a bowel movement following administration of the ordered medications (approximately seven and a half hours after MOM was administered). NA #3 reported Resident #5 was not responding and at approximately 7:35 AM, RN #3 called a code and CPR was initiated. Emergency Medical Services (EMS) arrived and continued the code until Resident #5 was pronounced deceased .Interview with LPN #1 on [DATE] at 2:11 PM identified she was assigned to provide care for Resident #5 during the 3:00 PM to 11:00 PM shift on [DATE] and continued care into the 11:00 PM to 7:00 AM shift on [DATE] into [DATE]. LPN #1 identified she administered Ondansetron to Resident #5 at approximately 7:30 PM and noted improvement. She identified that at approximately 10:30 PM Resident #5 vomited multiple times and she believed Resident #5 should be transferred to the hospital. LPN #1 identified she administered MOM at approximately 12:00 AM; however, the administration and outcome were not documented. Interview with the DNS on [DATE] at 12:00 PM identified it depends on the resident when a follow up assessment should be done after administering Milk of Magnesia. It could be anywhere from an hour to a few hours later.Review of the Administration Procedures for All Medications policy directed when administering as needed (PRN) medication, document the reason for giving, observe for medication actions/reactions, and record on the PRN effectiveness sheet or similar form.

Based on clinical record review, facility documentation, facility policies and interviews for two of three sampled residents (Resident #1 and Resident #2) reviewed for an allegation of staff-to-resident sexual abuse, the facility failed to ensure Resident #1 and Resident #2 were protected from sexual abuse by a staff member. The findings include:1. Resident #1's diagnoses included anxiety, depression, chronic substance abuse, and post-traumatic stress disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status score of 15), made reasonable and consistent decisions regarding tasks of daily living, did not exhibit any behaviors, was independent with care, and required touch supervision with bed mobility and ambulation. The Resident Care Plan (RCP) dated 9/30/25 identified Resident #1 had a self-care deficit and was at risk of falls. Interventions directed staff assistance with daily care as needed, physical and occupational therapy as ordered, call bell within reach, and use of non-skid socks. The Nurse's note dated 11/19/25 at 12:37 PM identified on 11/18/25, Resident #1 reported to Registered Nurse (RN) #1 (the 3 PM to 11 PM shift supervisor) that a male housekeeper (Housekeeper #1) entered Resident #1's room before breakfast on 11/18/25. Resident #1 was half asleep and while placing the bedspread on Resident #1, Housekeeper #1 began touching Resident #1 inappropriately. The police and Advanced Practice Registered Nurse (APRN) were notified. The APRN note dated 11/19/25 at 1:48 PM identified the APRN was asked to see Resident #1 due to an alleged incident with a staff member. Resident #1 reported feeling upset about the alleged incident but reported feeling safe. Resident #1 was advised to continue with psychotherapy along with medications to manage mood related to chronic substance abuse. 2. Resident #2's diagnoses included anxiety, bipolar disorder, chronic substance abuse, and post-traumatic stress disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was cognitively intact (Brief Interview for Mental Status score of 15), made reasonable and consistent decisions regarding tasks of daily living, did not exhibit any behaviors, required touch assistance with daily care, moderate assistance with bed mobility and was independent with ambulation. The Resident Care Plan (RCP) dated 10/8/25 identified Resident #2 had a self-care deficit and was at risk for falls. Interventions directed staff assistance with daily care as needed, physical and occupational therapy as ordered, call bell within reach, and use of non-skid socks. The Nurse's note dated 11/19/25 at 12:15 PM identified Resident #2 reported to the Director of Nursing (DON) that approximately one (1) week earlier, Housekeeper #1 kissed Resident #2 on the cheek. At the time Resident #2 did not tell anyone. The police and APRN were notified. The APRN note dated 11/20/25 at 11:28 AM identified he/she was asked to see Resident #2 due to an alleged incident with a staff member. Resident #2 identified a few days earlier, a male staff member approached Resident #2 in an inappropriate way and attempted to kiss Resident #2 which Resident #2 did not allow. Resident #2 did not want to report the incident but after hearing the same thing happened to another resident, came forward. Interview with Social Worker (SW) #1 on 11/21/25 at 11:49 AM identified she was familiar with Resident #1 and Resident #2. She identified Resident #1 and Resident #2 were cognitively intact, able to make their needs known and neither had a history of making false accusations or fabricating information. SW #1 indicated she believed both residents were truthful in their allegations. Review of the written statement and interview with Resident #1 on 11/21/25 at 12:30 PM identified on 11/18/25 before breakfast, Housekeeper #1 was cleaning his/her room and picked a blanket up off the floor. When Housekeeper #1 placed the blanket over Resident #1, Housekeeper #1 touched Resident #1's whole body outside of the blanket. Housekeeper #1 said, let me see your eyes, I bet they are beautiful and started to kiss Resident #1. Resident #1 identified he/she froze and was scared and that he/she was just waking up. Housekeeper #1 then put his hands under the blanket, under Resident #1's shirt, touched his/her upper body, and then put his hands in Resident #1's pants and inserted his fingers inside Resident #1. Resident #1 identified Housekeeper #1 was grabbing his genitals with his other hand and further identified Housekeeper #1 kept looking at the door. Resident #1 did not have a roommate at the time. Resident #1 reported feeling violated, scared, and further identified not fighting back due to a history of PTSD and abuse. Resident #1 proceeded to tell his/her friend (Resident #2) what occurred. Resident #1 voiced knowing the importance of reporting what occurred despite having an emotionally difficult time retelling the allegation. Resident #1's affect was flat during the investigation.Review of a written statement and interview with Resident #2 on 11/21/25 at 12:40 PM identified approximately one week earlier, Housekeeper #1 entered Resident #2's room to clean. While in the room, Housekeeper #1 reportedly blew kisses toward Resident #2 and attempted to kiss Resident #2. Resident #2 stated he/she told Housekeeper #1, stop it, you're being fresh, and put up his/her hand to block the attempt. Resident #2 reported Housekeeper #1 attempted a second time, and when Resident #2 turned his/her face away, Housekeeper #1 kissed Resident #2 on the cheek. Resident #2 identified he/she did not initially report the incident because he/she felt that he/she handled the situation and no further behavior occurred. However, on 11/18/25, Resident #1, who had befriended Resident #2 while at the facility, approached Resident #2 crying and disclosed an allegation involving Housekeeper #1. Resident #2 indicated he/she encouraged Resident #1 to report the incident, and at that time also reported the incident that had occurred approximately one week earlier, realizing it may not have been an isolated event.Review of the written statement and interview with Resident #3 (cognitively intact (Brief Interview for Mental Status score of 15), Resident #2's roommate, on 11/21/25 at 12:46 PM, identified Resident #3 did not witness the alleged incident between Resident #2 and Housekeeper #1 but did witness Housekeeper #1 being overly affectionate with Resident #2 when Housekeeper #1 hugged Resident #2. Resident #3 further identified, Resident #2 shrugged Housekeeper #1 off when he hugged Resident #2 and Resident #2 appeared uncomfortable. Interview with Housekeeper #1 on 11/21/25 at 1:25PM identified he denied all allegations. Interview with the DON on 11/21/25 at 1:45 PM identified if the alleged incidents occurred the facility failed to keep Residents #1 and Resident #2 safe from abuse and failed to follow the facility abuse policy. Interview with the facility Administrator and DON on 12/8/25 at 12:45 PM identified that the facility did not classify the allegations as unsubstantiated, but rather determined that they were unable to substantiate the allegations due to the absence of direct witnesses to the reported incidents. The Administrator stated that Housekeeper #1 was terminated on 11/25/25 for unsuccessful completion of probationary period. When asked to clarify what was considered unsuccessful, the Administrator reported that because the facility could not confirm whether the alleged abuse occurred, and the employee was still within the probationary period, the facility elected to terminate his employment. Although attempted, a call was not returned by the Police Department or the detective assigned the case. Review of the facility policy for Abuse, Neglect, and Exploitation directed in part that abuse is prohibited, and the facility will establish a safe environment that prevents sexual abuse. Review of the facility Resident's [NAME] of Rights identified residents have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion.

Based on review of clinical records, interviews, facility documents and facility policy for five (5) of six (6) residents (Resident #1, #2, #3, #4, and #6,) reviewed for abuse, the facility failed to ensure residents were kept safe from abuse. The findings included: 1a. Resident #1 was admitted to the facility in December of 2022 with diagnoses that included paranoid schizophrenia, Type 2 diabetes mellitus, and mild cognitive impairment. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 99) and required partial assistance with bathing, dressing, and personal hygiene. The Resident Care Plan (RCP) dated 2/3/25 identified Resident #1 enjoyed smoking. Interventions directed to observe for any signs and symptoms of unsafe smoking and supervision by staff while smoking on the patio. 1b. Resident #2 was admitted to the facility in August of 2020 with diagnoses that included schizophrenia, bipolar disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12) and was independent with eating, oral and personal hygiene, and mobility. The RCP dated 2/10/25 identified Resident #2 had schizophrenia, agitation, a history of inappropriate and aggressive behavior, a history of altercations with peers and staff, and often became quickly agitated. Interventions directed to observe for lethargy, mood or behavior changes, redirect when agitated, and encourage to seek assistance from staff when feeling anxious or restless. 1c. Resident #3 was admitted to the facility in November of 2021 and had diagnoses which included dementia, psychotic, mood and anxiety disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12), required set-up assistance with oral hygiene, toileting and personal hygiene and was independent with mobility. The RCP dated 2/25/25 identified Resident #3 enjoyed smoking and that he/she was independent for meeting emotional, intellectual, physical, and social needs. Interventions directed to observe for any signs and symptoms of unsafe smoking and supervision when smoking on the patio. The Reportable Event report dated 3/31/25 identified Resident #2 struck Resident #1 several times in the face. Review of written statements pertaining to the 3/31/25 incident identified Resident #1 had just finished smoking and was sitting in his/her wheelchair when a peer hit him/her once in the face. Interview with the Director of Nurses (DNS) on 6/4/25 at 10:17 AM identified Resident #1 indicated Resident #2 struck him/her in the face on 3/31/25 during a smoking session. The DNS further identified the residents were immediately separated, Resident #2 was put on 1:1 monitoring until deemed as not a harm to self or others, and was seen by psych on 4/1/25. Interview with Resident #3 on 6/4/25 at 2:11 PM identified he/she was a witness to the 3/31/25 altercation and witnessed Resident #2 hit Resident #1 in the face during a smoking session on 3/31/25. Resident #3 indicated Resident #1 was repeatedly saying he/she was dead, that Resident #2 stated he/she ain't dead and proceeded to hit him/her in the face with an opened hand. 2a. Resident #2 was admitted to the facility in August of 2020 and had diagnoses which included schizophrenia, bipolar disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12) and was independent with eating, oral and personal hygiene, and mobility. The RCP dated 4/30/25 identified Resident #2 had impaired social interaction and a risk for harm, either self-directed or other-directed. Interventions directed to evaluate affect, monitor for presence of negative thoughts and feelings, and monitor for signs and symptoms of agitation. 2b. Resident #3 was admitted to the facility in February of 2024 and had diagnoses of paranoid schizophrenia, schizoaffective disorder, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired (Brief Mental Interview for Mental Status (BIMS) score of 11), and required set-up assistance with oral hygiene, toileting and personal hygiene. The RCP dated 4/11/25 identified a behavior problem and use of psychotropic medications. Interventions directed to encourage the resident to express feelings appropriately and to administer psychotropic medications as ordered by the physician. The Reportable Event report dated 5/6/25 identified Resident #3 alleged he/she was slapped in the face by his/her roommate, Resident #2. Interview with RN #1 on 6/4/25 at 12:36 PM identified he/she was informed during second shift on 5/6/25 that Resident #3 was hit in the face that morning and did not report the incident until that evening. RN #1 indicated Resident #3 did not report any pain and Resident #3 was moved to a new room that evening as Resident #3 indicated he/she did not want to sleep in the same room as Resident #2. RN #1 identified Resident #2 had a history of anger and erratic behavior. RN #1 identified that when he/she asked Resident #2 what happened earlier that day, Resident #2 reported hitting Resident #3 in the face that morning. Interview with the DNS on 6/5/25 at 8:40 AM identified fifteen (15) minute checks were initiated for Resident #2 following the incident and Resident #2 had a history of paranoia, unpredictable behaviors, and a history of slapping people. The DNS further indicated Resident #2 was provoked by people saying things he/she did not like and would become aggressive. 3a. Resident #2 was admitted to the facility in August of 2020 and had diagnoses which included schizophrenia, bipolar disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12) and was independent with eating, oral and personal hygiene, and mobility. The RCP dated 4/30/25 identified Resident #2 had impaired social interaction and a risk for harm, either self-directed or other-directed. Interventions directed to evaluate affect, monitor for presence of negative thoughts and feelings, monitor for signs and symptoms of agitation, provide verbal feedback to the resident regarding behavior, and utilize diversion techniques as needed. 3b. Resident #4 was admitted to the facility in October of 2019 and had diagnoses which included epilepsy, schizophrenia, and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact (Brief Mental Interview for Mental Status (BIMS) score of 15), required substantial assistance with oral hygiene, toileting, and personal hygiene, and utilized a wheelchair. The RCP dated 5/8/25 identified Resident #4 required behavior management and had an activities of daily living deficit related to multiple co-morbidities. Interventions directed to ensure the safety of the resident and others, monitor for attempts to stand unassisted and redirect as needed, and to call for assistance for standing from wheelchair. The Reportable Events report dated 5/19/25 identified Resident #2 hit Resident #4 on the head after Resident #4 threw a chair at Resident #2 and called Resident #2 an a**h*** (profanity). Interview with the DNS on 6/5/25 at 8:40 AM identified interventions were added to Resident #2's care plan following each incident (3/31/25, 5/6/25, and 5/19/25). However, the DNS further indicated he/she was unsure if anything could be done to prevent Resident #2 from reacting aggressively towards others when provoked as Resident #2 could approach another resident and hit them without any indication. Interview with the DNS on 6/5/25 at 8:52 AM identified Resident #4 pushed a chair at Resident #2 and called him/her a profanity after he/she refused to share food purchased from an outside vendor. The DNS identified Resident #2 reacted and hit Resident #4 in the head. The DNS further indicated Resident #4 was unable to stand on his/her own without assistance, so it was questionable how he/she could have thrown a chair at Resident #2. Both residents were separated, placed on fifteen (15) minute checks, evaluated by psych on 5/20/25, and deemed safe to self and others. 4a. Resident #6 was admitted to the facility in February of 2023 and had diagnoses that included dementia, depression, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Mental Interview for Mental Status (BIMS) score of four (4), indicating Resident #6 was severely cognitively impaired. The MDS further identified Resident #6 was independent with oral and toileting hygiene, and mobility. The RCP dated 4/10/25 identified Resident #6 had a behavior problem: was threatening to staff/peers, restlessness, resistive to care, yelling/screaming related to schizophrenia, dementia, anxiety, depression, and aggressive behavior. Interventions directed to assist the resident in developing appropriate methods of coping and interacting, monitor behavior episodes, and attempt to determine the underlying cause. 4b. Resident #7 was admitted to the facility in December of 2004 and had diagnoses which included dementia, schizophrenia, and repeated falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), and required partial assistance with oral hygiene, toileting, and personal hygiene. The RCP dated 4/11/25 identified Resident #7 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, and unaware of safety needs. Interventions directed to redirect from reaching into closet/trash barrel and that the resident needs a safe environment. The Reportable Events report dated 5/11/25 identified Resident #6 was observed punching Resident #7 in the face after telling Resident #7 to stop going through the garbage. Interview with the DNS on 6/5/25 at 11:26 AM identified redness was observed on the left side of Resident #7's face following the altercation and that Resident #6 reported Resident #7 was going to hit him/her, so he/she hit him/her. The DNS further identified Resident #7 did not hit Resident #6 during the altercation. Interview with the DNS on 6/5/25 at 11:30 AM identified that residents should be free from abuse of any kind and that interventions were added to the resident's care plans following incidents of abuse with the intent of preventing further incidents from occurring. Review of the Abuse policy directed abuse, neglect, exploitation, and or mistreatment of residents or misappropriation of resident property was prohibited and that residents would not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on clinical record reviews, observations, facility documentation, and interviews for one (1) of four (4) sampled residents (Resident #2) who had documented food allergies, the facility failed to provide meals that were free of the items Resident #2 was allergic to. The findings include: Resident #2's diagnoses included asthma, anxiety, and pulmonary embolism. A physician's order dated 3/31/25 directed a regular diet. The nursing admission assessment dated [DATE] and the nutritional assessment dated [DATE] did not address the topic of food allergies. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place, time, and situation, and was independent with eating. A physician's order dated 4/30/25 identified food allergies to mayonnaise and eggs were added. The May 2025 allergy report identified Resident #2 had food allegories to mayonnaise and eggs. The facility menu dated 5/9/25 identified the alternate dinner food items were tomato soup and a tuna fish sandwich. The facility menu dated 5/10/25 identified the lunch menu included potato salad. Interview with the Director of Food Service on 5/27/25 at 12:25 PM identified the process of being made aware of a resident's food allergies was that the nursing staff would alert the kitchen and then the allergies would be printed on the dietary ticket. The dietary aides on the food line were responsible for reading the tickets to ensure the residents were not served something they were allergic to and if food was plated that the resident was allergic to, the nurse aide or nurse should have identified that and notified the kitchen for a replacement. The Director of Food Services indicated she had been made aware Resident #2 was allergic to a food item that was served. The food allergy had not been listed on the resident's record and the record was updated on 4/30/25 to reflect the food allergies which consisted of eggs and mayonnaise. The Director of Food Service identified those items should not have been served after that point. Interview with Resident #2 on 5/27/25 at 1:15 PM identified on 5/10/25 he/she had been served potato salad for lunch and was allergic to mayonnaise. Resident #2 identified he/she had been served food he/she was allergic to on multiple occasions and had received tuna fish the day before. Resident #2 indicated he/she tried to address getting the wrong food with both the nurse aides and the nurses on the unit but got the same response from them that they could not do anything about it because it was an issue with the kitchen. Observations on 5/27/25 at 1:25 PM identified Resident #2 was served a meal consisting of macaroni and cheese, a roll, milk, and what appeared to be a ham salad sandwich. The Food Service Director came to the room after the nurse aide and charge nurse were not able to identify the sandwich as being ham salad, verified the sandwich was a ham salad which was made with mayonnaise, took the sandwich from Resident #2's room and got a peanut butter and jelly sandwich to substitute. Interview with the Director of Nursing (DON) on 5/27/25 at 2:40 PM identified if a resident had any issues with the food they were served it was the responsibility of the charge nurse to call the kitchen to resolve the issue. The DON indicated Resident #2 should not have been served a food he/she was allergic to.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had chronic pain and required a controlled medication for relief, the facility failed to reorder the resident's pain medication to ensure the medication was available to be administered or administer an alternative medication in the absence. The findings include: Resident #1's diagnoses included stage four (4) pressure ulcer to coccyx and a surgical wound to the abdomen. A physician's order dated 2/20/25 directed Oxycodone HCL oral solution 5 milligrams (mg)/5 milliliters (ml) take 10 ml every four (4) hours as needed for abdominal pain, Tylenol 20.312 ml by mouth every six (6) hours as needed for pain, and pain monitoring every shift. The admission Resident Care Plan dated 2/21/25 identified that Resident #1 was at risk for impaired circulation. Interventions directed to administer pain medications per physician orders, follow non-medicated interventions as ordered, encourage and maintain bedrest with legs elevated, and evaluate pain level. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time, and situation, was independent with care, and experienced pain frequently, a level six (6) on the pian scale from zero (0) to ten (10). Review of the March 2025 Treatment Administration Record identified Resident #1's pain was assessed every shift and ranged from zero (0) to eight (8) from 3/9/25 through 3/11/25. The pain levels on 3/10/25 were documented as six (6) on the 7AM-3PM shift, eight (8) on the 3-11PM shift, and eight (8) on the 11PM-7AM. Review of the March 2025 Medication Administration Record (MAR) identified Resident #1 had pain and received Oxycodone on 3/9/25 at 3:08 AM and at 1:21 PM, the MAR identified the next dose of Oxycodone was not administered until 3/11/25 at 5:07 AM. The MAR failed to reflect documentation Resident #1 received any other medication for pain from 3/9/25 at 8:00 PM through 3/11/25 at 5:07 AM. The Control Substance Disposition Record identified the last dose of Oxycodone liquid from the bottle dispensed on 3/1/25 was on 3/9/25 at 1:21 PM. The Control Substance Disposition Record dated 3/10/25 identified a new bottle was received by the facility on 3/11/25 and the first dose was dispensed on 3/11/25 at 5:07 AM. The facility emergency backup medicine Disposition Record was reviewed from 3/9/25 through 3/11/25 and identified one (1) dose of Oxycodone 10 mg as dispensed for Resident #1 on 3/9/25 at 8:00 PM. Although the MAR and nurse's notes identified Resident #1 was given Oxycodone on 3/10/25 at 7:47 AM, neither set of Control Substance Disposition Records, (facility e-box or the resident's) reflected the Oxycodone had been administered. Interview with Resident #1 at on 3/14/25 at 12:40 PM identified the facility ran out of his/her pain medication on 3/9/25 and 3/10/25 and he/she was in a lot of pain. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #4, on 3/17/25 at 12:25 PM identified the facility run out of Resident #1's prescribed liquid Oxycodone and she asked the Nursing Supervisor to obtain Oxycodone from the emergency box so she could administer the medication. LPN #4 indicated she recalled crushing the pill and mixing it in liquid to administer to Resident #1. Interview with the Director of Nursing (DON) on 3/14/25 at 10:30 AM and 3/17/25 at 1:40 PM identified Resident #1 had made a complaint to her that he/she had not gotten his/her pain medication for three (3) days. The DON identified the expectation for as needed medications to be reordered when there were only seven (7) doses remaining. The DON identified it was against policy to document a med as administered when it was not given, and the facility should ensure residents' had medication available. The facility policy Medication Administration and Documentation identified the nurse is to notify the nursing supervisor if a medication is not available and the facility is to document all medications unavailable for medication administration.

Based on clinical record reviews, observations, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who was reviewed for a comprehensive plan of care, the facility failed to revise the resident's plan of care and implement a level of supervision to protect the resident when the resident consistently expressed a desire for discharge against the wishes of the conservator. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#1's clinical record identified Person #1 as R#1's conservator. A Resident Care Plan (RCP) dated [DATE] identified R#1's desire to be discharged from the facility to community-based living. Interventions directed to ask R#1 periodically how s/he was feeling about the stay at the facility. Review of the RCP identified the plan of care had been reviewed quarterly however the RCP lacked additional interventions related to R#1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R#1 was cognitively intact, had delusions, and was independent for locomotion on the unit. The assessment indicated R#1 was receiving antianxiety medication. The MDS indicated, over a period of several days R#1 expressed feeling bad about him/herself, that s/he was a failure or had let him/herself or his/her family down. Review of the RCP identified no new interventions had been incorporated into the plan of care related to R#1's feelings identified in the MDS dated [DATE]. Review of a nurse's note dated [DATE] identified R#1 stated I don't feel good, I am going to die in this place if I don't get out of here. Review of a social service note dated [DATE] identified Social Worker (SW) #1 met with R#1 and a local law enforcement representative as R#1 had called the Attorney General and stated s/he was kept in the facility against his/her will. A physician's progress note dated [DATE] indicated R#1 continued with behavioral disturbance with request for discharge. Review of the physician note identified it was not safe for R#1 to be discharged to the community due to psychiatric illness and safety issues. The note indicated R#1 was conserved and the Conservator wanted R#1 to remain in the facility. The Conservator indicated R#1 was stable in the facility with current medical management however when not in the facility R#1 refused to take his/her medications at times. The physician's note identified the plan of care was to continue follow up by the Psychiatry Advanced Practice Registered Nurse (APRN) and to continue follow up with Social Services about discharge. A Social Service note dated [DATE] identified that R #1's conservator continued to request R#1 remain in the facility despite R#1 wanting to leave. The Social Service note further identified R #1 stated there were chemicals being pumped into his room at night and he needed to get out of the facility. An elopement risk assessment dated [DATE] indicated R#1 was not considered at risk for elopement based on the content of the risk assessment. A Psychiatry note dated [DATE] identified R#1 was seen to follow up assessment of mood, behavior and medications. The note identified R#1 had anxiety, [CONDITION(S)], and restlessness. The note indicated that R#1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the psychiatric note identified R#1 was not a danger to self or others. A Social Services note dated [DATE] identified that a 30 day intent for discharge was given to R#1 and SW#1 indicated R#1 appeared pleased that s/he would be able to leave the facility. A Psychiatry note dated [DATE] identified R#1 was followed up for anxiety and medication renewal. The note identified R#1 was displaying anxiety, psychoses, and restlessness. The note identified R#1 was appropriate to continue on [MEDICATION(S)] with the plan to monitor for any changes in his behavior. The Psychiatry note further identified R#1 was not considered a danger to self or others. A Social Service note dated [DATE] identified R#1 was informed that proper signatures were needed on the 30 day intent for discharge and would have to be reissued once completed. Further review of the note identified R#1 seemed okay with the plan but stated s/he did not want to wait 30 days. The RCP initiated on [DATE], last reviewed on [DATE], identified R#1's psychosocial wellbeing was at risk due to chronic medical and or psychological conditions including; anxiety, paranoid [CONDITION(S)], substance use disorder, and Opioid withdrawal. Interventions directed to record and report any concerns or condition changes to the attending physician and conservator/family as needed. The facility social worker would have periodic and as needed contact with R#1 to assess and provide all needed counseling, and document any significant concerns or changes. Review of Reportable Event documentation and investigation identified that on [DATE] at approximately 6:00 AM a staff member reported that there was a body on the ground at the back of the building. The report identified that it was noted that a long strip of cloth was tied together and suspended from the 4th floor window. Resident verification rounds were completed which resulted in identifying that R#1 was not in the building. An investigation was initiated and during the investigation facility staff reported R#1 had exhibited no unusual behavior prior to the incident. R#1 was last seen at approximately 4:30 AM asleep in his/her room. Review of an Emergency Medical Services (EMS) report dated [DATE] identified EMS received a call from the facility on [DATE] at 5:56 AM and was at R#1's side at 6:05 AM. The report identified R#1 was found lying on the paved ground, visibly deceased , with coagulated blood around the head and face. R#1 was cold to touch, pulseless (no heart rate), and apneic (no breathing). The report identified R#1 had rigor mortis (stiffening of the joints and muscles of a body a few hours after death), lividity (bluish-purple skin discoloration which occurs when blood pools at the lowest point of the body due to loss of circulation) of all extremities, and a fracture of the right lower extremity. The report indicated it appeared R#1 was attempting to leave the facility as there was rope made of blankets and towels from the window all the way to the ground. The reported noted the impression as obvious death by crushing trauma and identified the time of death as 6:13 AM on [DATE]. Investigation of the event identified R#1's room window slid side to side to open with stoppers to prevent the window opening greater than 4 inches. R#1 had broken the stoppers, and removed the window to open it. Review of environmental checks completed monthly, identified the window had previously been intact with the 4 inch stoppers present. Review of facility egress routes identified a key pad secured stairwell and an elevator to the main level supervised by security at all times. In an interview with Nursing Assistant (NA) #1 on [DATE] at 11:25 AM, NA #1 identified that she overheard R#1 telling another resident that s/he would be leaving the facility soon. NA #1 stated that R#1 would frequently state I don't know why they are keeping me here so long; I want to go home. In an interview with Social Worker #1 (Program Director) on [DATE] at 1:00 PM Social Worker (SW) #1 indicated that R#1 remained in the facility despite being identified that the nursing facility level care was not necessary for him/her, as the resident was homeless and could not be discharged to the shelters during the pandemic. R#1 refused to be assessed by the Money Follow Person (MFP) program, refused assessment by Psychiatry (Ascend), and the Conservator was against R#1 leaving the facility. SW#1 identified R#1 was aware the conservator was not in agreement with the resident leaving the facility and indicated that R#1 became upset and expressed that it was unfair. SW #1 further stated that R#1 was aware the Conservator had to agree with R#1's discharge plan. SW#1 identified R#1 stated that s/he was being kept in the facility against his will, and that s/he did not belong in the facility and wanted to leave. SW #1 indicated that R#1's conflicting desires with the conservator were communicated with the nurses, MDS nurse, Director of Nursing (DNS), and Administrator during morning meetings. An interview with APRN #1 on [DATE] at 2:50 PM identified R#1 exhibited poor judgement and was paranoid but was not acutely psychotic, and did not display inward or outward violence. APRN #1 indicated R#1 refused antipsychotic medications shortly after being admitted to the facility (medications were discontinued on [DATE]). APRN #1 indicated the medications would have helped with R#1's paranoia. APRN #1 stated R#1 had expressed may times to everyone that s/he wanted to leave the facility. During an interview with the Administrator, DNS, and Corporate Nurse on [DATE] at 4:10 PM the Administrator stated R#1 was always expressing a desire to leave and that there were no changes in the resident's usual behavior prior to the incident, and the incident could not have been anticipated. A review of R#1's clinical record failed to identify R#1's RCP was reviewed and revised, to include interventions related to R#1's level of supervision when the resident exhibited paranoia and identified numerous times his/her desire to leave the facility. Review of the Care Plan policy identified the interdisciplinary team develops in collaboration with the resident, a comprehensive care plan based on the resident assessment instrument, which is comprised of the MDS, care area assessments, other applicable clinical information, resident's goals for admission, resident preferences, and the resident's preference and potential discharge. The policy further indicated that a care plan coordinator adds a new goal or intervention for a problem by dating and writing the new goal or intervention. As a result of the incident the facility provided a plan of correction to include; inspection and screwing shut of all windows, re-in-service education of all social workers on providing psychosocial support, and an assessment of the level of supervision needed of all conserved residents who expressed a desire to leave the building or be discharged .

Based on clinical record reviews, observations, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who was reviewed for care planning, the facility failed to ensure the resident was not able to exit through a window when the resident broke the window stoppers, removed the window and climbed out the forth floor window and was found deceased on the ground. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses that included paranoid [CONDITION(S)] and anxiety. A review of R#1's clinical record identified Person #1 as R#1's conservator. A Resident Care Plan (RCP) dated [DATE] identified R#1's desire to be discharged from the facility to community-based living. Interventions directed to ask R#1 periodically how s/he was feeling about the stay at the facility. Review of the RCP identified the plan of care had been reviewed quarterly with interventions related to R#1's diagnoses of paranoid [CONDITION(S)], anxiety, and desire for discharge, between [DATE] and [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R#1 was cognitively intact, had delusions, and was independent for locomotion on the unit. The assessment indicated R#1 was receiving antianxiety medication. The MDS indicated, over a period of several days R#1 expressed feeling bad about him/herself, that s/he was a failure or had let him/herself or his/her family down. Review of a nurse's note dated [DATE] identified R#1 stated I don't feel good, I am going to die in this place if I don't get out of here. Review of a social service note dated [DATE] identified Social Worker (SW) #1 met with R#1 and a local law enforcement representative as R#1 had called the Attorney General and stated s/he was kept in the facility against his/her will. A physician's progress note dated [DATE] indicated R#1 continued with behavioral disturbance with request for discharge. Review of the physician note identified it was not safe for R#1 to be discharged to the community due to psychiatric illness and safety issues. The note indicated R#1 was conserved and the Conservator wanted R#1 to remain in the facility. The Conservator indicated R#1 was stable in the facility with current medical management however when not in the facility R#1 refused to take his/her medications at times. The physician's note identified the plan of care was to continue follow up by the Psychiatry Advanced Practice Registered Nurse (APRN) and to continue follow up with Social Services about discharge. A Social Service note dated [DATE] identified that R #1's conservator continued to request R#1 remain in the facility despite R#1 wanting to leave. The Social Service note further identified R #1 stated there were chemicals being pumped into his room at night and he needed to get out of the facility. An elopement risk assessment dated [DATE] indicated R#1 was not considered at risk for elopement based on the content of the risk assessment. A Psychiatry note dated [DATE] identified R#1 was seen to follow up assessment of mood, behavior and medications. The note identified R#1 had anxiety, [CONDITION(S)], and restlessness. The note indicated that R#1 had a history of paranoid [CONDITION(S)] but choose not to take any medications. Further review of the psychiatric note identified R#1 was not a danger to self or others. A Social Services note dated [DATE] identified that a 30 day intent for discharge was given to R#1 and SW#1 indicated R#1 appeared pleased that s/he would be able to leave the facility. A Psychiatry note dated [DATE] identified R#1 was followed up for anxiety and medication renewal. The note identified R#1 was displaying anxiety, psychoses, and restlessness. The note identified R#1 was appropriate to continue on [MEDICATION(S)] with the plan to monitor for any changes in his behavior. The Psychiatry note further identified R#1 was not considered a danger to self or others. A Social Service note dated [DATE] identified R#1 was informed that proper signatures were needed on the 30 day intent for discharge and would have to be reissued once completed. Further review of the note identified R#1 seemed okay with the plan but stated s/he did not want to wait 30 days. The RCP initiated on [DATE], last reviewed on [DATE], identified R#1's psychosocial wellbeing was at risk due to chronic medical and or psychological conditions including; anxiety, paranoid [CONDITION(S)], substance use disorder, and Opioid withdrawal. Interventions directed to record and report any concerns or condition changes to the attending physician and conservator/family as needed. The facility social worker would have periodic and as needed contact with R#1 to assess and provide all needed counseling, and document any significant concerns or changes. Review of Reportable Event documentation and investigation identified that on [DATE] at approximately 6:00 AM a staff member reported that there was a body on the ground at the back of the building. The report identified that it was noted that a long strip of cloth was tied together and suspended from the 4th floor window. Resident verification rounds were completed which resulted in identifying that R#1 was not in the building. An investigation was initiated and during the investigation facility staff reported R#1 had exhibited no unusual behavior prior to the incident. R#1 was last seen at approximately 4:30 AM asleep in his/her room. The facility failed to ensure the the resident was not able to exit the 4th floor window. Review of an Emergency Medical Services (EMS) report dated [DATE] identified EMS received a call from the facility on [DATE] at 5:56 AM and was at R#1's side at 6:05 AM. The report identified R#1 was found lying on the paved ground, visibly deceased , with coagulated blood around the head and face. R#1 was cold to touch, pulseless (no heart rate), and apneic (no breathing). The report identified R#1 had rigor mortis (stiffening of the joints and muscles of a body a few hours after death), lividity (bluish-purple skin discoloration which occurs when blood pools at the lowest point of the body due to loss of circulation) of all extremities, and a fracture of the right lower extremity. The report indicated it appeared R#1 was attempting to leave the facility as there was rope made of blankets and towels from the window all the way to the ground. The reported noted the impression as obvious death by crushing trauma and identified the time of death as 6:13 AM on [DATE]. Investigation of the event identified R#1's room window slid side to side to open with stoppers to prevent the window opening greater than 4 inches. R#1 had broken the stoppers, and removed the window to open it. Review of environmental checks completed monthly, identified the window had previously been intact with the 4 inch stoppers present. Review of facility egress routes identified a key pad secured stairwell and an elevator to the main level supervised by security at all times. The facility failed to ensure the resident was not able to exit through the window when the resident broke the window stoppers, removed the window and climbed out the forth floor window and was found deceased on the ground. In an interview with Nursing Assistant (NA) #1 on [DATE] at 11:25 AM, NA #1 identified that she overheard R#1 telling another resident that s/he would be leaving the facility soon. NA #1 stated that R#1 would frequently state I don't know why they are keeping me here so long; I want to go home. In an interview with Social Worker #1 (Program Director) on [DATE] at 1:00 PM Social Worker (SW) #1 indicated that R#1 remained in the facility despite being identified that the nursing facility level care was not necessary for him/her, as the resident was homeless and could not be discharged to the shelters during the pandemic. R#1 refused to be assessed by the Money Follow Person (MFP) program, refused assessment by Psychiatry (Ascend), and the Conservator was against R#1 leaving the facility. SW#1 identified R#1 was aware the conservator was not in agreement with the resident leaving the facility and indicated that R#1 became upset and expressed that it was unfair. SW #1 further stated that R#1 was aware the Conservator had to agree with R#1's discharge plan. SW#1 identified R#1 stated that s/he was being kept in the facility against his will, and that s/he did not belong in the facility and wanted to leave. SW #1 indicated that R#1's conflicting desires with the conservator were communicated with the nurses, MDS nurse, Director of Nursing (DNS), and Administrator during morning meetings. An interview with APRN #1 on [DATE] at 2:50 PM identified R#1 exhibited poor judgement and was paranoid but was not acutely psychotic, and did not display inward or outward violence. APRN #1 indicated R#1 refused antipsychotic medications shortly after being admitted to the facility (medications were discontinued on [DATE]). APRN #1 indicated the medications would have helped with R#1's paranoia. APRN #1 stated R#1 had expressed may times to everyone that s/he wanted to leave the facility. During an interview with the Administrator, DNS, and Corporate Nurse on [DATE] at 4:10 PM the Administrator stated R#1 was always expressing a desire to leave and that there were no changes in the resident's usual behavior prior to the incident, and the incident could not have been anticipated. As a result of the incident the facility provided a plan of correction to include; inspection and screwing shut of all windows, re-in-service education of all social workers on providing psychosocial support, and an assessment of the level of supervision needed of all conserved residents who expressed a desire to leave the building or be discharged .