Every finding on record at Chestnut Ridge NSG & Rehab CTR

Based on observations, interviews, record review, and facility policy titled Housekeeping Operations Manual, the facility failed to ensure the dining room, and 2 of 2 communal shower rooms were maintained in a safe, clean, comfortable and homelike environment. The deficient practice had the potential to affect patient comfort and safety. Findings include:Review of the undated document titled Housekeeping Operations Manual, documented The main area of concern to a housekeeping department in a healthcare facility is the transmission of bacteria.Observation of the women's communal bathroom on 03/02/2026 at 11:48 AM, 03/04/2026 at 12:18 PM and 2:48 PM, revealed on a shelf: numerous bottles of shampoo, lotion, grooming items scattered across the surface; hairbrush, scissors, wipes, lotions, and cleaning products were observed intermixed and unlabeled. There were small pieces of debris scattered across the shower room floor and appeared unclean and unsanitary with residue along the lower portion of the tile wall. Used washcloths were observed on the hand grab bar, a resident gown was draped over a wheelchair holding both clean and used linen and a dirty slipper sock was on the floor in front of the toilet. The foam pad on the shower stretcher had small openings with debris accumulation in the foam. In addition, observation of the men's communal shower revealed clutter with multiple personal items including thera-gel shampoo, a resident hat, a used electric shaver, baby lotion, open containers of wipes and briefs.Observation of the dining room on 03/03/2026 at 3:03 PM, revealed used silverware, trash and a cookie on the floor and trash on the dining area tables. The dining tables and floor were sticky and did not appear to have been recently wiped or mopped.Interview with CNA QQ on 03/04/2026 at 12:20 PM, stated the nursing assistants are supposed to clean the shower rooms after each resident use.Interview with the Housekeeping Director (HKD) on 03/04/2026 at 12:30 PM, stated the multi-use showers are cleaned at 8:00 AM, 12:00 PM, and 3:00 PM, and the CNAs are supposed to clean them following each use and make sure the towels are removed following use. Interview with the Regional Nurse Consultant n 03/04/2026 at 2:56 PM, confirmed the lack of cleanliness during a tour of the men's and women's bathrooms. Interview with CNA SS on 03/05/2026 8:25 AM, stated the shower chair and bath stretcher should be sanitized between uses, even if it's just rinsed, the water still has body fluids from the previous resident. CAN SS stated she has not been trained to sanitize the equipment, but the equipment should be sprayed off after use.

Based on observations, record review, staff interviews, review of the facility's policies titled Administering Medications, the facility failed to ensure accurate administration of medications for six of 25 medication opportunities observed, resulting in a medication error rate of 24% (percent.) The deficient practice increased the risk of adverse clinical outcomes. Findings Include:Review of the facility's policy titled, Administering Medications, dated 2/2020 documented that Medications shall be administered in a safe and timely manner, and as prescribed.Observation on 03/04/2026 at 9:26 AM on A-Hall with Licensed Practical Nurse (LPN) DD revealed resident (R) R106 had physician orders for Glipizide 10 mg {milligrams}, give 1 tablet by mouth twice daily for Diabetes Mellitus (DM), and Fluticasone-Salmeterol inhalation powder 500/50 mcg {micrograms}, inhale 1 puff orally twice daily for Chronic Obstructive Pulmonary Disease (COPD). These medications were not administered due to lack of availability, and the physician was not notified of the missed doses. During the same medication administration observation, LPN DD administered Isosorbide Mononitrate ER {extended release} 120 mg, ordered as 1 tablet by mouth in the morning for hypertension (HTN), incorrectly by giving one 60 mg tablet instead of two tablets to equal 120 mg. The medication card contained a written note stating Give 2 tablets to equal 120 mg. The nurse also administered Clonidine HCL {hydrochloride} 0.1 mg, ordered every 12 hours as needed for HTN if systolic blood pressure >160 or diastolic >100; however, the medication was given when the resident's blood pressure was 150/59, which was outside the ordered parameters. Additionally, the nurse administered Allopurinol incorrectly by giving three 100 mg tablets (300 mg total) when the physician's order was Allopurinol 300 mg, give 2 tablets by mouth in the morning (600 mg total) for gout flare.Observation on 03/04/2026 at 10:29 AM on A-Hall with LPN DD revealed R103 had physician orders for Pantoprazole Sodium oral tablet Delayed Release 40 mg, give 1 tablet by mouth one time a day for GERD (Gastroesophageal Reflux Disease). The medication was observed to be crushed; however, Pantoprazole is a delayed-release medication and should not be crushed.Interview on 03/04/2026 at 2:05 PM with LPN DD regarding medication administration errors revealed that she acknowledged that Pantoprazole should not have been crushed, stating she knew it was a delayed-release medication that would act faster than intended and that she would notify the physician. Regarding Clonidine, the nurse stated she usually administers it in the morning and has never noticed those parameters before. Regarding Allopurinol, the nurse stated she did not realize the dosing error and requested the Unit Manager to pull additional medication from Pyxis {med dispensing machine.}Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that she expects to maintain medication error rates below 5 percent and emphasized that nursing staff should consistently follow proper medication administration procedures.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene, Insulin Administration, Housekeeping-Infection Control Procedures, and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to follow proper infection control practices for one of four nursing units and two of two shower rooms. Specifically, top of an insulin vial not disinfected, blood pressure cuff not disinfected between residents, Housekeeping Aide pouring liquid from resident cup into mop water, and nursing staff exiting resident rooms without removing gloves and performing hand hygiene. In addition, multiple personal items in the communal shower rooms were unlabeled. The deficient practice increased the risk of cross contamination and spread of infection. Facility census was 127.Findings Include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 2/2020, revealed that This facility considers hand hygiene the primary means to prevent the spread of infections. Further review of item 5. Hand hygiene is the final step after removing and disposing of personal protective equipment. Item 6. The use of gloves does not replace hand washing/hand hygiene. Review of the facility's policy titled, Insulin Administration revised September 2014, revealed under Steps in the Procedure (Insulin Infections via Syringe) step 8. Disinfect the top of the vial with an alcohol wipe. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 1/2023 revealed that Resident-care equipment, including reusable and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Further review of Item 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. Review of the facility's policy titled Housekeeping-Infection Control Procedures revised 11/2024 on page 69 documented under Infection Control Guidelines that The solution to controlling infection lies not in technology, but in human behavior. Further review revealed that The role of a housekeeping department in the infection control process is to halt the transmission of infectious organisms. 1.Observation and interview on 03/04/2026 at 10:03 AM during medication administration revealed Licensed Practical Nurse (LPN) DD drew insulin for Resident (R) (R106), Lantus (insulin glargine) 34 units subcutaneously for diabetes mellitus, and failed to clean the top of the insulin vial prior to drawing the medication. During interview, LPN DD stated she usually wipes the top of the insulin vial but did not do so on this occasion and acknowledged the infection control concern, stating that contaminants could be introduced onto the needle. Observation and interview on 03/04/2026 at 10:36 AM, during medication administration revealed Licensed Practical Nurse (LPN) DD used the same blood pressure cuff for two residents A04-A and A04-B, who were both on Enhanced Barrier Precautions (EBP), without cleaning or disinfecting the cuff between residents. During interview, LPN DD stated she forgot to wipe down the blood pressure cuff and did not have disinfectant wipes in her medication cart. She left the area to obtain disinfectant wipes and acknowledged the concern for potential contamination and infection transmission. Observation and interview on 03/04/2026 at 3:07 PM revealed Housekeeping Aide GG removed several dated resident cups from Room C38 and emptied the contents into the mop bucket she was using to clean resident rooms on the C-Hall. During interview, Housekeeping Aide GG indicated she spoke Creole and no English. At that time, the Director of Housekeeping was present, was informed of the observation, and spoke with Housekeeping Aide GG in English, instructing her to stop pouring used resident cups into the mop bucket. Observation and interview on 03/04/2026 at 3:20 pm revealed Certified Nursing Assistant (CNA) II exited a resident room wearing one glove and carrying a bag of used soiled linen while walking down the hallway to dispose of the bag. During interview, CNA II stated she was not aware that gloves should not be worn in the hallway and believed it was acceptable to do so. Observation and interview on 03/05/2026 at 10:28 AM revealed Registered Nurse (RN) JJ exited a resident room wearing one glove and walked into the hallway toward the medication cart. RN JJ removed the glove, disposed of it, and immediately opened the medication cart, removed items, and walked back toward the resident room without performing hand hygiene. During interview, RN JJ confirmed he did not perform hand hygiene after removing the glove and acknowledged walking through the hallway wearing one glove and touching items in the medication cart without performing hand hygiene. Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that staff should clean the top of insulin vials prior to injecting air or withdrawing medication to maintain a clean surface and prevent infection. The DON stated that gloves should not be worn in hallways after resident care, as they may carry contaminants from resident rooms, and emphasized that staff should perform hand hygiene after glove removal. Additionally, the DON stated that housekeeping staff should dispose of liquids from resident water cups, which may contain saliva, in designated areas such as the restroom, and use appropriate stations for filling mop buckets to maintain sanitation standards. 2. On 03/02/2026 at 11:48 AM, a general tour was conducted of the C Hall communal women's shower room. Observation revealed that Stall 1 contained an unlabeled bottle of shampoo/skin cleanser; in the second stall an open bottle of shampoo/skin cleaner, and a used washcloth was observed on the shower bench; on a shower room shelf there was a half-used bottle of VO5 shampoo, a reusable water bottle, resident clothing and a cell phone. On 03/04/2026 at 12:18 PM, during a follow up tour of the woman's shower room on C Hall, observation revealed an unlabeled container of secret deodorant was open and sitting on the shelf, next to an open, unlabeled bottle of shampoo, power stick 2-in-1 shampoo and conditioner, clean towels and washcloths were sitting on a resident wheelchair with a dirty resident gown. An open bottle of shampoo was observed on the shower stretcher. A used washcloth was left hanging over the shower rail, and a used slipper sock was on the floor in front of the toilet. None of the items were labeled with resident identification. On 03/04/2026 at 12:20 PM, during an interview with CNA QQ, she stated the aides use the residents' personal products for their bathing/showers and if the resident does not have anything they should use the multi-use bottle/product. CNA QQ stated the shower rooms are supposed to be cleaned following each use. CAN QQ confirmed the personal care products were not labeled. She stated she did not know whose belongings were in the shower room. On 03/04/2026 at 12:30 PM, the Housekeeping Director (HKD) stated the communal showers are cleaned at 8:00 AM, 12:00 PM, and 3:00 PM. The HKD stated CNA staff are supposed to clean the showers following each resident use and make sure the towels/washcloths are removed at the completion of the task. On 03/04/2026 at 2:48 PM, an observation tour of the men's communal shower room revealed personal items comingled. The items included a partially used bottle Thera-gel shampoo, an electric razor, Pantene shampoo and conditioner, and 2 open half used bottles of fresh scent baby lotion. Additionally, the men's shower stretcher had a greenish colored liquid pooling in the center of the foam stretcher. On 03/04/2026 at 2:56 PM, the Regional Nurse Consultant verified the personal care items were mixed in the men's and woman's communal bathrooms and stated she would have the personal items removed.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) was administered according to physician's order for two of 13 residents (R) (R140 and R75) who use O2. This deficient practice had the potential to result in inappropriate respiratory treatment and adverse clinical outcomes.Findings include:Review of the facility policy titled, Oxygen Administration, undated documented Preparation: 1. Verify that there is a physician order for this procedure. Review the physician's or facility protocol for oxygen administration.1.Record review of the Electronic Medical Record (EMR) revealed R140 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to acute respiratory failure with hypoxia, sleep apnea, chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina, presence of aortocoronary bypass graft, and anemia. Review of R140's entry MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Review of R140's care plan dated 02/26/2026, documented a problem of altered respiratory status/difficulty breathing related to underlying cardiopulmonary conditions. The goal included but was not limited to the resident remaining free from complications related to shortness of breath through the next review date. Interventions included but were not limited to observing for signs and symptoms of respiratory distress and reporting to the physician as needed (such as increased respirations, decreased pulse oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color changes); and administering oxygen as indicated in the care plan intervention, OXYGEN SETTINGS: O2 via (SPECIFY: nasal prongs/mask) @ (SPECIFY) L (SPECIFY FREQ). Review of the Physician's Orders for R140 revealed that there were no orders for oxygen prior to 03/03/2026. On 03/03/2026, an order was added for oxygen at 2 LPM (Liters Per Minute) via nasal cannula (NC) continuous.Review of R140's oxygen saturations (Sp02) indicates that over the period from 02/26/2026 to 03/04/2026 that SpO2 readings ranged from 93% to 98%. The resident's oxygen saturation revealed brief dips below 94%.Observation on 03/02/2026 at 1:35 PM revealed, R140 was wearing his oxygen via NC and the O2 concentrator was running at the setting of 2.5 LPM.Observation on 03/03/2026 at 5:08 PM revealed, R140 was wearing his oxygen via NC and the O2 concentrator was running at the setting of 2.5 LPM.Observation and interview with Licensed Practical Nurse (LPN) CC on 03/03/2026 at 5:10 PM confirmed that she was unable to locate any oxygen orders in the EMR. She stated that the resident had been admitted yesterday, 03/02/2026, and arrived from the hospital with oxygen set at 2 LPM. However, visual confirmation by LPN CC of the oxygen concentrator revealed it was set at 2.5 LPM, not 2 LPM.Interview with the Director of Nursing (DON) on 03/05/2026 at 11:05 AM, confirmed that residents receiving oxygen should have a physician order specifying the liter flow and monitoring of respirations and signs of respiratory distress. Oxygen should not be initiated without an order unless it is an emergency. Staff should complete and document a respiratory assessment and review nursing notes. Administering oxygen without an order could be unsafe, particularly for a resident with COPD, due to the risk of hyperoxygenation. The DON further stated staff should document the resident's respiratory status, notify the in-house Nurse Practitioner (NP), and obtain appropriate orders. The NP would evaluate the resident and determine whether oxygen should be initiated, continued, weaned, or changed to PRN (as needed), with all actions documented in the medical record.2. Review of the electronic medical record (EMR) revealed that R75 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, acute respiratory failure with hypercapnia, sleep apnea, morbid obesity, acute on chronic systolic (congestive) heart failure (CHF), cardiac arrhythmia, hypertension, and end-stage renal disease (ESRD).Review of R75's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Section GG (Functional Status) revealed that R75 required substantial to maximal assistance for activities of daily living (ADLs) and use of wheelchair. Section O: (Special Treatments) coded for the use of oxygen.Review of R75 care plan, revised 01/15/2026, indicated impaired oxygenation related to respiratory failure, sleep apnea, and congestive heart failure. Goals included but were not limited to maintaining adequate oxygenation and preventing complications related to respiratory status. Interventions included but were not limited to monitoring respirations and pulse oximetry for signs of respiratory distress, positioning with the head of the bed elevated to promote breathing, administering oxygen therapy per physician orders via nasal cannula, and notifying the physician of worsening respiratory symptoms.Review of the Physician's Orders for R75 included but was not limited to:Order dated 11/04/2024 for O2 2LPM via nasal cannula to keep SpO2 above 92%Observation and interview on 03/02/2026 at 1:03 PM with R75 revealed the resident was seated in a wheelchair wearing a nasal cannula connected to a portable oxygen tank attached to the back of the wheelchair. The oxygen flow rate was observed set at 1 liter per minute. The resident would not have been able to reach the oxygen tank to adjust the flow rate. During interview, R75 stated that she told the nurse to keep the oxygen at 1 liter and acknowledged that the physician order was for 2 liters but stated she prefers it at 1 liter.Observation and interview on 03/03/2026 at 5:04 PM with R75 and Licensed Practical Nurse (LPN) CC revealed the oxygen tank attached to the back of the resident's wheelchair was set at 1 liter per minute. LPN CC stated that the resident prefers the oxygen at 1 liter and staff maintain the oxygen at that level per the resident's request, although the physician order was for 2 liters. LPN CC stated the oxygen had been kept at 1 liter for a long time, but the order had not been changed, and she was unsure whether the prescribing physician had been notified, stating that someone may have informed the Nurse Practitioner (NP) at some

Based on observation, interview and record review the facility failed to assure that two residents (R) (R34 and R90) from a sample of 47 residents, received and consumed foods in the appropriate form as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with goals and preferences. The deficient practice increased the risk of adverse clinical outcomes. Findings include:Record review of the facility diet type report dated 03/05/2026, revealed R90's diet was listed as regular, mechanical soft, reduced concentrated sweets, no added salt. The report specified R34 should receive a mechanical soft, regular diet, reduced concentrator sweets, no added salt. 1.R90 was admitted [DATE]. The diagnoses included congestive heart failure, diabetes type 2, dysphagia (difficulty swallowing), and chronic kidney disease. The record also included a history of pneumonitis (aspiration). R90's diet order dated 02/13/2026, documented diet upgraded from pureed to mechanical soft texture, regular consistency.R90's care plan initiated 03/26/2025 and revised 02/26/2026, revealed R90 had a nutritional problem. and needed pureed meat/mech soft consistency for dysphagia. Speech therapy allowed some items per resident's request (see current diet order).The annual nutritional assessment dated [DATE], documented mechanical soft diet consistency/puree meat and bread; may have sandwiches and crackers as tolerated.Observation of R90's lunch meal on 03/02/2026 at 12:26 PM, revealed R90 was served pureed meat, pureed green beans, pureed mandarin oranges and pureed egg noodles. The meal tickets specified R90 could have mechanical soft sides.On 03/04/2026 at 12:38 PM, R90's lunch meal consisted of pureed roast beef, pureed squash and pineapple tidbits. The meal ticket indicated R90 was to receive pureed meat and bread, and mechanical soft sides. The meal ticket also indicated pureed meat, pureed bread, pureed squash, pureed pineapple tidbits and mashed potatoes. The Dietary Manager (DM) verified the meal served did not match the meal ticket and stated she would correct it. 2.Record review showed R34 was admitted to the facility 06/13/2023. R34's diagnoses included congestive heart failure, diabetes type 2, anemia, chronic kidney disease and dementia. R34's diet order dated 02/12/2024, specified reduced concentrated sweets, no added salt diet, mechanical soft texture, regular consistency.Record review of the annual diet assessment dated [DATE], specified reduced concentrated sweets, no added salt, mechanical soft diet. R34s care plan did not document specific dietary instructions or interventions. During lunch observation on 03/04/2026 at 12:39 PM, R34 was observed not eating. The meal consisted of shredded roast beef, with gravy, mashed potatoes, and squash. The meat was in shredded strands and contained pieces large enough that required chewing. The meat did not appear to be mechanically altered. R34 was served with pineapple chunks in place of cinnamon applesauce as was specified on the meal ticket. The meal ticket specified ground roast beef. R34 was unable to answer questions about his lunch. The dietary manager verified the meal served did not match the ticket and stated she would correct it. On 03/05/2026 at 8:46 AM, The dietary manager stated there were three staff working the tray line. There is a cook, a ticket reader and a finisher. The dietary manager stated the aid grabbed the wrong item and put it on the tray. On 03/05/2026 at 9:08 AM, the Director of Nursing (DON) stated the nursing assistants should be checking the tray slips to be sure what is placed on the tray is correct. On 03/05/2026 at 2:27 PM, during a follow up interview the DON confirmed the diet meal tickets did not match the active orders. The DON stated I see the inconsistencies and why that would be confusing.

Based on observations, staff interviews, and review of facility policies titled Administering Medications, the facility failed to maintain accurate records on controlled substances for resident (R) (R43) on one of three medication carts. The deficient practice increased the risk of medication error for R43 and the potential for drug diversion. Findings include:Review of the facility's policy titled, Administering Medications, dated 2/2020 revealed that Medications shall be administered in a safe and timely manner, and as prescribed.Review of the Physicians Orders for R43 included but was not limited to:Order dated 01/27/2026 for Methadone HCl {Hydrochloride} Oral Tablet 10 MG (Methadone HCl) *Controlled Drug* Give 2 tablet by mouth every 8 hours as needed for Chronic painReview of the electronic medical record (EMR) revealed R43 received Methadone on 03/04/2026 at 10:47 AM.Observation and interview on 03/04/2026 at 3:22 PM, of the nurse's medication cart with Registered Nurse (RN) HH on C-Hall revealed the following:Controlled Substance Record Book: Multiple pages were torn, loose, and no longer secured within the binder. During inspection, these pages easily fell out, creating a risk for inaccurate or incomplete controlled substance accountability.Review of the Controlled Substance Record Book for R43's Methadone administration on 03/04/2026 revealed no documentation by the administering nurse at the time the medication was given, violating facility policy requiring timely and accurate recording of controlled substances.Interview on 03/04/2026 at 3:24 PM with RN HH revealed that she documented the administration in the Medication Administration Record (MAR) at 10:47 AM but failed to make an entry in the controlled substance log. RN HH acknowledged the importance of maintaining an accurate controlled substance count but could not clearly explain why this is critical. She also stated that missing pages were discovered in the controlled substance book. Being an agency nurse, she indicated she was unsure how to address the issue and would need to ask the supervisor.Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that nurses are required to document administration of controlled substances immediately after giving the medication in the controlled substance log and ensure there are no missing signatures or loose pages. The DON explained that maintaining accurate documentation is necessary to ensure medication counts match and to prevent potential medication errors or delays in administration.

Based on observations, record review, staff interviews, and review of the policy titled, Accidents and Incidents-Investigation and Reporting, the facility failed to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision for two residents (R) (R49 and R145) from a sample of 47 residents. The deficient practice increased the risk of avoidable accidents and injury. Findings include: Review of the policy titled, Accidents and Incidents-Investigation and Reporting revised 02/2024 documented The facility shall provide the residents an environment free of accident hazards. Further review of section 7. Supervision item a.Adequacy of supervision is based on the individual's assessed needs and identified hazards in the resident's environment. 1. Review of the electronic medical record (EMR) revealed R145 was admitted to the facility on [DATE], with pertinent diagnoses including but not limited to Alzheimer's disease, unspecified dementia, aphasia, expressive language disorder, depression, chronic obstructive pulmonary disease (COPD), anemia, gastroesophageal reflux disease (GERD), hyperlipidemia, chronic cough, overweight, disorders of the skin and subcutaneous tissue, and a history of falling. Review of R145's entry Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of R145's care plan dated 02/25/2026, documented a problem of cognitive impairment related to dementia and Alzheimer's disease and a history of falling with prior fractures. Goals included but not limited to maintaining safety and preventing injury or complications through the review period. Interventions included but not limited to monitoring the resident for changes in condition, providing appropriate supervision, and implementing safety measures as indicated for the resident's condition and risk factors. Observation on 03/02/2026 at 2:25 PM in room (A 12-B) belonging to R145 revealed a shaving razor located on the resident's windowsill. The razor was unsecured and accessible. Observation on 03/03/2026 at 12:24 PM, revealed a shaving razor remaining on the resident's windowsill now inside a clear plastic bag. Interview on 03/03/2026 at 5:21 PM with Licensed Practical Nurse (LPN) CC confirmed the presence of a shaving razor on the windowsill in room A 12-B and stated that it was not supposed to be in the room and should be stored in a designated area. LPN CC further stated that the razor would be removed because anyone could walk into the room, take it, and injure themselves. Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed items such as razors should not be left in resident rooms, particularly for residents on blood thinners, as this could result in serious injury. She indicated that staff are expected to remove unsafe items if observed and notify appropriate personnel. 2. Review of the EMR for R49 revealed diagnoses including but not limited to type two diabetes mellitus, acquired absence of right leg below knee, polyneuropathy, and dysphagia. Review of the quarterly Minimum Data Set (MDS) for R49 dated 01/06/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Review of R49's EMR revealed a physician order dated 06/13/2025 which stated Resident cannot walk or transfer with prosthetic on. Use sliding board with wheelchair to bed transfers. Do not go to the bathroom. Review of R49 care plan dated 02/25/2026, indicated that he has an alteration in musculoskeletal status related to right BKA (below knee amputation). Interventions included but not limited to anticipating and meeting needs. Be sure call light is within reach and respond promptly to all requests for assistance. Further review of R49's EMR revealed skin/wound note from 12/05/2025 documented WCN (wound care nurse) in to evaluate Left Upper Lateral Thigh Blister. Blister intact clear fluid sac. Area cleansed and betadine applied. No discomfort noted. Resident denies discomfort. Dry dressing applied loosely. Review of Facility Incident Report Form from 12/08/2025 documented details of incident: A blister was observed on the resident left out thigh. Resident stated that he was carrying his coffee cup in his wheelchair between his left thigh and the arm of the wheelchair when the burn occurred. Interview with R49 on 03/05/2026 at 11:40 AM revealed that on 12/05/2026, the resident received a cup of very hot coffee from a staff member. R49 stated that while sitting in a manual wheelchair, he needed to free his hands and placed the cup next to his left side. The resident reported that the coffee was extremely hot and had been served in a thin plastic cup that was not appropriate for holding hot liquids. Interview with the Administrator on 03/05/2026 at 1:50 PM revealed that he reported the incident to the State Agency after it was brought to his attention.

Based on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Personal Property, the facility failed to promote dignity by not exercising reasonable care and protection to prevent damage to the glasses for one resident (R) (R109) from a sample of 47 residents. The deficient practice had the potential to affect R109 from reaching the highest practicable level of function. Findings include:Review of the Personal Property policy dated 03/2023, documented the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.On 03/02/2026 at 10:50 AM, R109 was observed in bed wearing broken glasses. R109 showed the arm broken off one side of the glasses and demonstrated that a staff person broke the glasses when something was placed on top of them. R109 stated she informed the nurse when it happened a couple weeks ago and had not heard if they would be repaired or replaced. On 03/04/2026 at 8:55 AM, R109 was observed in bed, wearing glasses that were seated crooked on her face. R109 stated no one has given her any information about getting her glasses replaced/repaired. Record review revealed a physician order for R109 dated 07/16/2024, documented R109 could have ophthalmic (vision care) as needed.Record review of the admission Minimum Data Set (MDS) assessment dated [DATE], coded in Section B that R109 could see adequately and required corrective lenses. Section C coded that R109 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Section I coded for diagnoses including but not limited to cerebral vascular accident (stroke), and high blood pressure.Record review of R109s care plan initiated 10/22/2024, documented deliver newspaper, or other appropriate reading material, on a regular basis for resident's reading pleasure. The care plan did not specify R109 required glasses for reading.Record review of nursing progress note for R109 dated 02/22/2026 at 6:50 PM, documented resident requested for her brother to buy her new prescription glasses as a CNA {Certified Nursing Assistant} broke them when a meal tray was placed on top of the glasses, notified desk clerk to inform social services for eyeglass replacement.Record review of a follow up social service progress note by Social Service Assistant (SSA) SSA RR dated 02/24/2026 at 1:50 PM, documented received notice resident broke her glasses. Contacted her responsible party who is requesting vision services for R109 to have a new pair of glasses made for her and provided information on [3rd party provider] completed and submitted paperwork for resident to be added to next vision clinic.On 03/04/2026 at 10:30 AM during an interview, SSA RR stated the vision provider makes quarterly visits to the facility and were last here 02/09/2026. The SSA stated if they can't come before the next visit in May, R109 will have to wait. Glasses would take a week or so later to arrive after the vision appointment. He confirmed that it may be mid-May before R109's glasses would be repaired/replaced. On 03/04/2026 at 10:50 AM, licensed practical nurse (LPN) LPN MM stated social services has a list and dates of when vision providers are coming. They are unable to schedule an appointment without an additional order from the provider. There is no order in the system currently for R109 to have a vision appointment scheduled. On 03/04/2026 at 11:29 AM, the Director of Nursing (DON) stated the facility would not delay treatment to get service and confirmed R109's glasses were broken on 02/22/2026. The DON verified the CNA put the meal tray on the glasses and broke them. The DON also confirmed the facility would absorb the cost of the glasses replacement.

Based on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Program, the facility failed to ensure safety and freedom from an act of physical abuse for one resident (R) (R84) from a sample of three residents reviewed for abuse. The deficient practice had the potential to affect the quality of life and safety for other residents. Findings include:Review of the policy titled Preventions of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, revised 7/2025, section titled Policy documented, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Review of R84 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R84 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. Section GG: (Functional status,) revealed R1 has no impairment with upper/lower extremities benefits from the use of a wheelchair, Self-Care: range from all forms of physical assistance, and Mobility: Is independent in most areas can wheel independently in manual wheelchair.Interview with Licensed Practical Nurse (LPN) AAA on 03/05/2026 at 2:50 PM, stated on a Sunday at the end of the shift a CNA came running towards the nurses' station stating, he stabbed him, he stabbed him. The CNA stated R135 had a knife and stabbed R84. LPN AAA stated when he got down there, he saw the nurse (agency) come out of the room where the incident happened. LPN AAA stated R84 had a laceration that was bleeding, so gauze and pressure were applied to stabilize bleeding. LPN AAA stated he went into R135's room and R135 cane out of the bathroom that is shared. LPN AAA stated there was another resident who was bedbound in the room, so he made R135 sit down and relax while another staff member was calling 911 and knew law enforcement was on the way. R135 wanted to go back to the bathroom but LPN AAA stated he made sure R135 did not go to the bathroom. The police arrived and searched the room and could not find the weapon and went to the bathroom and the knife was in the toilet. Afterwards, LPN AAA called the Administrator who was already at the facility by the time he walked out of the room. R135 was arrested and R84 was sent to the hospital. LPN AAA revealed he made the necessary calls to the family of R84, does not believe R135 had a contact on the list of who to call. R135 was very independent and took care of self. LPN AAA stated he did not make calls to anyone else. He confirmed after the incident happened, the facility implemented checking residents in order to make sure the other residents were safe. He stated R135 was typically pleasant and nice and did not have any outburst that he could recall but was up and walking around. He stated R84 does have behavioral outburst.Phone interview on 03/05/2026 at 3:27 PM with the daughter of R84 revealed she was notified of the incident by a male nurse at the facility and was able to speak to the police officer. She stated the officers told her there was a resident who entered the room and cut her dad on his head and the perpetrator was removed from the facility and her dad was stable and the ambulance was at the facility to transport him to the hospital. The daughter stated she received daily updates from the Administrator when the resident returned back to the facility from the hospital and went over the plan of care and a safety plan. She stated the facility changed the entrance door code and the other resident was not allowed back into the facility. The daughter stated R84 was moved to another room and confirmed that anytime something happens with her dad the facility calls her no matter what time it happens. She does not have any issues with the treatment of the facility. Interview on 03/05/2026 at 5:17 PM with the Administrator revealed when he came into the facility, he was informed that there was a stabbing from resident to resident. The Administrator was able to speak to the police officer who let him know R135 was going to be handcuffed and taken with them to intake. The Administrator revealed he interviewed LPN AAA at that time but was unable to speak with the Agency Nurse. The Administrator stated he spoke to a CNA who no longer works in the facility and this CNA gave a statement that the bathroom door was locked and R135 was upset that he could not get in the bathroom. The Administrator stated he spoke with the Regional Nurse and told her what happened. In addition, he spoke with R84's daughter while he was on his way to the hospital via ambulance. The Administrator stated R135 was put in handcuffs and left with the police. He revealed R135 does not have family involved because he is his own responsible person. He stated R84 was referred to psych services, and he stayed in touch with R84s daughter. He confirmed abuse education was started at the time of the event.

Based on resident and staff interviews, record reviews, and review of the facility's policy titled Transfer of Discharge Notice, the facility failed to ensure two of two sampled residents (R) (R131 and R133) were provided with a written bed hold notice or reason for transfer at the time of transfer. This failure had the potential to place the resident or resident's representative at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility.Findings include:Review of the policy, Transfer or Discharge Notice, revised [DATE], documented Our facility shall provide a resident and/or the resident's representative a notice of transfer or discharge and the reason for the move in writing (Notice Form for Transfer or Discharge). 3. The resident and or representative will be notified in writing of the following information: the reason for the transfer or discharge; the effective date; the location to which the resident is being transferred or discharged ; a statement of the residents rights to appeal . the facility bed hold policy; the name, address, and telephone number of the Office of the State Long-term Care Ombudsman . 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. 5. The reasons for the transfer or discharge will be documented in the resident medical record. 1.Review of R131's clinical record revealed an admission date of [DATE], with diagnoses including, but not limited to, malignant neoplasm of colon, unspecified, anemia, ileostomy, diverticulitis, schizoaffective disorder, bipolar type, and schizophrenia.Review of R131's entry Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C: (Cognitive Patterns) Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Review of R131's Clinical Census revealed R131 was transferred to the hospital from the oncologist office on [DATE], and from the facility to the hospital on [DATE]. The bed hold expired [DATE], at which time billing was stopped. R131 was readmitted to the facility on [DATE].Review of R131's clinical record revealed no evidence of a notice of bed hold or reason for transfer provided to R131 on [DATE].Review of R131's electronic medical record (EMR) revealed Licensed Practical Nurse, (LPN) LL, documented on [DATE] at 8:00 PM, During shift change patient presents to hallway at med cart that she's in severe abdominal pain that start since last night and has progressively got worse. Patient has low-grade temp 100.9, chills, abdominal pain to R quadrant, pain upon palpitation, patient reports nausea and emesis x 1 after dinner. Patient reports a history of diverticulitis and had flare up in December. Covid test negative. Also documented at 8:13 PM, by LPN LL Received an order to send R131 to the emergency department. Sent by ambulance. The transfer note revealed no documentation that the bed hold policy was provided to R131 who was her own representative.2.Review of R133's clinical record revealed an admission date of [DATE], with diagnoses including but not limited to, chronic obstructive pulmonary disease and weakness. Review of R133's Clinical Census revealed R133 was discharged on [DATE]. R133's clinical record review revealed no evidence of a bed hold or if the bed hold policy was reviewed. There was no entry MDS completed, and no care plan had been developed at the time of discharge. Review of R133's clinical record revealed no evidence of a notice of bed hold or reason for transfer provided to R133 on [DATE].An interview with the Business Office Manager (BOM) on [DATE] at 1:35 PM confirmed through chart review there was no bed hold notice located and no note of any contact with R133 to inform him of the bed hold policy. An interview with LPN MM on [DATE] at10:39 AM, stated when a resident transfers they have to go with a bed hold policy. Two copies are made, one remains at the facility, and one is sent with the resident. LPN MM stated it is explained to residents that the bed hold policy is 48 hours, and we notify the responsible party of the facility rates after the bed hold expires. The copy is sent to the business office for them to follow up. LPN MM was unable to find a copy of the bed hold agreement in the record for either R131, or R133.During a follow up telephone interview, a representative from the Office of the State Long-term Care Ombudsman office stated there was no notification of discharge or transfer for either R131, or R133.

Based on record review, policy review, and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two of four residents (R) (R112 and R113) reviewed for elopement risk. This deficient practice had the potential to place R112 and R113 at increased risk of not receiving care and services according to their assessed needs. Findings include: Review of the policy titled Wandering, Unsafe Resident, dated 05/2023, documented Policy Interpretation and Implementation: 3. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering: a. Residents shall be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care team. B. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. C. The effectiveness of interventions shall be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 1. Review of the electronic medical record (EMR) revealed resident R113 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to Vascular Dementia, Mild, With Mood Disturbance, Psychotic Disturbance and Mood Disturbance, And Anxiety. Review of R113's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Section P: (Functional Status) coded for alarms not used. Review of R113's care plan dated 11/20/2024, documented a problem At risk for elopement and exhibits exit-seeking behavior. I have a wander guard. Goals included but not limited to I will not successfully elope the facility and will be monitored of my whereabouts on an ongoing basis through review date. Interventions included but not limited to observe me for 'tailgating' when visitors are in the building. provide direct staff supervision for me when attending an out of facility activity. Reassess elopement risk as least quarterly. Seek a referral for a mental health evaluation from primary care physician as needed. Use audible monitoring system to alert staff of exit seeking behaviors. Use diversional activities when exit-seeking behavior is occurring (offer food, activities, one on one, company). Review of the Physician's Orders for R113 revealed there was no evidence an order for the wander guard was written. Review of the document titled Wander Guard List, provided by the facility revealed R113 was on the list. Observation of R113 on 03/05/2026 at 3:00 PM revealed a wander guard bracelet applied around her ankle. Interview on 03/05/2026 at 4:22 PM with the Director of Nursing (DON), stated that for those residents who wander, an elopement assessment is completed to see if there is a need for a wander guard. The DON further stated for those residents who wander and attempt to exit seek, they may be a good candidate for the wander guard, and the social worker is the one who would make sure the assessment is completed as well as the doctor order in place. The DON added nursing is also able to complete the assessment. Interview on 03/05/2026 at 5:17 PM with the Administrator stated when it comes to having a doctor order for anything, the nurses should call the emergency line after hours once the Nurse Practitioners (NP) leaves the facility. Anytime they call a Medical Doctor (MD), the MD will call back in 15-20 minutes. If there is a problem staff have been instructed to let him know what is going on. There is a possibility of a negative effect on resident needs if there is no order to follow. 2. Review of the EMR revealed resident R112 was admitted to the facility on [DATE] and pertinent diagnoses included but were not limited to unspecified dementia, unspecified mood, major depressive disorder, anxiety disorder, other symptoms and signs involving appearance and behavior. Review of R112's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Section P: (Functional Status) coded for alarms not used. Review of R112 care plan dated 10/24/2025, documented a problem including wanderer and sometimes goes into other resident's rooms related to disoriented tplace. Interventions included but not limited to distracting resident from wandering, identify pattern of wandering and wander guard placement on 01/07/2026. Review of the Physician's Orders for R112 revealed there was no evidence an order for the wander guard was written. Review of the document titled Wander Guard List, provided by the facility revealed R112 was on the list. Observation of R112 on 03/02/2026 at 11:15 AM, revealed a wander guard bracelet applied around her ankle. Interview with MDS Coordinators LPN NN, and LPN OO on 03/05/2025 at 2:10 PM, confirmed that R112's quarterly MDS assessment and R113's quarterly MDS assessment were inaccurately coded in Section P. The MDS Coordinators acknowledged the coding errors and indicated that modifications would be completed to correct the assessments.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Administering Medications, Provision of Care, and Change in a Resident's Condition or Status, the facility failed to ensure that residents received care in accordance with physician orders and facility policy for five residents (R) (R47, R72, R106, R137, and R128) of 47 sampled residents. Specifically, the facility failed to: ensure a wound vac was applied and connected; ensure medications were administered by the nurse who pulled the medication; notify the physician of deviations from orders; accurately document medication administration; obtain resident weights as ordered; and provide timely pain medication. These deficient practices increased the risk of adverse clinical outcomes. Findings Include: Review of the facility's policy titled, Administering Medications, dated 2/2020 revealed that Medications shall be administered in a safe and timely manner, and as prescribed. Further review of item 4. The individual administering medications should check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Item 6. The individual administering the medication should document the administration on the eMAR. Review of the facility's policy titled, Provision of Care undated revealed that Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choices. Further review of item 3, The standards of care shall include person-centered care, clinical care standards, safety and prevention protocols, and accurate documentation. Item 5. Qualified persons shall provide care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. Review of the facility's policy titled, Change in a Resident's Condition or Status date 05/2023 revealed that Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Further review of item 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): f. refusal of treatment or medications. 1. Observation and interview on 3/4/2026 at 2:50 pm revealed Licensed Practical Nurse (LPN) EE handed a medicine cup containing pills to LPN FF, who was walking by in the hallway, and asked her to administer the medication to a resident in a specified room. During interview, LPN EE stated the medication in the cup was Tylenol and reported that she only hands medications to another nurse to administer in emergency situations. When asked to clarify the emergency at that time, LPN EE stated the surveyors were in the facility. Interview with LPN FF upon her return confirmed she administered the medication but did not know what medications were in the cup, as she was not the nurse who pulled the medication or verified the medication order prior to administration. 2. Review of the EMR revealed that R106 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, Type 2 Diabetes Mellitus (DM) with Diabetic Neuropathy, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD), and emphysema. Review of R106 quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating little to no cognitive impairment. Section GG: (Functional Status) indicated the resident required use of a wheelchair. Section N: (Medications), indicated the resident received insulin. Review of the Physician's Orders for R106 included but was not limited to: Order dated 09/18/2025 for Glipizide, give 1 tablet by mouth two times a day for DM Order dated 01/07/2026 for Fluticasone-Salmeterol, 1 inhalation inhale orally two times a day for COPD Review of the Medication Administration Record (MAR) for R106 revealed that LPN DD documented administration of Glipizide and Fluticasone at the scheduled 9:00 AM medication pass on 03/04/2026. However, these medications were not available in the facility and were not administered. Despite the medications not being available, LPN DD documented them as given on the MAR, resulting in inaccurate documentation. Interview on 03/04/2026 at 2:11 PM with LPN DD confirmed that she had documented administering R106's Glipizide and Fluticasone when the medications were not given. She stated, I will strike them out. I just corrected it. 3. Review of the EMR revealed that R47 was admitted to the facility on [DATE], with pertinent diagnoses including, but not limited to, other intervertebral disc degeneration-lumbar region, spinal stenosis-lumbar region without neurogenic claudication, intervertebral disc disorders with radiculopathy-lumbar region, Type 2 DM with Diabetic Polyneuropathy, and pain-unspecified. Review of R47 annual MDS assessment dated [DATE], revealed a BIMS score of 14, indicating little to no cognitive impairment. Section GG: (Functional Status), revealed that R47 required partial to moderate assistance with activities of daily living and used a walker. Section N: (Medications), indicated R47 received antidepressant, opioid, and anticonvulsant medications. Section J: (Health Conditions) reflected that R47 received pain medication, with pain present occasionally at a moderate intensity. Review of R47 care plan, revised 01/14/2026, indicated a problem of pain management related to chronic conditions, including back pain from disc degeneration and lumbar spinal stenosis and neuropathic pain. Goals included but were not limited to reducing the impact of pain on daily life, achieving adequate pain relief or the ability to cope with partially relieved pain, and preventing adverse reactions to opioid or anticonvulsant medications. Interventions included but were not limited to administering opioid and anticonvulsant medications as ordered, monitoring and documenting side effects and reporting them to the physician, assessing pain levels and medication effectiveness, responding promptly to complaints of pain, and observing and reporting changes in functional ability, sleep patterns, or resistance to care. Review of the Physician's Orders for R47 included but was not limited to: Order dated 12/9/2025 for Tramadol HCL oral tablet 50 mg, give 1 tablet by mouth as needed for pain (5-10) may have between 1pm-5pm Order dated 1/20/2026 for Tramadol HCL oral tablet 50 mg, give 1 tablet by mouth two times a day for pain Order dated 3/3/2026 for Tramadol HCL oral tablet 50 mg, give 1 tablet by mouth as needed for pain (4-8) 1 tab prn pain between 1300-1700 Review of R47's controlled substance records and physician orders revealed that the PRN Tramadol HCL 50 mg order dated 12/09/2025 expired on 01/23/2026, leaving a six-week gap during which no refill was obtained until a new order was placed on 03/03/2026. Observation and interview on 3/2/2026 at 2:02 pm with R47 and daughter who was on the phone at the time, revealed that R47 has been having issues with her pain medications, many times they have run out and there have been re-ordering delays. Additionally, they stopped giving her the prn pain medication even when she asks for it and does not know why. Interview on 3/3/2026 with LPN CC revealed that R47 did not have the PRN Tramadol in the medication cart and did not know when it had run out. 4. Review of the EMR revealed that R137 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, unspecified severe protein-calorie malnutrition, adult failure to thrive, unspecified dementia, altered mental status-unspecified, and depression. Review of R137 comprehensive MDS assessment dated [DATE] revealed BIMS was not completed. The Staff Assessment for Mental Status indicated short and long-term memory problems, inability to recall usual information, and severe impairment in daily decision-making, demonstrating that R137 had severe cognitive impairment. Section GG, functional status, revealed that R137 was fully dependent on staff for all activities of daily living, including eating, hygiene, dressing, and transfers. Mobility was also fully dependent, with transfers and bed mobility not attempted due to medical or safety concerns. Functional limitations were noted in both lower extremities, while upper extremities had no impairment. Section K, swallowing/nutritional status, revealed no signs of a swallowing disorder. R137 was 63 inches tall and weighed 92 pounds, requiring a mechanically altered diet (pureed or thickened foods). Review of the Care Area Assessment (CAA) on the comprehensive MDS dated [DATE] indicated R137 was identified with cognitive loss/dementia, communication impairment, urinary incontinence/indwelling catheter, falls, nutritional status issues, dehydration/fluid maintenance needs, pressure ulcer risk, and psychotropic drug use. Review of R137 care plan, dated 11/05/2025 indicated a problem of nutritional deficits and risk for significant weight changes related to UTI (Urinary Tract Infection), dementia, epilepsy, and adult failure to thrive. Goals included but were not limited to maintaining stable weight, preventing further malnutrition, and ensuring adequate intake and hydration. Interventions included but were not limited to monitoring and documenting weight, observing and reporting signs of malnutrition, monthly and as-needed weights, dietitian evaluation and recommendations, and promoting adequate hydration and nutrition. Review of the Physician's Orders for R137 included but was not limited to: Order dated 11/05/2025 for Weights: Weekly one time a day every Wed for 3 Weeks screening x3 Order dated 11/09/2025 for Weekly weights x 3 weeks every day shift every Sun for monitoring for 3 Days Review of R137 weight monitoring revealed underweight status with a BMI of 16.5. Recorded weights were 91.6 lbs on 11/5/2025 and 93.1 lbs on 11/16/2025. Missed weights were noted on 11/9/2025, 11/12/2025, 11/19/2025, and 11/23/2025. No weights were documented between 11/16/2025 and 11/27/2025. The resident presented to the emergency department on 11/27/2025 with a weight of 76 lbs, reflecting a total weight loss of approximately 17 lbs since the last recorded weight on 11/16/2025. Interview on 03/03/2025 at 3:36 PM with Unit Manager LPN BB revealed that weights are obtained on admission for a baseline, then on days 1, 2, and 3, followed by weekly weights for three weeks, and then monthly thereafter, usually on the first of the month. LPN BB stated that she did not notice R137 sustaining any weight loss. Interview on 03/05/2026 at 2:26 PM with Unit Manager LPN MM revealed that she is responsible for monitoring resident weights, entering the orders, and ensuring weights are obtained monthly, typically before the 10th of the month, and recorded in her weight tracking log. She explained that during SOC (Patients at Risk) meetings, weight trends are reviewed to identify residents who may need appetite stimulants or other interventions. LPN MM confirmed that R137 did not have her weight checked for over a week, resulting in a missed weight. She noted that weights are not always obtained consistently due to staffing challenges, as only two staff members are trained to obtain weights and agency staff are unable to perform them. Interview on 03/05/2026 at 11:05 AM with Director of Nursing (DON) revealed that staff are expected to follow physician orders and facility policies when providing care and administering medications. If medication is not available, staff should first contact the pharmacy to follow up on the refill, and if the issue is not resolved, they must notify the Unit Manager, DON, and physician for further direction. The DON emphasized that nurses must only administer medications they are familiar with and have prepared themselves; medications should not be handed off to another nurse, as improper administration could result in adverse outcomes. Regarding respiratory care, staff are expected to document the resident's preferences, perform assessments, and notify the in-house NP as needed, who then determines whether a weaning process is appropriate or if therapy should be changed to PRN, with all assessments and communications thoroughly documented. The DON also stated that weights must be obtained as ordered, particularly for new admissions, to establish baseline measurements. Accurate weights are essential for identifying changes in a resident's condition, including potential disease processes or nutritional decline. A follow-up interview at 12:32 PM, the DON further stressed that timely and accurate documentation of medication administration as they are administered is critical, as delays or inaccurate recall of medication administration can negatively impact clinical outcomes. 5. R72 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, type 2 diabetes mellitus with other diabetic neurological complications and long-term use of insulin. Record review of the physician orders for medications included Jardiance 10 mg once daily for diabetes with a start date of 08/26/2025; Metformin HCL extended release 500 mg twice daily for diabetes with a start date of 10/30/2025; Lantus Solostar 10 units inject subcutaneously at bedtime for diabetes. AccuChecks (blood sugar checks) were ordered to be checked before every meal and at bedtime, with a start date of 03/25/2025. R72's Care plan noted Type 2 diabetes with long term use of insulin initiated 09/23/2022, and last revised on 10/05/2023. Record review of R72's blood sugar record showed blood sugars being checked once daily at bedtime. There was no record of blood sugar checks before meals as ordered by the physician. On 03/05/2026 at 2:21 PM, LPN MM stated R72 has a physician order to check blood sugar before meals and at bedtime. LPN MM verified blood sugars being checked once daily at bedtime. She stated she needed to clarify the order with hospice, currently it looks like they are not doing what is ordered. On 03/05/2026 at 2:32 PM, during a joint interview the DON and Regional nurse consultant (RNC), stated if a resident had orders for accuchecks {fingerstick blood sugar} before meals and at bedtime, they should be checked according to that order. On 03/05/2026 at 2:45 PM, The nurse practitioner (NP) stated during a telephone interview if there were active orders she would expect them to be followed, if not she would expect the nurse to notify the provider. On 03/05/2026 at 3:40 PM, during a follow up interview the RNC stated she contacted hospice and was told the resident no longer needed before meals and at bedtime, and they would fax over an order for blood sugars to be checked at bedtime. She stated she felt the order was initially entered incorrectly in the electronic health record. 6.Resident (R) 128 was admitted to the facility on [DATE]. R128's diagnoses included Acute osteomyelitis, left ankle and foot. (infection of the bone). R128 was admitted to the facility with a wound vac medical device which used controlled suction to pull fluid and infection away from a wound to help the wound heal. Clinical record review of the physician order dated 02/28/2026 included monitor wound vac dressing site every shift for intact seal, proper suction, function drainage output, and signs of infection. Ensure VAC is functioning properly and dressing remains intact. Suction set to 100mmHg. Notify provider of any abnormal findings. If vac suction is lost and cannot be patched, remove vac dressing and resume wet to dry dressing utilizing moistened gauze with quarter strength Dakin's to wound bed cover with ABD dressing, secure with tape, notify WCN. Additionally, cleanse left foot hell surgical wound bed with ns/wc {normal saline or wound cleanser] or equivalent. Apply black foam to wound. Seal and apply wound vac. Set suction to 100 mm/Hg. Change [wound vac] dressing every day shift Tuesday and Friday. R128's care plan did not specify any focus, goal or interventions related to the wound vac device, monitoring or dressing changes. Record review of the medication administration/treatment administration record for February and March 2026 showed two entries to monitor the wound vac. One entry specified wound suction to be set at 100mmHg. The second entry noted to monitor wound vac suction set to 125mmHg. Record review of a nursing progress note dated 03/02/2026 at 16:47 PM, documented resident currently has wound vac in place. On 03/02/2026 at 3:35 PM, R128 stated the wound vac was placed at the hospital and it was supposed to be on until she followed up with the podiatry surgeon. R128 stated staff took the wound vac off but she did not know why because it seemed to be working well. She stated it had not alarmed and the dressing was in place. The wound vac was observed disconnected, sitting on the bedside table. On 30/03/2026 at 8:20 AM, The wound vac was observed still sitting on the bedside table. R128 stated wound vac taken off yesterday and the nurse said they were waiting to hear back from the podiatrist to determine if the wound vac needed to remain on. On 03/03/2026 at 1:38 PM, during an interview R128 stated there had not been any wound care done yet today to R128's foot. The wound vac machine was observed not connected and remained on the bedside table. 03/03/2026 1:45 PM, During an interview LPN YY stated she was assigned to R128. LPN YY was not aware the wound vac was not on or connected. She verified there were no orders for the wound vac to be off or on hold. She verified there were no new dressing change orders, and stated, I don't know why it's off. I was not aware that it was off. I don't see any order for it to be off. Nurse confirmed wound vac was not on or connected to the resident. On 03/03/2026 at 2:39 PM, during an interview, LPN AA stated he removed the wound vac on 03/02/2026 for the NP to take pictures of the wound to send to the podiatrist. The resident was discharged from the hospital following left calcaneal surgery and came to the facility with the wound vac. LPN AA stated there was no order to discontinue or hold the wound vac and that it had been disconnected for about 24 hours. LPN AA stated he was busy making rounds yesterday and did not put it back on but would put it back on today. 03/05/2026 at 2:45 PM, The nurse practitioner (NP) stated during a telephone interview if there were active orders she would expect them to be followed, if not she would expect the nurse to notify the provider

Based on observations, staff interviews, and review of the facility's policy titled Food-Related Garbage and Refuse Disposal, the facility failed to ensure that the area around the dumpster was free from garbage and refuse. This deficient practice had the potential to attract pest. The facility census was 135. Findings include: Review of the facility policy titled Food-Related Garbage and Refuse Disposal with a revision date of October 2017, revealed that garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pets. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 1/31/2025 at 8:30am during the initial tour of the kitchen with [NAME] II revealed, that the area around the dumpster contained garbage and refuse on the ground. Interview on 1/31/2025 at 8:40 am with [NAME] II revealed, that when the dumpster got too full, they must open the lid, so that they could make more room for garbage. [NAME] II revealed that when the lids were open, the wind would blow garbage out of the dumpster onto the ground behind it. Observation on 1/31/2025 at 11:05 am revealed, staff cleaning the garbage and refuse from the area around the dumpster that contained garbage and refuse on the ground. Observation on 1/31/2025 at 1:25 pm with the Registered Dietitian and the Regional Nurse Consultant revealed, the garbage and refuse had been picked up and the area was noted to be clean.

Based on staff interviews, record review, and review of the facility's policy titled Competency of Nursing Staff, the facility failed to conduct annual performance reviews to ensure competency for the Certified Nursing Assistants (CNAs) employed by the facility. The census was 135. Findings include: Review of the undated facility's policy titled Competency of Nursing Staff revealed the Policy Statement: Licensed nurses and nursing assistants employed by the facility will participate in facility-specific, competency - based staff development and training program and demonstrate competencies and skill sets necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care. Policy Interpretation and Implementation: Number 5. Facility and resident specific competency evaluations will be conducted upon hire, annually, and as deemed necessary. Number 7. Competency demonstrations will be evaluated based on staff members ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge. Number 8. Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or the Personnel Director. Review of the facility's Staff Development Review dated 8/23/2024 completed by [name of auditor] revealed 17 Certified Nurses Aides on staff at the facility. Review of the Certified Nursing Assistant (CNA) training hours revealed that the sampled selection of CNA's (CNA LL, CNA MM, CNA NN) met the State in-service requirements for the year. However, when asked for the yearly competency evaluations for the sampled CNA's, the facility was unable to provide the documents requested. Review of the Job Description and Performance Evaluation provided by the facility for CNA MM, revealed she was hired on 6/15/2004 and the evaluation was dated 6/15/2005. There were no other evaluations provided for CNA MM. There was no evidence that performance evaluations were completed since for CNA LL with hire date of 6/17/2018 and CNA NN with hire date of 6/19/2017. Interview on 2/2/2025 at 2:19 pm, Director of Human Resources and Payroll stated that in the four years that she has been employed at the facility, there have not been any competency evaluations completed on any of the CNA's. During Further interview, she stated that the completion of the yearly competency evaluations is the responsibility of the Director of Nursing (DON). Interview on 2/2/2025 at 2:22 pm, with Regional Nurse Consultant (RNC) BB, stated the facility has had high turnover rates for the DON position, and stated that the other healthcare facilities in the area make it hard to keep a DON. She stated the current DON is new to the position, and the facility would work on completing competency evaluations for the nursing staff.

Based on observations, staff interviews, and review of the facility's policy titled Food and Nutrition Services, and review of the facility document titled [Name of supply company] TELS (The Equipment Lifecycle System) Ice Machines Preventative Maintenance, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure foods were not left open to air, label and date opened and unopened foods in addition to, serving cold fruit at 68 degrees Fahrenheit (F). Also, the facility failed to ensure that one of two ice machines was clean and sanitary as evidenced by one ice machine had discoloration on the inside middle part of the machine. This deficient practice had the potential to cause a diminished quality of life for 132 out of 135 residents receiving an oral diet. Findings include: Review of the facility's undated policy titled Food and Nutrition Services revealed, that foods that are left without a source of heat for hot foods or refrigeration for cold foods longer than (2) two hours will be discarded. Review of the facility document titled [Name of supply company] TELS: Ice Machines Preventative Maintenance under the section titled Sanitize Interior revealed, 1. Sanitize interior of ice machine per manufacturer's instructions. 2. Clean out and sanitize the ice bin. 1. Observation on 1/31/2025 at 8:15 am during the initial tour of the kitchen revealed, the following: -An open bag of breaded chicken patties in the walk-in freezer with no open date that was left open to air. -An open box of sweet potato pie with no open or discard date and that was left open to air. -A container of peaches in the walk-in cooler covered with saran wrap with a date of 1/30/2025. -A metal container of cole slaw covered with saran wrap dated 1/28/2025 - 1/30/2025. -Two bags of cheese (one Parmesan and one cheddar) were not labeled without a receive or discard date. -Five packages of sliced cheese were not labeled without a received or discard date. -Ground pepper, granulated onion, chicken seasoning, cinnamon, [name] seasoning salt, and Parsley flakes, were opened, and were not labeled with an open date. Observation and interview on 1/31/2025 at 8:45am during the follow up tour of the kitchen with [NAME] II confirmed the following: -An open bag of breaded chicken patties in the walk-in freezer with no open date that was left open to air. -An open box of sweet potato pie with no open or discard date and that was left open to air. Cook II stated, I didn't even know anything about that. -A metal container of cole slaw covered with saran wrap dated 1/28/2025 - 1/30/2025. Cook II stated, I was supposed to get rid of that yesterday, when I did the dishes, and I forgot to pull it out. -A container of peaches in the walk-in cooler covered with saran wrap with a date of 1/30/2025. [NAME] II stated, I will take care of that. - Two bags of cheese (one Parmesan and one cheddar) were not labeled without a receive or discard date and five packages of sliced cheese were not labeled without a received or discard date. [NAME] II, verified that they were not labeled. -Ground pepper, granulated onion, chicken seasoning, cinnamon, [name] seasoning salt, and Parsley flakes, were opened, and were not labeled with an open date. [NAME] II stated, I just opened and used them today. I didn't have time to label them. 2. Observation on 2/1/2025 at 12:10 pm in the kitchen of the mid-day meal preparation revealed, [NAME] II was observed preparing pureed food. Before serving the meal trays, the food temperatures were collected which revealed, the apples topped with cinnamon temperature was 68 degrees F. The fruit was then pre-served in bowls, covered with saran wrap, and placed on a metal tray. Interview on 2/1/2025 at 12:13 pm revealed, [NAME] II was asked if the fruit was to be served at that temperature. She stated, no it is not. Interview on 2/1/2025 at 2:05 pm revealed, The Regional Dietary Manager was asked if the fruit was served at the correct temperature of 68 degrees F and he stated, probably not. 3. Observation on 1/31/2025 at 8:21 am during the initial tour of the facility's kitchen revealed, that the kitchen ice machine had discoloration on the inside middle part of the ice machine. Observation and Interview on 1/31/2025 at 8:25 am of the ice machine with [NAME] II confirmed the inside middle part of the ice machine had discoloration. [NAME] II stated, it was the responsibility of the Maintenance department to clean it.

Based on observations, staff interviews, record review, review of the facility's policy titled Maintenance Service, and review of documents titled [Name of supply company] TELS (The Equipment Lifecycle System), the facility failed to provide a safe, clean, comfortable, homelike environment related to dirty filters in the Packaged Terminal Air Conditioner (PTAC) units, walls in disrepair and missing paint, missing chair rail, and missing/falling ceiling tiles for nine resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on three of four halls (B,C, and D halls) and falling ceiling tiles the kitchen. The deficient practice had the potential to place the residents at risk for accidents and hazards and diminished quality of life. The facility's census was 135. Findings include: Review of the facility's undated policy titled Maintenance Service revealed, the Policy Statement was Maintenance service shall be provided to all areas of the building, grounds, and equipment. The section titled Policy Interpretation and Implementation revealed under number two Functions of maintenance personnel include but are not limited to: b. Maintaining the building in good repair and free from hazards and d. maintaining the heat/cooling system . Review of the document titled [Name of supply company] TELS under the section titled Recommended Schedule revealed, the cleaning schedule for the PTAC filter was every three months. Review of the TELS task titled Inspect exhaust fans for proper operation and clean if necessary revealed, that the vents are to be clean using a vacuum and air compressor, when needed to remove all dust. Staff are to ensure that air flow is sufficient to hold a piece of paper to the vent when operating. 1. Review of the maintenance Logbook Documentation revealed, that the PTAC clean air filters were marked as done on September 30, 2024, October 31, 2024, November 29, 2024, and December 26, 2024. Observations conducted on 1/31/2025 on the C-Hall revealed: At 8:53 am in room [ROOM NUMBER] the PTAC filters were covered in a gray fuzzy substance. At 9:31 am in room [ROOM NUMBER] the PTAC filters were covered in a gray fuzzy substance. At 9:50 am in room [ROOM NUMBER] the PTAC filters were covered in a gray fuzzy substance. The wallpaper behind the headboards of all three beds were peeling away from the wall, and the chair rail behind bed C was missing. At 10:46 am in room [ROOM NUMBER] the PTAC filters were covered with a thick fuzzy. Observations conducted on 2/2/2025 on the C-Hall revealed: At 8:57 am in room [ROOM NUMBER] the PTAC filters were covered with a gray fuzzy substance. At 9:04 am in room [ROOM NUMBER] the PTAC filters were covered with a gray fuzzy substance. At 9:05 am in room [ROOM NUMBER] the wall paper behind bed A and C was peeling away from the wall, the chair rail was missing behind bed C, and PTAC filters were covered with a gray, fuzzy substance. At 9:07 am in room [ROOM NUMBER] the PTAC filters were covered with a thick, gray, fuzzy substance. Observations on 2/2/2025 at 9:47 am rounds made with the Corporate Maintenance Director and the Administrator in Absence (AIA), FF revealed, room [ROOM NUMBER] - PTAC filters were covered with were covered with a thick gray substance. room [ROOM NUMBER] - PTAC filters were covered with a fuzzy gray substance. room [ROOM NUMBER] - PTAC filters were covered with a layer of fuzzy gray substance, the wallpaper behind bed A and C was not attached to the wall, and the chair rail was missing behind bed C. room [ROOM NUMBER] - PTAC filters were covered with a thick gray fuzzy substance. Interview on 2/2/2025 at 9:47 am with the Corporate Maintenance Director and AIA, FF, both confirmed and verified all observations made of rooms 40, 44, 45, and 48. The Corporate Maintenance Director revealed his expectation was that the PTAC filters would be cleaned monthly and documented on the checklist found in the TELs system and the expectation was that the building would be maintained in good repair in a timely manner, he stated wall paper should not be left peeling away from the wall and the missing chair rail should be repaired. 46579 2. Observations conducted on 1/31/2025 on the B Hall revealed: At 10:37 am in room [ROOM NUMBER] the front of the PTAC was falling off and was missing paint noted behind the C-bed. There was missing paint and part of baseboard also falling off of the wall, next to the window. In the shared bathroom of 27 and 29, there was a missing ceiling tile noted, and a greyish substance on the vent cover. At 11:24 am in room [ROOM NUMBER] both PTAC filters were covered with a grayish substance. The wall around the PTAC was white, as if it was repaired and did not match the color of the bedroom wall. At 11:39 am in the shared bathroom for 31 and 33 there were gaps in two of the ceiling tiles and the vent cover was noted to have a greyish substance on it. At 11:45 am in room [ROOM NUMBER] the area of the wall, that was white, appeared to have been repaired, did not match the room wall paint color Observations conducted on 2/1/2025 on the D Hall and the kitchen revealed: At 8:33 am in room [ROOM NUMBER] the ceiling tile was hanging down. At 12:10 pm in the kitchen three ceiling tiles in kitchen were falling or had gaps. Observations conducted on 2/2/2025 at 2:54 pm with the Regional Maintenance Director, Housekeeping and AIA, FF the following concerns were confirmed and verified all of the findings for B and D Halls and the Kitchen.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plan, Comprehensive Person Centered, the facility failed to develop and implement care plans for four of 42 (R) (R84, R50, R20, and R90) sampled residents. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Care Plan, Comprehensive Person Centered with a revision date of September 2023 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of the physician orders revealed that R84 was to receive but was not limited to docusate sodium (a stool softener), and acetaminophen. Review of the nurse's progress notes revealed that on more than one occasion between the dates of 1/18/2025 and 1/31/2025, the resident refused medications that included Colace (docusate sodium- a stool softener). Review of the care plan revealed no mention of R84 refusing medications as a behavior on the care plan. Interview on 2/2/2025 at 10:30 am with Licensed Practical Nurse /Unit Manager (LPN/UM) HH revealed that R84 does refuse medication. She stated that if she refused regularly, then the nurse should be documenting and then they should let the providers know. She then stated that it should then be care planned as a behavior, if it was something that continued. Interview on 2/2/2025 at 10:40 am with Minimum Data Set (MDS) LPN JJ and MDS LPN KK, they verified that if the resident refused medications, especially if it occurred more often, then it would need to be addressed and added to the care plan as a behavior. They were to be notified if it was documented, and it would be changed during the clinical meetings. It was verified that it was not on the care plan. Interview on 2/2/2025 at 11:18 am with the Director of Nursing (DON), she revealed that it was her expectation that if a resident refused medications, the resident representative and the medical provider would be notified of the behavior. When the medical provider was notified, they could make the decision to place the medication on hold or be discontinued. She then stated that it would need to be documented in a progress note and then care planned as a behavior. We would also need to try and find out the reason for refusing the medication. 2. Observation on 1/31/2025 at 11:02 am, R50 was observed laying in her bed. She had facial hair on the right side of her chin. The surveyor asked her if she had asked staff to help her with it, and she stated that she has, and no one would come in and help her. On 2/1/2025 at 9:15 am, R50 was observed laying in the bed with her eyes closed. She was still noted to have facial hair on the right side of her chin. Review of the care plan for R50 revealed that she had an ADL (activities of daily living) deficit and cognitive deficit, having trouble in performing tasks of daily living such as dressing, bathing, toileting, and bed mobility. There were no interventions added for personal hygiene. Interview on 2/2/2025 at 10:30 am with Licensed Practical Nurse /Unit Manager HH, she stated that if a female resident had facial hair, that it needed to be taken care of. If it was refused, then it needed to be documented. If a resident refused care frequently, then it would need to be documented, responsible party notified, and care planned as a behavior. Interview on 2/2/2025 at 11:32 am with the DON, she stated that if something needed to be added to the care plan that it should be added to the task list, so that it was a reminder for them to do it. 38988 3. Review of the resident's admission MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Section GG revealed that the resident was assessed for moderate assistance for dressing and personal hygiene. Review of the care plan for R20, dated 1/9/2025, revealed resident has self-care deficit experiencing difficulty in performing tasks of ADLs. Interventions to care include assist with dressing/undressing as needed, 1-2-person assistance with transfers and use consistent routines and allow adequate time to complete tasks. Observation on 1/31/2025 at 9:54 am, R20 was dressed and sitting up in her bed. Her hair appeared to be oily and disheveled. She stated at this time that she had not received any type of bath since she was admitted to the facility. Observations on 2/1/2025 at 8:47 am and 5:03 pm and 2/2/2025 at 9:20 am, R20's hair remained oily and fingernails on both hands were long with brown dirty substance underneath the nails. 4. A review of the clinical record for R90 revealed he was admitted to the facility on [DATE] with diagnoses including infection of amputated right stump, peripheral vascular disease (PVD), diabetes, HTN, dementia, anxiety, and depression. Review of the R90's annual MDS assessment dated [DATE], revealed BIMS was coded as 13, which indicated no cognitive impairment. Section GG revealed that the resident requires maximum assistance for ADL's. Review of the care plan for R90, dated 4/9/2024, revealed resident has ADL deficit/self-care deficit related to muscle weakness, acute illness, musculoskeletal problems, impaired cognition, and cardiovascular problem. Interventions to care include assist with dressing/undressing as needed, 1-2-person assistance with transfers. Observation on 2/1/2025 at 9:55 am, R90 lying in bed awake. His fingernails are long and dirty. He stated at this time that he would like for someone to cut them for him. Observation on 2/1/2025 at 4:57 pm, revealed R90 sitting in wheelchair at bedside awaiting dinner to be served. Fingernails remain dirty and long. Observation on 2/2/2025 at 9:08 am, R90 lying in bed. Fingernails remain dirty.

Based on staff interviews, record review, and review of the facility's policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, the facility failed to ensure one of one resident (R) (R99) reviewed with a serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R99. Findings include: A review of the facility's undated policy titled Resident Assessment-Coordination with PASARR Program revealed the Policy was The center coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy explanation and Implementation section included . 8. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. A review of the Electronic Medical Record (EMR) revealed R99 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Post Traumatic Stress Disorder (PTSD), depression, and anxiety. A review of the Admission Minimum Data Set (MDS) dated [DATE] revealed, Section A (Identification Information) documented the resident was not currently considered by the State Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I (Active Diagnoses) documented PTSD, depression, and anxiety. A review of the EMR revealed a PASRR Level I request dated 12/20/2022 without PTSD, depression, or anxiety marked on the form. A further review revealed no re-submission for a PASARR Level I after R34 was admitted to the facility and no PASARR Level II. In an interview on 2/1/2025 at 11:30 am, the Social Services Director (SSD) stated when a resident was admitted to the facility, the PASRR Level I had been submitted by the referring hospital, the results went to the facility's central admissions office, and then to the facility to be scanned into the medical record. She stated she was unsure who was responsible for ensuring the diagnoses on the PASSR Level I were accurate when a resident was admitted to the facility or for re-submission for a PASRR evaluation. In an interview on 2/1/2025 at 11:50 am, the Director of Nursing (DON) verified there was no PASSR Level II for R99. She further verified that R99's PASRR Level I, dated 12/20/2025, did not contain the resident's diagnoses of PTSD, depression, and anxiety. She stated she was unsure who was responsible for ensuring the diagnoses on the PASSR Level I were accurate upon admission to the facility. She further stated the diagnoses on the PASSR Level I submission should be accurate in order to ensure the resident's needs are met.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 42 sampled residents (R) (R20, R90, and R50) related to showers, nail care, and shaving of facial hair. This failure placed R20, R90, and R50 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's undated policy titled Activities of Daily Living (ADLs) revealed the Policy Statement included, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The Policy Interpretation and Implementation section included . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . d. Dining (meals and snacks). 1. A review of the clinical record for R20 revealed that the resident was admitted to the facility on [DATE] with diagnoses including skin infection, diabetes, hypertension (HTN), hyperlipidemia, stage 4 kidney disease, coronary artery disease (CAD), and asthma. Review of the resident's Admission Minimum Data Set (MDS) assessment, dated 1/9/2025, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident required substantial/maximal assistance with shower/bath and partial/moderate assistance with personal hygiene. Review of the undated document provided by the facility titled Shower Sheet: Shift 3:00 pm - 11:00 pm indicated that R20 was to receive showers on Monday and Thursday on the 3:00 - 11:00 pm shift. Observation on 1/31/2025 at 9:54 am revealed R20 was dressed and sitting up in her bed. Her hair appeared to be oily and disheveled. During an interview with R20, she stated she had not received any type of bath since she was admitted to the facility. Observation on 2/1/2025 at 8:47 am and 5:03 pm and 2/2/2025 at 9:20 am revealed that R20's hair remained oily, and her fingernails on both hands were long with a brown substance underneath the nails. In an interview on 2/1/2025 at 8:47 am, R20 stated she hadn't had a bath in three weeks. She stated she could bathe herself if someone would set her up with a bucket of water and some soap. She stated the first shift was just too busy to give her a bath, and the second shift was unhelpful when you asked them for anything. In an interview on 2/2/2025 at 11:12 am, Certified Nursing Assistant (CNA) AA stated that residents were bathed/showered two times per week, and nail care should be done with every bath/shower. She further stated that she asked the residents about washing their hair because some residents get their hair done at the beauty shop. 2. A review of the clinical record for R90 revealed diagnoses including infection of amputated right stump, peripheral vascular disease (PVD), diabetes, HTN, dementia, anxiety, and depression. Review of R90's Annual MDS assessment, dated 12/12/2024, revealed section C (Cognitive Patterns) documented a BIMS of 13 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident requires substantial/maximal assistance for personal hygiene. Observation on 2/1/2025 at 9:55 am revealed R90 lying in bed. Further observation revealed his fingernails were long and dirty. In an interview, R90 stated he would like someone to cut his fingernails. Observation on 2/1/2025 at 4:57 pm revealed R90 sitting in a wheelchair at his bedside, waiting for his dinner to be served. Observation revealed his fingernails remain dirty and long. Observation on 2/2/2025 at 9:08 am revealed R90's fingernails remained dirty. In an interview on 2/2/2025 at 2:00 pm, Licensed Practical Nurse (LPN) Unit Manager (UM) HH stated that nail care should be performed on the days the residents were scheduled for showers and as needed. In an interview on 2/2/2025 at 2:26 pm, CNA CC stated that residents are not allowed to self-bath with a basin of water. She stated they either received a bed bath or shower. She stated that residents could get a bath when they requested. She stated she had not noticed R20's fingernails were long and dirty. She confirmed that R20's nails were dirty and stated she would ask the next shift to assist her with a bath. 46579 3. Review of R50's EMR revealed diagnoses including chronic obstructive pulmonary disease (COPD), dementia, and anxiety. Review of the Quarterly MDS, dated [DATE], revealed section C (Cognitive Patterns) documented a BIMS of 8 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that R50 required partial/moderate assistance for personal hygiene. Observation on 1/31/2025 at 11:02 am revealed R50 had facial hair on the right side of her chin. She stated she had asked staff to help her remove it, and no one would help her. Observation on 2/1/2025 at 9:15 am revealed R50 with continued facial hair on the right side of her chin. In an interview on 2/2/2025 at 10:39 am, CNA LL stated R50 had never refused to ADL care with her. In an interview on 2/2/2025 at 11:32 am, the DON stated if facial hair was noted, the CNA should ask the resident if they wanted it removed.

Based on observations, staff interviews and review of the facility's policy titled Laundry Operations Manual, the facility failed to ensure the soiled linen hampers located in the hallways of the facility, were emptied immediately when full. This failure has the potential to impact 71of 128 residents residing on the A and C Halls. Findings include: Review of the facility's policy titled, Laundry Operation Manual, revised in January 2022, under the section titled Sorting Soiled Linens revealed, Treat all soiled linen as if it were potentially infectious-never treat soiled linen different simply if it does not look dirty and Keep soiled linen covered at all times. During the initial tour of the facility, it was revealed that the facility had four halls, A, B, C and D. Each hall had had two or three soiled linen hampers in the hallways. During an observation on 10/30/2024 at 9:49 am, one soiled linen hamper on the C hall was observed to be full and overflowing as the lid to the hamper was left ajar. During an observation on 11/5/2024 at 11:55 am, two soiled linen hampers were observed overflowing on the A hall. One of these soiled linen hampers was observed in front of a resident's room, however there was no Certified Nursing Assistant (CNA) providing patient care in that room. During an observation on 11/5/2024 at 11:57 am, one soiled linen hamper was overflowing on the C hall. During an observation on 11/5/2024 at 11:58 am, the Regional Nurse Consultant (RNC) alerted a facility staff to empty the overflowing cart on the A hall. In an interview on 11/5/2024 at 12:12 pm, the Housekeeping Director revealed the soiled linen hampers were emptied by the CNAs at least every two hours. The Housekeeping Director further revealed that the hampers were moved outside during mealtimes. Interview on 11/5/2024 at 12:25 pm, CNA UU revealed, the CNAs were responsible for emptying the soiled linen hampers when they were full and to take them outside during mealtime. In an interview on 11/5/2024 at 12:30 pm the RNC stated the soiled linen hamper being emptied when full had been a pain point, they continued to address. In an interview on 11/6/2024 at 9:00 am, the RNC stated they had performed an in-service regarding the soiled linen hamper on 11/5/2024 at 4:00 pm, 7:00 pm and 11:00 pm. The summary of the in-service revealed, laundry baskets need to be empty once it is full (immediately). All soiled linen needs to be disposed of in a timely manner. When hamper is full, please the take the dirty linen to the laundry room immediately. In an Interview on 11/6/2024 at 9:46 am, the Assistant Director of Nursing and Infection Preventionist (ADON/IP) revealed that they re-educated the staff on the expectations for the soiled linen hampers being emptied on a consistent basis. The ADON/IP stated the CNAs are responsible for ensuring the soiled linen hampers were emptied when full. In an Interview on 11/6/2024 at 2:06 pm, CNA XX revealed that everybody must be accountable for emptying the soiled linen hampers. CNA XX stated I can't be the only person dumping the cart all the time. Other people need to be held accountable for dumping the carts.

Based on record review, resident, family and staff interviews, and review of the policy titled Abuse Neglect and Exploitation policy and Accidents and Supervision, Investigation, and Reporting, the facility failed to ensure the immediate reporting of verbal, sexual, and/or physical abuse for three of 31 sampled residents (R) (R#11, R#18, and R#28). Specifically, the facility failed to ensure allegations of physical and verbal abuse for R#11 and R#28 were reported to the Abuse Coordinator, and an allegation of physical abuse was reported timely to the State Survey Agency (SSA) for R#18. The facility's systemic failure to ensure the reporting of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the policy titled Abuse Neglect and Exploitation policy, dated 12/2017 indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Reporting/Documentation Requirements: When abuse, neglect or exploitation is suspected: immediately report all alleged violations to the Administrator/Designee, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes. 1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. Resident #11 is a new admission and entry tracking Minimum Data Set (MDS) dated [DATE] is only MDS available, therefore, no data available at this time. R#11's Brief Interview for Mental Status (BIMS) score, dated 1/6/2023 and found in the electronic medical record (EMR) under the MDS tab, was 14, indicating the resident was cognitively intact. Review of document titled Grievance Log dated 9/1/2022 through 4/26/2023 revealed a grievance entered on behalf of R#11 on 1/9/2023, by the resident's family member and the nature of the grievance indicated care. The log entry indicated the outcome was Reportable and the resolution date of the grievance indicated 1/17/2023, eight days after the grievance was initially reported. Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date (eight days after the initial report). Review of the Incident Follow-Up Investigation Report related to the resident's report of care concerns dated 1/17/2023 indicated, Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. She alleged CNA BB and CNA CC left her lying in her own feces. According to the investigation report, the SW never reported the allegation of abuse to the Administration. Administration was not made aware of these allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later). Because the allegation of abuse was not timely reported to the Administration, CNA BB and CNA CC were not put on administrative leave and continued to work in the facility with R#11 and other residents for eight days after the initial allegation of abuse. Review of the Nursing Schedules, dated 1/9/2023 through 1/17/2023 revealed CNA BB and CNA CC remained at work in direct contact with residents, including R#11. Interview on 4/24/2023 at 12:30 p.m., responsible party (RP) for R#11, confirmed report of an allegation of physical abuse/rough treatment by two CNAs was made to the facility SW on 1/9/2023 and then again to the DON on 1/17/2023. Interview on 4/28/2023 at 5:45 p.m., CNA CC, she verified she was still working consistently in the facility as a CNA and indicated she did not recall R#11. CNA CC stated she did not remember ever being put on administrative leave related to any allegation of abuse. Interview on 4/27/2023 at 2:15 p.m., the Social Services Director (SSD) confirmed the Grievance related to R#11's allegation of physical and verbal abuse had not been reported to the facility's Administration as it should have. She stated the grievance should have been immediately referred to the Abuse Coordinator/Administrator on 1/9/2023 when the allegation was initially reported. 2. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy. The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD. Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help, and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging, he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Two staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the investigation report, the allegation of potential abuse was not reported to the facility's Abuse Coordinator until the following morning. Because the alleged abuse was not timely reported to the Administrator/Abuse Coordinator until the morning of 12/22/22, CNA DD was not put on administrative leave after the allegation of abuse, and instead remained in the facility for the remaining seven hours of her shift while working in direct contact with residents. Review of the Nursing Schedules, dated 12/21/2022 revealed CNA DD remained in the facility for the remainder of her shift on 12/21/2022, in direct contact with residents, including R#28. Interview on 4/29/2023 at 10:23 a.m. with CNA DD, confirmed she was not put on administrative leave on the night of the alleged abuse. She stated she remained in the facility working with residents until the end of her shift the next morning. She stated she was put on administrative leave the next day after the Administrator arrived at work. Interview on 4/27/2023 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated abuse was to be reported to himself immediately after an allegation and stated any facility staff member could report abuse. He stated after abuse allegations had been reported to him, it was his responsibility to investigate the allegation. Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC), serving as Interim Director of Nursing (DON), stated his expectation was any allegation of abuse was to be reported to a supervisor immediately and the supervisor was to then immediately call the Abuse Coordinator. 3. Review of the policy titled Accidents and Supervision, Investigation, and Reporting, revised September 2022, revealed all accidents or incidents must be reported and recorded. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia. The resident's annual MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally. Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. The DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's two daughters refused, stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport. Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple. Review of a document titled Risk Management indicated R#18 was noted to have an injury of unknown cause on 4/12/2023 at 3:00 p.m. The document recorded family members at bedside and requested an immediate call to 911 for EMS (Emergency Medical Services) to remove the resident from facility due to their concerns of care. Resident states that her left great toe and foot has pain and there is a small bruise on top of left great toe, and small bruise to left ankle, and a yellow discoloration to left temple. Scattered petechiae to right shin. Head to [sic] assessment from wound care nurse completed. 911 called to transport the patient to acute hospital per family request. Administrator aware and submitting reportable and called Ombudsman. The DON notified MD and RP and sister at bedside. Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. The incident report's conclusion portion indicated the investigation is inconclusive. During the interview with DON and others, the resident stated that she wasn't experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action is Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI (Quality Assurance and Performance Improvement) in facility up-coming QAPI. Interview on 4/27/2023 at 7:00 p.m., the CNC stated R#18's injuries noted on 4/12/2023 were not reported because nothing happened. Interview on 4/28/2023 at 10:37 a.m., the WCN confirmed that she performed a full body skin assessment on R#18 after the family had reported bruising to her left upper foot. The WCN reported the skin assessment revealed yellow discoloration to the temple, purple/blue discoloration to bilateral upper extremities, petechiae to left lower extremity, and a small ulcer opening to the labia. Interview on 4/28/2023 at 10:58 a.m., the DON confirmed that on 4/12/2023, R#18's family reported she had bruising of which she was unaware. The DON stated she was aware of R#18's complaints of foot pain. The DON stated the WCN performed a full body skin assessment and that is when she became aware of the bruising on R18's body. which revealed discoloration to her foot, possible injury to the foot, and pain reported in one of her feet. Interview on 4/28/2023 at 2:55 p.m., the Administrator/Abuse Coordinator stated that he reported the injury on 4/12/2023 but confirmed he did not submit a five-day follow-up. The Administrator did not provide a reason the five-day follow-up report was not submitted. Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) confirmed that staff working with R#18 did not report the bruising immediately as they should have reported. The IP confirmed it was the family member who brought the bruising to the attention of the facility.

Based on record review, resident, family and staff interviews, and review of the policy titled Abuse Neglect and Exploitation policy, the facility failed to ensure allegations of verbal, sexual, and/or physical abuse were thoroughly investigated for four of 31 sampled residents (R) (R#11, R#12, R#18, and R#28). Specifically, resident and staff interviews were not conducted during investigations into the allegations to determine if abuse occurred, and the facility failed to identify potential perpetrators of abuse. The facility's systemic failure to ensure the thorough investigation of abuse allegations created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the policy titled Abuse Neglect and Exploitation policy dated 12/2017 indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, family members, friends, or others. Investigation of abuse, neglect, and exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: Identifying staff responsible for the investigation; Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence); Ensure resident safety is not jeopardized. Physically assess resident; Investigating different types of alleged violations; Identifying an interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, ensure confidentiality; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation; Continue investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures/changes will be implemented. 1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. The resident was discharged from the facility on 1/11/2023. Resident #11 is a new admission and entry tracking Minimum Data Set (MDS) dated [DATE] is only MDS available, therefore, no data available at this time. R#11's Brief Interview for Mental Status (BIMS) score, dated 1/6/2023 and found in the electronic medical record (EMR) under the MDS tab, was 14, indicating the resident was cognitively intact. Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date. Review of the Incident Follow-Up Investigation Report related to the resident's report of care concerns dated 1/17/2023 indicated, Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. She alleged CNA BB and CNA CC left her lying in her own feces. Administration was not made aware of these allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later). The investigation did not include interviews with residents related to potential verbal abuse and rough care by staff members, rather six residents were interviewed by the SW regarding the amount of time it took for staff to answer call lights. The investigation did not include interviews with other staff members, other than the two CNAs about whom the allegations were made. In addition, a physical assessment was not completed of R#11 after the allegation of potential abuse to ensure no injuries were obtained. 2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses including gastrointestinal hemorrhage and anemia. R#12's BIMS score, dated 3/27/2023, and found in the EMR under the MDS tab, was 13, indicating the resident was cognitively intact. Review of a ''Progress Notes,'' dated 4/9/2023 at 7:31 p.m. revealed CNA reported to the writer that resident reported to her someone had come to her room and took his penis and rubbed it against her vagina. Review of the Incident Report Form, dated 4/9/2023, indicated an allegation of sexual abuse was entered into the facility's incident tracking system on that date for R#12. The details indicated, ''Resident informed staff that a man sexually abuse [sic] her, however she could not recall the date and time of the incident.'' Review of the Incident Follow-Up Investigation Report dated 4/9/2023 related to the resident's allegation of sexual abuse was reviewed and indicated Initial Report: Staff to Resident Sexual Abuse. The report indicated R#12 alleged sexual abuse by a staff member to an unidentified CNA on 4/9/2023 at approximately 7:30 p.m. Review of the investigation report revealed the facility did not attempt to identify the potential perpetrator of the abuse or conduct interviews with staff and residents to attempt to determine if the abuse had occurred. The investigation conclusion indicated unsubstantiated. Review of the Nursing Schedules, dated 4/7/2023 through 4/9/2023 revealed four male staff members had been working in direct contact with residents, including R#12 during the allegation timeframe. There was no investigation to specifically rule in or out if any of the four male staff members who were identified as working in direct contact with residents during the time frame of the allegation of sexual abuse. 3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy. R#28's BIMS score, dated 2/2/2023, and found in the EMR under the MDS tab, was eight, indicating the resident was moderately cognitively impaired. Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD. Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help, and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging, he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Two staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the report, no additional staff interviews were conducted, and no resident interviews were conducted related to the allegation to determine if the abuse occurred. According to the records, R#28 was not physically assessed to determine if he had been injured during the incident. The investigation conclusion indicated: Unverified, even though reports of verbal abuse by CNA DD to R#28 were verified per interview with staff members present during the incident. Interview on 4/2720/23 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated after an abuse allegation had been reported to him, it was his responsibility to investigate the allegation. The Administrator confirmed his expectation was witness statements would be obtained, including additional residents and staff who might know of the potential abuse. The DON stated she did not believe any of the above investigations were thorough. The Administrator stated, We should have interviewed residents about staff treatment and other staff as well (related to the above allegations of potential abuse). Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC) stated his expectation was any allegation of abuse was expected to be thoroughly investigated and residents were to be protected while the investigation was conducted. 4. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia. The resident's MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally. Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. The DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's two daughters refused, stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport. Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae (pinpoint, round spots that appear on the skin as a result of bleeding) to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple. Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. There was no documentation of steps taken by the facility to prevent further incidents. Review of the Incident Follow-Up Investigation Report dated 4/28/2023 at 11:00 p.m. and signed by the Administrator indicated summary of interview(s) with other residents: at approximately 3:10 p.m., resident 30-A was asked if she had observed anyone mistreat [R#18] and responded no. At 3:15 p.m., resident 30-B was asked if they had observed anyone mistreating [R#18] and responded no. At 3:18 p.m., resident 31-A was asked if she had observed anyone mistreating [R#18] and responded that she was not aware. The Report recorded the direct-care staff assigned to R#18 on 4/12/2023 was asked if she had observed a bruise on R#18's left foot, and she stated she saw a little purple bruise on the foot but did not report it. The Report recorded the charge nurse assigned to R#18 on that day denied knowledge of R#18 being in pain. The conclusion section of the report indicated, . The conclusion of this investigation is inconclusive. During the interview with DON and others, the resident stated that she was not experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action . Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI [Quality Assurance and Performance Improvement] in facility up-coming QAPI. There was no documentation of the residents' interviews or whether the residents were asked any other questions related to abuse and neglect. There were no interviews with staff members or potential witnesses, other than the two assigned to the resident. The report was not completed until 04/28/23, after the surveyors had brought the incident to the attention of the Administrator.

Based on record review, interviews, and review of the policy titled Abuse Neglect and Exploitation, the facility failed to ensure administration provided oversight and monitoring related to the prevention, reporting and investigation of abuse. Four of 31 sampled residents (R) (R#11, R#12, R#18, and R#28) reported allegations of abuse and these allegations were not reported and/or investigated per facility policy. In addition, the Administration failed to ensure residents were appropriately protected from further potential abuse after the allegations. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the policy titled Abuse Neglect and Exploitation dated December 2017 indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind. Residents will not be subjected to abuse by anyone, including but not limited to, center staff, other residents, consultants, volunteer staff, family members, friends or others. Bullet III. Prevention of Abuse, Neglect and Exploitation: Provide education on what constitutes abuse, neglect, and misappropriation of property. Take appropriate action to allegations or questions of abuse by residents, family members, employees, or visitors. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. Bullet IV. Identification of Abuse, Neglect and Exploitation. The facility will consider factors indicating possible abuse, neglect and/or exploitation of residents including, but not limited to, the following possible indicators: Resident, staff, or family report of abuse. Verbal abuse of a resident overheard. Physical abuse of a resident observed. Reporting/Documentation Requirements: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator/Designee, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames. Investigation of abuse, neglect, and exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include, identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence; ensure resident safety is not jeopardized. Physically assess resident; investigating different types of alleged violations; Identifying an interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, ensure confidentiality; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation; continue investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures/changes will be implemented. Review of the Administrator Job Description indicated the Basic Function: Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state, and local standards, guidelines and regulations as directed by corporate office and for ensuring that the highest degree of quality patient/resident care is maintained at all times. Number 6. Ensure that patient/resident rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints are well established and maintained at all times. The Role of the Abuse Coordinator within the facility's undated Abuse Investigation and Reporting Policies, revealed the role of the Abuse Coordinator: 1. The facility administrator may take the role of the Abuse Coordinator in the facility. 2. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown origin is reported, the Administrator/Abuse Coordinator will assign the investigation to an appropriate individual. 3. The Abuse Coordinator shall provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 4. The Abuse Coordinator or designated staff shall keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The Administrator/Abuse Coordinator or designated staff (i.e., DON (Director of Nursing), Department Manager) shall suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 6. The Administrator/Abuse Coordinator shall ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. 7. The Administrator or designated staff shall inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Review of the Incident Follow-Up Investigation Report revealed on 1/9/2023, an allegation of physical and verbal abuse was reported for R#11 to the Social Worker (SW). The allegation was not reported to the Administration until 1/17/2023, by R#11's Responsible Party. After the allegation of physical abuse was reported to administration on 1/17/2023, the facility failed to ensure resident safety by suspending the potential perpetrator, failed to assess the resident for potential injury, and failed to thoroughly investigate the allegation of abuse (staff and resident interviews were not completed to attempt to identify whether abuse was occurring in the facility). Due to the staff member not reporting the abuse allegations timely, Certified Nursing Assistant (CNA) BB and CNA CC continued to work with residents. Review of the Incident Follow-up Investigation Report revealed on 4/9/2023, an allegation of sexual abuse was reported for R#12. The facility failed to ensure resident safety by suspending the potential perpetrators and failed to thoroughly investigate the allegation of abuse (staff and resident interviews were not completed to attempt to identify whether or not abuse was occurring in the facility). The facility failed to attempt to identify the staff member who perpetrated the abuse, hence allowing multiple potential perpetrators (male staff members) to continue to work with residents during the investigation. Review of the Facility Reported Incident revealed on 4/12/2023, an allegation of multiple injuries of unknown origin/physical abuse was reported for R#18. Facility staff failed to timely report the injuries to administration, the facility failed to thoroughly investigate the injuries of unknown origin (staff and resident interviews were not completed to attempt to identify whether abuse was occurring in the facility), and the facility did not perform a follow-up investigation (5-day) until 4/28/2023. Review of the Incident Follow-Up Investigation Report revealed on 12/21/2022, an allegation of physical and verbal abuse by CNA DD was made for R#28. The facility did not ensure resident safety by suspending the alleged perpetrator during the investigation (the alleged perpetrator remained at work for the remainder of her shift while working in direct contact with residents), R#28's allegation of abuse was not reported to facility Administration until the next morning (12/22/2022), an investigation into the allegation of physical/verbal abuse was not thorough (it failed to include interviews of staff and residents to determine whether the abuse occurred), and the resident was not physically assessed related to the allegation of physical/verbal abuse. In addition, the alleged abuse allegation was not substantiated despite reports from two staff members that the alleged perpetrator of the abuse loudly made the statement ''You should have offered him some food and watched how fast he got up'' in front of the resident before knocking the residents' cups off his overbed table and storming out of the room. Interview 4/27/2023 at 10:25 a.m., the Director of Nursing (DON) and the Administrator confirmed the Administrator acted as the facility's Abuse Coordinator. The Administrator confirmed the above staff members were not placed on suspension per policy, assessments were not completed of the residents per policy, and the investigations into the allegations of abuse were not thorough. Interview on 4/27/2023 at 1:05 p.m., the Administrator stated in response to the survey team's questions, you were right. I thought I was thorough but that is not what it is. [After talking with the surveyors] I realize staff should be suspended and were not suspended. Interview on 4/29/2023 at 12:30 p.m., the DON stated she was aware the abuse investigations were not thorough. She stated the Administrator was the facility's abuse coordinator and his involvement with abuse investigations was not what it should be. Cross-reference F600, F609, and F610.

Based on record review, resident, family and staff interviews, and review of policy titled ''Abuse Neglect and Exploitation policy'', the facility failed to maintain an environment free from verbal, sexual, and/or physical abuse for four residents (R) R#11, R#12, R#18, and R#28) of 31 sampled residents. The facility failed to ensure the residents were protected after allegations of abuse by suspending alleged perpetrators of abuse during each investigation of alleged abuse and failed to thoroughly investigate and report potential allegations of abuse. The facility's systemic failure to ensure the prevention of abuse created the potential for residents to be or to continue to be abused/neglected/exploited which can lead to serious physical and/or psychological harm for all 126 residents residing in the facility. On 4/28/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Clinical Nurse Consultant was informed of the Immediate Jeopardy (IJ) on 4/28/2023 at 3:50 p.m. The noncompliance related to the IJ was identified to have existed on 12/21/2022. An Acceptable Removal Plan was received on 5/2/2023. The removal plan included in-service training for staff on Abuse prevention, Reporting Abuse allegations, and Investigating allegations of abuse, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 5/1/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding Abuse prevention, Reporting, and Investigating allegations of Abuse. Findings include: Review of the facility's ''Abuse Neglect and Exploitation policy'' dated 12/2017 indicated each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind . Resident will not be subjected to abuse by anyone, including but not limited to, Center staff, other residents, consultants, volunteer staff, family members, friends or others. Bullet III. Prevention of Abuse, Neglect and Exploitation: Provide education on what constitutes abuse, neglect, and misappropriation of property. Take appropriate action to allegations or questions of abuse by residents, family members, employees, or visitors . Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. Bullet IV. Identification of Abuse, Neglect and Exploitation: The facility will consider factors indicating possible abuse, neglect and/or exploitation of residents including, but not limited to, the following possible indicators: Resident, staff or family report of abuse. Verbal abuse of a resident overheard. Physical abuse of a resident observed. 1. Review of the clinical record revealed R#11 was admitted to the facility on [DATE] with diagnoses including fracture of upper and lower end of right fibula and fracture of right tibia. The resident was discharged from the facility on 3/11/2023. The resident's Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Review of document titled Grievance Log dated 9/1/2022 through 4/26/2023 revealed a grievance entered on behalf of R#11 on 1/9/2023, by the resident's family member and the nature of the grievance indicated care. The log entry indicated the outcome was Reportable and the resolution date of the grievance indicated 1/17/2023 (more than a week after the grievance was initially reported). Review of the Incident Report Form, dated 1/17/2023, indicated the above allegation was entered into the facility's incident tracking system on that date (eight days after the initial report). Review of the ''Incident Follow-Up Investigation Report'' dated 1/17/2023 related to R#11's report of care concerns was reviewed and indicated Initial Report: Abuse. The report indicated on 1/9/2023, R#11 alleged to the Social Worker (SW) that Certified Nursing Assistant (CNA) BB (agency) was rough and verbally abusive during activities of daily living (ADL) care. R#11 also alleged CNA BB and CNA CC left her lying in her own feces. According to the investigation report, the SW never reported the allegation of abuse to the Administration. Administration was not made aware of R#11's allegations of abuse until reported by the resident's Representative (RP) to the Director of Nursing (DON) on 1/17/2023 (eight days later) during a Circle of Care/Care Coordination Meeting. The investigation did not include interviews with residents related to potential verbal abuse and rough care by staff members, rather six residents were interviewed by the SW regarding the amount of time it took for staff to answer call lights. The investigation also did not include interviews with any other staff members other than the two CNAs about whom the allegations were made. CNA BB and CNA CC were not put on administrative leave after the first allegation of abuse on 1/9/2023 or during the investigation after a second report of abuse on 1/17/2023. Both CNAs continued to work in the facility with R#11 and other residents after the initial allegation of abuse. A physical assessment of the resident was not completed of R#11 after the allegation of abuse to ensure no injuries were obtained. The investigation conclusion revealed Abuse not verified. Both staff members were still working regularly at the facility in direct contact with residents through the survey exit date of 5/3/2023. Interview on 4/24/2023 at 12:30 p.m., R#11's RP confirmed report of an allegation of physical abuse/rough treatment by two CNAs was made to the facility social worker on 1/9/2023 and then again to the DON on 1/17/2023. Interview on 4/28/2023 at 5:45 p.m. with CNA CC, verified she was still working consistently in the facility as a CNA and indicated she did not recall R#11. She stated she did not remember ever being put on administrative leave related to any allegation of abuse. CNA BB was unavailable for interview during the survey. Interview on 4/27/2023 at 2:15 p.m., the Social Services Director (SSD) confirmed the Grievance related to R#11's allegation of physical and verbal abuse had not been reported to the facility's Administration as it should have. She stated the grievance should have been immediately referred to the Abuse Coordinator/Administrator on 1/9/2023 when the allegation was initially reported. 2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with diagnoses including gastrointestinal hemorrhage and anemia. The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Review of a ''Progress Notes,'' dated 4/9/2023 at 7:31 p.m. revealed the CNA reported to the writer that resident reported to her someone had come to her room and took his penis and rubbed it against her vagina. The writer accompanied by the fllor [sic] nurse went to the resident's room. Resident A/O [alert and oriented] x 2 narrated +- what the CNA had reported to the writer. With the help of the floor nurse the resident's generterial [sic] area was assessed. Noted was redness to inner thighs. Resident was also able to show where the rubbig [sic] was by touching the top of her vagina. The note indicated the facility's Abuse Coordinator'' (Administrator), the police, and the resident's family had been notified of the allegation. Review of the Incident Report Form, dated 4/9/2023, indicated an allegation of sexual abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, ''Resident informed staff that a man sexually abuse [sic] her, however she could not recall the date and time of the incident.'' Review of the Incident Follow-Up Investigation Report dated 4/9/2023 related to the resident's allegation of sexual abuse was reviewed and indicated Initial Report: Staff to Resident Sexual Abuse. The report indicated R#12 alleged sexual abuse by a staff member to an unidentified CNA on 4/9/2023 at approximately 7:30 p.m. The CNA immediately reported the allegation to the charge nurse. The resident reported that a male tech came into her room, took his penis, and rubbed it against her vagina. The investigation report indicated the resident was noted to have redness to her inner thighs and was able to point out the area that was being rubbed by pointing to the top of her vagina. The report indicated the resident was sent to the hospital after the report of sexual abuse on the evening of 4/9/2023 and sexual abuse could not be determined by the staff at the Emergency Department. Review of the investigation report revealed the facility did not attempt to identify the potential perpetrator of the abuse or conduct interviews with staff and residents to attempt to determine if the abuse had occurred. The investigation conclusion indicated unsubstantiated. Review of the Nursing Schedules, dated 4/7/2023 through 4/9/2023 revealed four male staff members had been working in direct contact with residents, including R#12 during the allegation timeframe. None of the four staff members were put on administrative leave during the investigation to ensure the residents' protection. All four of the identified staff members were still working consistently in the facility and in direct contact with residents as of the survey exit date of 5/3/2023. R#12 was unavailable for interview due to the resident being hospitalized for part of the survey timeframe and was too ill to interview/asleep during the remaining timeframe. Interview on 4/27/2023 at 10:25 a.m., the Administrator confirmed there were multiple male staff members who worked during the time frame of R#12's allegation. 3. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including morbid obesity, unspecified psychosis, and Wernicke's Encephalopathy. The resident's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, which indicated moderate cognitive impairment. Review of the Incident Report Form, dated 12/21/2022, indicated an allegation of physical abuse was entered into the facility's incident tracking system on that date for the resident. The details indicated, Resident had a fall and states CNA pushed me. The form indicated the alleged perpetrator of the abuse to be CNA DD. Review of the Incident Follow-Up Investigation Report dated 12/21/2022 related to the resident's allegation of physical abuse was reviewed and indicated Initial Report: Staff to Resident Abuse. The report indicated R#28 alleged physical abuse by a staff member on 12/21/2022. The resident stated CNA DD pushed him down and he cried for help and no one would help him. The report indicated R#28 was found on the floor by another CNA crying and lying face down next to his bed. The report indicated interviews were obtained from three staff members who were working with the alleged perpetrator on the night of the alleged abuse. Two of the three staff members interviewed indicated they were present in the resident's room while he was alleging he had been abused by CNA DD. Both staff members indicated the resident was found face down on the floor and was crying. Both staff members confirmed the allegation of abuse by CNA DD. Both staff members revealed R#28 was further abused (verbally) by CNA DD when she returned to the resident's room and loudly yelled, ''You should have offered him [R#28] some food and watched how fast he got up'' before knocking the resident's cups off his bedside table, and then storming out of the room. According to the investigation report, the allegation of potential abuse was not reported to the facility's Abuse Coordinator until the following morning. CNA DD was not put on administrative leave after the allegation of abuse, and instead remained in the facility for the remaining seven hours of her shift while working in direct contact with residents. According to the report, no additional staff interviews were conducted, and no resident interviews were conducted related to the allegation to determine if the abuse occurred. According to the records, R#28 was not physically assessed to determine if he had been injured during the incident. The investigation conclusion indicated: Unverified, even though reports of verbal abuse by CNA DD to R#28 were verified per interview with staff members present during the incident. Review of the Nursing Schedule for 12/21/2022 revealed CNA DD remained in the facility for the remainder of her shift on 12/21/2022. In addition, the schedule verified CNA DD was still working consistently in the facility as of the survey exit date of 5/3/2023. R#28 was unable to be interviewed related to the allegation due to his poor cognition. Interview on 4/29/2023 at 10:23 a.m. with CNA DD, indicated she was familiar with R#28 and stated she remembered the incident from 12/21/2022. She stated, All I know is I cleaned him [R#28] up and he didn't want to get clean. I cleaned him up and when I finished, I put the bed to the lowest [position] and he pushed himself to the ground. CNA DD confirmed she was not put on administrative leave on the night of the alleged abuse. She stated she remained in the facility working with residents until the end of her shift the next morning. CNA DD stated she was placed on administrative leave the next day after the Administrator arrived at work. She stated after the investigation was done, she was asked to return to work. Interview on 4/2720/23 at 10:25 a.m., the DON and the Administrator confirmed the Administrator was acting as the facility's Abuse Coordinator. The Administrator stated abuse was to be reported to himself immediately after an allegation and stated any facility staff member could report abuse. He stated after abuse allegations had been reported to him, it was his responsibility to investigate the allegation. The Administrator confirmed his expectation was witness statements would be obtained and the police, the family, the physician, and the local Ombudsman be called. He stated the alleged perpetrator should be suspended pending the outcome of the investigation. The DON confirmed the allegation of potential abuse was not reported timely for R#11 and stated she did not believe any of the above investigations were thorough. The Administrator stated, We should have interviewed residents about staff treatment and other staff as well (related to the above allegations of potential abuse). Interview on 4/29/2023 at 2:20 p.m. the Clinical Nurse Consultant (CNC) stated his expectation was any allegation of abuse was to be reported to a supervisor immediately and the supervisor was to then immediately call the Abuse Coordinator. He stated allegations of abuse were expected to be thoroughly investigated and residents were to be protected while the investigation was conducted. 4. Review of the policy titled Accidents and Supervision, Investigation, and Reporting, revised 9/2022, indicated the facility shall provide the residents an environment free of accident hazards and each resident receives adequate supervision and assistive devices to prevent accidents. All accidents or incidents must be reported and recorded. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including osteoarthritis and dementia. The resident's MDS dated [DATE], revealed a BIMS score of five, indicating the resident had severe cognitive impairment. Additionally, it was indicated R#18 had no falls since admission, required extensive assistance of one person with bed mobility, dressing, transfers, required two-person assistance with toileting, extensive assistance of one person with personal hygiene, and had impairments to the lower extremities bilaterally. Review of the care plan revised 2/27/2023 indicated R#18 required assistance with bathing, bed mobility including turning and repositioning, dressing, undressing, transfers, and incontinence care. The care plan indicated R18 had a diagnosis of atrial fibrillation and required the administration of blood thinners. Review of the Incident Note dated 4/12/2023 at 1:30 p.m. revealed Administrator was present onsite and aware of incident at the time of the concern. DON, ADON (Assistant Director of Nursing), and Administrator responded to bedside to address family and resident concern. When DON asked the resident what caused her bruises, the resident stated, I don't know. DON asked resident directly, Did anyone hurt you intentionally? Resident responded, No. DON requested wound care nurse to complete a head-to-toe skin assessment. DON offered to call MD (Medical Doctor) for radiology of left foot and ankle and resident's RP refused stating to call 911 and have her transported to a hospital. DON called 911 for transport and the resident was transferred to non-emergent transport. Review of Weekly Skin Observation dated 4/12/2023 at 1:39 p.m., indicated the resident had purple/blue discolorations to the left dorsal great toe and left dorsal proximal foot, purple/blue discolorations to the right upper arm and left upper arm, purple/blue discolorations with petechiae to the right lower extremity, a small open area to left labia, and yellow discolorations to left temple. Review of a document titled Risk Management indicated R#18 had an injury of unknown cause on 4/12/2023 at 3:00 p.m. The document recorded family members at bedside and requested an immediate call to 911 for EMS (Emergency Medical Services) to remove the resident from facility due to their concerns of care. Resident states that her left great toe and foot has pain and there is a small bruise on top of left great toe, and small bruise to left ankle, and a yellow discoloration to left temple. Scattered petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to right shin. Head to [sic] assessment from wound care nurse completed. 911 called to transport patient to acute hospital per family request. Administrator aware and submitting reportable and called Ombudsman. The DON notified MD and RP and [family member] at bedside onsite at facility and packed up her belongings. DON answered all question for family. Review of the Facility Incident Report Form, dated 4/12/2023, indicated R#18 had a dark bruise on left foot reported by resident's family member and informed the Administrator/Abuse Coordinator of the bruise. The report recorded the facility offered to obtain an x-ray, but the family declined. The report recorded the concern was an injury of unknown origin and the alleged perpetrator was unknown. There was no documentation of steps taken by the facility to prevent further incidents. The conclusion of the investigation on 4/12/2023 recorded, . The conclusion of this investigation is inconclusive. During the interview with DON and others, the resident stated that she wasn't experiencing ankle pain. Secondly the resident takes both Anticoagulant and Anastrozole medications, and lastly the Responsible Party informed the Administrator that her friend advised her how to get the [R#18] closer to home. Corrective action . Administration will continue employee's education on residents' assessments and reporting injuries. This is a late reportable and will be QAPI (Quality Assurance and Performance Improvement) in facility up-coming QAPI. Interview on 4/26/2023 at 4:29 p.m., the Wound Care Nurse (WCN) stated R#18 was not able to turn and reposition herself, had limited range of motion to her upper extremities, and required full assistance with bilateral lower extremity movement. Interview on 4/27/2023 at 7:00 p.m., the CNC stated R#18's injuries noted on 4/12/2023 were not reported because nothing happened. Interview on 4/28/2023 at 9:40 a.m., the Visiting Administrator (VA) EE confirmed the facility did not do an investigation on 4/12/2023 related to R#18's injuries and no witness statements or investigation documentation were available. Interview on 4/28/2023 at 10:37 a.m., the WCN confirmed that she performed a full body skin assessment on R#18 with the family at the bedside. WCN stated R#18's family member reported bruising to left upper foot and further skin assessment revealed yellow discoloration to the temple, purple/blue discoloration to bilateral upper extremities, and petechiae to left lower extremity, and a small ulcer opening to the labia. Interview on 4/28/2023 at 10:58 a.m., the DON confirmed that on 4/12/2023, R#18's family was visiting in the resident's room and was upset, stating they wanted her moved out of the facility. The DON she was not aware of any bruising to R#18's body but was aware that the resident was complaining of foot pain. The DON stated the WCN performed a full body skin assessment which revealed discoloration to her foot, possible injury to the foot, and pain reported in one of her feet. Interview on 4/28/2023 at 2:55 p.m., the Administrator/Abuse Coordinator stated that he reported the injury on 4/12/2023 but did not submit a five-day follow-up. The Administrator did not provide a reason the five-day follow-up report was not submitted. Interview on 4/28/2023 at 4:24 p.m., the Infection Preventionist (IP) confirmed that on 4/12/2023 she was employed as the ADON and was asked to speak with R#18's family at the bedside. The IP stated she was made aware of a dark purple discoloration to R#18's left great toe, along with purple discoloration to the left ankle, and yellow discoloration to the left temple/forehead area. The ADON confirmed that staff working with R#18 should have reported any bruising immediately but did not. The IP confirmed it was the family member who brought the bruising to the attention of the facility. Interviews with 11 staff members throughout the facility on 4/27/2023 between 12:00 p.m. and 12:30 p.m. indicated nine of 11 staff members were agency staff working in the facility and three of 11 reported they had not received abuse training from the facility. One agency CNA staff member indicated she had not received abuse training from either her agency or the facility.

Based on record review and interview, it was determined the facility failed to follow the wandering care plan interventions for one resident (R) (R#135) of 35 sampled residents. This failure resulted in actual harm when R#135 wandered out of the facility on 10/28/16 and sustained a fall resulting in a right [MEDICAL CONDITION]/femoral neck requiring right hip hemiarthroplasty. Refer F323 Findings include: Review of the facility's undated policy titled Care Plan documented: Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. Review of the undated document titled Resident Assessment Management System documented Comprehensive Care Plan - It is the policy of the facility to develop, in conjunction with resident/and or representative, the comprehensive care plan. The plan is directed toward achieving and maintaining optimal status of health, function and quality of life. Care Planning Process - The individualized care plan is accessible to all caregivers to assure informed consistent delivery of service. Record review for R#135 revealed a Health Status note on 10/29/16 at 2:46 a.m. documented Res was ambulating with walker and went out the front door and fell in the parking lot near c-hall bldg. Res complaining of right hip pain. Staff member stays with res as this nurse calls 911. Res transferred to NSF hosp (sic). Voicemail left for Family members (names). Review of the closed record for R#135 revealed that she was admitted into the facility 7/28/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of three indicating severe cognitive impairment. Wandering behavior occurred four to six days of the look back period. Review of the functional status revealed R#135 required limited assistance for transfers, supervision for walking in her room and in corridors and on the unit but extensive assistance for ambulation off the unit. Review of the Care Plan for R#135 initiated on 10/14/15 and revised on 12/20/16 indicated: the resident is an elopement risk/wanderer by attempting to leave facility unattended. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Additionally, provide structured activities: toileting, walking inside and outside, re-orientation strategies including signs, pictures and memory boxes. Wander Alert: wander guard bracelet. Interview with the Administrator on 12/21/16 at 11:53 a.m. revealed that there was a Halloween event in the facility on the night of 10/28/16. R#135 went outside and fell on that night. A volunteer reset the Wanderguard alarm because she thought that the resident could go outside alone, unsupervised. Further interview with the Administrator on 12/22/16 at 9:50 a.m. revealed that the facility surveillance video showed R#135 walked out of the building while a volunteer coming into the facility held the door for her. The Wanderguard alarm did sound but a volunteer reset the code on the door and stopped the alarm. The facility failed to follow R #135's care plan interventions for wandering resulting in a fall with [MEDICAL CONDITION] requiring surgery.

Based on interview, record review and review of facility policy and procedures, the facility failed to ensure adequate supervision for two (2) Residents (R) #135 and #182 from 35 sampled residents. Specifically, a facility volunteer disarmed the alarm system as R#135, a resident with a history of wandering, exited the facility unattended on 10/28/16. This failure resulted in actual harm when R#135 sustained a fall in the parking lot and fractured her right femur requiring a right hip hemiarthroplasty. R#182 was identified at risk for wandering and elopement with physician orders [REDACTED]. The facility failed to document placement checks for the month of October and discontinued the WanderGuard on 10/31/16. However, the facility failed to put a system in place to monitor the resident for reoccurring wandering/elopement behaviors, poor safety awareness and increased confusion. On 12/19/16 the resident was found outside the facility unsupervised. This failure had the potential to result in a negative outcome to the resident's safety. Findings include: Review of facility policy and procedures titled Elopement dated 4/2/10 revealed elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Purpose of the policy was noted as to establish a procedure to respond to a near or actual resident elopement. The premises of the facility were defined as: Front parking lot to 1st speed bump; area outside fenced backyard; area outside fenced side yard; property line around perimeter of side parking lots. Review of the policy titled Resident Wandering/WanderGuard with revision date 4/10, revealed guidelines that included: staff will respond to all door alarms immediately to prevent a resident from wandering out of the health care center. Review of the facility's undated document titled General Do's and Don'ts for volunteers indicated to clear all resident requests you are unsure of (food, drinks, walks, etc.) with the nurse in charge before carrying them through. 1. Review of the closed record for R#135 revealed that she was admitted into the facility 7/28/15. Medical [DIAGNOSES REDACTED]. Hospice was initiated for R#135 on 12/16/16. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of three indicating severe cognitive impairment. Wandering behavior occurred four to six days of the look back period. Review of the functional status revealed R#135 required limited assistance for transfers, supervision for walking in her room and in corridors and on the unit but extensive assistance for ambulation off the unit. R#135 did not have a terminal prognosis. R#135 had no falls during the assessment period or since last assessment. Review of the Wander Data Collection Tool for R#135 dated 10/11/16 indicated in the summary of findings that resident showing signs of wandering out of building and identified a wander/elopement risk. Review of the care plan for R#135 dated 10/14/15 and revised on 12/20/16 revealed plans for: Elopement risk/wanderer by attempting to leave facility unattended intervention include to distract resident from wandering offering pleasant diversions, structured activities, food, conversation, television, book. Wander Alert: WanderGuard bracelet. Resident has functional mobility deficit initiated 10/13/15 and revised and resolved on 10/11/16. Interventions: Cue resident using task segmentation. Encourage well-fitting foot wear with shoe laces snuggly tied. Invite to walk to meals/activities as interested and tolerated. Praise resident to build confidence. Review of the Progress Notes for R#135 revealed: A Social Service note dated 10/18/16 documented R#135 wears WanderGuard bracelet due to wandering behavior. A Social Service note dated 10/25/16 documented resident continues to wander, WanderGuard in place. A Health Status note on 10/29/16 at 2:46 a.m. documented Res was ambulating with walker and went out the front door and fell in the parking lot near c-hall bldg. Res complaining of right hip pain. Staff member stays with res as this nurse calls 911. Res transferred to NSF hosp (sic). Voicemail left for Family members (names). Health Status note dated 11/3/16 at 12:31 a.m. indicated R#135 returned to the facility on [DATE] at 6:30 p.m. had a right hemiarthroplasty on 10/31/16 from a fall on 10/28/16. Interview with family member of R#135 on 12/19/16 at 9:00 a.m. in the resident's room revealed the resident fell on the night of the Halloween party in October, 2016. The party was in the in the dining room. The Family put the resident to bed at 8:30 p.m. At 9:30 p.m., the resident went outside and fell behind a car. Someone heard her crying out. The facility sent the resident to the hospital. R#135 sustained a hip fracture that required replacement at the hospital. The family of R#135 stated that the facility has video of R#135 walking in the parking lot around the cars. R#135 had a WanderGuard bracelet on her left arm. The family member of R#135 further stated that the resident walked with a walker before the fall. She was animated an actively participated in the Halloween party. Now R#135 is bedbound and on Hospice. The facility staff hadn't said too much about the WanderGuard alarm going off. R#135 walked out with someone who had come to the party. R#135 has Alzheimer's. Now she can't do anything. Now, she sleeps all the time. Interview with R#135's power of attorney (POA) on 12/21/16 at 10:22 a.m. in the D hall day room validated that R#135 was put to bed at 8:30 p.m. on 10/28/16. The POA said that R#135 would not change her clothes. She had a sweater and pants on with her nightgown on top of her clothes. The POA removed the resident's shoes and covered her up. The POA further stated she waved good bye to the staff so that they would know she was leaving the facility. R#135 was admitted into the hospital and had x-rays before the family arrived. They were told R#135's hip was broken. R#135's hip joint was replaced on 10/31/16. R#135's POA commented that before her fall, R#135 could walk all over with her walker, this was not the first time that she had gotten out. She got out the back door, once. The POA also stated that the Administrator told the family that there were some students standing outside talking. A person opened the door and let R#135 out of the front door. R#135 went into the parking area. R#135's POA added that the family cannot find out whether the WanderGuard alarm went off. Since then they have replaced the door alarm. The POA stated R#135 has had the WanderGuard on her body. She will leave with a crowd. When the family visits they take her out. Interview with the Administrator 12/21/16 at 11:53 a.m. in the conference room revealed that there was a Halloween event in the facility on the night of 10/28/16. R#135 went outside and fell in the parking lot that night. A volunteer reset the WanderGuard alarm because she thought that the resident could go outside alone, unsupervised. The facility has changed the system because of the inconsistency of the WanderGuard system and the ease of residents eloping. The volunteer failed to check the facility's wanderers identification book which would have identified R#135 as a wanderer. Further interview with the Administrator on 12/22/16 at 9:50 a.m. in the Administrator's office revealed that the facility surveillance video showed R#135 walked out of the building while a volunteer was coming into the facility held the door for her. The WanderGuard alarm did sound but a volunteer reset the code on the door and stopped the alarm. There were six or eight volunteers outside the door of the facility. The Administrator stated she honestly didn't think the volunteer contract mentions specific behaviors for volunteers related to residents that wander. The Administrator said she spoke to the volunteer supervisor. The supervisor of the volunteers did some teaching with them. The Administrator was unable to find a policy for the volunteers. Instead she provided the volunteer orientation packet. Review of facility records dated 8/9/16 indicated a financial quote for a replacement of the patient wandering system for five door locations and the addition of a patient wandering system on two additional door locations. Going with a different manufacturer from the existing system will required that all wrist tags be replaced for the residents, as the existing wrist tags are not compatible with the new proposed system. The quote included the front door, B hall exit, C hall exit, D hall exit and patio exit door locations and two additional door locations. Review of document titled Contract Invoice # for the door security replacement system dated 10/21/16 indicated a payment was made on 10/21/16 with an outstanding balance of less than 50 percent. Review of the Roam Alert Installation Dates documentation dated 12/21/16 indicated the initial install date was 10/19 -10/20/16. On 11/8/16 two remaining doors were added. On 11/17/16 the contractor worked on the B hall door due to the loitering setting not working. On 11/18/16 the contractor wired two doors to release upon fire alarm activation. On 12/6/16 the contractor returned to discuss putting a keypad on exterior of doors and/or relocate the exciter antenna. Review of Step Five Bypassing the Door Controller of the Access Keypad Installation Guide for the Roam Alert System indicated there were three automatic times enabled by the system when the bypass function is activated: Bypass timeout: The user has 10 seconds to enter the detection zone after the bypass code is entered. If no Tag enters the zone within the 10-second period, the bypass is terminated. Transport: Once the Tag enters the detection zone, the user has 90 seconds to transport the patient through the zone before the alarm is activated. Rearm: Once the Tag is through the zone or the door closes, the system will automatically reset itself in eight seconds. Observation of the residents with Roam Alert bracelets with the Social Service Director on 12/21/16 at 12:25 p.m. revealed 12 of 13 residents observed with Roam Alert bracelets in place and in working order. R#182's bracelet was not on the resident. R#182 said that she removed her bracelet herself. Interview with the Social Service Director in her office on 12/21/16 at 12:36 p.m. revealed that an in-service about the Roam Alert system was provided to the managers when the system was installed. Interview and observation of the door alarm system with the maintenance director on 12/21/16 at 1:03 p.m. revealed test of the C hall egress door indicated a chirping sound when the Roam Alert bracelet was near the door. Subsequent tests on the B hall egress door revealed the same results. There was a chirping sound when a resident was near the door. Each door tested sounded a loud screeching sound when Roam Alert bracelet was brought back into the facility after the bypass alarm had reset. The facility failed to ensure that R#135 was supervised by staff and failed to ensure that an appropriate response to the wandering alert system by staff and volunteers. 2. Record review revealed R#182 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Hospital admission due to mental status changes and shortness of breath with a readmission to the facility on [DATE]. Review of Admission Minimum Data Set (MDS} assessment revealed an admission date of [DATE]. R#182 required supervision with walking in room and corridor which involved oversight, encouragement, or cueing. No physical support from staff was needed. A Brief Interview for Mental Status (BIMS) revealed a score of six indicating severe cognitive impairment. R#182 was noted to frequently have trouble concentrating on things, such as watching TV. R#182 did not exhibit any wandering behavior. A review of the physician's orders [REDACTED]. Review of the resident's care plan initiated 8/18/16 identified R#182 had a problem with wandering due to disorientation. The interventions included distracting the resident from wandering and the use wander alert bracelet. However, the care plan interventions did not include placement checks every shift as ordered by physician. A review of a facility form titled Wanderer Data Collection Tool dated 8/17/16 revealed the resident was assessed as elopement/wanderer risk. However, the sections for interventions implement and care plan were left blank. A review of the resident's admission summary dated 8/17/16 at 6:56 p.m. revealed R#182 arrived in private vehicle from NSFH. She is alert w/ confusion. WanderGuard placed on wrist due to history (hx) of wandering previously. Wander Data Collection Tool completed, information was provided by a family member of R#182. A review of a social service note dated 8/24/16 at 11:13 a.m. revealed R#182 is a long-term care resident. She states that her vision and hearing are adequate. She was able to understand social service staff in normal conversation. She indicates that she wears glasses all of the time. R#182 has a BIMS score of six. She states that she has had a few days of trouble concentrating. She has a WanderGuard bracelet on, due to her wandering behavior. R#182 has a DNR set in place. Social service staff will continue to monitor for changes. The facility was unable to provide documentation that the resident's WanderGuard bracelet was checked for placement every shift from admission on 8/17/16 to 9/25/16 in accordance with the physician's orders [REDACTED]. A review of the resident's MDS PPS 14-Day/Quarterly assessment with re-admission date of [DATE] and Assessment Reference Date (ARD) of 10/18/16 revealed R#182 walked in room and hallway independently, no help or staff oversight was needed at any time. A Staff Assessment for Mental Status was conducted and R#182 was coded with short and long term memory problems. R#182 was coded with ability to recall current season, location of own room, staff names and faces, and that she is in a nursing home. Cognitive skills for daily decision making was coded as independent, decisions consistent/reasonable. R#182 did not exhibit any wandering behavior. A review of the social service note dated 10/5/16 at 5:43 p.m. revealed R#182 recently readmitted to facility. Nursing staff reports no wandering behavior. Staff will continue to monitor for wandering behaviors. No (WanderGuard) bracelet at this time. A review of the resident's care plan revealed a revision date of 10/5/16 revealed the resident's problem with wandering due to disorientation was resolved and the use of the WanderGuard bracelet was resolved. Further review of the resident's care plan failed to reveal a revision of the care plan interventions to include the new physician's orders [REDACTED]. physician's orders [REDACTED].#182 noted for WanderGuard for safety. Check placement every shift. Review of Medication Administration Record (MAR) for R#182 for October, 2016, revealed WanderGuard was checked for placement on 10/11/16 through 10/13/16. No further placement monitoring was documented from 10/13/16 through 10/31/16. Review of Resident Alert Bracelet(s) Checklist revealed R#182 was documented as in hospital 10/1/16 through 10/31/16. No WanderGuard placement was documented after re-admission to the facility from the hospital on [DATE]. Record review revealed Wander Data Collection Tool dated 10/11/16 indicates R#182 is a risk for wander/elopement risk. The tool also documents as an intervention the resident requires frequent monitoring with checks every shift. Review of social service note dated 10/12/16 at 5:06 p.m. revealed social service staff informed daughter that R#182 does not have a WanderGuard on at this time, due to not qualifying for it. Social service staff informed her that she has not been trying to leave at this time, but that if staff notices any differences, nursing staff will redo the assessment. Social service staff will continue to monitor for changes. Psychiatric Diagnostic Evaluation: dated 10/26/16 revealed R#182 was non-compliant with safety, very disoriented, mixed up at times, stated I'm in Milwaukee, poor safety awareness and forgets (oxygen), and can walk with rollator. A physician's orders [REDACTED].#182 noted to clarification - DC WanderGuard for safety. Review of Functional Abilities and Goals assessments dated 11/29/16, 11/30/16, and 12/1/16 revealed R#182's mobility as independent. A review of the Health Status notes revealed the following: 11/22/2016 at 6:53 p.m.- R#182 alert and verbal with confusion. Up ambulates in hallways ad lib though needs assistance to get back to room and put on 02 due to confusion. Removes 02 frequently and ambulates in facility. 12/5/2016 at 3:59 a.m. Received R#182 in bed, alert and confused, resident continually refused to keep O2 on and becomes belligerent and agitated when redirected. 12/8/2016 at 7:17 a.m. R#182 is confused and occasionally there is difficulty in redirecting. 12/18/2016 at 3:45 a.m. R#182 noted to have increased confusion. Record review of Social Service Note dated 12/19/2016 at 6:03 p.m. revealed Social worker observed R#182 outside on front porch, very cold and walking toward parking lot (had left rollator and oxygen inside). Social worker stepped outside and asked R#182 why she was out there. R#182 stated a man asked her to come outside. Social worker asked what man and R#182 was unable to name anyone and there was not a man outside. R#182 came inside with social worker and walked to the dining room for dinner. Social worker informed nursing staff and nursing staff to do assessment. Review of Nurse's Note dated 12/19/2016 at 7:26 p.m. for R#182 revealed WanderGuard for safety was initiated. Message was left for daughter. MD was notified. physician's orders [REDACTED]. Review of the Wander Data Collection Tool dated 12/19/16 indicated R#182 was a risk for wander/elopement risk. Evaluation Factors noted R#182 was known to wander, did wander at home, in previous settings, and family voiced concerns. Wandering placed R#182 at significant risk of getting to a potentially dangerous place such as stairs or outside the facility. Wandering was noted to intrude on the privacy or activities of others. R#182 was noted to ambulate independently with or without the use of assistive devices. She was noted to have expressed the desire to leave the facility and seeking to find family. Care plan addressing R#182's wandering due to disorientation to place initiated on 8/18/16 was noted as resolved and was revised on 12/19/16. Review of care plan addressing risk for elopement dated 12/19/16 revealed goal of R#182 will not leave facility unattended through the next review date of 2/13/17. Interventions were noted to provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. No interventions were initiated to include the use of a WanderGuard with nursing checking for placement every shift. Documentation provided by the Risk Manager in the conference room dated 12/21/16 at 10:00 a.m. revealed that there have been zero resident elopements off the facility property throughout the course of 2016. Risk Manager stated that the premise's perimeters noted in the Elopement policy and procedure are used to determine if an elopement occurred. Observation conducted on 12/19/16 at 3:15 p.m. in hallway revealed R#182 ambulating without staff assistance. Ambulation was not noted without a purpose as evidenced by resident going to and within the same area multiple times. R#182 was pleasant and smiled but did not engage in conversation. Attempt at interview was unsuccessful. Additional observation 12/21/16 at 12:25 p.m. revealed R#182's bracelet was not on the resident. R#182 said that she removed her bracelet herself. Interview was conducted on 12/21/16 at 3:00 p.m. with the DON confirmed she was aware of R#182 going outside by herself on 12/19/16. Since R#182 did not leave the parking lot she did not elope from the facility and no incident investigation was conducted. An assessment was done after she was brought back inside from the parking lot and a WanderGuard was put on her. R#182's daughter was notified. Physician was notified and he gave the nurse an order for [REDACTED]. Interview and record review for R#182 was conducted on 12/22/16 at 2:30 p.m. in the conference room with the Director of Nursing (DON). She confirmed the physician's orders [REDACTED]. The DON confirmed that no elopement risk assessment was conducted and the WanderGuard was not used or monitored from 10/13/16 through 10/31/16. However, physician's orders [REDACTED]. Follow-up interview was conducted on 12/22/16 at 1:40 p.m. with DON in the conference room to request copies of Wander Data Collection Tool dated 10/13/16 and 10/31/16. She stated no assessments for risk for elopement were completed on 10/13/16 when nurse's no longer used or monitored R#182's WanderGuard. Also no assessment was completed on 10/31/16 when WanderGuard was discontinued. Interview conducted on 12/22/16 at 9:20 a.m. at the nurses' station with LPN YY revealed R#182 frequently walks around the facility by herself. Interview conducted on 12/22/16 at 9:15 a.m. at the nurses' station with Certified Nursing Assistant (CNA) XX revealed R#182 was sick in October and she needed some extra help but she's been back to normal for the past couple months. She has walked around by herself since she's been feeling better. She walks wherever she wants to go by herself.