Every finding on record at Civita Care Bayview

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of four (4) residents (Residents #1 and #2) reviewed for medication management, the facility failed to ensure accurate control, handling, administration, and documentation of controlled medications; failed to follow facility procedures for reconciling and accounting for controlled substances; and failed to ensure discrepancies were identified, reported, and investigated as required. The findings include:1. Resident #1 was admitted to the facility on [DATE] with diagnoses including phantom limb syndrome with pain, orthopedic aftercare following surgical amputation, absence of the left leg below the knee, and type II diabetes mellitus with a right heel foot ulcer.A physician's order dated 7/16/26 directed administration of oxycodone 5 milligrams (mg) every four (4) hours as needed for moderate pain and 10 mg every four (4) hours as needed for severe pain.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required supervision for bed mobility and substantial assistance for transfers and mobility with a manual wheelchair.The Resident Care Plan (RCP) dated 7/23/26 identified Resident #1 had complaints of pain and a surgical wound from a left below-the-knee amputation due to diabetic foot infection/ulcer. Interventions included administering pain medications as ordered and assessing pain characteristics.The facility Reportable Event (RE) dated 7/29/26 identified that at 8:00 AM, Resident #1 reported to LPN #3 that LPN #1 had administered the wrong medication. Resident #1 saved the medication and did not swallow it. The order was verified, the correct medication was administered, police were notified, and LPN #1 was suspended pending investigation. Additional residents on the unit were evaluated for pain with no reported issues.The July 2026 Medication Administration Record (MAR) identified LPN #1 signed off administration of oxycodone 10 mg for a pain level of 6/10 on 7/29/26 at 6:12 AM, with no additional PRN oxycodone documented that day.The Controlled Drug Record (CDR) identified LPN #1 signed out two (2) oxycodone 5 mg tablets at 6:40 AM and two (2) additional oxycodone 5 mg tablets at 6:50 AM, leaving two (2) tablets unaccounted for.A statement dated 7/29/26 by the Administrator identified he was present during a phone call in which LPN #1 reported taking two (2) oxycodone 5 mg tablets because she was in pain.Interview with Resident #1 on 8/25/26 at 10:12 AM identified that shortly after 6:00 AM on 7/29/26, he/she requested oxycodone from LPN #1. LPN #1 returned with medication in a cup. Resident #1 became suspicious of the size and shape of the pills, removed them after LPN #1 left the room, and provided them to LPN #3, who confirmed they were not oxycodone. LPN #1 then administered two (2) pills identified as oxycodone. Resident #1 reported prior concerns because pills administered by LPN #1 had appeared different on previous occasions.Re-review of the CDR compared to the July 2026 MAR identified two (2) additional oxycodone 5 mg tablets signed out by LPN #1 on 7/29/26 at 2:16 AM that were not documented on the MAR, leaving an additional two (2) tablets unaccounted for. LPN #1 had administered oxycodone to Resident #1 nine (9) times prior to the 7/29/26 incident.Interview with LPN #2 on 8/25/26 at 11:11 AM identified multiple complaints over the prior year from former residents who reported remaining in pain despite pain medications being documented as administered by LPN #1. Some residents reported pain medications had been signed out as given but were not received. LPN #2 reported LPN #1 was often excessively tired and slurred her speech and that she had informed the DON the previous summer. LPN #1 continued working.Interview with LPN #3 on 8/25/26 at 11:39 AM identified that when she went to Resident #1's room shortly after 8:00 AM on 7/29/26, Resident #1 gave her two (2) pills and reported they were the wrong shape and size. LPN #3 reported LPN #1 initially identified the medication as oxycodone, then indicated it may have been Lasix. LPN #1 subsequently administered the oxycodone. LPN #3 reported the pills appeared to be allergy pills.Interview with LPN #4 on 8/25/26 at 11:50 AM identified no resident concerns but reported LPN #1 was often overly tired and shift report took a long time.Interview with LPN #1 on 8/25/26 at 1:44 PM identified she could not recall reporting that she took oxycodone for personal use. She described mixing up allergy pills with oxycodone while preparing medications at the cart and acknowledged she should not have taken facility medications for personal use. She could not explain the additional two (2) oxycodone tablets signed out at 2:16 AM.Interview with RN #2 on 8/25/26 at 3:23 PM identified LPN #1 would often report taking medications before work, appeared excessively tired, and sometimes fell asleep while talking. RN #2 did not report these concerns to administration.Interview with the DON on 8/25/26 at 3:54 PM identified she was not aware of resident or staff concerns regarding LPN #1 prior to 7/29/26. The DON identified that licensed nurses were required to document controlled substances on both the CDR and MAR and that the two (2) oxycodone 5 mg tablets signed out at 2:16 AM but not documented on the MAR were unaccounted for. The DON could not rule out additional misappropriation.2. Resident #2's diagnoses included malignant neoplasm of the supraglottis, pain, and anxiety disorder.A physician's order dated 6/23/26 directed administration of hydromorphone 2 mg by mouth every six (6) hours as needed for moderate to severe pain.The 5-day MDS assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with bed mobility and transfers.The RCP dated 6/27/26 identified Resident #2 had complaints of pain related to paracentesis, squamous cell cancer of the right neck, status post chemotherapy and radiation, and malignant neoplasm of the supraglottis. Interventions included assessing pain characteristics and administering pain medications as ordered.Interview with Resident #2 on 8/25/26 at 10:45 AM identified several instances since July 2026 when he/she requested PRN pain medication on first shift but was told it was too soon because LPN #1 had signed the medication out as given, although Resident #2 denied receiving it.Interview with LPN #2 on 8/25/26 at 11:11 AM identified Resident #2 reported a similar incident approximately one month earlier. LPN #2 reported she did not report the concern because the CDR showed the medication had been signed out.The July 2026 MAR identified LPN #1 documented hydromorphone 2 mg as administered to Resident #2 on 7/1/26 at 6:41 AM, 7/2/26 at 6:52 AM, 7/11/26 at 11:31 PM, and 7/24/26 at 12:20 AM.The CDR identified hydromorphone signed out by LPN #1 on 7/1/26 at 6:42 AM, 7/2/26 at 6:50 AM, 7/3/26 at 6:45 AM, 7/10/26 at 3:08 AM, 7/11/26 at 11:32 PM, 7/15/26 at 6:50 AM, and 7/24/26 at 12:19 AM. On 7/26/26, LPN #1 signed out two (2) tablets at 4:00 AM. Four (4) administrations documented on the CDR were not documented on the MAR and were unaccounted for.Interview with LPN #1 on 8/25/26 at 1:44 PM identified she was unsure why the MAR and CDR did not match and reported she should have documented each administration.Interview with the DON on 8/25/26 at 3:54 PM identified she was unaware of Resident #2's concerns. The DON identified that hydromorphone should be documented on both the MAR and CDR and that misappropriation could not be ruled out for the unaccounted tablets.The Controlled Substances policy dated 5/1/26 directed, in part, that the facility must comply with requirements for the handling, storage, disposal, and documentation of controlled medications; reconcile controlled substances at receipt, administration, disposition, and end of each shift; document receipt, administration, waste, and destruction with a witness; immediately report discrepancies; and maintain procedures to prevent loss or diversion.The Administration of Medications policy dated 8/2/26 directed, in part, that staff must verify orders, review care plans, confirm medication labels and doses, complete pre-administration assessments, remain with residents until medications are taken, and ensure accurate documentation and reporting.A Plan of Correction for past non-compliance with a compliance date of 8/3/26 was submitted and accepted by the state agency during an on-site visit on 8/25/26:The plan of correction included:Licensed nursing staff were re-educated on controlled-substance accountability, accurate and timely MAR/eMAR documentation, narcotic sign-out procedures, shift-to-shift counts, PRN effectiveness documentation, medication security, and immediate reporting of any discrepancy.The DON/ ADON/designee would audit five residents receiving controlled substances to verify provider orders, MAR/eMAR documentation, narcotic sign-out records, pharmacy dispensing information, and remaining medication quantities reconcile appropriately.Controlled-substance reconciliation audits would be completed daily for 14 days, weekly for 8 weeks, and then monthly for 3 months. Medication-pass observations would be completed weekly for 8 weeks. Audit results and trends would be reviewed by the DON/ Administrator and reported through QAPI.

Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of four (4) residents (Residents #1 and #2) reviewed for misappropriation of medications, the facility failed to ensure residents were free from misappropriation of controlled medications and failed to ensure controlled medications were accurately administered, documented, reconciled, and investigated when discrepancies occurred. The findings include:1. Resident #1 was admitted to the facility on [DATE] with diagnoses including phantom limb syndrome with pain, orthopedic aftercare following surgical amputation, absence of left leg below the knee, and type II diabetes mellitus with right heel foot ulcer.A physician's order dated 7/16/26 directed oxycodone 5 mg every four (4) hours as needed for moderate pain and 10 mg every four (4) hours as needed for severe pain.The admission Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition (Brief Interview for Mental Status (BIMS) score of 15).The Resident Care Plan (RCP) dated 7/23/26 identified pain and a surgical wound related to the left below-the-knee amputation, with interventions including administering pain medications as ordered and assessing pain characteristics.A Pain Evaluation dated 7/26/26 identified continued left below-the-knee and knee pain described as aching, dull, and nagging, with medications reported to resolve the pain.The facility Reportable Event (RE) dated 7/29/26 identified that at 8:00 AM, Resident #1 reported to LPN #3 that LPN #1 had administered the wrong medication for pain. Resident #1 had saved the medication and did not swallow it. The order was verified, the correct medication was administered, police were notified of possible medication misappropriation, and LPN #1 was suspended pending investigation.The July 2026 Medication Administration Record (MAR) identified LPN #1 documented oxycodone 10 mg as administered for a pain level of 6/10 on 7/29/26 at 6:12 AM, with no additional as-needed oxycodone documented that day.The Controlled Drug Record (CDR) identified LPN #1 signed out two (2) oxycodone 5 mg tablets at 6:40 AM and two (2) additional tablets at 6:50 AM, leaving two (2) tablets unaccounted for. Re-review of the CDR compared to the MAR identified two (2) additional oxycodone 5 mg tablets signed out by LPN #1 at 2:16 AM that were not documented on the MAR, leaving another two (2) tablets unaccounted for. LPN #1 had administered oxycodone to Resident #1 nine (9) times prior to the incident.A statement by the Administrator dated 7/29/26 identified he was present during a telephone call in which LPN #1 reported taking the two (2) oxycodone 5 mg tablets because she was in pain.Interview with Resident #1 on 8/25/26 at 10:12 AM identified that shortly after 6:00 AM on 7/29/26, Resident #1 requested oxycodone for pain. LPN #1 returned with medication in a cup. Resident #1 became suspicious of the tablets' size and shape, removed them from the mouth after LPN #1 left, and provided them to LPN #3, who confirmed they were not oxycodone. Resident #1 reported LPN #1 indicated the medication may have been Lasix. LPN #1 subsequently administered two (2) tablets identified as oxycodone. Resident #1 reported experiencing moderate pain from the initial request until receiving the prescribed medication and felt comfortable within approximately 30 minutes. Resident #1 also reported receiving tablets of different shapes and sizes from LPN #1 on at least three (3) prior occasions, with pain not relieved after those administrations.Interview with LPN #2 on 8/25/26 at 11:11 AM identified multiple complaints over the prior year from former residents who reported remaining in pain despite medications being documented as administered by LPN #1. Some residents reported medications had been signed out by LPN #1 although they had not received them. LPN #2 reported informing the Director of Nursing (DON) the previous summer and identified LPN #1 was often excessively tired and slurred her speech.Interview with LPN #3 on 8/25/26 at 11:39 AM identified Resident #1 provided her the two (2) tablets and reported they were identified by LPN #1 as oxycodone. LPN #3 reported LPN #1 initially indicated she had administered oxycodone, then indicated it may have been Lasix, and subsequently administered oxycodone to Resident #1. LPN #3 identified the medications were not similar in appearance and reported LPN #1 often appeared tired.Interview with LPN #1 on 8/25/26 at 1:44 PM identified she had placed two (2) allergy tablets in a medication cup for personal use, signed out two (2) oxycodone 5 mg tablets in another cup, and ingested what she believed were the allergy tablets. LPN #1 then brought the cup containing the oxycodone to Resident #1. When questioned by LPN #3, LPN #1 reported she had administered the oxycodone, although she could not explain why she subsequently indicated the medication may have been Lasix. LPN #1 identified she should not have taken facility medications for personal use and could not explain the additional two (2) oxycodone tablets signed out at 2:16 AM or where they went.Interview with RN #2 on 8/25/26 at 3:23 PM identified LPN #1 frequently communicated having taken medications prior to shifts and was often excessively tired or dozing while speaking. RN #2 did not report these concerns because LPN #1 completed her work.Interview with the DON on 8/25/26 at 3:54 PM identified staff were prohibited from taking facility stock or resident-labeled medications for personal use and that concerns regarding possible impairment or misappropriation should have been investigated immediately. The DON identified LPN #1 admitted to misappropriating Resident #1's oxycodone. The DON also identified controlled substances were required to be documented on both the CDR and MAR and acknowledged the additional oxycodone signed out at 2:16 AM was not documented on the MAR and remained unaccounted for, such that additional misappropriation could not be ruled out.2. Resident #2 had diagnoses including malignant neoplasm of the supraglottis, pain, and anxiety disorder.A physician's order dated 6/23/26 directed hydromorphone 2 mg by mouth every six (6) hours as needed for moderate to severe pain.The 5-day MDS assessment dated [DATE] identified intact cognition (Brief Interview for Mental Status (BIMS) score of 15).The RCP dated 6/27/26 identified pain related to frequent paracentesis, newly diagnosed squamous cell cancer of the right neck, status post chemotherapy and radiation, and malignant neoplasm of the supraglottis. Interventions included assessing pain characteristics and administering pain medications as ordered.Interview with Resident #2 on 8/25/26 at 10:45 AM identified several instances since July 2026 when Resident #2 requested pain medication and was told it was too soon because LPN #1 had already signed the medication out, although Resident #2 had not received it. Resident #2 reported these missed doses resulted in moderate neck pain.Interview with LPN #2 on 8/25/26 at 11:11 AM identified Resident #2 had reported approximately one month earlier that pain medication could not be administered because LPN #1 had signed it out as administered on the CDR, although Resident #2 denied receiving it. LPN #2 did not report the concern because the medication had been signed out and she assumed it had been administered.The July 2026 MAR identified LPN #1 documented hydromorphone 2 mg as administered to Resident #2 on 7/1/26 at 6:41 AM, 7/2/26 at 6:52 AM, 7/11/26 at 11:31 PM, and 7/24/26 at 12:20 AM.The CDR identified hydromorphone 2 mg signed out by LPN #1 on 7/1/26 at 6:42 AM, 7/2/26 at 6:50 AM, 7/3/26 at 6:45 AM, 7/10/26 at 3:08 AM, 7/11/26 at 11:32 PM, 7/15/26 at 6:50 AM, and 7/24/26 at 12:19 AM, with two (2) tablets signed out on 7/26/26 at 4:00 AM. Four (4) administrations were not documented on the MAR and were unaccounted for.Interview with LPN #1 on 8/25/26 at 1:44 PM identified she could not explain why the MAR and CDR did not match and acknowledged each administered dose should have been documented on the MAR. LPN #1 denied misappropriating Resident #2's hydromorphone.Interview with the DON on 8/25/26 at 3:54 PM identified hydromorphone should have been documented on both the CDR and MAR and that, because additional hydromorphone tablets were unaccounted for, additional misappropriation could not be ruled out.The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy directed that residents must be free from misappropriation of property; staff must monitor, identify, and report behaviors associated with misappropriation; suspected misappropriation must be reported, investigated, and managed within required timeframes; and corrective and preventive actions must be implemented when misappropriation is identified.The Controlled Substances policy dated 5/1/26 directed that controlled medications be handled, stored, disposed of, and documented in accordance with applicable requirements; reconciled upon receipt, administration, disposition, and at the end of each shift; and that discrepancies be immediately reported and investigated by the Director of Nursing Services. The policy also required procedures to prevent loss or diversion.The Administration of Medications policy dated 8/2/26 directed staff to verify medication orders, confirm the medication, dose, and resident identity, administer medications safely, remain with the resident until medications were taken, and accurately document and report medication administration.A facility policy for Medication Misappropriation was requested but was not available.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for abuse, the facility failed to ensure a thorough investigation was completed following an incident of medication misappropriation. Specifically, the facility failed to interview staff who worked with LPN #1 the morning of the incident and staff who frequently relieved or worked alongside LPN #1. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including phantom limb syndrome with pain, orthopedic aftercare following surgical amputation, absence of left leg below the knee, and type II diabetes mellitus with right heel foot ulcer.A physician's order dated 7/16/26 directed oxycodone 5 milligrams (mg) every four (4) hours as needed for moderate pain and 10 mg every four (4) hours as needed for severe pain.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The Resident Care Plan (RCP) dated 7/23/26 identified Resident #1 had complaints of pain related to a surgical wound from the left below-the-knee amputation, with interventions including administering pain medications as ordered and assessing pain characteristics.The facility Reportable Event (RE) dated 7/29/26 identified that at 8:00 AM, Resident #1 reported to LPN #3 that LPN #1 had administered the wrong medication for pain. Resident #1 saved the medication and did not swallow it. The order was verified, the correct medication was administered, police were notified of possible medication misappropriation, and LPN #1 was suspended pending investigation.The July 2026 Medication Administration Record (MAR) identified LPN #1 documented oxycodone 10 mg as administered for a pain level of 6/10 on 7/29/26 at 6:12 AM.The Controlled Drug Record (CDR) identified LPN #1 signed out two (2) oxycodone 5 mg tablets at 6:40 AM and two (2) additional tablets at 6:50 AM, leaving two (2) tablets unaccounted for. Re-review of the CDR compared to the MAR identified two (2) additional oxycodone 5 mg tablets signed out by LPN #1 at 2:16 AM that were not documented on the MAR, leaving another two (2) tablets unaccounted for.Interview with Resident #1 on 8/25/26 at 10:12 AM identified that shortly after 6:00 AM on 7/29/26, Resident #1 requested oxycodone for pain. LPN #1 returned with medication in a cup, which Resident #1 identified as different in size and shape from the prescribed oxycodone. Resident #1 removed the tablets from the mouth after LPN #1 left the room and provided them to LPN #3, who confirmed they were not oxycodone. Resident #1 reported LPN #1 indicated the medication may have been Lasix. LPN #1 subsequently administered two (2) tablets identified as oxycodone. Resident #1 reported experiencing moderate pain until the prescribed medication was administered and reported the pain resolved within approximately 30 minutes. Resident #1 also reported receiving tablets of different shapes and sizes from LPN #1 on at least three (3) prior occasions, with pain not relieved after those administrations.Interview with LPN #3 on 8/25/26 at 11:39 AM identified Resident #1 provided her the two (2) tablets and reported LPN #1 had identified them as oxycodone. LPN #3 reported LPN #1 initially indicated she had administered oxycodone, then indicated it may have been Lasix, and subsequently administered oxycodone to Resident #1. LPN #3 reported the tablets provided by Resident #1 were not similar in appearance to oxycodone or Lasix and identified LPN #1 often appeared tired.A statement dated 7/29/26 by the Administrator identified he was present during a telephone call in which LPN #1 reported taking two (2) oxycodone 5 mg tablets because she was in pain.Interview with LPN #2 on 8/25/26 at 11:11 AM identified she had received multiple complaints over the prior year from former residents who reported remaining in pain despite medications being documented as administered by LPN #1. Some residents reported medications had been signed out as administered although they had not received them. LPN #2 reported informing the DON the previous summer and identified LPN #1 was often excessively tired and slurred her speech. LPN #2 also identified she frequently relieved LPN #1 at 7:00 AM but was not interviewed or asked to provide a statement following the 7/29/26 incident.Interview with LPN #5 on 8/25/26 at 11:47 AM identified LPN #1 was often very tired. LPN #5 could not recall residents reporting unrelieved pain or requesting pain medications that could not be administered because LPN #1 had signed them out.Interview with LPN #4 on 8/25/26 at 11:50 AM identified she had not received resident concerns related to pain or LPN #1 but reported LPN #1 was often overly tired and shift-to-shift report was lengthy.Interview with LPN #1 on 8/25/26 at 1:44 PM identified she had placed two (2) allergy tablets in a medication cup for personal use, signed out two (2) oxycodone 5 mg tablets in another cup, and ingested what she believed were the allergy tablets. LPN #1 then brought the cup containing oxycodone to Resident #1. When questioned by LPN #3, LPN #1 reported she had administered oxycodone to Resident #1. LPN #1 could not explain why she subsequently indicated the medication may have been Lasix or why an additional two (2) oxycodone tablets were signed out at 2:16 AM and remained unaccounted for. LPN #1 identified she should not have taken facility medications for personal use.Interview with RN #2 on 8/25/26 at 3:23 PM identified LPN #1 frequently communicated having taken medications prior to coming to work and was often excessively tired or dozing while speaking. RN #2 did not report these concerns to administration because LPN #1 completed her work.Review of the facility Accident and Investigation (A&I) dated 7/29/26 and facility schedules identified LPN #2 and LPN #5 frequently relieved LPN #1 at 7:00 AM prior to the incident. The schedules also identified NA #1 and NA #2 consistently worked alongside LPN #1 on the 11:00 PM to 7:00 AM shift and worked the night/morning of the incident. Statements were not obtained from LPN #2, LPN #5, NA #1, or NA #2.Interview with the DON on 8/25/26 at 3:54 PM identified that although LPN #1 admitted to misappropriating resident medications for personal use, she did not complete a thorough investigation that included interviewing staff who frequently relieved LPN #1 at 7:00 AM or staff who worked alongside LPN #1 prior to and during the incident.Although attempted, interviews with NA #1 and NA #2 were not obtained.The Residents Right to Freedom from Abuse, Neglect, and Exploitation policy directed, in part, that residents must be free from misappropriation of their property; staff must monitor, identify, and report behaviors associated with misappropriation; suspected misappropriation must be reported and thoroughly investigated within required federal and state timeframes; and appropriate corrective and preventive actions must be taken when misappropriation is identified.The Controlled Substances policy, dated 5/1/26, directed, in part, that controlled medications be reconciled upon receipt, administration, disposition, and at the end of each shift; discrepancies be immediately reported and investigated by the Director of Nursing Services; and procedures be maintained to prevent loss or diversion.Although requested, a facility policy for Medication Misappropriation was not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for one of three residents (Resident #1) reviewed for medication administration, the facility failed to ensure a PRN treatment and an as needed medication effectiveness were documented timely. The findings include: Resident #1's diagnoses included malignant neoplasm (cancerous tumor) of the left breast, secondary malignant neoplasm of the pleura (lining of the lungs and chest wall), pneumothorax (collapsed lung), chronic pain, anxiety disorder and depression. The admission Evaluation dated 5/9/26 identified Resident #1 was alert to person, place and time, had weakness and impairment to both upper and lower extremities and was independent with bed mobility, required continuous oxygen at 3.0 liters (L) per minute via nasal cannula, and had a PleurX catheter (drain/(a thin flexible tube that's placed in the chest to drain fluid from the pleural space and has a catheter extending outside of the body with a one-way valve that is capped until it is time to be drained) on the right and left sides. The Resident Care Plan (RCP) dated 5/10/26 identified Resident #1 had altered respiratory status/difficulty breathing related to pleural effusions (abnormal buildup of excess fluids between the layers of the pleura surrounding the lungs), had pleural drains, utilized oxygen related to the pleural effusions and had malignant neoplasms and subsequent pain. Interventions directed to drain up to one (1) L from the pleural drains three (3) times weekly on Mondays, Wednesdays and Friday. The Brief Interview for Mental Status (BIMS) Evaluation dated 5/11/26 identified Resident #1 had a BIMS of 14, indicative of intact cognition. A physician order dated 5/10/26 directed to drain the pleural drain as needed (PRN), maximum amount one (1) liter, for difficulty breathing and oxygen level less than 92 percent (%) - on three (3) Liters per minute (l/m) oxygen as needed for Shortness of Breath (SOB) or difficulty breathing. Late entry nursing note by LPN #4 dated 5/12/26 at 10:10 PM identified she drained 400 mL from the right and 250 mL from the left PleurX catheters. The Sp02 was 94%, lung sounds were diminished and Resident #1 was anxious at times. Review of the nursing note identified the note dated 5/12/26 failed to identify why the PleurX catheters were drained, failed to note the Sp02 and lung sounds levels prior to and after the procedure, and a description of the fluid drained during the procedure or a description of the PleurX drain sites prior to the dressing being reapplied. Review of the May 2026 Medication Administration Record (MAR) failed to identify LPN #4 signed the MAR on 5/12/26 to indicate the PleurX catheters were drained in accordance with the physician PRN order PRN. Although attempted an interview with LPN #4 was unable to be obtained during the survey. a. A physician order dated 5/12/26 directed to administer Lorazepam intensol oral concentrate (used to treat anxiety) two (2) milligrams per milliliter (mg/mL), give 0.25 mL sublingually every eight (8) hours as needed for panic/fear/anxiety for 14 days. MAR review identified Lorazepam intensol was administered by LPN #5 on 5/13/26 at 6:30 AM. Nursing note by RN #1 dated 5/13/26 at 11:28 AM identified Resident #1 was observed to be non-responsive with eyes closed and was unable to hold up his/her head at 11:30 AM. Emergency Services was activated, and Resident #1 was transferred to the hospital. Review of Emergency Medical Services run sheet dated 5/13/26 identified EMS was called at 11:38 AM, and they were at the resident at 11:45 AM. Record review failed to identify the effectiveness of the Lorazepam was documented prior to Resident #1's transfer at 11:45 AM (5 hours and 15 minutes after administration). Further, the MAR effectiveness was documented at 2:20 PM as unknown. Interview with LPN #5 on 7/6/26 at 12:04 PM identified she worked on 5/13/26 until 8 AM, and she administered the Lorazepam intensol to Resident #1 on 5/13/26 at 6:30 AM for fidgeting, crying out, and complaints of difficulty breathing. LPN #5 stated she checked on Resident #1 before the end of her shift and Resident #1 was calm with no complaints, and she must have forgotten to document the effectiveness of the Lorazepam, and she should have completed the documentation before the end of her shift. Interview with the DON on 7/6/26 at 1:59 PM identified licensed staff are responsible for reevaluating residents who are administered PRN medication within the hour for effectiveness and documenting it in the MAR. interview failed to identify why it was not completed. Review of the facility Behavior Assessment and Monitoring policy dated 3/2/26 directed, in part, when medications are prescribed and administered for behavioral symptoms, documentation will include monitoring for efficacy and adverse consequences. Review of the Charting Documentation policy dated 10/3/25 directed, in part, the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation will include care-specific details including how the resident tolerated the treatment.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident #1) reviewed for care and services, the facility failed to ensure adequate supplies (drainage kit) to manage a PleurX catheter prior to Resident #1's admission, resulting in Resident #1 being transferred to the hospital. The findings include: Resident #1's diagnoses included malignant neoplasm (cancerous tumor) of the left breast, secondary malignant neoplasm of the pleura (lining of the lungs and chest wall), pneumothorax (collapsed lung), chronic pain, anxiety disorder and depression. The admission Evaluation dated 5/9/26 identified Resident #1 was alert to person, place and time, had weakness and impairment to both upper and lower extremities and was independent with bed mobility, required continuous oxygen at 3.0 liters (L) per minute via nasal cannula, and had a PleurX catheter (drain/(a thin flexible tube that's placed in the chest to drain fluid from the pleural space and has a catheter extending outside of the body with a one-way valve that is capped until it is time to be drained) on the right and left sides. A physician order dated 5/9/26 directed to drain the right-side and the left-side pleural drain up to 1.0 Liter three (3) times per week on Monday, Wednesday and Friday on the day shift. A physician order dated 5/10/26 directed to drain the pleural drain as needed, maximum amount one (1) liter, for difficulty breathing and oxygen level less than 92 percent (%) - on 3 Liters per minute (l/m) oxygen as needed for Shortness of Breath (SOB) or difficulty breathing. The Resident Care Plan (RCP) dated 5/10/26 identified Resident #1 had altered respiratory status/difficulty breathing related to pleural effusions (abnormal buildup of excess fluids between the layers of the pleura surrounding the lungs), had pleural drains, utilized oxygen related to the pleural effusions and had malignant neoplasms and subsequent pain. Interventions directed to drain up to one (1) L from the pleural drains three (3) times weekly on Mondays, Wednesdays and Friday. The Brief Interview for Mental Status (BIMS) Evaluation dated 5/11/26 identified Resident #1 had a BIMS of 14, indicative of intact cognition. A nursing note by LPN #2 on 5/10/26 at 2:43 AM identified Resident #1 reported feeling SOB and requested to have his/her pleural drain emptied. Vital signs were obtained and blood pressure was 87/42 (hypotensive/low blood pressure), heart rate was 111 (tachycardic/fast heart rate) and oxygen level was 96% (normal 90% and above) on 3.0 L of supplemental oxygen. The note indicated equipment was unavailable for the pleural drain, the on-call provider was notified, and orders were obtained to transfer Resident #1 to the hospital to evaluate and manage the PleurX catheter. Ambulance run sheet dated 5/10/26 identified Resident #1 reported feeling SOB, and Resident #1 indicated that was how he/she feels when the PlureX catheter is not drained at night. Staff reported they did not have the equipment to drain the PleurX. Lung sounds were diminished in the lower fields, blood pressure was 108/74, heart rate was 108 (tachycardic), respirations were 20 and oxygen level was 99%. A nursing note dated 5/10/26 at 11:28 AM identified, Resident #1 returned from the hospital and after the hospital emptied the pleural drains. Hospital sent two (2) additional drain bottles for use until more were able to be ordered by the facility. Interview with LPN #3 on 7/6/26 at 11:45 AM identified he completed Resident #1's admission on [DATE] (Saturday) and stated Resident #1 did not arrive at the facility with any PleurX drainage kits, which includes the catheter drainage line and vacuum bottles. LPN #3 stated the facility did not have supplies prior to Resident #1's admission and LPN # identified he did not order them or notify anyone the supplies were needed. LPN #3 was unable to explain why the supplies were not ordered. Interview with LPN #2 on 7/6/26 at 12:11 PM identified on 5/10/26 when Resident #1 complained of SOB, she looked for the drainage kits but was unable to locate any. She notified RN #4 and stated RN #4 did not locate any so Resident #1 was transferred to the hospital to have the PleurX drained. LPN #2 stated if she had the supplies available she would not have had to transfer Resident #1 to the hospital. Interview with the DON on 7/6/26 at 1:59 PM identified drainage kits should have been ordered for the PleurX prior to Resident #1's admission. The DON stated she thought the facility had supplies available and she was not notified there were no supplies until Resident #1 was transferred to the hospital. interview failed to identify why the facility did not verify supplies were available prior to Resident #1's admission. The DON stated if the supplies were available, Resident #1 would not have required transfer to the hospital. Review of the facility admission Criteria policy dated 2/1/26 directed, in part, residents are admitted to the facility as long as their needs can be met adequately by the facility. Although requested, a facility policy for ordering specialized equipment/treatments prior to admission was not provided for surveyor review.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident #1) reviewed for care and services, the facility failed to ensure staff education was provided prior to a resident admission with a PleurX drainage catheter. The findings include: Resident #1's diagnoses included malignant neoplasm (cancerous tumor) of the left breast, secondary malignant neoplasm of the pleura (lining of the lungs and chest wall), pneumothorax (collapsed lung), chronic pain, anxiety disorder and depression. The admission Evaluation dated 5/9/26 identified Resident #1 was alert to person, place and time, had weakness and impairment to both upper and lower extremities and was independent with bed mobility, required continuous oxygen at 3.0 liters (L) per minute via nasal cannula, and had a PleurX catheter (drain/(a thin flexible tube that's placed in the chest to drain fluid from the pleural space and has a catheter extending outside of the body with a one-way valve that is capped until it is time to be drained) on the right and left sides. A physician order dated 5/9/26 directed to drain the right-side and the left-side pleural drain up to 1.0 Liter three (3) times per week on Monday, Wednesday and Friday on the day shift. A physician order dated 5/10/26 directed to drain the pleural drain as needed, maximum amount one (1) liter, for difficulty breathing and oxygen level less than 92 percent (%) - on 3 Liters per minute (l/m) oxygen as needed for Shortness of Breath (SOB) or difficulty breathing. The Resident Care Plan (RCP) dated 5/10/26 identified Resident #1 had altered respiratory status/difficulty breathing related to pleural effusions (abnormal buildup of excess fluids between the layers of the pleura surrounding the lungs), had pleural drains, utilized oxygen related to the pleural effusions and had malignant neoplasms and subsequent pain. Interventions directed to drain up to one (1) L from the pleural drains three (3) times weekly on Mondays, Wednesdays and Friday. The Brief Interview for Mental Status (BIMS) Evaluation dated 5/11/26 identified Resident #1 had a BIMS of 14, indicative of intact cognition. A nursing note by LPN #2 on 5/10/26 at 2:43 AM identified Resident #1 reported feeling SOB and requested to have his/her pleural drain emptied. The note indicated equipment was unavailable for the pleural drain, the on-call provider was notified, and orders were obtained to transfer Resident #1 to the hospital to evaluate and manage the PleurX catheter. A nursing note dated 5/10/26 at 11:28 AM identified, Resident #1 returned from the hospital and after the hospital emptied the pleural drains. Hospital sent two (2) additional drain bottles for use until more were able to be ordered by the facility. a. Nursing note written by LPN #3 dated 5/11/26 at 9:15 AM identified Resident #1 complained of Shortness of Breath (SOB) and was scheduled to have the PleurX drained. LPN drained both PleurX catheters utilizing a sterile field and gloves; 450 milliliters (mL) was drained from the right side and 250 mL was drained from the left side. Resident #1 reported following the procedure, he/she was able to breathe normally again, was comfortable and Sp02 (blood oxygen levels) returned to baseline. The PleurX sites were then redressed. The note failed to identify the following:Sp02 levels prior to and after the procedure.Lung sounds prior to and after the procedure.A description and color of the fluid drained during the procedure or a description of the PleurX drain sites prior to the dressing being reapplied. Interview and record review with LPN #3 on 7/6/26 at 11:45 AM identified he received training on the PleurX system for another resident a few months prior to Resident #1's admission to the facility. Although he performed the PleurX drainage procedure to Resident #1 on 5/11/26, he was not aware an assessment was required prior to and after the procedure or that he should have documented on the color and consistency of the drainage from each PleurX catheter/drain, and the appearance of the catheter sites prior to redressing the areas. LPN #3 stated he could not recall that was included with training he received, and stated he only received education about the procedure. He was unable to recall what Resident #1's Sp02 levels were prior to and after the procedure, and stated he should have documented the levels in his note and was unsure why he had not done so. b. Nursing note written by LPN #1 dated 5/13/26 at 12:21 identified Resident #1 appeared lethargic, unable to hold head up and refused medications. Supervisor was notified and Resident #1 was transferred to the hospital. Nursing note written by RN #1 dated 5/13/26 at 11:58 AM identified at 11:30 AM Resident #1 was non-responsive with eyes closed and unable to hold his/her head up. Oxygen saturation was 94% (normal 90% and above) on oxygen, heart rate was 105, respirator rate was 28 with use of accessory muscles, and 911 was implemented. Interview and record review with LPN #1 on 7/6/26 at 12:31 PM identified she was the 7:00 AM to 3:00 PM charge nurse on 5/13/26 and around 11:30 AM Resident #1 was lethargic, appeared to be in respiratory distress and sne notified the RN #1. LPN stated she had not been trained on the PleurX system and she had not attempted to drain the PleurX because she was not provided education. Interview with RN #1 on 7/6/26 at 12:57 PM identified she was notified by LPN #1 on 5/13/226 that Resident #1 was in respiratory distress and she assessed the resident. RN #1 stated that she had not been trained recently on the PleurX system or the assessment and documentation requirements. Review of facility in-service documentation identified PleurX education was provided by the Staff Development nurse on 2/27/26 to LPN #3 and verbal education was offered to LPN #4. The education attached for LPN #3 was a printout on the PleurX procedure, but there was no documentation identifying assessment and documentation requirements for residents with a PleurX. Additional facility documentation review failed to identify LPN #1 or RN #1 had received education or training on the PleurX system. An interview with the Staff Development Nurse on 7/6/26 at 1:20 PM identified facility policy required all licensed nurses to be educated and signed off as competent on any specialized equipment and treatments prior to a resident's admission or prior to the start of any shift during which they would be responsible for that resident's care. The Staff Development Nurse (SDN) stated Resident #1 was admitted on a Saturday, and she was off duty and unaware of the admission. The SDN stated in her absence, any supervisor was responsible for providing the required education and training to licensed staff, and if she was notified of the admission, she would have ensured staff were educated and trained prior to Resident #1's arrival at the facility. The SDN stated she attempted to PleurX provide education for LPN #4, however, LPN #4 declined the education offered and had stated she was comfortable with how to perform the procedure. The SDN was unable to provide documentation that education was provided previously for LPN #4 regarding use of the PleurX. Although the SDN stated she provided education regarding assessing and documenting lung sounds and SpO2 levels before and after draining the PleurX system, and assessing, documenting the color and consistency of the drainage and the condition of the catheter site for any changes, she stated she did not have documentation of the education provided. She stated although she educated staff to perform the assessments and documentation, she did not know why staff had not completed them as per her description. Review of facility in-service documentation dated 2/27 and 3/30/26 identified the only RN that received education on the PleurX was the ADON. Interview with APRN #1 on 7/6/26 at 1:35 PM identified staff should be listen to lung sounds before and after draining the catheter, obtain Sp02 levels before and after draining, and document the observed drainage and monitor for changes for all residents with PleurX catheters. Interview with the DON on 7/6/26 at 1:59 PM identified all licensed nurses are required to be educated and signed off as competent on any specialized equipment and treatments prior to a resident's admission or prior to the start of any shift during which they will provide care. The DON stated she was not aware all staff assigned to care for Resident #1 and all nursing supervisors had not received training on the PleurX system and its associated assessment and documentation requirements. The DON stated if she was aware, she would have ensured the required education and training was completed. Review of the facility Specialized Equipment Training and Competency Policy dated 10/3/25 directed, in part, the facility shall ensure that only employees who have successfully completed required education and demonstrated competency are authorized to operate specialized equipment. Training shall be provided before independent use of equipment, whenever new equipment is introduced, when equipment or manufacturer instructions change, following identified competency concerns, and at intervals determined by facility policy or manufacturer recommendations. Employees shall not use equipment for which they have not received training and documented competency validation. Education shall include, as applicable: purpose of equipment, resident selection criteria, indications and contraindications, documentation requirements and return demonstration. Competency shall include: review of written educational materials, demonstration by qualified instructor, return demonstration, verbal questioning when appropriate, observation during resident care, successful skills completion and documentation of training. Employees who do not demonstrate competency shall receive additional education before independent use.

Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of four (4) residents (Residents #1, #2 and #3) reviewed for neglect, the facility failed to ensure allegations of neglect were reported to the State Agency timely (within 2-hours). The findings include:1. Resident #1's diagnoses included mild cognitive impairment, chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissues), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), depressive episodes and anxiety disorder.A physician's order dated 9/13/24 directed Resident #1 be placed on continuous oxygen at 2.0 to 4.0 liters per minute (lpm) via nasal cannula to keep oxygen saturation greater than 90 percent (%) and obtain oxygen saturation every shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required setup assistance with personal hygiene, was independent with bed mobility, transfers and ambulation and utilized oxygen therapy.The Resident Care Plan (RCP) dated 1/28/26 identified Resident #1 had a diagnosis of COPD, asthma, chronic respiratory failure with hypoxia and a history of COPD exacerbation requiring oxygen support. Interventions include administering oxygen and monitoring effectiveness by checking saturation as/if indicated.A nurse's note by LPN #1 dated 4/5/26 at 2:06 PM identified at around 11:00 AM Resident #1's representative (Person #1) arrived to pick up Resident #1 and asked for Resident #1's oxygen tank to be changed but it had been changed a few minutes prior so Resident #1 was fine to go out. They left and returned at around 1:45 PM and while LPN #1 was performing care for another resident, Person #1 waited outside the door, reported the oxygen tank was empty and asked LPN #1 to change the tank. LPN #1 communicated that any other licensed nurse or NA could change the tank because she was in the middle of a dressing change. The note identified Person #1 waited outside the room until LPN #1 was done and then stated the tank was supposed to last four (4) hours, but it was empty within two (2) hours and LPN #1 communicated that Person #1 assumed that LPN #1 did not change the oxygen tank and Person #1 started yelling and carrying on. The note identified LPN #1 then changed the oxygen tank and Person #1 asked for the nursing supervisor.Review of nurse's notes failed to identify a nurse's note from the nursing supervisor (RN #1) dated 4/5/26.A social service note by the Director of Social Services dated 4/6/26 at 12:00 PM identified a call was placed to Person #1 and Resident #1's family with herself, the DON and the ADON when Person #1 updated them on the events from the Leave of Absence (LOA) from the weekend. The note reported a follow-up family meeting was requested and scheduled for 4/9/26.A social service note by the Director of Social Services dated 4/6/26 at 7:29 PM identified, in part, Resident #1's family requested an in-person family meeting with the Interdisciplinary Team (IDT) to discuss care concerns and the recent LOA. She identified a family meeting was scheduled for 4/9/26 at 3:00 PM.A facility Grievance Sheet dated 4/6/26 identified Person #1 reported concerns over the oxygen tank administration and an interaction with staff and Resident #1's family. Education on oxygen with return demonstration was to be given to all nursing staff.A social service note by the Director of Social Services dated 4/9/26 at 12:06 PM identified a family meeting was held to review Resident #1's plan of care. The note reported Resident #1's plan of care was reviewed and they addressed concerns with the oxygen tank and education of staff.Review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/12/26 failed to identify the 4/5/26 incident was reported to the State Agency as an allegation of abuse or neglect.Interview with Person #1 on 5/12/26 at 12:14 PM identified on 4/5/26 he/she took Resident #1 on an LOA but had to return early due to the oxygen tank being almost empty. Person #1 identified when he/she returned to the facility with Resident #1 just before 2:00 PM, LPN #1 was in the hallway at a cart and Person #1 reported that the oxygen tank was empty. LPN #1 stated she was busy and told Person #1 to find someone else to change it and then went into another resident's room. Person #1 identified everyone was busy and LPN #1 made Resident #1 wait over five (5) minutes. When LPN #1 arrived to assist, she yanked the oxygen tubing off the oxygen tank with the nasal cannula still attached to Resident #1's face, almost causing Resident #1 to fall. Person #1 identified he/she immediately reported the prolonged changing of the oxygen tank and the incident with LPN #1 to RN #1 (nursing supervisor) alleging neglect and roughness and then left a voicemail for the Director of Social Services with the timeline of events. Person #1 identified he/she spoke with the DON and Director of Social Services the next day, explaining the chain of events including LPN #1 making Resident #1 wait for more oxygen and the way she roughly pulled the oxygen tubing off the oxygen tank almost causing Resident #1 to fall and the DON reported RN #1 never reported the complaint to her. Person #1 reported during the 4/9/26 meeting, he/she again reported the chain of events and stated it was neglect and abuse. He/she told the DON he/she no longer wanted to visit the building without a witness and the DON identified she would ensure LPN #1 no longer cared for Resident #1 as an intervention.Interview with LPN #1 accompanied by the DON on 5/12/26 at 2:32 PM identified on 4/5/26 she changed Resident #1's oxygen tank to a full tank about fifteen (15) minutes prior to Person #1 arriving to take Resident #1 out on an LOA and ensured it was set to 3.0 lpm. She reported when Person #1 arrived to take Resident #1 out on the LOA, the regulator on the oxygen tank still read that the tank was full. At about 1:45 PM she was in the hallway at the treatment cart when Person #1 approached her and reported Resident #1's oxygen tank was empty. LPN #1 reported she was going to do a dressing change and told Person #1 she needed a few minutes. She further told Person #1 another licensed nurse or NA could change the oxygen tank. She reported she should have confirmed the oxygen tank was empty prior to entering another resident's room and should have checked Resident #1's oxygen level. She identified when she responded, the oxygen tank gauge was in the red area and on low but not completely empty.Interview with RN #1 accompanied by the DON on 5/12/26 at 2:47 PM identified on 4/5/26 Person #1 approached her upset because Resident #1 ran out of oxygen while on an LOA and LPN #1's response time in changing the oxygen tank but could not recall Person #1 reporting LPN #1 yanked the oxygen tubing almost causing Resident #1 to fall. RN #1 reported she immediately reported the complaint to the DON.Interview with the DON on 5/12/26 at 1:13 PM identified she could not recall RN #1 notifying her on 4/5/26 of Person #1's concerns. She recalled being notified on 4/6/26 by Person #1 regarding Resident #1 running out of oxygen on the LOA and LPN #1 not responding immediately but she spoke with LPN #1 who denied Resident #1 ran out of oxygen. The DON indicated she was not aware LPN #1 was in the hallway when Person #1 approached LPN #1 regarding Resident #1's oxygen tank being empty and LPN #1 should have assisted Resident #1 immediately. The DON identified she did not initiate an investigation to include statements from other staff working at the time to include LPN #1 and RN #1 and did not believe the concerns voiced by Person #1 on 4/6/26 were allegations of abuse or neglect so she did not report to the State Agency. The DON identified all allegations of abuse and/or neglect are to be reported to the Stage Agency within two (2) hours and investigated.Interview with the Director of Social Services on 5/13/26 at 8:36 AM identified she could not recall listening to a voicemail on 4/6/26 from Person #1 regarding Resident #1 but she did speak with Person #1 on 4/6/26 who reported concerns about the oxygen becoming empty on the LOA on 4/5/26 and LPN #1's response time. She reported she could not recall what words Person #1 used to describe Resident #1 losing his/her balance when the oxygen tank was changed but identified there were concerns presented by Person #1 regarding the oxygen and LPN #1 that were concerning and should have been addressed immediately. The Director of Social Services reported the DON directed to write up the concerns as a grievance on 4/6/26.2. Interview with Person #2 on 5/13/26 at 1:36 PM identified on 4/20/26 during the 11:00 PM to 7:00 AM shift, NA #3 reported that all the residents on the west unit were independent and frequent rounds did not need to be done, despite the west unit being a short-term rehabilitation unit. Person #2 reported that NA #3 was on her phone all night, turned off call bells from the nurse's station without responding and did not perform rounds until 5:30 AM. Person #2 identified that at that time, residents' sheets were visibly dirty with dried urine and feces, residents were left incontinent all night and dried blood was noted on the floor all night and not cleaned. Person #2 reported the concerns to the staffing scheduler on 4/21/26.Interview with the staffing scheduler on 5/13/26 at 1:36 PM accompanied by the DON identified on 4/21/26, Person #2 reported that during the previous 11:00 PM to 7:00 AM shift on the west unit, residents' beds were dirty, dried blood was on the floor, and it did not appear that care had been provided for the residents. The staffing scheduler identified that she immediately reported the concerns to the DON. Review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/12/26 failed to identify the 4/20/26 incident was reported to the State Agency as an allegation of neglect.Interview with the DON on 5/13/26 at 1:38 PM identified she could not recall the staffing scheduler reporting any lack of resident care on 4/21/26, and that the lack of care was an allegation of neglect which should have been reported to the State Agency within two (2) hours and investigated. Although attempted an interview with NA #3 was not obtained.3. Resident #2's diagnoses included Enterocolitis due to Clostridium Difficile (C. Diff) (inflammation in both intestines caused by a bacteria that causes an infection of the colon), acute kidney failure, adult failure to thrive, need for assistance with personal care and weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was dependent on staff for personal hygiene and transfers, required partial assistance for toileting hygiene and bed mobility and was always incontinent of bowel.The Resident Care Plan (RCP) dated 4/20/26 identified Resident #2 had an Activities of Daily Living (ADL) deficit due to generalized weakness and renal failure, had C. Diff and was incontinent of bowel and/or bladder. Interventions included keeping the call bell and needed items within reach, providing an assist of one (1) with all ADLs, offering to toilet or use the commode before leaving the room for activities, meals or ambulation and upon request and providing incontinent care approximately every two hours and as needed and upon request. Interview with Resident #2 on 5/13/26 at 8:50 AM identified he/she utilized the bedside commode independently on the overnight shift (11:00 PM to 7:00 AM), although he/she is not supposed to, because the call bell it is not answered and no one checks on him/her. Resident #2 identified the bedside commode is rarely emptied on the overnight shift, bed sheets are visibly dirty and staff do not change them unless requested and he/she feels afraid something will happen on the overnight shift and no one will know or respond.Review of the May 2026 Documentation Survey Report (NA documentation) failed to identify any documentation on the overnight shift on 5/1/26, 5/2/26 or 5/8/26 for bladder or bowel tasks.4. Resident #3 's diagnoses included Congestive Heart Failure (CHF), chronic kidney disease stage IV (severe kidney function loss), acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), weakness and depression.The admission assessment dated [DATE] identified Resident #3 was alert and oriented to person, place and time and required partial assistance for self-care, toileting hygiene and transfers. Resident #2 utilized oxygen via a nasal cannula at 2.0 liters per minute.The RCP dated 5/12/26 identified Resident #3 had ADL deficits due to generalized weakness and recent hospitalization, utilized oxygen therapy due to CHF and had a foley catheter intact due to urinary retention. Interventions included performing catheter care every shift and as needed, keeping the call bell and needed items within reach and providing assistance with all ADLs.A Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified Resident #3 was cognitively intact (score of 14). Interview with Resident #3 on 5/13/26 at 8:54 AM identified long wait times when using the call-bell on the overnight shift and staff do not perform safety checks every two (2) hours. Resident #3 reported bowel incontinence the previous night and staff did not assist timely. Resident #3 reported staff do not change the bed linens unless requested. Interview with RN #2 on 5/13/26 at 12:49 PM identified NA's are not doing every two (2) hour rounds, turn off the call bells, do not respond, hide out and play on their phones during the overnight shift. She reported when she would do her own rounds, she would question NA's about turning and repositioning the residents and they would reply they already did and ignore her. The Nas would tell her she cannot do anything about it because they would not be fired. RN #2 identified she reported the concerns to the DON many times but that the staff were never suspended, kept coming to work and she was afraid her car tires would be slashed in retaliation. RN #2 reported she did not feel comfortable naming the NA staff that were ignoring their duties on the overnight shift.Interview with the DON on 5/13/26 at 1:33 PM identified she was unaware there were complaints regarding care and call bell response time. She reported she could not recall licensed nurses reporting that NAs were not doing every 2-hour rounds, toileting residents or turning and repositioning residents. She was unaware that NA's were refusing to perform resident care tasks when directed by licensed nurses and that licensed nurses were afraid of retaliation by the NAs. The DON identified that NAs should complete every 2-hour rounds for all residents, turn and reposition residents per their plan of care and as needed, attend to call bells timely and never turn off call bells without first responding. Linens should be changed daily and when visibly soiled. NAs and other staff should be visible on the unit and not in the break room unless on break and other staff are aware they are on break. The DON reported if she were aware of the allegations of neglect, she would have suspended the employees that were accused of neglect and investigated the allegations immediately Interview with LPN #3 on 5/13/26 at 2:08 PM identified she regularly worked with NA's #2 and #3 on the short-term unit overnight shift and they turn alarming call bells off at the nurse's station and do not respond to the residents rooms, do not perform rounds until after 5:00 AM, do not toilet residents, are rude to the residents, and hide in the break room with the door shut on their phones and sleep. LPN #3 reported when she requested NA #2 or #3 to do something they refused and told her to complain to administration because they cannot be fired. She identified she reported the behavior to the DON multiple times. LPN #3 identified she does her job and the NA's jobs when they refuse to respond. Subsequent to surveyor inquiry, review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/14/26 failed to identify the allegations of neglect reported by this surveyor to the DON on 5/13/26 were reported to the State Agency within two (2) hours as required.Review of the Residents Right to Freedom from Abuse, Neglect and Exploitation policy (undated) directed, in part, staff must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion against any resident. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including, but not limited to: Taking steps to prevent further abuse, reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations, conducting a thorough investigation of the alleged violation, taking appropriate corrective action and the facility will revise the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall: Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported in the proper time frame pursuant to this policy, have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation or mistreatment while the investigation is in progress.Review of the Reportable Events policy dated 9/1/22 directed, in part, that the facility shall identify, classify, document and report all events that meet criteria for reportable incidents under Connecticut DPH regulations. A Class B event includes a complaint or allegation of patient abuse, or any act involving abuse toward a patient by any person. Abuse includes verbal, mental, sexual or physical attack, injury, unreasonable confinement, intimidation or punishment.

Based on clinical record review, facility policy review and staff interviews for two (2) of four (4) sampled residents (Residents #2 and #3) reviewed for neglect, the facility failed to ensure residents were free from neglect on the overnight shift when staff failed to respond timely to call bells, failed to provide incontinent and toileting care, failed to complete required rounds and failed to provide necessary supervision and assistance to residents on the short-term rehabilitation unit. The findings include:1. Resident #2's diagnoses included Enterocolitis due to Clostridium Difficile (C. Diff) (inflammation in both intestines caused by a bacteria that causes an infection of the colon), acute kidney failure, adult failure to thrive, need for assistance with personal care and weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was dependent on staff for personal hygiene and transfers, required partial assistance for toileting hygiene and bed mobility and was always incontinent of bowel.The Resident Care Plan (RCP) dated 4/20/26 identified Resident #2 had an Activities of Daily Living (ADL) deficit due to generalized weakness and renal failure, had C. Diff and was incontinent of bowel and/or bladder. Interventions included keeping the call bell and needed items within reach, providing an assist of one (1) with all ADLs, offering to toilet or use the commode before leaving the room for activities, meals or ambulation and upon request and providing incontinent care approximately every two hours and as needed and upon request.Interview with Resident #2 on 5/13/26 at 8:50 AM identified he/she utilized the bedside commode independently on the overnight shift (11:00 PM to 7:00 AM), although he/she is not supposed to, because the call bell it is not answered and no one checks on him/her. Resident #2 identified the bedside commode is rarely emptied on the overnight shift, bed sheets are visibly dirty and staff do not change them unless requested and he/she feels afraid something will happen on the overnight shift and no one will know or respond.Review of the May 2026 Documentation Survey Report (NA documentation) failed to identify any documentation on the overnight shift on 5/1/26, 5/2/26 or 5/8/26 for bladder or bowel tasks.2. Resident #3 's diagnoses included Congestive Heart Failure (CHF), chronic kidney disease stage IV (severe kidney function loss), acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), weakness and depression.The admission assessment dated [DATE] identified Resident #3 was alert and oriented to person, place and time and required partial assistance for self-care, toileting hygiene and transfers. Resident #2 utilized oxygen via a nasal cannula at 2.0 liters per minute.The RCP dated 5/12/26 identified Resident #3 had ADL deficits due to generalized weakness and recent hospitalization, utilized oxygen therapy due to CHF and had a foley catheter intact due to urinary retention. Interventions included performing catheter care every shift and as needed, keeping the call bell and needed items within reach and providing assistance with all ADLs.A Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified Resident #3 was cognitively intact (score of 14).Interview with Resident #3 on 5/13/26 at 8:54 AM identified long wait times when using the call-bell on the overnight shift and staff do not perform safety checks every two (2) hours. Resident #3 reported bowel incontinence the previous night and staff did not assist timely. Resident #3 reported staff do not change the bed linens unless requested.Interview with RN #2 on 5/13/26 at 12:49 PM identified NA's are not doing every two (2) hour rounds, turn off the call bells, do not respond, hide out and play on their phones during the overnight shift. She reported when she would do her own rounds, she would question NA's about turning and repositioning the residents and they would reply they already did and ignore her. The Nas would tell her she cannot do anything about it because they would not be fired. RN #2 identified she reported the concerns to the DON many times but that the staff were never suspended, kept coming to work and she was afraid her car tires would be slashed in retaliation. RN #2 reported she did not feel comfortable naming the NA staff that were ignoring their duties on the overnight shift.Interview with Person #2 on 5/13/26 at 1:36 PM identified on 4/20/26 during the 11:00 PM to 7:00 AM shift, NA #3 reported that all the residents on the west unit were independent and frequent rounds did not need to be done, despite the west unit being a short-term rehabilitation unit. Person #2 reported that NA #3 was on her phone all night, turned off call bells from the nurse's station without responding and did not perform rounds until 5:30 AM. Person #2 identified that at that time, residents' sheets were visibly dirty with dried urine and feces, residents were left incontinent all night and dried blood was noted on the floor all night and not cleaned. Person #2 reported the concerns to the staffing scheduler on 4/21/26.Interview with the staffing scheduler on 5/13/26 at 1:36 PM accompanied by the DON identified on 4/21/26, Person #2 reported that during the previous 11:00 PM to 7:00 AM shift on the west unit, residents' beds were dirty, dried blood was on the floor, and it did not appear that care had been provided for the residents. The staffing scheduler identified that she immediately reported the concerns to the DON.Interview with the DON on 5/13/26 at 1:38 PM identified she could not recall the staffing scheduler reporting any lack of resident care on 4/21/26, and that the lack of care was an allegation of neglect which should have been reported to the State Agency within two (2) hours and investigated. She identified she was unaware there were complaints regarding care and call bell response time. She reported she could not recall licensed nurses reporting that NAs were not doing every 2-hour rounds, toileting residents or turning and repositioning residents. She was unaware that NA's were refusing to perform resident care tasks when directed by licensed nurses and that licensed nurses were afraid of retaliation by the NAs. The DON identified that NAs should complete every 2-hour rounds for all residents, turn and reposition residents per their plan of care and as needed, attend to call bells timely and never turn off call bells without first responding. Linens should be changed daily and when visibly soiled. NAs and other staff should be visible on the unit and not in the break room unless on break and other staff are aware they are on break. The DON reported if she were aware of the allegations of neglect, she would have suspended the employees that were accused of neglect and investigated the allegations immediately.Interview with LPN #3 on 5/13/26 at 2:08 PM identified she regularly worked with NA's #2 and #3 on the short-term unit overnight shift and they turn alarming call bells off at the nurse's station and do not respond to the residents rooms, do not perform rounds until after 5:00 AM, do not toilet residents, are rude to the residents, and hide in the break room with the door shut on their phones and sleep. LPN #3 reported when she requested NA #2 or #3 to do something they refused and told her to complain to administration because they cannot be fired. She identified she reported the behavior to the DON multiple times. LPN #3 identified she does her job and the NA's jobs when they refuse to respond. Although attempted, interviews with NAs #2 and #3 were not obtained.Review of the Residents Right to Freedom from Abuse, Neglect and Exploitation policy (undated) directed, in part, the facility is to ensure residents are free from abuse and neglect and staff must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion against any resident. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including, but not limited to: Taking steps to prevent further abuse, reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations, conducting a thorough investigation of the alleged violation, taking appropriate corrective action and the facility will revise the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall: Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported in the proper time frame pursuant to this policy, have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation or mistreatment while the investigation is in progress.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for activities of daily living (ADL) care and allegations of neglect, the facility failed to ensure Resident #1 received showers and related hygiene care in accordance with physician's orders and the resident's comprehensive care plan, failed to ensure refusals or missed showers were accurately documented in the clinical record, and failed to ensure the resident's responsible party was notified when showers were refused or not provided as directed. The findings include:Resident #1's diagnoses included mild cognitive impairment, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), depressive episodes and anxiety disorder. A physician's order dated 5/7/25 directed Resident #1 was to have supervision with showering and Activities of Daily Living (ADL) tasks and directed to provide increased verbal cues to complete personal hygiene as well as peri care on a daily basis and provide assistance when needed. Encourage Resident #1 to use shampoo and fully rinse.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required setup assistance with personal hygiene and showering/bathing self and was independent with bed mobility, transfers and ambulation.The Resident Care Plan (RCP) dated 1/28/26 identified Resident #1 had ADL deficits related to generalized weakness and recent hospitalization. It identified Resident #1 refused showers at times or refused assistance when in shower and to notify the responsible party (Person #1) when Resident #1 refused. Interventions included the NA is to notify the nurse if the resident refused any care, showers, etc., staff to assist or cue concerning tasks including showers, changing clothes, brushing teeth, personal hygiene as well as peri care daily and licensed nurse to call Person #1 with refusals of care, showers, dental hygiene and the NA was to notify the licensed nurse.A. A physician's order dated 2/8/25 directed to notify Person #1 of any and all refusals of showers, care and medications and document in the clinical record every day shift on Wednesdays and Saturdays.A physician's order dated 8/27/25 directed to perform weekly skin checks on bath/shower day, Wednesday 7:00 AM to 3:00 PM shift and Saturdays 7:00 AM to 3:00 PM shift and notify Person #1 if Resident #1 refused and document in the clinical record why Resident #1 refused every day shift every Wednesday and Saturday.Review of the April 2026 Treatment Administration Record (TAR) failed to identify documentation on 4/29/26 that a shower had been given or that Person #1 was notified of a refusal.Review of nurse's notes dated 4/29/26 failed to identify documentation that Resident #1 received a shower or that Resident #1 refused a shower.A On the Job Training document for LPN #2 dated 4/29/26 identified, in part, that for Resident #1, LPN #1 needed to ensure Person #1 was notified of Resident #1 refusing showers and care, to document in the clinical record and to use the shift to shift report tool and give good report to the oncoming licensed nurse.Interview with LPN #1 accompanied by the DON on 5/13/26 at 11:51 AM identified on 4/29/26 Resident #1 refused his/her shower and she should have documented the refusal and notified Person #1 per the plan of care.Interview with the DON on 5/13/26 at 2:30 PM identified LPN #1 should have notified Person #1 of Resident #1's refusal to shower on 4/29/26 per the plan of care and documented that Resident #1 refused.B. A physician's order dated 4/29/26 directed to notify Person #1 of any and all refusals of showers, care and medications and document in the clinical record every day shift on Wednesdays and Saturdays.A physician's order dated 4/29/26 directed to perform weekly skin checks on bath/shower day, Wednesday 7:00 AM to 3:00 PM shift and Saturdays 7:00 AM to 3:00 PM shift and notify Person #1 if Resident #1 refused and document in the clinical record why Resident #1 refused every day shift every Wednesday and Saturday.A nurse's note by the ADON dated 5/7/26 at 3:16 PM identified a NA brought Resident #1 to another unit to use the shower because the shower room was being worked on and out of use. Resident #1's shower day should have been Wednesday (5/6/26), however the shower was being worked on so the NA was instructed to bring Resident #1 to another unit for a shower.Review of the May 2026 TAR identified on 5/6/26 Resident #1's shower was documented as administered and notification of Person #1 for any refusals is signed off as 'NA'.Interview with LPN #1 accompanied by the DON on 5/13/26 at 11:51 AM identified on 5/6/26 NA #4 notified her that she did not give Resident #1 a shower because the shower was broken and it was being worked on. She reported she was unsure why she documented that Resident #1 received the shower but should have questioned NA #4 whether there was another shower Resident #1 could have used and documented accurately that the shower was not given. Additionally, she reported she was unsure if she reported to the next shift that Resident #1 didn't receive his/her shower but should have.Interview with NA #4 accompanied by the DON on 5/13/26 at 2:25 PM identified she did not give Resident #1 a shower on 5/6/26 because the shower stall was being worked on. She identified she should of offered Resident #1 a different shower room. Interview with the DON on 5/13/26 at 2:30 PM identified NA #4 should have offered Resident #1 another shower stall or shower room on a different unit and if Resident #1 refused, she should have reapproached Resident #1 later. The DON reported if Resident #1 continued to refuse the shower, then LPN #1 should have been notified of the refusal so that she could document appropriately and notify Person #1.Review of the Comprehensive Care Planning policy dated 9/1/22 directed, in part, a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.Review of the Charting Documentation policy dated 9/1/22 directed, in part, documentation in the medical record will be objective, complete and accurate, whether the resident refused the procedure/treatment and notification of family, physician or other staff, if indicated. Although requested, facility policies for following physician's orders and showers were not provided.

Based on review of the clinical record, facility documentation, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to ensure Resident #1's hearing aids were timely sent for repair, monitored for return, and followed up on after staff identified the hearing aids were broken and unavailable beginning on 3/11/26. As a result, Resident #1 remained without hearing aids for approximately two (2) months. The findings include:Resident #1's diagnoses included mild cognitive impairment, depressive episodes and anxiety disorder. A physician's order dated 2/7/25 directed to apply hearing aids in the morning and remove at bedtime. The order directed to keep the hearing aids in the treatment cart and open the battery compartment. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required setup assistance with personal hygiene and was independent with bed mobility, transfers and ambulation. Additionally, it identified Resident #1 utilized hearing aids. The Resident Care Plan (RCP) dated 1/28/26 identified Resident #1 had Activities of Daily Living deficits related to generalized weakness and recent hospitalization. Interventions included Resident #1 utilized hearing aids. A nurse's note by RN #4 dated 3/11/26 at 5:31 PM identified Resident #1's hearing aids needed to be repaired by the vendor. The hearing aids were sent on 3/11/26 and Resident #1 was aware. Nurse's notes dated 3/12/26 through 5/12/26 failed to identify a follow up note regarding the whereabouts of the hearing aids or if they were returned. Review of the March, April and May 2026 Treatment Administration Record (TAR) for Resident #1 identified from 3/11/26 through 5/12/26 Resident #1's hearing aids were 'Not Available'. Interview with Person #1 on 5/12/26 at 12:14 PM identified on 5/8/26, after awaiting the return of Resident #1's hearing aids for over a month he/she was notified by the facility that Resident #1's hearing aids were found in the appointment schedulers desk and were never sent out. Person #1 reported the facility communicated they would send them out as soon as possible. Interview with the DON on 5/12/26 at 1:13 PM identified she was unaware Resident #1's hearing aids were not sent out per the 3/11/26 nurse's note until questioned by Person #1. She reported Resident #1's hearing aids were subsequently found in the former appointment scheduler's desk about two (2) weeks prior and when returned to her, she cleaned them and changed the batteries, and they still did not work. The audiology group was contacted to inquire about the next steps but identified they should have been initially sent out immediately upon discovering they were broken. The DON reported they were sent for repair on 5/12/26 but was unable to identify why it took an additional 2 weeks to do so. Additionally, the DON identified that nursing staff, who had been signing off on both the day and evening shifts that the hearing aids were unavailable should have notified her or the appointment scheduler that the hearing aids had still not been returned and inquired about their whereabouts prior to the family having to inquire 2 months later. Interview with the former appointment scheduler on 5/13/26 at 12:10 PM identified her last day of employment was on 4/21/26. She reported broken medical devices would go to the nursing supervisor, ADON or DON and they would clean them to try to get them functioning. She identified if they were unable to do so, they would notify her that they needed to be sent out for repair but she could not recall ever being given Resident #1's hearing aids to send out and no staff had come to her inquiring about the whereabouts of Resident #1's hearing aids prior to her last day. Although requested, a policy on repair of medical devices was not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to review and act upon in-house dental consult recommendations, coordinate recommended community dental appointments, document follow-up actions, and timely notify the resident's representative of dental findings and refusals of recommended care. As a result, recommended dental restorations were not completed and dental decline progressed from restorations being recommended to multiple teeth becoming non-restorable and requiring extractions. The findings include: Resident #1's diagnoses included dental caries (cavities/tooth decay), mild cognitive impairment, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), depressive episodes and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 13), and was independent with oral and personal hygiene, transfers and ambulation. The Resident Care Plan (RCP) dated 2/6/25 identified Resident #1 has a history of oral/dentalhealth problems, has been diagnosed with dental caries and has Activities of Daily Living deficits related to generalized weakness and recent hospitalization. Interventions included monitoring, documenting and reporting as needed any signs and symptoms of oral/dental problems needing attention, coordinating arrangements for dental care and transportation as needed/as ordered and nursing to call resident representative with refusals of in part, care and dental hygiene- the NA is to notify the nurse of refusals. A physician's order dated 2/6/25 directed to notify Resident #1's responsible party (Person #1) of any and all refusals of showers, care and medications every day shift every Wednesday and Saturday. A dental consult note dated 3/4/25 identified, in part, Resident #1 had decay to upper tooth number (#) 9 (left front tooth) and the mesial portion (facing forwards, towards the midline) of the tooth was fractured (broken). Root caries and plaque on the teeth and on and under the partial and oral hygiene needed to be greatly improved or Resident #1's teeth would break off at the gumline from root caries. The note identified Resident #1 would be referred to a community health center or a dental practice for four handed dentistry (a practice with a dental assistant) for large restorations (procedure to repair or replace damaged or decayed teeth) to teeth #9, #20, #21, and #29. Review of nurse's notes dated 3/4/25 through 6/19/25 failed to identify documentation of Resident #1's 3/4/25 dental visit, notification of Person #1 or documentation that the facility attempted to set up an appointment with an outside dental clinic for the dental restorations to be completed per recommendations. A dental consult note dated 6/20/25 identified, in part, Resident #1 had not had the restorations completed that were recommended last visit and a dental cleaning and dental x-rays were recommended. The note directed to refer Resident #1 to a community health center or a dental practice for four handed dentistry for restorations to teeth #9, #20, #21, and #29. Review of nurse's notes dated 6/20/25 through 7/6/25 failed to identify documentation of Resident #1's 6/20/25 dental visit, notification of Person #1 or documentation that the facility attempted to set up an appointment with an outside dental clinic for the dental restorations to be completed per recommendations. A dental consult note dated 7/7/25 identified Resident #1 was seen by the Registered Dental Hygienist (RDH), dental x-rays were obtained and Resident #1 tolerated the procedure well. A dental consult note dated 8/19/25 identified dental x-rays were reviewed and Resident #1 had moderate decay to tooth #8 (right upper front tooth) and non-restorable decay to tooth #9 and #29 (right bottom premolar). Resident #1 had deep decay with sensitivity to tooth #20 and #21 (left bottom premolars) and recommendations were made for extractions to teeth #9, #20, #21 and #29. The note identified Resident #1 was refusing the extractions at that time and the next visit they would restore (fill) tooth #8. Review of nurse's notes dated 8/19/25 through 9/14/25 failed to identify documentation of Resident #1's 8/19/25 dental visit or notification of Person #1 of the visit or the refusal of the extractions. A late entry nurse's note by the DON dated 9/15/25 at 6:15 PM (created on 9/16/25 at 7:49 AM) identified she spoke with Person #1 and updated him/her in part, dental consults and any refusals (27 days after the last dental visit). A dental consult note dated 9/16/25 identified restoration of tooth #8 was attempted but Resident #1 refused anesthesia and pulled away when the lingual surface (the inner facing side of the tooth that directly faces the tongue) was touched so the restoration was unable to be completed. Extractions were discussed with Resident #1 but Resident #1 stated he/she was too nervous and did not like shots. The note reported Resident #1 was to be referred for extraction of teeth #9, #20, #21 and #29 when Resident #1 was accepting. Review of nurse's notes dated 9/16/25 through 10/29/25 failed to identify documentation of Resident #1's 9/16/25 dental visit or notification of Person #1 of the visit or the refusal of the dental restoration. Interview with Person #1 on 5/12/26 at 12:14 PM identified although abnormalities were noted to Resident #1's dentition, he/she was not notified of Resident #1's dental visits on 3/4/25, 6/20/25 or 8/19/25 or the recommendations made until September of 2025. Person #1 identified had he/she known of the recommendations, he/she could have been present for future dental visits, encouraged Resident #1 to have the dental work done and assisted with setting up the appointments for the restorations and extractions. Person #1 reported that due to the lack of communication, Resident #1's dental care has been delayed. Interview with the former appointment scheduler on 5/13/26 at 12:10 PM identified following in-house appointments, the consult notes are emailed to herself, the DON and the ADON and the DON and/or ADON were responsible for reviewing them for any abnormalities and new recommendations. She reported if a resident required an appointment in the community, the ADON or ADON would have first had to review the recommendations, ensure the resident and/or responsible party agreed with the appointment and then she would be directed to make the appointment if applicable. She identified she was unsure if and when she was notified to set up a dental appointment in the community for Resident #1. Interview with the DON on 5/13/26 at 1:33 PM identified that following in-house dental visits, nursing staff should have written notes in the clinical record identifying Resident #1 was seen by the dentist and again when the consult notes were available if recommendations were noted. Person #1 should have been notified immediately. The DON reported the consult notes were emailed to the ADON and herself and the recommendations should have been identified and acted upon. Additionally, she was unsure why she did not contact Person #1 following Resident #1's dental visit on 8/19/25 until 9/15/25. She identified Person #1 should have been notified immediately of all refusals of care, including dental care. Review of the Coordination of Care from External Providers policy dated 9/01/22 directed, in part, the facility shall coordinate care and services provided by external healthcare providers to ensure that all resident care is integrated, communicated appropriately, documented accurately and consistent with the resident's plan of care, physician orders, goals, preferences and applicable regulations. The facility shall ensure services are integrated into the resident's comprehensive care plan and maintain documentation of all consultations, recommendations, treatments and follow-up care. The medical record shall include: consultation reports, provider recommendations, orders received, treatment documentation, progress notes, follow-up actions, appointment summaries and diagnostic reports. The facility shall review external provider documentation and ensure recommendations are addressed appropriately. The Director of Nursing is responsible for: oversight of clinical coordination processes, ensuring timely communication and documentation and monitoring compliance with policy.Review of the Refusing or Requesting Discontinuation of Care policy dated 9/01/22 directed, in part, Residents/representatives are informed in advance of: the care that will be furnished or made available to the resident based on his or her assessment and plan of care, the risks and benefits of the proposed care, treatment, treatment alternatives or treatment options, the type of caregiver or professional that will provide the care and any changes to the resident's care plan. If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team will meet with the resident/representative to: determine why he/she is requesting, refusing or discontinuing care or treatment, try to address his/her concern and discuss alternative options and discuss the potential outcomes or consequences of the decision.

Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of four (4) residents (Residents #1, #2 and #3) reviewed for neglect, the facility failed to thoroughly investigate allegations of neglect. The findings include:1. Resident #1's diagnoses included mild cognitive impairment, chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissues), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), depressive episodes and anxiety disorder.A physician's order dated 9/13/24 directed Resident #1 be placed on continuous oxygen at 2.0 to 4.0 liters per minute (lpm) via nasal cannula to keep oxygen saturation greater than 90 percent (%) and obtain oxygen saturation every shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required setup assistance with personal hygiene, was independent with bed mobility, transfers and ambulation and utilized oxygen therapy.The Resident Care Plan (RCP) dated 1/28/26 identified Resident #1 had a diagnosis of COPD, asthma, chronic respiratory failure with hypoxia and a history of COPD exacerbation requiring oxygen support. Interventions include administering oxygen and monitoring effectiveness by checking saturation as/if indicated.A nurse's note by LPN #1 dated 4/5/26 at 2:06 PM identified at around 11:00 AM Resident #1's representative (Person #1) arrived to pick up Resident #1 and asked for Resident #1's oxygen tank to be changed but it had been changed a few minutes prior so Resident #1 was fine to go out. They left and returned at around 1:45 PM and while LPN #1 was performing care for another resident, Person #1 waited outside the door, reported the oxygen tank was empty and asked LPN #1 to change the tank. LPN #1 communicated that any other licensed nurse or NA could change the tank because she was in the middle of a dressing change. The note identified Person #1 waited outside the room until LPN #1 was done and then stated the tank was supposed to last four (4) hours, but it was empty within two (2) hours and LPN #1 communicated that Person #1 assumed that LPN #1 did not change the oxygen tank and Person #1 started yelling and carrying on. The note identified LPN #1 then changed the oxygen tank and Person #1 asked for the nursing supervisor.Review of nurse's notes failed to identify a nurse's note from the nursing supervisor (RN #1) dated 4/5/26.A social service note by the Director of Social Services dated 4/6/26 at 12:00 PM identified a call was placed to Person #1 and Resident #1's family with herself, the DON and the ADON when Person #1 updated them on the events from the Leave of Absence (LOA) from the weekend. The note reported a follow-up family meeting was requested and scheduled for 4/9/26.A social service note by the Director of Social Services dated 4/6/26 at 7:29 PM identified, in part, Resident #1's family requested an in-person family meeting with the Interdisciplinary Team (IDT) to discuss care concerns and the recent LOA. She identified a family meeting was scheduled for 4/9/26 at 3:00 PM.A facility Grievance Sheet dated 4/6/26 identified Person #1 reported concerns over the oxygen tank administration and an interaction with staff and Resident #1's family. Education on oxygen with return demonstration was to be given to all nursing staff.A social service note by the Director of Social Services dated 4/9/26 at 12:06 PM identified a family meeting was held to review Resident #1's plan of care. The note reported Resident #1's plan of care was reviewed and they addressed concerns with the oxygen tank and education of staff.Review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/12/26 failed to identify the 4/5/26 incident was reported to the State Agency as an allegation of abuse or neglect.Interview with Person #1 on 5/12/26 at 12:14 PM identified on 4/5/26 he/she took Resident #1 on an LOA but had to return early due to the oxygen tank being almost empty. Person #1 identified when he/she returned to the facility with Resident #1 just before 2:00 PM, LPN #1 was in the hallway at a cart and Person #1 reported that the oxygen tank was empty. LPN #1 stated she was busy and told Person #1 to find someone else to change it and then went into another resident's room. Person #1 identified everyone was busy and LPN #1 made Resident #1 wait over five (5) minutes. When LPN #1 arrived to assist, she yanked the oxygen tubing off the oxygen tank with the nasal cannula still attached to Resident #1's face, almost causing Resident #1 to fall. Person #1 identified he/she immediately reported the prolonged changing of the oxygen tank and the incident with LPN #1 to RN #1 (nursing supervisor) alleging neglect and roughness and then left a voicemail for the Director of Social Services with the timeline of events. Person #1 identified he/she spoke with the DON and Director of Social Services the next day, explaining the chain of events including LPN #1 making Resident #1 wait for more oxygen and the way she roughly pulled the oxygen tubing off the oxygen tank almost causing Resident #1 to fall and the DON reported RN #1 never reported the complaint to her. Person #1 reported during the 4/9/26 meeting, he/she again reported the chain of events and stated it was neglect and abuse. He/she told the DON he/she no longer wanted to visit the building without a witness and the DON identified she would ensure LPN #1 no longer cared for Resident #1 as an intervention.Interview with LPN #1 accompanied by the DON on 5/12/26 at 2:32 PM identified on 4/5/26 she changed Resident #1's oxygen tank to a full tank about fifteen (15) minutes prior to Person #1 arriving to take Resident #1 out on an LOA and ensured it was set to 3.0 lpm. She reported when Person #1 arrived to take Resident #1 out on the LOA, the regulator on the oxygen tank still read that the tank was full. At about 1:45 PM she was in the hallway at the treatment cart when Person #1 approached her and reported Resident #1's oxygen tank was empty. LPN #1 reported she was going to do a dressing change and told Person #1 she needed a few minutes. She further told Person #1 another licensed nurse or NA could change the oxygen tank. She reported she should have confirmed the oxygen tank was empty prior to entering another resident's room and should have checked Resident #1's oxygen level. She identified when she responded, the oxygen tank gauge was in the red area and on low but not completely empty.Interview with RN #1 accompanied by the DON on 5/12/26 at 2:47 PM identified on 4/5/26 Person #1 approached her upset because Resident #1 ran out of oxygen while on an LOA and LPN #1's response time in changing the oxygen tank but could not recall Person #1 reporting LPN #1 yanked the oxygen tubing almost causing Resident #1 to fall. RN #1 reported she immediately reported the complaint to the DON.Interview with the DON on 5/12/26 at 1:13 PM identified she could not recall RN #1 notifying her on 4/5/26 of Person #1's concerns. She recalled being notified on 4/6/26 by Person #1 regarding Resident #1 running out of oxygen on the LOA and LPN #1 not responding immediately but she spoke with LPN #1 who denied Resident #1 ran out of oxygen. The DON indicated she was not aware LPN #1 was in the hallway when Person #1 approached LPN #1 regarding Resident #1's oxygen tank being empty and LPN #1 should have assisted Resident #1 immediately. The DON identified she did not initiate an investigation to include statements from other staff working at the time to include LPN #1 and RN #1 and did not believe the concerns voiced by Person #1 on 4/6/26 were allegations of abuse or neglect so she did not report to the State Agency. The DON identified all allegations of abuse and/or neglect are to be reported to the Stage Agency within two (2) hours and investigated.Interview with the Director of Social Services on 5/13/26 at 8:36 AM identified she could not recall listening to a voicemail on 4/6/26 from Person #1 regarding Resident #1 but she did speak with Person #1 on 4/6/26 who reported concerns about the oxygen becoming empty on the LOA on 4/5/26 and LPN #1's response time. She reported she could not recall what words Person #1 used to describe Resident #1 losing his/her balance when the oxygen tank was changed but identified there were concerns presented by Person #1 regarding the oxygen and LPN #1 that were concerning and should have been addressed immediately. The Director of Social Services reported the DON directed to write up the concerns as a grievance on 4/6/26.2. Interview with Person #2 on 5/13/26 at 1:36 PM identified on 4/20/26 during the 11:00 PM to 7:00 AM shift, NA #3 reported that all the residents on the west unit were independent and frequent rounds did not need to be done, despite the west unit being a short-term rehabilitation unit. Person #2 reported that NA #3 was on her phone all night, turned off call bells from the nurse's station without responding and did not perform rounds until 5:30 AM. Person #2 identified that at that time, residents' sheets were visibly dirty with dried urine and feces, residents were left incontinent all night and dried blood was noted on the floor all night and not cleaned. Person #2 reported the concerns to the staffing scheduler on 4/21/26.Interview with the staffing scheduler on 5/13/26 at 1:36 PM accompanied by the DON identified on 4/21/26, Person #2 reported that during the previous 11:00 PM to 7:00 AM shift on the west unit, residents' beds were dirty, dried blood was on the floor, and it did not appear that care had been provided for the residents. The staffing scheduler identified that she immediately reported the concerns to the DON. Review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/12/26 failed to identify the 4/20/26 incident was reported to the State Agency as an allegation of neglect.Interview with the DON on 5/13/26 at 1:38 PM identified she could not recall the staffing scheduler reporting any lack of resident care on 4/21/26, and that the lack of care was an allegation of neglect which should have been reported to the State Agency within two (2) hours and investigated. Although attempted an interview with NA #3 was not obtained.3. Resident #2's diagnoses included Enterocolitis due to Clostridium Difficile (C. Diff) (inflammation in both intestines caused by a bacteria that causes an infection of the colon), acute kidney failure, adult failure to thrive, need for assistance with personal care and weakness.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was dependent on staff for personal hygiene and transfers, required partial assistance for toileting hygiene and bed mobility and was always incontinent of bowel.The Resident Care Plan (RCP) dated 4/20/26 identified Resident #2 had an Activities of Daily Living (ADL) deficit due to generalized weakness and renal failure, had C. Diff and was incontinent of bowel and/or bladder. Interventions included keeping the call bell and needed items within reach, providing an assist of one (1) with all ADLs, offering to toilet or use the commode before leaving the room for activities, meals or ambulation and upon request and providing incontinent care approximately every two hours and as needed and upon request. Interview with Resident #2 on 5/13/26 at 8:50 AM identified he/she utilized the bedside commode independently on the overnight shift (11:00 PM to 7:00 AM), although he/she is not supposed to, because the call bell it is not answered and no one checks on him/her. Resident #2 identified the bedside commode is rarely emptied on the overnight shift, bed sheets are visibly dirty and staff do not change them unless requested and he/she feels afraid something will happen on the overnight shift and no one will know or respond.Review of the May 2026 Documentation Survey Report (NA documentation) failed to identify any documentation on the overnight shift on 5/1/26, 5/2/26 or 5/8/26 for bladder or bowel tasks.4. Resident #3 's diagnoses included Congestive Heart Failure (CHF), chronic kidney disease stage IV (severe kidney function loss), acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), weakness and depression.The admission assessment dated [DATE] identified Resident #3 was alert and oriented to person, place and time and required partial assistance for self-care, toileting hygiene and transfers. Resident #2 utilized oxygen via a nasal cannula at 2.0 liters per minute.The RCP dated 5/12/26 identified Resident #3 had ADL deficits due to generalized weakness and recent hospitalization, utilized oxygen therapy due to CHF and had a foley catheter intact due to urinary retention. Interventions included performing catheter care every shift and as needed, keeping the call bell and needed items within reach and providing assistance with all ADLs.A Brief Interview for Mental Status (BIMS) assessment dated [DATE] identified Resident #3 was cognitively intact (score of 14). Interview with Resident #3 on 5/13/26 at 8:54 AM identified long wait times when using the call-bell on the overnight shift and staff do not perform safety checks every two (2) hours. Resident #3 reported bowel incontinence the previous night and staff did not assist timely. Resident #3 reported staff do not change the bed linens unless requested. Interview with RN #2 on 5/13/26 at 12:49 PM identified NA's are not doing every two (2) hour rounds, turn off the call bells, do not respond, hide out and play on their phones during the overnight shift. She reported when she would do her own rounds, she would question NA's about turning and repositioning the residents and they would reply they already did and ignore her. The Nas would tell her she cannot do anything about it because they would not be fired. RN #2 identified she reported the concerns to the DON many times but that the staff were never suspended, kept coming to work and she was afraid her car tires would be slashed in retaliation. RN #2 reported she did not feel comfortable naming the NA staff that were ignoring their duties on the overnight shift.Interview with LPN #3 on 5/13/26 at 2:08 PM identified she regularly worked with NA's #2 and #3 on the short-term unit overnight shift and they turn alarming call bells off at the nurse's station and do not respond to the residents rooms, do not perform rounds until after 5:00 AM, do not toilet residents, are rude to the residents, and hide in the break room with the door shut on their phones and sleep. LPN #3 reported when she requested NA #2 or #3 to do something they refused and told her to complain to administration because they cannot be fired. She identified she reported the behavior to the DON multiple times. LPN #3 identified she does her job and the NA's jobs when they refuse to respond. Interview with the DON on 5/13/26 at 1:33 PM identified she was unaware there were complaints regarding care and call bell response time. She reported she could not recall licensed nurses reporting that NAs were not doing every 2-hour rounds, toileting residents or turning and repositioning residents. She was unaware that NA's were refusing to perform resident care tasks when directed by licensed nurses and that licensed nurses were afraid of retaliation by the NAs. The DON identified that NAs should complete every 2-hour rounds for all residents, turn and reposition residents per their plan of care and as needed, attend to call bells timely and never turn off call bells without first responding. Linens should be changed daily and when visibly soiled. NAs and other staff should be visible on the unit and not in the break room unless on break and other staff are aware they are on break. The DON reported if she were aware of the allegations of neglect, she would have suspended the employees that were accused of neglect and investigated the allegations immediately Subsequent to surveyor inquiry, review of the Connecticut Department of Public Health Facility Licensing and Investigations Section portal on 5/14/26 failed to identify the allegations of neglect reported by this surveyor to the DON on 5/13/26 were reported to the State Agency within two (2) hours as required.Review of the Residents Right to Freedom from Abuse, Neglect and Exploitation policy (undated) directed, in part, staff must not use verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion against any resident. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The facility will increase enforcement action, including, but not limited to: Taking steps to prevent further abuse, reporting the alleged violation and investigation within required timeframes pursuant to federal and state statutes and regulations, conducting a thorough investigation of the alleged violation, taking appropriate corrective action and the facility will revise the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility shall: Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported in the proper time frame pursuant to this policy, have evidence that all alleged violations are thoroughly investigated and prevent further abuse, neglect, exploitation or mistreatment while the investigation is in progress.Review of the Reportable Events policy dated 9/1/22 directed, in part, that the facility shall identify, classify, document and report all events that meet criteria for reportable incidents under Connecticut DPH regulations. A Class B event includes a complaint or allegation of patient abuse, or any act involving abuse toward a patient by any person. Abuse includes verbal, mental, sexual or physical attack, injury, unreasonable confinement, intimidation or punishment.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure the resident was free from a significant medication error when a schedule III opioid medication, which was prescribed for another resident, was inadvertently administered to Resident #1 causing the develop of an opioid-induced respiratory depression requiring hospitalization and treatment. The failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included pulmonary embolism, depression, and difficulty walking.The five (5) day Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of 7), was dependent on staff for toileting, dressing, bed mobility, and transfers, was non-ambulatory and utilized a wheelchair. The Resident Care Plan dated 2/5/26 identified Resident #1 had a self-care deficit. Interventions directed to keep the call bell in reach, administer medications as ordered, and monitor for side effects of medications.The nurse's note dated 2/5/26 at 9:30 PM by LPN #2 identified during the narcotic medication count, LPN #1 reported Resident #1 inadvertently received a dose of Suboxone eight (8) - two (2) milligrams (mg) prescribed to Resident #2. The Advanced Practice Registered Nurse (APRN), RN #1 (the 3:00 PM to 11:00 PM supervisor), and the Director of Nursing (DON) were immediately notified. Resident #1 was alert, verbal, with some confusion noted. Previous vital signs had been normal. The APRN directed to apply oxygen at 5 liters via nasal cannula for supportive therapy due to oxygen saturation levels between 83% to 86% (normal range 95% to 100%) on room air. Respiratory rate was thirteen (13) and non-labored and previously had been eighteen (18). Heart rate was ninety-two (92) and pupils were pinpoint. 911 was called and a nurse remained with Resident #1 until emergency medical services (EMS) arrival at 10:10 PM. Narcan was administered per APRN directions.The Emergency Department (ED) admission notes dated 2/5/26 identified Resident #1 arrived to the ED at 10:50 PM on 2/5/26 and was admitted with opioid-induced respiratory depression and altered mental status. Four (4) milligrams (mg) of intranasal Narcan was administered and Resident #1 was placed on five (5) liters of oxygen via nasal canula by EMS during transfer to the hospital. Resident #1 was not on oxygen at baseline. Resident #1 was given an additional two (2) doses of Intravenous (IV) Narcan and IV potassium due to a low potassium level (2.9). Resident #1 was admitted to the Intensive Care Unit (ICU) for hypertension, tachycardia (high heart rate), and continued somnolence. IV Diltiazem (for elevated blood pressure) was started. Resident #1 required constant telemetry and pulse oxygen monitoring. Resident #1 was hospitalized for a total of eleven (11) days.Interview with LPN #1 on 3/3/26 at 12:30 PM identified she administered medications to Resident #1 on 2/5/26 for the first time. LPN #1 was preparing medications for Resident #2 when a family member approached her and requested she meet Resident #1 since LPN #1 was Spanish speaking. After meeting the resident, LPN #1 continued preparing the medications for Resident #2 and reported there was an additional interruption by an NA. She then proceeded into Resident #1's room, who she thought was Resident #2, because both residents were Spanish speaking. LPN #1 did not verify Resident #1 by name or check the name bracelet and began to administer the medications. Resident #2 refused all medications except for the Suboxone. When reporting the medication refusal to LPN #2 during shift change, LPN #1 then realized she administered the medication to the wrong resident. She did not administer medications to Resident #2. The medication error was reported to RN #1.Interview with the APRN on 3/3/26 at 12:50 PM identified Suboxone was not prescribed for Resident #1 and Resident #1 had never been prescribed opioids. The APRN received a phone call from the facility reporting Resident #1 was administered Suboxone in error. The APRN directed monitoring and the administration of Narcan if Resident #1 had signs of respiratory depression and to transfer Resident #1 to the ED with any change in condition. The APRN identified complications of administering Suboxone in error were respiratory depression, change in level of consciousness, hypotension, and hypoxemia. The dose administered to Resident #1 was a super therapeutic dose for someone who had never previously taken Suboxone. The APRN further identified the administration of Suboxone to Resident #1 was dangerous, could cause significant respiratory depression and central nervous system depression, and was considered a significant medication error.Interview with the DON on 3/3/26 at 12:55 PM identified that the administration of Suboxone to Resident #1 was dangerous and was a significant medication error. The facility immediately initiated an internal investigation. The facility subsequently completed a plan of correction and initiated training and audits.The facility Medication Error Policy identified a medication error as the preparation or administration of drugs not in accordance with physician's orders and included a drug being administered without a physician's order. The policy further identified a significant medication error, in part, as an error that results in the resident requiring hospitalization, requiring the administration of a prescription medication to treat the error, and an error that is life threatening and/or could potentially lead to death.Review of facility documentation identified that a Plan of Correction was initiated immediately:Staff training was completed and included review of the five rights of medication administration and medication competencies were performed for all licensed nursing staff. LPN #1 received one-to-one education from the consulting pharmacy.Random audits of weekly narcotic reconciliation and medication pass observations with two (2) licensed staff, change-of-condition documentation, and RN assessment audits were completed weekly for four (4) weeksAudits were reviewed at the monthly QAPI meeting.The Director of Nursing was responsible for the implementation and monitoring with the Administrator maintaining overall regulatory oversight.Alleged compliance as of 2/9/26.The plan of correction was reviewed on 3/4/26 during an on-site visit by the state agency and the facility met all components for past non-compliance.

Based on record reviews, facility documentation, policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1), who required two-person assistance and a mechanical lift for safe transfers, the facility failed to follow established transfer procedures during a transfer on 12/12/25. A Nurse Aide (NA #1) relied on an outdated assignment sheet indicating single-staff assistance, did not verify current transfer requirements on the resident care card, and attempted a manual pivot transfer without obtaining a second staff or mechanical lift. The wheelchair brakes were not reliably engaged, resulting in Resident #1 falling face-first, sustaining a bloody nose and nasal laceration requiring sutures and hospital transport. The findings include:Resident #1's diagnoses included vascular dementia without behavioral disturbances, muscle weakness and anxiety disorder. A physician's order dated 10/28/25 directed to transfer Resident #1 in and out of the bed and chair via a mechanical lift and the assistance of two (2) staff. The Resident Care Plan dated 11/13/25 identified Resident #1 had Activities of Daily Living (ADL) deficits related to generalized weakness, vascular dementia, and forgetfulness. Interventions included the resident required a mechanical lift and assistance of two (2) staff for transfers. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) indicating Resident #1 had poor short-and-long term memory recall and was dependent on staff for bed mobility and transfers. The nurse's note dated 12/12/25 at 11:02 AM identified Resident #1 had a witnessed fall at 8:30 AM when a nurse aide, Nurse Aide (NA) #1, transferred Resident #1 into a wheelchair, the locks failed and Resident #1 fell to the floor. The note indicated Resident #1 hit his/her face on the floor, remained alert, sustained a bloody nose and a skin tear to the bridge of the nose. The note identified Resident #1 was transferred to the hospital at 8:40 AM and the Director of Nursing (DON), nursing supervisor, Advanced Practice Registered Nurse (APRN) and family were notified of the incident. The hospital documentation dated 12/12/25 identified Resident #1 presented in the Emergency Department (ED) following a fall and was noted with a bleeding laceration (a cut, tear or rip in the skin and soft tissue) to the bridge on the nose and was on Eliquis (a blood thinner). The note indicated head and cervical spine imaging were obtained and resulted negative for any acute injuries or fractures and five (5) sutures were required to repair the nasal laceration. The note indicated Resident #1 was transferred back to the facility on [DATE]. Interview with NA #1 on 1/13/26 at 11:48 AM identified he did not consistently care for Resident #1 so prior to transferring Resident #1 to the wheelchair on 12/12/25 he checked his assignment sheet which identified Resident #1 was an assist of one (1) for transfers. NA #1 explained he placed the wheelchair on the right side of Resident #1's bed and sat Resident #1 up on the side of the bed, placed the gait belt around Resident #1's waist and then stood Resident #1 up. NA #1 identified Resident #1 was much weaker and heavier than he had expected, and instead of sitting Resident #1 back down on the side of the bed and requesting help, he bear hugged Resident #1 and pivoted Resident #1 with difficulty into the wheelchair. NA #1 indicated he was only able to get Resident #1 partially into the wheelchair so Resident #1 was seated at the edge of the wheelchair seat, the wheelchair then began to roll backwards, and Resident #1 fell forwards out of the wheelchair and hit his/her face on the floor. NA #1 identified although he put the brakes on the wheelchair prior to transferring Resident #1, he did not move or jiggle the wheelchair to ensure the locks were engaged and the chair would not move. NA #1 stated when he stood Resident #1 prior to the transfer and identified Resident #1 was weak and heavy, he should have sat Resident #1 back down on the bed and requested assistance. NA #1 identified he was not sure of what a resident care card was or where it was located and was not aware he should have been following the transfer status on the resident care card and not the assignment sheet. Interview with the charge nurse, Licensed Practical Nurse (LPN) #1, on 1/13/26 at 11:31 AM identified although she was unsure if the assignment sheet was updated with the Resident #1's transfer status prior to the 12/12/25 fall, the assignment sheet was only used to briefly summarize Resident #1 and was not Resident #1's accurate plan of care, and NA #1 should have reviewed the resident care card for the transfer status and not the assignment sheet. Interview with the Occupational Therapist, (OT) #1, on 1/13/26 at 1:10 PM identified as of 10/28/25, Resident #1 required assistance of two (2) staff and a Hoyer (mechanical) lift for all transfers due to safety and Resident #1 had been a Hoyer lift for more than a month prior to the fall on 12/12/25. Interview with the Director of Nursing (DON) on 1/13/26 at 1:46 PM identified the nurse aides are directed to check a residents' activity of daily living status, including transfer status on the resident care card each shift prior to contact with the resident. The DON indicated the assignment sheets are only to be used for a quick summary and should always be compared to the care card and if there are discrepancies then the nurse aide should be clarifying the discrepancies with the charge nurse. The DON identified NA #1 should have checked Resident #1's care card prior to the transfer and if he had, he would have known to secure a second staff member and utilize a Hoyer lift to transfer Resident #1 from the bed to the wheelchair, which would have prevented the fall and also one (1) of the staff members would have been standing behind the wheelchair which would have prevented the wheelchair from rolling if the brakes truly were in disrepair. The DON explained NA #1 should have sat Resident #1 down on the bed immediately and requested assistance when he realized Resident #1 was too weak to stand and should never have bear hugged Resident #1 and continued transferring Resident #1 by himself. Review of the Wheelchair policy dated April 2015 directed, in part, that when transferring a resident to a wheelchair, position the wheelchair in the appropriate position for transfer, apply brakes to lock the wheels and secure the chair and assist the resident into the chair using proper transfer techniques and the use of a gait belt.

Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Resident #1 and #3) who were reviewed for falls, the facility failed to ensure a quarterly fall risk assessment was completed at the time the assessment was due. The findings include: 1. Resident #1's diagnoses included vascular dementia without behavioral disturbances, muscle weakness and anxiety disorder. The Resident Care Plan dated 11/13/25 identified Resident #1 was at risk for falls related to a history of several falls, generalized weakness, unsteadiness on their feet and forgetfulness. Interventions directed the resident required a mechanical lift and assistance from two (2) staff for transfers, to ensure the room was well lit and clutter free, ensure personal items were within reach, and provide frequent reminders to use the call light for assistance, and ensure the call light was within reach when in the room. Review of the quarterly Fall Risk Evaluation dated 12/2/25 identified although the assessment was opened by the Minimum Data Set Assistant, the assessment was noted to be blank and not filled out and the fall risk score was to be determined. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS)score of six (6) out of fifteen (15) indicating Resident #1 had poor short- and long-term memory recall and was dependent on staff for bed mobility and transfers. The nurse's note dated 12/12/25 at 11:02 AM identified Resident #1 had a witnessed fall at 8:30 AM when a nurse aide, Nurse Aide (NA) #1, transferred Resident #1 into a wheelchair, the locks failed and Resident #1 fell to the floor. The note indicated Resident #1 hit his/her face on the floor, remained alert, sustained a bloody nose and a skin tear to the bridge of the nose. The note identified Resident #1 was transferred to the hospital at 8:40 AM and the Director of Nursing (DON), nursing supervisor, Advanced Practice Registered Nurse (APRN) and family were notified of the incident. 2. Resident #3's diagnoses included polyneuropathy (the malfunction of many peripheral nerves throughout the body causing numbness, tingling weakness and burning pain), epilepsy (a brain disorder that causes seizures), weakness and anxiety. Review of the quarterly Fall Risk Evaluation dated 12/10/25 identified although the assessment was opened by the Minimum Data Set Assistant, the assessment was noted to be blank and not filled out and the fall risk score was to be determined. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating Resident #3 was alert and oriented and was independent with bed mobility, transfers and ambulating. The Resident Care Plan dated 12/23/25 identified that Resident #3 was at risk for falls secondary to being newly admitted , generalized weakness, syncopal (fainting) episodes and seizures. Interventions directed to place the call light within reach and orient the resident to their surroundings. The nurse's note dated 1/1/26 at 6:58 AM identified Resident #3 had a fall. The note indicated Resident #3 reported he/she was trying to get to the bathroom, started to feel weak and slid to the floor onto his/ her knees. Interview with the Minimum Data Set (MDS) Assistant and the MDS nurse, Registered Nurse (RN) #3, on 1/13/26 at 2:26 PM identified the MDS Assistant was responsible for opening the assessments that were required for the upcoming MDS schedule so they would show up on the dashboard for the nurses to complete. They identified the nurses were then responsible for completing the assessments, including the Fall Risk Evaluations that were to be completed on admission, quarterly, annually and following a fall and were unsure why nursing did not complete the 12/2/25 quarterly Fall Risk Evaluation for Resident #1 or the 12/10/25 quarterly Fall Risk Evaluation for Resident #3. Interview with the Director of Nursing (DON) on 1/13/26 at 1:46 PM identified the quarterly Fall Risk Evaluations for both Resident #1 and Resident #2 should have been completed by nursing staff when the assessments were due. Review of the Falls Management policy dated August 2018 directed, in part, that a fall risk evaluation will be conducted on each resident upon admission, with the quarterly MDS cycle and when a significant change in status occurs including a fall.

Based on clinical record reviews, facility documentation, facility policies and interviews for four (4) of sixteen (16) sampled residents (Residents #1, #2, #3, and #4) who were reviewed for medication administration, the facility failed to properly secure medications when left unattended at the residents' bedside without an order for the residents to self-administer the medications or the resident was sleeping. The findings include: 1.Resident #1's diagnoses included mild cognitive impairment, chronic obstructive pulmonary disease, and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable decisions regarding tasks of daily life. Review of the October and November 2025 physician orders identified there was no physician's order for self-administration of medication. Interview with Resident #1 and observations conducted with the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1 present, on 11/12/25 at 9:40 AM identified upon entering the room Resident #1 was noted to be sleeping and on the bedside table a white medication cup filled with several medications was observed. After interviewing and assessing Resident #1, LPN #1 picked up the medication to administer them to Resident #1. Resident #1 identified he/she was asleep when it was time for his/her medication which was why the medications were at the bedside. Interview with LPN #1 at 9:40 AM identified she left the medications in Resident #1's room because Resident #1 was asleep. LPN #1 explained she left the room to give another resident his/her medications with the intention of going back into Resident #1's room to administer the medications. LPN #1 stated she typically does not leave medications for the residents unless they had a physician's order to self-administer their medications. 2. Resident #2's diagnoses included diabetes mellitus, asthma, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable decisions regarding tasks of daily life. The Resident Care Plan dated 10/14/25 identified Resident #2 had a physician's order to self-administer albuterol, simethicone, and Voltaren gel. Interventions directed to assess the resident's ability to self-administer medications, discuss the medications with the resident, and to monitor the self-administration of the medications. Physician orders dated through 11/13/25 identified several medications Resident #2 could keep at the bedside and self-administer, these included inhalers, vaginal cream and the simethicone. Observations of Resident #2's room on 11/12/25 at 9:50 AM identified Resident #2 was asleep, there was a white medication cup on Resident #2's bedside stand with a small white pill in it, this pill did not match the description of the simethicone Resident #2 was allowed to self-administer. Interview with LPN #1 at 10:10 AM identified she left Resident #2's medications at the bedside because Resident #2 had an order to self-administer his/her medications. 3. Resident #3's diagnoses included end stage renal disease and macular degeneration. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 made reasonable decisions regarding tasks of daily life. The self-administration of medication evaluation dated 9/11/25 identified Resident #3 had no desire to self-administer medications. Review of the physician's orders and care plan to the current date 11/12/25 failed to reflect documentation that Resident #3 could self-administer medications. Observations and interview with Resident #3 on 11/12/25 at 9:53 AM identified Resident #3 was awake and there was a white medication cup on Resident #3's bedside stand with an unidentified tablet in it. Resident #3 identified the pill was for his/her eye function. Interview with LPN #1 at 10:10 AM identified she left Resident #3's medications at the bedside because the resident had an order to self-administer his/her medications. 4. Resident #4's diagnoses included osteomyelitis of the left ankle, type two diabetes mellitus, anxiety, and opioid dependence. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 made reasonable decisions regarding tasks of daily life. Review of the physician's orders and care plan to the current date 11/12/25 failed to reflect documentation that Resident #3 could self-administer medications. Observations and interview with Resident #4 on 11/12/25 at 9:56 AM identified Resident #4 was awake and there was a white medication cup on Resident #4's bedside stand with an unidentified tablet in it. Resident #4 identified the pill was for the pancreas and the physician said he/she could take the medicine on his/her own. Interview with LPN #1 at 10:10 AM identified she left Resident #4's medications at the bedside because Resident #4 had an order to self-administer his/her medications. Interview with the 7AM-3PM floor nurse, Licensed Practical Nurse (LPN) #2 on 11/12/25 at 12:50 PM identified she would not leave medications at a resident's bedside unless they had an order for medication self-administration and if the resident was sleeping, she would never leave the medication at the bedside. Interview with the Director of Nursing (DON) on 11/12/25 at 2:30 PM identified medications should not be left at a resident's bedside if they did not have an order for medication self-administration and medications should not be left at the resident's bedside if the resident was asleep. The DON indicated the Medication Administration Policy was not followed when the medications were left at the resident's bedside without proper orders and when the resident was asleep. Review of the facility Self-Administration of Medication Policy identified that a physician's order must be present for all medications that are to be self administered.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of four (4) sampled residents (Resident #1) who required set up and reminders to complete daily hygiene care, the facility failed to implement the care plan and notify Resident #1's conservator when the resident refused to perform any portion of daily care. The findings include:Resident #1's diagnoses included mild cognitive impairment, chronic obstructive pulmonary disease, and congestive heart failure. The admission Record identified there was a family member that was appointed Resident #1's Conservator of Person (COP). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable decisions regarding tasks of daily life, was independent with most daily living skills, and required set up for hygiene and showers. The Resident Care Plan dated 7/30/25 identified Resident #1 had a self-care deficit, occasionally refused showers and had a history of dental problems with dental caries. Interventions directed to call Resident #1's conservator when refusing any care, assist with daily living skills as needed, administer medications as ordered, encourage tooth brushing two (2) times a day and apply prescribed oral treatments as ordered. Review of the July, August, September, and October 2025 nurse aide documentation sheets identified although the majority of time Resident #1 was compliant with care, there were occasions care did not occur and there was no documentation completed. Review of the September and October 2025 Medication Administration Records (MAR) identified entries to notify the conservator for refusal of care occurred two (2) times per week on shower days. The MAR failed to reflect documentation of notification of refusals for all care. Review of the nurse's notes from 10/13/25 to 11/10/25 failed to identify notification to the conservator of any refusals of care. Interview with Resident #1 on 11/12/25 at 9:40 AM identified Resident #1 was independent with personal care and per Resident 1's choice, did not wash, brush his/her teeth, or change clothes daily. Resident #1 identified he/she did take showers on shower days. Resident #1 indicated he/she felt there was no reason to perform hygiene tasks daily because he/she did not do anything to get dirty and when living at home he/she would not do these tasks daily. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 11/12/25 at 1:10 PM identified she was Resident #1's primary nurse aide on the 7AM-3PM shift. NA #1 identified on shower days Resident #1 complied with showers however once NA #1 set the water temperature, toiletries and clean clothes and Resident #1 got in the shower, she left Resident #1 to perform the task independently because Resident #1 refused assistance. NA #1 indicated she would frequently check on Resident #1 and noticed Resident #1 with a washcloth, and Resident #1 would always change clothes on days she worked with Resident #1. NA #1 identified Resident #1 would refuse assistance with toothbrushing and would indicate he/she had done that independently. Interview with the Director of Nursing (DON) on 11/12/25 at 2:30 PM identified the facility had agreed to notify the Conservator of all refusals of care by Resident #1 and the DON was not aware refusals of care were not documented as identified in the RCP. The DON indicated she spoke to the Conservator multiple times regarding her concerns about Resident #1 not agreeing to daily care. Review of the Care Plan Policy identified the Resident Care Plan would be developed with the resident and/or caregiver and implemented.

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure kitchen dry goods were stored appropriately and the kitchen hood was cleaned and maintained. The findings include:Observation of the kitchen during initial tour on 9/15/25 at 9:40 AM with Dietary Director identified the following.Muffin Mix bag in the dry storage food area of the kitchen with a receipt date of 8/1 (no year) and no expiration date.Traditional stuffing mix 1 opened bag and 3 unopened bags. Best by date 8/7/25 on all 4 bags. One bag of croutons, opened, with no expiration date.Visible dust and debris present under the hood, matted to the underside, including fire suppression system. No date of last cleaning nor cleaning log was maintained or available to review. Interview on 9/15/25 at 10:15AM with Dietary Manager identified anyone who is in the dry storage is responsible for going through the food and seeing if things are labeled or expired. Usually, the Dietary Manager will go through the food to see if it is labeled and she talks to her staff regularly about doing the same, however it must have been missed. The food in the dry storage should be labeled with both a receipt date, an open date and expiration date if it is not already printed on the bag. The hood in the kitchen is usually cleaned weekly by the Dietary Manager however there is no log kept, and every six months by a professional company, however she would have to look for the paperwork from the company. Staff have not been cleaning it recently as they have been short staff. Interview on 9/22/25 at 11:30 AM with the Dietary Manager identified the hood was last cleaned on 11/19/24 by a professional company however she wasn't sure why there was not a sticker on the hood or why they hadn't come back in 6 months. Maintenance was responsible for doing the scheduling. Interview on 9/22/25 at 11:50 AM with Assistant Maintenance Director identified the professional company did the last cleaning and they may or may not have come back between then, however it should be completed every 6 months. Maintenance usually does schedule the cleanings, however if there is money owed from the facility the company usually will not come back until payment is received. Interview on 9/22/25 at 11:58AM with Person #5, owner of professional company identified the previous balance from 11/19/24 was never paid and therefore they would not come out to do another cleaning. If the balance was paid, they could come out as soon as October 2025 for a cleaning. Interview on 9/22/25 at 12:15 AM with the Administrator identified she was unaware as to why the bill had not been paid as it was in corporates hands and unsure why the hood had not been cleaned. However, the last time it was cleaned was during the time she was administrator at the facility. Currently she is filling in for the administrator who is out on leave. Review of the Dietary Department guidelines directed all food items should be labeled and dated to allow for rotation of supplies. All areas of the Dietary Department will be cleaned on a regular schedule. Logs/schedule will be kept of cleaning tasks as they are completed. The Dietary Departments will be maintained in a clean and sanitary manner to prevent food borne illness.

Based on review of facility documentation, facility policy, and interview for water management, the facility failed to provide documentation of water sampling (for legionella and other waterborne pathogens), ice machine cleaning, and the facility failed to ensure the annual water management plan meeting was conducted with records maintained according to the facility's water management plan. The findings include: Review of facility documentation regarding monthly ice machine cleaning failed to identify the ice machines in the facility were cleaned from August 2024 through December 2024, 4 months. In addition, the records failed to identify any water sampling testing results for testing done on 1/29/24 and 1/27/25. Review of the Facility Water Management Plan with the Director of Maintenance and the Assistant Director of Maintenance on 9/18/25 at 2:23 PM identified the facility water management plan included flushing monthly, of water supply areas not frequently used, water sampling testing twice yearly for legionella, hot water temperature checks, and monthly ice machine cleaning. In addition, they identified the facility also had a contract with a vendor for their water management program. Interview with the Director of Maintenance and the Assistant Director of Maintenance on 9/18/25 at 2:23 PM identified the facility does not have a copy of the water sampling test results due to lack of payment to the contracting water management company. They identified the contracting water management company would notify the facility or the State agency if they had a positive water sampling test. They identified the facility should maintain and have in their records a copy of the results but if the bills were not paid then they would not be able to obtain a copy. Interview with the Assistant Director of Maintenance in the presence of the Administrator on 9/22/25 at 10:43 AM identified the facility maintenance staff were responsible for cleaning the ice machines monthly in the facility. He identified that he was unable to locate any documentation that the ice machine cleaning had been done from August 2024 to December 2024. He indicated the facility had a different director at time, so he does not know where/how that documentation was done. Review of the Water Management Policy identified facility should maintain the environmental assessment, sampling, and management plan and any associated sampling results on the facility premises for at least three years, such records should be made available to the local and the state department upon request. Review of the Annual Water Management Plan Revision and Updates dated 1/29/24 that was provided to the facility by the contracted company identified all efforts should be made to utilize the mitigation set forth by the contracting company on risk assessment and the facility shall continue documentation to establish compliance in all areas of the plan.Review of the Facility Water Management Plan for 2024 to 2025 failed to identify that the facility had a water management meeting to review water sampling results, updating or revising the water management plan provided by the company that was contracted by the facility to manage the facility's water management plan. The last record of a water management meeting identified the meeting was held in July of 2024. Interview with the Director of Maintenance and the Assistant Director of Maintenance on 9/18/25 at 2:23 PM identified the facility did not have a water management meeting or a water management committee that they were aware of. The Director of Maintenance identified he had only started working as the director six months ago and has had no water management meetings. The Assistant Director identified the facility had no results of the water sampling testing due to lack of payment by the facility to the contracted company. In addition, the facility does not have an updated and revised plan as it is usually provided by the contracted company and due to the lack of payment to the company the facility had no documentation of the revised policy. Interview with the Infection Preventionist (RN #4) on 9/17/25 at 1:37 PM identified she could not recall being a part of a water management meeting as the facility had not received the water sampling testing result. Although a request was made on 9/22/25 for the safety meeting minutes or any water management meeting minutes conducted from January 2024 through September 2025, the facility failed to provide such documentation and had only provided the water management committee meeting dated 7/10/24. Interview with the Administrator on 9/22/25 at 10:43 AM identified water management committee consisted of the infection control nurse, DNS, Director of Maintenance and Administrator, and they would conduct a meeting to review the water sampling results and to discuss the water management plan. She further identified the facility would receive the results of the water sampling testing when the bill was made to the contracted company, however they had not received the results or the updated plan due to lack of payment. She identified the water sampling testing would be done twice yearly according to the Assistant Director of Maintenance. Review of the Annual Water Management Plan Revision and Updates dated 1/29/24 that was provided to the facility by the contracted company identified the facility has identified team members to become a part of the water committee and meet annually. The water committee shall meet and review the water management plan, record topics discussed, and record meeting minutes with signatures of attendees, which meeting minutes are conducted by the facility.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 3 of 3 sampled residents (Residents #1, 58 and 110) reviewed for advance directives, the facility failed to ensure the resident's choice for code status was honored. The findings include: 1. Resident #1 was admitted to the facility [DATE]. Diagnosis included dementia with agitation, Type II diabetes mellitus with hyperglycemia and difficulty in walking.The admission MDS dated [DATE] identified Resident #1 had severely impaired cognitive skills for daily decision making.Review of the Facility Advance Directives Declaration Code Status form dated [DATE] identified Resident #1 was a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) as received by Resident #1's daughter by phone. The bottom of the form notes the physician must write an order and a progress note in the resident's chart.Physician's order dated [DATE] directed full code status (perform CPR if Resident #1's heart stopped).Physician's progress note dated [DATE] at 4:45 PM identified Resident #1's code status was DNR: RN may pronounce.The care plan dated [DATE] identified Resident #1 had an established advance directive of Full code/CPR.APRN progress note dated [DATE] at 1:15 PM identified Resident #1's code status as full code/CPR.Interview on [DATE] at 11:40 AM with RN #6 identified she works at the facility per diem and indicated the code status is listed on the bed board printout the nurses utilize during the shift and indicated Resident #1 was identified as a full code in both the EHR and on the bed board. RN #6 indicated the paper chart should also be checked to verify the code status.Interview [DATE] at 11:45 AM with RN #7, nursing supervisor, identified that the elected advance directive in Resident #1's paper chart was a DNR/DNI but indicated the code status listed in the EHR and on the bed board was full code and identified it needed to be corrected. RN#7 identified the responsibility for adding the order or updating the care plan was that of the DNS or ADNS. Interview on [DATE] at 12:48 PM with the DNS identified the advance directives are obtained by the admission nurse initially at the time the residents come into the facility or when the forms are signed by family representatives. The DNS indicated that the nurse who received the information regarding code status should the information in the computer as orders and add them to the care plan. The DNS identified this is normally done by the nurse, admits the resident and is usually the nursing supervisor.Interview on [DATE] at 1:14 PM with the DNS identified the admission nurse is responsible for getting the signatures on admission and the RN supervisors are responsible to follow up with obtaining the signatures within 2 days but indicated sometimes it takes longer. The DNS reviewed Resident #1's clinical chart and identified Resident #1 should be a DNR but that it was ordered in the computer as CPR and indicated that it had to be changed. Subsequent to surveyor inquiry physician's order dated [DATE] directed Resident #1's code status as DNR and RN may pronounce.Subsequent to surveyor inquiry the care plan was revised on [DATE] to reflect Resident #1's code status choice of Do not resuscitate, RN may pronounce.The facility policy for Advance Directives identified the admissions coordinator will discuss with the resident and/or responsible party whether or not they have executed any form of advanced directive and will obtain a copy to be placed in the resident's medical record and will document the existence of the advance directive on the MDS sheet and on the advance directive checklist. The policy indicated that the advance directive status of each resident will be reviewed at their resident care conference 2. Resident #58 was admitted to the facility in [DATE]. Diagnosis included adjustment disorder with anxiety, chronic embolism and depression. Review of the Facility Advance Directives Declaration Code Status form signed [DATE] by the power of attorney elected do not resuscitate (DNR) and do not intubate (DNI).The interdisciplinary care plan meeting form dated [DATE] did not address advance directive status. APRN progress note dated [DATE] at 1:45 PM identified Resident #58's code status was full code/CPR.The quarterly MDS dated [DATE] identified Resident #58 had intact cognition.The care plan dated [DATE], first initiated [DATE] identified Resident #58 had an established advance directive of CPR with interventions to administer CPR and review advance directives with resident and/or healthcare decision maker quarterly.The interdisciplinary care plan meeting form dated [DATE] identified Resident #58's code status was discussed as being a full code/CPR.Physician's order dated [DATE] directed a code status of full code/CPR. APRN progress note dated [DATE] at 3:45 PM identified Resident #58's code status was full code CPR. Interview on [DATE] at 11:40 AM with RN #6 identified the code status is listed on the bed board printout the nurses utilize during the shift and indicated Resident #58 was identified as a full code in both the EHR and on the bed board. RN #6 indicated the paper chart should also be checked to verify the code statusInterview [DATE] at 11:45 AM with RN #7, nursing supervisor, identified that the elected advance directive in Resident #58's paper chart was a DNR/DNI but indicated the code status listed in the EHR and on the bed board was full code and identified it needed to be corrected. RN #7 identified the responsibility for adding the order or updating the care plan was that of the DNS or ADNS. Interview on [DATE] at 12:48 PM with the DNS identified the advance directives are obtained by the admission nurse initially at the time the residents come into the facility or when the forms are signed by family representatives. The DNS indicated that the nurse who received the information should put it in the computer as orders and add them to the care plan. The DNS identified this is normally done by who admits the resident and is usually the nursing supervisor.Interview on [DATE] at 1:14 PM with the DNS identified the admission nurse is supposed to get the signatures on admission and the RN supervisors are supposed to follow up with obtaining the signatures within 2 days but indicated sometimes it takes longer. The DNS reviewed Resident #58's clinical chart and identified Resident #58 should be a DNR but that it was ordered in the computer as CPR and indicated that it had to be changed. Interview on [DATE] at 9:34 AM with Person #3 identified that she had selected DNR for Resident #58 and indicated that she had signed paperwork for the facility quite a while ago, at the time Resident #58 was admitted to the facility.The facility policy for Advance Directives identified the admissions coordinator will discuss with the resident and/or responsible party whether or not they have executed any form of advanced directive and will obtain a copy to be placed in the resident's medical record and will document the existence of the advance directive on the MDS sheet and on the advance directive checklist. The policy indicated that the advance directive status of each resident will be reviewed at their resident care conferenceSubsequent to surveyor inquiry a physician's order dated [DATE] directed a code status of DNR and RN may pronounce.Subsequent to surveyor inquiry the care plan was revised on [DATE] to identify Resident #58 had an established advance directive with interventions to not administer CPR and that RN may pronounce. 3. Resident #110 was admitted to the facility [DATE] with diagnosis that included unspecified dementia, alcohol dependence with alcohol-induced persisting dementia, unspecified mood disorder and urinary tract infection. Review of the Facility Advance Directives Declaration Code Status form dated [DATE] identified Resident #110 did not want resuscitation efforts performed and elected code status was DNR. This form was signed by Resident #110 and witnessed by a nursing supervisor.Resident #110 had a hospital stay and was re-admitted to the facility [DATE].Physician's orders dated [DATE] directed a code status of full code/CPR.The admission MDS dated [DATE] identified Resident #110 had intact cognition.The care plan dated [DATE] identified Resident #110 had an established advance directive with interventions to perform CPR. Interview on [DATE] at 11:40 AM with RN #6 identified the code status is listed on the bed board printout the nurses utilize during the shift and indicated Resident #110 was identified as a full code in both the EHR and on the bed board. RN #6 indicated the paper chart should also be checked to verify the code status.Interview [DATE] at 11:45 AM with RN #7, nursing supervisor, identified that the elected advance directive in Resident #110's paper chart was a DNR/DNI but indicated the code status listed in the EHR and on the bed board was full code and identified it needed to be corrected. RN #7 identified the responsibility for adding the order or updating the care plan was that of the DNS or ADNS. Interview on [DATE] at 12:48 PM with the DNS identified the advance directives are obtained by the admission nurse initially at the time the residents come into the facility or when the forms are signed by family representatives. The DNS indicated that the nurse who received the information should put it in the computer as orders and add them to the care plan. The DNS identified this is normally done by who admits the resident and is usually the nursing supervisor.Interview on [DATE] at 1:14 PM with the DNS identified the admission nurse is supposed to get the signatures on admission and the RN supervisors are supposed to follow up with obtaining the signatures within 2 days but indicated sometimes it takes longer. The DNS reviewed Resident #110's clinical chart and identified Resident #110 should be a DNR based on the previously signed advance directive, but that this should have been reviewed at the subsequent admission to the facility. The DNS identified the code status was ordered in the computer as CPR and indicated that it should have been followed up with Resident #110 and had to be changed. The facility policy for Advance Directives identified the admissions coordinator will discuss with the resident and/or responsible party whether or not they have executed any form of advanced directive and will obtain a copy to be placed in the resident's medical record and will document the existence of the advance directive on the MDS sheet and on the advance directive checklist. The policy indicated the advance directive status of each resident will be reviewed at their resident care conference.Subsequent to surveyor inquiry an advance directives declaration code status form dated [DATE] was signed by Resident #110 and signed by the physician Subsequent to surveyor inquiry physician's orders dated [DATE] directed a code status of DNR/DNI and RN may pronounce. Subsequent to surveyor inquiry on [DATE], the care plan was revised to identify Resident #110 had an established advance directive that identified do not resuscitate and RN may pronounce and indicated the advance directives would be reviewed with resident and/or healthcare decision maker quarterly.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one of three residents reviewed for adequate supervision, the facility failed to supervise one resident (Resident #1) who had a history of inappropriate sexual behaviors and behavior of wandering, as a result, Resident #3 requested a room change to avoid Resident #1's continued intrusive behaviors, and Resident #2 was touched in a sexual manner, resulting in a finding of Immediate Jeopardy. The IJ template was provided to the Administrator on 6/9/22 at 3:15 PM. During an onsite visit on 6/14/22 the action plan was reviewed and the IJ was removed effective 6/10/22. The findings include: 1. Resident #1 had diagnoses that included Alzheimer's, dementia with behavioral disturbance, Wernicke's encephalopathy, and an adjustment disorder. A State Probate Court document dated 9/27/18 identified Resident #1 had a conservator of person. The clinical record identified that Resident #1 had a history of inappropriate sexual behaviors (10/29/18 the resident was found in another resident's room, undressed, lying in the resident's bed with the other resident's gown open). Psychiatry APRN note dated 3/14/22 identified Resident #1 was trying to get into other resident's rooms, was more irritable and would wheel around the facility rapidly. Depakote sprinkles 250 mg at 10 AM was ordered to address the behaviors. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognition, required extensive assistance with Activities of Daily Living (ADL) had independent mobility in a wheelchair and had wandering behavior that occurred daily. A quarterly social service assessment dated [DATE] identified Resident #1 would self-propel up and down the halls and would be intrusive to others at times. Resident #1 was followed by the psych APRN for medication management and was seen on multiple occasions during that review period related to escalating exit seeking and barging in behaviors. The note further identified that Resident #1 continued to be intent on wandering into other resident rooms. Staff would redirect as needed and some stop signs were in use to discourage h/her from entering other resident rooms. A Psychiatry APRN progress note dated 4/21/22 identified Resident #1 wandered down the halls and had entered other resident rooms episodically. The progress notes further identified that a new order for Seroquel 12.5 milligrams (mg) at 2:00 PM and at hour of sleep were added to the medication regime to address these behaviors. The care plan dated 5/4/22 identified Resident #1 had inappropriate behavior as evidenced by the resident disrobing in public, making inappropriate comments, and sexually inappropriate behaviors. The care plan identified that on 10/29/18 the resident was found in another resident's room, undressed, lying in the resident's bed with the other resident's gown open. The interventions included to provide specific diversional activity such as snack, entertainment or physician activity, re-direct resident to common area if seen wandering the halls or attempting to enter other resident rooms, document any negative behaviors, and refer to the physician, psychiatry, or social services as needed. The care plan further identified Resident #1 had impaired cognition, wandered up and down the halls and occasionally intruded on others. Interventions included to reorient as needed, repeat messages sent, provide cueing and reminders. A behavioral health progress note dated 5/20/22 identified Resident #1 had been increasingly intrusive which was bothering other residents. Resident #1 continued to explore the hallways and the provider suggested that staff encourage activities to address intrusive behavior. The clinical record failed to identify the specific activities that would be offered to address the behaviors. Behavior Flow Sheet Records for January 2022 through June 2022 identified Resident #1 was being monitored every shift for anxiety, depressive statements, combativeness, and yelling. The behavior monitoring flow sheets failed to identify that the resident was being monitored for sexually inappropriate or wandering behaviors. Observations of the Resident #1's nursing unit on 6/9/22 did not identify any stop signs on the doors. a. Resident #2 had diagnoses that included dementia with behavioral disturbance, heart failure and bipolar disorder. A State Probate Court document dated 10/8/20 identified Resident #2 had a Conservator of Person. An annual MDS dated [DATE] identified Resident #2 had severely impaired cognition, had an impairment with range of motion on both sides of upper extremities, was an extensive assist for bed mobility and required two staff physical assist with ADLs, and was always incontinent of bowel and bladder. The care plan dated 5/12/22 identified Resident #2 had an ADL deficit related to generalized weakness, spinal stenosis, polyneuropathy, and anxiety with interventions that included total dependence for bed mobility, mechanical lift transfer with a non-ambulatory status. The care plan further identified that Resident #2 had a communication and cognition problem related to a hearing deficit and word finding problems with interventions that included to encourage communication with the resident throughout the shift. Resident #1 and Resident #2 resided on the same unit, however resided in different hallways. Review of the facility reportable event report dated 6/4/22 at 7:20 AM identified that Resident #1 was found in Resident #2's room, sitting on Resident #2's bed. Resident #1 was not wearing any pants and Resident #2's gown was pulled up above the waist and h/her brief was undone and Resident #1 had h/her hand on Resident #2's genital area. Resident #1 was sent to the emergency department for psychiatric evaluation and was placed on 1:1 observation with a sitter upon return to the facility. Resident #2 was sent to the emergency department for an evaluation. A nursing note dated 6/4/22 at 1:23 PM written by Registered Nurse (RN) #1 identified at 7:25 AM he was called to the floor by the primary nurse and was informed that Resident #1 as found in Resident #2's room. When found, Resident #1 was sitting on Resident #2's bed without his/her pants on and Resident #2 was lying in bed with his/her gown pulled up above the waist and briefs were unfastened and pulled down. Resident #1's hand was on Resident #2's genital area. Resident #1 was removed from Resident #2's room and placed on 1:1 observation. The DNS, ADNS, Medical Director, Social Worker and family were updated on the incident. Resident #1 was sent to the emergency department for a psychiatric evaluation. The nursing note dated 6/4/22 at 7:39 PM identified Resident #1 returned from the emergency department and a 1:1 sitter was immediately placed with Resident #1. Interview with NA #2 on 6/9/22 at 11:26 AM identified on 6/4/22 she last saw Resident #1 sitting in his/her wheelchair at the nursing station at 7:00 AM. NA #2 further identified Resident #1 has been observed in empty beds before, and Resident #1's usual daily behavior was wandering up and down the halls. Interview with LPN # 3 (who worked the 11:00 PM to 7:00 AM shift) on 6/9/22 at 11:29 AM identified on 6/4/22 she observed Resident #1 sleeping in his/her wheelchair in his/her hall around 6:05 AM. She identified around 6:50 AM she told Resident #1 to go to bed, Resident #1 headed in the direction of h/her room. LPN #3 further identified it is normal behavior for Resident #1 to wander up and down the halls and sometimes go to lie another room in an empty bed. Interview with NA #1 on 6/8/22 at 11:00 AM identified on 6/4/22 at 7:20 AM she entered Resident #2's room to provide morning care and observed Resident #1 with nothing on from the waist down and sitting on the side of Resident #2's bed. Resident #2 did not have a top on, and his/her brief was opened with Resident #1's hand on his/her private area. The NA yelled out to the other NA in the hall who alerted Licensed Practical Nurse (LPN) #1 and the residents were immediately separated. NA #1 further identified Resident #1 has a history of roaming up and down the halls. Interview with LPN #1 on 6/8/22 at 11:41 AM identified on the morning of 6/4/22 she was called into Resident #2's room by the NA and observed Resident #2 lying in bed with his/her gown up, brief open and Resident #1 on the side of the bed over him/her with no pants on. Resident #1 transferred into h/her wheelchair and was transported back into h/her room. LPN #1 further identified Resident #1 wanders down the halls, and she has seen him go into rooms and lie in empty beds before. Interview with RN #1, (the nursing supervisor on 6/4/22) on 6/9/22 at 10:37 AM identified on 6/4/22 Residents #1 and #2 were separated when he walked in, and Resident was placed on 1:1 observation. RN #1 identified Resident #1 and #2 did not have any acute distress and were sent to the emergency department after the police evaluated the residents in the facility. RN #1 further identified Resident #1 has a history of wandering, and he has found Resident #1 several times going into other resident rooms and has had to remove and redirect him/her on several occasions. Interview with LPN #4 on 6/10/22 at 2:12 PM identified that Resident #1 usually wanders the halls and will camp out at the end of the hallways or the nursing station. LPN #4 identified she has caught the resident going into other resident rooms and has found the resident in empty rooms asleep on the bed. LPN #4 further identified some residents have stated they don't like the fact that Resident #1 wanders the halls, and the facility has placed stop signs outside of the rooms of the residents who don't like his behaviors. She further identified there have been two residents that have had their rooms moved because of his intrusive behaviors. She identified these residents had their rooms at the end of the hall which is where Resident #1 would gravitate (although there were a few stop signs observed on resident doors, they were not across the door, and left hanging by the side of the door). Interview with LPN #2 on 6/9/22 at 10:02 identified she has observed Resident #1 wandering up and down the hallways in his/her wheelchair. Interview with the DNS on 6/9/22 at 3:15 PM identified Resident #1 had a history of wandering the halls and would occasionally enter other resident rooms with no harmful behavior identified, if harmful behavior was identified, the facility would have increased h/her supervision. The DNS identified Resident #1 was being followed by the psychiatric provider and Resident #1's psychiatric medications had been adjusted. The DNS identified Resident #1 had the intervention of redirection when wandering or enter other residents' rooms. The facility implemented continuous 1:1 observation for Resident #1 following return from the emergency department on 6/4/22 with no identified end date at this time. Staff were educated on inappropriate sexual behaviors/contact between residents, signs of sexual abuse in long term care and reporting abuse. However, the facility failed to address when to monitor residents more closely if necessary. The facility failed to provide the necessary supervision to Resident #1 to prevent wandering and inappropriate sexual touch involving Resident #2. As a result, Immediate Jeopardy was identified. b. Resident #3 had diagnoses that included dementia and an adjustment disorder. A quarterly MDS dated [DATE] identified Resident #3 was alert and oriented, and required extensive assistance with ADLs. A Social Service progress note dated 4/21/22 at 4:21 PM identified Resident #2 accepted a room change following complaint that in his/her current location he/she is bothered by a peer who wanders, hangs outside his/her door and has been intrusive. A Social Service note dated 5/10/22 at 4:56 PM identified Resident #3 continued to cope with the wandering peer who had been intrusive at times. The note further identified the room change was delayed again due to the need to use the room to isolate a COVID-19 positive peer. Social Service note dated 5/18/22 at 4:06 PM identified Resident #3 moved to a different room today and a stop sign was provided for the door as a deterrent to a wandering peer. Interview with Resident #3 on 6/14/22 at 11:00 AM identified that Resident #1 would enter h/her bedroom daily, and on one occasion, when h/she was getting dressed and had the door closed, Resident #1 opened the door and ripped open the privacy curtain. Resident #3 stated that when Resident #1 would enter h/her room, Resident #1 made h/her nervous at times so h/she would point and tell Resident #1 to leave. Resident #3 identified that the facility had attempted to place Velcro stop signs on the door, but Resident #1 would just rip them down, and come into the room. Resident #3 stated that she had told facility staff about Resident #1, however they would respond with things like Resident #1 doesn't know what h/she is doing. Resident #3 stated that h/she had a room change because of the resident but was very distressed when Resident #1 found h/her in the new room. Review of Resident #1's care plan during the period of 4/21/22-5/18/22 failed to address the continued behaviors of wandering. Interview with Social Worker (SW) #1 on 6/9/22 at 12:00 PM identified Resident #1 was the wandering and intrusive peer described in Resident #3's progress notes. SW #1 identified Resident #3 had no cognitive impairments and requested his/her room to be changed due to Resident #1 wandering into h/her room and sitting in the room. SW #1 identified she notified the interdisciplinary team including the Administrator and Director of Nursing Services (DNS). SW #1 further identified Resident #4 (who resided across the hall from Resident #3) also had expressed concerns with Resident #1 entering h/her room. Interview with the DNS on 6/9/22 at 2:25 PM identified she was aware that Resident #1 was intrusive to Resident #3 on multiple occasions and that Resident #3 requested a room change due to Resident #1's intrusiveness. The DNS identified she did not make modifications to Resident #1 ' s care plan, or add interventions because she had no concerns. The DNS further indicated although she was aware of Resident #1's history of sexually inappropriate behavior, she did not think Resident #1 was a risk to Resident #3 because Resident #1 would sit in Resident #3's room with wheelchair and Resident #3 would tell Resident #1 to get out of his/her room. The facility failed to update the plan of care to address Resident #1's continued wandering behaviors. On 6/9/22 at 3:15 PM, the CT Department of Public Health requested an action plan to address supervision of residents who wandered and had inappropriate sexual behaviors. The immediate action plan identified that Resident #1 would remain on one-to-one observation. Staff will be in serviced on the facility abuse policy and how to manage and monitor sexual behaviors, education will include the need for increased monitoring of residents as necessary. An audit was conducted to identify residents with a history of sexual behaviors and identified two additional residents with a history of sexual behaviors. The care plans, progress notes and behavior documentation records are being reviewed for these residents. Observation audits were conducted in the facility and all residents were found to be free of abuse. Random weekly audits will be conducted to ensure that staff are managing and monitoring sexual behaviors per each resident ' s individualized care plan until substantial compliance has been achieved and will be presented during QAPI committee meetings. Although the facility identified that there was no specific policy to address the monitoring of a resident who was exhibiting wandering and intrusive behaviors, subsequent to the incident the staff was educated to report these behaviors to the nursing supervisor and appropriate intervention will be added to the plan of care.

Based on clinical record review, facility documentation, facility policy, and interviews for one of three residents reviewed for abuse, the facility failed to protect a resident (Resident #2) from sexual abuse, resulting in a finding of Immediate Jeopardy. The IJ template was given to the Administrator on 6/9/22 at 3:15 PM. During an onsite visit on 6/14/22 the action plan was reviewed and the IJ was removed effective 6/10/22. The findings include: Resident #1 had diagnoses that included Alzheimer's, dementia with behavioral disturbance, Wernicke's encephalopathy, and an adjustment disorder. A State Probate Court document dated 9/27/18 identified Resident #1 had a conservator of person. Psychiatry APRN note dated 3/14/22 identified Resident #1 was trying to get into other resident's rooms, was more irritable and would wheel around the facility rapidly. Depakote sprinkles 250 mg at 10 AM was ordered to address the behaviors. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognition, required extensive assistance with Activities of Daily Living (ADL) had independent mobility in a wheelchair and had wandering behavior that occurred daily. A quarterly social service assessment dated [DATE] identified Resident #1 would self-propel up and down the halls and would be intrusive to others at times. Resident #1 was followed by the psych APRN for medication management and was seen on multiple occasions during that review period related to escalating exit seeking and barging in behaviors. The note further identified that Resident #1 continued to be intent on wandering into other resident rooms. Staff would redirect as needed and some stop signs were in use to discourage h/her from entering other resident rooms. A Psychiatry APRN progress note dated 4/21/22 identified Resident #1 wandered down the halls and had entered other resident rooms episodically. The care plan dated 5/4/22 identified Resident #1 had inappropriate behavior as evidenced by the resident disrobing in public, making inappropriate comments, and sexually inappropriate behaviors. The care plan identified that on 10/29/18 the resident was found in another resident's room, undressed, lying in the resident's bed with the other resident's gown open. The interventions included to provide specific diversional activity such as snack, entertainment or physician activity, re-direct resident to common area if seen wandering the halls or attempting to enter other resident rooms, document any negative behaviors, and refer to the physician, psychiatry, or social services as needed. The care plan further identified Resident #1 had impaired cognition, wandered up and down the halls and occasionally intruded on others. Interventions included to reorient as needed, repeat messages sent, provide cueing and reminders. A behavioral health progress note dated 5/20/22 identified Resident #1 had been increasingly intrusive which was bothering other residents. Resident #1 continued to explore the hallways and suggested to encourage finding activities to address intrusive behavior. Behavior Flow Sheet Records for January 2022 through June 2022 identified Resident #1 was being monitored every shift for anxiety, depressive statements, combativeness, and yelling. The behavior monitoring flow sheets failed to identify that the resident was being monitored for sexually inappropriate or wandering behaviors. Observations of the Resident #1's nursing unit on 6/9/22 did not identify any stop signs on the doors. a. Resident #2 had diagnoses that included dementia with behavioral disturbance, heart failure and bipolar disorder. A State Probate Court document dated 10/8/20 identified Resident #2 had a Conservator of Person. An annual MDS dated [DATE] identified Resident #2 had severely impaired cognition, had an impairment with range of motion on both sides of upper extremities, was an extensive assist for bed mobility and required two staff physical assist with ADLs. The care plan dated 5/12/22 identified Resident #2 had an ADL deficit related to generalized weakness, spinal stenosis, polyneuropathy, and anxiety with interventions that included total dependence for bed mobility, mechanical lift transfer with a non-ambulatory status. The care plan further identified that Resident #2 had a communication and cognition problem related to a hearing deficit and word finding problems with interventions that included to encourage communication with the resident throughout the shift. Resident #1 and Resident #2 resided on the same unit, however resided in different hallways. Review of the facility reportable event report dated 6/4/22 at 7:20 AM identified that Resident #1 was found in Resident #2's room, sitting on Resident #2's bed. Resident #1 was not wearing any pants and Resident #2's gown was pulled up above the waist and h/her brief was undone and Resident #1 had h/her hand on Resident #2's genital area. Resident #1 was sent to the emergency department for psychiatric evaluation and was placed on 1:1 observation with a sitter upon return to the facility. Resident #2 was sent to the emergency department for an evaluation. A nursing note dated 6/4/22 at 1:23 PM written by Registered Nurse (RN) #1 identified at 7:25 AM he was called to the floor by the primary nurse and was informed that Resident #1 was found in Resident #2's room. When found, Resident #1 was sitting on Resident #2's bed without his/her pants on and Resident #2 was lying in bed with his/her gown pulled up above the waist and briefs were unfastened and pulled down. Resident #1's hand was on Resident #2's genital area. Resident #1 was removed from Resident #2's room and placed on 1:1 observation. The DNS, ADNS, Medical Director, Social Worker and family were updated on the incident. Resident #1 was sent to the emergency department for a psychiatric evaluation. The nursing note dated 6/4/22 at 7:39 PM identified Resident #1 returned from the emergency department and a 1:1 sitter was immediately placed with Resident #1. Interview with NA #2 on 6/9/22 at 11:26 AM identified on 6/4/22 she last saw Resident #1 sitting in his/her wheelchair at the nursing station at 7:00 AM. NA #2 further identified Resident #1 has been observed in empty beds before, and Resident #1's usual daily behavior was wandering up and down the halls. Interview with LPN # 3 (who worked the 11:00 PM to 7:00 AM shift) on 6/9/22 at 11:29 AM identified on 6/4/22 she observed Resident #1 sleeping in his/her wheelchair in his/her hall around 6:05 AM. She identified around 6:50 AM she told Resident #1 to go to bed, Resident #1 headed in the direction of h/her room. LPN #3 further identified it is normal behavior for Resident #1 to wander up and down the halls and sometimes go to lie another room in an empty bed. Interview with NA #1 on 6/8/22 at 11:00 AM identified on 6/4/22 at 7:20 AM she entered Resident #2's room to provide morning care and observed Resident #1 with nothing on from the waist down and sitting on the side of Resident #2's bed. Resident #2 did not have a top on, and his/her brief was opened with Resident #1's hand on his/her private area. The NA yelled out to the other NA in the hall who alerted Licensed Practical Nurse (LPN) #1 and the residents were immediately separated. NA #1 further identified Resident #1 has a history of roaming up and down the halls. Interview with LPN #1 on 6/8/22 at 11:41 AM identified on the morning of 6/4/22 she was called into Resident #2's room by the NA and observed Resident #2 lying in bed with his/her gown up, brief open and Resident #1 on the side of the bed over him/her with no pants on. Resident #1 transferred into h/her wheelchair and was transported back into h/her room. LPN #1 further identified Resident #1 wanders down the halls, and she has seen him go into rooms and lie in empty beds before. Interview with RN #1, (the nursing supervisor on 6/4/22) on 6/9/22 at 10:37 AM identified on 6/4/22 Resident #1 and #2 were separated when he walked in, and Resident #1 was placed on 1:1 observation. RN #1 identified Resident #1 and #2 did not have any acute distress and were sent to the emergency department after the police evaluated the residents in the facility. RN #1 further identified Resident #1 has a history of wandering, and he has found Resident #1 several times going into other resident rooms and has had to remove and redirect him/her on several occasions. Interview with LPN #4 on 6/10/22 at 2:12 PM identified that Resident #1 usually wanders the halls and will camp out at the end of the hallways or the nursing station. LPN #4 identified she has caught the resident going into other resident rooms and has found the resident in empty rooms asleep on the bed. LPN #4 further identified some residents have stated they don't like the fact that Resident #1 wanders the halls, and the facility has placed stop signs outside of the rooms of the residents who don't like his behaviors. She further identified there have been two residents that have had their rooms moved because of Resident #1's intrusive behaviors. She identified these residents had their rooms at the end of the hall which is where Resident #1 would gravitate (although there were a few stop signs observed on resident doors, they were not across the door, and left hanging by the side of the door). Interview with LPN #2 on 6/9/22 at 10:02 identified she has observed Resident #1 wandering up and down the hallways in his/her wheelchair. Interview with the DNS on 6/9/22 at 3:15 PM identified that she was aware of Resident #'s history of innapropriate sexula behavioprs and that Resident #1 had a history of wandering the halls and would occasionally enter other resident rooms, however, no harmful behavior had been identified, if harmful behavior was identified, the facility would have increased h/her supervision. The DNS identified Resident #1 was being followed by the psychiatric provider and Resident #1's psychiatric medications had been adjusted. The DNS identified Resident #1 had the intervention of redirection when wandering or enter other residents' rooms. The facility failed to ensure Resident #1 was monitored to prevent sexual abuse involving Resident #2. As a result, Immediate Jeopardy was identified. b. Resident #3 had diagnoses that included dementia and an adjustment disorder. A quarterly MDS dated [DATE] identified Resident #3 was alert and oriented, and required extensive assistance with ADLs. A Social Service progress note dated 4/21/22 at 4:21 PM identified Resident #2 accepted a room change following complaint that in his/her current location he/she is bothered by a peer who wanders, hangs outside his/her door and has been intrusive. A Social Service note dated 5/10/22 at 4:56 PM identified Resident #3 continued to cope with the wandering peer who had been intrusive at times. The note further identified the room change was delayed again due to the need to use the room to isolate a COVID-19 positive peer. Social services note dated 5/18/22 at 4:06 PM identified Resident #3 moved to a different room today and a stop sign was provided for the door as a deterrent to a wandering peer. Interview with Resident #3 on 6/14/22 at 11:00 AM identified that Resident #1 would enter h/her bedroom daily, and on one occasion, when h/she was getting dressed and had the door closed, Resident #1 opened the door and ripped open the privacy curtain. Resident #3 stated that when Resident #1 would enter h/her room, Resident #1 made h/her nervous at times so h/she would point and tell Resident #1 to leave. Resident #3 identified that the facility had attempted to place Velcro stop signs on the door, but Resident #1 would just rip them down, and come into the room. Resident #3 stated that she had told facility staff about Resident #1, however they would respond with things like Resident #1 doesn't know what h/she is doing. Resident #3 stated that h/she had a room change because of the resident but was very distressed when Resident #1 found h/her in the new room. Interview with Social Worker (SW) #1 on 6/9/22 at 12:00 PM identified Resident #1 was the wandering and intrusive peer described in Resident #3's progress notes. SW #1 identified Resident #3 had no cognitive impairments and requested his/her room to be changed due to Resident #1 wandering into h/her room and sitting in the room. SW #1 identified she notified the interdisciplinary team including the Administrator and Director of Nursing Services (DNS). SW #1 further identified Resident #4 (who resided across the hall from Resident #3) also had expressed concerns with Resident #1 entering h/her room. Interview with the DNS on 6/9/22 at 2:25 PM identified she was aware that Resident #1 was intrusive to Resident #3 on multiple occasions and that Resident #3 requested a room change due to Resident #1's intrusiveness. The DNS identified she did not make modifications to Resident #1's care plan, or add interventions because she had no concerns. The DNS further indicated although she was aware of Resident #1's history of sexually inappropriate behavior, she did not think Resident #1 was a risk to Resident #3 because Resident #1 would sit in Resident #3's room with wheelchair and Resident #3 would tell Resident #1 to get out of his/her room. Review of the facility abuse policy identified that each resident has the right to be free from abuse, and that it is the facility's responsibility to identify events, occurrences, patterns and trends of potential abuse for residents. On 6/9/22 at 3:15 PM, the CT Department of Public Health requested an action plan to address supervision of residents who wandered and had inappropriate sexual behaviors. The immediate action plan identified that Resident #1 would remain on one-to-one observation. Staff will be in serviced on the facility abuse policy and how to manage and monitor sexual behaviors, education will include the need for increased monitoring of residents as necessary. An audit was conducted to identify residents with a history of sexual behaviors and identified two additional residents with a history of sexual behaviors. The care plans, progress notes and behavior documentation records are being reviewed for these residents. Observation audits were conducted in the facility and all residents were found to be free of abuse. Random weekly audits will be conducted to ensure that staff are managing and monitoring sexual behaviors per each resident ' s individualized care plan until substantial compliance has been achieved and will be presented during QAPI committee meetings.

Based on clinical record reviews, review of facility documentation, and interviews for 4 sampled residents (Residents #1001, 1002, 1003 and #1004) reviewed for resident-to-resident altercations and criminal history, the facility failed to ensure a resident was free from abuse when staff failed to communicate a resident's criminal history and probation status to the team resulting in an altercation with injury. The findings include: Resident #1001 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set assessment dated [DATE] identified Resident #1001 had a serious mental illness, was cognitively intact, used a wheelchair and had a conservator. The Resident Care Plan dated 9/8/21 identified Resident #1001 was verbally aggressive towards other patients. Interventions directed to seek out staff for assistance when agitated by other residents. Resident #1002 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1002 was cognitively intact. The Resident Care Plan dated 9/16/21 identified Resident #1002 had adjustment disorder with depressed mood and could be verbally aggressive with agitation. Interventions directed to encourage verbalization and provide emotional support. A review of the facility's reportable event form and investigation dated 10/15/21 identified Resident #1002 reported an unwitnessed event in which Resident #1001 entered his/her room, stated he/she was going to kill him/her, assaulted Resident #1002 in his/her room by attempting to choke him/her, and injured his/her Adam's apple. The reportable event form identified Resident #1001 was placed on 1:1 observation. Subsequently Resident #1002 complained of difficulty swallowing, throat pain and abrasion to right neck and was sent to the emergency department for evaluation. The facility's investigation identified that the conservators and police were notified, and an investigation was initiated. The allegations were substantiated by the facility. A review of the emergency room provider notes for Resident #1002 dated 10/16/21 at 12:27 AM identified a clinical impression of alleged assault with complaints of slight difficulty swallowing and findings of contusion of neck. The note indicated Resident #1002 was discharged back to the facility with recommendations for cryotherapy and over the counter analgesics. Observation on 10/26/21 at 12:40 PM during a tour of the facility identified Resident #1001 on 1:1 observation. Review of the facility's Concern Log dated 6/15/21 identified documentation of another altercation between Resident #1001 and Resident #1002 where Resident #1002 reported to staff that Resident #1 had a steak knife and when Resident #1002 made a comment about the knife, Resident #1001 told Resident #1002 to stand still, and he/she would flick the knife at him/her. Review of Resident #1001's nurse's notes dated 1/1/21 to 10/25/21 identified three documented verbal altercations which occurred between Resident #1 and Resident #1002. An interview with the DNS and the Administrator on 10/26/21 at 9:09 AM identified the team became aware that Resident #1001 had a criminal history on 10/18/21 (3 days after the incident) which included threatening and strangulation. The DNS indicated that staff found Resident #1001's legal history through a Google search. An interview with Resident #1001's probation officer and the chief police officer of New [NAME] on 10/26/21 at 10:34 AM identified that the probation department communicated with the facility a total of seven times between 2/2/21 and 10/12/21. In an interview with Resident #1002 on 10/26/21 at 12:25 PM, Resident #1002 stated that Resident #1001 was trying to kill him/her and indicated he had flashbacks as Resident #1001 was still around. Resident #1002 indicated he/she did not think Resident #1001 could get to him/her from the next floor. Resident #1002 stated that in the past Resident #1001 had run a wheelchair over his/her toe, threatened to kill him/her if he/she mentioned his/her son again and attempted to run him/her down with the wheelchair when Resident #1001 thought he/she was watching him/her. Resident #1002 indicated he/she reported the incidents to staff but was unable to recall dates and names. In an interview with Social Worker (SW) #1 on 10/26/21 at 12:48 PM, SW #1 stated she was unaware of Resident #1001's criminal background. SW #1 reported she had worked with the resident since his/her admission on 6/2020. SW #1 stated she could recall being in contact with the Probation department in March of 2021 when she received a call from the probation officer asking for permission for Resident #1001 to attend a mandatory education. SW #1 indicated she was aware that the issue was domestic in nature. SW #1 stated she did not share this information with the team and indicated that in retrospect she should have shared this information with the facility's interdisciplinary team. An interview with the DNS, Administrator, and Cooperate Nurse on 10/26/12 at 3:00 PM identified that had the facility known of Resident #1001's history prior to his/her admission to the facility, the facility would have reached out to the Corporate office to determine whether the resident was appropriate for admission to the facility. Interview with the Corporate Nurse on 10/26/21 at 10:10 AM identified that it was the practice of the facility to perform a background check on all residents prior to admission to the facility. The corporate nurse indicated that this information would be entered into a shared drive in the computer and communicated to the interdisciplinary team during morning reports. The Corporate Nurse stated that the interdisciplinary team was not aware that Resident #1001 was on probation and indicated that the Probation department had not reached out to the facility. The Corporate Nurse further indicated that subsequent to the physical altercation between Resident #1001 and Resident #1002 and knowledge of Resident #1001's legal issues, a criminal background check was completed on all residents within the facility. The background check identified that Resident #1003 (admitted to the facility on [DATE]) had an ongoing case for threatening to shoot his/her conservator and Resident #1004 (admitted to the facility on [DATE]) was on probation for a 3rd degree assault which the facility was unaware of. In an interview with the Admissions Coordinator on 10/26/21 at 11:37 AM, she indicated that the facility performed criminal background checks on all residents referred to the facility and she would share every referral with the interdisciplinary team to include sharing of results of criminal background checks. The Admission's Coordinator further indicated she could not recall taking the referral or conducting the background check for Resident #1001 and stated this may have been done by an admission's supervisor who no longer worked with the facility. The Admission's Coordinator stated that upon checking Resident #1003's background record prior to admission she identified the resident had a criminal record which was [NAME] sealed and indicated she did not discuss the finding with the multidisciplinary team and could not recall escalating the concern with the admissions supervisor. The Admission's Coordinator further indicated that when Resident #1004's clinical background was checked and pending cases not found, she did not access the convictions where the resident's 3rd degree assault was documented. The Admission's Coordinator further indicated, she did not communicate the criminal history of the residents to the team because she was not aware of the history and indicated she should have checked the convictions for Resident #1004. Subsequent to surveyor's inquiry, the facility indicated that a plan of correction was initiated to include in-service of all staff who may potentially receive phone calls from law enforcement and probation officers to report this communication to the DNS and Administrator, that random review of information in the shared computer K drive would be done, along with auditing and QAPI involvement. Review of the facility's admission review process and categories of residents requiring special considerations included patients who would pose a danger to themselves and others. A review of the facility's Abuse policy identified it was the facility's responsibility to identify events, occurrences, patterns and trends of potential abuse for residents. Review of the Patient's Bill of Rights identified that as a patient you have the right to be free from verbal, physical, sexual, or mental abuse, corporal punishment, and involuntary seclusion.

Based on a review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of six sampled residents (Resident #285) reviewed for accidents, the facility failed to ensure adequate supervision was provided for a resident at risk for falls resulting in a fall with serious injuries, and the facility failed to ensure the resident was transferred to the hospital in a timely manner. The findings include: Resident #285's diagnoses included dementia, [CONDITION(S)] requiring long term anticoagulants, [CONDITION(S)], and [CONDITION(S)]. The quarterly MDS assessment dated [DATE] identified that Resident #285 had severe cognitive impairment, required extensive assistance of two staff for bed mobility, transfers and toileting. The assessment further identified that the resident did not ambulate, required total assistance with locomotion in the wheelchair and was frequently incontinent of bowel and bladder. In addition, the assessment noted that the resident's balance was unsteady, and he/she was only able to stabilize with staff assistance when moving from a seated to standing position. It further identified that the resident had a range of motion deficit in one upper extremity and had fallen within the past three months. The RCP dated [DATE] identified Resident #285 was at risk for falls due to cognitive impairment, generalized weakness, and unsteady gait with interventions that included; custom wheelchair with a positioning plan, do not leave unattended in personal leather recliner chair, low bed and instruct resident to ask for assistance prior to attempting to transfer as needed. Physician's orders for the month of December/2020 directed to administer [MEDICATION(S)] (used to treat blood clots) 2.5 mg to be administered every evening. The reportable event report dated [DATE] completed by RN #3, identified that at 4:15 AM Resident #285 was found on the floor and was observed to have a 9.0 centimeter (cm) hematoma to the mid forehead, a skin tear measuring 0.25 cm near the bridge of the nose, a 0.5 cm skin tear on the right index finger, and a 0.5 cm skin tear on the left elbow. The nurse's note dated [DATE] at 7:30 AM written by RN #3 (worked the 11:00 PM to 7:00 AM shift) identified that following Resident #285's fall his/her range of motion was within normal limits for all extremities, Resident #285 complained of pain on movement of the left arm and neurological (neuro) checks and vital signs were initiated. The note further identified that ice was applied to the hematoma and dressings were applied to skin tears on left elbow and right index finger. The nurse's note dated [DATE] at 7:50 AM written by RN #4 (worked the 7:00 AM to 3:00 PM shift) identified Resident #285 had a fall at 4:15 AM and sustained a head injury. The note further identified that Resident #285 was transferred to the hospital for evaluation. The emergency ambulance run report dated [DATE] identified that a 911 call was placed to Emergency Medical Services (EMS) at 7:47 AM. EMS arrival to the facility at 7:58 AM, Resident #285 was noted to have a large hematoma on the forehead (4 x 5 cm with swelling approximately 1.5 inches high). The resident had complaints of right shoulder and collar bone pain, a c-spine collar for stabilization was placed on the resident. Resident #285 departed the facility at 8:14 AM (4 hours after the 4:15 AM fall). The hospital emergency room physician's progress note dated [DATE] at 10:29 AM identified Resident #285 was sent to the emergency room for a fall out of bed and noted the resident was on [MEDICATION(S)] with a therapeutic international normalized ratio (INR) which is a blood test that measures the time it takes for an individual's blood to clot. The progress note identified the INR level was 2.4 (therapeutic range is 2.0 to 3.0) and noted Resident #285 complained of a headache and was noted to have a hematoma with an abrasion to his/her forehead. The CT scan of the brain demonstrated an [CONDITION(S)] with subdural and subarachnoid bleeding, an acute minimally displaced fracture of the occipital bone, a subcutaneous hematoma to the anterior midline forehead/scalp and a new fairly large approximately 6 by 2.5 by 5.5 centimeter (cm) [MEDICATION(S)] hematoma along the posterior left occipital region, a small to moderate with a maximum of 10 millimeter (mm) acute subdural hemorrhage along the inner table of the left temporal-parietal regions, and an acute hemorrhage was seen along the upper surface of the tentorium and the left of the posterior falx. A hospital progress note dated [DATE] at 3:33 PM identified Resident #285 was being transferred to a second hospital due to blood in his/her bilateral nares, a large hematoma in the center of the forehead, increased confusion and a repeat CT scan that identified his/her condition had deteriorated. A hospital progress note dated [DATE] at 3:49 PM identified Resident #285 had increased confusion, agitation and repeat imaging showed an expansion of the bleeding in the brain. Resident #285 was admitted to the neuro intensive care unit (NICU) for closer monitoring and placed on comfort measures only after a family conference with the physician. The hospital discharge summary dated [DATE] at 7:06 AM identified Resident #285 expired on [DATE] at 6:54 AM. Interview with NA #1 on [DATE] at 9:30 AM identified that on [DATE] she went to Resident #285's room with NA #2 and observed Resident #285 on the floor with blood under his/her head. NA #1 indicated RN #3 assisted to roll Resident #285 onto his/her back and he/she was talking. NA #1 further identified that she saw a large knot on Resident #285's forehead and a cut on the top of the nose and noted that RN #3 assisted with transferring the resident from the floor into bed using the mechanical lift. Interview with MD #1 on [DATE] at 10:40 AM identified that he would not have been the physician notified of Resident #285's fall on [DATE] at 4:15 AM because the facility utilizes a service for after hour concerns. MD #1 indicated he did not recall being notified of the fall on [DATE] and noted that if the nurse called the covering doctor and conveyed Resident #285 was on [MEDICATION(S)], they would have directed that the resident be sent out to the hospital right away. MD #1 did not identify whether or not the delay in sending the resident to the hospital made a difference in the resident's prognosis. Interview with NA #2 on [DATE] at 3:45 PM identified on [DATE] she entered Resident #285's room and observed him/her sitting on the edge of the bed and the floor at his/her feet was wet. NA #2 indicated she left the room to get supplies and NA #1 to assist. Upon returning to the room NA #2 heard Resident #285 calling for help. She identified that she entered the room with NA #1, and they observed Resident #285 face down on the floor with blood on the floor near his/her head. NA #2 indicated she stayed with Resident #285 while NA #1 went and to get RN #3 and indicated the nurse assessed the resident and then NA #1 and RN #3 used the mechanical lift to transfer Resident #285 off the floor and into bed. All attempts made to contact RN #3 for an interview were unsuccessful. Interview on [DATE] at 9:55 AM with RN #4 identified that on [DATE] she arrived to work at 7:00 AM and received report from RN #3. She identified that RN #3 communicated that Resident #285 had a fall with a head injury. RN #3 also communicated that she had placed a call to the physician and was waiting for a call back to obtain an order to transfer Resident #285 to the hospital. RN #4 indicated she reviewed the clinical record, noted Resident #285 was on [MEDICATION(S)], and called 911. She further noted that after calling 911 (emergency services) she sent a message to MD #1 to report the fall and the call to 911. Interview, clinical record review, and facility documentation review with the DNS on [DATE] at 11:15 AM identified that when NA #2 observed Resident #285 sitting on the edge of the bed without a brief on and the floor wet, she should not have left the resident alone. The DNS further identified that NA #2 should have stayed with the resident and called for help. In addition, the DNS indicated that RN #3 should have transferred Resident #285 to the hospital immediately via 911 after the fall due to the resident's [MEDICATION(S)] use and head injury. She further noted that RN #3 sent a text message to the physician but should have notified the physician of the change in condition by phone. Review of the facility's Significant Change of Condition policy dated ,d+[DATE] identified in part: professional staff will communicate with the physician regarding changes in condition to provide timely communication of resident status change which is essential to quality management. The physician will be notified by the nurse in the event of a change in condition. The order changes given by the physician will be carried out, including emergency transport if necessary. This notification will be documented in the clinical record.

Based on review of the clinical records, review of facility documentation, and interviews for two of six sampled residents reviewed for accidents (R#4 and R# 45) the facility failed to follow interventions in the care plan to prevent injuries. The findings include: 1. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident was alert and oriented, had no cognitive or memory impairments and was totally dependent on two staff for bed mobility and transfers. The care plan dated 2/27/17 identified the resident was at risk for falls secondary to quadriplegia. Interventions included to provide assist of two for turning, requests 1/4 rails up, perimeter mattress, and turn every 2 hours. Review of facility Reportable Events and investigations identified that on 2/14/16, R#4 slid out of bed. The investigation identified that the fall occurred while NA#4 was repositioning the resident in bed. The Resident's statement identified that while being turned in bed, his/her legs slid off the bed and he/she was unable to prevent his/her body weight from causing him/her from sliding off the bed. On 2/15/16 the care plan was updated to include the use of two staff for turning and positioning. A reportable event dated 3/15/16 identified that R #4 was observed by NA#2 rolling out of bed. Interview with Resident #4 on 3/29/17 at 2:35 PM identified that NA#2 had pulled him/her to the side of the bed closest to NA#2 and then NA#2 pushed the resident over by placing his/her hand on Resident #4's right shoulder and hip while the resident used the rail to assist. Resident #4 identified that his/her right leg slid off the bed and, in slow motion, the weight of the right leg pulled him/her off the bed. Resident #4 identified that he/she can't feel anything from the chest down so was not aware that he/she was sliding off the bed until the fall occurred. NA#2 was repositioning the resident without assistance from a 2nd staff member. The nurse's progress note dated 3/19/17 at 11:16 PM identified that the resident fell out of bed during repositioning. While on his/her left side, facing the NA, his/her right leg shifted causing redistribution of his/her body weight ultimately causing the fall. The fall was witnessed, the resident did not hit his/her head, and vital signs were refused. The resident denied pain. The resident was Hoyer lifted back to bed. Once the resident was in bed, there was noticeable swelling under his/her right knee. MD orders dated 3/19/17 directed facility staff to obtain an x-ray. A Reportable Event dated 3/19/17 at 10:10 PM identified that during repositioning of Resident #4, s/he slid out of bed due to uneven distribution of the resident's body weight caused by the resident's right leg unexpectedly shifting during repositioning. The fall was witnessed by NA#3. NA#3's statement dated 3/19/17 identified that s/he was repositioning the resident and his/her top leg rolled off the edge (of the bed) onto the floor. While lowering the resident's bed s/he heard a cracking sound and when the resident was returned to bed, the resident's right leg was swollen under the knee. NA#3's second statement dated 3/21/17 identified that he/she did not realize that the resident required assistance from two staff (for repositioning) when s/he glanced at his/her care card. X-ray results dated 3/20/17 identified a fracture of the tibial proximal metaphysis that was not present on the prior exam. Review of the NA care card dated 1/20/17 identified that the resident was at high risk for falls, was on an air mattress and was an assist of two staff for turning and repositioning. Interview with Resident #4 on 3/29/17 at 2:38 PM identified that the fall that occurred on 3/19/17 was the same type of fall as the one that occurred on 3/15/16. Resident #4 identified NA#3 was in back of him/her and pushed him/her over by placing a hand on the right shoulder and hip. Resident #4 identified he/she grabs the rail while the NA pushes but that this time first his/her toes, then knees started falling off the bed. Resident #4 heard a pop and noted that he/she had turned 180 degrees and was now facing the door instead of the window. Resident #4 identified that since the fractured leg there are two bars on the bottom of the bed and that s/he always has two staff to turn him/her over. Interview and review of facility documentation with NA#3 on 3/30/17 at 10 AM identified that s/he was assigned to the resident and while s/he was rolling the resident over to reposition him/her, the top leg rolled off the edge and onto the floor with the lower part of the resident's body following. NA#3 immediately put the bed to the lowest position and went to get the nurse. NA#3 identified that the resident did not hit his/her head but NA#3 heard a cracking sound. When the resident was returned to bed via Hoyer lift, by the nurse, 2 other NA's and NA#3, NA #3 noticed that the right leg was swollen under the knee. A statement written by NA #3 identified that s/he was not aware that the resident was an assist of two staff when s/he glanced at the care card. Interview and review of facility documentation with the DNS on 3/30/17 at 12:10 PM identified that the care plan dated 11/30/15 directed facility staff to use two staff members with turning and repositioning and that two staff should have been used for both the fall that occurred on 2/14/16 and the fall that occurred on 3/19/17. The DNS identified that when he/she updated the fall care plan to include two staff for turning and positioning on 2/15/16, he/she was not aware it was already on the care plan dated 11/30/15 for ADL's. 2. Resident #45's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified the resident had moderately impaired cognition, required extensive assistance with ADL's, and two person extensive with transfers. The Resident Care Plan dated 11/20/16 identified the resident was at risk for skin breakdown related to fragile skin and dry skin. Interventions included to apply lotion to legs two times a day, ensure the resident's fingernails were cut, and inspect the skin for redness and breakdown during care. A Facility Reportable Event dated 11/21/16 identified that the resident sustained [REDACTED]. The RCP was revised to include the use of shin tubes on both legs to prevent further skin tears. A nurse's note dated 2/16/17 identified that at 10:30 AM, the resident was observed with a skin tear on the left calf that measured 4 cm by 7 cm in length, by 1 cm in width, by 1 cm depth. The APRN was notified and the resident was transferred to the ED for evaluation. The ED discharge documentation identified a left calf laceration that measured three inches. The wound was approximated with three buried sutures and steri strips. The resident returned to the facility on [DATE] at 6:21 PM with a dry and intact dressing on the left calf. A Facility Reportable Event and Investigation dated 2/16/17 identified that while transferring the resident from the bed to a wheelchair, the resident bumped her/his left calf on the wheelchair causing the skin tear. Although the transfer was conducted with the assistance of two NA's, the shin tubes were not utilized as directed in the RCP. Interview on 3/30/17 at 9:35 AM with NA#2 identified that although the resident's shin tubes were in the closet at the time, they were not utilized during the transfer due to the resident's refusal. NA#2 indicated that the charge nurse was not notified that the resident had refused. Interview, review of the clinical record, and review of the facility's investigation of the incident with the DNS identified that although the MAR/TAR for 2/2017 identified that the shin tubes were put on in the morning and removed at bedtime daily, the shin tubes were not utilized during the transfer on 2/16/17. Although the DNS indicated that the resident often refuses the shin tubes, the RCP failed to address the resident's refusal and/or identify additional measures to protect the skin when the shin tubes were not in use.

Based on review of the clinical record, facility documentation, interviews, and review of facility policy and procedure for one of three residents reviewed for an allegation of abuse, (Resident #1), the facility failed to ensure the resident was free from abuse. The findings include: Resident #1's [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] identified the resident with severe impaired cognition, no behaviors exhibited, totally dependent with assist of two staff members for bed mobility, transfer and personal hygiene. The care plan dated 10/24/12 identified a problem with Psycho-Social wellbeing/adjustment related to episodes of hitting or spitting with care. Interventions included to attempt to reassure the resident and re-approach at another time when the behaviors were exhibited. The Reportable Event Form dated 11/24/12 at 10:50pm identified on 11/24/12 between 7:30pm and 8:00pm that Nurse Aide (NA) #2 witnessed NA #1 make derogatory comments to the resident and used profanity while roughly removing the resident's clothing. Further observation noted NA#1 forcefully shove a washcloth into R #1's mouth and pinch the resident's nose three times during care. Interview with the Director of Nurses (DNS) on 12/18/12 at 9:30am indicated the facility substantiated the allegation of abuse and NA #1 and NA #2 were terminated. NA #2 in an in interview on 12/18/12 at 9:35am identified that on 11/24/12 she/he witnessed NA #1 jam a washcloth into the resident's mouth, pinch his/her nose three times, spoke in a derogatory manner and used profanities when providing care. NA #2 indicated she did not stop NA #1 at the time and/or report the incident immediately because she was afraid of retaliation from NA #1. Several attempts to interview NA #1 were unsuccessful.

Based on clinical record reviews and staff interviews for 2 of 3 sampled residents reviewed for weight loss (R #73, 159), the facility failed to implement interventions to prevent further weight loss and/or revise the plan of care when the resident was noted to have weight loss, and/or document offering/consumption of supplements. The findings include: 1. Resident #73's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was severely cognitively impaired. The care plan dated 7/12/11 noted the resident was at risk for weight loss. Interventions included to monitor weights and provide snacks. A nutritional assessment dated [DATE] identified the resident's intake was decreased, weight was mildly decreased, and that the resident had received milkshakes as needed. Review of the resident's weights noted the following: On 4/6/11, the resident weighed 150 pounds. On 7/5/11, 142 pounds On 9/6/11, 136 pounds. A nutritional assessment dated [DATE] identified that the resident's weight was 138 pounds. The resident's ideal body weight was 160 pounds and the resident was only at 86% of his/her IBW. The assessment also noted that the resident's [MEDICATION NAME] (last done 1/2/11) was 2.8 indicating moderate protein [MEDICAL CONDITION]. The summary/plan indicated to monitor weight and intake and continue to provide snacks between meals. Interview and clinical record review on 10/17/11 at 11:48 AM with the DNS identified that residents are provided with snacks "as needed", that they were a "food first" facility, and that she was unable to provide documentation that supplements, snacks and/or milkshakes were offered and/or consumed and/or that the care plan had been reviewed/revised as the resident continued to lose weight and/or had laboratory values indicative of protein [MEDICAL CONDITION]. 2. Resident #159 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] identified that the resident was severely cognitively impaired, dependent on staff for all ADL's including eating, had no known history of weight loss and weighed 108 pounds. A nutrition care plan dated 9/13/11 identified that weight loss was expected with removal of the splint and decrease of "[MEDICAL CONDITION]". Interventions included to assist/feed the resident, offer ice cream between meals, monitor weight "weekly/monthly and prn" (as needed). A nutritional assessment dated [DATE] identified that the resident's ideal body weight (IBW) was 110 pounds, that he/she was 98% of the IBW and that mild weight loss was expected due to [MEDICAL CONDITION] and splint. The assessment also noted an [MEDICATION NAME] of 2.3 gm/dl indicating moderate protein [MEDICAL CONDITION]. The assessment lacked documentation of likes and dislikes, but indicated that the resident's meal consumption for all three meals was 50% or less. Plan was to implement protein and vitamin supplements (started on 9/13/11). On 9/20/11, the dietitian noted poor intake; consumes ice cream only. Plan was to continue to offer ice cream/shakes. On 9/29/11, the dietitian noted the weight was down to 104 pounds, with decreased [MEDICAL CONDITION]. No interventions initiated. On 10/6/11, the dietitian noted a weight of 92 pounds and that the resident only desired to consume ice cream. The plan was to await conservator appointment and decision regarding feeding tube placement. The resident's weight record indicated that on 9/20/11, the resident's weight had declined to 103 pounds; on 9/27/11 101 pounds, and on 10/4/11, 92 pounds. Interview and review of the clinical record with LPN #3 on 10/13/11 at 2:10 PM failed to provide documentation that supplements were offered to the resident (either milkshakes and/or ice cream). Further review noted the care plan failed to reflect interventions to prevent further weight loss. LPN #3 noted that the facility no longer documents offering of milkshakes and that the shakes are now made at the facility and available on the units, but the offering and/or consumption of the milkshakes is not documented anywhere in the clinical record.

Based on clinical record review, review of facility policy and staff interviews for one sampled resident with an allegation of verbal and physical abuse (R #34), the facility failed to prevent mistreatment to a resident. The findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A resident assessment dated [DATE] identified that the resident's cognitive skills for decision making as modified independence, vision as severely impaired, and required limited assistance with toileting. Review of the facility's documentation dated 11/16/09 at 7:45 PM identified that the resident complained of physical and verbal abuse. The resident was assessed for injuries and required [MEDICATION NAME] 0.25 milligrams (mg) for anxiety/agitation. The resident was noted to be crying, fearful, anxious with no apparent physical injuries. NA #1 was suspended on 11/16/09, pending investigation. Review of social service notes dated 11/17/09 and untimed, identified the resident indicated NA#1 was yelling orders at him/her in an inappropriate manner, however the resident indicated NA#1 did not hit him/her. Resident #34 indicated the care was quick, abrupt and was pulled and pushed about. A Behavioral Health Follow-Up dated 11/17/09 and untimed, identified the resident was evaluated due to allegations of emotional/physical abuse by staff. The note indicated the resident had no recall of the events and appeared calm, cooperative and the anxiety of the event had resolved. Review of LPN #1's written statement obtained by the facility during the investigation, identified that she overheard NA#1 speaking to the resident in a verbally aggressive manner directing the resident to "sit down, I told you to sit there, you don't listen to me." Interview with LPN #1 on 8/20/10 at 8:40 PM identified that the resident was visibly upset on 11/16/09. According to the written statement LPN #1 intervened twice and on the second occassion had to ask NA#1 to leave the room because the resident was crying. In a sworn statement dated 8/20/10 at 2:05 PM, LPN #1 identified that NA #1 was speaking to the resident in a very stern voice and had observed NA #1 providing peri care in a rough manner on 11/16/09. LPN #1 indicated that she heard the resident saying, "Ouch", while NA#1 provided care and indicated R #34 was upset and crying. NA #1 was terminated on 11/17/09 for lack of courtesy, being abrupt, and handling the residents roughly on numerous occasions.