Every finding on record at Civita Care Center at Cheshire

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #75) reviewed for hospitalization, the facility failed to promptly notify the physician when the resident reported new onset of severe pain in the unstageable pressure ulcer to the coccyx during wound care. Resident #75 was subsequently hospitalized two days later with a primary diagnosis of a wound infection of the unstageable pressure ulcer to the coccyx. The findings include: Resident #75 was admitted to the facility in April 2026 with diagnoses that included a healing fracture. The admission MDS dated [DATE] identified Resident #75 had intact cognition, required one person assist with bed mobility, two person assist with transfers and was mobile with the use of a wheelchair. Resident #75 was at risk for the development of pressure ulcers, did not have any unhealed pressure ulcers and had frequent pain within the preceding five days of the assessment. The care plan dated 5/13/26 identified Resident #75 developed a pressure injury to the coccyx, had a potential for pain related to a rib fracture and was able to make needs known. Interventions included providing wound care as ordered, notifying the physician of wound deterioration, assess for pain and intervene as indicated. An APRN progress note dated 5/29/26 at 12:03 PM identified Resident #75 was being evaluated for acute and chronic pain noting decreased mobility and a history of fractures. Symptoms were chronic but have worsened since a recent fall. Resident #75 had an allergy to Percocet. Physical assessment identified generalized joint tenderness and lumbar discomfort with movement. The treatment plan included Tylenol every eight hours, start Tramadol every six hours as needed for pain, monitor pain control, monitor bowel patterns closely for constipation secondary to decreased mobility and opioid use. Physician orders dated 6/1/26 identified Resident #75 had allergies that included Morphine, Oxycodone and Percocet. Physician orders directed to administer Acetaminophen 1000 mg (milligrams) three times daily at 8:00 AM, 2:00 PM, 9:00 PM and Tramadol 50mg every eight hours as needed for severe pain. The MAR dated 6/1/26 through 6/10/26 identified Tramadol 50 mg had not been administered and was subsequently discontinued. Nurse's notes 6/4/26 through 6/10/26 identified Resident #75 had no complaints of discomfort. Wound consultation dated 6/10/26 noted an unstageable pressure ulcer to the coccyx region measuring 3.0 cm x 1.0 cm x 0.5 cm with a moderate amount of serosanguineous drainage and no foul order. The wound was described as deteriorated from the previous week, now 100% full thickness necrosis with extensive denuded peri wound (protective top layer of the skin is gone) no odor and no pain. The MAR dated 6/3/26 through 6/11/26 identified on 6/7/26 during the dayshift (no time) Resident #75 had one episode of pain, 4 out of 10 (the 1-10 pain scale is a numerical tool to rate pain intensity, with 0 = no pain and 10 = the worst pain imaginable) generalized pain relieved with repositioning with no other no complaints of discomfort. The MAR dated 6/12/26 during the day shift (no time) identified Resident #75 with a documented pain scale of 10 out of 10 pain in his/her legs occurring during repositioning with no documented intervention. The progress note did not include information related to documented severe pain noted on the MAR or notification to the APRN. The MAR dated 6/12/26 during the evening shift (no time) identified Resident #75 with a documented pain of 10 out of 10 pain in his/her back with no documented intervention. Nurses note dated 6/12/26 10:39 PM (recorded as late entry on 6/13/26 at 12:45 AM by LPN #5) identified Resident #75 was alert and oriented with a poor appetite, very rigid and stiff muscles observed and complaining of severe pain 10 out of 10. Resident #75 was swearing with repositioning and requesting a stronger pain reliever other than Tylenol. Resident #75 took all medication. Treatment was completed to coccyx as ordered. Emotional support provided to Resident #75 due to pain with dressing change. The note failed to reflect the physician was notified of the severe pain with the dressing change to the coccyx. Nurses note dated 6/14/26 at 10:46 PM identified Resident #75 was complaining of chest pain and requested to be sent to the hospital. No shortness of breath noted. Breathing unlabored. The APRN notified and in agreement to send the resident to emergency room. Resident #75 was subsequently transferred to the hospital at 9:20 AM. A voice message was left with the responsible party. Review of the APRN communications log identified on 6/12/26, Resident #75 was still complaining of severe pain and requesting Tramadol or Percocet. APRN response dated 6/14/26 noted Resident #75 was in the hospital currently. Hospital Discharge summary dated [DATE] identified Resident #75 was admitted with a primary diagnosis of a sacral wound infection. Resident #75 underwent a surgical debridement of the wound, antibiotic therapy was initiated with recommendations to continue the course following discharge. Interview with RN #4 on 7/28/26 at 11:16 AM identified she was the assigned nursing supervisor on 6/12/26 during the 3:00 PM to 11:00 PM shift. RN #4 indicated the charge nurse was responsible for reporting any change of condition to the nursing supervisor who would then complete an assessment, notify the physician/APRN if warranted and document the assessment and any interventions in the clinical record. RN #4 identified she could not recall whether she was notified on 6/12/26 during the 3:00 PM to 11:00 PM shift when Resident #75 was experiencing severe pain. If notified, RN #4 would have completed a nursing assessment, notified the on call APRN immediately and document findings and actions in the clinical record. Interview with APRN #2 on 7/28/26 at 11:56 AM identified the after-hours APRN should be notified right away of any new onset of acute severe pain. APRN #2 indicated Resident #75 had a recently resolved ileus therefore at increased risk for reoccurrence. APRN #2 confirmed the after hours APRN was not contacted on 6/12/26 by the facility. Interview and clinical record review with the DNS on 07/28/26 12:08 PM identified the LPNs were expected to notify the nursing supervisor of any change in condition and complete a pain observation that details type of pain and location and reassessment and document findings. The nursing supervisor was expected to complete an assessment with immediate notification to the APRN by phone and not placed in the communications book. Subsequent interview with APRN #2 on 07/29/26 at 9:46 AM identified careful consideration needed to be made for pain management due to Resident #75's allergies to opioids and increased risk of ileus. APRN #2 further identified she assessed Resident #75 on 6/12/26 and would have documented pain if it was mentioned. APRN #2 identified had she been notified of severe pain during the day or evening shift, she would have prescribed Tylenol if not already scheduled or a onetime dose of Tramadol to address the pain. Interview with LPN #5 on 7/29/26 at 10:17 AM identified she was the assigned charge nurse on 6/12/26 during the 3:00 PM to 11:00 PM shift for Resident #75. LPN #5 she was responsible for reporting any change of condition to the nursing supervisor and documenting. LPN #5 identified she premedicated Resident #75 one hour prior to wound care which was completed at approximately 10:30 PM. During wound care, Resident #75 reported severe pain 10 out of 10 despite premedication. The wound was observed to be beefy red, with a small amount of tan drainage and no odor. LPN #5 did not work with Resident #75 on a routine basis so was unable to determine if these findings represented a change from Resident #75's current baseline. LPN #5 reported the change of condition to RN #4, who instructed her to document the information in the APRN communication book and check back with her later. LPN #5 was unaware whether an assessment was completed or if the APRN was notified and received no further direction. LPN #5 further identified Resident #75 did report relief at approximately 11:30 PM which was also relayed to RN #4. LPN #5 indicated that although she documented events on 6/13/26 at 12:45 AM she did not document notification to RN #5, interventions, resident response or include any additional information in the APRN communication book as an oversight. Interview and clinical record review with MD #1, the Medical Director on 7/29/26 at 10:47 AM identified any new onset of acute severe pain should be promptly assessed, managed for comfort, reassessed and closely monitored including consideration for hospital transfer when clinically indicated. MD #1 indicated new onset of severe pain should be immediately reported to the APRN or physician. If notified, MD #1 would have considered diagnostic imaging, laboratory testing attempt to identify the underlying cause, and provide guidance for pain management and determine the need for a hospital transfer. MD #1 further identified infection should be considered when a wound is causing severe pain, with increased redness and warmth. While Resident #75 was subsequently admitted to the hospital two days later with a wound infection, it was difficult to determine if there was a delay in treatment as there could have been other attributing conditions not known as there was no assessment or notification to the APR/physician. Interview with RN #1 on 7/29/26 at 11:46 AM identified he was responsible for wound management at the facility and routinely provided wound care for Resident #75. RN #1 indicated Resident #75's coccygeal wound was much smaller prior to hospitalization (6/14/26 to 6/23/26), and debridement. Prior to hospitalization, Resident #75 did not complain of pain or discomfort during wound care. Review of the facility policy for Physician Notification and Communication directs for a significant change of condition, a full assessment should be completed that includes vital signs, recent labs, medications, history, compare with baseline. All physician communication should follow the SBAR format: S - Situation. Identify self, facility, resident name and immediate concern. B - Background. Diagnosis, relevant history, recent changes. A - Assessment. Vital signs, symptoms, nurse's clinical impression R - Recommendations. Request specific orders or guidance. After hours communication is accomplished by contacting the on-call provider using the approved contact list. If unable to reach the provider after 15 minutes in urgent situations, follow the escalation protocol. Document all attempts to contact (time, number, message left). If you are unable to reach a provider and the condition worsens, activate emergency services per policy. The nurse must document the date and time of the change in condition, assessment findings, time physician notified, method of communication, orders received, read back verification, implementation of orders, notification of responsible party and resident response to interventions. Attempts to interview LPN #6 were unsuccessful. Although requested, a copy of the nursing twenty-four-hour handwritten shift to shift communication report for 6/12/26 was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for the 1 resident (Resident #16) reviewed for abuse, the facility failed to ensure the Resident #16 was free from verbal and physical abuse by Resident #63 (roommate) who spit in Resident #16's face, swung at and kicked. The findings include: Resident #16 was admitted to the facility in November 2020 with diagnoses that included hypertension, alcohol-induced dementia, and seizures. The quarterly MDS dated [DATE] identified Resident #16 had intact cognition, had a functional limitation in range of motion to both lower extremities, and required setup or clean-up assistance with wheeling 150 feet in a manual wheelchair. The care plan dated 7/13/26 identified Resident #16 had potential issues with conflict resolution due to relationships with 3 residents, with interventions that included encouraging the resident to participate in activities and interact with peers and staff. The Psychiatric Evaluation and Consultation dated 7/16/26 identified Resident #16's mood was stable and no behavioral concerns were reported or noted; the resident denied being anxious, denied depression, and reported sleeping well and having a good appetite. The Reportable Event dated 7/18/26 identified that on 7/18/26 at 10:20 AM a resident-to-resident altercation occurred between Resident #16 and 63. Resident #16 reported that he/she was self-propelling the wheelchair from the beside to the bathroom when he/she asked Resident #63 to move out of the way. Resident #63 reportedly wheeled toward Resident #16 while making negative comments regarding weight. Resident #16 reported that Resident #63 then spit in his/her face and kicked his/her leg. The Charge Nurse was immediately outside the room, witnessed the escalating interaction, and intervened promptly. Resident #16 denied pain or injury, assessment of the left leg revealed no redness, bruising, swelling, skin break or other visible injury and denied feeling fearful following the incident. The local Police Department responded to the facility, interviewed Resident #16, and completed a report, no charges were filed. Social services met with Resident #16 following the incident, provided emotional support and addressed his/her concerns. Resident #16 remained calm and continued to exhibit baseline behavior. Resident #63 was placed on immediate 1:1 observation until transport to the emergency department for evaluation due to altered mental status in the setting of a recent cerebral vascular accident. Upon Resident #63's return to the facility, he/she resumed the 1:1 observation. A telehealth evaluation with the facility's psychiatric provider was completed, and appropriate recommendations were implemented. A room change was completed following the incident, Resident #63 was relocated to a room closer to the nursing station to facilitate increased observation. Initial assessment indicated good compatibility with his/her new roommate. Interview with Resident #16 on 7/26/26 at 9:55 AM identified that he/she and Resident #63 had been roommates for about one week, and the day after becoming roommates Resident #63 called him/her fat. Resident #16 further identified that he/she laughed and wheeled out of the room following the comment and notified a nurse but could not recall the nurses name. On 7/18/26, he/she was sitting in the wheelchair near the window and Resident #63 approached him/her and starting swinging, so he/she grabbed Resident #63's wrists to block being hit in the face, and Resident #63 spit in his/her face and kicked his/her leg. Resident #16 indicated that the encounter made him/her angry, but he/she was primarily concerned with removing the spit from his/her face. Resident #16 further indicated that he/she felt safe in the facility and had no concerns or fear related to Resident #63. Interview with NA #3 on 7/28/26 at 8:19 AM identified that while Resident #63 has had a hard time agreeing with roommates, his/her behaviors of yelling, screaming, and spitting were directed towards staff and that staff needed to approach and speak to him/her slowly. Interview with LPN #8 on 7/28/26 at 9:00 AM identified that on 7/18/26, around 10:00 AM, she was outside the door of Resident #16 and 63's room, at the medication cart and she heard Resident #63 say, you fat *****. LPN #8 indicated that she immediately went into the room and saw that Resident #63 had wheeled him/herself to Resident #16's side of the room and Resident #63 tried to hit Resident #16, so he/she grabbed Resident #63's hands, then Resident #63 kicked Resident #16 and spit in his/her face. LPN #8 identified that she immediately removed Resident #63 from the room, but the resident did not indicate why he/she kicked and spit at Resident #16. LPN #8 indicated that she was a per diem nurse and did not work with Resident #63 often, and while she was unaware of him/her having behaviors towards other residents, prior to this incident, Resident #63 had sworn at her a few months ago; she did report the incident to the RN supervisor but could not recall who the supervisor was; she was told that it was Resident #63's baseline and to calmly reapproach him/her later.During an interview with the Director of Social Services (SW #1) and SW #2 on 7/28/26 at 9:24 AM, SW #2 indicated Resident #63 was known to verbally lash out at staff members, but that Resident #63 had not had any physically or verbally aggressive behaviors directed towards other residents. Resident #63 did have recent room changes due to his/her desire to turn off the air conditioner and open the windows during the July heat wave, but she was unaware of any altercations between Resident #63 and his/her prior roommates.Interview with the DNS on 7/28/26 at 3:15 PM identified that Resident #63 had a history of spitting and being verbally aggressive towards staff but not towards other residents; she had also noticed that following the residents second stroke, earlier in July, Resident #63 had experienced a cognitive decline. The DNS indicated that during the investigation Resident #16 told her that he/she was at the foot of his/her bed (near the window) and Resident #63 was at the foot of his/her own bed (near the door), and Resident #16 said move out of my way and Resident #63 then kicked and spit at Resident #16. The DNS indicated that Resident #63 had demonstrated poor impulse control and that she would not have expected him/her to kick and spit at Resident #16.The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy directs that the facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation. The facility shall review altercations from resident to resident as a potential situation of abuse, staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include but are not limited to: verbally aggressive behavior, such as screaming, cursing bossing around slash demanding, insulting to race or ethnicity group intimidating, physically aggressive behavior such as hitting, kicking, grabbing, scratching, pushing slash shoving, biting, spitting, threatening gestures, throwing objects, and wandering into other's room/space.

Based on observation, review of the clinical record, facility policies, and interviews for 1 of 3 residents (Resident #11) reviewed for position/mobility, the facility failed to develop a comprehensive care plan after it was observed that the resident had a developing left arm contracture and was exhibiting pain with left arm movement during routine ADL care. The findings include: Resident #11 was admitted to the facility in February 2026 with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and malignant neoplasm of the right bronchus or lung. The admission Observation dated 2/25/26 at 7:01 PM failed to identify documentation that a complete musculoskeletal history and physical observation was completed. The document included an area to document the assessment of functional limitation in range of motion for the upper and lower extremities which was blank. The Physical Therapy Evaluation and Plan of Treatment dated 2/26/26 identified Resident #11's left upper extremity range of motion (ROM) was within functional limits, demonstrating 75-100% full range. The significant change in status MDS dated [DATE] identified Resident #11 had severely impaired cognition, his/her upper extremity had an impairment on one side, and he/she was dependent for upper and lower body dressing, rolling left to right, and required partial/moderate assistance with eating. A physician's order dated 4/7/26 directed hospice services due to non-small cell lung cancer, end stage COPD, and advanced dementia. The nurse's note dated 5/1/26 at 7:28 AM identified that a call was placed to hospice and a one-time order for a PT evaluation was obtained for an evaluation of a left arm contracture, question of a splint. Therapy was updated on the request. Review of the clinical record dated 5/1/26 through 7/27/26 failed to identify that a PT evaluation for question of a left arm contracture was completed. The care plan dated 6/18/26 failed to identify notation or interventions related to the left arm contracture. Observations on 7/26/26 at 8:30 AM and 11:00 AM and on 7/27/26 at 7:30 AM and 10:00 AM identified Resident #11's left arm in a tightly flexed position with his/her palm closed. Interview with RN #5 on 7/27/26 at 3:22 PM identified that on 5/1/26 hospice gave her an order for a one-time PT evaluation for Resident #11's left arm, and that based on how her note was written she would have verbally notified therapy of the evaluation, additionally that progress note would have been reviewed during morning report with all disciplines present, including therapy. RN #5 indicated that the concern related to Resident #11's left arm positioning must have come up during morning report because if she had identified the concern on her own, she would have written a note that included her RN assessment. RN #5 further indicated that she did not know if a PT evaluation of Resident #11's left upper extremity had been completed. Interview with the hospice nurse aide (NA #2) on 7/28/26 at 12:53 PM identified that Resident #11 would experience a lot of pain to his/her left upper extremity while performing care, and that even if she moved the left arm a little bit or pulled out his/her hand, Resident #11 would yell out in pain, and that he/she usually kept the left arm tucked in. NA #2 indicated that she was not sure if there were any interventions in place to assist with managing Resident #11's left upper extremity pain during care. Interview with NA #3 on 7/28/26 at 12:57 PM identified that Resident #11 experienced pain with care to the left upper extremity, in particular when getting him/her dressed, repositioning, completing fingernail trimming, and cleaning the inner hand. NA #3 indicated that she would always proceed slowly and in a gentle manner while providing care or moving the left upper extremity. Review of the clinical record with the DNS on 7/28/26 at 1:55 PM failed to identify that the PT evaluation for Resident #11's left arm had been completed. Interview with the DNS on 7/28/26 at 1:56 PM DNS identified that Resident #11's left arm was in a fixed position and that she believed that the concern of Resident #11's left arm positioning was raised during morning report, around the time the nursing progress note was written for a one-time PT evaluation but she was unable to recall the details of the conversation. The DNS indicated that, while Resident #11 was receiving hospice services and on a continuous decline, she would have expected the hospice order for a PT evaluation to have been completed. The DNS further indicated that there was an opportunity for improvement in communication between nursing and therapy staff, and that she would expect a written request to have been submitted to therapy for an evaluation, but that there would have also been a verbal report during morning report, which would be attended by the interdisciplinary team, including staff from nursing and therapy. The DNS identified that she would have Resident #11's left arm evaluated by therapy and speak to the medial provider about premedicating Resident #11 prior to care for pain management. Interview with the Director of Rehabilitation Services (OT #1) on 7/29/26 at 9:36 AM identified that he never received the screen from nursing to complete an evaluation on Resident #11's left upper extremity. OT #1 indicated that Resident #11 was discharged from therapy services on 3/17/26 and he/she had 75-100% passive ROM to the left upper extremity and that the rehab services had not worked with Resident #11 since discharge. OT #1 indicated that the process for receiving a therapy screen from nursing could happen either verbally or on paper, but a paper screen was infrequent, he mostly learned about the screens during morning report, which would always be attended by a staff member from therapy. OT #1 identified that having documentation was very important and that there was an opportunity for improvement with streamlining the communication between nursing and therapy and ensuring there was written or electronic documentation in place. OT #1 indicated that he had rescreened Resident #11 based on the request of the DNS, on 7/28/26, and identified a left elbow and wrist contracture; the left elbow, wrist, and digits had 26-50% passive ROM, which was a change from Resident #11's prior evaluation. OT #1 identified that he was able to place a left elbow and left wrist splint on Resident #11 with minimal discomfort, following his 7/28/26 evaluation, and once splints were in place Resident #11 reported that they were comfortable. OT #1 indicated that he was not sure that early intervention of the contracture would have prevented the contracture or worsening of the contracture because it would be resident specific; Resident #11 was on hospice, remained in bed, and did not participate in much physical activity, in that setting a contracture could develop or worsen, even with interventions in place. The Medical Director's (MD #1) written statement dated 7/29/26 identified that it was his medical judgement that restorative physical therapy and splinting would not have been expected to restore function, reverse contracture, prevent further progression, or improve Resident #11's comfort or quality of life. Given the resident's terminal illness, poor prognosis, advanced functional decline, and Hospice goals of care, splinting would likely have resulted in additional discomfort without providing meaningful clinical benefit and therefore was not medically indicated. Although the requested physical therapy evaluation was not completed due to a communication breakdown, this did not alter the resident's medical management, prognosis, Hospice plan of care, or overall quality of life. Resident #11 continued to receive appropriate Hospice directed comfort measures, symptom management, repositioning, nursing care, and pain management consistent with his individualized goals of care. The facility's Resident Mobility and Range of Motion policy directs that residents will not experience an avoidable reduction in range motion, residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency and duration of interventions, as well as measurable goals and objectives. The facility's Comprehensive Care Planning policy directs that 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 time frames, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #15) reviewed for smoking, the facility failed to ensure that an individualized care plan was reviewed and revised following multiple violations of facility smoking policy. The findings include: A hospital Discharge summary dated [DATE] identified that Resident #15 had a history of tobacco use but had not smoked in 2 months.Resident #15 was admitted to the facility in May 2025 with diagnoses that included diabetes with diabetic peripheral angiopathy and adjustment disorder.Review of the clinical record identified a facility document No-Smoking Policy Acknowledgement Form dated 5/23/25 and signed by Resident #15. The acknowledgment form identified the facility had a strict no smoking policy and identified Resident #15 initialled each of the following items to acknowledge understanding:1) Residents were not allowed to smoke on facility grounds at any time.2) Resident #15 was not allowed to keep any type of smoking materials/cigarettes in his/her room or on his/her person.3) Resident #15 was not allowed to receive smoking materials from visitors.4) Resident #15 understood that non-compliance with the non-smoking policy may necessitate discharge to ensure the safety of other residents.5) Resident #15 understood that smoking materials were defined as, but not limited to, the following products: cigarettes, lighters, matches, electronic cigarettes, cigars, and pipes. The care plan dated 5/27/25 identified Resident #15 had a history of smoking. Interventions included to complete a smoking assessment per facility policy, educating the resident and family, if applicable, on smoking practices and the facility policy. Review of the clinical record failed to identify a smoking assessment was completed upon Resident #15's admission to the facility. a. A psychological services evaluation dated 6/10/25 identified Resident #15 reported lighting a cigarette recently but put the cigarette out before smoking it. Review of the clinical record failed to identify additional information related to Resident #15's report of attempted cigarette use on 6/10/25. The admission MDS dated [DATE] identified Resident #15 had intact cognition and no current tobacco use.A smoking assessment dated [DATE] identified Resident #15 did not use any smoking devices or lighter source. b. A nurse's note dated 12/23/25 at 6:04 PM identified that Resident #15 was observed smoking a cigarette while seated in his/her power wheelchair between parked vehicles outside the facility entrance. The note further identified an attempt was made to educate the resident that the facility was a non-smoking campus, and that Resident #15 identified he/she did not care. The note also identified the DNS was notified of the incident. A facility accident and incident (A&I) form dated 12/23/25 identified that Resident #15 was observed smoking by staff. The note further identified that MD #1 (Medical Director) was notified, that Resident #15 was educated on the facility's smoking policy, and Resident #15 was to be monitored per facility policy. Review of the clinical record failed to identify any additional interventions related to Resident #15's observed non-compliance of the facility no smoking policy including the location of Resident #15's smoking materials, any monitoring checks of Resident #15 following the incident, or any attempts by facility staff to request Resident #15 relinquish any smoking items. A safe smoking evaluation dated 12/24/25 at 11:19 AM completed by the DNS identified Resident #15 was observed smoking by a staff member outdoors. The evaluation identified that Resident #15 was given the facility smoking policy and advised that the facility was nonsmoking. Further review of the evaluation identified that while dated 12/24/25 (a day after the 12/23/25 observed smoking incident), the completed date was 1/29/26 at 11:22 AM, approximately 5 weeks after the incident. Review of the clinical record failed to identify any revisions or interventions to Resident #15's care plan related to the 12/23/25 incident. A care conference note dated 1/14/26 by RN #2 (MDS Coordinator) identified a care conference was held and included the DNS, Person #1 (LTC Ombudsman), multiple resident representatives including Person #2, and Resident #15. The note identified the facility nonsmoking policy and smoking cessation was reviewed. The note further identified that the DNS reported she would set up a lockbox with cigarettes and a lighter on the 1st floor of the facility and that Resident #15 would have to take a leave of absence from the facility and leave the facility property to smoke. The note further identified that Person #2 requested Resident #15 be allowed to smoke where facility staff were allowed to smoke and that the DNS identified she would forward the request to corporate. The care plan dated 1/14/26 identified revisions on that date related to Resident #15's history of smoking. Interventions included offer transfer to a smoking facility (resident refused), offer smoking cessation (refuses). Additional interventions also included smoking paraphernalia would be given to staff and stored properly in the supervisors office and may ask for items when going LOA off property.Review of the physician's orders failed to identify any orders related to independent LOA for Resident #15. c. A facility accident and incident (A&I) form dated 1/27/26 at 6:40PM identified that Resident #15 was observed smoking by the Administrator. The note further identified that MD #1 (Medical Director) was notified on 1/28/26, Resident #15 was educated regarding the plan of care put in place on 1/14/26, reeducated on the facility's nonsmoking policy, and that Resident #15 continued to decline interventions. A statement from the Administrator was also included with the A&I form and identified he observed Resident #15 in the facility lobby going to the RN supervisor's office, however that office was locked as the RN supervisor was not present. The statement identified that Resident #15 was then observed proceeding outside of the facility to the front of the building and the Administrator was able to observe Resident #15 smoking from his office window. The statement further identified that the Administrator approached Resident #15 after he/she returned inside of the building and inquired how Resident #15 was able to obtain a lighter (the supervisor's office which continued Resident #15's cigarettes and lighter was locked) and also asked for Resident #15 to turn over the lighter as they were not permitted in the facility and that Resident #15 refused. A nurse's note dated 1/28/26 at 5:55 PM by the DNS identified that Resident #15 was admitted to the facility and started on a nicotine replacement patch from 5/23/25 until approximately 1/14/26 when a meeting was held with Resident #15, Person #1, Social Services, RN #2 and the DNS. The note further identified that following a discussion regarding Resident #15's desire to smoke, the following agreement was put into place: Resident 15 would be allowed to keep his/her cigarettes and lighter in a lock box in the RN supervisor's office. Review of the clinical record failed to identify any additional interventions related to Resident #15's observed non-compliance of the facility no smoking policy including the location of Resident #15's smoking materials, any monitoring checks of Resident #15 following the incident, or any additional attempts by facility staff to request Resident #15 relinquish any smoking items. The care plan dated 1/29/26 identified revisions related to Resident #15's history of smoking. An additional intervention of offer smoking cessation was added, which was a duplicate intervention originally added on 1/14/26.Review of facility leave of absence (LOA) sign out sheets for Resident #15 failed to identify any LOA sign outs for 1/2026. Further review of facility LOA forms for Resident #15 identified that Resident #15 signed out on LOA on 7/30/25, 10/15/25, with the next date signing out as 2/4/26.d. A facility accident and incident (A&I) dated 2/4/26 at 3:00 PM identified that Resident #15 was observed smoking by staff on facility grounds. The note further identified that APRN #3 was notified and actions taken included continuing Resident #15's plan of care and place on 1:1 observation until Resident #15 returned smoking materials. A statement from the Administrator was also included with the A&I form and identified he observed Resident #15 smoking on facility property and instructed Resident #15 that he/she must go off the property if he/she chose to smoke, and that Resident #15 refused to comply.A nurse's note dated 2/4/26 at 3:04 PM identified that Resident #15 requested to go on independent LOA and was provided with smoking materials and subsequently observed by staff smoking on facility grounds. The note further identified that Resident #15 was re-educated on facility policy that required resident to leave the property if choosing to smoke. Upon return to the facility, Resident #15 declined to surrender smoking materials and due to safety concerns, Resident #15 was placed on 1:1 supervision.Review of a 1:1 monitoring form dated 2/4/26 identified 1:1 monitoring was in place from 3:00 PM until 3:35 PM when Resident #15 returned smoking materials. Review of facility leave of absence (LOA) sign out sheet for Resident #15 failed to identify any LOA sign outs for 2/4/26 at 3:00 PM. Review of the Further review of facility LOA forms for Resident #15 identified that Resident #15 signed out on LOA on 7/30/25, 10/15/25, with the next date signing out as 2/4/26 at 4:30 PM as the first LOA sign out on that date.Review of the clinical record failed to identify any revisions or interventions to Resident #15's care plan related to the 2/4/26 incident. e. A facility accident and incident (A&I) form dated 4/14/26 at 9:15 AM identified that Resident #15 was observed smoking in the facility parking lot. The note further identified that MD #1 was notified, a room search was conducted, and Resident #15 was to be monitored per facility policy. Review of the LOA sign out log dated 4/14/26 for Resident #15 failed to identify that Resident #15 was signed out on an LOA at 9:15 AM. Review of the log identified Resident #15 signed out for LOA at 8:20 AM and returned at 8:30 AM, with the next sign out at 10:20 AM.A nurse's note dated 4/14/26 at 10:02 AM by the DNS identified Resident #15 was noncompliant with his/her plan of care of signing out on independent LOA and going off property. Resident #15 was observed smoking in the parking lot. The note further identified that Resident #15 did sign out for LOA, obtained smoking materials from the supervisor's office, and replaced them upon return. The note identified The DNS reviewed the smoking policy and Resident #15 individualized plan of care, and that Resident #15 verbalized understanding and ensured future compliance. The note also identified a room search was conducted with Resident #15's consent in his/her presence and no smoking paraphernalia was found. Review of the clinical record failed to identify any revisions or interventions to Resident #15's care plan related to the 4/14/26 incident. A physician's order dated 5/11/26 directed Resident #15 may go on independent LOA with power wheelchair. f. A facility accident and incident (A&I) form dated 5/15/26 at 2:00 PM identified that Resident #15 was observed smoking in the facility parking lot. The note further identified that APRN #3 was notified and actions taken included to continue Resident #15's plan of care. A nurses note dated 5/15/26 at 3:02 PM identified the Resident #15 was observed smoking in the parking lot by staff at approximately 2:00 PM. The note further identified that Resident #15 was self responsible and was re-educated regarding smoking off of the facility policy and that the facility would continue to encourage compliance with the facility smoking policy. Review of the LOA sign out log dated 5/15/26 failed to identify that Resident #15 was signed out on an LOA at 2:00 PM. Further review of the log identified Resident #15 signed out on LOA at 12:30 PM, returned at 12:45 PM, and signed out again at 3:36 PM.A care plan dated 5/15/26 identified Resident #15 had behavioral symptoms that included failure to comply with the facility smoking policy and refused to sign education or review nonsmoking policy when presented. Interventions included to continue Resident #15's compliance with smoking agreement plan of care, continue educating the resident on the smoking agreement, and to remind the resident to sign out LOA at the reception desk. An undated facility in-service education document signed by facility staff from multiple departments included recreation, housekeeping, laundry, rehab, nursing, and administration. The in-service education identified that effective immediately Resident #15's cigarettes and lighter would maintained at the reception desk and that the Secretary would provide the smoking materials to Resident #15 and ensure Resident #15 signed out on LOA and returned the materials after signing back into the facility. The in service education also identified if Resident #15 did not return the materials, staff must follow Resident #15 and maintain direct 1:1 supervision until the materials were returned, and that the RN supervisor, DNS, and Administrator must be notified. The education also identified if Resident #15 was observed smoking in the parking lot, the RN supervisor, DNS, and Administrator must be notified. The signature page for the in service was dated 5/15/26.g. A nurse's note dated 5/18/26 at 2:51 AM by the DNS identified that Resident #15 was observed by staff smoking in the parking lot at 9:15 AM (6 hours and 24 minutes in the future) and failed to leave the facility property per his/her plan of care, and that education and discussion were provided.A facility accident and incident (A&I) form dated 5/18/26 at 9:15 AM identified that Resident #15 was observed smoking by the Administrator. The note further identified that APRN #3 was notified and actions taken included discussing Resident #15's individual plan of care and not fully leaving the property, providing education, and continue Resident #15's plan of care.A revised care plan dated 5/18/26 identified Resident #15 had behavioral symptoms that included failure to comply with the facility smoking policy and refused to sign education or review nonsmoking policy when presented. Revision included interventions included that Resident #15 preferred to scribble or place a line on the LOA sign out form indicating his/her signature. h. A facility accident and incident (A&I) form dated 5/19/26 (no time noted) identified that Resident #15 was observed smoking by the Administrator and the Secretary. The note further identified that APRN #3 was notified and actions taken included that Resident #15 was asked to move off property and agreed, Resident #15's individual plan of care and smoking policy were reviewed, and to continue Resident #15's plan of care.A nurse's note dated 5/19/26 at 9:21 AM identified Resident #15 was observed smoking in the parking lot by the Administrator and Secretary. The note further identified Resident #15 was asked to move to a previously agreed upon area on the sidewalk off the facility property and educated again on the smoking agreement, and that Resident #15 declined to move to the area. The note further identified to continue the plan of care and that Resident #15 was responsible.A revised care plan dated 5/19/26 identified Resident #15 had behavioral symptoms that included failure to comply with the facility smoking policy and refused to sign education or review nonsmoking policy when presented. Revision included intervention to continue to encourage compliance with smoking agreement plan of care, which was duplicated from the same intervention added on 5/15/26.Interview with the DNS on 7/29/26 at 11:21 AM identified that Resident #15 was admitted to the facility on [DATE] and had not smoked at the time of admission. The DNS identified the first incident that the facility was aware that Resident #15 began smoking was on 12/23/25. The DNS identified that following the identification of smoking materials with Resident #15 on that date common no follow up was completed by any facility staff to determine if the resident had any materials on his or her person or in his or her room and no revisions were made to the care plan and that this was an oversight by her and the facility staff. The DNS further identified that the ombudsman notified the facility of a complaint regarding Resident #15's ability to smoke which prompted the meeting on 1/14/26 and to preserve the resident's rights, an individualized smoking agreement was offered and accepted by Resident #15. The DNS identified this offer had not and was not made to any other residents of the facility who had a history of smoking. The DNS further identified that since that time multiple incidents with Resident #15 being observed smoking on facility property had been made but the facility felt due to Person #1 and the LTC Ombudsman's office being involved that they were unable to prevent Resident #15 from smoking despite multiple incidents of noncompliance, and due to the multiple incidents of noncompliance the care plan at times was not updated or was updated with duplicate interventions. The facility policy on comprehensive care planning directed that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs would be developed and implemented for each resident. The policy also directed that care plan interventions should address the underlying source of a problem area and not just symptoms or triggers whenever possible, and that the interdisciplinary team would review and update the care plan when a desired outcome was not met. The policy further directed that assessments of the residents were ongoing and care plans were revised as information about the resident and the resident's conditions changed.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #75) reviewed for hospitalization, the facility failed to promptly conduct an RN assessment after the resident complained of new onset severe pain during wound care of a pressure injury. Resident #75 was subsequently hospitalized two days later with a primary diagnosis of a wound infection of that pressure injury. The findings include: Resident #75 was admitted to the facility in April 2026 with diagnoses that included a healing fracture and atrial fibrillation (AFib). The admission MDS dated [DATE] identified resident #75 was cognitively intact, was at risk for the development of pressure ulcers, did not have any unhealed pressure ulcers and frequent pain within the preceding five days of the assessment. The care plan dated 5/13/26 identified Resident #75 developed a pressure injury to the coccyx, had a potential for pain related to a rib fracture and was able to make needs known. Interventions included providing wound care as ordered, notifying the physician of wound deterioration, assess for pain and intervene as indicated. An APRN progress note dated 5/29/26 at 12:03 PM identified Resident #75 was being evaluated for acute and chronic pain noting decreased mobility and a history of fractures. Symptoms were chronic but had worsened since a recent fall. Physician orders dated 6/1/26 directed to administer Acetaminophen 1000 mg (milligrams) three times daily at 8:00 AM, 2:00 PM, 9:00 PM and Tramadol 50mg every eight hours as needed for severe pain. The MAR dated 6/1/26 through 6/10/26 identified Tramadol 50 mg had not been administered and was subsequently discontinued. Nurse's notes 6/4/26 through 6/10/26 identified no complaints of discomfort. Wound consultation dated 6/10/26 noted an unstageable pressure ulcer to the coccyx region measuring 3 cm x 1cm x 0.5 cm with a moderate amount of serosanguineous drainage and no foul order. The wound was described as deteriorated from the previous week, now 100% full thickness necrosis with extensive denuded peri wound (protective top layer of the skin is gone) no odor and no pain. The MAR dated 6/3/26 through 6/11/26 identified on 6/7/26 during the dayshift (no time), Resident #75 had one episode of 4 out of 10 (The 1-10 pain scale is a numerical tool to rate pain intensity, with 0 = no pain and 10 = the worst pain imaginable) generalized pain with repositioning with no other no complaints of discomfort. The MAR dated 6/12/26 during the day shift (no time) identified Resident #75 with a documented pain scale of 10/10 pain in his/her legs occurring during repositioning with no documented intervention.Nurses note dated 6/12/26 at 2:43 PM (recorded as late entry on 6/12/26 at 3:51 PM by LPN #6) failed to reflect information related to reported severe pain noted on the MAR. The MAR dated 6/12/26 during the evening shift (no time) identified Resident #75 with a documented pain of 10/10 pain in his/her back with no documented intervention. Nurses note dated 6/12/26 10:39 PM (recorded as late entry on 6/13/26 at 12:45 AM by LPN #5) identified Resident #75 was alert and oriented with a poor appetite, very rigid and stiff muscles observed and complaining of severe pain 10/10. Resident #75 was swearing with repositioning and requesting a stronger pain reliever other than Tylenol. Treatment was completed to coccyx as ordered. Emotional support provided to Resident #75 due to pain with dressing change.The note did not include documentation related to any further actions taken following a report of severe pain with wound care. Nurses note dated 6/14/26 at 10:46 PM identified Resident #75 was complaining of chest pain and requested to be sent to the hospital. No shortness of breath noted. Breathing unlabored. The APRN notified and in agreement to send the resident to emergency room. Resident #75 was subsequently transferred to the hospital at 9:20 AM. A voice message was left with the responsible party. Review of the APRN communications log identified on 6/12/26, Resident #75 was still complaining of severe pain and requesting Tramadol or Percocet. APRN response dated 6/14/26 noted Resident #75 was in the hospital currently. Hospital Discharge summary dated [DATE] identified Resident #75 was admitted with a primary diagnosis of a sacral wound infection. A cardiac workup also identified Resident #75 with an elevated Troponin level (one indicator of heart muscle damage) due to supply/demand mismatch and anemia with no cardiac medication changes. Resident #75 underwent a surgical debridementof the wound during hospitalization, antibiotic therapy was initiated with recommendations to continue the course following discharge. Interview with RN #4 on 07/28/26 at 11:16 AM identified she was the assigned nursing supervisor on 6/12/26 during the 3:00 PM to 11:00 PM shift. RN #4 indicated the charge nurse was responsible for reporting any change of condition to the nursing supervisor who would then complete an assessment, notify the physician/APRN if warranted and document the assessment and any interventions in the clinical record. RN #4 identified she could not recall whether she was notified on 6/12/26 during the 3:00 PM to 11:00 PM shift when Resident #75 was experiencing severe pain. If notified, RN #4 would have completed a nursing assessment, notified the on call APRN immediately and document findings and actions in the clinical record. Interview with APRN #2 on 07/28/26 at 11:56 AM identified the after-hours APRN should be notified right away of any new onset of acute severe pain. APRN #2 indicated Resident #75 had a recently resolved ileus therefore at increased risk for reoccurrence. APRN #2 confirmed the after hours APRN was not contacted on 6/12/26 by the facility. Interview and clinical record review with the DNS on 07/28/26 12:08 PM identified the LPNs were expected to notify the nursing supervisor of any change in condition and complete a pain observation that details type of pain and location and reassessment and document findings. The nursing supervisor was expected to complete an assessment with immediate notification to the APRN by phone and not placed in the communications book. Subsequent interview with APRN #2 on 7/29/26 at 9:46 AM identified careful consideration needed to be made for pain management due to Resident #75's allergies to opioids and increased risk of ileus. APRN #2 further identified she assessed Resident #75 on 6/12/26 and would have documented pain if it was mentioned. APRN #2 identified had she been notified of severe pain during the day or evening shift, she would have prescribed Tylenol if not already scheduled or a onetime dose of Tramadol to address the pain. Interview with LPN #5 on 07/29/26 at 10:17 AM identified she was the assigned charge nurse on 6/12/26 during the 3:00 PM to 11:00 PM shift for Resident #75. LPN #5 she was responsible for reporting any change of condition to the nursing supervisor and documenting. LPN #5 identified she premedicated Resident #75 with his/her scheduled dose of Tylenol one hour prior to wound care which was completed at approximately 10:30 PM. During wound care, Resident #75 reported severe pain 10/10 despite being premedicated. The wound was observed to be beefy red, with a small amount of tan drainage and no odor. LPN #5 did not work with Resident #75 on a routine basis so was unable to determine if these findings represented a change from Resident #75's current baseline. LPN #5 reported the change of condition to RN #4, who instructed her to document the information in the APRN communication book and check back with her later. LPN #5 was unaware whether an assessment was completed or if the APRN was notified and received no further direction. LPN #5 further identified Resident #75 did report relief at approximately 11:30 PM which was also relayed to RN #4. LPN #5 acknowledged that although she documented on 6/13/26 at 12:45 AM, she did not document notification to RN #5, interventions, resident response or include any additional information in the APRN communication book as an oversight. Interview and clinical record review with MD #1, the Medical Director on 07/29/26 at 10:47 AM identified any new onset of acute severe pain should be promptly assessed, managed for comfort, reassessed and closely monitored including consideration for hospital transfer when clinically indicated. MD #1 indicated new onset of severe pain should be immediately reported to the APRN/physician. If notified, MD #1 would have considered diagnostic imaging, laboratory testing attempt to identify the underlying cause, provide guidance for pain management and determine the need for a hospital transfer. MD #1 further identified infection should be considered when a wound is causing severe pain, with increased redness and warmth. While Resident #75 was subsequently admitted to the hospital two days later with a wound infection, it was difficult to determine if there was a delay in treatment as there could have been other attributing conditions not known as there was no assessment or notification to the APR/physician. Regardless. The sudden onset of acute pain should have been addressed. Interview with RN #1 on 07/29/26 at 11:46 AM identified he was responsible for wound management at the facility and routinely provided wound care for Resident #75. RN #1 indicated Resident #75's coccygeal wound was much smaller prior to hospitalization (6/14/26 to 6/23/26), and debridement. Prior to hospitalization, Resident #75 did not complain of pain or discomfort during wound care. Review of the facility policy for Physician Notification and Communication directs for a significant change of condition, a full assessment should be completed that includes vital signs, recent labs, medications, history, compare with baseline. All physician communication should follow the SBAR format:S- Situation. Identify self, facility, resident name and immediate concern.B- Background. Diagnosis, relevant history, recent changes.A-Assessment. Vital signs, symptoms, nurse's clinical impressionR- Recommendations. Request specific orders or guidance. After hours communication is accomplished by contacting the on-call provider using the approved contact list. If unable to reach the provider after 15 minutes in urgent situations, follow the escalation protocol. Document all attempts to contact (time, number, message left).If you are unable to reach a provider and the condition worsens, activate emergency services per policy. The nurse must document the date and time of the change in condition, assessment findings, time physician notified, method of communication, orders received, read back verification, implementation of orders, notification of responsible party and resident response to interventions. Review of the facility Clinical Protocol for Pain Assessment and Recognition directed, in part, that nursing staff will assess each individual for pain, on admission, quarterly, when there is a significant change of condition, and when there is new onset or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity. Staff will use a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level. Direct examination of the resident will help identify the pain, reviewing the resident history and discussions with the resident and staff. Goals for pain will be established with appropriate nonpharmacologic and medication to address pain. Ongoing monitoring should take place at regular intervals at least every shift for acute pain or significant changes in levels of chronic pain. Attempts to interview LPN #6 were unsuccessful. Although requested, a copy of the nursing twenty-four-hour handwritten shift to shift communication report for 6/12/26 was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #7) reviewed for vision services, the facility failed to follow up on ophthalmology recommendations for a resident with limited vision. The findings include: Resident #7 was admitted to the facility in March 2023 with diagnoses that included Type II diabetes and dementia. The quarterly MDS dated [DATE] identified Resident #7 was moderately cognitively impaired, required one person assist with bed mobility, two person assist with transfers and wore corrective lenses. The care plan dated 8/28/25 identified Resident #7 had cognitive loss due to dementia. Interventions included the provision of a calendar and clock and provide safety for all activities at all times. Optometry consult dated 9/18/25 identified Resident #7 had mixed cataracts in both eyes described as bothersome. Recommendations included to monitor as the patient declined cataract surgery despite reduced vision. Resident #7 was to return in 2-3 months with consideration for a surgical referral at the follow up exam. Optometry consult dated 9/24/25 identified Resident #7 had mixed cataract to both eyes. Recommendations included referral to ophthalmology for cataract surgery. Resident #7 was to return in 4-5 months. Nurse's note dated 10/31/25 identified Resident #7 had a consult for ophthalmology scheduled for 3/2/26 at 1:00 PM. Optometry consult dated 2/2/26 identified Resident #7 had stable mixed cataract both eyes. Recommendations included to monitor. The consult further noted a previously requested referral to ophthalmology for surgical evaluation of the cataracts. Resident #7 was recommended to return in 4-5 months. Ophthalmology consult dated 3/2/26 was blank with no documentation related to the service or facility actions. Interview with the responsible party on 07/26/26 at 8:42 AM identified Resident #7 was scheduled for what she/he believed to be cataract surgery a few months back. The responsible party was supposed to attend the appointment but was told it was scheduled for the following day, so she missed the appointment. The responsible party was informed by facility staff (unsure by whom) that Resident #7 arrived for the ophthalmology consult and was told by the provider they had no information about the resident who was returned to the facility with no follow up appointment. The responsible party had since inquired about a follow up appointment on several occasions (not sure with whom) and was told the matter would be looked into. According to the responsible party, Resident #7's vision seemed to be getting worse making it more difficult to recognize people. Interview, clinical record and facility documentation review with the DNS on 07/26/26 at 12:53 PM identified she was responsible for tracking the contracted services that provide healthcare services such as eye care to residents in long-term care facilities. Residents leave the facility with a nurse aide/driver, their medical information and a blank consult to be completed by the provider. Upon return, the nurse aide/driver provides the receptionist, Secretary #1, with the paperwork who will scan and upload information into the clinical record. The paperwork is also provided to the charge nurse/ nursing supervisor. Any follow up is discussed in morning report, placed on a task list for the day that the nursing supervisor was responsible for addressing. This information is communicated to the receptionist who schedules the next consult as needed. The DNS further identified Resident #7 was scheduled to go to ophthalmology on 3/2/26 but had no additional information regarding the outcome of that appointment and wound need to consult with Secretary #1. Interview and facility documentation review with Secretary #1 on 07/27/26 at 6:04 AM identified she was responsible for scheduling the medical appointments and transportation in the community. Secretary #1 indicated she could not confirm why Resident #7 was not seen on 3/2/26 as there were no notations. Secretary #1 believed it was due to family not being present when Resident #7 arrived but would have to check with NA #1 who went with Resident #7 to the appointment. Subsequent interview with the DNS on 7/27/26 at 6:25 AM identified completed consults for each provider type are sent electronically to her from the service provider. The DNS indicated she reviews them before moving the consults into a separate file and then scanned into the clinical record. The DNS further identified that a recent audit was conducted for the service provider consults after she identified there was a problem with ensuring consults were uploaded in the clinical record and follow ups were not being monitored consistently. Despite the facility's process of tracking, monitoring and audit, the DNS did not know the status of the ophthalmology appointment. Interview with Person #3, a customer care billing specialist for the service provider on 7/27/26 at 8:16 AM, identified Resident #7 was seen by Optometry on 9/18/25 but refused recommendations for cataract surgery. The responsible party contacted the provider, explained Resident #7 was unable to make medical decisions and requested a referral for cataract surgery. A follow up appointment was then made for 9/24/26 where the recommendation for an ophthalmology consultation for cataract removal was made again based on the responsible party's request. Resident #7 was seen by optometry again on 2/2/26 who noted a previously requested ophthalmology consult for cataract removal. Resident #7 was scheduled to be seen by optometry again on 6/2/26 but was cancelled by the service provider likely due to the unavailability of provider. Interview with Person #4, representative for the ophthalmology provider on 7/27/26 at 8:44 AM identified, subsequent to surveyor inquiry, Resident #7's evaluation for cataract surgery was rescheduled for 10/5/26. Person #4 indicated the previous appointment did not occur because NA #1 could not complete the required paperwork for the consult to take place. Interview with NA #1 on 7/27/26 at 9:20 AM identified he transported Resident #7 to the ophthalmology appointment on 3/2/26. When they arrived Resident #7 was unable to be evaluated as paperwork required by the provider needed to be signed and family were required to be present. NA #1 indicated he notified Secretary #1 and LPN #7, the charge nurse upon return to the facility. Interview with APRN #2 on 7/27/26 at 12:48 PM identified she relied on staff to provide updates and recommendations following any specialty consultation. APRN #2 was aware Resident #7 was recommended to ophthalmology for cataract surgery but had not been notified Resident #7 did not attend. APRN #2 indicated that although Resident #7 was at baseline functionally which would not change once vison was restored, she would expect to be updated of any consult that did not occur so she could request a follow up appointment to be arranged to include any necessary family involvement. Interview with the DNS on 7/28/26 at 6:41 AM identified she would expect the APRN to be updated on the outcome of the consult so a follow up consult could be arranged. Review of the facility policy for Specialty Consultations directed, in part, the facility to ensure residents have timely access to medically necessary specialty services, including podiatry, dentistry, audiology, optometry, psychiatry, psychology, wound care, orthopedics, dermatology and other eternal consultants. Services will be coordinated to promote continuity of care, maintain resident health and well-being and comply with federal and state regulations. Following each consultation, the licensed nurse shall review the recommendations immediately, obtain physician review, when necessary, transcribe physician orders, initiate new orders, update the care plan, notify the resident and responsible party of any significant findings when appropriate. Attempts to interview LPN #7 were unsuccessful.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #45) reviewed for position/mobility, the facility failed to ensure splinting devices were being applied, per the physician's order, for a resident with multiple contractures. The findings include: Resident #45 was admitted to the facility in December 2024 with diagnoses that included anoxic brain damage, contracture of the muscle (multiple sites) and Wernicke's encephalopathy. The Occupational Therapy Evaluation & Plan of Treatment dated 2/5/25 (certification period: 2/5/25 through 5/5/25) identified Resident #45's musculoskeletal system assessment identified the following for his/her right upper extremity range of motion: shoulder was moderately impaired - demonstrated 26 -50% of full range; elbow / forearm was moderately impaired - demonstrated 26 -50% of full range; wrist was moderately impaired - demonstrated 26 -50% of full range; hand was moderately impaired - demonstrated 26 -50% of full range; thumb was moderately impaired - demonstrated 26 -50% of full range; index finger was moderately impaired - demonstrated 26 -50% of full range; middle finger was moderately impaired - demonstrated 26 -50% of full range; ring finger was moderately impaired - demonstrated 26 -50% of full range; little finger was moderately impaired - demonstrated 26 -50% of full range, and identified the following for Resident #45's left upper extremity range of motion: shoulder was moderately impaired - demonstrated 26 -50% of full range; elbow / forearm was moderately impaired - demonstrated 26 -50% of full range; wrist was moderately impaired - demonstrated 26 -50% of full range; hand was moderately impaired - demonstrated 26 -50% of full range; thumb was moderately impaired - demonstrated 26 -50% of full range; index finger was moderately impaired - demonstrated 26 -50% of full range; middle finger was moderately impaired - demonstrated 26 -50% of full range; ring finger was moderately impaired - demonstrated 26 -50% of full range; little finger was moderately impaired - demonstrated 26 -50% of full range. The Musculoskeletal System Assessment identified splints were ordered from vendor: right arm elbow brace, hip abductor, easy-care hand splint; complete passive range of motion (PROM) therapy until splints arrive. The Occupational Therapy Evaluation & Plan of Treatment dated 4/21/26 (certification period: 4/21/26 through 7/19/26) identified Resident #45's musculoskeletal system assessment identified the following for his/her right upper extremity range of motion: shoulder was severely impaired - demonstrated 0 - 25% of full range; elbow / forearm was severely impaired - demonstrated 0 - 25% of full range; wrist was severely impaired - demonstrated 0 - 25% of full range; hand was moderately impaired - demonstrated 26 -50% of full range; thumb was mildly impaired; index finger was mildly impaired; middle finger was mildly impaired; ring finger was mildly impaired; little finger was mildly impaired, and identified the following for Resident #45's left upper extremity range of motion: shoulder was severely impaired - demonstrated 0 - 25% of full range; elbow / forearm was severely impaired - demonstrated 0 - 25% of full range; wrist was severely impaired - demonstrated 0 - 25% of full range; hand was moderately impaired - demonstrated 26 -50% of full range; thumb was mildly impaired; index finger was mildly impaired; middle finger was mildly impaired; ring finger was mildly impaired; little finger was mildly impaired. Resident #45's Objective Progress / Long-Term Goals included tolerating wearing a left elbow splint for 8 hours daily in order to increase ROM and decrease pain, however he/she has frequently been removing splints independently due to discomfort, tolerating wearing right elbow splint for 8 hours daily in order to increase ROM and decrease pain, and tolerating wearing a left and right hand splint for 8 hours daily in order to increase ROM and decrease pain. Review of the physician's orders from 2/5/25 through 5/20/26 failed to identify an order was in place directing the application of a hand splint and/or palm guard. A physician's order dated 5/20/26 directed to apply palm guards in the AM, remove for care, and remove the palm guards at bedtime. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition, had a range of motion impairment on both sides of the upper and lower extremities, and was dependent for rolling left to right and for chair/bed-to-chair transfers The care plan dated 7/13/26 identified Resident #45 had limited ability to perform ADLS related to functional quadriplegia as evidenced by the resident requiring assistance with washing, dressing, and grooming, transfers with an assist of two people via Hoyer into wheelchair as tolerated, with interventions that included bilateral upper extremity splint on elbows to be worn 8 hours daily and to use adaptive equipment and assistive devices as needed for care. A physician's order dated 7/8/26 through 7/29/26 directed to apply bilateral upper extremity elbow splints to be worn 8 hours daily, apply at 12:00 AM and remove at 8:00 AM. Special instructions included checking the splints cleanliness/condition, check skin integrity pre/post application, perform ROM as needed, fasten straps, and monitor the device during use. Observation on 7/26/26 at 7:10 AM failed to identify Resident #45 had elbow splints in place, and observations at 8:15 AM and 11:30 AM failed to identify he/she had palm guards in place. Observation on 7/27/26 at 7:38 AM failed to identify Resident #45 had elbow splints in place, and observations at 8:10 AM, 11:00 AM, and 1:00 PM failed to identify that he/she had palm guards in place. Observation and interview with LPN #10 on 7/27/2026 8:10 AM identified that Resident #45 did not have the bilateral elbow splints or palm guards in place and while they were signed off in the electronic health record as having been put on at midnight, they were currently not in place, and she did not take them off at the start of her shift or see them on at the change of shift. LPN #10 further identified that she usually did not work on that unit, and she was unable to locate the palm guards or elbow splints in the room. Observation with RN #1 on 7/27/26 at 8:37 AM identified that Resident #45's elbow splints were located in his/her closet, and Resident #45 did not have a palm guard in place. Interview with NA #3 on 7/27/26 at 11:30 AM identified that she did not remove Resident #45's elbow splints during morning care, and that the splints located in the resident's closet were old splints and not the ones he/she was supposed to be wearing. NA #3 indicated that Resident #45 had specialty palm guards, but they had gone down to the laundry, and she had not seen them in over a month. Review of the clinical record with the Director of Rehabilitative Services (OT #1) on 7/27/26 at 1:40 PM failed to identify an order for hand splints or palm guards was in place prior to 5/20/26. Interview with OT #1 on 7/27/26 at 1:40 PM identified that Resident #45 had been using hand splints in the past, but he/she would get out of them, so they switched to hand rolls; while the clinical record did not reflect an order for hand splints and/or palm guards/hand rolls prior to 5/20/26, interventions were in place and were being implemented. OT #1 identified that Resident #45 should only have an order for a splint to the left elbow, not bilateral elbows, and that he would expect that order to be followed, but he would likely change the order for the elbow splint to be worn during the day. OT #1 indicated that Resident #45 was challenging to assess for range of motion, as he/she was fearful of pain and that fear compromised his/her ability to fully participate and which limited the accuracy of the assessment, but Resident #45's contractures have not worsened since his/her admission to the facility. Observation on 7/28/26 at 6:57 AM identified Resident #45 did not have bilateral elbow splints in place; subsequent to surveyor inquiry bilateral hand rolls were in place. Interview with the night nurse (LPN #12) on 7/28/26 at 7:01 AM identified that she was unable to locate Resident #45's elbow splints and that she needed to update her documentation to reflect that the splints were not put on at midnight or during her shift, per the physician's order. Interview with Resident #45's responsible party (Person #5) on 7/28/26 at 9:42 AM identified that Resident #45 could move his/her shoulders and elbows really good due to the Botox injection therapy, but he/she has not seen Resident #45 wearing elbow splints or palm/finger guards in about 1-2 months, and he/she did feel like the splints had been helping. Interview with the DNS on 7/28/26 at 2:48 PM identified that her expectation would be that the physician's orders for elbow splints and palm guards (or a hand roll until the palm guards could be located from the laundry) would be followed, and it would be the responsibility of the charge nurse to ensure the orthotic devices were put on and taken off in accordance with the order. The DNS indicated that she would also have expected an order to have been in place for the management of the hand contracture prior to 5/20/26, to prevent the contracture from worsening. The facility's Resident Mobility and Range of Motion policy directs that residents will not experience an avoidable reduction in range motion, residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency and duration of interventions, as well as measurable goals and objectives.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 15) reviewed for smoking, the facility failed to provide adequate supervision for a resident who was a smoker in a nonsmoking facility and had repeated noncompliance and violations of the facility smoking policy to maintain an environment as free of accident hazards as possible. The findings include: The hospital Discharge summary dated [DATE] identified that Resident #15 had a history of tobacco use but had not smoked in 2 months.Resident #15 was admitted to the facility in May 2025 with diagnoses that included diabetes with diabetic peripheral angiopathy and adjustment disorder.Review of the clinical record identified a facility document No-Smoking Policy Acknowledgement Form dated 5/23/25 and signed by Resident #15. The acknowledgment form identified the facility had a strict no smoking policy and identified Resident #15 initialled each of the following items to acknowledge understanding:1) Residents were not allowed to smoke on facility grounds at any time.2) Resident #15 was not allowed to keep any type of smoking materials/cigarettes in his/her room or on his/her person.3) Resident #15 was not allowed to receive smoking materials from visitors.4) Resident #15 understood that non-compliance with the non-smoking policy may necessitate discharge to ensure the safety of other residents.5) Resident #15 understood that smoking materials were defined as, but not limited to, the following products: cigarettes, lighters, matches, electronic cigarettes, cigars, and pipes. The care plan dated 5/27/25 identified Resident #15 had a history of smoking. Interventions included to complete a smoking assessment per facility policy, educating the resident and family, if applicable, on smoking practices and the facility policy. Review of the clinical record failed to identify a smoking assessment was completed upon Resident #15's admission to the facility. a. A psychological services evaluation dated 6/10/25 identified Resident #15 reported lighting a cigarette recently but put the cigarette out before smoking it. Review of the clinical record failed to identify additional information related to Resident #15's report of attempted cigarette use on 6/10/25. The admission MDS dated [DATE] identified Resident #15 had intact cognition and no current tobacco use.A smoking assessment dated [DATE] identified Resident #15 did not use any smoking devices or lighter source. b. A nurse's note dated 12/23/25 at 6:04 PM identified that Resident #15 was observed smoking a cigarette while seated in his/her power wheelchair between parked vehicles outside the facility entrance. The note further identified an attempt was made to educate the resident that the facility was a non-smoking campus, and that Resident #15 identified he/she did not care. The note also identified the DNS was notified of the incident. A facility accident and incident (A&I) form dated 12/23/25 identified that Resident #15 was observed smoking by staff. The note further identified that MD #1 (Medical Director) was notified, that Resident #15 was educated on the facility's smoking policy, and Resident #15 was to be monitored per facility policy. Review of the clinical record failed to identify any additional interventions related to Resident #15's observed non-compliance of the facility no smoking policy including the location of Resident #15's smoking materials, any monitoring checks of Resident #15 following the incident, or any attempts by facility staff to request Resident #15 relinquish any smoking items. A safe smoking evaluation dated 12/24/25 at 11:19 AM completed by the DNS identified Resident #15 was observed smoking by a staff member outdoors. The evaluation identified that Resident #15 was given the facility smoking policy and advised that the facility was nonsmoking. Further review of the evaluation identified that while dated 12/24/25 (a day after the 12/23/25 observed smoking incident), the completed date was 1/29/26 at 11:22 AM, approximately 5 weeks after the incident. Review of the clinical record failed to identify any revisions or interventions to Resident #15's care plan related to the 12/23/25 incident. A care conference note dated 1/14/26 by RN #2 (MDS Coordinator) identified a care conference was held and included the DNS, Person #1 (state agency representative), multiple resident representatives including Person #2, and Resident #15. The note identified the facility nonsmoking policy and smoking cessation was reviewed. The note further identified that the DNS reported she would set up a lockbox with cigarettes and a lighter on the 1st floor of the facility and that Resident #15 would have to take a leave of absence from the facility and leave the facility property to smoke. The note further identified that Person #2 requested Resident #15 be allowed to smoke where facility staff were allowed to smoke and that the DNS identified she would forward the request to corporate. The care plan dated 1/14/26 identified revisions on that date related to Resident #15's history of smoking. Interventions included offer transfer to a smoking facility (resident refused), offer smoking cessation (refuses). Additional interventions also included smoking paraphernalia would be given to staff and stored properly in the supervisors office and may ask for items when going LOA off property.Review of the physician's orders failed to identify any orders related to independent LOA for Resident #15. c. A facility accident and incident (A&I) form dated 1/27/26 at 6:40PM identified that Resident #15 was observed smoking by the Administrator. The note further identified that MD #1 (Medical Director) was notified on 1/28/26, Resident #15 was educated regarding the plan of care put in place on 1/14/26, reeducated on the facility's nonsmoking policy, and that Resident #15 continued to decline interventions. A statement from the Administrator was also included with the A&I form and identified he observed Resident #15 in the facility lobby going to the RN supervisor's office, however that office was locked as the RN supervisor was not present. The statement identified that Resident #15 was then observed proceeding outside of the facility to the front of the building and the Administrator was able to observe Resident #15 smoking from his office window. The statement further identified that the Administrator approached Resident #15 after he/she returned inside of the building and inquired how Resident #15 was able to obtain a lighter (the supervisor's office which continued Resident #15's cigarettes and lighter was locked) and also asked for Resident #15 to turn over the lighter as they were not permitted in the facility and that Resident #15 refused. A nurse's note dated 1/28/26 at 5:55 PM by the DNS identified that Resident #15 was admitted to the facility and started on a nicotine replacement patch from 5/23/25 until approximately 1/14/26 when a meeting was held with Resident #15, Person #1, Social Services, RN #2 and the DNS. The note further identified that following a discussion regarding Resident #15's desire to smoke, the following agreement was put into place: Resident 15 would be allowed to keep his/her cigarettes and lighter in a lock box in the RN supervisor's office. Review of the clinical record failed to identify any additional interventions related to Resident #15's observed non-compliance of the facility no smoking policy including the location of Resident #15's smoking materials, any monitoring checks of Resident #15 following the incident, or any additional attempts by facility staff to request Resident #15 relinquish any smoking items. The care plan dated 1/29/26 identified revisions related to Resident #15's history of smoking. An additional intervention of offer smoking cessation was added, which was a duplicate intervention originally added on 1/14/26.Review of facility leave of absence (LOA) sign out sheets for Resident #15 failed to identify any LOA sign outs for 1/2026. Further review of facility LOA forms for Resident #15 identified that Resident #15 signed out on LOA on 7/30/25, 10/15/25, with the next date signing out as 2/4/26. d. A facility accident and incident (A&I) dated 2/4/26 at 3:00 PM identified that Resident #15 was observed smoking by staff on facility grounds. The note further identified that APRN #3 was notified and actions taken included continuing Resident #15's plan of care and place on 1:1 observation until Resident #15 returned smoking materials. A statement from the Administrator was also included with the A&I form and identified he observed Resident #15 smoking on facility property and instructed Resident #15 that he/she must go off the property if he/she chose to smoke, and that Resident #15 refused to comply.A nurse's note dated 2/4/26 at 3:04 PM identified that Resident #15 requested to go on independent LOA and was provided with smoking materials and subsequently observed by staff smoking on facility grounds. The note further identified that Resident #15 was re-educated on facility policy that required resident to leave the property if choosing to smoke. Upon return to the facility, Resident #15 declined to surrender smoking materials and due to safety concerns, Resident #15 was placed on 1:1 supervision.Review of a 1:1 monitoring form dated 2/4/26 identified 1:1 monitoring was in place from 3:00 PM until 3:35 PM when Resident #15 returned smoking materials. Review of facility leave of absence (LOA) sign out sheet for Resident #15 failed to identify any LOA sign outs for 2/4/26 at 3:00 PM. Review of the Further review of facility LOA forms for Resident #15 identified that Resident #15 signed out on LOA on 7/30/25, 10/15/25, with the next date signing out as 2/4/26 at 4:30 PM as the first LOA sign out on that date.Review of the clinical record failed to identify any revisions or interventions to Resident #15's care plan related to the 2/4/26 incident. e. A facility accident and incident (A&I) form dated 4/14/26 at 9:15 AM identified that Resident #15 was observed smoking in the facility parking lot. The note further identified that MD #1 was notified, a room search was conducted, and Resident #15 was to be monitored per facility policy. Review of the LOA sign out log dated 4/14/26 for Resident #15 failed to identify that Resident #15 was signed out on an LOA at 9:15 AM. Review of the log identified Resident #15 signed out for LOA at 8:20 AM and returned at 8:30 AM, with the next sign out at 10:20 AM.A nurse's note dated 4/14/26 at 10:02 AM by the DNS identified Resident #15 was noncompliant with his/her plan of care of signing out on independent LOA and going off property. Resident #15 was observed smoking in the parking lot. The note further identified that Resident #15 did sign out for LOA, obtained smoking materials from the supervisor's office, and replaced them upon return. The note identified The DNS reviewed the smoking policy and Resident #15 individualized plan of care, and that Resident #15 verbalized understanding and ensured future compliance. The note also identified a room search was conducted with Resident #15's consent in his/her presence and no smoking paraphernalia was found. Review of the clinical record failed to identify any revisions or interventions to Resident #15's care plan related to the 4/14/26 incident. A physician's order dated 5/11/26 directed Resident #15 may go on independent LOA with power wheelchair. f. A facility accident and incident (A&I) form dated 5/15/26 at 2:00 PM identified that Resident #15 was observed smoking in the facility parking lot. The note further identified that APRN #3 was notified and actions taken included to continue Resident #15's plan of care. A nurses note dated 5/15/26 at 3:02 PM identified the Resident #15 was observed smoking in the parking lot by staff at approximately 2:00 PM. The note further identified that Resident #15 was self responsible and was re-educated regarding smoking off of the facility policy and that the facility would continue to encourage compliance with the facility smoking policy. Review of the LOA sign out log dated 5/15/26 failed to identify that Resident #15 was signed out on an LOA at 2:00 PM. Further review of the log identified Resident #15 signed out on LOA at 12:30 PM, returned at 12:45 PM, and signed out again at 3:36 PM.A care plan dated 5/15/26 identified Resident #15 had behavioral symptoms that included failure to comply with the facility smoking policy and refused to sign education or review nonsmoking policy when presented. Interventions included to continue Resident #15's compliance with smoking agreement plan of care, continue educating the resident on the smoking agreement, and to remind the resident to sign out LOA at the reception desk. An undated facility in-service education document signed by facility staff from multiple departments included recreation, housekeeping, laundry, rehab, nursing, and administration. The in-service education identified that effective immediately Resident #15's cigarettes and lighter would maintained at the reception desk and that the Secretary would provide the smoking materials to Resident #15 and ensure Resident #15 signed out on LOA and returned the materials after signing back into the facility. The in service education also identified if Resident #15 did not return the materials, staff must follow Resident #15 and maintain direct 1:1 supervision until the materials were returned, and that the RN supervisor, DNS, and Administrator must be notified. The education also identified if Resident #15 was observed smoking in the parking lot, the RN supervisor, DNS, and Administrator must be notified. The signature page for the in service was dated 5/15/26. g. A nurse's note dated 5/18/26 at 2:51 AM by the DNS identified that Resident #15 was observed by staff smoking in the parking lot at 9:15 AM (6 hours and 24 minutes in the future) and failed to leave the facility property per his/her plan of care, and that education and discussion were provided.A facility accident and incident (A&I) form dated 5/18/26 at 9:15 AM identified that Resident #15 was observed smoking by the Administrator. The note further identified that APRN #3 was notified and actions taken included discussing Resident #15's individual plan of care and not fully leaving the property, providing education, and continue Resident #15's plan of care.A revised care plan dated 5/18/26 identified Resident #15 had behavioral symptoms that included failure to comply with the facility smoking policy and refused to sign education or review nonsmoking policy when presented. Revision included interventions included that Resident #15 preferred to scribble or place a line on the LOA sign out form indicating his/her signature. A facility accident and incident (A&I) form dated 5/19/26 (no time noted) identified that Resident #15 was observed smoking by the Administrator and the Secretary. The note further identified that APRN #3 was notified and actions taken included that Resident #15 was asked to move off property and agreed, Resident #15's individual plan of care and smoking policy were reviewed, and to continue Resident #15's plan of care.A nurse's note dated 5/19/26 at 9:21 AM identified Resident #15 was observed smoking in the parking lot by the Administrator and Secretary. The note further identified Resident #15 was asked to move to a previously agreed upon area on the sidewalk off the facility property and educated again on the smoking agreement, and that Resident #15 declined to move to the area. The note further identified to continue the plan of care and that Resident #15 was self-responsible.A revised care plan dated 5/19/26 identified Resident #15 had behavioral symptoms that included failure to comply with the facility smoking policy and refused to sign education or review nonsmoking policy when presented. Revision included intervention to continue to encourage compliance with smoking agreement plan of care, which was duplicated from the same intervention added on 5/15/26.A facility document ESS Announcement dated 5/27/26 identified that a staff education notice was sent to facility staff via the text message system. The text message identified that smoking was no longer permitted anywhere on facility grounds for staff, and if staff smoked, they may smoke in their personal vehicle or smoke off property. Observation with the LPN #2 (Regional Clinical Support Nurse) on 7/27/26 at 8:36 AM identified an outside patio area to the right of the facility and rear entrance where the parking lot was located. Observation identified a large black top patio area with 2 cigarette butt stops (cigarette waste receptacle), one large back metal and one beige plastic. Both butt stops appeared partially open and not secured, with the plastic butt stop full of water and the metal butt stop with multiple web like material in the funnel for cigarette disposal and did not appear recently used. Observations also identified a sign that identified No Smoking beyond this point posted in front of the sidewalk at the facility's main entrance. Interview with the DNS on 7/27/26 at 9:36 AM identified that the facility was nonsmoking, but that Resident #15 had refused to comply with the no smoking policy and following the initial incident on 12/23/25, contacted Person #1 to lodge a complaint. The DNS identified following a meeting on 1/14/26. Resident #15 was able to keep smoking items in a locked box with the RN supervisor and then smoke off property after signing out on LOA. The DNS identified that Resident #15 had repeated noncompliance and violations of the policy, but that he/she was allowed to continue to smoke due to repeated refusals of smoking cessation materials (nicotine replacement patch and gum) and also refusal of multiple offers to transfer to various facilities that did allow smoking. The DNS identified that the smoking agreement was driven by Person #1 in order to preserve Resident #15's right to smoke, and that the facility felt they had no option but to continue the agreement, despite Resident #15's repeated noncompliance. Interview with Person #1 on 7/27/26 at 11:12 AM identified she initially received a complaint from Resident #15 over multiple issues, including not being able to smoke at the facility, which prompted the meeting she attended with the resident and facility on 1/14/26. Person #1 identified Resident #15 reported initially being able to smoke and that the DNS would provide smoking materials to him/her, but at some point smoking was taken away. Person #1 identified Resident #15 reported to her that he/she had been a 50+ year smoker and was smoking independently until 12/23/25. Person #1 also identified that while the facility was nonsmoking for residents, staff were allowed to smoke and it was not fair to the residents of the facility if staff could smoke as they wished on facility property. Following the meeting on 1/14/26, Person #1 identified that there was a 2nd issue related to smoking on 1/28/26 which she was aware of but was not involved with any issues related to smoking after that time. Person #1 identified there had been attempts by the facility to offer transfer the resident to a smoking facility, but that Resident #15 declined, and due to his/her use of a motorized wheelchair, other alternate facility options were limited and identified that if staff were no longer able to smoke, and Resident #15 continued to violate the plan of care therefore it would be reasonable for the facility to take additional steps including discharge to ensure the safety of all the residents. Person #1 also identified she had personally witnessed one instance with Resident #15 in the facility parking lot attempting to light a cigarette and redirected him/her to leave the property per the plan of care but was unable to provide a date/time when she witnessed this. Interview with Resident #15 and Person #2 on 7/27/26 at 1:35 PM identified that Resident #15 routinely smoked on the facility property due to staff and other residents being able to smoke on the property. Resident #15 identified multiple residents also smoked on the property but declined to identify any other residents. Person #2 identified that he/she was aware that Resident #15 was required to smoke off the property on a sidewalk in front of the facility, but he/she felt this was unsafe due to the side walk being located next to a road. Resident #15 and Person #2 also identified that while staff were not allowed to smoke on the facility grounds, the staff routinely smoked in their cars and outside and there should be no issue if Resident #15 wanted to smoke as well. Resident #15 identified that he/she was aware of the smoking agreement but felt it was not fair that he/she had to leave the property.Observation on 7/27/26 at 2:30 PM with the DNS, Administrator, and LPN #2 identified Resident #15 seated in in his/her motorized wheelchair outside of the rear entrance of facility, approximately 50 feet from the entrance, in the parking lot. Resident #15 was observed smoking a cigarette while positioned in the middle of the driving area of the parking lot, next to an area where 2 large metal dumpsters were located. Resident #15 was positioned next to one of the dumpsters which was full and contained cardboard boxes. LPN #2 spoke with Resident #15 and was observed providing education to Resident #15 regarding the care plan that was in place that allowed for Resident #15 to be able to sign out on LOA and retrieve his/her cigarettes from the receptionist and then leave the facility property prior to smoking. Resident #15 was observed flicking ash from his/her lit cigarette and identified he/she had not been and would not follow the care plan due to concerns that his/her motorized wheelchair battery would run out if he/she had to leave the property. Following surveyor inquiry regarding Resident #15's flicking of ash and his/her proximity to the large dumpster of cardboard boxes which was next to the facility building and possible safety concerns of the other residents of the facility, Resident #15 stated (Oh well. Everybody has to die sometime).Subsequent to surveyor inquiry on 7/27/26 at 4:00 PM following the observations and interview with Resident #15 and concerns for residents of the facility, the facility took steps to ensure the safety of resident. Steps included:The resident was immediately counseled regarding the facility's No Smoking Policy and Smoking Procedure. The residents were provided a copy of the policy and educated that smoking is prohibited anywhere within the facility or on facility grounds. Smoking cessation counseling, nicotine replacement therapy, and alternative interventions were offered. The resident's care plan was reviewed and revised to include additional safety interventions that included The resident will continue to independently exercise the right to leave the facility on pass.Prior to receiving smoking materials, the resident must sign out in accordance with facility procedure.Staff will issue the resident's cigarettes and lighter only after the resident has signed out.The resident will be placed on one-to-one observation from the time smoking materials are issued until staff have visually confirmed the resident has exited facility property.Once the resident has left facility grounds, the one-to-one observation will be discontinued.Once staff become aware of the resident's return to facility grounds, the resident will be placed on one-to-one observation until staff have verified that all smoking materials, including the lighter, have been returned to reception and secured in the resident's designated lock box.Staff will document the issuance and return of all smoking materials and any episodes of non-compliance. If the resident is observed smoking on facility grounds or refuses to leave facility property:Staff will immediately intervene and re-educated on smoking policy and remain with the resident at all times to ensure the safety of the resident, other residents, visitors, and staff.If the resident refuses to leave the property, staff will ensure the cigarette or other smoking material is safely extinguished in the designated smoking receptacle located at least 25 feet from the building,Once the smoking material has been extinguished, staff will escort the resident to the reception to ensure all cigarettes, lighter, and smoking materials are returned and secured in the resident's designated lock box.The charge nurse and Administrator or designee will be notified of the incident.Staff will document the resident's response to redirection, the intervention provided, the return and securing of smoking materials, and any additional actions taken.The interdisciplinary team will review repeated episodes of non-compliance and revise the resident's care plan as indicated. A nurse's note by LPN #2 dated 7/27/26 at 5:27 PM identified that at 5:00 PM, Resident #15 requested to smoke and in accordance with the facility's plan. The resident signed out and was provided his/her cigarettes and lighter from the secured lock box. LPN #2 identified she accompanied the resident from the facility to ensure compliance with the smoking process however while still in the facility parking lot, Resident #15 attempted to light a cigarette before leaving the property. LPN #2 immediately intervened and reminded the resident that smoking was prohibited anywhere on the facility property. LPN #2 identified Resident #15 again attempted to smoke on the facility property and subsequently she proceeded to accompany the resident to the public sidewalk beyond the facility property to smoke. Following a return to the facility with LPN #2, Resident #15 identified that he/she would be smoking every 15 minutes and hoped the facility had enough staff to accommodate his/her needs. Interview with the DNS on 7/29/26 at 11:21 AM identified that Resident #15 was admitted to the facility on [DATE] and had not smoked at the time of admission. The DNS identified the first incident that the facility was aware that Resident #15 began smoking was on 12/23/25. The DNS identified that following the identification of smoking materials with Resident #15 on that date, no follow up was completed by facility staff to determine if the resident had any materials on his or her person or in his or her room and no revisions were made to the care plan and which was an oversight by her and the facility staff. The DNS further identified that the a meeting was held on 1/14/26 regarding the resident not being able to smoke. In response, and to preserve the resident's rights, an individualized smoking agreement was offered and accepted by Resident #15. The DNS identified this offer had not and was not made to any other residents of the facility who had a history of smoking. The DNS further identified that since that time multiple incidents with Resident #15 being observed smoking on facility property had been made but the facility felt they were unable to prevent Resident #15 from smoking and despite multiple incidents of noncompliance, and due to the multiple incidents of noncompliance the care plan at times was not updated or was updated with duplicate interventions. The DNS identified that Resident #15's plan of care had not ever involved staff observing the resident physically leaving the property after being provided smoking materials prior to 7/27/26. The DNS identified that going forward, Resident #15 would be required to have staff walk to the property line with Resident #15 and physically hand Resident #15 has her smoking materials once off the facility property to ensure compliance. The DNS identified that this had not occurred to any of the staff to implement as an intervention prior to 7/27/26. The facility no smoking policy directed that residents and visitors were prohibited from smoking in the facility or on facility grounds, including electronic cigarettes. Further, noncompliance with the smoking policy which included residents who were suspected of holding cigarettes, vapes, E cigarettes, lighters, matches or other similar materials would be asked to voluntarily relinquish such objects. Additionally, a search of the resident's room, person and/or belongings would be performed with the consent of the resident and the resident would be present. Residents suspected or determined to be in violation of the smoking policy would be provided a copy of the policy and continued violations of the policy could result in the following actions:Reeducation.Random, periodic searches of the residence room, belongings, in person with the residence consent and in the presence of the resident.Fifteen minute checks or other appropriate monitoring of the resident.Searches upon return from leaves of absence or appointment.Immediate discharge.Residents who express a desire to smoke would be provided information on smoking cessation programs and nicotine replacement.Any identification of smoking paraphernalia such as used cigarette butts, etc. should be investigated by the Administrator or designee to determine the source.No smoking signs should be posted at all entrances of the facility. The facility policy on incidents and accidents - investigating and reporting directed that incident accident reports would be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 74) reviewed for care planning, the facility failed to ensure social service intervention, including the recommendation of additional evaluation to determine cognitive function and establishing a POA or conservator when the resident had a significant cognitive decline. The findings include:A hospital discharge note dated 8/27/25 identified Resident #74 had a capacity evaluation by psychiatry while hospitalized due to previous psychiatric disease and was determined to have full capacity. Resident #74 was admitted to the facility in August 2025 with diagnoses that included congestive heart failure and paranoid schizophrenia. The care plan dated 8/27/25 identified Resident #74 had a neurological/neuromuscular deficit related to right sided weakness. Interventions included observing for changes in cognition, alertness, or movement and report to the physician as needed. A social service note dated 8/29/25 by SW #2 identified Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition) based on assessment questions completed on that date. SW #2 identified Resident #74 was unable to name the day of the week. The admission MDS dated [DATE] identified Resident #74 had intact cognition, was continent of bowel and bladder and required supervision by staff with bathing and set up assistance with toileting and dressing.A social service note dated 10/18/25 by SW #2 identified Resident #74 had a BIMS score of 4/15 (severely impaired cognition) based on assessment questions completed on that date. SW #2 identified Resident #74 had a decline and was able to repeat 2 repetition words and one memory word, but was unable to name the year, the day of the week, and named the wrong month (September instead of October). Review of the clinical record failed to identify any additional actions or interventions by SW #2 following the identified change in cognition from intact on 8/29/25 to severely impaired on 10/18/25, approximately 7 weeks later. A social service note dated 10/18/25 by Social Worker SW #2 identified Resident #74 had a BIMS score of 4/15 (severely impaired cognition) based on assessment questions completed on that date. SW #2 identified Resident #74 was able to repeat 2 repetition words and one memory word, but was unable to name the year, the day of the week, and named the wrong month (September instead of October). A social service note dated 2/6/26 by SW #2 identified she completed a record review of progress notes dated 2/6/26 and 2/20/26 (a date in the future) by psychiatry for Resident #74. SW #2 identified that BIMS score from a record review identified 11/15 (moderately impaired cognition) with difficulty with recall and was unable to name the day of the week at the time of the evaluation. Review of the clinical record failed to identify any documentation of psychiatric notes or BIMS assessments on 2/6 or 2/20/26 for Resident #74 by any psychiatric provider at the facility. A social service note dated 3/9/26 by SW #2 identified Resident #74 had a BIMS score of 4/15 (severely impaired cognition) based on assessment questions completed on that date. SW #2 identified Resident #74 was unable to name the month or the year.A social service note dated 6/5/26 by SW #2 identified Resident #74 had a BIMS score of 3/15 (severely impaired cognition) and identified this was Resident #74's usual baseline.A quarterly MDS dated [DATE] identified Resident #74 has a BIMS score of 1/15 (severely impaired cognition).Review of the clinical record failed to identify additional actions or interventions by SW #2 following Resident #74's continued identified cognitive impairment on 3/9/26, 6/5/26, and 6/30/26.Review of the clinical record identified Resident #74 was responsible for self and had no power of attorney or conservator on file. Interview and clinical record review with SW #2 on 7/29/26 at 8:36 AM (SW #1, the Social Services Director present) identified that the social services department was responsible for completing BIMS assessments for all facility residents. SW #2 identified that the assessments were completed on admission, readmission, with a change of condition, and quarterly. SW #2 identified that if the BIMS assessment determined a change in a resident's cognition, that the assessment findings were reviewed with the resident's floor nurse and during morning report. SW #2 also identified that a referral was also made to the psychiatric providers at the facility to further evaluate the resident but she did not typically document the referral in the clinical record. SW #2 identified that Resident #74 was admitted to the facility with intact cognition and she completed multiple BIMS assessments for the resident and identified the resident had a decline in cognition. SW #2 identified she did not look into the matter further and did not discuss the issue with the resident's physician or APRN or make a referral to any psychiatric provider as she attributed the decline to Resident #74 not feeling well due to the need for medical procedures and multiple health issues that would intermittently require hospital evaluation. SW #2 also identified that Resident #74 had a family member who had power of attorney upon admission to the facility and she felt because of this there were no issues. Interview with SW #1 (Social Services Director) on 7/29/26 at 8:40 AM identified when Resident #74 was initially identified with a significant cognitive decline, it was the responsibility of the social worker to make a referral to complete a cognitive evaluation and to notify the DNS, Administrator, and Business office Manager of the issue. SW #1 also identified if the resident did not have designated POA or conservator, a referral would be made to probate for the state to start the process for conservatorship. SW #1 identified she was unable to identify any documentation of a POA on file, but she would look into the matter further. Subsequent to surveyor inquiry, the facility provided a typed notarized document on 7/29/26 at 9:40 AM that identified Resident #74 directed for a family member to have full authority and decision making over the resident. Review of the document identified it was dated 1/10/26, approximately 5 months after admission to the facility and after 10/18/25, Resident #74 was identified to have severely impaired cognition. Subsequent to surveyor inquiry the facility provided e-mail documentation initiated by the DNS on 7/29/26 at 9:58 AM requesting a neurocognitive evaluation and referral to probate for possible conservatorship related to a change in BIMS from 14/15 to 3/15.The facility policy on Social Services directed that the facility would provide medically related social services to ensure that each resident could attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy also directed that medically related social services were provided to maintain or improve each resident's ability to control everyday physical needs, mental means, and psychosocial needs. The policy further directed that the social service department was responsible for maintaining appropriate documentation of referrals and providing social service data summaries to such agencies and working with individuals and groups and developing supportive services for residents according to their individual needs and interest. The facility policy on cognitive evaluation directed the purpose was to establish a consistent process for evaluating a resident's cognitive status while protecting the resident's rights, dignity, autonomy, and right to refuse an assessment. The policy further directed that the facility would evaluate each resident's cognitive status as part of the comprehensive resident assessment process and whenever a change in cognition was suspected. Evaluations would be conducted using appropriate standardized instruments, clinical observation, record review, and information from the interdisciplinary team. The policy further directed that a cognitive screening result was not, by itself, a determination of legal competency or decision-making capacity and also directed a cognitive evaluation would be completed or attempted when staff, the resident, the resident representative, or a practitioner identified a possible change in cognition.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #12 and 81) reviewed for hospitalization and for resident hospital transfers in October 2025 and March 2026, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in accordance with regulatory requirements when the residents were transferred to the hospital. The findings include: 1. Resident #12 was admitted to the facility in December 2025 with diagnoses that included malignant neoplasm of colon and seizures. A nurse's note dated 3/20/26 at 5:29 PM identified Resident #12 was transferred to the hospital and was readmitted on [DATE].A nurse's note dated 3/30/26 at 2:25 PM identified Resident #12 was transferred to the hospital and was readmitted on [DATE]. 2. Resident #81 was admitted to the facility in March 2025 with diagnoses that included chronic kidney disease stage 3 and diabetes.A nurse's note dated 10/2/25 at 1:31 PM identified Resident #81 was transferred to the hospital and was readmitted on [DATE].A nurse's note dated 10/13/25 at 2:13 PM identified Resident #81 was transferred to the hospital from the cardiologist office and was readmitted on [DATE].Review of facility documentation failed to reflect that the Office of the State Long-Term Care Ombudsman had been notified when Residents #12 and 81 were transferred to the hospital.Review of the monthly transferred file uploaded forms identified the admission/discharge report for October 2025 was not submitted to the Office of the State Long-Term Care Ombudsman.Review of the admission/discharge report (transfer to hospital) failed to reflect documentation that the Office of the State Long-Term Care Ombudsman had been notified of residents transferred to the hospital in March 2026 on a monthly basis. Interview with the DNS on 7/27/26 at 11:00 AM identified she was not aware that notification to the Office of the State Long-Term Care Ombudsman was not completed monthly. The DNS indicated that the previous social worker was responsible for ensuring that the monthly admission/discharge report was submitted to the State Long-Term Care Ombudsman. The DNS indicated that SW #1 will be educated on the process of submitting the monthly admission/discharge report to the State Long-Term Care Ombudsman. Interview with the Administrator on 7/27/26 at 11:15 AM identified he was not aware of the issue. The Administrator indicated going forward the monthly admission/discharge report will be submitted to the State Long-Term Care Ombudsman in a timely manner. Although attempted, an interview with the previous Social Worker was not obtained.The facility Connecticut Long-Term Care Ombudsman Notification through the LTCOP electronic portal policy identified to ensure compliance with Connecticut state law, federal regulations, and Connecticut Long-Term Care Ombudsman (LTCOP) requirements by providing timely notification of resident transfers, discharges, and applicable resident-initiated discharges through the Connecticut Long-Term Care Ombudsman electronic discharge portal. The facility will maintain documentation demonstrating completion of all required portal submissions.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #24, 33, 36, 58, and 78) reviewed for resident assessment, the facility failed to ensure the quarterly MDS assessments were completed within the federally required timeframes. The findings include: 1. Resident #24 was admitted to the facility in December 2025 with diagnoses that included hemiplegia affecting the left nondominant side and diabetes.The quarterly MDS assessment identified an Assessment Reference Date (ARD) of 3/24/26. The MDS section Z0500 identified the assessment was signed as completed on 4/24/26 (31 days after the ARD) and (17 days after the required 14-days completion).The CMS submission report dated 4/27/26 identified that the quarterly MDS assessment with an ARD of 3/24/26 was transmitted on 4/27/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD. 2. Resident #33 was admitted to the facility in July 2025 with diagnoses that included dementia and anxiety disorder. a. The quarterly MDS assessment identified an ARD of 3/27/26. The MDS section Z0500 identified the assessment was signed as completed on 4/28/26 (32 days after the ARD) and (18 days after the required 14-days completion).The CMS submission report dated 4/30/26 identified that the annual MDS assessment with an ARD of 3/27/26 was transmitted on 4/30/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD.b. The quarterly MDS assessment identified an ARD of 6/27/26. The MDS section Z0500 identified the assessment was signed as completed on 7/27/26 (30 days after the ARD) and (16 days after the required 14-days completion).The CMS submission report dated 7/27/26 identified that the quarterly MDS assessment with an ARD of 6/27/26 was transmitted on 7/27/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD. 3. Resident #36 was admitted to the facility in March 2026 with diagnoses that included depression and anxiety disorder.The quarterly MDS assessment identified an ARD of 6/25/26. The MDS section Z0500 identified the assessment was signed as completed on 7/27/26 (32 days after the ARD) and (18 days after the required 14-days completion).The CMS submission report dated 7/27/26 identified that the quarterly MDS assessment with an ARD of 6/25/26 was transmitted on 7/27/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD. 4. Resident #58 was admitted to the facility in December 2024 with diagnoses that included diabetes and atrial fibrillation.The quarterly MDS assessment identified an ARD of 6/26/26. The MDS section Z0500 identified the assessment was signed as completed on 7/27/26 (31 days after the ARD) and (17 days after the required 14-days completion).The CMS submission report dated 7/27/26 identified that the quarterly MDS assessment with an ARD of 6/26/26 was transmitted on 7/27/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD. 5. Resident #78 was admitted to the facility in December 2022 with diagnoses that included schizoaffective disorder and depression.a. The quarterly MDS assessment identified an ARD of 12/31/25. The MDS section Z0500 identified the assessment was signed as completed on 1/26/26 (25 dys after the ARD) and (12 days after the required 14-days completion).The CMS submission report dated 1/26/26 identified that the quarterly MDS assessment with an ARD of 12/31/25 was transmitted on 1/26/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD.b. The quarterly MDS assessment identified an ARD of 3/26/26. The MDS section Z0500 identified the assessment was signed as completed on 4/28/26 (33 days after the ARD) and (19 days after the required 14-days completion).The CMS submission report dated 4/30/26 identified that the quarterly MDS assessment with an ARD of 3/36/26 was transmitted on 4/30/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD.c. The quarterly MDS assessment identified an ARD of 6/24/26. The MDS section Z0500 identified the assessment was signed as completed on 7/27/26 (33 days after the ARD) and (19 days after the required 14-days completion).The CMS submission report dated 7/27/26 identified that the quarterly MDS assessment with an ARD of 6/24/26 was transmitted on 7/27/26. The report identified the assessment was completed late, and the assessment completion date was more than 14 days after the ARD.Interview and clinical record review with RN #2 (MDS Coordinator) on 7/27/27 at 9:06 AM identified she is the only staff member assigned to the MDS department. RN #2 indicated she was aware that some MDS assessments were completed after the required timeframes. RN #2 indicated she will review the clinical record for Resident #24, 33, 36, 58, and 78 to determine which MDS assessments were completed late and address identified concerns.Interview with the DNS on 7/27/26 10:00 AM identified she was not aware that some MDS assessments were completed after the required timeframes. The DNS indicated RN #2 was responsible for the completion of the MDS. Interview and clinical record review with RN #2 on 7/28/26 at 9:50 AM identified she was responsible for completion of the MDS assessments and the development and revision of the care plans, although she indicated the process involved an interdisciplinary team effort. RN #2 indicated she facilitated the care plan conference meetings. RN #2 indicated she notified the Regional Clinical Reimbursement Director regarding the late MDS assessments identified during the survey. Interview with the Administrator on 7/28/26 at 10:45 AM identified he was not aware that some MDS assessments had been completed late. The Administrator indicated that he would discuss with corporate the need for additional MDS support, including the possibility of utilizing a part-time MDS staff member, to assist the MDS Coordinator with workload demands and ensure assessments are completed timely. Review of the facility MDS assessment completion and submission policy identified the facility will ensure all MDS assessments are completed accurately, timely, and submitted in accordance with CMS and state requirements. The facility will maintain systems to monitor MDS schedules, prevent late assessments, and ensure timely correction and resubmission when errors are identified. Review of the MDS assessment policy identified the facility shall complete all MDS assessments using a comprehensive interdisciplinary approach. Information entered on the MDS must accurately reflect the resident's status during the Assessment Reference Date (ARD) look-back period and be supported by documentation contained within the medical record. Assessment Scheduling - The MDS Coordinator shall: Establish and maintain an MDS assessment schedule. Ensure assessments are completed according to federal and state requirements. Monitor compliance with assessment due dates. Communicate assessment schedules to interdisciplinary team members. Required assessments may include: admission Assessments, Quarterly Assessments, Annual Assessments, Significant Change Assessments, Medicare PPS Assessments, Discharge Assessments, and Other CMS-required assessments.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for personal hygiene, the facility failed to ensure Resident #1 was treated with dignity by a nurse aide when providing care. The findings include:Resident #1's diagnoses included schizophrenia, depression, anxiety, adult failure to thrive and muscle weakness. The Resident Care Plan dated 1/21/26 identified Resident #1 needed assistance with activities of daily living related to cognitive and physical deficits. Interventions directed to allow extra time to complete tasks, encourage the resident to make choices to the extent that is possible, praise the resident for efforts, and report changes in functional ability to the physician. Review of a complaint voiced by a family member, Person #1, that the facility received on 2/24/26 identified on 2/21/26 at approximately 10:30 AM Person #1 entered Resident #1's room to find Resident #1 completely undressed, fully exposed with nothing covering him/her while lying flat in the bed. The Significant Change in Condition Minimum Data Set assessment dated [DATE] identified Resident #1 had poor memory recall deficits, was always incontinent of bowel and bladder and dependent on staff for all activities of daily living that included bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting hygiene. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, who was assigned to Resident #1, on 3/23/26 at 1:29 PM identified on 2/21/26 while she was providing care to Resident #1 she needed to step out of the room to obtain some cream. NA #1 explained she pulled the curtain and closed the door to the room, but left Resident #1 on the bed without the benefit of anything covering Resident #1's body. Interview with the 7AM-3PM nursing supervisor, Registered Nurse (RN) #1, on 3/23/26 at 2:02 PM identified on 2/21/26, Resident #1's family (Person #1) member reported to her that she found Resident #1 exposed in the room. RN #1 indicated she inquired to NA #1 and found that NA #1 had left Resident #1 in the room to retrieve some cream and denied leaving Resident #1 on the bed without anything covering Resident #1. Interview with the Director of Nursing (DON) on 3/23/26 at 2:11 PM identified it was not reported to her that on 2/21/26, Resident #1 was found exposed in his/her bed by Person #1. The DON identified facility policy directed that all residents are to be treated with dignity and respect, and every staff member was responsible for ensuring this happened. The DON identified on 2/21/26, Resident #1 was not treated with dignity when he/she was left on the bed without the benefit of being covered, NA #1 made an error in judgement, and Resident #1 should not have been left in the bed exposed. Review of the facility policy titled Resident Rights, last reviewed 10/3/25, directed, in part, federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's right to a dignified existence and to be treated with respect, kindness, and dignity.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for personal hygiene, the facility failed to ensure Resident #1 was provided with incontinent care in accordance with the plan of care that directed incontinent care every two (2) hours, as needed, and five (5) times a day at specific times. The findings include:Resident #1's diagnoses included schizophrenia, depression, anxiety, adult failure to thrive and muscle weakness. The Resident Care Plan dated 1/21/26 identified Resident #1 needed assistance with activities of daily living related to cognitive and physical deficits, had urinary incontinence, and a pressure ulcer. Interventions directed to check the resident for incontinent episodes every two (2) hours and change as needed, assist with toileting, and resident specific toileting-upon rising, after meals, bedtime, and as needed five times a day at 8:00 AM, 10:30 AM, 2:00 PM, 6:30 PM, and 9:00 PM. Review of a complaint voiced by a family member, Person #1, that the facility received on 2/24/26 identified on 2/21/26 at approximately 10:30 AM Person #1 arrived to find Resident #1 saturated in urine and feces and reported this to the charge nurse, Licensed Practical Nurse (LPN) #1. The Significant Change in Condition Minimum Data Set assessment dated [DATE] identified Resident #1 had poor memory recall deficits, was always incontinent of bowel and bladder and dependent on all activities of daily living including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting hygiene. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 3/24/26 at 1:29 PM identified she could not recall any specific information regarding the incident on 2/7/26. NA #1 did identify incontinent care should be provided every two (2) hours and as needed to any incontinent resident. Interview with the 7AM-3PM charge nurse, LPN #1, on 3/24/26 at 1:55 PM identified on 2/7/26, Person #1 reported to her that Resident #1 was soaked in urine. LPN #1 explained at that time she asked NA #1 when Resident #1 had been provided care last, and NA #1 reported she had been busy and had not provided incontinent care since first rounds at the beginning of the shift, 7:00 AM, almost five (5) hours prior. LPN #1 indicated facility policy directed to provide incontinent care to an incontinent resident at least every two (2) hours. Interview with the Director of Nursing (DON) on 3/23/26 at 2:11 PM identified she was not made aware of the concern reported to the charge nurse on 2/7/26 regarding Resident #1 not receiving incontinent care from 7:00 AM until 12:45 PM (almost five (5) hours). The DON explained incontinent care and/or monitoring for incontinent care should be done during first rounds, at the beginning of the shift, and then at least four (4) times per shift, including at the end of each shift. The DON identified it was the responsibility of the charge nurse to ensure the nurse aides are providing incontinent care per policy. Review of the facility policy titled Urinary Continence and Incontinence, dated 9/1/22, directed, in part, management of incontinence will follow relevant clinical guidelines. The policy further directed, in part, a check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments with the primary goal to maintain dignity and comfort and to protect the skin.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who required a mechanical lift for transfers in and out of the bed and chair, the facility failed to ensure the appropriate number of staff transferred the resident into bed in accordance with the resident care plan. The findings include: Resident #1's diagnoses included unspecified dementia without behavioral disturbances and anxiety. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had poor memory recall and was dependent on staff for personal care, transfers, and turning and repositioning. A physician's order dated 1/3/25 directed to use a Hoyer lift for all transfers. The Resident Care Plan dated 1/13/25 identified Resident #1 needed assistance with mobility and activities of daily living. Interventions directed to transfer via a mechanical lift with the assistance of two (2) and assist of two (2) for care. The nurse's note dated 1/16/25 at 8:08 PM identified new skin tears were noted on Resident #1's right hand that measured 3 x 2 centimeters (cm), a 1 x 2 cm to the right arm and a 1 x 2 cm to the left hand, the areas were cleaned with normal saline, no active bleeding was noted, and the Advanced Practice Registered Nurse (APRN) was notified. The nurse's note dated 1/16/25 at 10:00 PM identified a skin tear was noted to the back of the head that was 2 cm long, the area was cleansed, bacitracin ointment was applied and the APRN was notified. The nurse's note dated 1/17/25 at 5:47 AM identified a light discoloration noted in the medial aspect of the right thigh and no pain was noted. The nurse's note dated 1/22/25 at 3:31 PM identified Resident #1 reported pain during care. At 4:17 PM very faint fading bruising was noted to the left outer thigh and knee, fading yellow/green bruising to the left pubic region, the APRN was updated, and stat x-ray of the bilateral hips and femurs was ordered. The nurse's note dated 1/22/25 at 9:02 PM identified Resident #1 had sustained an acute fracture of the left intertrochanteric hip, due to Resident #1's age, [AGE] years old, the family declined hospital transfer and to keep Resident #1 comfortable. Interview with the 7AM-3PM charge nurse, Licensed Practice Nurse (LPN) #1, on 2/6/25 at 10:51 AM identified residents are transferred via mechanical lift with the assist of two (2). LPN #1 stated she worked the day shift on 1/16/25 and Resident #1 had no new areas of skin breakdown of the upper extremities or bruising. Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #3, on 2/6/25 at 11:30 AM identified she cared for Resident #1 on 1/16/25 and there were no new skin tears or bruising noted. Interview with the Director of Nursing (DON) on 2/6/25 at 11:39 AM identified on 1/17/25 the 3-11PM charge nurse, Registered Nurse (RN) #1, reported Resident #1 had new skin tears to the upper extremities, a laceration to the back of the head and a bruised inner left thigh that were sustained on 1/16/25 during the 3-11PM shift. The DON identified during the investigation, the 3-11PM nurse aide, NA #6, reported on 1/16/25 at 6:32 PM she did not have assist from another staff member when transferring Resident #1 back to bed using the mechanical lift and denied any knowledge of how Resident #1 sustained the injuries. The DON stated at the conclusion of the investigation NA #6 was no longer employed at the facility. Review of the Lifting Machine, using a mechanical dated 7/2017 identified at least (2) nursing assistants are needed to safely move a resident with a mechanical lift. Although attempted, an interview with the evening charge nurse, RN #1, was unsuccessful. Although attempted, an interview with the evening nurse aide, NA #6, was unsuccessful. The facility identified the deficient practice and developed an immediate plan of correction: Resident #1 has been changed to a full body mesh lift pad from a split leg pad and is now an assist of two (2) with care. A house wide audit was conducted of all residents identified as a Hoyer lift transfer to ensure reflected transfer status was on the resident care card. The facility has completed in-servicing and competencies with all working clinical staff on the mechanical lift. A house wide audit conducted on all Reportable Events to review for proper classification for the past thirty days. Findings and trends will be reviewed at QAPI meetings monthly. Date of compliance 1/20/25.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for activities of daily living and diabetes management, the facility failed to ensure a baseline care plan was implemented for a resident who required assistance with activities of daily living and had type 2 diabetes mellitus with hyperglycemia. The findings include: Resident #2 had diagnoses that included need for assistance with personal care, type 2 diabetes mellitus type with hyperglycemia The nursing admission evaluation dated 12/13/24 at 3:56 P.M. completed by LPN #2 identified Resident #2 has an amputation to h/her right lower leg and Resident #2 requires extensive assistance with transfers. Review of Occupational Therapist Assistant (OTA) #1's summary of daily skilled services dated 12/15/24 at 1:31 P.M. identified for Resident #2 use Hoyer at this time for h/her safety as well as the safety of staff due to frequent falls at home and the hospital. OTA #1 identified Resident #2's had poor sitting balance during ADLS, Resident #2 was unable to stand and Resident #2 was unable to participate in toileting. The Physical Therapy (PT) evaluation dated 12/16/24 at 2:22 P.M. completed by PT #1 identified Resident #2 requires moderate assistance with 2 for transfers and requires moderate assistance with bed mobility. Review of the Resident #2's 72-hour meet and greet admission meeting form dated 12/16/24 completed by SW #2 identified Resident #2 required rehabilitation services for bed mobility, gait, needed devices, need for assistance, strengthening, ADL/self-care, impaired vision/hearing, and cognitive abilities. The admission MDS dated [DATE] identified Resident #2 had a Brief Interview for Mental Status score of twelve (12) indicative of moderately impaired cognition, rejection of care behavior occurring one (1) to three (3) days, always incontinent of bowel, occasionally incontinent of bladder, required moderate assistance with personal hygiene, transfers, and non-ambulatory. The MDS dated [DATE] further identified Resident #2 received insulin injections 6 days during the last 7 days and Resident #2 is taking high-risk drug classes which included hypoglycemics. The care plan dated 12/13/24 to 12/27/24 failed to reflect documentation that identified Resident #2 required assistance with ADLs. a) The physician's order dated 12/16/24 directed to provide the assistance of one with ADLs and transfers with Hoyer lift. Interview with OT #1 on 1/23/25 at identified Resident #2 required moderate assistance with ADLs, with transfers required the assistance of two with use of a Hoyer lift, and Resident #2 was non-ambulatory. b. Review of physician's orders dated 12/13/24 directed to administer Ozempic (medication for diabetes mellitus) 2 mg/3ml 0.5 mg once a day on Monday, Toujeo solostar U-300 (insulin glargine ) 300 unit/ml (medication used for diabetes mellitus) 1.5 ml /80 unit at bedtime, Glimepiride (medication used for diabetes mellitus) 4 mg twice per day at 9:00 A.M. and 5:00 P.M., Actos (medication used for diabetes mellitus) 30 mg once per day, and administer Lispro insulin (medication used for diabetes mellitus) 100 unit/ml subcutaneously before meals and at bedtime per sliding scale: Blood Glucose (BG) is below 70, call MD. BG 150-200 administer 8 units. BG 201-250 administer 10 units. BG 251-300 administer 12 units. BG 301-350 administer 14 units. BG 351-400 administer 16 units. BG 401-450 administer 18 units. BG 451-500 administer 18 units. If BG is greater than 500, call MD. Review of the baseline care plan failed to address the for the assistance with ADLs and diabetes management. Interview and clinical record review with DNS on 1/23/25 at 12:10 P.M. identified the expectation is when a resident is admitted a baseline care plan is developed and implemented to meet the resident's needs within 72 hours. The DNS identified her expectations are the care plan would be implemented to identify ADL status and disease management. The DNS identified Resident #2 should have had a care plan developed and implemented for ADLs and for diabetes mellitus. Review of facility baseline care plan policy identified a baseline plan of care to meet the resident's immediate needs shall be developed for each resident on admission. The interdisciplinary team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the residents' immediate care needs including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for diabetes management, the facility failed to ensure the medical record was complete and accurate to reflect treatment of hypoglycemia. The findings include: Resident #2 had diagnoses that included need for assistance with personal care, type 2 diabetes mellitus type with hyperglycemia, abnormalities of gait and mobility, repeated falls, acquired absence of right below knee amputation, and generalized muscle weakness. The admission MDS dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of twelve (12) indicative of moderately impaired cognition, moderate assistance with ADLs The MDS and insulin injections 6 days during the last 7 days and Resident #2 was taking high-risk drug classes which included hypoglycemics. The physician's orders dated 12/20/24 directed to administer Ozempic (medication for diabetes mellitus) 4 mg/3 ml 1 mg every Monday at 9:00 A.M., Toujeo solostar U-300 (insulin glargine ) 300 unit/ml (medication used for diabetes mellitus) 60 units once per day at bedtime, Glimepiride (medication used for diabetes mellitus) 4 mg twice per day at 9:00 A.M. and 5:00 P.M., Actos (medication used for diabetes mellitus) 30 mg once per day, administer Glucagon 1mg as needed if blood sugar is under 60 and the resident is unable to take anything by mouth, and administer Lispro insulin (medication used for diabetes mellitus) 100 unit/ml subcutaneously before meals and at bedtime per sliding scale Blood Glucose (BG) is below 70, call MD. BG 150-200 administer 8 units. BG 201-250 administer 10 units. BG 251-300 administer 12 units. BG 301-350 administer 14 units. BG 351-400 administer 16 units. BG 401-450 administer 18 units. BG 451-500 administer 18 units. If BG is greater than 500, call MD. a) Review of Resident #2's Vitals Report dated 12/20/24 at 8:52 A.M. identified LPN #2 recorded Resident #2's blood sugar as 36. Review of Resident #2's Medication Administration Record (MAR) dated 12/20/24 at 8:53 A.M. LPN #2 administered Glucagon solution 1 mg to Resident #2 and the result was effective. Review of Resident #2's Vitals Report dated 12/20/24 identified LPN #2 did not recheck Resident #2's blood sugar until 11:37 A.M. and recorded Resident #2's blood sugar as 149. b) Review of Resident #2's Vitals Report dated 12/21/24 at 8:56 A.M. identified LPN #2 recorded Resident #2's blood sugar as 51. Review of Resident #2's Vitals Report dated 12/21/24 identified LPN #2 did not recheck Resident #2's blood sugar until 11:35 A.M. and recorded Resident #2's blood sugar as 70. c) Review of Resident #2's Vital Report dated 12/22/24 at 9:04 A.M. identified LPN #2 recorded Resident #2's blood sugar as 41. Review of Resident #2's Medication Administration Record (MAR) dated 12/22/24 at 9:05A.M. LPN #2 administered Glucagon solution 1 mg to Resident #2 and the result was effective. Review of Resident #2's Vitals Report dated 12/22/24 identified LPN #2 did not recheck Resident #2's blood sugar until 12:24 P.M. and recorded Resident #2's blood sugar as 60. The nurse's note dated 12/22/24 at 2:34 P.M. written by LPN #2 identified Resident #2's blood sugar this morning was 41, glucagon was administered, and blood sugar was 52. Resident #2 ate breakfast and she rechecked Resident #2's blood sugar at 11:30 A.M. with a result of 60. RN #1 was notified and will notify the APRN. The nurse's note dated 12/22/24 at 4:26 P.M. written by RN #1 identified Resident #2 ate breakfast and lunch and had 2 boosts (oral supplement) for dinner. RN #1 identified Resident #2's blood sugar before dinner was 68 and Resident #2 had no signs or symptoms of hypoglycemia. RN #1 indicated Resident #2's Toujeo and Glimepiride will be held. The physician's orders dated 12/22/24 directed to hold Toujeo and Glimepiride evening doses. The nurse's note dated 12/22/24 at 6:40 P.M. written by LPN #4 identified Resident #2's blood sugar was 60 and Resident #2 did not eat supper. LPN #4 identified Resident #2 has 2 boost beverages and has no signs or symptoms of hypoglycemia. Review of Resident #2's Vitals Report identified Resident #2's blood sugar was not obtained again until 12/23/24 at 8:02 A.M. by LPN #2 and Resident #2's blood sugar was 49. d) Review of Resident #2's Vitals Report identified on 12/23/24 at 11:51 A.M. LPN #2 recorded Resident #2's blood sugar as 37. The nurse's note dated 12/23/24 at 1:49 P.M. written by RN #2 identified she was updated by LPN #2 that Resident #2's blood glucose levels over the weekend ranged between 26-189 and Resident #2 had no signs or symptoms of hypoglycemia. RN #2 identified she notified APRN #2, verbal orders obtained to hold Glimepiride and decrease Toujoe to 50 units once a day at bedtime. The physician's orders dated 12/23/24 directed to administer Toujeo solostar U-300 (insulin glargine ) 300 unit/ml (medication used for diabetes mellitus) 50 units once per day at bedtime and discontinue Glimepiride 4 mg. Review of Resident #2's Vitals Report dated 12/23/24 at 7:07 P.M. identified LPN #4 recorded Resident #2's blood sugar as 67 and at 8:58 P.M. LPN #4 recorded Resident #2's blood sugar as 72. e) Review of Resident #2's Vitals Report dated 12/24/24 at 4:36 P.M. identified LPN #3 recorded Resident #2's blood sugar as 64. Interview with LPN #2 on 1/23/25 at 8:15 A.M. identified when Resident #2's blood sugars were below 60 on 12/20/24, 12/21/24, 12/22/24, 12/23/24, and on 12/24/24 she indicated Resident #2 alert and did not exhibit any signs or symptoms of hypoglycemia. LPN #2 indicated when Resident #2's blood sugars were 60 or below she gave Resident #2 two (2) boost nutritional shakes and Resident #2 drank both shakes. LPN #2 indicated after Resident #2 drank the shakes she would wait 15 minutes and always recheck Resident #2's blood sugar and notify the RN supervisor. LPN #2 identified she is responsible for recording resident's blood sugar readings in the resident's Vitals report. LPN #2 identified although she rechecked Resident #2's blood sugar levels anytime h/her blood sugar was below 60 she forgot to enter the blood sugar results in Resident #2's clinical record. Interview with RN #2 on 1/23/25 at 9:25 A.M. identified she was notified by LPN #2 on 12/20/24, 12/22/24, and 12/23/24 that Resident #2's blood sugars were below 60. RN #2 identified LPN #2 would notify her within 30 minutes that she rechecked Resident #2's blood sugar and Resident #2 was stable. RN #2 identified the charge nurses are responsible for entering blood sugars readings in the resident's Vitals report or by writing a nurse's note. RN #2 indicated on 12/20/24, 12/22/24, and 12/23/24 she did notify APRN #2 when Resident #2's blood sugars were under 60. RN #2 identified she did not write nurse's notes in Resident #2'clinical record every time she updated APRN #2, because she wrote notes on the supervisor's reports. Interview with APRN #2 on 1/23/25 at 11:10 A.M. identified she was aware of Resident #2's low blood sugar readings. APRN #2 indicated when Resident #2's blood sugars were below 60, RN #2 notified her. APRN #2 identified multiple medication changes were made to address Resident #2's low blood sugars. Interview and clinical record review with the DNS on 1/23/25 at 12:10 P.M. unable to reflect on 12/20/24, 12/21/24, 12/22/24, 12/23/24, and 12/24/24 LPN #2, LPN #3, and LPN #4 what interventions were implemented when Resident #2's blood sugars were under 60, that the provider was notified, and Resident #2's blood sugars were rechecked within 15 minutes and what the results were. The DNS identified the expectation is when a resident's blood sugar is under 70 the nurse administers juice, health shakes, or a snack to the resident, notifies the supervisor or APRN, rechecks the resident's blood sugar in 15 minutes and documents in the clinical record the blood sugar result. The DNS identified when Resident #2's blood sugars were below 70 the nurses LPN #2, LPN #3, and LPN #4 should have written a nurse's note to identify what Resident #2's blood sugar reading was, how they treated the hypoglycemia, Resident #2's response, and obtained another blood sugar in 15 minutes documented the follow-up blood sugar reading in Resident #2's clinical record. Review of the facility management of hypoglycemia policy dated 9/1/2022 identified management for level 1 hypoglycemia is to give the resident an oral form of rapidly absorbed glucose, notify the provider immediately, remain with the resident, recheck the blood glucose in 15 minutes and document the resident's blood glucose before the intervention, note blood sugar after each administration of rapid-acting glucose and the follow up blood sugar, and document any provider instructions.

Based on observation, review of facility documentation, facility policies, and interviews, the facility failed to ensure dietary staff monitored food temperatures prior to meal service. The findings include: Review of the Service Line Checklists dated 12/1/24 through 1/12/25 failed to identify food temperatures had been obtained on the steam table, prior to plating dinner service on the following dates: 12/2/24, 12/23/24, 12/25/24, 12/31/24, 1/1/25, 1/2/25, and one undated checklist. Observation and interview with [NAME] #1 on 1/14/25 at 11:15 AM, during lunch service plating, identified that once all the food is on the steam table and ready to be plated, he obtains a temperature reading on each item to ensure the food is at the correct temperature. Interview with the Dietary Manager on 1/14/25 at 11:20 AM identified that she was aware that the Service Line Checklists dated 12/2/24, 12/23/24, 12/25/24, 12/31/24, 1/1/25, 1/2/25, and one undated form, were not completed. The Dietary Manager indicated that when she identified the missing documentation for temperatures on the checklist, she intended to speak with the cook that was responsible for documenting the missing temperatures, but it had been a busy month, and she had not had the opportunity to follow up with the cook responsible for the missing entries. The Dietary Manager identified that she was very involved in what happens on the food service line and that she believes that the cook most likely obtained the food temperatures but did not write them down. The Dietary Manager further indicated that even though the temperature fields, on the identified days, were left blank, the cooks were expected to obtain temperatures on all food items, including the alternative menu items, to ensure food safety and quality, and she expects the cooks to document all food temperatures on the Service Line Checklist for each meal. Interview and review of facility documentation with the Administrator on 1/14/25 at 1:38 PM identified he was unaware that Service Line Checklists dated 12/2/24, 12/23/24, 12/25/24, 12/31/24, 1/1/25, 1/2/25, and one undated form, were not completed, and that it was his expectation that the cook obtains and documents food temperatures for every single meal. The facility's Food Preparation and Service policy directs food and nutrition employees prepare and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food service. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services. The facility's Preventing Foodborne Illness-Food Handling policy directs food to be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1of 3 residents (Resident #39) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #39 had diagnoses that included hemiplegia/hemiparesis (weakness and paralysis) affecting the left, non-dominant side following a cerebral infarction (stroke) and history of seizures. The baseline care plan dated 12/23/24 identified Resident #39 had a functional rehabilitation potential and was at risk for falls. Interventions included to provide the necessary set up cueing support/assistance to carry out activities of daily living. The admission MDS dated [DATE] identified Resident #39 was cognitively intact, required substantial one person assist with bed mobility, two-person assist with transfers using a mechanical lift and set up assist with eating. Interview with Resident #39 on 1/12/25 at 9:07 AM identified he/she was finishing up an afternoon meal recently and asked a nurse aide (NA #12), for a food item. NA #12 told the resident he/she was not from an African American [NAME] and therefore did not understand food deprivation and that Americans get whatever they want. Resident #39 felt NA #12 was disrespectful. Interview with NA #12 on 1/13/25 at 10:59 AM identified that although he denied making the specific statement to Resident #39 and was only speaking of his own chartable work, he did recall that at one time, Resident #39 requested various food items while he was providing the resident his/her meal tray. NA #12 asked Resident #39 why he/she doesn't eat the meal tray first before eating cookies. NA #12 returned sometime later after the meal and provided one food item and that nothing else was mentioned. Interview with the DNS on 1/13/25 at 3:16 PM identified NA #12 informed the DNS that he told the resident to eat the food first before getting cookies as the meal was more filling. Verbal education was provided to NA #12 regarding customer service as the resident had the right to have preferences regarding what he/she ate. NA #12 was removed from providing any further care to Resident #39. A review of the facility policy for Resident Rights directed that employees shall treat all residents with kindness, respect and dignity including self-determination.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #45) reviewed for care planning, the facility failed to consistently hold interdisciplinary resident care conferences and invite the resident to participate. The findings include: Resident #45 was admitted to the facility in November 2020 with diagnoses that included chronic embolism and thrombosis of deep veins of left lower extremity, history of falls, major depression, poly neuropathy and seizures. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition, was independent for dressing, toileting, and personal hygiene. Additionally Resident #45 participated in assessment. The care plan dated 3/26/23 identified code status with interventions to review quarterly and as needed with Resident #45. Review of the clinical record 4/13/23 to 10/10/24 identified the last quarterly interdisciplinary care conference was held on 4/13/23, over a year and a half ago, which included a recreation person, a social worker, and Resident #45. Six quarterly interdisciplinary care conferences were not held. Interview with Resident #45 on 1/12/25 at 10:20 AM indicated that he/she has not meet with the interdisciplinary team for a care conference in about 2 years. Resident #45 indicated that the facility used to have those meetings but did not know why the facility stopped having them. Resident #45 indicated that if they had the quarterly interdisciplinary care conference, he/she would want to attend, again. Interview with RN #7 (MDS coordinator) on 1/13/25 at 8:54 AM indicated that she had worked at the facility as the MDS coordinator for the last 9 years. RN #7 indicated that she creates the MDS schedule every month for the quarterly, annual, and significant change in condition MDS's. RN #7 indicated that the quarterly and annual interdisciplinary care conferences were scheduled by the social worker based off the MDS calendar each month. RN #7 indicated that the social worker must call or see each resident and resident representative to schedule that month's interdisciplinary care conference that are due. RN #7 indicated that the social worker must schedule the care conference at a time that is convenient for the resident and resident's representative so they can attend. RN #7 indicated that she was aware that she was expected to attend the care conferences, but she rarely attends any of the care conferences because she does not have the time to attend them. RN #7 indicated that the last couple of years she has not had the time to attend those meetings. RN #7 indicated that she has asked the Administrator many times over the last couple of years for a second person in her department so she would be able to attend the meetings, but that has not occurred. RN #7 indicated that the whole team should attend the quarterly interdisciplinary care conferences including the social worker, a floor RN, therapy if resident is on therapy, the dietitian (but she is only in the facility 2 days a week), and the MDS person. RN #7 indicated that she had to cut something out to get everything done so she stopped attending about 2 years ago. Interview with SW #1 on 1/13/25 at 9:10 AM indicated that the MDS coordinator was responsible to make the monthly calendar for who was due for a care conference. SW #1 indicated that it was her responsibility and her part time social worker to speak with residents and call resident representative to schedule each month's care conferences based on their schedules. SW #1 indicated that the resident care conference should include the resident, resident representative, social worker, MDS coordinator, recreation, dietitian, and the nurse responsible for that unit the resident is on. SW #1 indicated that the social worker attending the meeting was responsible to have all attendees sign in and then write a note in the electronic medical record of who attended and what was discussed. SW #1 indicated that the nurse's aide assigned to the resident does not get invited to attend. SW #1 indicated that she did not have any sign in sheets for Resident #45 for his/her resident care conferences. After review of the clinical record, SW #1 indicated that for each quarterly and annual meeting scheduled for Resident #45 since 4/13/23, only the social worker attended and no one else attended and that does not meet the requirement of a quarterly or annual interdisciplinary resident care conference. SW #1 indicated that Resident #45 was scheduled on 1/9/25 for a interdisciplinary resident care conference, but only she had meet with Resident #45, not the interdisciplinary team. SW #1 indicated she had brought to the attention of the Administrator and DNS during a morning report with all management present that all staff that should be attending were not. SW #1 indicated that the last time she brought this to their attention was October 2024. SW #1 indicated she was documenting that the interdisciplinary resident care conferences were being conducted but it was only a one-on-one meeting with her or the other social worker. Review of the Care Plans, Comprehensive Person-Centered Policy identified 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 interdisciplinary team in conjunction with the resident or resident representative develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team includes the attending physician, a registered nurse, a nurse's aide who is responsible for that resident, a member of the dietary services staff, the resident and resident representative, and other appropriate staff or professionals as determined by the resident's needs or requested by the resident. The resident has the right to participate in his/her plan of care., including the right to participate in the planning process, identify individuals or roles to be included in meetings, request meetings, request revision of the plan of care, participate in establishing the expected goals and outcomes of care, participate in determining type, amount, frequency, and duration of care. Resident has the right to see the care plan and sign it after significant changes are made. The care plan process will facilitate resident and/or resident representative involvement. The interdisciplinary team must at least quarterly review and update the care plan. The resident has the right to participate in this development of his/her care plan. Review of the Care Planning identified the interdisciplinary team was responsible for the development of a resident's individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a care planning interdisciplinary team which includes: the attending physician, the registered nurse who is responsible for the resident, the dietitian or dietary manager, the social worker, the activities director, therapies if applicable, consultants as appropriate, the DNS if appropriate, the charge nurse responsible for the resident, the nurses aide responsible for the residents care. The resident, resident's representative are encouraged to participate in the development and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and resident representative.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #44) reviewed for advance directives, the facility failed to inform the resident/resident representative of their rights upon admission. The findings include: Resident #44 was admitted to the facility in September 2024 with diagnoses that included stroke, gastrostomy placement, and dysphagia. The care plan dated 10/1/24 identified Resident #44 had impaired cognition related to a stroke, including being nonverbal. Interventions included to report any concerns or changes to the resident representative. A social work admission note dated 10/3/24 at 11:03 AM identified an admission care conference meeting was held with Person #1 (resident representative) related to the admission and included a review of medical and psychiatric history, current status, care plan, and goals of treatment. The admission MDS dated [DATE] identified Resident #44 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with bathing, Interview with Person #1 on 1/12/25 at 9:49 AM identified the facility had not reviewed any documentation related to Resident #44's admission to the facility. Person #1 identified that upon Resident #44's admission, and with all subsequent communication with facility staff following admission, the facility at no time reviewed or requested a review of any documents related to admission. Person #1 identified they hadn't asked him/her to sign any paperwork since admission and questioned if they had any paperwork on file and how they were being paid if no one signed paperwork. Review of the clinical record on 1/12/25 identified blank admission documents including a consent to treatment, authorizing medical treatment by providers, a personal item inventory list, a consent for use of side rails, leave of absence policy no smoking policy; consent and request for audiology services including billing, payment criteria, authorization to share protected health care information, consent and request for supportive care services including billing, payment criteria, and authorization to share protected health care information, and consent and education for pneumococcal and influenza vaccinations. Further the record did not have a signed admission agreement. The Admission Agreement was in the clinical record and included Resident #44's name. Further, admission agreement documentation was in the clinical record, unsigned, undated and blank, and included the following. Review of treatment and services. General provisions for payment. Compliance with facility policies. Resident charge rates for services and charges for non-covered services. Medicare pay rates and authorizations. Privacy waivers, privacy consents. Right to refuse treatment. Medications obtained and administered by the facility. Involuntary discharge, emergency discharge, alternate placements. Bed hold. Facility liability related to the resident's care and services. Facility's right to change, amend, or alter the admission agreement at any time with 30 days written notice to the resident or resident representative. Interview with the Admissions Director on 1/15/25 at 8:52 AM identified that she was responsible for reviewing the admission agreement documentation with all newly admitted residents or the resident representative upon admission to the facility. The Admissions Director identified she wrote notes on the admission documents indicating her attempts to reach Person #1 on 9/28, 10/2, and 10/14 but did not speak with him/her and did not make any additional attempts. The Admission Director identified she did not speak with the DNS or Administrator to notify them that she did not reach Person #1 to review the admission agreement and identified since she reached out via phone with no return calls, she did not make any additional attempts. The Admission Director identified that the admission agreement document reviewed the specifics related to admission and care at the facility, including administrative processes related to billing, bed holds, and charges incurred outside of insurance paid services. Interview with the DNS on 1/15/25 at 9:38 AM identified that it was the responsibility of the admitting nurse to ensure that the clinical admission paperwork was completed within 48 hours of a resident's admission to the facility. The DNS identified that the timeframe for completion was based on when a resident was admitted to the facility (i.e. nights, weekends, etc.) and if the admitting nurse was unable to complete the paperwork with the resident or a resident representative, the nurse was responsible to report off to the next oncoming nurse to ensure that the paperwork was completed. The DNS identified that she had been able to reach and speak with Person #1 multiple times since Resident #44's admission and Person #1 had also been in the facility to visit Resident #44 so the admission paperwork should have been done. The facility admission agreement directed that the agreement was a legally binding contract between and amongst the resident and resident parties, and the resident parties acknowledged that they wanted the residents to be admitted and receive services provided by the facility. The agreement further directed that by signing, the facility and resident parties were legally bound by it. The facility policy on resident rights directed that residents of the facility were guaranteed certain basic rights that included the right to be informed of rights and responsibilities, be informed of, and participate in treatment.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident, (Resident #35), reviewed for accidents, the facility failed to ensure adequate supervision while the resident was seated on the toilet to prevent a fall with subsequent femur fracture. The findings included: Resident #35 was admitted to the facility with diagnoses that included dementia with behavioral disturbance, major depression, right femur necrosis and generalized muscle weakness. A fall risk assessment dated [DATE] identified Resident #35was at high risk for falls due to history of falling and impaired gait. The quarterly MDS dated [DATE] identified Resident #35 had impaired cognition, required extensive assistance for bed mobility, total 2-person assistance for transfers, did not ambulate in room or on unit and utilized a wheelchair for locomotion on the unit. Additionally, Resident #35 was dependent for toileting. The care plan dated 12/6/21 identified Resident #35 was at risk for falls due to history of falls, cognitive impairment and decreased mobility due to right femur necrosis. Interventions included to ensure call light was in reach and to wear appropriate foot footwear. Additionally, the care plan identified Resident #35 had cognitive impairment with interventions to always provide safety and use simple, direct communication. A physician's order dated 12/18/21 directed 2 staff for transfers with a slide board bed to wheelchair and 2 staff with a functional squat pivot from wheelchair to toilet. The nursing care card dated 12/18/21 identified Resident #35 required 2 staff for transfers with a slide board bed to wheelchair and 2 staff with a functional squat pivot from wheelchair to toilet. An SBAR Communication form dated 1/8/22 identified that Resident #35 had an unwitnessed fall. The reportable event form dated 1/8/22 identified Resident #35 fell as he/she was trying to get up and sustained a contusion to the left eyebrow and a fracture of the left hip. The nurse ' s note dated 1/8/22 at 3:30 PM identified Resident #35 was observed lying on the left side in the bathroom, stating that he/she had tried to get up and fell . Resident #35 hit his/her head and bleeding was noted over left eyebrow. An x-ray report dated 1/9/22 at 8:52 PM identified Resident #35 had a left hip impaction fracture with mild displacement, appearing acute. The nurse ' s note dated 1/9/22 at 10:32 PM identified Resident #35 was status post fall day 1 and was sitting in the dining room when he/she started to scream in pain. An x-ray was taken and came back positive for a hip fracture. Subsequently, Resident #35 was transferred to hospital. The hospital discharge summary dated 1/14/22 at 8:34 AM identified Resident #35 was admitted on [DATE] with diagnosis of closed sub capital fracture of the left neck of the femur. Resident #35's presented after a mechanical fall and hip pain with a cat scan on 1/10/22 identifying a complex femoral neck fracture that required surgical repair on 1/11/22. An APRN progress note dated 1/17/22 at 9:18 AM identified that Resident #35 was readmitted to the facility after being sent to the hospital for evaluation of a left hip fracture that was repaired. Interview with LPN #3 on 9/20/22 at 10:00 AM identified that she was assigned and had toileted Resident #35 on 1/8/22. As LPN #3 was exiting the bathroom, LPN #3 saw NA #1 in the hall. LPN #3 called out to NA #1 to report that she had gotten Resident #35 on the toilet. LPN #3 did not recall if NA #1 entered Resident #35's room prior to her exiting, but she did recall that she proceeded to attend to another resident who needed a dressing change. LPN #3 stated that she believed NA #1 heard her and that NA #1 was going to take care of Resident #35 while in the bathroom. LPN #3 indicated she responded to Resident #35's room after hearing a call for help, seeing NA #1 and NA #2 in the bathroom with Resident #35 and that Resident #35 was on the bathroom floor. After the supervisor evaluated the resident, Resident # 35 was transferred with a mechanical lift back to bed. Interview with NA #1 on 9/20/22 at 11:45 AM identified that she had been assigned to Resident #35 on 1/8/22 and was returning from her break. NA #1 stated that LPN #3 saw her in the hallway and stated that she had put Resident #35 in the bathroom. NA #1 indicated that she started back to her resident's rounds believing that LPN #3 had toileted the resident and was all set. NA #1 indicated that within a few minutes she heard NA #2 calling out for help in Resident #35's room and when she arrived, she saw Resident #35 on the floor in the bathroom. NA #1 routinely cared for Resident #35 and indicated that Resident #35 should not have been left alone on the toilet as he/she was confused and may not use the call light. NA #1 identified that Resident #35 could not transfer him/herself and needed a lot of assistance from staff to transfer from wheelchair to toilet and then back. NA #1 indicated that there was a miscommunication between she and LPN #3 resulting in Resident #35 being left alone in the bathroom while on the toilet. Interview with RN #1 on 9/20/22 at 2:00 PM identified that she responded to Resident #35's room when notified of the fall. Resident #35 was on the floor in the bathroom and that it was an unwitnessed fall; no one was with the resident when the fall occurred stating that the resident attempted to self- transfer. Interview and review of Resident #35's reportable event form with the DNS on 9/21/22 at 9:57 AM identified that if the fall was unwitnessed it meant that staff were not observing Resident #35 prior to the fall. The DNS identified that Resident #35 was a max assist of 2 staff with a slide board transfer for bed to wheelchair and assist of 2 staff for a squat pivot transfer to bathroom. The DNS indicated with Resident #35's dementia diagnosis she would have expected a staff member to supervise, not needing direct supervision but to be in the area when Resident #35 was toileted to monitor. Interview with the Director of Rehab Therapy on 9/21/22 at 9:35 AM identified that the therapy service was new starting in January and did not treat Resident #35 prior to the fall on 1/8/22 and although requested, she could not provide therapy documentation from the previous therapist. In reviewing Resident #35's physician's transfer orders in place at the time of Resident #35's 1/8/22 fall directed that Resident #35 required a bed to wheelchair sideboard transfer with an extensive assistance of 2 staff members to wheelchair and an assist if 2 staff members to squat and pivot to the toilet. The Director of Rehab indicated Resident #35 should have been supervised after transfer to the toilet. In general, any resident who requires an assist of 2 for transfer to the toilet, would require supervision while on the toilet. Interview with NA #2 on 9/26/22 at 9:20 AM identified that she was on Resident #35's unit on 1/8/22 and recalled be assigned as a float to assist as needed for resident care. NA #2 had been checking rooms and saw that Resident #35 was on the floor in the bathroom. NA #2 identified that there were no other staff in Resident #35's room, or near the bathroom and upon finding Resident #35, she immediately called for help. NA #2 indicated that she cared for Resident #35 on occasion and knew that staff needed to stay with Resident #35 when he/she was toileted or at least in the room to monitor Resident #35 as the resident was often confused. The Falls Management policy directs that the facility would identify hazards, resident risk factors and implement interventions to minimize falls.

Based on observations, clinical record review, review of facility documentation and interviews for one of one sampled resident reviewed for dysphagia and/or behaviors (R#139), the facility failed to provide adequate supervision and/or an environment free of hazards for the resident who required a specialized diet and direct supervision with feeding resulting in finding of immediate jeopardy and for one of six residents reviewed accidents (R#139), the facility failed to ensure that the alarms initiated to prevent falls, were tested and/or functioning. The findings include: The findings include: 1. Resident #139's [DIAGNOSES REDACTED]. The 30 day MDS assessment dated [DATE] identified the resident had moderately impaired cognition and was dependent on staff for eating. The In-service Meeting Minutes dated 9/14/17 through 9/22/17 that were observed on 10/10/17 posted at the nursing station, identified that due to the resident's impulsive self- feeding, food must be out of reach and resident is not to be left alone with food nearby. A review of the staff signature sheet identified that NA #2 (who was assigned on 10/10/17 to the dining room) had not signed the in-service attendance and/or indicated having reviewed the directions. The Resident Care Plan dated 9/18/17 identified the resident had an alteration in nutrition including an aspiration risk and unsafe self- feeding with impulsive behaviors. Interventions included to provide a dysphagia ground diet, total feeding assistance from staff, and to refer to the speech language pathology protocol. Speech Therapy Orders dated 9/29/17 identified that no food or liquids were to be left in front of the resident unattended and that the resident was a total feed for all food, liquid and medications. Speech Therapy Discharge Summary dated 9/29/17 identified the resident required total assistance with feeding with food kept out of reach. Resident was to be fed 1 sip and 1 teaspoon at a time and no food or drink was to be left in reach of the resident as he/she is impulsive and unsafe with self-feeding. Observation on 10/10/17 at 10:45 AM identified Resident #139 was sitting in a wheelchair in the 2nd floor dining room with his/her back to the door. The resident was positioned next to a table that had a plate with approximately 4-6 dinner rolls on it. The plastic wrap was pulled back from the plate and Resident #139 was observed with a roll in his/her hand. LPN #1 was present at the time, told the resident that he/she should not have the rolls and removed the plate as well as the roll from the resident's hand and exited the dining room. As the Surveyor went around to the front of the wheelchair, the resident was noted to have an expiratory wheeze, followed by a cough which resulted in the resident expectorating a piece of the dinner roll. Review of the medical record noted orders for a dysphagia ground diet. The Surveyor informed LPN #1, who had left the resident in the dining room without conducting any evaluation after the resident had consumed and coughed up some of the bread. At approximately 10:47 AM, LPN #1 and the Surveyor entered the dining room and observed the resident to have a ball (approximately the size of a baseball) of soggy, semi chewed bread on his/her chest. The Resident indicated that he/she threw up the bread. Resident #139 then coughed up another small piece of bread (approximately 1 inch in length). LPN #1 initiated an evaluation of the resident including vital signs, lung sounds and pulse oximetry and notified the RN Supervisor. Interview with the Food Service Director (FSD) on 10/10/17 at 11:00 AM identified the plate of rolls were sent up for the dinner meal on 10/9/17 and not today. Interview with NA#1 on 10/10/17 at 11:10 AM noted that s/he got the resident up around 10 AM. NA#1 indicated that the resident brought his/herself to the dining room and that the resident self-propels in the wheelchair all over the unit. Subsequent constant observation on 10/10/17 from 11:57 AM through 12:08 PM identified Resident #139 was positioned in his/her wheelchair at the dining room table with two other residents that had their trays in front of them and were eating. Both of the meal trays were within Resident #139's reach. NA #2 was alone in the dining room passing trays to other residents that were present. Interview with NA #2 on 10/10/17 at 11:58 AM identified that having Resident #139 positioned at the table with other resident's food within reach was not a safety issue. NA#2 stated that Resident #139 would not remove food from fell ow resident's trays. Observation on 10/10/17 at 12:08 PM identified LPN #2 entered the dining room and removed Resident #139 from the table and into the hallway. At this time, NA #1 wheeled the resident back into the dining room, set up the meal tray and proceeded to feed the resident. Interview with LPN #2 on 10/10/17 at 12:27 PM identified that he/she removed Resident #139 from the table for two reasons; first s/he felt bad that the resident was watching the other two residents eat and second, s/he did not want the resident to try to get something off of the other resident's trays. When LPN #2 was asked if that could be a concern, s/he along with the Infection Control Nurse both indicated that yes it was a concern because Resident #139 was so impulsive. The facility failed to ensure that the environment was free from accident hazards for Resident #139 who had dysphagia and that no food or drink was to be left in reach of the resident after the resident had access to rolls that were left in the dining room and when food was left within the resident's reach in the dining room resulting in a finding of immediate jeopardy. Review of the 15- minute check records for R#139 dated 10/10/17 noted they were blank from 7 AM through 11 AM when they were reviewed by the Surveyor. Subsequent to the incident, the physician was notified and ordered a STAT chest x-ray. The Radiology report dated 10/10/17 identified the resident had a left base minimal infiltrate. Interview with the Director of Nursing on 10/10/17 at 1:20 PM identified it would have been the responsibility of the nursing staff to ensure the dining room was cleared of all food items at the conclusion of the meal. The DNS indicated that the resident had been placed on 15 minute checks for a resident to resident incident. The above is a violation of the Regulations of Connecticut State Agencies Section 19-13-D8t(j)(2) and/or (m)(2).

Based on clinical record review, interviews and review of facility documentation for one of three sampled residents (Resident #106) reviewed for allegations of mistreatment, the facility failed to ensure the resident was free from misappropriation of property. The findings include: Resident # 106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified moderately impaired cognition, no behaviors and required extensive assistance of two staff members for bed mobility, dressing and personal hygiene. The care plan dated 12/18/15 identified resident has a history of misplacing items then making accusations that they were taken with interventions which included to encourage resident to the leave money in business office and encourage family not to bring in valuables. The reportable event form dated 12/18/15 identified the resident reported a nurse aide took her Visa card three weeks ago and has not returned it. The investigation identified the card had been recovered by the nurse aide in question and the allegation of misappropriation was substantiated. Interview with Resident#106 on 1/12/16 at 10:25AM identified he/she did not give NA#1 permission to take and/or use the credit card. The resident further identified that he/she did not report the incident right away because he/she thought NA#1 would return the credit card. Interview and review of the investigation with the ADNS on 1/12/16 at 12:00PM identified on 12/18/15 Resident #106 reported a credit card had been missing for three weeks and Resident #106 did not report it right away as he/she thought the nurse aide would return it. The ADNS identified the NA in question was not in duty at the time of the allegation however he/ she was scheduled for the next day which was a Saturday. The ADNS came to the facility at the beginning of NA#1's next scheduled shift and questioned him/her about the credit card. Initially NA #1 identified he/she knew nothing about the credit card and then changed the story and identified he/she returned it to the resident after he/she purchased candy for the resident. The ADNS informed NA#1 the resident reported the card missing at which time NA#1 checked her car and then returned home to look for the card. NA#1 returned to the facility a short time later with the credit card and was sent home pending investigation. The ADNS identified the police were notified and the facility was informed that there was over $400.00 of charges on the credit card. Multiple attempts to reach NA #1 were unsuccessful. A review of the facility abuse policy identified misappropriation of resident property as the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled (Resident #1) who were dependent on staff for bed mobility and/or repositioning, the facility failed to ensure that the resident care card reflected the appropriate number of staff required for bed mobility to provide adequate supervision to prevent an accident. The findings include: Resident #1's [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had no cognitive impairment, verbal behavioral symptoms directed towards others that put the resident at significant risk for physical illness or injury and disrupted care or the living environment, required extensive two person assistance with bed mobility (repositioning), was totally dependent on two staff for transfers, had a weight of 306 pounds and was non-ambulatory. Review of activities of daily living flow sheets from 4/1/14 through 4/7/14 identified that Resident #1 was dependent on two staff for bed mobility, (turning and repositioning) and bathing. The interim care plan dated 1/30/14 through 4/8/14 identified that the resident was at risk for physical injury from falls and was unable to complete activities of daily living. Interventions directed for staff to utilize a two person assist with transfers, bathing, and activities of daily living. The resident care plan dated 2/4/14 identified that the resident at risk for altered skin integrity. Interventions directed to assess the skin, incontinent care per policy and low air loss mattress. The nurse's note dated 4/8/14 identified that at 11:00 AM the charge nurse was called into the room by the Nurse Aide (NA). Resident #1 was noted to be kneeling beside the bed with the left knee on top of the overbed table bar and a large amount of blood underneath the knee. Resident #1 indicated to the charge nurse that she was on the side of the bed and slid off the bed onto his/her knees. Resident #1 was Hoyer lifted back to bed. The resident sustained [REDACTED]. Subsequent to physician notification Resident #1 was transferred to the hospital for an evaluation. The 4/8/14 at 11:30 PM nurse's note indicated that Resident #1 returned to the facility at 10:10 PM. The left toe area had five sutures and the left knee eleven sutures. Review of the facility's investigation dated 4/8/14 in a written statement NA #1 identified that while providing morning care Resident #1 was rolled onto his/her side. The resident was on the side and before NA #1 could roll the resident onto his/her back, Resident #1 slid off the bed on his/her knees. NA #1 indicated that she tried to hold the resident while calling for help but had to let go and slowly lower Resident #1 the rest of the way down to the floor and then get help. The Registered Nurse (RN) #1, 7-3 PM Supervisor, indicated in a written statement the nurse aide card did not specify the number of assist required for bed mobility. Review of the nurse aide care card dated 6/11/14 identified that on 4/8/14 a revision directed for two person assist with bed mobility after the fall. The care card had failed to reflect documentation of the significant change in status MDS assessment dated [DATE] that Resident #1 had required extensive two person assistance with bed mobility (repositioning). Interview with the Unit Manager, RN #1, on 6/17/14 at 1:30 PM identified that Resident #1 did require the assistance of two staff for bed mobility when being boosted in the bed and had required the assistance of one staff when activities of daily living were being provided. RN #1 was unable to provide documentation to support a change in the resident's plan of care. Interview with Resident #1 on 6/18/14 at 10:00 AM identified that when he/she slipped out of bed on 4/8/14 while being bathed with the assistance of one staff. Resident #1 identified that at that time two staff usually helped to roll him/her in bed and did not know why there was only one person on 4/8/14.

Based on clinical record review, observation and interview for one of four sampled residents reviewed for pressure ulcers, (R#73), the facility failed to implement measures to prevent the development of a pressure ulcer. The findings include: Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nursing Resident Evaluation Form also dated 11/30/13 identified a Stage 2 pressure ulcer on the left buttock, no notations of skin conditions existing of the bilateral heels, the resident requiring assistance with bed mobility and dependent with transfers and locomotion. The interim care plan dated 11/30/13 identified the resident at risk for break in skin integrity related to a Stage 2 pressure ulcer with interventions that included to elevate heels off the bed surface. The Braden scale dated 12/3/13 identified a score of 17, indicating the resident at risk for pressure sore development. A physical therapy note dated 12/03/13 indicated the resident complained of left heel pain and, upon assessment, was noted to have a darkened area. Nursing was notified and the resident was educated to elevate the heels off the bed on a pillow for complete unloading. Nursing assessment of the area dated 12/3/13 identified a 5.0 cm x 7.0 cm intact, purple, nonblanchable area with redness surrounding to the lower posterior aspect of the left heel. Physician order [REDACTED]. An admission MDS dated [DATE] identified the resident with intact cognition, requiring extensive assistance with ADL's, a Stage 2 pressure ulcer, and an unstageable DTI. A APRN note dated 12/7/13 indicated R#73 with a [DIAGNOSES REDACTED]. Interview with the DNS on 2/7/13 at 10:30 AM indicated R#73 is at risk for pressure ulcers and interventions are required to protect the heel. Although the interim care plan dated 11/30/13 included to elevate heels off bed, the pressure ulcer care card originally dated 11/30/13, was updated on 12/03/13 to offload heels when in bed. In addition, interview with Resident#73 on 2/7/13 at 1:45 PM indicated the resident was not educated to offload heels until after the injury was identified. Facility policy for care and prevention of pressure ulcer includes to use pressure reducing devices to relieve pressure and/or use elbow and heel protectors if needed.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for falls, the facility failed to ensure the resident was not left unattended in the bathroom which resulted in a fall with an injury. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #1 had severe cognitive impairments, short and long term memory deficits, required supervision for transfers and ambulating, limited one person assistance for toilet use, the resident's balance was not steady and only able to stabilize with staff assistance moving on and off the toilet and a walker was utilized for mobility. The resident care plan dated 8/18/13 identified that the resident was at risk for falls. Interventions directed to ambulate with assistance, sensor pad alarm to the bed, motion detector to the door of room, encourage the resident to ask for assistance to the bathroom and supervise the resident in the bathroom. The fall risk assessment dated [DATE] identified a score of 17 (10 or greater indicated at risk) therefore Resident #1 was at risk for falls. Review of the care card dated 5/13/13 directed that Resident #1 was not to be left unattended in the bathroom. Review of the Reportable Event Form dated 9/1/13 at 7:05 AM identified Resident #1 was found in a sitting position under the sink in the bathroom with his/her head leaning backwards and against the wall. Resident #1 had sustained a laceration to the occipital area that required ten staples for closure. Interview with Nurse Aide (NA) #5 on 1/27/14 at 2:40 PM identified that she had heard Resident #1's alarm and responded. Resident #1 indicated that he/she needed to use the toilet. NA #5 escorted Resident #1 to the bathroom and left the resident on the toilet. NA #5 indicated that she was under the impression Resident #1 was independent in the bathroom. NA #5 identified that she had been getting the specific information relative to the residents from another NA. Interview with the Director of Nurses (DON) on 1/28/14 at 11:30 AM indicated that Resident #1 was a high risk for falls and required alarms, therefore Resident #1 should not have been left unattended in the bathroom.

Based on clinical record review and staff interview for two of four sampled resident reviewed for pressure ulcers (R#156 and R#162), the facility failed to provide care and services to prevent the development of a pressure ulcer and/or monitor a pressure ulcer. The findings include: 1. Resident #156's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident as cognitively intact and requiring extensive assistance of two staff members for bed mobility, transfers and toileting. The MDS further identified the resident required extensive assistance of one staff member for dressing and personal hygiene. A care plan dated 1/3/13 identified a potential for alteration in skin integrity with interventions that included to complete a weekly body audit, encourage meals and a provide pressure relieving device for the bed and chair. a. Physical Therapy notes dated 2/11/13 identified the resident presented to therapy with a sneaker on the left foot without benefit of a sock, and with a slipper sock and sneaker on the right foot. The resident stated his/her compression stockings were missing. Upon skin inspection when removing the left shoe, PT indicated that the resident complained of pain and was noted to have a blister to the left posterior heel. Nurse's notes dated 2/11/13 on the 7:00 AM to 3:00 PM shift, identified that the resident did not have the compression stockings applied and the nurse aide applied the shoes on the resident's feet with out a sock. R#156 was noted with a 5.0 cm by 0.3 cm fluid filled blister to the left heel. Interview with NA# 1 on 2/27/13 at 3:00 PM identified that the resident's compression stockings were applied to the resident's roommate and indicated she informed the nurse that compression stockings were missing. NA#1 indicated that she attempted to place a gripper sock on the resident's feet and apply the sneaker and although the resident agreed to wear the gripper sock with sneakers to the right foot, he/she would only wear a sneaker to the left foot without the benefit of a sock. NA#1 further identified that she did not remember if the Charge Nurse was informed that the was resident wearing a sneaker without the benefit of a sock. Interview with LPN#1 on 2/28/13 at 8:57 AM identified that NA#1 informed her that R#156's compression stockings were not available and indicated she was only able to locate a pair of thigh high compression stockings but could not utilize them because she needed a physician order. LPN#1 indicated that NA#1 did not report that the resident was only wearing a sneaker to the left foot without the benefit of a sock. Review of physician orders [REDACTED]. Interview with PT#1 on 2/27/13 at 2:50 PM identified that when NA#1 could not obtain compression stockings, she should have left the sneaker off because R#156 had impaired sensation from [MEDICAL CONDITION] and would not know if the sneaker was rubbing on the foot. PT#1 further noted that the resident was seen by an Orthosist on 2/12/13 and directed not to ambulate while the blister was present. The blister was present as of 3/05/13 and therefore the resident was not ambulated. b. Interview with the ADN'S on 2/27/13 at 3:15 PM and review of the treatment administration record and facilities wound monitoring list, failed to identify that weekly wound monitoring had been completed of the left heel blistered area from the initial observation on 2/11/13, until surveyor inquiry on 2/27/13. Further interview with the ADN'S at that time identified the Charge Nurse was to have initiated a pressure ulcer wound documentation sheet when PT#1 identified the left heel blister. Interview with LPN#1 on 2/28/13 at 8:57 AM identified that she did not initiate a wound tracking sheet because the Nursing Supervisor was assisting her with the measurements and thought that the Supervisor had initiated the wound tracking sheet. Review of the facility's policy regarding wound evaluation and documentation identified that upon discovery of a new wound, weekly wound observation/documentation will include location, measurements, presence of exudate and/or pain and wound bed characteristics. 2. Resident #162's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident as having intact cognition and requiring extensive assistance with activities of daily living. A RCP dated 2/07/13 identified an actual alteration in skin integrity related to a chronic left malleolous ulcer. Interventions include to complete a weekly total body audit, to monitor the healing process and elevate the legs on pillows while in bed. Facility weekly wound tracking identified R#162 had an unstageable left ankle pressure ulcer to the left ankle. physician's orders [REDACTED]. Then apply 4 by 4 kling gauze, and a tubi-grip around dressing to keep in place, and change daily. Physician orders [REDACTED]. a. Observation on 2/26/13 at 2:30 PM identified R#162 seated in her/his the wheelchair in the room, with her/his legs in the dependent position on the leg rests, without the benefit of the left leg being elevated and/or supported with a pillow. Interview with the resident, at the time, identified that he/she came back to the room prior to lunch and had been in that position ever since. Interview with NA#2 on 2/26/13 at 2:49 PM indicated that she did not know that the resident was to have the left leg elevated on a pillow when up in the wheelchair because it was not written on the Nurse Aide care card. Interview with the ADN'S on 2/26/13 at 3:00 PM identified that the Charge Nurse who took the order should have updated the care card in the NA assignment kardex. Subsequent to surveyor inquiry, LPN#3 obtained a pillow, elevated the resident's leg in the wheelchair with the pillow.