Every finding on record at Civita Care Center at Danbury

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to appropriately respond to an emergency situation in which a resident experienced a medical emergency, and failed to provide interventions when the resident was identified to be unresponsive and had a respiratory rate of three (3) breaths per minute, resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 had a diagnosis of opioid dependence and diabetes. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition and was independent with transfers and wheelchair mobility. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 may go on Leave of Absence (LOA) with a wheelchair. Interventions directed independent LOA, and perform room search with consent.Physician order dated [DATE] directed independent with outdoor mobility and community outings with use of a walker or wheelchair. Physician order dated [DATE] directed to administer Naloxone (Narcan - used to reverse drug overdose) one (1) dose as needed for opioid overdose, may repeat three (3) times, three (3) minutes apart, call the provider and call 911.Record review identified Resident #1 went on an independent LOA on [DATE].Nursing note dated [DATE] at 5:50 AM identified Resident #1 was observed at approximately 5:40 AM lying supine (face up) across the bed. Resident #1 appeared pale, unresponsive to verbal stimuli, and did not respond to repeated calling of his/her name or to a sternal rub. Resident #1 was noted with agonal respirations (a medical emergency of abnormal gasping, snorting, or labored breathing caused by a lack of oxygen to the brain) at a rate of three (3) breaths per minute (normal adult rate 12 to 18). Initial assessment identified pulse was 83 beats per minute, blood pressure was 98/60, temperature was 97.8, oxygen saturation was 98% on room air (normal 90% and above), and blood glucose was at 206. Respirations remained shallow. irregular, and labored. Resident #1 was unable to follow commands, was unable to communicate needs, and exhibited no purposeful movement during assessment. Pupils were sluggish and skin was cool to touch. No signs of acute trauma or injury were observed. Staff activated Emergency Medical Services (EMS/911) at approximately 5:45 AM due to unresponsive status and respiratory distress, and Resident #1 remained unresponsive while awaiting EMS arrival. Further, the note indicated continuous monitoring and supportive measures were maintained by nursing staff. EMS arrived and Resident #1 was transferred to the hospital, and the provider was notified and updated on resident status.Reportable event dated [DATE] at 3:30 PM identified on [DATE] at approximately 5:40 AM, Resident #1 was found unresponsive in bed with agonal respirations. Nursing staff activated EMS/911 services, and Resident #1 was transferred to the hospital. Facility follow-up with the hospital identified Resident #1 had a suspected opioid overdose with positive toxicology findings. Emergency Medical Services (EMS/911) run sheet dated [DATE] identified 911 was called at 5:25 AM (15 minutes prior to the time referenced in the nursing note) and they were at Resident #1 at 5:37 AM (3 minutes prior to the time referenced in the nursing note). EMS identified Resident #1 was lying sideways on the hospital-style bed, legs hanging off the bed, with his/her head supported by a side table and was neither alert nor oriented. Facility reported Resident #1 was last seen about 2 AM and was checked at 5 AM when they found him/her in the present condition. Blood glucose was 125. Glasgow Coma Scale (GCS/Level of consciousness, normal score of 15 indicates awake, alert and responsive) score was three (3) (score 3 to 8 indicates severe injury/coma), with agonal respirations and no signs of trauma or bleeding. Pupils were pinpoint. Oxygen saturation at 5:38 AM was 84% (nursing note at 5:50 AM had identified 98%) and had a respiratory rate of six (6), and EMS initiated assisted ventilations via an oral airway with a bag valve mask. EMS noted lungs had good compliance with ventilations, lung sounds were clear and no evidence of possible aspiration or choking. Staff denied knowing anything about prescribed medications or access to narcotics and had insufficient answers for EMS questions. The report indicated EMS physical exam identified suspected alcohol or drug use. Paperwork revealed physician order for Naloxone as needed but no evidence of opiates ordered. EMS administered Naloxone two (2) milligrams and continued with assisted respirations and transport to the hospital. Resident #1 began to improve while in transport to the hospital; opened his/her eyes spontaneously, GCS score of 12 (indicating moderate impairment), began to follow commands and slow to respond in one-word answers such as good morning. Record review identified although the nursing note at 5:50 AM indicated Resident #1's oxygen saturation was 98% on room air, EMS report indicated PO 84% when they arrived. Staff called 911, and additional record review failed to identify any additional interventions were taken by RN #1 or LPN #1.emergency room documentation dated [DATE] identified Resident #1 was diagnosed with opiate overdose, with positive test results for Cocaine and Fentanyl.Hospital Discharge summary dated [DATE] at 12:14 PM identified Resident #1's toxicology was positive for Cocaine and Fentanyl and was treated for acute kidney injury.Reportable event summary dated [DATE] identified upon notification of the toxicology results, the facility conducted a room search on [DATE] and identified a white powdery substance, Marijuana, vape devices, and an empty alcohol container. Items were removed and local authorities were notified.Although attempted, an interview with NA #1 was unable to be obtained during the survey.Interview with LPN #1 on [DATE] at 12:19 PM identified she was the charge nurse on [DATE] and last saw Resident #1 about 3:30 AM to 4 AM laying in the middle of the bed. When she returned to the room about 5:30 AM, Resident #1 was laying supine across the bed and was unresponsive to verbal and physical stimulation and unresponsive to a sternal chest rub. LPN #1 stated NA #1 was in the room giving care to the roommate, and she told NA #1 to stay in the room and LPN #1 left the room to notify RN #1 and obtain the crash cart. LPN #1 then obtained vital signs and identified a respiratory rate of three (3). LPN #1 stated she did not perform any additional interventions while awaiting EMS arrival because she thought Resident #1 was just sleeping. She kept trying to wake him/her up and did not know Resident #1 had an active order for Narcan at the time of the incident.Interview with RN #1 on [DATE] at 12:45 PM identified LPN #1 notified her about 5:40 AM that Resident #1 was short of breath, and she observed Resident #1 laying across the bed and unresponsive to verbal and physical stimulation. RN #1 noted Resident #1 was not breathing well and was breathing at a rate of three (3) breaths per minute. The crash cart was there but was not used because Resident #1 was still breathing. RN #1 then left the room and called 911. RN #1 stated no additional interventions were performed while EMS was enroute because the resident was still breathing. RN #1 further stated she knew Resident #1 had an order for Narcan, but she did not administer it because she did not believe he/she was having an overdose. Further, RN #1 stated it was not a code (CPR) situation because Resident #1 was still breathing and she did not think Resident #1 needed any form of oxygen.Interview with the Director of Nursing (DNS) on [DATE] at 3:10 PM identified she did not believe Narcan should have been administered because there was no reason to suspect an overdose, and to her knowledge neither oxygen nor rescue breaths should have been administered because the resident had an oxygen saturation of 98%.Interview with the Medical Director on [DATE] at 9:37 AM identified staff called him regarding the incident and stated he did not recall that staff informed him Resident #1 was unresponsive to verbal or physical stimulation and was taking only three (3) breaths per minute. The Medical Director stated he asked staff if CPR needed to be performed, and staff had informed him that Resident #1 was fine and breathing on his/her own. He was informed the oxygen saturation was fine, and Resident #1 only had shallow breathing. The Medical Director stated if staff had informed him the resident was breathing at a rate of three (3) breaths per minute and not responding to stimulation, then he would have directed staff to put place oxygen on the resident, to perform rescue breaths, and to administer Narcan.Review of facility undated Opioid Overdose Management/Use of Naloxone directed in part, any licensed nurse shall be allowed to administer Naloxone upon reasonable suspicion of an opioid overdose and if the resident was not breathing or breathing remains shallow to continue to perform rescue breathing while awaiting Naloxone to take effect.Review of facility documentation identified education was initiated on [DATE] for all nursing staff and included education on the recognition of signs and symptoms of a suspected drug overdose, including opioid overdose, and the immediate nursing response required to protect resident safety, including prompt administration of naloxone (Narcan). The education included to perform the following while awaiting EMS arrival: to maintain the resident's airway, provide oxygen if available and ordered per facility protocol, to begin rescue breathing if indicated, initiate CPR if he resident becomes pulseless, place resident in recovery position if breathing resumes and continue monitoring respiratory status, oxygen saturation, level of consciousness, vital signs, and remain with resident until EMS assumes care. Audits were initiated and will be reviewed by facility QAPI. Based on review of facility documentation, a finding of past non-compliance was identified.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1), reviewed for resident rights, the facility failed to honor the resident's right for self-determination and honor the resident's right to make choices about his/her lift to interact and participate in community activities outside the facility, and failed to honor the resident's right for leave of absence (LOA) privileges upon readmission. The findings include: Resident #1 had a diagnosis of opioid dependence. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 indicating an intact cognition, no behaviors, and was independent with transfers and wheelchair use. The Resident Care Plan dated 2/17/26 identified Resident #1 may go on leave of absence with wheelchair. Interventions directed if warranted staff may perform room search with Resident #1's consent. Record review failed to identify a physician's order regarding Resident #1's LOAs rights. Nursing note dated 5/7/26 at 5:50 AM identified Resident #1 was observed at approximately 5:40 AM lying supine (face up) across the bed pale, unresponsive to verbal stimuli, with agonal respirations (a medical emergency of abnormal gasping, snorting, or labored breathing caused by a lack of oxygen to the brain) at a rate of three (3) breaths per minute (normal adult rate 12 to 18). Staff activated Emergency Medical Services (EMS/911) at approximately 5:45 AM due to unresponsive status and respiratory distress, and Resident #1 remained unresponsive while awaiting EMS arrival. EMS arrived and Resident #1 was transferred to the hospital. Reportable event dated 5/11/26 at 3:30 PM identified on 5/7/26 at approximately 5:40 AM, Resident #1 was found unresponsive and follow-up with the hospital identified Resident #1 had a suspected opioid overdose with positive toxicology findings. Emergency Medical Services (EMS/911) run sheet dated 5/7/26 identified 911 was called at 5:25 AM (15 minutes prior to the time referenced in the nursing note) and they were at Resident #1 at 5:37 AM (3 minutes prior to the time referenced in the nursing note). EMS identified Resident #1 was neither alert nor oriented with a Glasgow Coma Scale (GCS/Level of consciousness, normal score of 15 indicates awake, alert and responsive) score was three (3) (score 3 to 8 indicates severe injury/coma), with agonal respirations and no signs of trauma or bleeding. Pupils were pinpoint. Oxygen saturation at 5:38 AM was 84% (nursing note at 5:50 AM had identified 98%) and had a respiratory rate of six (6), and EMS initiated assisted ventilations via an oral airway with a bag valve mask. The report indicated EMS physical exam identified suspected alcohol or drug use. Paperwork revealed physician order for Naloxone as needed but no evidence of opiates ordered. EMS administered Naloxone two (2) milligrams and continued with assisted respirations and transport to the hospital. Resident #1 began to improve while in transport to the hospital; opened his/her eyes spontaneously, GCS score of 12 (indicating moderate impairment), began to follow commands and slow to respond in one-word answers such as good morning. emergency room documentation dated 5/7/26 identified Resident #1 was diagnosed with opiate overdose, with positive test results for Cocaine and Fentanyl. Nursing note dated 5/11/26 at 3:16 PM identified Resident #1 was readmitted from the hospital. Physician order dated 5/11/26 directed Resident #1 may not go out on LOA. Physician order dated 5/12/26 directed Resident #1 ambulated independently in his/her room only with a rollator walker however requires assist of 1 (contact guard assist) with rollator when ambulating outside of room or throughout the facility. Record review identified Resident #1 was independent mobility in his/her wheelchair. Reportable event summary dated 5/15/26 identified the facility immediately conducted a room search on 5/8/2026 (while Resident #1 was in the hospital) to ensure resident and facility safety. During the search, items identified as potential paraphernalia/substances were noted, including a white powdery substance, marijuana, vape devices, and an empty alcohol container, and the items were removed. Physician order dated 5/22/26 directed Resident #1 may go LOA with supervision (11 days after the readmission order directed no LOAs). Interview with the Director of Rehabilitation on 6/9/26 at 3:29 PM identified Resident #1 was independent with wheelchair use in the facility after he/she returned to the facility, and she did not know of any reason Resident #1 could not go on LOA after readmission. Interview with the DNS and LPN #1 (regional nurse) on 6/9/26 at 3:41 PM identified they did not allow Resident #1 to go on LOA upon readmission to the facility because Resident #1 needed to be cleared by therapy first. Further, although Resident #1 was independent mobility in his/her wheelchair, the interview identified Resident #1 required assist of one with contact guard with rollator walker during ambulation outside of his/her room. Record review identified Resident #1 had independent LOAs prior to the incident on 5/7/2026 and remained independent in wheelchair mobility, and interview failed to identify why Resident #1 was not granted independent LOAs upon readmission on [DATE]. Review of facility undated Leave of Absence from the Facility Policy directed in part, residents will be able to have appropriate LOAs. Review of facility undated Resident Rights Policy and Procedure Policy directed in part, each resident had a right to interact with members of the community and participate in community activities both inside and outside the facility.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure a quarterly Minimum Data Set (MDS) and a Discharge MDS assessment were completed and transmitted timely. The findings include:Resident #1 had a diagnosis of opioid dependence. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 indicating an intact cognition, no behaviors, and was independent with transfers and wheelchair use. The Resident Care Plan dated 2/17/26 identified Resident #1 may go on leave of absence with wheelchair. Interventions directed if warranted staff may perform room search with Resident #1's consent. Record review identified the clinical record identified Resident #1 was discharged from the facility with return anticipated on 3/29/2026. Review of the discharge MDS dated [DATE] identified Section Z was signed and dated 5/15/2026 to indicate the MDS was complete (48 days after the discharge). Additional review identified the MDS was transmitted to CMS on 5/22/2026 (55 days after Resident #1 was discharged ). Review of the quarterly MDS dated [DATE] identified Section Z was not signed to indicated it was completed and it was not submitted prior to prior to review on 6/9/2026. Review of the discharge MDS dated [DATE] identified Section Z was not signed to indicated it was completed, and it was not transmitted prior to prior to review on 6/9/2026. Interview with LPN #2 (MDS coordinator) on 6/9/2026 at 10:42 AM identified she does not know why the quarterly MDS dated [DATE] and the Discharge return anticipated MDS dated [DATE] were not signed and submitted timely. LPN #2 stated both MDS assessments should have been signed as complete and submitted to CMS timely. LPN #2 stated she was not aware the prior MDS coordinator did not submit them and that it was the MDS coordinators responsibility for ensuring MDSs are submitted timely per the regulation. Subsequent to surveyor inquiry, Section Z on the quarterly MDS dated [DATE] and the discharge MDS dated [DATE] were signed and dated 6/9/2026, and were both transmitted to CMS on 6/9/2026. Interview with the Director of Nursing (DNS) and LPN #3 (Regional nurse) on 6/9/26 at 2:47 PM identified they did not know why the MDS assessments above were not completed and were not submitted timely. Interview identified it was their expectation that MDS assessments were to be completed and transmitted/submitted/submitted timely, and that it was the MDS coordinators responsibility for ensuring they are submitted timely. Review of facility MDS Assessment and Completion and Submission Policy dated 2/2/26 directed the facility will ensure all MDS assessments are completed accurately, timely, and submitted in accordance with the Center for Medicare and Medicaid Services (CMS) and state requirements. Review of the CMS Resident Assessment Instrument (RAI) Manual, directed in part, the RN coordinator reviews and signs Section Z to indicate the MDS assessment is complete. The entire assessment must be completed, signed, and certified that the whole assessment is complete, which must be done within 14 days of the ARD (assessment reference date). Additional review directed the quarterly MDS must be transmitted to CMS within 14 days after the Care Plan completion, and the discharge MDS must be transmitted to CMS within 14 days following the discharge.

.Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for professional standards of care, the facility failed to ensure a licensed nurse remained with Resident #1 when staff identified a change in condition that included the resident was unresponsive with agonal respirations at a rate of three (3) per minute, until Emergency Medical Services (EMS) arrival. The findings include: Resident #1 had a diagnosis of opioid dependence and diabetes. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition and was independent with transfers and wheelchair mobility. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #1 may go on Leave of Absence (LOA) with a wheelchair. Interventions directed independent LOA, and perform room search with consent. Nursing note dated 5/7/26 at 5:50 AM identified Resident #1 was observed at approximately 5:40 AM lying supine (face up) across the bed. Resident #1 appeared pale, unresponsive to verbal stimuli, and did not respond to repeated calling of his/her name or to a sternal rub. Resident #1 was noted with agonal respirations (a medical emergency of abnormal gasping, snorting, or labored breathing caused by a lack of oxygen to the brain) at a rate of three (3) breaths per minute (normal adult rate 12 to 18). Initial assessment identified pulse was 83 beats per minute, blood pressure was 98/60, temperature was 97.8, oxygen saturation was 98% on room air (normal 90% and above), and blood glucose was at 206. Respirations remained shallow. irregular, and labored. Resident #1 was unable to follow commands, was unable to communicate needs, and exhibited no purposeful movement during assessment. Pupils were sluggish and skin was cool to touch. No signs of acute trauma or injury were observed. Staff activated Emergency Medical Services (EMS/911) at approximately 5:45 AM due to unresponsive status and respiratory distress, and Resident #1 remained unresponsive while awaiting EMS arrival. Further, the note indicated continuous monitoring and supportive measures were maintained by nursing staff. EMS arrived and Resident #1 was transferred to the hospital, and the provider was notified and updated on resident status. Reportable event dated 5/11/26 at 3:30 PM identified on 5/7/26 at approximately 5:40 AM, Resident #1 was found unresponsive in bed with agonal respirations. Nursing staff activated EMS/911 services, and Resident #1 was transferred to the hospital. Facility follow-up with the hospital identified Resident #1 had a suspected opioid overdose with positive toxicology findings. Emergency Medical Services (EMS/911) run sheet dated 5/7/26 identified 911 was called at 5:25 AM (15 minutes prior to the time referenced in the nursing note) and they were at Resident #1 at 5:37 AM (3 minutes prior to the time referenced in the nursing note). EMS identified Resident #1 was lying sideways on the hospital-style bed, legs hanging off the bed, with his/her head supported by a side table and was neither alert nor oriented. Facility reported Resident #1 was last seen about 2 AM and was checked at 5 AM when they found him/her in the present condition. Blood glucose was 125. Glasgow Coma Scale (GCS/Level of consciousness, normal score of 15 indicates awake, alert and responsive) score was three (3) (score 3 to 8 indicates severe injury/coma), with agonal respirations and no signs of trauma or bleeding. Pupils were pinpoint. Oxygen saturation at 5:38 AM was 84% (nursing note at 5:50 AM had identified 98%) and had a respiratory rate of six (6), and EMS initiated assisted ventilations via an oral airway with a bag valve mask. EMS noted lungs had good compliance with ventilations, lung sounds were clear and no evidence of possible aspiration or choking. Staff denied knowing anything about prescribed medications or access to narcotics and had insufficient answers for EMS questions. The report indicated EMS physical exam identified suspected alcohol or drug use. Paperwork revealed physician order for Naloxone as needed but no evidence of opiates ordered. EMS administered Naloxone two (2) milligrams and continued with assisted respirations and transport to the hospital. Resident #1 began to improve while in transport to the hospital; opened his/her eyes spontaneously, GCS score of 12 (indicating moderate impairment), began to follow commands and slow to respond in one-word answers such as good morning. Record review identified although the nursing note at 5:50 AM indicated Resident #1's oxygen saturation was 98% on room air, EMS report indicated PO 84% when they arrived. Staff called 911, and additional record review failed to identify any additional interventions were taken by RN #1 or LPN #1. Although attempted, an interview with NA #1 was unable to be obtained during the survey. Interview with LPN #1 on 6/8/26 at 12:19 PM identified she was the charge nurse on 5/15/26 and about 5:30 AM she observed Resident #1 laying supine across the bed and was unresponsive to verbal and physical stimulation, and unresponsive to a sternal chest rub. LPN #1 stated NA #1 was in the room giving care to the roommate, and she told NA #1 to stay in the room and LPN #1 left the room to notify RN #1 and obtain the crash cart. LPN #1 then obtained vital signs and identified a respiratory rate of three (3), and indicated she left the room to call 911 while RN #1 tried to contact the on-call provider. Interview failed to identify a licensed staff member remained with Resident #1 until EMS arrived. Interview with RN #1 on 6/8/26 at 12:45 PM identified LPN #1 notified her about 5:40 AM that Resident #1 was short of breath, and she observed Resident #1 laying across the bed and unresponsive to verbal and physical stimulation. RN #1 noted Resident #1 was not breathing well and was breathing at a rate of three (3) breaths per minute. RN #1 then left the room and called 911. Interview failed to identify a licensed staff member remained with Resident #1 until EMS arrived. Record review and interviews failed to identify licensed staff remained with Resident #1 while awaiting EMS arrival. Interview with the Director of Nursing (DNS) on 6/8/26 at 3:10 PM identified she believed staff stayed in Resident #1s room while until EMS arrival. No policy was provided for surveyor review regarding staff remaining with a resident experiencing a change in condition until EMS arrived.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #163) reviewed for infection control, the facility failed to ensure a resident with an indwelling medical device was placed on enhanced barrier precautions (EBP). The findings include: Resident #163 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence on renal dialysis. A physician's order dated 4/15/25 directed to observe permcath (an indwelling medical device used as a vascular access for dialysis) site every shift. Monitor for signs and symptoms of infection. The physician's orders failed to identify a directive for the use of EBP. The nurse's note dated 5/2/25 at 8:03 PM identified Resident #163 was readmitted to the facility, was alert and oriented, had a permcath to the right chest, dressing was intact, dry and no signs of infection noted. This writer was able to verify the medications with the APRN. The skin was intact, with no open areas noted. The care plan dated 5/4/25 identified Resident #163 was at risk for complications related to dialysis. Interventions included monitoring for signs and symptoms of bleeding at the port site and applying pressure, as needed. Review of the facility's Enhanced Barrier Precautions list failed to identify Resident #163 required the employment of EBP. Interview with LPN #8 on 5/7/25 at 10:00 AM identified Resident #163 had not been placed on enhanced barrier precautions. LPN #8 indicated that Resident #163 received dialysis, at an outpatient clinic, through a permcath in his/her right upper chest wall. LPN #8 further indicated that she had not used PPE while providing care to Resident #163, and she would have to check with the Infection Preventionist to see if Resident #163 should be placed on EBP, but she thought he/she probably should be on EBP. LPN #8 identified there was no sign on Resident #163's door indicating that he/she was on EBP. Interview with the Infection Preventionist (LPN #1) on 5/7/25 at 10:04 AM identified Resident #163 was not placed on EBP. LPN #1 indicated that she would check to see if Resident #163 belonged on enhanced barrier precautions because the resident has a permcath. Interview and clinical record review with the DNS on 5/7/25 at 10:10 AM identified that Resident #163 receives dialyses through a permcath, and the resident should be on EBP. The DNS indicated Resident #163 should have an order for enhanced barrier precautions and there should also be signage on his/her door identifying that he/she is on EBP and directing staff to use PPE during care. The Enhanced Barrier Precautions policy directs EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. EBPs are indicated (when contact precautions do not otherwise apply) for residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 8 residents (Resident #1, 7, 13 and 82) reviewed for pneumococcal vaccinations, the facility failed to ensure that pneumococcal vaccines were offered timely. The findings include: 1. Resident #1 was admitted to the facility in April 2025 with diagnoses that included dementia, diabetes, and hyperlipidemia. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition. Additionally, pneumococcal vaccine was not up to date and was not offered. The Preventative Health Record for Resident #1 did not reflect a pneumococcal vaccine status. Interview with LPN #1 (Infection Preventionist Nurse) on 5/6/25 at 10:20 AM indicated that Resident #1 has a conservator, and she had offered all the vaccines except the pneumococcal. LPN #1 indicated that she must have missed it because it was not on the same form as the other 3 vaccines. 2. Resident #7 was admitted to the facility in January 2025 with diagnoses that included dementia, chronic obstructive pulmonary disease, and adult failure to thrive. The quarterly MDS dated [DATE] identified Resident #7 had severely impaired cognition and was not up to date with the pneumococcal vaccine. The Preventative Health Record for Resident #7 did not reflect a pneumococcal vaccine status. Interview with LPN #1 on 5/6/25 at 10:22 AM indicated that Resident #7 has a resident representative. LPN #1 offered the pneumococcal 23 in June of 2023, and it was declined, but she did not offer or educate about the other pneumococcal vaccines at that time. LPN #1 indicated that when someone refuses a vaccine, she is responsible to go back a year later and reoffer that vaccine again. LPN #1 indicated that she does not know why she had not reoffered the pneumococcal 23. LPN #1 indicated that she only offered pneumococcal 23 in the facility and does not offer the other pneumococcal vaccines. 3. Resident #13 was readmitted to the facility in March 2025 with diagnoses that included diabetic, stroke, and hypothyroidism. The quarterly MDS dated [DATE] identified Resident #13 had moderately impaired cognition. Additionally, Resident #13 was not up to date with pneumococcal vaccines, it was offered but declined. The Preventative Health Record for Resident #13 did not reflect a pneumococcal vaccine status. Interview with LPN #1 on 5/6/25 at 10:25 AM indicated that Resident #13 has a resident representative. LPN #1 had offered the pneumococcal 23 on 5/23/23, and it was declined, but she did not offer or educate about the other pneumococcal vaccines since then. LPN #1 indicated that when someone refuses a vaccine, she is responsible to go back within a year and reoffer and educate about the vaccine again. 4. Resident #82 was admitted to the facility in March 2024 and readmitted in February 2025 with diagnoses that included respiratory syncytial virus, diabetes, and hyperlipidemia. The quarterly MDS dated [DATE] identified Resident # 82 had intact cognition. Additionally, Resident #82 was up to date with the pneumococcal vaccines. The Preventative Health Record for Resident #82 did not reflect a pneumococcal vaccine status. Interview with LPN #1 on 5/6/25 at 10:43 AM indicated did not offer the pneumococcal vaccine because Resident #82 was [AGE] years old. LPN #1 indicated that she did not ask the physician or the APRN if Resident #82 would be eligible due to comorbidities like diabetes due to the residents age. Interview with LPN #1 (Infection Preventionist) on 5/6/25 at 10:45 AM indicated that she was responsible to get the resident's history for vaccines and then educate and offer the vaccines to the resident or the resident's representative on admission and readmission. Interview with MD #1 on 5/6/25 at 11:35 AM indicated if Resident 1, 7, 13, or 82 or their resident representative wanted the pneumococcal vaccine and signed the consent form, he would write the order to give administer the vaccine based on CDC guidelines. MD #1 indicated that he would order the pneumococcal vaccine to be given to Resident #82 due to the residents health status despite the age of [AGE] years old, which is a guide. MD #1 indicated that these residents were eligible and could have received the pneumococcal vaccine. Interview with LPN #3 (corporate) on 5/6/25 at 12:30 PM indicated the expectation was the infection preventionist makes sure all residents are offered vaccines and tracks the vaccines. LPN #3 indicated that the facility is to offer the Prevnar 20 first because it is one dose needed following the CDC guidelines. Review of the facility Pneumococcal Vaccines Policy identified all residents will be offered pneumococcal vaccines to aid in preventing pneumonia and pneumococcal infections. Prior to admission or upon admission resident's will be assessed to receive the pneumococcal vaccine series and then offered the vaccine series on admission to the facility unless medically contraindicated or the resident already been vaccinated. Before receiving the pneumococcal vaccine, the resident or resident representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. See current vaccine information on the CDC website. Provisions of education will be documented in the residents EMR. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Center for Disease Control and Prevention (CDC) recommendations at the time of vaccination.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 residents (Resident #34) who expressed the desire to self-administer medications, the facility failed to complete a self-administration assessment and obtain a physician's order, according to facility policy, to ensure the resident was safe to self-administer medications. The findings include: Resident #34 was admitted to the facility in September 2024 with diagnoses that included hyperkalemia, end stage renal disease requiring dialysis, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #34 had intact cognition. Resident #34 required maximum assistance with toileting, dressing, and personal hygiene. The nurses note dated 2/20/25 at 3:44 PM identified Resident #34 was changing rooms and wanted to be present during moving of personal belongings. The care plan dated 2/25/25 identified Resident #34 has end stage renal disease. Interventions included communication to dialysis regarding weights, medications, diet, lab results, etc. Additionally, Resident #34 has COPD with interventions to provide medications as needed. The monthly physician's orders dated 4/1/25 to 4/30/25 directed to administer Lokelma powder packet 5 grams give 3 packets equaling 15 grams at 6:00 PM, DuoNeb 0.5mg-2.5mg in 3 ml vial in inhalation machine use 4 times a day, and Albuterol/Ventolin HFA 90 mcg aerosol inhaler take 2 puffs every 6 hours as needed. Observation on 5/4/25 at 8:40 AM identified the Albuterol inhaler was visible on the bedside table. Additionally, Resident #34 has 3 packets of Lokelma on top of the dresser and the top dresser draw that was open completely contained 2 - 4 Lokelma packets and multiple vials of nebulizer treatments. Resident #34 indicated he/she uses the Ventolin inhaler prior to receiving the nebulizer treatments and when he/she feels short of breath. Resident #34 indicate that the nurse gave him/her the inhaler to use when he/she needed. Resident #34 indicated that he/she takes one packet of 5 grams of Lokelma and mixes it in a cup of water with every meal and has done that independently since he/she was admitted into the facility. Resident #34 indicated that he/she gets the packets from the nurses. Interview with the DNS on 5/5/25 at 7:44 AM indicated that there currently weren't any residents in the facility that self-administer any medications or inhalers. The DNS indicated that if someone could do self-administration, the resident would have to be assessed, and it would be done on paper, and the physician would have to agree and give the orders for that specific medication, and resident would receive a lock box for the medication. The DNS indicated that Resident #34 does not have a self-administration assessment done and is not permitted to self-administer any medications since admission until now. Interview with Resident #34 with the DNS present on 5/5/25 at 7:55 AM indicated that his/her Ventolin inhaler and the Lokelma packets were visible by standing at the foot of the bed. Resident #34 indicated that he/she uses the Ventolin inhaler when he/she needs it and before his/her nebulizer treatments because he is not going to wait 30 minutes for the nurse when he/she is having difficulty breathing and the inhaler is from the facility pharmacy. Resident #34 indicated that he/she has been using the inhaler independently since admission in September 2024 when it runs out the nurses will give him/her another one from the medication cart and he/she takes 1 packet of Lokelma 3 times a day with each meal. Resident #34 indicated that the nurses give it to him/her and he/she mixes it in a cup of water and has been doing it independently in the facility since admission. Resident #34 identified he did not have a lock box for the medications. The interview with RN #1 (corporate) on 5/5/25 at 8:19 AM indicated she has removed all the medication from Resident #34's bedside, and she will do a self-administration assessment with Resident #34 and if appropriate she will notify the physician and get physician's order for self-administration, get a lock box for the medications, and revise the care plan. RN #1 indicated that the admission nurse should have done a self-administration assessment or when the resident requests to do self-administration of any medications. RN #1 indicated that the LPN can do the self-administration observation because it is in EMR as an observation but if it was an assessment it would have to be done by an RN. The nurses note dated 5/5/25 at 11:40 AM identified Resident #34 requests self-administration of Lokelma, Budesonide, Albuterol and Ventolin inhaler. Notified APRN and he approved of self-administration. Resident #34 was educated by writer and APRN on medication administrations safety. Resident able to name medications, dosage, strength, frequency/schedule and purpose of medications. Resident #34 verbalized understanding of education and competency. Locked drawer and key provided to Resident #34 for medication storage safety. Review of the facility Medication at the Bedside identified nurses are not to leave any medications at the resident's bedside unless there is a physician's order stating may leave at bedside. The risks are harmful to the residents from omitting the dose, doubling a dose later, or mixing the medication. Additionally, other residents are at risk due to sharing, rummaging, or being medicated by the residents who kept the medication at their bedside. When a resident is requesting to keep medications at the bedside the facility is obligated to complete a self-administration observation, obtain an order from the provider, care plan that medication(s) can be left, and document it in the medical record. All medications must be secured and always locked when not in use. Although requested, a facility policy for resident self-administration of medication(s) was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #34 and 59) reviewed for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops), the facility failed to ensure the resident's wishes for code status were honored. The findings include: 1. Resident #34 was readmitted to the facility in [DATE] with diagnoses that included end stage renal disease, abnormal weight loss, protein-calorie malnutrition, opioid dependance, bipolar, major depression, chronic obstructive pulmonary disease, hyperkalemia. The admission physician's order dated [DATE] directed full code status (full code directs the medical team to take all possible measures to save the residents' life in the event of a medical emergency). The admission MDS dated [DATE] identified Resident #34 had intact cognition, and required maximum assistance with toileting, dressing, and personal hygiene. The care plan dated [DATE] identified Resident #34 had full code status. Interventions included making staff aware of his/her code status and social services to review code status with the resident quarterly and as needed. Interview with Resident #34 on [DATE] at 7:00 AM indicated that at the hospital he/she was a full code and wanted to continue as full code. Resident #35 indicated that no one at the facility since admission in [DATE] had talked to or educated him/her on code status or has had him/her sign any forms for a code status. Interview with the DNS on [DATE] at 7:20 AM indicated the charge nurse or supervisor should educate and have the resident sign for a code status on the day of admission. The DNS indicated there was an old form for full code status and then a second form for DNR status, but as of [DATE] there is a new form including both. The DNS indicated when a resident is found unresponsive and has no heart rate, the charge nurse would stay with resident, and have another nurse check the computer first then the chart whichever is easier to get or verify the code status. After clinical review, the DNS indicated that there was no code status designation in the medical record and that Resident #34 had not signed a code status form. 2. Resident #59 was admitted to the facility in [DATE] with diagnoses that included cystitis, multiple sclerosis, and diabetes. The annual MDS dated [DATE] identified Resident #59 had moderately impaired cognition. A physician's order dated [DATE] directed to advise resident or resident appointed health care representative to provide copies to the facility of any updated advance directives. Resident #59 has on record full code status. A Do Not Resuscitate Form identified Resident #59 had discussed the concept of a DNR with MD #1 and the staff at the facility, and knowingly and voluntarily requested DNR status. This means that no CPR measures will be administered at facility if cardiac or respiratory arrest occurs. The form was signed by Resident #59 and LPN #10 on [DATE] and MD #1 on [DATE]. The monthly physician's order dated [DATE] to [DATE] directed Resident #59 be full code status. The quarterly care conference notes dated [DATE], [DATE], [DATE], [DATE], [DATE] did not reflect that code status was discussed in the meeting or what Resident #59's wishes were. The census form identified Resident #59 went to the hospital on [DATE] and returned to the facility on [DATE]. The monthly physicians order dated [DATE] to [DATE] identified Resident #59 was full code status. The care plan dated [DATE] identified Resident #59's code status was full code and to perform CPR. Interview with LPN #14 on [DATE] at 12:28 PM indicated that she was Resident #59's charge nurse today from 7:00 AM until 3:00 PM and if Resident #59 had no pulse and was not breathing, she would check the face sheet list in the EMR on the medication cart for the code status, which lists Resident #59 as a full code, so she would start CPR. Interview RN #10 (supervisor) on [DATE] at 12:36 PM indicated that she works every weekend and today was working 16 hours from 7:00 AM until 11:00 PM as the supervisor. RN #10 indicated if a resident was to code she would look in the computer first and if close to the nurse's station the paper chart. RN #10 indicated when she arrived at the unit, if the charge nurse informed her Resident #59 was a full code she would immediately go to Resident #59 check for a pulse and if the resident had no pulse she would start CPR. RN #10 indicated if the charge nurse did not know the code status, she would look in the EMR under the face sheet for the code status and it identifies Resident #59 is a full code. After clinical record review, RN #10 indicated that Resident #59 was admitted and signed a full code on [DATE] but then Resident #56 signed a code status of DNR on [DATE] and MD #1 signed it on [DATE]. RN #10 indicated that she would have to follow the most current code status of a DNR. Interview with LPN #10 on [DATE] at 1:01 PM indicated she discussed the code status with Resident #59 on [DATE] and Resident #59 signed that his/her wish was to be a DNR, and she signed as the witness. LPN #10 indicated she then leaves the signed DNR form it in the APRN and physician book for the APRN or physician to sign it. After reviewing the form, she indicated that MD #1 had signed the DNR form on [DATE] and it was the responsibility of the nurse that was on duty on [DATE] to put in the EMR as the physician order for the DNR code status. LPN #10 indicated she did not know why that did not happen. Interview with the DNS on [DATE] at 7:20 AM indicated that the nurse or supervisor on admission or readmission was responsible, upon arrival to the facility, to have the resident or resident's representative sign the code status or call the resident representative for a code status if not present. The DNS indicated that prior to [DATE] there were 2 separate forms, one for a full code and one for a DNR. The DNS indicated that if a resident was found not breathing and no pulse the nurse would check resident for a pulse and if breathing and stay with the resident and have another nurse check the computer for the code status and then the chart, whichever is easier to get the code status. After clinical review, the DNS indicated the most recent is a DNR signed by the Resident #59 on [DATE], the nurse that signed as the witness LPN #10 should have called the APRN or physician to change the order from a full code to a DNR on [DATE] and then leave in the communication book for MD #1 to sign. The DNS indicated the EMR identified Resident #59 as a full code. Even though Resident #59's wish was to be a DNR. The DNS indicated that she would get this corrected. Although attempted, an interview with APRN #3 was not obtained. Review of the facility Advance Directive Policy identified upon admission the resident will be provided with written information concerning the right the right to refuse or accept medical treatment. Advanced directives are written instructions recognized by state law relating to the provisions of health care when the resident is incapacitated. The resident has the right to refuse a resident will not be treated against his/her own wishes.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #37) reviewed for pressure ulcers, the facility failed to ensure that the physician and resident representative were notified following a newly identified skin issue. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included hemiplegia of the left side, insulin dependent diabetes, and dementia. A physician's order dated 4/5/23 directed to complete weekly skin checks on Wednesdays on the 3:00 PM - 11:00 PM shift and to complete a weekly skin observation if any new areas were identified. The quarterly MDS dated [DATE] identified Resident #37 had moderately impaired cognition, was always incontinent of bowel and bladder and required staff to provide moderate assistance with toileting, dressing, and bathing. The care plan dated 11/5/24 identified that Resident #37 had a potential for alteration in skin integrity. Interventions included complete skin assessments of the body upon admission, weekly, and as needed. The interventions also included reporting any changes in skin status to the physician. A Braden Scale (Braden Scale is a tool used to assess a resident's risk of developing a pressure ulcer) dated 12/15/24 identified Resident #37 was at moderate risk to develop pressure ulcers. A nurse's note dated 12/15/24 at 4:47 AM, by the Prior DNS, identified that she was working on the 11:00 PM - 7:00 AM shift to assist a nurse aide with completion of competencies and that Resident #37 was part of the assignment. The Prior DNS identified that while performing incontinent care, she discovered a non-blanchable area of redness on Resident #37's sacrum that measured 2cm x 1.3cm x 0.0cm. The Prior DNS identified she performed a head-to-toe assessment and no other non-blanchable areas were present. The Prior DNS identified she would put interventions into place including a specialty low air loss (LAL) mattress, turn and positioning schedule, toileting/incontinent care schedule, and application of barrier paste. The Prior DNS also identified she would discuss Resident #37's wheelchair cushion with the rehab department. Review of the 12/2024 TAR identified a treatment order for application of house barrier ointment after each incontinent episode every shift and as needed was implemented on 12/15/24. A nurse's note dated 12/15/24 at 9:58 AM identified that the Prior DNS identified she spoke with the therapy department, who were no longer working with Resident #37 but confirmed that Resident #37 had a ROHO cushion in place. The DNS identified she would be initiating a physical therapy (PT)/occupational therapy (OT) evaluation screening. Review of the clinical record failed to identify any documentation that a PT/OT evaluation screening was requested or completed on or after 12/15/24. Review of the clinical record failed to identify a specialty LAL mattress was implemented on or after 12/15/24. Review of the clinical record failed to identify any additional documentation related to additional assessments of the non-blanchable area on the sacrum identified on 12/15/24. Review of the clinical record failed to identify any documentation related to notification to Resident #37's physician or resident representative regarding the newly identified non blanchable area on the sacrum on or after 12/15/24. Review of the 12/2024 TAR identified Resident #37's weekly skin check signed off on 12/18/24 on the 3:00 PM - 11:00 PM shift. Further review of the clinical record failed to identify any observation documentation of Resident #37's sacrum. A nutrition note dated 12/19/24 at 2:33 PM identified that Resident #37 was seen for a non-blanchable area of redness to the sacrum identified on 12/15/24. Recommendations included initiation of a carbohydrate-controlled diet for improved blood sugar control and initiation of Proheal 30ml to aid in wound healing. A nurse's note dated 12/19/25 at 7:37 PM by RN #11 (Agency) identified that Resident #37 was seen by the dietitian for concerns about a non-blanchable area of redness on the sacrum on 12/15/24. The identified recommendations included initiating a carbohydrate-controlled diet for improved blood sugar control and starting Proheal (a protein supplement used to add in wound healing) twice daily to aid in wound healing. The note further identified the orders were implemented in Resident #37's record. Review of the 12/2024 TAR identified an order for Proheal 30ml twice daily which was started on 12/19/24 to be given twice daily at 9:00 AM and 5:00 PM. Review of the clinical record failed to identify any additional documentation or interventions related to the non-blanchable area on the sacrum after 12/19/24. Interview with LPN #3 (Regional Corporate LPN) on 5/5/25 at 11:00 AM identified she was unable to locate any additional documentation related to further assessments of Resident #37's non-blanchable sacral area following the initial documentation on 12/15/24. LPN #3 identified that Resident #37 had an order for a weekly skin check. LPN #3 identified that the facility policy was that the skin checks were signed off on the TAR weekly and only issues that were identified were documented as a skin observation. LPN #3 identified that Resident #37's physician or APRN should have been notified of the new skin issue as well as Resident #37's resident representative and the non-blanchable skin area should have been followed and assessed at least weekly once it was identified. Interview with APRN #2 on 5/7/25 at 9:05 AM identified she was not notified of the non-blanchable sacral area identified by the prior DNS on 12/15/24. APRN #1 identified that while the interventions implemented by the Prior DNS appeared to be appropriate, if she had been notified, she would have assessed the area or requested that the RN who works with her and alternates visits to the facility to assess the area and notify her of the findings. APRN #2 identified that a non-blanchable area to the sacrum as identified in the Prior DNS's note would possibly have been a pressure ulcer, but she would have needed to assess the area to be sure however she was not notified. Interview with LPN #1 on 5/7/25 at 9:10 AM identified she was the facility wound nurse on 12/15/24. LPN #1 identified she had not been notified regarding the non-blanchable area on Resident #37's sacrum identified on 12/15/24. LPN #1 identified that the process for any newly identified skin area that could potentially be a pressure injury included adding the resident to the upcoming weekly wound rounds so that the wound physician could assess and determine the next steps in treatment. LPN #1 also provided a weekly wound round list dated 12/18/24. Review of the 12/18/24 weekly wound round list failed to identify any documentation that Resident #37 was added to the list to be seen by the wound physician. Review of the 24-hour nursing report sheets from 12/15/24 - 12/20/24 failed to identify any additional documentation related to the non-blanchable area on the sacrum. Although attempted, an interview with the Prior DNS was not obtained. Although attempted, an interview with RN #11 was not obtained. The facility policy on change in a resident's condition or status directed that a significant change of condition included a major decline or improvement in the resident status that required interdisciplinary review and or revision to the care plan and impacted more than one area of the residence health status. The policy directed that prior to notifying the physician or health care provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact S bar communication form. The policy also directed that the nurse would notify the resident's attending physician or physician on call when there was a significant change to the residents' physical emotional or mental condition. The policy also directed that except in medical emergencies notifications would be made within 24 hours of a change occurring in the resident's medical mental condition or status. The policy directed that unless otherwise instructed by the resident, the nurse would also notify the resident representative when there was a significant change in the residence physical mental and psychosocial status.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #79 and 87) reviewed for abuse, the facility failed to ensure the residents were free from verbal and physical abuse by another resident. The findings include: 1a. Resident #79 had diagnoses that included dementia and mild neurocognitive disorder with behavioral disturbance. The quarterly MDS dated [DATE] identified Resident #79 had severely impaired cognition and was independent with ambulation. The care plan dated 3/4/25 identified Resident #79 had behavioral symptoms related to dementia, inappropriate behaviors towards staff and other residents, agitation, and verbal behaviors. Interventions included psychiatry for increased aggression and approach resident in a calm manner. b. Resident #91 had diagnoses that included dementia and history of traumatic brain injury. The quarterly MDS dated [DATE] identified Resident #91 had memory problems with continuous inattentiveness and disorganized thinking and was independent with ambulation and toileting. The care plan dated 12/26/24 identified Resident #91 behavioral symptoms including wandering and intrusiveness. Interventions included encouraging diversional activities and encourage to walk with staff when possible. Physician's orders dated 3/1/25 directed independent ambulation on the unit without an assistive device. A reportable event form dated 3/4/25 identified at 5:00 PM, Resident #79 and Resident #91 were walking in the hallway, and Resident #79 said to Resident #91 that he/she was going to (kick his/her a**). Resident #91 said stop and put his/her right hand around Resident #79's neck slightly and pinned Resident #79 against the wall for two seconds. No injuries were sustained. Resident #91 was placed on 1:1 enhanced monitoring. The physician, police and resident representative were notified and Resident #91 was subsequently transferred to the emergency department. A late entry nurses note dated 3/5/25 at 5:15 PM completed by LPN #9 identified Resident #79 was observed walking in the hallway in front of Resident 91 and then stopped. Resident #91 asked Resident #79 to move. Resident #79 stated he/she was not going to move and to f*** off. Resident #91 grabbed Resident #79 around the neck, loosely. LPN #9 was immediately able to release and remove Resident #91's hand. No injury was noted. Both residents were separated without further issue. Psychiatric evaluation dated 3/6/25 identified Resident #79 was unable to remember the event. Medication adjustments were made to address behaviors with ongoing monitoring in place. Resident #79's care plan was further revised to attend recreational activities between 3:00 PM and 5:00 PM, to use distraction techniques and remove potential triggers. Resident #91's care plan was revised to include moving to a separate floor and to monitor hallway dynamics for known behaviors and intervene if needed. An interview with NA #1 on at 5/6/25 8:18 AM identified she was working during the 3:00 PM to 11:00 PM shift on 3/4/25 but was not assigned to Resident #79 or Resident #91. NA #1 indicated it was a busy night on the dementia unit. Residents were sundowning (a term used to describe increased agitation and restlessness in the late afternoon/early evening for those with dementia). NA #1 had just walked up to the nurse's station when she observed Resident #91 walk past her in the hall, pacing as he/she normally does. Resident #79 was also in the hall approximately 10 feet away from the nurse's station, standing with other residents, yelling out and using profanities. NA #1 further identified she was unclear of what was being said as the profanities were not directed at anyone particular and not unusual for Resident #79. NA #1 heard screaming, turned around and observed Resident #91 with his/her hands just below the base of Resident #79's neck. NA #1 and the nurse, LPN #9 quickly intervened. Resident #91 released after approximately 10 seconds. Other staff also intervened, and both residents were separated. NA #1 identified Resident #91 had never previously been involved in any other resident to resident altercations that she was aware of. An interview and facility documentation review with the Administrator on 5/6/25 at 2:19 PM identified prior to this incident, Resident#91 had not displayed any aggressive behaviors towards other residents and has not since. The Administrator further identified the interdisciplinary team initiated a plan of correction for licensed, nurse aides and all agency staff in response to the resident-to-resident altercation. However, the education provided was limited to staff on duty between 3/4/25 through 3/6/25 and was not inclusive of all staff working from 3/6/25 forward. The Administrator alleged correction of past noncompliance with continued biweekly audits in place monitoring combative behaviors. The Administrator indicated she would expect that all residents be free from abuse. A review of the facility policy for abuse directs the facility to provide protection for the health, welfare and rights of each resident to prevent abuse defined as the willful infliction of injury. Attempts to interview LPN #9 were unsuccessful. A plan of correction with an alleged compliance date of 3/6/25 was initiated following the resident-to-resident altercation. Actions taken included immediate separation of residents with Resident #91 moving to a separate floor, medical and behavioral response with ongoing support services. Care plans were updated to include triggers and de-escalation strategies, increased monitoring and staff awareness, cues, enhanced documentation of mood and behavior. Resident #91 was placed on 1:1 monitoring during waking hours and every 15 minute checks while in his/her room post hospital discharge until stability was observed. Education was provided to licensed and nurse aide staff for recognizing early signs of agitation or conflict and managing interpersonal interactions, promote respectful communication, preventing conflict and support emotional wellbeing. A Quality Assurance and Performance Improvement (QAPI) was initiated to track behavior and monitor trends and trigger proactive interventions. Education was limited only to staff on schedule between 3/4/25 and 3/6/25. 2.a Resident #1 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder and dementia. The quarterly MDS dated [DATE] identified Resident #1 had intact cognition, reported feeling down, depressed, or hopeless 2 - 6 days over the last 2 weeks, and did not exhibit physical or verbal behavioral symptoms directed towards others. The care plan dated 3/4/25 identified Resident #1 had symptoms/needs related to depression. Interventions included maintaining a calm environment and setting limits and expectations for behavior. The nurse's note dated 3/10/25 identified at 2:55 AM the nurse reported that the Resident #1 was wailing and said he/she wanted to kill him/herself. The writer confirmed the statements were true with Resident #1, he/she answered yes but refused to answer additional questions. The APRN was notified and an order to transfer the resident to the emergency department for evaluation was obtained. Resident #1 was transferred to the emergency department at 3:30 AM via stretcher, accompanied by 3 EMS staff members. The nurse's note dated 3/10/25 at 4:48 AM identified that Resident #1 was transferred back from the emergency department. The facility staff sent Resident #1 back to the emergency department with the paramedic because the resident was not sent with clearance papers from the psychiatric provider. The nurse's note dated 3/10/25 at 5:49 AM identified that Resident #1 was sent back from the emergency department at 5:22 AM with clearance paperwork that he/she was not a danger to self or others. The resident was treated with Trazadone 50mg in the emergency department with recommendations to follow up with attending physician per emergency department recommendation. The emergency department paperwork dated 3/10/25 identified Resident #1 was evaluated on 3/10/25 and did not appear to be a threat to him/herself or others, and at this time it was recommended that the patient could return to his/her current living conditions and resume the maintenance of his/her current medications. b. Resident #87 was admitted to the facility on [DATE] with diagnoses that included arthrodesis status and spondylolisthesis. The admission MDS dated [DATE] identified Resident #87 had intact cognition and required moderate assistance with walking 10 feet. The care plan dated 2/25/25 identified Resident #87 had complaints of acute back pain related to back surgery. Interventions included handling the resident gently and trying to eliminate any environmental stimuli. The nurse's note dated 3/10/25 at 8:22 AM identified Resident #87 notified the writer that Resident #1 threw a remote control at him/her while he/she was in bed. The remote control hit Resident #87 on the left side of the face and the resident sustained a 5cm x 2cm bruise. No open area was observed. The reportable event form dated 3/10/25 identified that Resident #1 and Resident #87 were roommates. Resident #1 was transferred to the emergency department for suicidal ideation on 3/10/25 at 3:30 AM. Shortly after returning to the facility, Resident #1 was in his/her room, the nurse aide passed by and heard Resident #1 talking to him/herself, and then Resident #1 left and went to the lounge. After a couple of minutes Resident #1 returned to the room, went into bed, and continued to talk to him/herself. Resident #87 reported that Resident #1 was unhappy most of the day on 3/9/25. Resident #87 also said that Resident #1 kept repeating that another resident was telling everyone he/she had money. Resident #87 said he/she tried to ignore Resident #1, and on the early morning of 3/10/25 another resident came into their room, and Resident #87 offered the other resident some chips, and when Resident #1 saw the other resident, he/she appeared to be upset, and started saying to Resident #87, that's why you became pregnant, and have 15 children, and they are *profanity used*. Resident #87 said he/she then reported what Resident #1 was saying to the nurse, Resident #87 left the room, and later returned to the room to have labs drawn, and as Resident #87 sat on the bed, Resident #1 threw the remote-control hitting Resident #87 on the side of the face. Resident #87 then yelled out for the nurse, and the staff came immediately, removed Resident #87 out of the room, and Resident #1 was transferred to the hospital. Interview with Resident #87 on 5/4/25 at 10:00 AM identified that on the evening of 3/9/25 Resident #1 was starting to have some behaviors, and then on 3/10/25 between midnight and 2:00 AM, Resident #1 started saying he/she was going to kill him/herself, and then Resident #1 was transferred to the hospital. Resident #87 indicated that Resident #1 returned from the hospital about an hour or 2 later, began pacing the hallways, and had awoken other residents, one of which was a male resident that wandered into their room asking for a snack. Resident #87 indicated that Resident #1 returned to their room as the male resident was exiting the room with a snack, Resident #1 returned to his/her bed, and started yelling at Resident #87 that he/she was a *profanity used*, had *profanity used* children, and that he/she hoped Resident #87 would die. Resident #87 indicated that he/she was trying to ignore Resident #1, and then Resident #1 threw a remote control, from a 3 - 4-foot distance, striking Resident #87 on the side of the head, behind the left ear. Resident #87 indicated that he/she left the room immediately and Resident #103 (who lived directly across the hall) witnessed the event and started calling for help. Resident #87 identified that he/she was assessed by a nurse, declined going to the hospital for further evaluation, and requested an immediate room change; Resident #1 was transferred back to the hospital. Interview with Resident #1 on 5/4/25 at 10:50 AM identified that he/she had gotten along with his/her old roommate; it just didn't work out. Resident #1 indicated that while he/she tries not to get into arguments with other residents, he/she was not sure that he/she has friends at the facility. Interview with the Administrator on 5/5/25 at 1:08 PM identified that the incident between Resident #1 and Resident #87 was an isolated incident and after completing their investigation, the facility was not able to substantiate abuse, as Resident #1 did not intentionally try to hurt Resident #87. Resident #1 was feeling slighted that Resident #87 had shared chips with another resident. The Administrator indicated that just prior to the alleged incident, Resident #1 was evaluated at the hospital, after making suicidal remarks, and had received psychiatric clearance that he/she was safe to return to the facility and did not pose a threat to him/herself or others. Interview with the Nursing Supervisor (RN #7) on 5/06/25 at 9:59 AM indicated that she did not have her notes in front of her but from what she could remember on 3/10/25, Resident #1 was having behavior issues, and he/she stated that he/she wanted to kill him/herself. RN #7 indicated that she sent Resident #1 to the emergency department around midnight for talk of suicidal ideation, and the hospital sent Resident #1 back to the facility about 30 minutes later, with no papers indicating that he/she had been cleared by a psychiatric provider. RN #7 further indicated that she sent Resident #1 back to the hospital for psychiatric clearance; Resident #1 was then sent back to the facility, after approximately 30 minutes, with the paperwork that he/she was cleared and did not pose a risk to her/himself or others. RN #7 identified that she re-assessed Resident #1 upon admission and he/she was not agitated at that time. Approximately an hour later the floor nurse notified her that Resident #1 threw a remote control at Resident #87. RN #7 indicated that she identified a small bruise during her assessment of Resident #87's head. RN #7 further indicated that she tried to make Resident #87 comfortable, but he/she indicated that he/she was fine, and Resident #1appeared calm and was returned to the hospital. Interview with the Charge Nurse (LPN #6) on 5/06/25 at 11:11 AM identified that he did not have his notes in front of him, but from what he could recall on 3/10/25, he checked Resident #1's vital signs when he/she returned from the hospital, and Resident #1 was calm and did not appear agitated. LPN #6 indicated that, sometime later, while he was providing care to another resident, he heard yelling and loud talking from many residents. LPN #6 indicated that he went to see why residents were yelling, he saw Resident #87 being assisted out of his/her room (could not recall by whom), and when he asked what had happened Resident #87 reported to him that Resident #1 threw a remote control at his/her head. LPN #6 could not recall if he looked at Resident #87's head, but he notified the Nursing Supervisor. LPN #6 identified he recalled that something triggered Resident #1 to become agitated, but he could not recall what the trigger was. Interview with Resident #103 (intact cognition) on 5/7/25 at 8:25 AM identified that a few months ago (could not recall the exact day or time of day), Resident #1 was sent out to the hospital for emotional reasons and then came back to the facility. Resident #103 further indicated that, at that time, Resident #1 and #87's room was directly across the hall, and he/she had been sitting in his/her wheelchair and could see their room. Resident #103 identified that approximately half hour to one hour after Resident #1 returned to the facility, he/she heard Resident #1 expressing her/himself loudly and started to say nasty things to Resident #87. Resident #103 identified that he/she saw Resident #1 pick up an object and throw it, hitting Resident #87 right at the back of his/her head, Resident #1 had good aim. Resident #103 indicated that he/she began yelling for help, and Resident #87 was assisted out of the room. The Abuse, Neglect, and Exploitation policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations, and defines willful as the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. The policy further directs that the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property, and exploitation that achieves, in part, identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #34) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to incorporate the PASARR recommendations from the Level 2 determination into the resident's assessment and plan of care. Notice of PASARR dated 7/16/24 identified Resident #34 had a diagnosis of depression, anxiety, and Bipolar. Resident #34 was not on any antidepressants, mood stabilizers, antipsychotics, or other health medications prescribed currently, or other mental health medications prescribed currently or within the last 6 months. Resident #34 received a Level 2 approval with no specialized services needed. The PASARR did not reflect Resident #34 had opioid dependance. Resident #34 was admitted to the facility on [DATE] with diagnoses that included anxiety, opioid dependance, bipolar, depression, and psychotic disorder. A physician's order dated 9/20/24 directed to give Buprenorphine-Naloxone (Suboxone - medication for opioid dependance) 8-12 mg tablet sublingual at bedtime daily. The care plan dated 10/10/24 identified Resident #34 had a substance abuse problem and depression. Interventions included psychiatric consultation as ordered. The admission MDS dated [DATE] identified Resident #34 had intact cognition, and no behavior. Notice of PASARR Level 1 screen dated 12/24/24 identified Resident #34's PASARR was submitted for review. Resident #34 has a diagnosis of major depression, bipolar disorder, and opioid dependency. The outcome identified a Level 2 must be conducted based on the information submitted. Notice of PASARR level 2 outcome dated 1/6/25 identified Resident #34 had a Level 2 approval with recommendations. Resident #34 has a diagnosis of substance abuse disorder for opioids. Recommendations included to provide services and support through the nursing home including a support group for recovery from substance abuse (AA, AN, etc.) and mental health counseling. The care plan dated 2/25/25 identified Resident #34 has a substance abuse problem. Interventions included educating resident, resident friends, and family to not bring controlled substances to the dialysis center and not have visitor's at dialysis treatments. Interview with SW #1 on 5/5/25 at 2:18 PM indicated that Resident #34 was admitted with a Level 2 PASARR, and had a 30-day exemption to file for another PASARR from date of admission. SW #1 indicated that she did not submit the PASARR by 10/20/24. SW #1 indicated she submitted the PASARR late on 12/24/24 for another Level 2, which would be done onsite. SW #1 indicated that someone had come to the facility to evaluate Resident #34 and the facility received the Level 2 approval on 1/6/25. SW #1 indicated that she did not review Resident #34's Level 2 PASARR to see if there were any recommendations. SW #1 indicated that she was responsible to make sure all PASSAR recommendations are followed. SW #1 indicated that the facility does not offer support group for recovery from substance abuse (AA, AN, etc.). SW #1 indicated that she was not aware that Resident #34 had recommendations for support groups for recovery until now, so she did not speak with Resident #34 to see if he/she was interested in attending. SW #1 indicated that if she had read the recommendations, she would have tried to find Resident #34 a support group for recovery in the community. Additionally, SW #1 indicated she was responsible to do a care plan for any PASARR Level 2 and any recommendations but she had not updated Resident #34's care plan related to the PASSAR recommendations. The social worker note dated 5/6/25 at 6:50 PM identified Resident #34 was interested in attending NA support group meeting and had been attending them prior to admission in this facility. The social worker note dated 5/6/25 at 7:07 PM identified she was able to locate a NA meeting in the community and would follow up in the morning. The social worker note dated 5/7/25 at 8:57 AM identified Resident #34 was interested in attending the NA/AA meetings virtually if unable to attend in community and left a message with the NA number in the community to see if NA facility was wheelchair accessible. The interview with the Administrator on 5/7/25 at 7:30 AM indicated that SW #1 was responsible to update the PASARR within the 30 or 60-day time frame that PASARR had given. The Administrator indicated that she was not aware SW #1 had submitted the level 2 PASARR late for Resident #34. The Administrator indicated that the social worker was responsible to do a PASARR care plan and including any PASARR recommendations and follow up on the recommendations to make sure they were done. The Administrator indicated that SW #1 did not inform her that Resident #34 had recommendations for NA support group services. Review of the Resident Assessment and Coordination with PASARR Program Policy identified the facility coordinates assessments with the preadmission screening and resident review PASARR program under Medicaid to ensure that individuals with mental disorder, intellectual disabilities, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to the facility will be screened for serios mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. PASARR level 1 initial pre-screen is completed prior to admission. If level 1 is negative, the process ends. A positive level 1 screen necessitates a PASARR level 2 evaluation prior to admission. A PASARR level 2 is a comprehensive evaluation by the appropriate state designated authority, that determines the appropriate setting for a resident and recommends any specialized services and/or rehabilitation services that a resident would need. If a resident had an exemption from admission and remained in the facility for longer than 30 days, the facility must screen the individual using the states level 1 process. The level 2 resident review must be completed within 40 calendar days of admission. The social services director is responsible for tracking each residents PASARR screening status, and referring to the appropriate authority. Recommendations, such as specialized services, from PASARR level 2 determine and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 5 residents (Resident #13) reviewed for PASARR, the facility failed to notify the state designated authority when Resident #13 received a new mental health and intellectual disability diagnosis. The findings include: Resident #13 was admitted to the facility in [DATE] with diagnoses that included stroke and age-related cognitive decline. Review of the PASARR dated [DATE] identified the reason for screening as Resident #13's approval had expired and the resident needs additional time in the nursing facility. Resident #13 is expected to stay for long term care with a start date of [DATE]. Resident #13 had an admitting diagnosis of metabolic encephalopathy, diabetes, and hyperlipidemia. Resident #13 requires medication management and assistance with ADLs. Determination date [DATE] Resident #13 received long term care approval based on submitted information but if medical condition improves resident may be discharged if safe. The psychiatric APRN note dated [DATE] identified Resident had a diagnosis of mood disorder due to physiological condition and will be treated with Zyprexa (antipsychotic medication) 2.5mg for disorder and delusions. Resident #13's diagnosis form identified on [DATE], Resident #13 received a diagnosis of psychotic disorder with delusion. The care plan dated [DATE] identified Resident #13 receives psychotropic medications. Interventions included to complete an AIMS (AIMS is a diagnostic tool designed to assess and monitor involuntary movement disorders, most commonly used to screen for and monitor tardive dyskinesia (TD), a condition characterized by repetitive, jerky movements often resulting from long-term use of antipsychotic medications) every quarter, assess behavioral symptoms and attempt a gradual dose reduction as indicated to give the lowest dose possible. The quarterly MDS dated [DATE] identified Resident #13 had moderately impaired cognition and required extensive assistance with personal hygiene and transfers, had a diagnosis of anxiety and depression and received antipsychotic and antidepressant medications for the last 7 days or since admission. A physician note dated [DATE] identified Resident #13 returned from the hospital for cutting him/herself with a butterknife. The hospital recommended to increase the Zyprexa to 7.5 mg at bedtime. The psychiatric licensed social worker note dated [DATE] identified Resident #13 had a diagnosis of mild intellectual disabilities. The psychiatric APRN note dated [DATE] identified Resident #13 had psychosis with memory impairment. Resident #13 is on antipsychotics and is at high risk for relapses and exacerbation, so no gradual dose reduction attempted at this time. A physician order dated [DATE] directed to administer Zyprexa (antipsychotic medication) 15 mg daily for diagnosis of psychotic disorder. The psychiatric evaluation and consultation dated [DATE] identified Resident #13 was seen for diagnosis of psychotic disorder with delusions, dysthymic disorder, and mild intellectual disability-neuropathy. A physician order dated [DATE] directed to administer Zyprexa (antipsychotic medication) 10 mg twice a day for diagnosis of psychotic disorder. The quarterly MDS dated [DATE] identified Resident #13 had moderately impaired cognition and required extensive assistance with personal hygiene and transfers and had a diagnosis of anxiety, depression, and psychotic disorder. The interview with SW #1 on [DATE] at 2:10 PM indicated that she was responsible to do the PASARRs and if a resident receives a new psychiatric diagnosis she is responsible to update the state designated authority. SW #1 indicated if a resident already had a Level 2 PASARR and received a new diagnosis she would not have to update PASARR because the resident already has a Level 2 PASARR. SW #1 indicated that Resident #13 already has a Level 2 PASARR dated [DATE] so because Resident #13 already has long term care approval, she was not required to update the state designated authority when Resident #13 received a new diagnosis of psychotic disorder with delusions in [DATE], or intellectual disabilities in [DATE]. SW #1 indicated Resident #13 already receives psychiatric services. SW #1 indicated that during 2023 and into 2024 there was a lack of communication between the psychiatric group and herself. SW #1 indicated that she will call the state designated authority to see if the resident requires a new PASSAR. Interview with SW #1 on [DATE] at 12:49 PM indicated she called the state designated authority who informed her that Resident #13 does not have a Level 2 PASARR, and that when a resident receives a new psychiatric diagnosis the state designated authority must be updated so they can evaluate if the resident requires any new specialized services. Interview with the Administrator on [DATE] at 7:30 AM indicated that SW #1 was responsible to update the state designated authority within the 30 or 60 days when there was a new diagnosis of psychotic disorder with delusions and mild intellectual disabilities. Interview with the Psychiatric APRN (APRN #3) on [DATE] at 8:56 AM indicated Resident #13 was currently receiving Seroquel (antipsychotic) for the psychotic disorder with delusions, but she was not sure how long Resident #13 had that diagnosis. APRN #3 indicated that Resident #13 has a diagnosis of mild intellectual disabilities but does not know when Resident #13 received that diagnosis. Review of the Resident Assessment Coordination with PASARR Program Policy identified the facility coordinates with the PASARR program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States Medicaid rules for screening. Level 1 initial prescreening is completed prior to admission. A negative level 1 permits admission unless there is a change for a possible serious mental health disorder or intellectual disability arises after admission. A level 2 a comprehensive evaluation by the appropriate state designated authority (not the facility) determines whether a resident has MD, ID, or related condition, determines the appropriate setting for residing, and recommendations for any specialized services and/or rehabilitation services the resident needs. The Social Services Director is responsible for keeping tracks for all PASARR's. The social worker is responsible for tracking, making referrals, care planning, and updating PASARR with any changes.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #91) reviewed for abuse, the facility failed to ensure interventions, including enhanced monitoring, were in place for a resident with a documented history of combative behavior towards staff, who later acted as the aggressor in a resident-to-resident physical altercation. The findings include: Resident #91 had diagnoses that included dementia and history of traumatic brain injury. The quarterly MDS dated [DATE] identified Resident #91 had memory problems with continuous inattentiveness and disorganized thinking and was independent with ambulation and toileting. The care plan dated 12/26/24 identified Resident #91's behavioral symptoms included wandering and intrusiveness. Interventions included encouraging diversional activities and encouraging the resident to walk with staff when possible. a. Psychiatric consult dated 1/17/25 identified Resident #91 was combative at times, refused to shower and attempted to hit staff when offering showers. A low dose of Trazadone 12.5mg (an antidepressant) every shift as needed (PRN) was ordered for combative behaviors before offering ADLs for 14 days. Further, continue to monitor Resident #91's mood and behavior. b. Psychiatric consult dated 1/29/25 identified a request was made to evaluate Resident #91 as soon as possible due to very combative, aggressive behaviors during care. Further, Resident #91 had been chasing the nurse aides with objects and pencils. LPN #2 reported continued combative behaviors, and that Trazadone had not been effective. Labs and an electrocardiogram were ordered along with an increase in Olanzapine (antipsychotic used to treat psychiatric disorders) from 5mg to 7.5mg daily with ongoing recommendations to monitor Resident #91's mood and behavior. c. Psychiatric consult dated 2/5/25 identified nursing staff reported Resident #91 continued to be combative, hitting staff, refusing care and was unable to be redirected despite an increase in Olanzapine and use of PRN Trazadone. Lorazepam 1mg twice daily and 1mg every eight hours was ordered PRN for 14 days with discontinuation of the PRN Trazadone and continued monitoring of Resident #91's mood and behavior. A reportable event form dated 3/4/25 identified at 5:00 PM Resident #79 and Resident #91 were ambulating in the hallway. Resident #79 stated to Resident #91 that he/she was going to kick his/her a**. Resident #91 said Stop and put his/her right hand around Resident #79's neck slightly and pinning Resident #79 against the wall for two seconds. No injuries were sustained. Resident #91 was placed on 1:1 enhanced monitoring. The physician, police and resident representative were notified and Resident #91 was subsequently transferred to the emergency department. An interview with the Administrator on 5/6/25 at 2:19 PM identified she was unaware of Resident #91's combativeness towards staff but would expect the nursing supervisor and DNS to discuss behaviors and the care plan be revised to address combative behaviors towards staff. An interview and clinical record review with APRN #3 on 5/6/25 at 3:14 PM identified she provided routine psychiatric support services to Resident #91 beginning on 1/10/25. APRN #3 identified she had not witnessed combative behaviors firsthand from Resident #91 however, would document behaviors based on staff reports before evaluating each resident. APRN #3 confirmed, based on her documentation, LPN #2 reported combative behaviors towards staff. Medication adjustments, lab tests and other diagnostic testing had been ordered in response to those reports, however, Resident #91 had not been responsive. APRN #3 identified she has requested staff to initiate non pharmacologic interventions to address Resident #91's behaviors and would expect staff to track all instances of combativeness towards staff in the care planning process. An interview and clinical record review with LPN #2 on 5/07/25 at 9:13 AM identified a nurse aide, formerly employed by the facility, whose name she could not recall, had reported Resident #91's combative behavior towards staff. LPN #2 reported the concerns to APRN #3 but could not recall if the information was ever reported to the nursing supervisor. Although requested, a policy for revisions to the care plan based on change of condition were not provided. A review of the policy for Behavioral Assessment and Monitoring directed the interdisciplinary team to document improvements or worsening of behavioral symptoms, mood or function for any resident being treated for altered behavior or mood and that interventions will be adjusted based on impact of behavior and other symptoms.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #7) reviewed for unnecessary medications, the facility failed to follow the physician's orders for lab monitoring following the start of a new medication, and for Resident #46 the facility failed to obtain physician's orders for the use of oxygen post hospitalization. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD), major depressive disorder with psychotic features, and dementia. Review of the clinical record identified that Resident #7 was hospitalized from [DATE] - 2/28/25 due to behavioral health issues including worsening agitation and aggression. Review of the W-10 dated 2/28/25 identified Resident #7 had new medications including Depakote 250mg twice daily (a seizure and mood stabilizing medication) to stabilize mood. A physician's order dated 2/28/25 directed to administer Depakote 250mg twice daily at 9:00 AM and 9:00 PM. Review of a pharmacy psychoactive medication use recommendation dated 3/3/25 identified Resident #7 was admitted on Depakote and there was no recent serum valproic acid level in the chart. Recommendations included to consider obtaining lab work to check the level. The admission MDS dated [DATE] identified Resident #7 had severely impaired cognition, was always incontinent of bowel, occasionally incontinent of bladder, and was dependent on staff assistance with eating, bathing, and toileting. A psychiatric APRN note dated 3/7/25, by APRN #3, identified that she reviewed Resident #7's labs, was unable to locate a recent valproic acid level (used to monitor the serum level of Depakote in the blood), and ordered the valproic acid level as requested by the pharmacy. An APRN order dated 3/7/25 directed to obtain a valproic acid level on 3/10/24. Review for the March 2025 MAR identified that the order for valproic acid level was signed off as completed on 3/10/25 during the 7:00 AM - 3:00 PM shift. The care plan dated 3/11/25 identified that Resident #7 had a history of cognitive loss due to dementia. Interventions included administering medications as ordered. A psychiatric APRN note dated 4/3/25, by APRN #3, identified that she reviewed the valproic acid level done for Resident #7 on 3/5/25 and the level was within normal limits. Review of the clinical record failed to reflect a valproic acid level for Resident #7 on 3/5/25 or 3/10/25. Interview with LPN #3 on 5/5/25 at 11:00 AM identified she was unable to locate any valproic acid levels for Resident #7 since readmission on [DATE]. LPN #3 identified she had contacted the lab and there was no record of any lab requests or specimens for Resident #7 regarding a valproic acid level. Interview with APRN #3 on 5/7/25 at 8:47 AM identified that she ordered the valproic acid level to be done on 3/10/25 and reviewed the valproic acid level for Resident #7 on 4/3/25. APRN #3 identified it was her practice that when she reviewed lab results for a resident, she also took a picture of the lab results which she saved, to go along with the documentation in the visit note. During the interview, APRN #3 attempted to locate the photo of the valproic acid level but after several minutes she identified she was unable to locate the photo. Upon review of the clinical record and documentation related to the 3/7/25 order date and the 3/10/25 draw date for the valproic acid level, and information obtained from the facility that the valproic acid level had not been obtained, APRN #3 identified she was unsure what happened or why she documented that she had reviewed the valproic acid level results for Resident #7. APRN #3 identified that for residents who were started on Depakote for behavioral health issues, valproic acid levels were drawn within one to two weeks of initiation of the medication, and if the levels were within normal limits, she would then check the levels every six months and as needed to ensure that the levels were not high and in the toxic range. APRN #3 identified that she would reorder the valproic acid level to be done and ensure the level was obtained and documented correctly. Although requested, a policy on psychotropic medications was provided. The policy on behavioral assessment and monitoring directed that residents would have minimal complications associated with the management of altered or impaired behavior, and that the facility would comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy also directed that interventions would be adjusted based on the impact on behavior and other symptoms including any adverse consequences related to treatment. The policy on lab results and diagnostic testing directed that the physician would identify, and order diagnostic and lab testing based on the resident's needs, and facility staff would process test requisitions and arrange for tests, and the laboratory, diagnostic radiology provider, or other testing sources would report test results to the facility. The policy on charting and documentation directed that all services provided to the resident would be documented in the residence medical record and the medical record should facilitate communication between the interdisciplinary team regarding the residence condition and response to care. The policy further directed that the documentation in the medical record would be objective, complete, and accurate. 2. Resident 46 had diagnoses that included congestive heart failure and dementia. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition, was independent with bed mobility and transfers, and did not require oxygen therapy. The care plan dated 2/14/25 identified Resident #46 had a diagnosis of congestive heart failure and dementia. Interventions directed to administer medications and provide cues/supervision for ADL's. A nurses note dated 3/10/15 at 9:45 AM identified Resident #46's recorded oxygen saturation (amount of oxygen in the blood) was 80% (normal 95% - 100%), and the resident was short of breath and anxious. Resident #46 was placed on 4 liters of oxygen via nasal cannula with additional orders for stat (as soon as possible) labs, covid/flu/RSV swabs, chest x-ray and DuoNeb (bronchodilator) now and every six hours. A nurse's note dated 3/10/25 at 10:26 AM identified Resident #46 received DuoNeb with little effect. The APRN was notified and a new order received to send Resident #46 to the emergency department for further evaluation. The hospital Discharge summary dated [DATE] identified Resident #46's discharge diagnosis included respiratory failure, sepsis and pneumonia. Resident #46 required oxygen at 5 liters during hospitalization with recommendations to wean off oxygen as tolerated with a goal to maintain levels between 92% and 94%. A review of the admission physician's orders dated 3/15/25 failed to include orders for oxygen. A review of nurse's notes dated 3/15/25 through 3/17/25 identified Resident #46 was maintained on oxygen at 4 liters/minute via nasal cannula with an oxygen saturation between 94% and 98%. The APRN progress note dated 3/17/25 at 7:15 AM identified Resident #46's hypoxia had improved, and the resident no longer required the use of supplemental oxygen. Nurse's notes dated 3/17/25 through 3/19/25 at 3:15 AM identified Resident #46 continued on oxygen at 4 liters/minute via nasal cannula, was occasionally removing the oxygen and was in no acute distress. A nurse's note dated 3/19/25 at 1:47 PM identified at 12:42 PM Resident #46 was minimally responsive with an oxygen saturation of 80% on 4 liters of oxygen via nasal cannula. Resident #46 was placed on a nonrebreather and the oxygen saturation increased to 98%. The APRN was called to assess and Resident #46 and was ordered to be sent to the emergency department for further evaluation. An interview with RN #1 on 5/05/25 at 1:14 PM and 5/14/25 at 11:33 PM identified the admitting nurses were responsible for reviewing the hospital discharge summary with the provider to determine which orders were continue on admission. Resident #46 still required the use of oxygen upon readmission as part of hospital recommendations and the order was not transcribed on admission. The DNS indicated based on documentation, Resident #46 continued to receive oxygen until the error was identified on 3/22/25 upon return from his/her second hospitalization. An interview with APRN #5 on 5/14/25 at 12:25 PM identified the nurse would normally review and transcribe the orders on admission and he would review all orders the following day. APRN #5 identified he did not note nor transcribe the orders for oxygen as recommended by the hospital discharge summary as an oversight but acknowledged Resident #46 still required oxygen on readmission. APRN #5 further identified that although his progress note dated 3/17/25 identified Resident #46 no longer required oxygen, that was an entry error. APRN #5 indicated Resident #46 still required and was regularly receiving oxygen. A review of the policy for transcribing medication orders directed for oxygen, the rate, flow, route and rationale must be specified on the physician orders.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #13) reviewed for accidents, the facility failed to ensure the resident was transferred per the physician's orders resulting in a fall, for 1 resident (Resident #27) reviewed for smoking, the facility failed to ensure the resident was supervised and redirected when necessary to smoke in a safe manner, and the facility failed to ensure that smoking materials were accounted for, equipment in the smoking area was inspected at least monthly, and smoking materials were secured. The findings include: 1. Resident #13 was admitted to the facility in November 2021 with diagnoses that included edema, diabetes, anxiety, diabetic neuropathy, urge incontinence, obesity. The care plan dated 9/19/24 identified Resident #13 was at risk for frequent falls. Interventions included a left leg brace and right sneaker while out of bed. A physician's order dated 12/13/24 directed to transfer with a standard walker and assistance of 2 people while wearing a right sneaker and a left cam boot. The quarterly MDS dated [DATE] identified Resident #13 had moderately impaired cognition was frequently incontinent of bowel and always incontinent of bladder and required maximum assistance for toileting. A reportable event form dated 12/16/24 at 9:00 PM indicated that Resident #13 was in the bathroom with NA #4 who was assisting Resident #13 in the bathroom. NA #4 stated Resident #13's knees got weak, and the resident fell, but did not hit his/her head. Resident #13 had no injuries noted. The witness was NA #4. Interview with LPN #7 on 5/5/25 at 10:29 AM indicated she was outside Resident #13's room and heard a commotion in the bathroom. As she entered, NA #4 was lowering Resident #13 to the floor. LPN #7 indicated she did not recall if NA #4 had used a gait belt. LPN #7 indicated that the RN supervisor, NA #4, and herself used the mechanical lift to get Resident #13 off the floor. Interview with the DNS on 5/5/25 at 12:25 PM indicated the expectation was that NA #4 would have reviewed the resident care card prior to doing the transfer and follow the physician's order for transfers, which included assistance of 2 people. The DNS indicated if the nurse aide had any concerns, she should have spoken with the nurse to clarify. Review of investigation for the fall on 12/16/24, the DNS indicated that NA #4 did a transfer with only 1 assistance, however, she did not see anything regarding if the gait belt, cam boot, or right sneaker were on at the time of the fall. The DNS indicated that it was the facility policy that the nurse aides use a gait belt when transferring a resident. The DNS indicated that there was a physician order for Resident #13 to transfer with a standard walker and assistance of 2 people while wearing a right sneaker and a left cam boot. The DNS indicated based on the investigation NA #4 transferred the resident alone when she should have had 2. Interview with the Administrator on 5/7/25 at 10:50 AM indicated she was informed that Resident #13 was required only 1 person for transfers. The Administrator indicated that she did not realize that Resident required 2 at that time per the physician's order. The Administrator indicated that if she was aware Resident #13 required the assist of 2, and that NA #4 had done the transfer alone and did not follow the care card and plan of care, she would have been educated and had done a written discipline with NA #4 at that time. Although attempted, an interview with NA #4 was not obtained. Review of the Falls Management Policy identified the facility will identify hazards and resident risk factors and implement interventions to minimize falls. Each resident is assisted in attaining and maintaining his/her highest practical level of function by providing the resident with adequate supervision, assistive devices, and/or functional programs to minimize the risk for falls. The licensed nurse will assess residents for fall risk upon admission, re-admission, quarterly, annually, and with a significant change in condition. The interdisciplinary team will review all resident falls within 24 - 72 hours at the morning meeting to evaluate and investigate the circumstances and probable cause for the fall and modify the plan of care to minimize repeat falls and update the resident care card and care plan. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, nicotine dependence, and iron deficiency anemia. A physician's order dated 9/26/24 directed that Resident #27 may go outside to smoke as per facility guidelines. A smoking assessment dated [DATE] identified that Resident #27 was a current smoker and had been educated on the smoking policies and procedures for the facility. Review of the clinical record failed to identify any additional smoking evaluations for Resident #27 after 11/4/24. The quarterly MDS dated [DATE] identified Resident # 27 had moderately impaired cognition, was always continent of bowel and bladder, required set with meals and dressing and was independent with toileting. The care plan dated 3/14/25 identified Resident #27 wished to smoke and would be assessed for the supervised smoking program. Interventions included educating the resident on safe smoking practices and monitoring safety during smoking. Interview with Resident #27 on 5/4/25 at 10:40 AM identified that the facility provided two smoking times at 11:00 AM and 6:00 PM, the facility secured the resident smoking materials, and that a staff member accompanied Resident #27 to an outside patio during smoking. Observation on 5/4/25 at 10:55 AM identified that Resident #27 requested to be able to smoke on the outside patio. NA #7 was observed speaking to RN #10, who was inside of the RN supervisor's office requesting keys to the locked smoking cabinet. NA #7 was observed entering the employee locker room directly next to the RN supervisor's office and opening a locked cabinet which contained a plastic caddy which contained 2 packs of cigarettes. After looking through the caddy, NA #7 identified she was unable to locate the lighter that was normally contained in the caddy. NA #7 placed the plastic caddy on top of the cabinet next to the cabinet keys and left the unit. The plastic caddy was observed unattended in the employee locker room from 11:00 AM to 11:04 AM when this surveyor notified LPN #3 (regional corporate LPN) who was on the unit. Observation and interview with LPN #3 on 5/4/25 at 11:04 AM identified that the smoking materials should not be left unsecured anywhere on the unit and that the lighter with the smoking materials should always be accounted for. LPN #3 identified that the lighter was likely to be still with a staff member from the 3:00 PM - 11:00 PM shift the day prior since that would have been the last smoking time however she was not sure of this and would need to investigate. Interview with NA #7 at 11:05 AM identified she was unsure where the other lighter went. Observation of Resident #27 and NA #7 on 5/5/25 beginning at 11:10 AM identified that NA #7 was seated in the immediate vicinity of Resident #27. Resident #27 was not within reach of a metal ash receptacle. Resident #27 was observed seated on a rollator walker flicking cigarette ash onto the cement patio. Resident #27 was positioned directly in front of a wooden bench and wood mulch for the duration of the smoking time. During this observation, NA #7 did not attempt to educate or redirect Resident #27 to use the metal ash receptacle located approximately 2 feet from Resident #27. Resident #27 was observed discarding the cigarette butt into the metal ash receptacle after finishing the cigarette. NA #7 assisted Resident #27 back into the building at 11:21 AM. During this observation, the wood mulch located next to Resident #27 was wet due to an active rainstorm. Observation of the smoking area on 5/4/25 at 11:22 AM identified that the fire extinguisher in the smoking area had no documentation of a monthly inspection record tag since 10/2024, approximately seven months prior. The patio area was also noted to have a large wooden barrel planter that contained a mixture of soil, and a partial covering of wood mulch also observed to have multiple cigarette butts (a total of 7) located inside the planter. Interview with the Director of Maintenance (covering regional) on 5/4/25 at 11:45 AM identified that the facility fire extinguishers were to have a visual inspection check to ensure that the extinguishers were charged and ready to use at least monthly, and that the maintenance staff would sign the tag on the extinguisher. The Director of Maintenance identified he was only covering the building for the day due to the regular Director of Maintenance being out but that it was the procedure to sign the tag directly, and he would have to investigate any policies or logs in the maintenance office. Interview with LPN #3 on 5/4/25 at 12:00 PM identified she was assisting with staff development in the facility until a staff development nurse was hired. A request was made for education documentation and in-services related to smoking supervision for NA #7. Interview with the Director of Maintenance (covering regional) on 5/4/25 at 12:08 PM identified that he was unable to locate any documentation related to policies on fire extinguisher checks or monthly logs for the smoking area fire extinguisher and identified that the tag on the extinguisher served as the log. Interview with LPN #3 on 5/6/25 at 1:30 PM identified that the facility did not have any documentation related to education or in-services prior to 5/4/25. LPN #3 identified that the facility had recently undergone a change of ownership in 10/2024, and prior to the change, the facility allowed smoking, but following the change, smoking was prohibited. LPN #3 identified Resident #37 was one of 2 residents who were grandfathered in to continue to have supervised smoking. LPN #3 identified that following the observations on 5/4/25, she began in-service education on smoking supervision and safety with all facility nursing staff and initiated an audit tool to ensure that all smoking materials were accounted for and secured following each smoking time. LPN #3 also identified that the missing lighter from the smoking caddy on 5/4/25 had not been located. Review of the in-service education dated 5/4/25 identified staff were educated on safe handling and storage of smoking materials. The education identified that all smoking materials must be strictly managed in accordance with facility policy and state regulations. Guidelines identified in the education included securing all smoking materials after each smoking time, not leaving smoking materials including cigarettes, lighters or cart keys unattended, keeping the smoking cart locked at all times, reporting any missing items immediately to the charge nurse and facility administration, and monitoring residents behavior during smoking sessions and intervening if any unsafe behavior was observed. Further review of the in-service education also included a staff notice smoking safety reminder which identified that all smoking materials must be secured and to ensure that this smoking area was free of clutter and safe from fire hazards, and that all supervised smoking events should be documented per facility policy. Review of a smoking competency education dated 5/6/25 for NA #7 and completed by the DNS identified that NA #7 had met competencies including education on gathering smoking materials from the locked smoking cart, safely assisting residents to the assigned smoking area 20 feet away from the building, monitoring residents who smoke for the entire time without distractions, and ensuring cigarettes were properly extinguished and placed in an approved receptacle. Interview with the DNS on 5/7/25 at 11:15 AM identified she was aware of the issues identified related to Resident #37's supervised smoking and smoking materials. The DNS identified that Resident #37 should have been using the metal ash receptacle in the smoking area as there could have been a fire if the wood mulch had been dry and Resident #37 flicked ash into this area. The DNS identified education and in service had been initiated with staff. The policy on smoking for residents directed that the facility should establish and maintain safe resident smoking practices. The policy further directed that metal containers with self-closing cover devices were available in the smoking area and ashes would be emptied only and designated receptacles. The policy also directed any resident who had been grandfathered in would be reevaluated quarterly, upon a significant change in condition physical or cognitive, and as determined by staff.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #34) reviewed for a specialized medical procedure, the facility failed to ensure consistent monitoring and documentation of intake and output for a resident on fluid restriction. The findings include: Resident #39 was admitted to the facility in February 2025 with diagnoses that included end stage renal disease, and fluid overload. The care plan dated 2/28/25 identified Resident #39 had a diagnoses of end stage renal disease and received dialysis. Interventions included dialysis on Mondays, Wednesdays, and Fridays. Review of the intake and output record for March 2025 identified staff failed to document the resident's intake and the resident failed to meet the 1,000 ml/day fluid restriction 26 of 93 occasions. The initial nutrition assessment dated [DATE] at 12:36 PM identified Resident #39 was on a renal diet with 1,000 ml/day fluid restrictions. Intake by mouth has been good since admission. Recommendations included to honor resident preferences. Fluid breakdown: 1,000 ml/day. Nursing: 520 ml, Dietary: 480 ml (total), breakfast - 240 ml, lunch 120 ml, dinner 120 ml. The admission MDS dated [DATE] identified Resident #39 had intact cognition, was independent with eating, and was receiving specialized services. Review of the education form dated 3/12/25 for fluid intake and output monitoring procedure identified an in-service was provided to the nursing staff. Review of the intake and output record for April 2025 identified staff failed to document the resident's intake and the resident failed to meet the 1,000 ml/day fluid restriction 25 out of 90 occasions. The care plan dated 4/17/25 identified Resident #39 had low fluid intake related to fluid restriction of 1,000 ml daily due to end stage renal disease and dialysis. Interventions included nurse aides, nursing, and food service will follow fluid restrictions at medication pass, mealtimes every shift. The physician's order dated 5/1/25 directed a fluid restriction of 1,000 ml/24 hours. The physician's orders dated March 2025, April 2025, and May 1 - 6, 2025 failed to direct the breakdown of the amount of fluid Resident #39 could consume from nursing and dietary in a 24-hour period. Review of the intake and output record for May 1 - 6, 2025 staff failed to document the resident's intake and the resident failed to meet the 1,000 ml/day fluid restriction 6 out of 18 occasions. Subsequent to surveyor inquiry a physician's order dated 5/7/25 was obtained for the breakdown of the amount of fluid Resident #39 could consume from nursing and dietary in a 24-hour period. Interview with NA #5 dated 5/7/25 at 8:25 AM identified all nurse aides document intake and output in the computer for residents that are on intake and output. NA #5 indicated the nurse aides do not use paper for documenting intake and output. NA #5 indicated she is assigned to Resident #39 most of the time and when she is assigned to Resident #39, she documents the resident intake and output in the computer. Interview with NA #6 dated 5/7/25 at 10:20 AM identified all nurse aides document intake and output in the computer for residents that are on intake and output. NA #6 indicated nurse aides do not use paper for documenting intake and output. Interview with LPN #3 (Regional Clinical Support) dated 5/7/25 at 11:00 AM identified she was aware of the facility not following the intake and output policy. LPN #3 indicated she had provided education on 3/12/25 regarding fluid intake and output monitoring procedures to the nursing staff. LPN #3 indicated she was not aware Resident #39 was not meeting the fluid restriction per physician's order. LPN #3 indicated the nurse aides, and the licensed nurses are responsible for documenting the intake and output each shift. Interview with the DNS on 5/7/25 at 11:15 AM identified she was aware of nursing staff were not following the intake and output policy. The DNS indicated the facility had educated the nursing department in March 2025 regarding intake and output. The DNS indicated she was not aware Resident #39's intake and output were not being filled out completely by each shift. The DNS indicated she was not aware of the fluid restriction physician's order was not being followed. Interview with RN #9 (Registered Nurse at dialysis center) on 5/7/25 at 11:25 AM identified Resident #39 was on a 1,000 ml a day fluid restriction. RN #9 indicated in reviewing the resident's record, there was no evidence that the facility had notified the dialysis center that the resident intake and output were inconsistently monitored. RN #9 indicated Resident #39 fluid intake and output should be monitored. Interview with MD #1 on 5/8/25 at 11:52 PM identified he was not aware the facility was not following the physician's order and the specialized treatment center order for fluid restriction. MD #1 indicated his expectation would be that the nurses follow the physician's order. Interview with APRN #5 on 5/8/25 at 12:47 PM identified he was not aware the facility was not following the physician's order. APRN #5 indicated his expectation would be that the nurses followed the physician's order especially when the resident is receiving specialized treatment. Although attempted, an interview with the dietitian was not obtained. Review of the facility intake measurements policy identified the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy. Inform the resident and his or her family and visitors that the resident is on intake and output. Record the fluid intake as soon as possible after the resident has consumed the fluids. At the end of your shift, total the amounts of all liquids the resident consumed. Record all fluid intake on the intake and output record in cubic centimeters (ml's).

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure that a discrepancy for a controlled medication was investigated and resolved in a timely manner, failed to ensure that an individual use medication was labeled and dated, and failed to ensure that the controlled drug change of shift audits were completed. The findings include: 1. Observation of the electronic medication cabinet on 5/6/25 at 10:40 AM with RN #8 (agency nursing supervisor), located in the 2nd floor nursing supervisor's office, identified an alert on the sign on screen which identified You have one unresolved discrepancy on this cabinet. Interview with RN #8 at that time identified she was unable to resolve the discrepancy alert displayed on the medication cabinet as the facility did not allow any agency staff the ability to access the medication cabinet. RN #8 identified she worked at the facility sporadically but had noted that the discrepancy alert had been in place since her last shift at the facility on 5/2/25, 4 days ago. Interview with RN #5 (3rd floor nursing supervisor) on 5/6/25 at 11:07 AM identified that she had attempted to resolve the discrepancy in electronic medication cabinet but did not have access to do so, and it was the responsibility of the DNS to resolve any discrepancies related to the electronic medication cabinet. Observation and interview with the DNS on 5/6/25 at 11:25 AM identified she was responsible for investigating and resolving any discrepancies related to the electronic medication cabinet. The DNS identified she became aware of the discrepancy with the electronic medication cabinet earlier in the morning of 5/6/25 and had not observed any discrepancy alert prior. The DNS and RN #5 were then observed signing into the electronic medication cabinet, and the DNS was observed completing a controlled drug audit which identified there was a discrepancy related to a narcotic count of Oxycodone 10 mg which occurred on 4/16/25 with the last count entered as 27 tabs and the electronic medication cabinet alerting that the count should have been 28 tabs. Further, the DNS and RN #5 completed the count of the Oxycodone 10mg and identified 28 tablets which resolved the discrepancy. Interview with the DNS immediately following this observation identified that she was unable to identify the last time she accessed the electronic medication cabinet for any reason. A review of the medication cabinet electronic controlled substance transaction log from 4/16/25 - 5/6/25, 20 days, identified that the DNS did not access, sign into, inventory any controlled substances during that time frame. The facility policy on the BD PYXIS station cabinet medication policies and procedures for Connecticut directed that at a minimum, a bimonthly inventory would be performed on all controlled substances stored in the medication cabinet by the director of nursing along with the designated representative. The bimonthly controlled substance inventory would be maintained at the facility for a minimum of three years. The facility policy on schedule II-controlled substance medications directed that schedule II-controlled substance medications included drugs with acceptable medical use but with high abuse potential. The policy further directed that the director of nurses was designated by the facility to be responsible for the control of such drugs and medications. The facility policy on shift-to-shift narcotic counts directed that the purpose of the policy included detecting and addressing discrepancies immediately. The policy further directed that any discrepancies must be reported immediately to the supervisor, DNS or designee and that the facility staff should document actions taking and resolving any discrepancies. 2. Observation of the 2 [NAME] medication cart with LPN #8 on 5/6/25 at 10:56 AM identified a 1.5 fluid oz bottle of [NAME] care saline nasal spray inside of a clear plastic cup. The bottle did not contain any resident identifying information. Further observation identified upon LPN #8 lifting the bottle from the plastic cup, a small torn piece of paper was located at the bottom of the cup which identified 225 D but failed to identify any additional information regarding who the saline nasal spray belonged to. Interview with LPN #8 immediately following this observation identified that it was the policy of the facility to label and date any multi dose over the counter use medications and she was unsure why the bottle was located in the medication cart and could not confirm that the current occupant of room [ROOM NUMBER] D was the resident who the nasal spray belonged to. Subsequent to survey or inquiry, LPN #8 was observed disposing of the saline nasal spray. Interview with the DNS on 5/7/25 at 11:15 AM identified that all medications used for residents should be labeled appropriately with the resident's name and the date the medication was opened. Although requested, the facility failed to provide a policy on the use of over the counter medications. The policy on the storage of medications directed that the facility store all drugs and biologicals in a safe, secure, and orderly manner. The policy directed that nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy also directed that discontinued, outdated, or deteriorated drugs or biologicals were to be returned to the dispensing pharmacy or destroyed. 3. Review of the controlled drug/change of shift audit forms dated May 2025 for the 2nd floor medication carts identified the following: The 2 East medication cart-controlled drug/change of shift audit form failed to identify any controlled drug/change of shift count completed for 5/1/25 during the 11:00 PM - 7:00 AM (off going nurse and oncoming nurse), 7:00 AM - 3:00 PM (oncoming nurse and off going nurse), 3:00 PM - 11:00 PM (oncoming nurse and off going nurse). 5/2/25 11:00 PM - 7:00 AM (off going nurse). 5/3/25 11:00 PM - 7:00 AM (oncoming nurse). 5/4/25 11:00 PM - 7:00 AM (off going nurse). 5/5/25 7:00 AM - 3:00 PM (oncoming nurse), 7:00 AM - 3:00 PM (off going nurse), 3:00 PM - 11:00 PM (oncoming nurse), 3:00 PM - 11:00 PM (off going nurse), 11:00 PM - 7:00 AM (oncoming nurse). 5/6/25 11:00 PM - 7:00 AM (off going nurse), 7:00 AM - 3:00 PM (oncoming nurse). The 2 [NAME] medication cart-controlled drug/change of shift audit form failed to identify any controlled drug/change of shift count completed for: 5/1/25 11:00 PM - 7:00 AM (off going nurse), 3:00 PM - 11:00 PM (off going nurse), 11:00 PM - 7:00 AM (oncoming nurse). 5/2/25 11:00 PM - 7:00 AM (off going nurse), 3:00 PM - 11:00 PM (oncoming nurse), 3:00 PM - 11:00 PM (off going nurse). 5/3/25 3:00 PM - 11:00 PM (oncoming nurse), 3:00 PM - 11:00 PM (off going nurse), 11:00 PM - 7:00 AM (oncoming nurse). 5/4/25 11:00 PM - 7:00 AM (off going nurse). 5/5/25 11:00 PM - 7:00 AM (off going nurse). Interview with the DNS on 5/6/25 at 11:25 AM identified that the facility licensed nursing staff were responsible to complete a controlled substance count and sign off controlled drug/change of shift audit form following each shift and coming onto each shift. A request was made to the DNS to provide all controlled drug/change of shift audit forms for 2025 for the facility. Review of the controlled drug/change of shift audit forms dated 12/24 and 2/2025 - 4/2025 provided by the DNS, identified multiple missing change of shift audits for controlled drugs. Review of the single 12/2024 audit form provided for the 2 [NAME] medication cart identified 25 of 155 missing controlled substance shift audits. Review of the 2/2025 audit forms for the 2 [NAME] medication cart identified 19 of 140 missing controlled substance shift audits; 2 East medication cart identified 21 of 140 missing controlled substance shift audits; and the 3 East medication cart identified 14 of 140 missing controlled substance shift audits. The 2/2025 3 [NAME] audit form was not provided. Review of the 3/2025 audit forms for the 2 [NAME] medication cart identified 23 of 155 missing controlled substance shift audits; 2 East medication cart identified 26 of 1155 missing controlled substance shift audits; and the 3 East medication cart identified 12 of 155 missing controlled substance shift audits. The 3/2025 3 [NAME] audit form was not provided. Review of the 4/2025 audit forms for the 2 [NAME] medication cart identified 19 of 150 missing controlled substance shift audits; 2 East medication cart identified 19 of 150 missing controlled substance shift audits; the 3 East medication cart identified 39 of 150 missing controlled substance shift audits; and 3 [NAME] medication cart identified 47 of 150 missing controlled substance shift audits. Although requested, the facility failed to provide any additional controlled drug/change of shift audit forms for 12/2024, 1/2025, 2/2025 or 3/2025. The policy on shift to shift narcotic counts directed to ensure strict accountability and security for all controlled substances through a shift-to-shift narcotic count and that the process helped prevent medication diversion, insured accurate documentation, and promoted resident safety. The policy further directed at the beginning of each shift, a licensed nurse from the outgoing shift and a licensed nurse from the incoming shift must jointly conduct a controlled substance count. The policy further directed the counts must occur prior to the transfer of shift responsibilities and that the licensed nurses were to count each controlled medication in the narcotics storage areas including medication cards medication rooms or locked drawers, verify the counts against the controlled substance proof of use sheets, blister packets, or unit dose packaging. The policy further directed that the staff were to ensure the medication count matched the documented balance and confirm that all doses were administered, wasted, or returned were correctly documented. The policy also directed the documentation must include both nurses initialing and signing the narcotic count log for the shift, reporting any discrepancies immediately to the nursing supervisor, DNS, or designee, and document actions taken to resolve any discrepancies. The policy also directed that the DNS or designee would conduct random audits of narcotic counts at least monthly and audit findings would be documented and corrective actions would be taken if necessary. The policy also directed that failure to comply with the policy may result in disciplinary action up to and including termination and reporting to the appropriate state licensing board.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #37) reviewed for pressure ulcers, the facility failed to document weekly assessments and/or healing of a newly identified non-blanchable area of redness on the sacrum. The findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses that included hemiplegia of the left side, insulin dependent diabetes, and dementia. A physician's order dated 4/5/23 directed to complete weekly skin checks on Wednesdays on the 3:00 PM - 11:00 PM shift and to complete a weekly skin observation if any new areas were identified. The quarterly MDS dated [DATE] identified Resident #37 had moderately impaired cognition, was always incontinent of bowel and bladder and required staff to provide moderate assistance with toileting, dressing, and bathing. The care plan dated 11/5/24 identified that Resident #37 had a potential for alteration in skin integrity. Interventions included complete skin assessments of the body upon admission, weekly, and as needed. The interventions also included reporting any changes in skin status to the physician. A Braden Scale (Braden Scale is a tool used to assess a resident's risk of developing a pressure ulcer) dated 12/15/24 identified Resident #37 was at moderate risk to develop pressure ulcers. A nurse's note dated 12/15/24 at 4:47 AM, by the Prior DNS, identified that she was working on the 11:00 PM - 7:00 AM shift to assist a nurse aide with completion of competencies and that Resident #37 was part of the assignment. The Prior DNS identified that while performing incontinent care, she discovered a non-blanchable area of redness on Resident #37's sacrum that measured 2cm x 1.3cm x 0.0cm. The Prior DNS identified she performed a head-to-toe assessment and no other non-blanchable areas were present. The Prior DNS identified she would put interventions into place including a specialty low air loss (LAL) mattress, turn and positioning schedule, toileting/incontinent care schedule, and application of barrier paste. The Prior DNS also identified she would discuss Resident #37's wheelchair cushion with the rehab department. Review of the 12/2024 TAR identified a treatment order for application of house barrier ointment after each incontinent episode every shift and as needed was implemented on 12/15/24. A nurse's note dated 12/15/24 at 9:58 AM identified that the Prior DNS identified she spoke with the therapy department, who were no longer working with Resident #37 but confirmed that Resident #37 had a ROHO cushion in place. The DNS identified she would be initiating a physical therapy (PT)/occupational therapy (OT) evaluation screening. Review of the clinical record failed to identify any documentation that a PT/OT evaluation screening was requested or completed on or after 12/15/24. Review of the clinical record failed to identify a specialty LAL mattress was implemented on or after 12/15/24. Review of the clinical record failed to identify any additional documentation related to additional assessments of the non-blanchable area on the sacrum identified on 12/15/24. Review of the clinical record failed to identify any documentation related to notification to Resident #37's physician or resident representative regarding the newly identified non blanchable area on the sacrum on or after 12/15/24. Review of the 12/2024 TAR identified Resident #37's weekly skin check signed off on 12/18/24 on the 3:00 PM - 11:00 PM shift. Further review of the clinical record failed to identify any observation documentation of Resident #37's sacrum. A nutrition note dated 12/19/24 at 2:33 PM identified that Resident #37 was seen for a non-blanchable area of redness to the sacrum identified on 12/15/24. Recommendations included initiation of a carbohydrate-controlled diet for improved blood sugar control and initiation of Proheal 30ml to aid in wound healing. A nurse's note dated 12/19/25 at 7:37 PM by RN #11 (Agency) identified that Resident #37 was seen by the dietitian for concerns about a non-blanchable area of redness on the sacrum on 12/15/24. The identified recommendations included initiating a carbohydrate-controlled diet for improved blood sugar control and starting Proheal (a protein supplement used to add in wound healing) twice daily to aid in wound healing. The note further identified the orders were implemented in Resident #37's record. Review of the 12/2024 TAR identified an order for Proheal 30ml twice daily which was started on 12/19/24 to be given twice daily at 9:00 AM and 5:00 PM. Review of the clinical record failed to identify any additional documentation or interventions related to the non-blanchable area on the sacrum after 12/19/24. Interview with LPN #3 (Regional Corporate LPN) on 5/5/25 at 11:00 AM identified she was unable to locate any additional documentation related to further assessments of Resident #37's non-blanchable sacral area following the initial documentation on 12/15/24. LPN #3 identified that Resident #37 had an order for a weekly skin check. LPN #3 identified that the facility policy was that the skin checks were signed off on the TAR weekly and only issues that were identified were documented as a skin observation. LPN #3 identified that Resident #37's physician or APRN should have been notified of the new skin issue as well as Resident #37's resident representative and the non-blanchable skin area should have been followed and assessed at least weekly once it was identified. Interview with APRN #2 on 5/7/25 at 9:05 AM identified she was not notified of the non-blanchable sacral area identified by the prior DNS on 12/15/24. APRN #1 identified that while the interventions implemented by the Prior DNS appeared to be appropriate, if she had been notified, she would have assessed the area or requested that the RN who works with her and alternates visits to the facility to assess the area and notify her of the findings. APRN #2 identified that a non-blanchable area to the sacrum as identified in the Prior DNS's note would possibly have been a pressure ulcer, but she would have needed to assess the area to be sure however she was not notified. Interview with LPN #1 on 5/7/25 at 9:10 AM identified she was the facility wound nurse on 12/15/24. LPN #1 identified she had not been notified regarding the non-blanchable area on Resident #37's sacrum identified on 12/15/24. LPN #1 identified that the process for any newly identified skin area that could potentially be a pressure injury included adding the resident to the upcoming weekly wound rounds so that the wound physician could assess and determine the next steps in treatment. LPN #1 also provided a weekly wound round list dated 12/18/24. Review of the 12/18/24 weekly wound round list failed to identify any documentation that Resident #37 was added to the list to be seen by the wound physician. Review of the 24-hour nursing report sheets from 12/15/24 - 12/20/24 failed to identify any additional documentation related to the non-blanchable area on the sacrum. Although attempted, an interview with the Prior DNS was not obtained. Although attempted, an interview with RN #11 was not obtained. The facility policy on pressure ulcers/skin breakdown directed that the facility would help prevent and manage pressure ulcers consistent with established guidelines. The policy further directed that the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers; For example, immobility and medical instability, and that the physician would help to identify the type and characteristics of any identified ulcer and help identify and define any complications related to pressure ulcers. The policy further directed that the physician would help identify factors contributing or predisposed residents to skin breakdown and would help clarify the status of relevant medical issues including the impact of comorbid conditions on healing and existing wounds.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #46 and Resident 50) reviewed for hospitalization, the facility failed to provide written notice of the bed hold policy to the resident representative when the resident was transferred to the hospital. The findings include: 1. Resident #46 had diagnoses that included congestive heart failure and dementia. The resident census identified the following hospital transfers for Resident #46: Resident #46 was transferred to the hospital on 3/10/25 and returned to the facility on 3/15/25. Resident #46 was transferred to the hospital on 3/19/25 and returned to the facility on 3/22/25. Review of the clinical record failed to identify that written notice of the bed hold policy had been provided to the resident/representative at or following the time of the transfers on 3/10/25 and 3/19/25. An interview with the Administrator on 5/5/25 at 10:54 AM identified it was the nursing staff responsibility to ensure the bed hold policy was provided to the resident/resident representative at the time of the hospital transfer. An interview and clinical record review with RN #5 on 5/05/25 at 11:00 AM identified her role as a nursing supervisor normally scheduled for the 7:00 AM to 3:00 PM shift included to ensure the bed hold policy was completed and provided to the resident representative at the time of a hospital transfer. RN #5 further identified the bed hold policy form was not completed for Resident #46 as an oversight. Additionally, the bed hold policy was not included as part of the transfer packet. 2. Resident #50 had diagnoses that included hypoxia and Alzheimer's disease. The resident census identified the following hospital transfers for Resident #46: Resident #50 was transferred to the hospital on 2/26/25 and returned to the facility on 3/1/25. Resident #50 was transferred to the hospital on 3/26/25 and returned to the facility on 3/29/25. Review of the clinical record failed to identify that written notice of the bed hold policy had been provided to the resident/representative at or following the time of the transfers on 2/26/25 and 3/26/25. An interview with the Administrator on 5/5/25 at 10:54 AM identified it was the nursing staff responsibility to ensure the bed hold policy was provided to the resident/resident representative at the time of the hospital transfer. An interview and clinical record review with RN #5 on 5/05/25 at 11:00 AM identified her role as a nursing supervisor normally scheduled for the 7:00 AM to 3:00 PM shift included to ensure the bed hold policy was completed and provided to the resident representative at the time of a hospital transfer. RN #5 further identified the bed hold policy form was not completed for Resident #46 as an oversight. Additionally, the bed hold policy was not included as part of the transfer packet. The facility's Bed-Hold and Returns policy directs that prior to a transfer, written information will be given to the resident and the resident representative that explains in detail: a. The rights and limitations of the resident regarding bed-holds. b. The reserve bed payment policy as indicated by the state plan (Medicaid residents). c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer).

Based on review of facility documentation, facility policy, and interviews for 1 of 3 certified nurse aide personnel files reviewed, the facility failed to complete annual employee performance reviews at least every twelve months. The findings include: Review of NA #10's personnel file identified her date of hire as 2/10/15. The last performance review was on 8/3/20, 5 years ago. An interview with the Administrator on 5/6/25 at 9:13 AM identified it was the responsibility of the DNS and ADNS to ensure the completion of annual evaluations. Frequent turnover in staffing likely contributed to the evaluation not being completed annually. The Annual Employee Evaluation policy directs all employees' job performance be evaluated annually based on their hire date or facility - defined cycle and applies to all full time, part time and per diem employees across all departments.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1), reviewed for accidents, the facility failed to ensure that staff provided the required assistance with a resident transfer which resulted in a fall with injuries. The findings include: Resident #1 had diagnoses that included reduced mobility, depression, and anxiety. Review of the Activity of Daily Living (ADL) administration history record dated 12/11/2024 identified that Resident #1 is non-ambulatory and requires the assistance of 2 staff members for all ADLs. Review of the care plan dated 12/11/2024 identified Resident #1 requires a Hoyer lift (a device that lifts patients mechanically) for transfers related to reduced mobility as evidenced by impaired physical mobility with interventions that directed to provide the assistance of two (2) staff for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicative of moderately impaired cognition, was frequently incontinent of bowel and bladder, required maximal assistance with ADLs. Review of Resident #1's fall risk assessment dated [DATE] identified Resident #1 was at a high risk for falls. The physician's order dated 1/15/2025 identified Resident #1 was non-ambulatory and required a Hoyer lift for transfers. Review of Resident #1's undated care card (directs the care the resident required) identified Resident #1 was non-ambulatory and required the assistance of 2 staff with a Hoyer lift for transfers. Review of the Facility's Accident and Incident Form dated 1/22/2025 at 2:45 P.M. identified while Nurse Aide (NA) #1 was transferring Resident #1 to obtain h/her weight, Resident #1's legs buckled, and Resident #1 fell. Resident #1 was transferred to the hospital and reported to have a left ankle and right femur fracture. Review of the nurse's note dated 1/22/2025 at 2:46 P.M. written by the Director of Nursing Services (DNS) identified that Resident #1 had a witnessed fall in the shower room while NA #1 was attempting to obtain Resident #1's weight. The DNS indicated Resident #1 lost h/her balance and fell to the floor. The DNS identified she spoke with Advanced Practice Registered Nurse (APRN) #2 who ordered further evaluation and 911 was activated and the resident was transferred to the hospital. Review of the Facility's Accident and Incident and Summary dated 1/22/2025 identified Resident #1 was non-ambulatory and required a Hoyer lift for transfers when NA #1 was attempting to obtain Resident #1's readmission weight Resident #1 lost h/her balance on the standing scale and sustained a fall. Resident #1 complained of severe pain and was transferred to the emergency room for further evaluation. An investigation was initiated, and it was determined that NA #1 did not follow Resident #1's plan of care by attempting to transfer Resident #1 without the use of a Hoyer lift. Review of the hospital orthopedic surgeon note dated 1/22/2025 at 6:46 P.M. identified Resident #1 sustained an acute traumatic fall at h/her facility earlier this evening upon arrival to the emergency department Resident #1 was noted to have an obvious open fracture of h/her lower left extremity with associated deformity. Resident #1 had severe pain and deformity of h/her right knee. MD #2 identified imaging demonstrated a severely displaced (bones are not in alignment) and comminuted (bones are broken into several pieces) left distal tibia (shin bone) and fibular (calf bone) fracture as well as a comminuted displaced and impacted (ends of bones are forced together) right femur (thigh) fracture. MD #2 identified Resident #1 was splinted and stabilized and received intravenous (IV) antibiotics for an open fracture in the emergency department. MD #2 identified Resident #1 required urgent operative intervention for the left lower extremity and semi-urgent operative intervention for the right femur. Review of the Hospital Discharge summary dated [DATE] identified Resident #1 was admitted on [DATE] for a fall with an open tibial fracture (broken bone breaks through the skin), open fibular fracture. Resident #1 is status post irrigation (cleaning) and debridement (removes damaged tissue) of the left tibia, intramedullary nailing (IM) ( a metal rod used to stabilize the bone) of left tibia fracture with accompanying fibula fracture, as well as closed reduction (re-alignment of bones without the need for surgery) and splinting of the right distal femur fracture. The nurse's note dated 1/26/2025 at 3:17 P.M. identified Resident #1 was readmitted with diagnoses of a right distal femur fracture and left tibia and fibula fracture. Interview with NA #1 on 2/19/2025 at 11:45 A.M. identified on 1/22/2025 when LPN #1 directed her to obtain Resident #1's weight, NA #1 did not review Resident #1's plan of care nor ask LPN #1 what Resident #1's plan of care was for transfers. NA #1 identified on 1/22/2025 she assumed Resident #1 was able to transfer from the wheelchair to the standing scale because when she went to get Resident #1 out of bed into the wheelchair Resident #1 transferred independently into the wheelchair. NA #1 stated she wheeled Resident #1 into the shower room and pulled the wheelchair in front of the standing scale, Resident #1 stood up placed h/her hands on the metal grab bar around the scale, stepped on to the scale, and when Resident #1 took another step toward the middle of the scale NA #1 heard a popping sound and Resident #1 fell down on h/her buttocks on to the scale. NA #1 identified that she should not have assumed Resident #1 could transfer on to the standing scale without reviewing Resident #1's plan of care or asking LPN #1 how Resident #1 transferred. NA #1 further identified she knows better as it is her responsibility to review the resident's plan of care prior to providing care. Interview with the Director of Nursing Services (DNS) on 2/19/2025 at 10:45 A.M. identified on 1/22/2025 NA #1 did not follow Resident #1's plan of care for transfers, the resident fell and sustained fractures of the left tibia, left fibula, and right distal femur. The DNS identified NA #1 should have used the Hoyer lift scale instead of the standing scale, as the resident was not able to stand or transfer without the use of a Hoyer lift. The DNS further identified that she expects that all nurse aides review a resident's plan of care prior to providing care. Review of the facility falls protocol policy; in part, directed based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one three sampled residents (Resident #1) who was reviewed for an allegation of abuse, the facility failed to ensure a resident was free from sexual mistreatment following an allegation of staff to resident sexual abuse which resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included cirrhosis of the liver, anxiety, panic attacks and post-traumatic stress disorder (PTSD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented and able to make needs known and able to recall events and was independent with personal care. The Resident Care Plan dated 12/29/22 identified Resident #1 had ineffective coping related to PTSD. Interventions included to assess the resident for suicidal or homicidal ideation, ensure safety of the client and others, assess anxiety level, determine severity of condition and course of treatment or therapy, and establish trust with the resident. The Facility Reported Incident report dated 1/30/23 at 6:00 PM identified 911 was called by Resident #1 for an allegation of sexual assault, inappropriate physical touching, taking personal items in and out of the room for unknown reasons. The report indicated the staff member involved in the allegation was removed from the schedule and Resident #1 was sent to the emergency room for an evaluation and upon return to the facility medication adjustments were made by the facility Advanced Practice Registered Nurse (APRN) in response to increased panic attacks, insomnia, and increased anxiety. An interview with Resident #1 on 2/17/23 at 9:11 AM identified beginning one and a half (11/2) years ago a nurse aide, NA #1, who was regularly assigned to him/her, began spending more time in his/her room, sitting on the bed talking, asking and sharing personal information and would frequently brush by him/her, face to face and from the back with his pelvic region making contact with his/her pelvic region and buttocks as NA #1 went by. Resident #1 identified over time, NA #1's behavior progressed where he attempted to kiss him/her on multiple occasions, try to extend his hands down his/her pants while rubbing his/her neck and touched personal items. Resident #1 identified in the Summer of 2022, while he/she was showering, NA #1 pulled the curtain back, grabbed a washcloth placing it between his/her inner thighs, moved the washcloth up towards the buttock region and he/she could feel NA #1 trying to push further into his/her perianal region. Resident #1 stated he/she screamed which made NA #1 nervous and NA #1 abruptly left the shower room. Resident #1 identified shortly after the incident, he/she reported to NA #2 he/she was not comfortable with NA #1 and did not want NA #1 in the room. Resident #1 identified subsequent to that time, additional acts of sexual abuse continued by NA #1 that included further attempts to kiss and one occasion of inappropriate touch while he/she was in bed where NA #1 attempted to pull down his/her pants while providing a warm towel to the abdomen. Resident #1 identified he/she set up video surveillance on 1/28/23 and 1/29/23 and NA #1 was noted to be rummaging through his/her personal items while he/she was on a Leave of Absence. Resident #1 identified the video showed NA#1 utilized personal items (toothbrush, hairbrush), removed undergarments from the dirty laundry, smelled the undergarments, left the room with the undergarments, and then returned the garments to the dirty laundry basket. Resident #1 indicated viewing the video made him/her very upset and had his/her roommate call 911. Resident #1 identified after the police came to interview him/her, he/she was transferred to the hospital for an evaluation. An interview with Resident #1's roommate, Resident #2 who was alert and oriented, on 2/17/23 at 1:11 PM identified he/she had witnessed acts of inappropriate touching and behavior by NA #1 towards Resident #1 beginning approximately six (6) months ago that included spending hours in the room, attempts to kiss Resident #1, brushing up against Resident #1 when there was plenty of room to get by, and messing with Resident #1's personal items. Resident #2 indicated he/she observed NA #1 crouch down by Resident #1's bed, take soiled underwear and rub the crotch area between his fingers without gloves and NA #1 would attempt to pull the curtain closed when in the room and Resident #1 who would say he/she did not want the curtain pulled. Resident #2 identified he/she was present a few months earlier when NA #1 was trying to massage Resident #1 who was saying he/she did not need a massage and he/she observed NA #1 attempting to pull down Resident #1's pants and that Resident #1 turned around and said Stop. Resident #2 identified he/she told NA #1 on a separate occasion that he was overstepping his bounds and NA #1 would reply he had done nothing wrong. Resident #2 indicated he/she tried on many occasions to encourage Resident #1 to report NA #1, but Resident #1 was scared and intimidated by NA #1 and stated he/she could handle the situation. Interview with NA #2 on 2/17/23 at 2:06 PM identified sometime in the Fall 2022, Resident #1 was observed in the hall, very upset, red in the face and stating he/she did not want NA #1 in his/her room anymore, that he made him/her uncomfortable when NA #1 had pulled the shower curtain open while he/she was in the shower and did not require any assistance. NA #2 indicated she told NA #1 what Resident #1 said stating she would provide anything needed going forward. NA #1 identified she and NA #1 proceeded into Resident #1's room and Resident #1 immediately apologized to NA #1 without anything first being said and that NA #2 then left as everything appeared to be fine. NA #2 indicated she did not report the incident to anyone as Resident #1 seemed fine and brought forward no other concerns. An interview with NA #1 on 2/21/23 at 8:24 AM identified he developed special feelings for Resident #1 from early on and felt as though they had a special friendship. NA #1 admitted he pulled the shower curtain open on Resident #1, went through Resident #1's personal items, and sniffed and removed garments however he had no explanation for doing so. An interview with a speech therapist (ST #1) on 2/21/23 at 10:57AM identified she had been the victim of sexual assault by NA #1 on 10/28/22. ST #1 learned from staff, Resident #1 may have also had questionable inappropriate encounter with NA #1 and requested the Administrator investigate as she was concerned a resident may be involved. The Administrator told ST #1 they would not be involving residents in a staff-to-staff allegation that was rumored to have happened. Interview with the Administrator on 2/21/23 at 1:42PM and 3/1/23 at 1:51 PM identified ST #1 brought up Resident #1's name during an investigation only stating the Administrator should talk with Resident #1 but gave no other details. The Administrator identified she did not follow up with Resident #1 as s/he was alert and oriented and could express any concerns him/herself. The Administrator indicated she was made aware of the details of the allegation(s) on 1/30/23 when the police were dispatched to the facility and NA #1 was immediately placed on suspension effective 1/30/23. The Administrator identified after reviewing the video of NA #1's activities, a decision was made to terminate NA #1, effective 2/6/23. The facility policy for Resident Rights directs a resident be free from abuse. The facility policy for Abuse, Neglect, Exploitation that directs the protection welfare and rights of each resident that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property and includes sexual abuse (any non-consensual sexual contact of any type with a resident). On 3/23/23, the facility provided the Department with an action plan to address the finding of IJ related to abuse to include in part education on the facility policies, Abuse, Neglect and Misappropriation and Sexual Abuse/Inappropriate touching to ensure all residents are free from Abuse, Neglect and Misappropriation and are kept safe. Education was provided to RN supervisors to ensure that in accordance with the facility policy entitled, Abuse, Neglect and Misappropriation, the Administrator and DON are notified immediately when any resident or staff member reports an allegation of Abuse, Neglect and Misappropriation. Education initiated 1/31/23. After 2/16/23, staff to be educated prior to start of shift. A Resident Council meeting was conducted on 1/31/23 to discuss Resident Rights and all residents were invited to attend. Meeting minutes were passed out to residents who did not attend. No further allegations were received. Completion Date 1/31/23. Interviews were conducted with all interviewable residents to determine if any resident had issues with Abuse, Neglect and Misappropriation at the hands of any staff member. Clinical Resident assessments were conducted on all non-interviewable residents in the facility looking for any change in behavior or mood in a confused resident for the last 3 months. No other issues were identified. Completed 2/1/23. Audits of residents via interviews by the Director of Social Service are being conducted to identify any resident who would be at risk for alleged Abuse, Neglect and Misappropriation are being conducted twice a week times two months, then once a week times one month. Weekly audits initiated 2/1/23. No further concerns identified. The results of the audits were reviewed in a QAPI meeting that was conducted on 2/17/23 at 8:00 AM, prior to the initiation of the DPH complaint survey. The facility alleged removal of the Immediate Jeopardy effective 2/24/23.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one of three sampled residents (Resident #1) who was reviewed for an allegation of abuse, a staff member (NA#2) failed to report an allegation of potential staff to resident sexual abuse and the facility failed to conduct a comprehensive investigation of potential misconduct when a speech therapist expressed concerns on 10/28/22 and as a result Resident #1 continued to be abused by a nurse aide until 1/30/23 when the police arrived to investigate concerns of abuse which resulted in Immediate Jeopardy. The findings include: Resident #1's diagnoses included cirrhosis of the liver, anxiety, panic attacks and post-traumatic stress disorder (PTSD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable decisions regarding tasks of daily life and was independent with personal care. The Resident Care Plan dated 12/29/22 identified Resident #1 had ineffective coping related to PTSD. Interventions included to assess the resident for suicidal or homicidal ideation, ensure safety of the client and others, assess anxiety level, determine severity of condition and course of treatment or therapy, and establish trust with the resident. The Facility Reported Incident report dated 1/30/23 at 6:00 PM identified 911 was called by Resident #1 for an allegation of sexual assault, inappropriate physical touching, taking personal items in and out of the room for unknown reasons. The report indicated the staff member involved in the allegation was removed from the schedule and Resident #1 was sent to the emergency room for an evaluation and upon return to the facility medication adjustments were made by the facility Advanced Practice Registered Nurse (APRN) in response to increased panic attacks, insomnia, and increased anxiety. An interview with Resident #1 on 2/17/23 at 9:11 AM identified beginning one and a half (11/2) years ago a nurse aide, NA #1, who was regularly assigned to him/her, began spending more time in his/her room, sitting on the bed talking, asking and sharing personal information and would frequently brush by him/her, face to face and from the back with his pelvic region making contact with his/her pelvic region and buttocks as NA #1 went by. Resident #1 identified over time, NA #1's behavior progressed where he attempted to kiss him/her on multiple occasions, try to extend his hands down his/her pants while rubbing his/her neck and touched personal items. Resident #1 identified in the Summer of 2022, while he/she was showering, NA #1 pulled the curtain back, grabbed a washcloth placing it between his/her inner thighs, moved the washcloth up towards the buttock region and he/she could feel NA #1 trying to push further into his/her perianal region. Resident #1 stated he/she screamed which made NA #1 nervous and NA #1 abruptly left the shower room. Resident #1 identified shortly after the incident, he/she reported to NA #2 he/she was not comfortable with NA #1 and did not want NA #1 in the room. Resident #1 identified subsequent to that time, additional acts of sexual abuse continued by NA #1 that included further attempts to kiss and one occasion of inappropriate touch while he/she was in bed where NA #1 attempted to pull down his/her pants while providing a warm towel to the abdomen. Resident #1 identified he/she set up video surveillance on 1/28/23 and 1/29/23 and NA #1 was noted to be rummaging through his/her personal items while he/she was on a Leave of Absence. Resident #1 identified the video showed NA#1 utilized personal items (toothbrush, hairbrush), removed undergarments from the dirty laundry, smelled the undergarments, left the room with the undergarments, and then returned the garments to the dirty laundry basket. Resident #1 indicated viewing the video made him/her very upset and had his/her roommate call 911. Resident #1 identified after the police came to interview him/her, he/she was transferred to the hospital for an evaluation. An interview with NA #2 on 2/17/23 at 2:06 PM identified sometime in the Fall of 2022, Resident #1 was observed in the hall, very upset, red in the face and stating he/she did not want NA #1 in his/her room anymore, that he made Resident #1 uncomfortable and that he had pulled the shower curtain open while Resident #1 was in the shower. NA #2 told NA #1 what Resident #1 reported and stated she would provide anything Resident #1 needed going forward. NA #2 indicated NA #1 told her to go with him to pass meal trays in Resident #1's room and when entering the room, Resident #1 immediately apologized to NA #1 without anything first being said and she then left as everything appeared to be fine. NA #2 indicated she did not report the incident to anyone as Resident #1 seemed fine. An interview with a Speech Therapist, ST #1, on 2/21/23 at 10:57 AM identified she had been the victim of sexual assault by NA #1 on 10/28/22. ST #1 reported while walking through a door threshold, NA #1 brushed up against her and grabbed her breast and this incident was not the first inappropriate sexual encounter with NA #1. ST #1 reported the incident to the Social Worker, Human Resources and the Administrator who initiated a limited investigation for the staff-to-staff allegation. ST #1 identified during the course of the investigation, she learned from staff, Resident #1 may have also had questionable inappropriate encounters with NA #1 and requested the Administrator investigate as she was concerned a resident may be involved. The Administrator told ST #1 they would not be involving residents in a staff-to-staff allegation that was rumored to have happened. An interview with an Occupational Therapist, OT #1, on 2/21/23 at 1:08 PM identified he provided representation for ST #1 following her allegation and was present in the room when it was communicated to the Administrator NA #1 was alleged to have been in Resident #1's room for an extended periods and that the Administrator stated they did not want to investigate rumors. Interview with OT #2 on 2/21/23 1:24 PM also stated she had encounters in years past with NA #1. OT #2 stated she and OT #1 were present when ST #1 stated something may have gone on between NA #1 and Resident #1 that the Administrator and Corporate Representative stated they would not be involving residents. An interview with the Administrator on 2/21/23 at 1:42 PM identified ST #1 brought up Resident #1's name during an investigation only stating she should talk with Resident #1 but gave no other details. The Administrator identified she did not follow up with Resident #1 as Resident #1 was alert and oriented and could express any concerns him/herself. The facility policy for Abuse, Neglect, Exploitation that directs responding immediately to an allegation to protect the alleged victim and integrity of the investigation and to complete an immediate investigation when suspicion of abuse has occurred of all involved persons including the alleged victim and perpetrator, witnesses and others who might have knowledge of the allegation(s).

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (R #1) reviewed for accidents, the facility failed to ensure adequate supervision for a resident identified at risk for elopement to prevent an elopement of R #1 from the 2nd floor without staff knowledge. The findings include: R #1's diagnoses included dementia, muscle weakness and anxiety. A physician's order dated 6/26/2020 directed Resident #1 was independent with transfers and gait throughout the facility. Psychiatric Physician's Assistant note dated 10/14/2020 identified R #1 was upset and wanted to leave the facility to get out of [NAME]. Facility elopement assessment dated [DATE] identified a score of eleven (11) which indicated Resident #1 was at risk for elopement. Social Services note dated 10/29/2020 at 10:27 AM identified R #1 ' s recent transfer request to [NAME] was declined, and R #1 took the news well. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen, indicative of moderate cognitive impairment, was independent with transfers and ambulation, continent of bowel and bladder and had no wandering behaviors. A Court of Probate Decree dated 11/3/2020 identified Resident #1 had a mental, emotional or physical condition that resulted in Resident #1 being incapable of caring for him/herself due to cognitive deficits. Resident #1 was incapable of caring for self-due to judgment, disorganization, and memory issues related to declining cognitive state, and the Court appointed a Conservator of Person for R #1. The Resident Care Plan (RCP) dated 11/5/2020 identified a deconditioned state and anxiety. Interventions directed to assist per physician orders, and to assess if behaviors present a danger to self or others. Facility Incident Report dated 11/13/2020 at 1:30 A.M. identified a conserved resident left the building unattended. Facility investigation summary identified R #1 left the facility without knowledge of the staff and was brought to the hospital at 1:30 AM. R #1 had no injury. R #1 exited the facility through the (2nd floor) patio door after he/she had viewed staff enter the door code in the keypad. Investigation further identified R #1 was last seen by staff at approximately 9:00 P.M. The report also noted staff was not aware that R #1 was missing until they received a call from the hospital at 1:30 A.M. informing them R #1 was at the hospital. Upon readmission to the facility, R #1 had no injuries identified, a wander guard bracelet was applied, and R #1 was transferred to the unit (3rd floor) with the wander guard alert system. Review of facility Wandering and Elopements Policy (dated March 2019) directed in part, the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. The hospital Emergency Department physician note dated 11/13/2020 identified R #1 left the facility because he/she does not like it there, left this evening and was headed to Bethel, however became tired when walking, legs gave out and he/she called an ambulance. No injuries were noted, R #1 was readmitted to the facility on [DATE]. Interview, clinical record review, and facility documentation review with the Administrator, the DON, Assistant Director of Nursing (ADON) and Director of Maintenance on 11/18/2020 at 10:46 A.M. identified that R #1 had watched staff enter the door code into the keypad prior to exiting the facility and was then able to enter the code into the keypad and exit the facility unobserved by staff on 11/13/2020 at approximately 10:57 PM. Interview identified the facility first became aware R #1 was not in the facility when they received a call from the hospital at 1:30 AM reporting that they had R #1 in the emergency room . Facility recorded video surveillance showed R #1 exited the patio door alone. Interview identified the door code was not change regularly; the code was changed only when there was an issue. The facility was unable to provide documentation of when the door code was last changed prior to R #1's elopement. The Administrator indicated that staff should shield the keypad when entering the code, residents should not have the door code and the code was changed on 11/14/2020. Interview and facility surveillance video review with the Administrator on 11/18/2020 at 1:55 P.M. identified the video dated 11/13/2020 showed the exterior of the building (no video of the interior of the facility). R #1 was observed to exit the facility alone, carrying a small grocery-size green plastic bag in his/her left hand and a large clear garbage-car type bag that appeared full of clothing items. R #1 was wearing long pants, shoes, and a plaid over-style shirt. R #1 placed the bags on a bench near the door and donned a knit-type hat, then opened the chain-link gate (lift type latch on gate) and exited the patio area. R #1 was observed to walk onto the public sidewalk, turn left and walk away into the darkness. Interview with R #1 on 11/18/2020 at 11:40 AM identified R #1 wanted to move to another facility and had previously verbalized his/her desire to leave the facility to staff on numerous occasions. R #1 indicated he/she packed his/her belongings in plastic bags, checked the hall for any staff, and exited the facility through the patio door without any staff seeing him/her. R #1 indicated that he/she had observed staff enter the door code in the keypad in the past. He/she knew the facility did not change the code and he/she was able to use the code to exit the building. R #1 identified the code he/she used was three digits. R #1 related that he/she walked to the cross street, walked up the street and wanted to go to a Bethel church to ask for help. R #1 further indicated that he/she got tired carrying the heavy bag of belongings and when he/she entered the school field he/she fell a few times. R #1 had a cell phone and called 911 for help. To assist EMS in locating him/her in the dark field he/she continuously kept hitting the buttons on his/her cell phone to illuminate where he/she was in the field. R #1 indicated that EMS located him/her and took him/her to the hospital. Interview, clinical record review, and facility documentation review with Licensed Practical Nurse (LPN #1) on 11/18/2020 at 12:36 PM identified LPN #1 worked the 11-7 A.M. shift on 11/13/2020, R #1 was her resident and she was aware that R #1 was not happy at the facility, wanted a transfer to another facility, but did not know he/she would leave the facility. She identified that although she usually does initial rounds to check on residents at the start of her shift, on 11/13/2020 she did not check on R #1, and that she should have checked on R #1 at the start of her shift. Interview, clinical record review, and facility documentation review with Nurse Aide ( NA #2) at 11/18/2020 1:23 PM identified that she worked 3-11 PM prior to R #1 ' s elopement on 11/13/2020, and R #1 was her resident. She identified that she last saw R #1 on his/her bed at about 9:00 or 9:30 PM. Interview, clinical record review, and facility documentation review with NA #3 on 11/18/2020 at 11:22 PM identified she worked on 11/13/2020, 11-7 AM shift and R #1 was her resident. She identified that she did initial rounds at the beginning of her shift and saw that R #1 was not in his/her bed. She indicated the bathroom light was on and the door was partly open so she assumed R #1 was in the bathroom; she did not see R #1 for her rounds check, and identified that she should have verified R #1 ' s location during her rounds. Interview, clinical record review, and facility documentation review with the Director of Recreation on 11/19/2020 at 9:40 A.M. identified the recreation staff would take R #1 outside daily through the patio door. Interview with Resident #1 on 11/19/2020 at 10:24 A.M. identified he/she obtained the door code by watching a Volunteer #1 enter the code into the keypad. Volunteer #1 was unavailable for interview during the survey. Interview, clinical record review, and facility documentation review with the Administrator and DON on 11/19/2020 at 11:32 A.M. identified the patio door code was the three digits (the same code that R #1 identified as the code). When EMS located R #1, he/she was on the sidewalk in front of the school past the hospital - approximately half a mile away from the facility. R #1 was readmitted to the facility on [DATE] at approximately 1:30 PM (14 1/2 hours after video recorded elopement). Surveyor observations on 11/19/2020 of route R #1 traveled identified he/she walked past a cemetery, [NAME] Hospital load docks, main entrance and emergency entrance, a fenced in sports field two traffic lights and would have had to cross a street with one lane of traffic for each direction to the identified location. Mileage from the patio door to the front of the school driveway was 0.7 miles. Facility did not provide a policy for surveyor review regarding monitoring resident's whereabouts, however interview with the Administrator identified that the expectation was that a residents should not have the codes to any exit doors.

Based on observation, a review of clinical records, facility documentation, police reports, interviews, and policy review, for one of four residents who were at risk for elopement (Resident #1), the facility failed to ensure a conserved resident was assessed for elopement risk upon admission, that interventions were in place when exit seeking behavior was identified, that staff kept the resident in eyesight once the resident left the facility, that a resident did not enter a resident restricted area, that staff maintained accurate documentation of resident observations, that staff responded to a door alarm timely, and that elopement books were up to date, resulting in a finding of Immediate Jeopardy. The Immediate Jeopardy was abated during the onsite visit on 12/5/19. The findings include: 1) Resident #1 was admitted to the facility on [DATE] at 2:30 PM from an acute care hospital with [DIAGNOSES REDACTED]. Review of a probate court appointment of conservator decree dated 11/5/19 identified that Resident #1 was appointed an involuntary conservator of estate and person (COE/COP). The document identified the following: COE/COP was appointed because there was clear and convincing evidence that the patient presented with a mental, emotional, and physical condition that rendered him/her unable to evaluate information and to care for him/herself. The decree further identified that the doctors at the discharging hospital recommended supervision in a long term care facility due to his/her cognitive deficits, the fact he/she cannot recognize unsafe situations, and cannot maintain a safe independent living environment. Review of the discharge summary dated 11/7/19 identified that the resident had a past medical history of [REDACTED]. Hospital behavioral progress notes dated 11/4, and 11/6/19, that were sent to the facility as part of the admission paperwork, identified that Resident #1 had long and short term memory deficits, was oriented to person, and had poor insight and judgement. The resident had minimal insight into cognitive limitations that would place him/her in danger if he/she were to return home. Furthermore, the resident did not have the capacity to make complex medical decisions such as signing out against medical advice. a) Review of an admission assessment dated [DATE] identified that the resident was independent with ambulation and had mild cognitive impairment, however, failed to contain an elopement assessment. A nurse's note dated 11/7/19 at 11:40 PM written by Registered Nurse (RN) #3 identified that the resident was admitted at 2:30 PM and was asking when he/she is going home and claimed that the hospital promised that he/she would only be staying a day or two. The Advanced Practice Registered Nurse (APRN) was made aware and the facility was awaiting a physician's orders [REDACTED]. Interview with the facility receptionist on 12/3/19 at 1:45 PM identified that she was working the front desk on 11/7/19 when the resident was admitted . Resident #1 was very agitated and repeated many times that he/she did not belong at the facility, and that he/she had a job and an apartment to go to. She called the nursing supervisor (RN #1) to come to the lobby, and when RN #1 arrived to speak with the resident she went to inform the Admissions Coordinator (AC) that the new admission (Resident #1) did not want to be in the facility and was looking to leave. She stated that RN #1 and the AC were able to talk the resident into staying. Interview with RN #3 on 12/3/19 at 3:45 PM identified that she had been the nursing supervisor for 3:00 PM to 11:00 PM shift on 11/7/19 when the resident was admitted , but she could not recall if she had done an elopement assessment, although it is usually completed upon admission. She identified that she felt that the resident was an elopement risk because he/she was independently ambulatory and was talking about wanting to go home. RN #3 further stated that she called the APRN to request a wander guard order, but she had not received a call back, and could not put a wander guard on the resident without a physician's orders [REDACTED]. Interview with RN #1 on 12/3/19 at 1:15 PM identified that she was the nursing supervisor on the 7:00 AM to 3:00 PM shift on 11/7/19. She identified that an elopement assessment was always done upon admission and she had admitted the resident to the facility around 2:30 PM and had completed an elopement assessment, which identified that the resident was not at risk for elopement (although the admission elopement assessment was requested by the surveyor on 12/3, 12/4, 12/5, and 12/6/19, the facility was unable to provide the assessment). RN #1 stated that the resident was not at risk for elopement because the resident had not specified that he/she had wanted to leave, the resident only stated that he/she was supposed to be in the facility for a few days (although the receptionist was concerned and notified RN #1 on the day of admission that the resident had repeatedly mentioned that h/she wanted to leave the facility.) Interview with the Director of Nurses (DON) on 12/4/19 at 1:45 PM identified that she was sure that RN #1 had done the elopement assessment, but was unable to locate it. She further identified that there was not an elopement assessment in place, but it should be done on admission, and identified that RN #3 should have put an intervention in place when she was informed the resident wanted to leave. The facility failed to do an elopement assessment upon admission, failed to follow-up with a licensed practitioner for a wander guard order, and failed to implement any interventions when RN #3 was aware Resident #1 wanted to leave the facility. b) Interview with Licensed Practical Nurse (LPN) #3 on 12/3/19 at 1:40 PM identified that she was Resident #1's charge nurse on 11/8/19 for the 7:00 AM to 3:00 PM shift, and when she introduced herself, the resident stated that he/she wanted to leave. LPN#3 called RN #1 and reported that the resident was talking about leaving, RN #1 told her that she was trying to get a hold of the conservator and physician to get consent for the wander guard, and to keep an eye on Resident #1. The clinical record failed to identify that measures were implemented to supervise the resident's whereabouts. Interview with the facility receptionist (desk located in the front lobby) on 12/3/19 at 1:45 PM stated on 11/8/19, a little after 8:00 AM, Resident #1 came through the lobby with his/her belongings and stated I'm out of here, (the facility doors are unlocked at 8:00 AM) and then walked out the front door. The receptionist called RN #1 and asked if the resident had been discharged , (but wasn't sure if the resident was an elopement risk at the time). The receptionist stated that she was informed by RN #1 that the resident had not been discharged , she then informed the supervisor that the resident had left the building by way of the front door. When RN #1 arrived in the lobby she told RN #1 which direction the resident had gone in and RN #1 was able to catch up with the resident in the parking lot and bring the resident back into the building. The receptionist was then given directive from RN #1 to watch out, for the resident, which she did throughout the morning. The receptionist stated that Resident #1 spent a good part of the morning on the first floor (adjacent to the lobby area) opening doors that did not lead to the outside. She further identified that she did not report to RN#1 that the resident was in the lobby and attempting to open doors on the first floor because she was told to watch the resident, but was not aware that she should have informed RN #1 that the resident was in the lobby area. Interview with RN #1 on 12/3/19 at 1:15 PM identified that on 11/8/19 sometime after 8:00 AM she was alerted by the receptionist that Resident #1 had walked out the front door and was in the parking lot heading to the street. She went outside and was able to get the resident back inside. The resident stated that h/she was trying to go to his/her apartment down the street. RN #1 identified that she brought the resident back upstairs and told the staff to keep an eye, on Resident #1. She stated that she told LPN #3 to put the resident on every fifteen (15) minute checks, but did not put a wander guard on the resident because they had not obtained a physician's orders [REDACTED]. RN #1 further identified that the receptionist did not inform her that the resident was in the lobby most of the morning and/or trying to open doors, if she had been aware she would have assigned a staff member to monitor the resident one to one. Interview and review of the every fifteen (15) minute checks dated 11/8/19 provided to the surveyor by RN #1 and LPN #3 on 12/3/19 at 3:45 PM identified that she had signed the 15 minute check sheets from 9:00 AM until 10:00 AM, 10:30 AM until 1:15 PM, and at 2:00 PM. LPN #3 identified that she only knew the resident's location on 11/8/19 from 8:00 AM to 9:00 AM when the resident was with therapy, from 12:00 PM to 1:00 PM when he/she was on the floor eating lunch, and at 2:00 PM when the resident was noted in the stairwell. She further stated that a staff member directed her to fill out the every 15 minute check sheets that afternoon (12/3/19), and was not told by the supervisor that the resident was on 15 minute checks on 11/8/19, and therefore they were not completed Further interview with RN #1 on 12/4/19 at 10:30 AM identified that she had asked LPN #3 to fill out the every 15 minute checks on 12/3/19, but it was because she had originally entered the every 15 minute checks on a scrap piece of paper and wanted to transfer the information onto a every 15 minute check form to provide to the surveyor. Further interview with LPN #3 on 12/4/19 at 2:00 PM identified that she did not copy the 15 minute checks from a piece of scrap paper, she filled the form out at the request of RN #1 on 12/3/19 LPN #3 identified that she was not told by RN #1 on 11/8/19 to place the resident on every 15 minute checks. Interview with the medical director on 12/5/19 at 11:30 AM identified that a wander guard could be applied to any resident, as a nursing measure, if determined to be at risk for elopement or put interventions into place if the resident was exhibiting exit seeking behavior. She further identified that although she was not the residents primary physician, she is the medical director and is responsible for all residents in the building, and if she was in the building when the eloped from the facility on 11/8/19 at approximately 8:00 AM, she would expect notification and would have given an order for [REDACTED].>Interview with the DON on 12/4/19 at 1:45 PM identified that the facility does not have a wander guard policy, but a physician's orders [REDACTED]. The DON further identified that if the resident had left the building and was found in the parking lot, she would expect nursing staff to place the resident on one to one supervision, if there was no order for the wander guard. Additionally, she would expect the nursing staff to notify the medical director of the attempted elopement when she was in the building. The facility failed to ensure adequate supervision was provided after the resident had made statements about wanting to leave, eloped to the parking lot, and failed to notify the medical director who was in the building at the time of the elopement to obtain a wander guard order. c) Interview with Licensed Practical Nurse (LPN) #3 on 12/3/19 at 1:40 PM stated that at 2:00 PM she was standing at the end of the second floor hallway, by the stairwell door, and heard knocking. She looked through the door and saw Resident #1 standing in the stairwell knocking to get back on the unit. LPN #3 stated that she asked the resident how he/she had gained entry into the stairwell since the door required passcode to exit, and the resident stated that he/she had followed a staff member through the door(s). LPN#3 stated that she called RN #1 (supervisor( to inform her that Resident #1 had been found in the stairwell, asked what the intervention should be and was told to keep an eye on Resident #1. The clinical record failed to identify that measures were implemented to supervise the resident's whereabouts. On 12/3/19 at 9:00 AM, the door that leads to the kitchen and staff breakroom was observed to be propped open with the mag lock. Signage on the door directed that the door must be kept closed at all times and that no residents are allowed. The door to enter the kitchen area, was also noted to be open, then noted to be closed at 9:10 AM. On 12/3/19 at 1:40 PM, the surveyor and LPN #3 observed that the door was observed open. Interview with LPN #3 door identified that the door should be kept closed and only a code can be entered into a keypad to open it. She further identified that on 11/8/19, this was the area that Resident #1 had gained access to the stairwell. On 12/3/19 subsequent to surveyor inquiry the facility immediately in-serviced the nursing staff on door safety which included that doors to non-patient areas must be kept closed, and to never prop a door open even for a few minutes, if additional help is needed getting items through the door get assistance from another person to watch the door, and to always look behind you as you enter the doors to ensure no one has entered behind the person. The facility failed to inservice dietary staff who were the ones propping the door while delivering the meal trucks to the units. Interview and further observation with the corporate nurse on 12/4/19 at 9:38 AM identified that the door was again open, she then closed the door. The corporate nurse identified that the door was open because the meal carts had passed through and the door should have been shut by staff after the meal carts had passed through. On 12/4/19 the facility educated the dietary staff on keeping the doors closed at all times. Interview with the maintenance director on 12/3/19 identified that the door leads to a staff-only section of the facility, the kitchen, and key padded access to a stairwell that leads to the second and third floors. He stated that the doors have a magnetic lock on the back so the door can stay open but should only be kept open when meal carts are being brought through the door and then immediately closed. When the door is closed it can only be opened by entering a code into the keypad. Interview with RN #1 on 12/3/19 at 1:15 PM identified that LPN #3 had never informed her that the resident was found in a non-resident area such as the stairwell and if she had been informed she would have ensured one to one supervision of the resident by a staff member. Interview with the DON on 12/4/19 at 1:45 PM identified that she had not been aware that the resident was found in a non-resident area, and in the stairwell. The DON further stated that the staff should have placed the resident on one to one supervision if exit seeking behavior was identified. The facility failed to ensure that non-resident areas were secured to prevent residents from gaining entry to staff areas and stairwells, and failed put interventions into place when further exit seeking behavior was identified. d) Review of a reportable event dated 11/8/19 identified that at 2:30 PM the resident was observed in the front lobby with 1 bag (of belongings) and was witnessed leaving the facility. Staff tried to re-direct the resident until he/she became combative and ran away from the staff member. A nurse's note dated 11/8/19 written by Registered Nurse (RN) #1 identified that she was informed (via text by LPN #3) that the resident went to the lobby, so she immediately responded to the lobby and the resident was not there. RN #1 rushed outside to the parking lot and observed the resident walking hurriedly towards to the street, RN#1 called out to the resident while running towards the resident, RN #1 caught up with Resident #1 and educated him/her about the proper discharge process, and steps that need to be taken if he does not want to stay at the facility. The resident stated No, I don't care, I don't want to be here and started to swing his/her bag at RN#1 and then crossed the street. RN #1 went back into the building while looking in the direction of the resident and immediately informed the receptionist to call the police, the physician and the conservator. Review of a police report dated 11/8/19 identified that the police were called to the facility for a missing person complaint and were told that the resident had left the facility without permission at approximately 2:00 PM. The officer was familiar with the resident and went to his/her apartment, but the resident was not there. A silver alert (a public notification system used to broadcast information about missing persons, especially senior citizens with dementia, in order to aid in locating the person) was then issued. On 11/13/19 (5 days after the resident had left the facility) the police again went to the resident's apartment and located the resident, who appeared to be in good health, and refused to go to the hospital. The facility was called and informed the resident had been found. Interview with Nurse Aide (NA) #1 on 12/3/19 at 12:30 PM identified that on 11/8/19 around 2:00 PM she saw Resident #1 heading for the elevator with a bag, so she informed the nurse, but did not attempt to talk to or stop the resident before h/she reached the elevator. Interview with LPN #3 on 12/3/19 at 1:40 PM identified that around 2:30 to 2:40 PM, NA #1 came to her and reported that the resident was headed for the elevator, but by the time she got to the elevator the resident was already gone. LPN #3 texted RN#1 and let her know that the resident was on the elevator, she stated that she did not go after the resident because the other nurse (LPN#4) was off the nursing floor, so she texted the nursing supervisor that the resident was on the elevator. Interview with the receptionist on 12/3/19 at 1:45 PM identified that between 2:20 PM and 2:35 PM Resident #1 ran out of the building with his belongings. She yelled for Resident #1 to stop but he/she kept going. RN #1 was near the lobby area and was able to follow Resident #1 out the door, but was not able to bring the resident back into the building, and when RN #1 came back into the building she asked the receptionist to call the police. The receptionist stated that she could not follow the resident out the door on either occasion because she must remain at the front desk to watch the door. Interview with RN #1 on 12/3/19 at 1:15 PM identified that she was alerted by that the resident had gone out the door. She went outside and caught up with the resident who was headed for the street, she attempted to get the resident to come back in the building, but the resident refused and started swinging his/her bag at her. The resident then ran across the street in a very fast manner, and although the resident was on the sidewalk across the street, and was still in her view, she turned around and headed back into the building to get help. She stated that she did not want to cross the street after the resident for fear of being hit by a car, and was also fearful because the resident was aggressive, and identified that safety is always a number one priority, not only for the residents but for herself. She stated that as soon as she entered the building she told the receptionist to call the police and went to inform the administrator. RN #1 was in the building for approximately 2 minutes before her and the administrator both got in the car and searched the area but could not locate Resident #1. Interview with LPN #4 on 12/3/19 at 2:00 PM identified that on 11/8/19 she was in first floor office and when she came out, she heard that the resident was outside. She went outside, and did not see RN#1 or Resident #1 on the patio in front of the building, so she walked down the sidewalk to the left that bordered the facility parking lot and saw Resident #1 on the other side of the street on the sidewalk heading towards the stop light. LPN #4 further identified that RN #1 was heading back up the sidewalk, and stated to LPN #4 he/she won't come back, and I can't force him to. Although Resident #1 was still in view of LPN #4, she turned around and headed back into the building with RN #1. LPN #4 stated that she was under the impression that the resident was self-responsible because RN #1 said she could not force him to come back in. LPN #4 further stated that if she knew he/she was conserved she would have followed the resident. Interview with the Director of Nursing (DON) on 12/4/19 at 1:45 PM identified that RN #1 and LPN #4 should not have gone back into the building if the resident was still within view, she would expect one staff member to follow the resident while the other staff member go back into the building and call the police and get additional help. Furthermore, the DON stated that RN #1 was educated on ensuring that a resident remain in her sights once a resident has eloped. The DON stated that immediately after the elopement, staff were educated on the elopement policy, and elopement drills were held. Interview with the Administrator on 12/5/19 at 11:00 AM identified that she was in the building on 11/8/19 and was not aware that the resident had left the building the morning of the elopement. She identified that around 2:30 PM, RN #1 rushed into her office and stated that the resident was outside, 911 was called and then they both got in the car and searched for the resident for approximately 2.5 hours but were unable to locate the resident. The administrator further identified that she and RN #1 had searched for the resident for the days following the elopement, but were unable to locate the resident. The administrator identified that the receptionist did not report Resident #1 as missing because there was an active search by facility staff that was ongoing, when she returned to the building around 5:00 PM she called the police to report Resident #1 missing, because they were unable to locate the resident. She stated that she received a phone call from police on 11/13/19 that the resident had been found, but was refusing an evaluation at the hospital. The administrator called the conservator and updated him that the resident had been found, and the conservator told her that he would take it from here. Interview with the conservator on 12/4/19 at 12:30 PM identified that he was under the impression that the facility knew that the resident was a flight risk and thought that the resident would be contained on a locked unit. The conservator further identified that he was only contacted (both via phone and voice mail) once when the resident had eloped and would have approved a wander guard device if he had been asked, but he was not contacted. Facility staff failed to follow the resident when he/she left the facility property to ensure his/her safety. 2) Observation of the facilities front door on 12/4/19 at 6:00 AM identified a buzzer to enter the facility, the buzzer was pushed by the surveyor and the door was able to be opened. A second door which allowed access to the lobby was opened by the surveyor at 6:02 AM and alarm started to sound. The alarm continued to sound until 6:14 AM (12 minutes) without any facility staff responding. At 6:14 AM Physical Therapist (PT) #1 entered the facility to start his shift, entered a code into the door and the alarm was silenced. Interview with LPN #6 and RN #8 on 12/4/19 at 6:20 AM who were working on the second floor identified that they did not hear a door alarming. Interview with RN #9 on 12/4/19 at 6:24 AM identified that he was the staff person who buzzed the front door open on 12/4/19 at 6:00 AM. RN #9 and NA #6 were working on the third floor and did not hear a door alarming. Interview with the Maintenance Director (DM) at 9:00 AM identified that he did not think that the front door had enunciators on the second and third floor, and was not sure if the front door alarm could be heard on the upper floors. He further identified that the front door is locked from 8:00 PM until 8:00 AM and can only be accessed by entering a code into the keypad. The door also had a delayed egress of 15 seconds and if pressed the alarm will ring for 15 seconds and then open, and the alarm will continue to ring until a code is entered into the keypad. The door is also wander guard equipped and when approached by a resident with a wander guard the door will lock and the alarm will sound. When the door is pushed for 15 seconds it will open and alarm will continue to sound. Observation and interview with the DM identified that the doors to enter the second floor are locked from 8:00 PM to 7:00 AM. At 7:00 AM the doors are unlocked and staff and residents can leave the floor without entering any codes into keypads. Observation of the third floor doors (the locked dementia unit) identified that they are also locked from 8:00 PM to 7:00 AM, the doors are wander guard equipped and will lock when a wander guarded resident approaches the door. The door can only be opened by entering a code into the keypad if the wander guard is in the vicinity. Further interview with the DM on 12/4/19 at 3:00 PM identified that he called the vendor, and the vendor stated that there should be an annunciator on another floor of the facility to alert staff that the front door alarm is going off. He stated that he had tested the doors and identified that the annunciator for the front door alarm was on the third floor. Interview and observation at 3:25 PM of the third floor alarm annunciator with the DM identified that an alarm does sound, but it is not loud enough to be heard at the end of the hallway and would not be heard in a room with the door closed, which may have been why the staff on the third floor did not hear the alarm that morning. The DM further identified that there was no annunciator on the second floor, so staff would not be altered if the front door alarmed. Subsequent to surveyor inquiry on 12/4/19 at 5:00 PM the facility put a plan into place to ensure that the doors on the second floor remain locked until staff were present to monitor the first floor doors. A staff member would be placed at the front door from 7:30 PM until 8:00 AM when the receptionist arrived on duty. The vendor was requested to come in to adjust the volume of the third floor annunciator and to place an annunciator on the second floor to ensure that staff were able to hear the first floor door alarm to ensure that no resident exited the front door of the building unaccompanied. Interview with the DON on 12/4/19 at 1:45 PM identified that although there is no policy on alarmed doors and staff response, the staff should respond to alarming doors immediately. The facility failed to ensure an a alarming door was responded to by nursing staff, that the front door alarm could be heard by the nursing staff by the annunciator on the third floor that alerts staff that the front door has been opened. 3) Resident #2 had a [DIAGNOSES REDACTED]. A care plan dated 11/14/19 identified that the resident had a potential for elopement with interventions that included a wander guard. Review of the facility wander guard list provided to the surveyor on 12/3/19 failed to identify that Resident #2 had a wander guard. Review of the wander risk books on the second and third floor which contain pictures and descriptions of all residents who are at risk for elopement, failed to contain information on Resident #2. Interview with the DON on 12/5/19 at 2:30 PM identified that there is no policy for the wander guard or wander guard books, but it is the procedure if the facility to monitor wander guard function and placement daily, and to have all residents who are a wander risk be placed in the wander risk books. The DON could not identify why Resident #2 was not on the wander guard list and not in the wander risk book. The elopement policy stated that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If the resident is at risk for wandering or elopement the resident's care plan will include strategies and interventions to maintain the resident's safety. On 12/5/19 the immediate jeopardy was abated as the facility educated staff on the elopement policy, assessment, and immediate interventions for exit seeking behavior, and staff monitoring once the resident has eloped. The facility began education and audits on not propping key padded doors open, and the wander guard system, and had staff monitor the front door continuously until changes could be made the alarm system.

Based on clinical record review, review of facility documentation, and interviews with facility staff for 1 of 3 residents reviewed for a change in condition, (Resident #147), the facility failed to contact the physician in a timely manner when a significantly abnormal vital sign was identified and/or complete and/or document re- assessments pursuant to identification of a significantly abnormal vital sign and/or provide education to nursing staff in assessing for a change in condition resulting in a finding of immediate jeopardy. The findings include: Resident #147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified that the resident was alert and oriented, required assistance with Activities of Daily Living, and had a regular heart rate of 92 beats per minute (normal resting heart 60-100 beats per minute). A physician order [REDACTED]. Nurses notes dated 10/12/16, untimed, identified in part, the resident was alert and oriented and offered no complaints of pain or respiratory distress. Review of a nurse's note dated 10/13/16 at 12:00 AM written by RN#1 identified that the resident was alert and responsive, and able to make his/her needs known with a temperature of 98.3 degrees, a heart rate of 184, a blood pressure of 100/60, and respirations were 24 a minute with an oxygen saturation of 98% on 2 liters of oxygen. The nurses note further identified that the nursing supervisor, Registered Nurse (RN) #2 was notified of the heart rate of 184 (normal heart rate is 60 to 100 beats per minute). Review of a nurse's note dated 10/13/16 at 1:20 AM (1 hour and 20 minutes after the significantly abnormal heart rate was identified and reported by RN#1) identified that the resident was observed in bed, alert and oriented, appeared to be in no distress, and voiced no complaints. The heart rate was noted to be 184, blood pressure of 100/60 and respirations of 24 with an oxygen saturation of 98%. The physician was notified and the resident was sent to the emergency department. The resident left the building at 2:30 AM with ambulance personnel. Although a significantly abnormal heart rate was noted at 12:00AM on 10/13/16, review of the clinical record failed to identify any additional nursing assessments and/or monitoring of the resident documented between 12:00AM and 1:20 AM. Review of an inter-agency referral report signed by RN#2 dated 10/13/16 identified that the resident had [MEDICAL CONDITION] a heart rate of 184, acute [MEDICAL CONDITION], and was given [MEDICATION NAME] at 1:00 AM (1 hour after the increased heart rate was identified). Review of ambulance company #1's incident report identified that the skilled nursing facility had called at 1:44 AM and upon arrival the nurse in attendance stated that the resident's heart rate was in the 180's and he/she reported not feeling well. Shortly after arrival of the ambulance company, the resident's breathing became noticeably labored and his/her mental status declined. Review of a nurse's note dated 10/13/16 at 5:45 AM identified that the resident had been admitted to the hospital with [REDACTED]. Review of a discharge summary from Hospital #1 dated 10/19/16 identified that on 10/13/16 emergency medical services (EMS) were called by the skilled nursing facility. Upon EMS arrival to the skilled nursing facility, the resident's heart rate was in the 180's. The resident received [MEDICATION NAME] 6 milligrams (mg) and then 12 mg, and [MEDICATION NAME] (cardiovascular medications). The resident had acute dyspnea (difficulty breathing) with oxygen saturations of 80 % (normal oxygen saturations are between 90-100 %) on 15 liters oxygen via non-rebreather, and was unresponsive. Resident #147 required intubation in the emergency department. The resident was then taken emergently for cardiac catheterization, which showed 100% blockage of the right coronary artery, a stent was placed and the resident was transferred to the intensive care unit. Interview with Registered Nurse (RN) #1 on 2/14/17 at 3:30 PM identified that he/she was Resident #147's charge nurse on the 11:00 to 7:00 PM shift on 10/13/16. He/she identified that around midnight a Nurse Aide (NA) came to him/her and stated that the pulse oximeter was reading a pulse of 184 for Resident #147. RN#1 identified that he/she went to the resident's room to check him out, and stated that he/she took the resident's blood pressure and noted the resident to be in no distress. RN#1 identified that he/she did not check the resident's heart rate because it had just been done by the NA. RN#1 further identified that he/she called the nursing supervisor (RN#2) to report the heart rate of 184. RN#1 identified that the supervisor stated that he/she would be come to the unit after he/she was finished with nursing report. RN#1 continued his/her nightly routine passing medications, and when the supervisor arrived on the unit about 30 to 45 minutes later, RN#2 took Resident #147's heart rate and requested RN#1 to give the resident medication for anxiety. RN#1 further stated that the resident's heart rate did not decrease with the medication and the physician was called. Interview with RN#2 at 1:30 PM identified that he/she was the nursing supervisor on 10/13/16 when RN#1 called him/her to report the heart rate of 184. RN#2 stated that he/she got up from report and went to assess the resident, he/she found the resident in no distress, but took the resident's apical rate and noted it to be 184 and irregular. RN#2 told RN#1 to medicate the resident with something for anxiety and then went back to nursing report. RN#2 further identified when he/she returned to the unit about 20-40 minutes later (although documentation in the medical record identified that he/she assessed the resident at 1:20 AM, 1 hour and 20 minutes after the increased heart rate the was reported to him/her by RN#1), and identified that the resident's heart rate had not decreased and called the physician. The physician ordered to send the resident to the emergency department. RN#2 identified that he/she did not contact the physician immediately about the heart rate because the resident did not appear to be in any distress, the only issue was the increased heart rate, but he/she thought it may have been due to anxiety. RN#2 further identified that upon Emergency Medical Services(EMS) arrival at the facility the resident's heart rate was in the 180's, but the resident was still in no distress, EMS had treated the resident for over an hour in the facility before the resident was transported out of the building by EMS. Interview with MD#1 on 2/14/17 at 12:30 PM identified that it would be his expectation to be notified immediately if a resident's heart rate was 184. MD #1 further stated it is an emergent situation, as a heart rate of 184 is not sustainable, and any delay in treatment could cause additional damage to the heart muscle. Interview with the Director of Nursing Services (DNS) on 2/15/17 at 3:45 PM identified that he/she would expect that RN#1 would have re-assessed the NA's report of a heart rate of 184, and that RN#1 and RN#2 would have contacted the physician immediately once the heart rate of 184 was identified, and/or documented additional nursing assessments between 12:00 AM and 1:20 AM. The DNS further identified that although the facility reviews 24 hour report in clinical report, the information on the 24 hour report did not identify a delay in calling the physician, but after reviewing the nurse's notes subsequent to surveyor inquiry it appeared as there was a delay in physician notification when a change in condition was identified. The DNS further identified that if he/she had been aware of the information on the discharge summary, he/she would have looked into the issue by interviewing the staff involved. Additionally the DNS stated that facility did not educate/and or train RN#1, RN#2, and/or facility staff on policies and procedures regarding how to assess and/or respond to a change in resident condition. Review of the change in condition policy identified that the physician will be notified when a resident's condition or status changes unexpectedly or substantially.

Based on interview, facility documentation and clinical record review for one of six residents (Resident #41) reviewed for accidents, the facility failed to follow the physicians order for the use of devices to prevent an accident with injury and/or provide adequate supervision and assistance to prevent an accident and/or assess the resident for fall risk per facility policy. The findings include: Resident #41 ' s [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] identified the resident was a high fall risk. A review of the clinical record with the Assistant Director of Nursing failed to identify a more recent fall risk assessment.The annual MDS assessment dated [DATE] identified impaired short term memory and moderately impaired cognitive skills for daily decision making and was dependent on staff assistance of 2 for bed mobility and transfers and was free of falls.The care plan dated 6/1/15 identified a potential fall risk related to decreased mobility, abnormal posture, poor safety awareness and use of medications placing the resident at risk with interventions including padded floor mats when the resident is in bed and a bed alarm.The physician's orders [REDACTED].The nurse's note dated 8/16/15 at 8:15 AM identified the resident was observed to be lying on the floor beside his/her bed in the prone position with a moderate amount of blood noted from the nostrils. Note indicated the resident was transferred to the ER for an evaluation.The acute care record dated 8/16/15 identified the resident presented with swelling and ecchymosis to the chin, a laceration under the lower lip and dried blood around the right nostril and lips. Documentation identified the resident required sutures to both the top and bottom lips and was transferred back to the skilled nursing facility on 8/16/15.Review of the reportable event/investigation dated 8/16/15 identified a physician's orders [REDACTED].Interview with NA#1 on 4/26/16 at 9:40 AM identified that he/she had removed the floor mats to provide care to Resident #41 and then left the room to get the mechanical lift to transfer the resident out of bed. NA#1 indicated he/she did elevate the side rails and the bed was in the low position with the bed alarm sensor in place when he/she left the room. NA#1 indicated he/she should have replaced the floor pads prior to leaving the room.Interview with the DNS on 4/28/16 at 9:35 AM identified it was the responsibility of the nurse aide to ensure the floor mats were in place prior to leaving the room. The DNS further indicated the resident should have been assessed for fall risk quarterly per the facility policy.The facility's fall policy and procedure identified residents will be evaluated by the interdisciplinary team for their risk for falls and a plan of care is developed and implemented based on this evaluation. Policy further identified a licensed nurse will assess residents for fall risk upon admission, re-admission, quarterly, annually and with a significant change.

Based on observation, review of the clinical record, facility documentation and interview for one sampled resident (Resident #4) reviewed for pressure ulcers, the facility failed to provide care and services to prevent the development of a pressure ulcer. The findings include: Resident #4's [DIAGNOSES REDACTED]. The Braden Scale dated 2/15/16 identified the resident was at mild risk for developing a pressure ulcer. The quarterly MDS assessment dated [DATE] identified moderate cognitive impairment and required extensive assistance of two or more persons for bed mobility. The care plan dated 3/15/16 identified a potential for alteration in skin integrity related to advanced age, decreased mobility, incontinence and diabetes with interventions that included to monitor for skin breakdown during daily care, perform weekly skin assessments and provide a pressure relieving mattress in the bed. The care plan further identified a risk for decreased circulation, stasis ulcer and pressure ulcers related to a [DIAGNOSES REDACTED]. The care plan failed to address off-loading of the resident's heels while in bed as an intervention. The nurse's note dated 4/9/16 8:00 AM identified the physician was notified of an elevated blood sugar (511.) physician's orders [REDACTED]. The nurse's note dated 4/9/16 at 10:00 AM identified the blood sugar remained elevated (472) and the MD was notified and ordered additional insulin coverage. The APRN note dated 4/11/16 identified the resident's blood glucose transiently elevated for the last few days and presented with a low grade temperature of 99.5. The nurse's note dated 4/11/16 identified the nurse aide who was assigned to provide care to the resident notified the charge nurse that an alteration in skin integrity of the resident's heels was noted during am care. The nurse's note indicated an open area on the left heel and the right heel was boggy. The Wound Care Specialist's wound assessment dated [DATE] identified an unstageable 4.4cm x 6.5cm x 0.2 cm left heel pressure ulcer with 26-50% eschar present. The physician's orders [REDACTED].Interview with the Wound Nurse on 4/28/16 at 1:50 PM identified that if a resident presented with a [DIAGNOSES REDACTED]. Facility Wound Nurse further indicated that the resident was currently on a standard pressure reducing mattress. Review of the clinical record and interview with the Director of Nursing Services on 4/29/16 at 9:10 AM failed to reflect the resident was afforded off-loading of the heels when in bed. The DNS indicated a resident with risk factors including [MEDICAL CONDITION], diabetes and limited bed mobility the expectation would be that preventative interventions to off load the heels would have been initiated prior to skin breakdown.The facility's skin care management policy and procedure identified residents at risk for skin compromise are provided appropriate treatment to encourage maintaining integrity.

Based on clinical record review, observation and interviews for one of four residents reviewed for accidents (Resident #75), the facility failed to ensure liquids were provided at a safe temperature and/or that an assesment was conducted to prevent an accident and injury . The findings include: Resident #75's [DIAGNOSES REDACTED]. The occupational therapy evaluation dated 4/13/15 identified the resident presented with decreased strength, balance and left joint shoulder pain impacting ability to don clothing and quality of life with recommendations to provide occupational therapy. The evaluation further identified the right upper extremity was grossly limited in range of motion while the left upper extremity was within functional limits. The quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident with moderately impaired cognitive skills, required extensive assistance for personal hygiene, dressing and toilet use, independence for eating and locomotion in and out of the unit. The MDS further identified a functional limitation on one side in the range of motion of the upper and lower extremity. The care plan dated 5/4/15 identified a risk for trauma related to arthritis and degenerative joint disease with interventions that included to encourage gentle range of motion during care, assist with difficult maneuvers, monitor for comfort and body alignment and provide physical/occupational therapy as ordered. The accident/incident report dated 5/7/15 identified the resident was in the therapy room and asked to have his/her coffee heated. The cap of the travel mug separated from the base and the coffee spilled onto the resident. The resident sustained [REDACTED]. The witness statement provided by PTA #1 on 5/7/15 identified the resident asked to have the coffee heated. The coffee was put in the microwave for 90 seconds and then given to the resident. PTA #1 indicated she/he had heated coffee for the resident before 5/7/15 and did not ever check the temperature of the liquid prior to giving the coffee to the resident. Furthermore, PTA #1 indicated that 5/7/15 was not the first time he/she witnessed the resident take the lid off the travel mug. PTA #1 did not indicate in the interview why he/she did not report the resident was removing the travel lid mug to nursing. The initial nursing assessment of the areas identified the resident sustained [REDACTED]. Three blisters were identified on the right hand that measured 2.75 cm x 2.0 cm, 2.0 cm x 3.0 cm and 0.5 cm x 1.0 cm. The physician directed to apply Silvadene cream to the burn areas daily. The attending physician progress notes [REDACTED]. Interview with Registered Nurse (RN) Supervisor #1 and Licensed Practical Nurse (LPN) #2 on 6/24/15 at 10:40 AM identified the resident attends therapy on a daily basis for left arm exercises. Before leaving the nursing unit, the resident often requested the staff to heat up his/her coffee. RN Supervisor #1 and LPN #2 indicated they would pour the coffee into a Styrofoam cup and place the cup in the 700 watt microwave oven located on the unit for approximately 30 to 45 seconds. Once heated the coffee was poured into a travel mug that had a twist cap and a straw like portal for access to the contents. LPN #2 indicated the resident is able to flip the straw like portal open without assistance and drink the coffee. RN Supervisor #1 and LPN #2 indicated the temperature of the coffee was never checked prior to giving the coffee to the resident. RN Supervisor #1 and LPN #2 were unaware of a facility policy to direct how long liquids should be heated in the microwave prior to giving to residents to ensure the liquids were not too hot. Observation of Resident #75 using the travel mug on 6/24/15 at 10:50 AM identified the resident placed the travel mug on his/her abdomen using the left hand. Using the left hand, the right hand was placed over the travel mug to hold the mug against the chest. Resident #75 then opened the straw like portal to access the contents with the left hand. Interview with RN #2 on 6/24/15 at 11:00 AM identified that when she responded to the therapy room, the resident was screaming and coffee was noted spilled on the floor and on the resident. The base of the travel mug was fully separated from the twist cap and was on the floor. RN #2 indicated cold compresses were immediately applied to the areas on the resident where the coffee had spilled. Interview, review of the clinical record and the accident/incident report dated 5/7/15 with the Assistant Director of Nurses (ADNS) on 6/24/15 at 11:10 AM identified Physical Therapy Assistant (PTA) #1 was in the therapy room with the resident on 5/7/15. PTA #1 heated the resident's coffee in a 900 watt microwave oven for 90 seconds, replaced the cap on the travel mug without testing the temperature and handed the mug to the resident. The ADNS was unable to provide documentation that a safety evaluation for use of the travel mug was conducted with the resident's dexterity and limitations in range of motion. Additionally, the ADNS was unable to provide a facility policy for heating liquids in a microwave and/or a protocol to direct staff as to the length of time to heat liquids in the microwave to ensure safe temperature of liquids. PTA #1 was unavailable for interview.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #14) reviewed for accidents, the facility failed to provide the appropriate supervision to keep residents safe from a resident who wandered and/or for one of three residents at risk for elopement (Resident #8), the facility failed to implement measures to keep residents safe and/or ensure the resident did not leave the facility without supervision. The findings include: 1. Resident #14's [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] identified Resident #14 was alert, pleasant and required assistance of one for bed mobility, two person assistance with transfers and one person assist with ambulating. The nurse's progress note dated 2/14/15 at 5:40 AM identified that Resident #14 stated while lying in bed, he/she felt someone touch him/her, when Resident #14 opened his/her eyes a resident (Resident #13) was observed standing by Resident #14's bedside and Resident #13 started to fall. Resident #14 intercepted the fall by grabbing the other resident, causing his/her shoulder to hurt. Subsequent to physician notification of Resident #14's pain and request to be transferred to the Emergency Department, Resident #14 was transferred to the hospital at approximately 6:00 AM and returned at 10:00 AM. The nurse's note dated 2/14/15 at 3:00 PM identified Resident #14 returned from the hospital at 10:00 AM with a sling to the left arm and a [DIAGNOSES REDACTED]. The orthopedic consultation report dated 2/16/15 identified a possible recurrent cuff tear with a recommendation for a Magnetic Resonance Imaging (MRI) of the left shoulder. The follow-up orthopedic consultation dated 3/2/15 identified Resident #14 had sustained a recurrent rotator cuff tear and the recommendation was for left shoulder arthroscopy and cuff repair surgery on 4/2/15. Interview with (Registered Nurse) RN #3 on 6/11/15 at 10:45 AM identified that on 2/14/15 at 5:20 AM Resident #14 was at the door to his/her room looking upset and stated that Resident #13 came to his/her room and woke him/her up. RN #3 indicated that Resident #14 reached for Resident #13, tried to grab the resident to prevent a fall and subsequently caused an injury to his/her arm. RN #3 stated that Resident #13 was agitated on a regular basis and routinely was difficult to monitor and would wander into resident rooms. Interview with the Assistant Director of Nursing (ADON) on 6/11/15 at 1:00 PM identified that she recalled Resident #13's history of wandering into resident rooms. The ADON stated that new interventions were not identified related to Resident #13's wandering. Review of facility policy directs that a resident's care plan will indicate the resident is at risk for elopement or other safety issues and interventions to try to maintain safety, such as a detailed monitoring plan. 2. Resident #8's [DIAGNOSES REDACTED]. The MDS identified the resident had wandering behaviors and was independent with ambulation and required supervision on and off the unit. Review of a RCP dated 2/14/15 identified that the resident was at risk for elopement related to aimless wandering and statement he/she was leaving. Interventions included to place a wanderguard bracelet on the resident, observe for indication that the resident may leave the building and place the resident's picture at the the reception desk alerting the risk for elopement. Review of a nurse's note dated 3/8/15 identified that the resident was found outside of the building, and although the resident had a wanderguard bracelet in place, the alarm did not sound. The note identified that the resident was redirected back into the building by another staff person and was assessed with [REDACTED]. Review of facility documentation dated 3/8/15 identified that at 3:30 PM, the receptionist notified the ADON that another resident believed he/she saw R#8 leave the parking lot of the facility. Concurrently, as the ADON was going to check on R#8 and call the elopement, she saw R#8 coming back toward the facility, escorted by the speech therapist. Resident #8 was easily redirected, had his/her wanderguard in place and was assessed with [REDACTED].#8 to the front door which he/she eloped through, the wanderguard sounded however when the ADON checked it again at the door, it did not alarm. The ADON stated that she notified the alarm company. Interview with the ADON on 6/8/15 at 2:00 PM identified that Resident was wearing a wanderguard bracelet that should have alarmed and, locked the door as he/she approached it to go outside, however the system was not effective. The alarm company was notified and was scheduled to come out the next day (3/9/15). The ADON identified that the front door was manned to ensure resident safety. On 3/9/15, the alarm company examined the system and noted that the wires on the alarm pad on the second floor had cut wires which was thought to be the cause of the intermittent malfunction of the wanderguard system. The wires were repaired and system was deemed functional. Review of an Action Plan dated 3/9/15 identified, in part, that in regard to the wires being cut, the facility had initiated a system that the Maintenance Department would check the wanderguard key pads daily on the 7:00 AM - 3:00 PM shift and the Nursing Supervisor would check that they were working on the 3:00 PM - 11:00 PM shifts and on weekends. Review of the facility's wanderguard key pad checks documentation for the period of 3/9/15 through 5/9/15 identified that the keypads were checked daily on each floor, however for the period of 5/9/15 through 6/10/15 the documentation failed to identify that the checks were performed. Interview with the Maintenance Director on 6/8/15 at 11:40 AM identified that since he had been employed by the the facility on 5/12/15 it was his understanding that that the Nursing Supervisors competed the checks. Interview with Nursing Supervisor #2 on 3/8/15 at 1:30 PM and review of facility documentation identified that the wanderguard bracelets and the wanderguard system on the front door are checked every shift, however the wanderguard keypads located on each floor are not included in these checks. The facility failed to ensure that the action plan was fully implemented for the period of 5/9/15 through 6/9/15. Subsequently, in an interview on 6/11/15 at 2:00 PM, the Assistant Administration identified that he and the Maintenance Director will resume the wanderguard key pads audits on each floor until such time that the facility's wanderguard/security system is replaced.

Based on clinical record review, review of facility documentation and interviews for one of four sampled residents (Resident #5) reviewed for risk for pressure ulcer development and/or who utilized a splint and / or brace device, the facility failed to consistently monitor the resident's skin integrity to prevent the development of a pressure ulcer. The findings included: Resident # 5's [DIAGNOSES REDACTED]. The nurse's notes dated 7/2/14 through 7/21/14 identified no skin impairment identified by the licensed staff. The RCP dated 7/30/14 identified an alteration in skin integrity due to a pressure ulcer on the right lateral foot. Interventions directed to handle the resident gently during care, to provide a specialty mattress and chair cushion, to provide a bed cradle and to reposition the resident every two hours and when needed. The RCP dated 7/30/14 further identified the use of adaptive equipment related to impaired skin integrity. Interventions included a high back wheelchair with pillow on the back and right foot UFO (Pediatric brace used for foot drop and ankle foot stability) while out of the bed. A review of the facility's Weekly Skin Audits dated 7/14/14, 7/21/14, 7/25/14 and 8/4/14 noted no areas of skin impairment. The nurse ' s notes dated 7/14/14 through 8/4/14 identified no concerns expressed by Resident #5 regarding his/her skin integrity. The July 2014 Treatment Record directed to apply a foam boot (UFO) to the reddened area on the resident's right lateral foot. The Treatment Record and/or nurse ' s notes failed to reflect that the UFO was removed daily and that the resident ' s skin was inspected before application and after removal. The 8/1/14 quarterly MDS assessment identified intact cognition and extensive assistance of two people for bed mobility and transfers to the wheelchair. Additionally, the assessment identified a high risk for developing pressure ulcers, absence of a pressure ulcer and indicated the resident was not receiving physical therapy. The nurse's notes dated 8/7/14 recorded at 7:00 P.M. identified Resident # 5 complained of right foot pain and the nursing supervisor was notified and the nurse ' s note indicated the physician would be in the morning to evaluate the resident. A review of the nurse ' s notes dated 8/8/14 through 8/13/14 failed to reflect the physician and/or the nursing staff removed the UFO and conducted an assessment of the resident ' s skin integrity on the right foot. The Wound Nurse's documentation dated 8/15/14 indicated a 0.2 Centimeter (CM) x 0.2 CM by 0.2 CM stage III pressure ulcer was identified on the right foot. The wound bed was noted to contain slough, moist yellow and necrotic tissue. The physician's orders [REDACTED]. The Podiatrist progress note dated 8/15/14 identified the resident had erosion and redness on the lateral aspect of right foot and ordered Duoderm and skin prep daily to right foot. The Treatment Record dated 8/15/14 directed to apply heel float boots on bilateral feet when in bed and wheelchair, to elevate the resident's heels and feet when in bed and the wheelchair and not to wear a shoe or sneaker on the right foot until wound healed. On 9/9/14 at 10:00 A.M. an interview with the Wound Nurse indicated Resident # 5's wound base was covered with slough and necrotic tissue and was miss-staged on 8/15/14. The Wound Nurse indicated the wound was unstageable because of slough in wound bed and the record was updated on 8/18/14. The Wound Nurse further indicated the pressure ulcer was most likely caused by the UFO splint. The Facility Splint policy indicates when splints/braces are used the resident's skin will always be inspected carefully before application and after removal. Further indicated all skin problems redness swelling pain or changes in fit are reported to nurse and therapy.

Based on review of the clinical record, facility documentation, facility policies and procedures, and interviews for one of six sampled residents reviewed for accidents (R#84), the facility failed to ensure that totally a dependent resident requiring mechanical lift transfers was handled appropriately to prevent an injury. The findings included: Resident #84's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was moderately cognitively impaired, totally dependent on staff for bed mobility and transfers, and utilized a mechanical lift for transfers. The resident care plan dated 12/30/10 identified impaired physical mobility. Interventions included maintain proper body alignment, reposition at least every two hours and monitor affected side frequently for injury. Review of nurse's notes and facility documentation dated 1/30/11 identified that at 9:30 AM, NA #4 reported to LPN#4 that the resident's left knee was swollen. On 1/29/11, NA#4 reported to LPN#4 that the resident was complaining of pain to the left knee. Nursing notes dated 1/29/10 at 10:00 AM documented that the resident was medicated for pain. On 10/26/11 at 3:30 PM, interview and review of the clinical record and investigation with the DON indicated that an x-ray obtained on 1/30/11 identified that the resident sustained [REDACTED]. The DON further indicated that investigation indicated that the resident's predisposing condition of osteopenia may have been a contributing factor. Although all staff who transferred the resident were interviewed and denied any issues with transfers, on 10/27/11 at 11:00 A.M. an interview with the Radiologist (MD #1) regarding the x-ray of the resident's fractured left knee indicated that "there was nothing on here (x-ray) that suggest a pathological fracture", and that the fracture was "most likely post traumatic".