Every finding on record at Civita Care Center at Newington

Based on clinical record review, facility documentation/policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision and develop a plan to maintain the resident's safety during a scheduled room maintenance activity that required removal from his/her room. Resident #1 had known aggressive behaviors and preferred to remain in his/her room; however, when displaced into a common area without an established supervision plan, the resident was not adequately monitored and entered another resident's room, resulting in a resident-to-resident altercation with injury. The findings included:1a. Resident #1 was admitted to the facility in March of 2023 and had diagnoses which included dementia, schizoaffective disorder, depressive type, and adjustment disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 4), dependent with toileting and lower body dressing, and was able to ambulate fifty (50) feet with moderate assistance. The Resident Care Plan (RCP) dated 1/31/26 identified Resident #1 received psychotropic medication related to the diagnosis of dementia, depression, schizoaffective disorder, anxiety, and insomnia, and a history of refusal of care, paranoia/delusions, and hitting, and resident to resident altercations. Interventions directed to monitor for depression as evidenced by refusal of care, hitting staff, paranoia, and delusions, a room change, and to keep the resident in visible area when out of bed.b. Resident #2 was admitted to the facility in March of 2023 and had diagnoses which included disorganized schizophrenia, schizoaffective disorder, unspecified, and generalized anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 as moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12) and was independent with all activities of daily living. The Resident Care Plan (RCP) dated 1/31/26 identified Resident #2 was at risk for adverse effects related to use of medication and for mood and behavior, as evidenced by agitation, yelling, emotional, and fidgeting. Interventions directed to monitor for changes in mood and behavior, update the provider as necessary, and ensure a quiet environment so the resident can work on self-calming techniques when feeling worked up or anxious. A Reportable Event (RE) form dated 3/16/26 at 1:10 PM identified Resident #2 reported being struck by another resident (Resident #1), and then pushed the resident (Resident #1), causing him/her to fall. Resident #2 was sent to the hospital for a psychological evaluation.An RE form dated 3/16/26 at 1:10 PM identified Resident #1 was observed lying on the floor of Resident #2's room, stating he/she was struck in the face by another resident and sustained a laceration to his/her right eyebrow. Resident #1 was placed on a one-to-one (assigned monitoring) and psyche consult. The hospital Discharge summary dated [DATE] identified Resident #2 did not demonstrate agitated or aggressive behaviors, remained in behavioral control, was compliant with care, and was discharged back to the nursing facility with a no harm letter.The hospital Discharge summary dated [DATE] identified Resident #1 sustained a laceration to the right eye and a closed fracture of the right maxillary sinus, however, did not receive a psychological evaluation while at the hospital.Interview with LPN #3 (assigned to Resident #1 during the 7:00 AM to 3:00 PM shift on 3/16/26) on 4/15/26 at 1:31 PM identified the facility was performing a thorough cleaning of Resident #1's room on 3/16/26, requiring him/her to be moved from his room into the hallway while cleaning took place and Resident #1 was monitored by NAs assigned to that wing. LPN #3 indicated an NA heard commotion in Resident 2's room and found Resident #1 on the floor bleeding. LPN #3 further indicated the two residents were separated immediately, the nursing supervisor, Director of Nursing Services and provider were informed, Resident #1 was assisted back to his/her chair and 911 was called. LPN #3 identified during the time of the incident, NAs were passing out lunch trays and LPN #3 was performing blood glucose monitoring and unable to monitor Resident #1 during that time. LPN #3 further indicated Resident #1 preferred to stay in his/her room. Interview with the Director of Housekeeping (DOH) on 4/16/26 at 9:35 AM identified Resident #1's floors were stripped and walls washed on 3/16/26. Resident #1 was removed from his/her room prior to 10:00 AM and was able to return to his/her room between 3:00 PM and 4:00 PM. The DOH further indicated that Resident #1 did not attempt to re-enter the room at any time the room was being cleaned as housekeeping staff manned the door to prevent re-entry until safe to do so. Interview with NA #2 on 4/16/26 at 1:53 PM identified he/she assisted Resident #1 with toileting prior to lunch (documented at 11:11 AM) on 3/16/26 and brought Resident #1 to the bathroom located near the shower station as resident's were not to use other resident's bathrooms. NA #2 further indicated Resident #1 preferred to stay in his/her room and did not wander.Interview with the Assistant Director of Nursing (ADNS) on 4/17/26 at 2:45 PM identified the facility planned for Resident #1 to participate in activities from 10:00 AM to 11:30 AM on 3/16/26, return to the chair located outside of his/her room around 11:30 AM to be served lunch, and then return to participate in activities after lunch. 2a. Resident #1 was admitted to the facility in March of 2023 and had diagnoses which included dementia, schizoaffective disorder, depressive type, and adjustment disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 00), was dependent with bathing, required substantial assistance with toileting and personal hygiene, and was able to ambulate with supervision/touch assistance.The Resident Care Plan (RCP) dated 8/16/25 identified Resident #1 received psychotropic medication related to the diagnosis of dementia, depression, schizoaffective disorder, anxiety, and insomnia, and a history of refusal of care, paranoia/delusions, and hitting, and that he/she was a resident with a dementia diagnosis in a secured memory care unit related to behaviors that required staff intervention and redirection for safety as well as life enriching specialized dementia program. Interventions directed to monitor for depression as evidenced by refusal of care, hitting staff, paranoia, and delusions, and intervene and redirect when wandering, exit seeking, or when behaviors become intrusive or affect other residents. b. Resident #5 was admitted to the facility in October 2024 and had diagnoses which included vascular dementia, schizoaffective disorder, bipolar type, and unspecified head injury.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 00), was dependent with bathing, toileting, and personal hygiene, and able to ambulate independently. The Resident Care Plan (RCP) dated 8/18/25 identified Resident #5 had a diagnosis of dementia and was placed in a secured memory care unit related to behaviors that required staff intervention and redirection for safety as well as life enriching specialized dementia program. Interventions directed to intervene and redirect when wandering, exit seeking or when behaviors became intrusive or affected other residents.The Reportable Event Form dated 10/11/25 identified Resident #5 was struck in the face by another resident (Resident #1), and mild swelling was noted to the left of Resident #5's face.The hospital Discharge summary dated [DATE] identified Resident #5 was struck in the face by another resident, experienced no loss of consciousness, no nausea/vomiting, with minimal swelling present.Interview with LPN #1 on 4/16/26 at 9:59 PM identified he/she was the charge nurse on 10/11/25. LPN #1 identified Resident #5 had wandering behaviors, kept to his/herself and was non-verbal.Interview with NA #1 on 4/16/26 at 10:14 AM identified Resident #5 was observed walking down the hallway, on the side of Resident #1's room. As Resident #5 approached Resident #1's doorway, Resident #1 stepped out of the room and punched Resident #5 in the face, just under the eye. NA #1 indicated he/she instructed Resident #1 to return into his/her room, immediately removed Resident #5 from the area and informed LPN #1.Interview with the Assistant Director of Nurses (ADNS) on 4/17/26 at 2:05 PM identified Resident #1 was moved to a different room in a different area of the facility (from a secured wing to an unsecured wing) following the altercation with Resident #5.Interview with the Director of Nursing Services (DNS) on 4/16/26 at 4:10 PM identified the facility had zero tolerance for abuse of any kind. The Resident's Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure identified the facility's residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Past Non-Compliance:The facility presented a corrective action plan dated 3/19/26 which included:-House-wide review of residents with cognitive impairment, wandering, intrusive behaviors, or history of aggression to ensure appropriate supervision levels and individualized interventions were in place.-Review and update of care plans as needed to reflect current risks and interventions, including supervision requirements, redirection strategies, behavioral monitoring, and environmental safety measures.-Re-education of all licensed nurses and direct care staff on resident-to-resident altercation prevention, abuse prevention, early identification of at-risk behaviors, supervision expectations, immediate intervention, timely reporting, notification requirements, documentation standards, and adherence to care plans. Staff were specifically instructed to redirect residents observed in proximity when risk was identified.-Director of Nursing to conduct audits of 3-5 residents identified as at risk for intrusive behaviors or altercations. Audits to occur weekly for four (4) weeks and monthly thereafter for two (2) months. Audit to include verification of accurate care plans, appropriate supervision, staff intervention and redirection, and proper documentation.-Results of audits to be reviewed through facility's QAPI program with identified concerns resulting in immediate corrective action, including staff re-education and increased monitoring. Compliance to be sustained through continued QAPI oversight.

Based on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Residents #1) reviewed for abuse, the facility failed to ensure the Resident Care Plan (RCP) was updated following a room change for a severity cognitively impaired resident with adjustment disorder, when the resident was moved from a room on the secured unit to a room on the non-secured unit after a resident-to-resident physical altercation. The findings included:Resident #1 was admitted to the facility in March of 2023 and had diagnoses which included dementia, schizoaffective disorder, depressive type, and adjustment disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 00), was dependent with bathing, required substantial assistance with toileting and personal hygiene, and was able to ambulate with supervision/touch assistance.The RCP dated 8/16/25 identified Resident #1 received psychotropic medication related to the diagnosis of dementia, depression, schizoaffective disorder, anxiety, and insomnia, and a history of refusal of care, paranoia/delusions, and hitting, and that he/she was a resident with a dementia diagnosis in a secured memory care unit related to behaviors that required staff intervention and redirection for safety as well as life enriching specialized dementia program. Interventions directed to monitor for depression as evidenced by refusal of care, hitting staff, paranoia, and delusions, and intervene and redirect when wandering, exit seeking, or when behaviors become intrusive or affect other residents. The Reportable Event Form dated 10/11/25 identified Resident #5 was struck in the face by another resident (Resident #1), and mild swelling was noted to the left of Resident #5's face.A nurse's note by the Assistant Director of Nurses on 10/12/25 at 12:05 PM identified Resident #1 continued with a one-to-one (staff assigned monitor) and appeared to be adjusting to the room change, had no complaints of pain or discomfort, and to continue with the plan of care.Interview with the Director of Nursing Services on 4/16/26 at 4:10 PM identified Resident #1 was moved from the secured unit to the non-secured unit on 10/11/25 following an incident with Resident #5. Review of the RCP failed to identify revisions following the move from a secured unit to a non-secured unit on 10/11/2025.Interview with SW #1 on 4/17/26 at 2:54 PM identified the interdisciplinary team (IDT) would typically meet to discuss resident's needs and develop a plan of care prior to changing a room. However, if the resident was moved due to a safety concern, the IDT would convene as soon as practicable thereafter, which did not occur for Resident #1.The Comprehensive Care Planning policy directed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs were developed and implemented for each resident and that care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between resident's problem areas and their causes, and relevant clinical decision making.

Based on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Residents #1) reviewed for abuse, the facility failed to ensure a resident involved in a physical altercation received a harm clearance prior to returning to the facility. The findings included: Resident #1 was admitted to the facility in March 2023 and had diagnoses which included dementia, schizoaffective disorder, depressive type, and adjustment disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired (Brief Mental Interview for Mental Status (BIMS) of 4), was dependent with toileting and lower body dressing, and was able to ambulate fifty (50) feet with moderate assistance. The Resident Care Plan (RCP) dated 1/31/26 identified Resident #1 received psychotropic medication related to the diagnosis of dementia, depression, schizoaffective disorder, anxiety, and insomnia, and a history of refusal of care, paranoia/delusions, and hitting, and resident to resident altercations. Interventions directed to monitor for depression as evidenced by refusal of care, hitting staff, paranoia, and delusions, a room change, and to keep the resident in visible area when out of bed.Review of facility documents dated 3/16/26 at 1:10 PM identified an unwitnessed incident between Resident #1 and Resident #2. Resident #2 reported being struck by another resident (Resident #1), then pushed the resident (Resident #1), causing him/her to fall. Resident #2 was placed with a one-to-one (continuous monitoring) and sent to the hospital for a psychiatric evaluation. However, Resident #1, observed lying on the floor, reported he/she was struck in the face by another resident and sustained a laceration to his/her right eyebrow. Resident #1 was placed with a one-to-one (continuous monitoring) with a request for a psychiatric consult. Review of APRN #1's note dated 3/16/26 at 3:48 PM identified Resident #1 was evaluated following a fall for a right eye laceration and agitation/pushing with another resident and recommended his/her transfer to the emergency department for evaluation.The hospital Discharge summary dated [DATE] identified Resident #1 sustained a laceration to the right eye and a closed fracture of the right maxillary sinus, however failed to indicate Resident #1 had received a psychiatric evaluation while at the hospital.A nurse's note by RN #2 on 3/17/26 at 12:54 AM identified Resident #1 returned to facility at 11:30 PM from a hospital evaluation.Review of facility documentation failed to identify a no harm letter was received for Resident #1 regarding the 3/16/26 resident-to-resident altercation. A nurse's note by APRN #2 on 3/17/26 at 7:25 AM identified Resident #1 was evaluated following the 3/16/26 altercation and was not considered a danger to self or others. However, this evaluation occurred seven (7) hours and fifty-five (55) minutes after Resident #1 was re-admitted to the facility.Interview with the Director of Nursing Services (DNS) on 4/16/26 at 4:10 PM identified although the facility identified both Resident #1 and Resident #2 were sent to the hospital to receive both medical and psychiatric evaluations, it was the hospital's providers that deemed Resident #1's concerns were trauma related versus psychiatric. The DNS identified the facility did have Resident #1 evaluated by a psychiatric provider on 3/17/26 at 7:25 AM, who indicated Resident #1 was not a risk to his/herself or other residents, and indicated normal rounding practices and staffs' awareness to monitor Resident #1 following the 3/16/26 altercation was sufficient to ensure residents at the facility were safe.Interview with the Regional Clinical Support Nurse (RCSN) on 4/17/26 at 2:18 PM identified the registered nurse readmitting the resident into the facility after being evaluated at the hospital for an altercation was responsible to review the hospital discharge paperwork, and if documentation was missing, the nurse was to notify the provider of the missing documentation to ensure the safety of the resident(s). The RCSN further indicated that the hospital's failure to complete the psychiatric evaluation should have resulted in a phone call to psychiatric provider/provider to obtain clearance for the patient's return, or to assign a one-to one monitor until clearance was obtained.Although requested, the facility did not have a policy specific to psychiatric evaluations/one-to-one assignments for residents involved in physical altercations.

Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #10) reviewed for accidents, the facility failed to ensure staff opened an access door to a resident unit in a safe manner to ensure a resident was not hit by the door. The failure resulted in a resident fall with injury. The findings include: Resident #10's diagnoses included Alzheimer's disease, dementia with behaviors and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 had severe cognitive impairment, required set up assistance to ambulate independently, and had no falls since the prior assessment (90 days).The Resident Care Plan (RCP) dated 11/25/2025 identified Resident # 10 as a fall risk. Interventions directed to wear gripper socks and directed frequent checks when ambulating in the hallway.The nursing note dated 1/14/2026 at 10:58 PM identified Resident #10 had an unwitness (ed) fall standing behind the double doors on unit. Resident #10 denied discomfort, had a nosebleed with discoloration, range of motion was at baseline. APRN was notified and ordered Resident #10 to be transferred to the hospital for x-ray of the face to rule out fracture. The nursing note dated 1/15/2026 at 3:07 PM identified Resident #10 returned from the hospital with a diagnosis of a closed nasal bone fracture. Facility reportable event form dated 1/15/2026 at 10 AM identified Resident #10 had an unwitnessed fall at the secured unit entrance. A staff member opened the double doors and did not recognize the resident positioned behind the door. Resident #10 subsequently fell and sustained a closed nasal bone fracture.Facility reportable event summary dated 1/19/2026 identified the fall occurred when a staff member opened the double doors to the unit and did not recognize the resident was positioned behind the door. Resident #10 subsequently fell to the floor. Resident #10 was alert with no loss of consciousness, had a nosebleed and was transferred to the hospital. The plan of care was updated to redirect Resident #10 away from unit doors and heightened staff awareness during door access.Observation of the nursing unit on 2/5/2026 at 10:30 AM identified access to Resident #10's unit had double metal doors. The door on the right side of the hallway had a push bar located approximately three (3) feet above the floor, to allow opening of the door; the opposite door had a push bar from the inside of the unit to allow exit from the unit. Above both push bars was a clear glass rectangular window near where the two (2) doors met. Each window was approximately 10 or 12 inches wide and approximately 24 inches tall. Continued observation identified Resident #10 paced walking near the walls. Observation and interview with the DNS and RN #1 on 2/5/2026 at 10:40 AM identified on 1/14/2026 when NA #2 entered the unit, Resident #10 was near the corner of the wall and the door that NA #2 opened. RN #1 stated NA #2 did not see Resident #10 when she opened the door, and the door hit Resident #10 causing him/her to fall. Observation identified a person positioned in the corner near the wall was visible through the door window. Interview identified NA #2 should have looked through the window to ensure there were no residents near the door and should have entered the unit slowly. Interview and record review with NA #2 on 2/5/2026 at 12:25 PM identified she did not see Resident #10 when she opened the unit door on 1/14/2026. The door hit Resident #10 causing the resident to fall. NA #2 stated she looked through the window but Resident #10 was in the corner (near the wall) and she did not see Resident #10. NA #2 stated when she pushed open the door, it knocked Resident #10 and he/she lost his/her balance and fell. NA #2 stated she needed to be more careful.Interview and record review with the DNS and LPN #2 on 2/5/2026 at 2:30 PM identified Resident #10 ambulated independently with a walker and paced on the unit, often walking close to the walls. Further, the unit had multiple residents that wandered or paced who could be near the doors. The DNS stated she expected staff to open the door slowly and to be attentive to residents when opening the door.Review of facility documentation identified education was initiated on 1/15/2026 and included to open doors slowly and to look at both sides of the doors to ensure no residents are standing nearby. Further, observation identified signs were posted on the doors that directed staff to stop, before you open the door, look through both glass windows to ensure there is no resident behind the doors. A second sign directed to open door slowly, as resident could be behind door! audits were initiated on 1/15/2026 and a QAPI meeting was held on 1/16/2026. A finding of past non-compliance was identified.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #6) reviewed for therapy, the facility failed to ensure the clinical record was complete and accurate to include orthopedic consults, post wrist surgery documentation and related therapy notes as part of the medical record. The findings include:| Resident #6 was admitted to the facility with diagnoses that included neurogenic bladder, stage 4 pressure wound of the sacral region (base of the spine), chronic pain and contractures (permanent tightening and shortening of muscle, tendons, skin or nearby tissue turning them into stiff tissue). An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he/she was alert and oriented, was dependent for all care, had an indwelling catheter, an ostomy for bowels, a feeding tube, and had a stage 4 pressure ulcer that was present on admission or readmission. A Resident Care Plan (RCP) dated 5/1/2021identified Resident #6 was dependent for activities of daily living requiring bilateral elbow extension splints and a personal tilt in space custom wheelchair due to poor postural control. Interventions directed gentle range of motion prior to donning splint and therapy screen as needed. APRN progress note dated 5/19/2021 at 2:40 PM identified Resident #6 was seen by a bone/joint specialist for contractures of the hands and right wrist carpectomy (removal of wrist bones) without complications and was scheduled for left wrist hand surgery on 5/25/2021. A nursing note dated 5/25/2021 at 3:40 PM identified Resident #6 returned from a surgical appointment with a left wrist dressing in place, dressing clean, dry and intact (CDI) and no acute distress noted. A grievance form dated 6/2/2021 identified Resident #6 had reported to the hospital bone and joint institute that he/she was not receiving physical therapy. The grievance response identified that after Resident #6's wrist surgery, the therapy required was specialized and the facility was unable to complete the therapy at the facility. Attempts were made to set up therapy outside the facility were complicated by Resident #6's special needs (tracheostomy, special transport and monitoring during therapy). Resident #6 was thoroughly evaluated by therapy and was not appropriate for any therapy pending removal of a wrist splint by the orthopedist. Record review failed to identify any therapy notes/records related to the wrist surgery, documentation of the 5/25/2021 orthopedic procedure, and outside consultations. Although requested, the facility was unable to provide any therapy documentation for 2021 or outside consultations prior to 6/1/2021. Interview and record review with APRN #1on 2/11/2026 at 12:40 PM identified she recalled that Resident #6 had orthopedic surgery and was followed by an outside orthopedist. APRN #1 stated that any documentation of the procedure and any therapy evaluations should be included as part of Resident #6's medical record. Interview with the DON on 2/11/2026 at 2:00PM identified she would expect Resident #6's medical record to include documentation of any therapy provided or why it was not provided, and orthopedic consultations/surgeries or results of any outside appointment or surgeries. The DON stated she did not know why the medical record did not include these documents. The facility Charting Documentation Policy directed in part, all services provided to the resident, progress toward goals, any changes in medical, physical, functional or psychosocial condition shall be documented in the resident's medical record in order to facilitate communication between the interdisciplinary team members.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1), reviewed for accidents, the facility failed to adequately supervise a resident with a known history of wandering who ambulated independently, during a period with a higher than usual volume of visitors, to ensure the resident remained on the secured memory care unit when visitors were entering and exiting. Subsequently, the resident exited the secured memory care unit, ambulated through two facility hallways, exited the main facility entrance without staff knowledge, and was located by police 0.4 miles away from the facility. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included dementia, anxiety, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3) had short and long-term memory recall deficits and was independent with transfers and ambulation. The Resident Care Plan (RCP) dated 8/27/25 identified Resident #1 had a self-care deficit and a history of wandering throughout the unit in and out of other resident's rooms while self-ambulating. Interventions directed to provide a structured routine and redirect when wandering or exit seeking.The Psychiatric note dated 11/13/25 identified the Advanced Practice Registered Nurse (APRN) saw Resident #1 due to an increase in agitation and increase in wandering in other residents' rooms. The APRN prescribed additional Trazadone 25 mg two times per day as needed for increased agitation/restlessness. The Facility Reported Incident form dated 11/19/25 at 1:10 PM identified Resident #1 left the unit unsupervised and was last seen by staff at 1:10 PM. The Nurse's note dated 11/19/25 at 4:27 PM identified Resident #1 left the unit without staff knowledge and upon return, stated he/she went for a walk. The APRN was notified and ordered labs and visual monitoring.Review of the undated facility's summary report indicated that at approximately 1:40 PM on 11/19/25, the police department notified the facility that Resident #1 was found 0.4 miles away from the facility and Resident #1 was returned to the facility by a police officer and two facility staff members. The facility was unaware Resident #1 left the facility unsupervised. Resident #1 was last seen by NA #1 at 1:10 PM in the lounge and was seen ambulating in the hall. Based on staff interviews, there were many visitors on the unit during the time Resident #1 exited the unit. The summary report indicated Resident #1 may have inadvertently walked out alongside visitors as they left the unit and that during the post-event interview, Resident #1 was able to demonstrate to staff that he/she exited the building by the main facility door. The summary report identified that an Elopement Risk assessment conducted on 8/27/25 identified Resident #1 had a history of wandering and the RCP was updated to reflect wandering behaviors with interventions to redirect when wandering or exit seeking and encourage recreation activities.A written statement dated 11/19/25 by the receptionist identified she did not see Resident #1 exit the building on 11/19/25. Interview with RN #1 on 12/18/25 at 11 AM identified on 11/19/25 the facility received a phone call from the police inquiring if a resident was missing from the facility. RN #1 identified Resident #1 was not on the secured memory care unit and then went with a police officer to assist the resident back to the facility. RN #1 identified Resident #1 had a history of wandering throughout the secured memory care unit and walked up and down the halls. RN #1 identified that on 11/19/25 from 7 AM to 3 PM, there were several out-of-state visitors, unfamiliar with the facility, who were entering and exiting the secured memory care unit in groups of six (6) to eight (8) at a time. RN #1 further identified Resident #1 likely walked off the unit with exiting visitors. In addition to the visitors, a Social Worker was visiting the unit and construction was occurring in the building. RN #1 identified secure door codes should not be given to visitors. Interview with NA #2 on 12/18/25 at 11:10 AM identified he/she worked the 7 AM to 3 PM shift on 11/19/25. NA #2 identified she did not give the secure door code to visitors and that staff were responsible for escorting visitors in and out of the secured memory care unit and ensuring the door shuts and locks once visitors pass through the door. NA #2 further identified the secured memory care unit was busier than usual on 11/19/25 due to several visitors entering and exiting. NA #2 saw Resident #1 ambulating in the hallway around 1 PM and did not recall assisting any visitors out of the secured memory care unit. Observation of the secured memory care unit and interview with the DON on 12/18/25 at 2 PM identified that when visitors enter and exit the secured memory care unit, staff should enter the secured door code to assist visitors in and out. The DON identified staff should stay at the door as visitors pass through the doorway, then close the door and ensure the door is secured, which is indicated by a light illuminating red above the door. Staff should not give the door security code to visitors or residents. On 11/19/25 Resident #1 was last seen seated in the lounge area adjacent to the locked exit door. The DON identified the facility investigation revealed Resident #1 likely exited the secured unit when visitors entered/exited and further identified there were multiple unfamiliar visitors on the secured memory care unit on 11/19/25. The facility was unable to identify which staff member assisted the visitors in or out when Resident #1 exited. The DON indicated that the staff member who entered the secure door code must not have remained at the door to ensure no residents exited and that after exiting the secured memory care unit, Resident #1 proceeded to exit the facility's main entrance unseen by the receptionist. The facility Elopement Prevention and Door Safety Policy identified residents with a history of dementia and wandering were at increased risk of elopement. The policy further identified large groups of visitors presented a risk for unnoticed residents to exit the locked unit and staff should monitor exit doors more closely during peak visitor times and to ensure residents do not exit with visitors. Review of facility documentation identified that a Plan of Correction was initiated immediately to include:Staff training was completed and included review of the Elopement Prevention and Door Safety Policy, rounding expectations, visual oversight of residents, alarm response and visitor monitoring.Random audits were completed daily for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly for one (1) month to ensure Wader Guard devices were in place and functional, door alarms were operational, care plans were accurate, and staff followed visitor exit-monitoring procedures to ensure no residents exited unsupervised and the door was secured before leaving/entering the area.Audits will be reviewed at the monthly QAPI meetings.The Administrator and DON were responsible for the Plan of Correction with a compliance date of 11/22/25. The Plan of Correction was reviewed by the State Agency during an on-site visit on 12/19/25 and the facility met all components for past non-compliance.

Based on clinical record review, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of falls, the facility failed to complete a fall risk assessment following the fall in accordance with facility policy. The findings include:Resident #1's diagnoses included dementia with behavioral disturbances and Parkinson's disease (a movement disorder of the central nervous system that worsens over time). The Resident Care Plan dated 3/21/24 identified Resident #1 was at risk for falls due to weakness. Interventions directed to ensure the call light was within reach and encourage the resident to call for assistance as needed, provide assistance with bed mobility, transfers, and ambulating as ordered and needed and ensure two (2) half side rails are up on the bed to aid with turning and repositioning as needed. The late entry nurse's note dated 4/25/25 at 11:26 AM for 4/20/25 at 11:25 PM identified Resident #1 was heard crying in his/her room and observed sitting on the floor crying. The note indicated Resident #1 was assessed and noted to have no injuries, skin was intact and displayed no signs of pain or discomfort, Resident #1 was then assisted up to bed, provided a snack and no further distress was noted for the remainder of the night. Review of the clinical record failed to identify that a Morse Fall Scale (fall risk assessment) had been completed following the 4/20/25 fall, the next assessment was conducted on 8/23/25, four (4) months later. Interview with the Director of Nursing (DON) and the Regional Nurse on 10/8/25 at 2:54 PM identified that the Morse fall scale was to be completed for each resident on admission, following a fall (change in condition), quarterly and as needed. They reported the Morse fall scale should have been completed for Resident #1 following the 4/20/25 fall. The DON identified she was responsible to ensure an assessment was completed when she was reviewing the completed Accident and Investigation (A & I). Review of the Assessing Falls and Their Causes policy (undated) directed, in part, that residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed immediately. When a resident falls, the following information should be recorded in the resident's medical record: Completion of a fall risk assessment.

Based on clinical record review, observations, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff assistance with personal hygiene, the facility failed to ensure infection control practices were implemented and dirty linen and a soiled incontinent brief were not left on top of the resident's table in the room. The findings include:Resident #1's diagnoses included dementia with behavioral disturbances and Parkinson's disease (a movement disorder of the central nervous system that worsens over time). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) conducted by the staff identifying Resident #1 had short and long-term memory problems, did not make decisions regarding tasks of daily life, had difficulty focusing attention, disorganized thinking and an altered level of consciousness, required substantial assistance for bed mobility and was dependent on staff for transfers and was incontinent of bowel and bladder. The Resident Care Plan dated 9/9/25 identified that Resident #1 has cognitive loss/dementia. Interventions directed to assist the resident with bathing, washing and dressing as needed and tolerated and the resident required the assistance of one (1) with activities of daily living. Observations of Resident #1's room on 10/8/25 at 10:46 AM identified dirty linen and a dirty incontinent brief on the dresser in front of Resident #1's bed and a dirty johnny coat on the overbed table. Observations on 10/8/25 at 10:56 AM identified the dirty linen and incontinent brief had not been removed from Resident #1's room. Interview with a 7AM-3PM nurse aide, Nurse Aide (NA) #1, on 10/8/25 at 10:56 AM identified she was Resident #1's assigned nurse aide that day. NA #1 explained she left the soiled linen and incontinent brief on both the dresser and overbed table because the soiled linen cart was unavailable in the hallway outside of Resident #1's room and she should have bagged the linen and then came back for it and not left it on table surfaces. Interview with the Regional Nurse, Licensed Practical Nurse (LPN) #1, on 10/8/25 at 11:06 AM identified staff should never place dirty linens or incontinent briefs on furniture surfaces, they should have been bagged separately and then discarded as NA #1 left Resident #1's room. Although requested, a policy on infection control practices related to disposing of soiled linens and incontinence supplies was not provided.

Based on observations, review of clinical records, review of the facility assessment and interviews for four sampled residents residing on a secured nursing unit (Residents #32, #69, #161 and #173) and reviewed for involuntary seclusion, the facility failed to assess, care plan, demonstrate that the secured unit was the least restrictive setting, and obtain consents for residents who were selected to reside on the secured unit. The findings include: Observation on 8/15/25 at 10:30 AM identified there was one nursing unit located on the first floor of the facility. The double doors at the entry to the unit had a key pad entry that required a numeric code, there was also a doorbell that rang at the nursing station on the unit, and the staff could allow entry. The stairwells also required a numeric code entered into a key pad to allow for entry or egress. 1. Resident #32 was admitted to the facility in January 2025. Diagnoses included Parkinson's disease, psychosis not due to a substance or known physiological condition, post-traumatic stress disorder (PTSD), anxiety and dementia with other behavioral disturbances. The quarterly MDS assessment dated [DATE] identified Resident #32 had intact cognition, did not utilize alarms, did not exhibit wandering or rejection of care behaviors, was independent with toileting, personal hygiene, dressing, transfers and ambulation.The care plan dated 5/15/25 identified Resident #32 had a cognitive loss related to dementia with interventions that included, assist resident with bathing, washing and dressing as needed/tolerated with an assist of one, complete a dementia functional assessment on a quarterly basis, maintain consistent routines and use redirection and validation therapy as needed. Further review of the care plan identified that it did not contain information concerning the resident residing on the secured unit. The physician's orders in place for May 2025 identified Resident #32's care plan was reviewed and approved by the physician.The social worker's note dated 7/3/25 at 5:04 PM identified Resident #32 kept his/her room door closed all the time and conveyed that he/she felt anxious when other residents entered his/her room. The note further identified staff was assisting the resident with coping skills. The social worker's note dated 7/17/25 at 2:31 PM identified Resident #32 kept his/her room door closed all the time and conveyed that he/she felt anxious when other residents wandered into his/her room.The social worker's note dated 8/13/25 at 11:21 AM identified Resident #32's family member requested a discharge meeting that was scheduled for 8/20 at 1:00 PM. Interview on 8/15/25 at 10:58 AM with Resident #32 identified that he/she could not recall anyone discussing his/her placement on the secured unit with him/her. He/she further identified that most of the residents on the unit are not able to conversate and many wander in and out of other residents' rooms, take items from the rooms and are disruptive at times. Resident #32 further identified that he did not understand why he/she could not leave the unit. A review of the clinical for the time period of 1/1/25 through 8/17/25 failed to identify the criteria met for Resident #32 to be placed on the secured unit, it also failed to identify that the secured unit was the least restrictive environment. It further failed to identify the physician's involvement in the decision to place the resident on the secured unit or consent from the resident and/or responsible party. Observation on 8/18/25 at 8:59 AM identified Resident #32 redirected a resident who wandered into his/her room to leave his/her room. No staff were observed in the area. Resident #32 further identified that there were other residents on the unit that wandered into his/her room at times.A nursing note dated 8/19/25 (subsequent to surveyor inquiry) identified that the interdisciplinary team (IDT) reviewed the criteria met for placement on the secured unit and noted that the facility reached out to the resident's family member and was awaiting a call back. Interview on 8/20/25 at 12:28 PM with LPN#2 identified there were a lot of residents on the unit with behaviors that require more attention and redirection, and it is not always possible to be everywhere. He further noted that they did not always have enough staff to provide the level of supervision that is needed for the residents on the secured unit. Interview on 8/18/25 at 9:58 AM with Resident #32's Responsible Party (Person #5) identified Resident #32 was placed on the secured unit after making an allegation of abuse against a staff member. Person #5 indicated the family had attempted to move Person #5 to another facility, but no other facility would accept the resident. She further identified that she felt the facilities would not accept the resident because the current facility has passed along the resident's behavior history. Person #5 identified that the facility had not notified her of the resident's placement on the secured unit and had not provided a rationale for the placement. Interview on 8/19/25 at 9:26 AM with RN #9 (nurse consultant hired as part of the change in ownership) identified the facility was working on care plans and assessments for the residents residing on the secured unit and noted that the facility had just hired an experienced unit manager for the unit. RN #9 further identified that the criteria for the secured unit was developed in November 2024. She further identified that assessments and reassessments or placement on the unit should be completed at admission and quarterly. Interview on 8/20/25 at 11:00 AM with the DNS identified that the regulatory criteria was not implemented for all of the residents residing on the secured unit. Interview on 8/20/25 at 11:21 AM with LPN #9 (Regional Director of Admissions) identified that the admission process for the secured unit involved reviewing the hospital discharge summary, speaking with the responsible party(ies) and with the resident if they are alert and oriented. LPN #9 identified that the hospital sometimes make a recommendation that a resident requires a secured unit. Further, LPN#9 identified the criteria for placement on the unit includes: a diagnosis of dementia, residents at risk for elopement, a resident who is not easily redirected, and a resident who is deemed unsafe to be on a non-secured unit. LPN #9 further conveyed that the decision to place Resident #32 on the secured unit was made prior to the resident's admission but could not locate documentation in the clinical record that identified why the resident required placement on a secured unit. Interview on 8/21/25 at 10:54 AM with the Social Worker and LPN #7 (MDS Coordinator) identified that they should discuss the resident's placement on the secured unit during the care plan meetings and the care plan should reflect that the resident resides on a secured unit but identified that review of Resident #32's clinical record failed to identify documentation that addressed the resident's placement on the secured unit.Interview on 8/21/25 at 11:35 AM with the DNS identified the follow-through for the secured unit was a work in progress and the facility is calling families and is still touching base regarding consent for the placement on the unit. She further identified that the implementation was started the day post surveyor inquiry. 2. Resident #69 was admitted to the facility in April 2024 with diagnoses that included dementia with behavioral disturbances, depression, and adjustment insomnia. The annual MDS assessment dated [DATE] identified Resident #69 had intact cognition, did not exhibit physical or verbal behaviors directed toward self or others, rejection of care or wandering behaviors, was independent with all mobility, transfers and did not use any physical restraints or alarms.The care plan dated 4/24/25 identified Resident #69 preferred to remain in the facility long term with interventions that include assess/discuss alternate discharge settings as needed to ensure resident's needs are met, discuss with resident/health care representative the experience and feelings about the stay in the facility at care plan meeting. The care plan identified Resident #69 had very mild cognitive decline and indicated he/she attempted to help other residents without permission. Interventions included: set boundaries with resident and redirect resident to call for assistance for other residents in need.Observation on 8/15/25 at 1:29 PM identified Resident #69 ambulating in the hallway on the secured unit. Interview on 8/15/25 at 1:29 PM identified Resident #69 conveyed that his/her rolling walker used for ambulation was missing from his/her room and noted that the only problem on the unit was the behaviors of some of the other residents on the unit. He/she identified that residents wander into his/her room. Resident #69 indicated that another resident had taken the rolling walker out of Resident #69's room and that it was required for Resident #69 to ambulate safely. Resident #69 identified that no one had ever discussed being locked in with him/her.A review of the clinical for the time period of 1/1/25 through 8/17/25 failed to identify the criteria met for Resident #69 to be placed on the secured unit, it also failed to identify that the secured unit was the least restrictive environment. It further failed to identify the physician's involvement in the decision to place the resident on the secured unit or consent from the resident and/or responsible party. Interview on 8/19/25 at 10:23 AM with Resident #69's family member (Person #9) identified there was no need for Resident #69 to be on a secured unit and noted that the facility had not discussed the placement on the unit with her. Person #9 further identified Resident #69 is legally responsible for signing paperwork and making decisions.Interview on 8/20/25 at 11:21 AM with LPN #9 (Regional Director of Admissions) identified that the admission process for the secured unit involved reviewing the hospital discharge summary, speaking with the responsible party(ies) and with the resident if they are alert and oriented. LPN #9 identified that the hospital sometimes make a recommendation that a resident requires a secured unit. Further, LPN#9 identified the criteria for placement on the unit includes: a diagnosis of dementia, residents at risk for elopement, a resident who is not easily redirected, and a resident who is deemed unsafe to be on a non-secured unit. LPN #9 further conveyed that the decision to place Resident #32 on the secured unit was made prior to the resident's admission but could not locate documentation in the clinical record that identified why the resident required placement on a secured unit. Interview on 8/21/25 at 10:54 AM with the Social Worker and LPN #7 (MDS Coordinator) identified that they should discuss the resident's placement on the secured unit during the care plan meetings and the care plan should reflect that the resident resides on a secured unit but identified that review of Resident #69's clinical record failed to identify documentation that addressed the resident's placement on the secured unit.Interview on 8/21/25 at 11:35 AM with the DNS identified the follow-through for the secured unit was a work in progress and the facility is calling families and is still touching base regarding consent for the placement on the unit. She further identified that the implementation was started the day post surveyor inquiry. 3. Resident #161 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, anxiety and chronic pain syndrome.An elopement risk assessment dated [DATE] identified Resident #161 was not an elopement risk.The admission MDS assessment dated [DATE] identified Resident #161 had severely impaired cognition, did not exhibit physical or verbal behaviors directed toward others, rejection of care or wandering, utilized a manual wheelchair and required partial/moderate assistance with mobility.The care plan dated 5/1/25 identified Resident #161 was at risk for decline related to dementia diagnosis and becomes easily agitated and is combative at times. The care plan further identified the resident resided on the long-term dementia unit with interventions that included: supply community referrals as needed, discuss with resident/health care representative their experience and feelings about their stay in the facility at care plan meetings and as needed.Review of the clinical record from January 2025 through 8/19/25 identified Resident #161 failed to identify documentation regarding placement or discussion of placement on the secured unit, and documentation identifying placement on the secured unit was the least restrictive setting. Subsequent to surveyor inquiry an elopement risk assessment dated [DATE] at 11:49 PM identified Resident #161 was not an elopement risk due to being bed bound. Additionally, on 8/16/25, the facility completed a dementia functional assessment tool that identified Resident #161 had moderate cognitive decline. Interview on 8/20/25 at 11:00 AM with the DNS identified that she was under the impression the facility was following the rules of the regulation and set up criteria for the secured unit. Review of Resident #161's documentation, The DNS indicated that the criteria had not been implemented for all residents and that the regulation was reviewed and the facility was entering c Interview on 8/20/25 at 11:21 AM with LPN #9, Regional Director of Admissions, identified the admission process for the secured unit involved review of the hospital stay/discharge for residents discharging for a clinical review to make sure they are appropriate for the building. LPN #9 indicated she would have a conversation with the families or case manager, and with the resident if they are alert and oriented, in the hospital prior to admission and explain the unit and the services they offer. LPN #9 identified that the hospital makes the recommendation that the resident requires the secured unit. LPN#9 identified criteria to include a diagnosis of dementia, a wander risk, not easily redirectable, not able to keep safe on the regular units. LPN #9 indicated that the placement was made prior to admission, that she had only participated in 2 placements, and that the decision for admission was not documented in the clinical chart, but rather an email thread in the hospital system.Interview on 8/19/25 at 12:15 PM with Person #8 (family member) identified Resident #161 had been bedbound for a while and after returning from the hospital last week, was placed on hospice services. Person #8 indicated there were a lot of other residents who are confused and walking into the room and touching things, including personal items. Person #8 further identified that the facility did not have a discussion with him/her or Resident #161 regarding placement on the secured unit. Interview on 8/21/25 at 10:54 AM with LMSW and LPN#7 (MDS), identified they set up the 72 hour meeting after admission and indicated the secured unit placement conversation happens prior to admission and no conversation occurs at the 72 hour meeting. LPN#7 identified that they also set up a 14 day meeting and go over with the resident/representative about being on the secured unit. LPN #7 could not identify where this conversation was documented.Interview on 8/21/25 at 11:27 with RN #4 identified that she assisted with the input of the care plans and after a recent IDT meeting, RN #4 was directed by the DNS to input items related to the secured unit. Reviewed Residents #32, #69, #161 and #173 care plan items added and status and indicated that the interventions were not appropriate or resident specific and indicated she was provided a template for the input into the care plan. 4. Resident #173 was admitted to the facility June 2025. Diagnoses included dementia, anxiety disorder and depression.The admission MDS assessment dated [DATE] identified Resident #161 had intact cognition, did not exhibit physical or verbal behavioral symptoms directed toward others, did not exhibit wandering behavior, did not utilize alarms and was independent with transfers and position changes The care plan dated 6/24/25 identified Resident #161 had dementia and confusion and required assistance of 1 person for activities of daily living. Review of the clinical record dated 6/19/25 through 8/18/25 failed to identify documentation of Resident #173's placement on a secured unit, assessment for placement or MD documentation that the placement was the least restrictive environment for the resident. Elopement risk assessment dated [DATE] identified Resident #173 was not an elopement risk. Elopement assessment dated [DATE] identified Resident #173 had exhibited behavior that would cause concern related to wandering, exit seeking or safety and verbally expressed desire to leave center or go home. The assessment indicated Resident #173 was cognitively impaired with poor decision-making skills, had a diagnosis of dementia, had a recent medication change, had a recent housing changed and changed to long-term care. The score is a 3.0 which means Resident #173 was at risk for elopement.Psychiatric progress note dated 8/13/25 at 4:10 PM identified Resident #161 was anxious and depressed related to SNF placement and was requesting discharge.Interview on 8/15/2025 at 11:11 AM with Resident #173 identified confusion over placement at the facility and not being able to leave or access any money. Resident #173 indicated living at home with family and some damage to the home. Resident #173 identified the preference to keep the room door closed because of the elderly people that walk into the room and take things and indicated stress related to being on the secured unit and not feeling safe with others entering the room.Interview on 8/18/2025 at 9:24 AM with Person #10, Legal assistant to Resident #173's conservator, identified Resident #173 was placed in long term care on the secured unit because Resident #173 was identified by the conservator's office as possibly being a flight risk due to wanting to return home. Person #10 indicated the placement was to prevent Resident #173's family from having access to the resident and agreed that Resident #173 should be in a secured unit until everything calmed down with the family. Person #10 identified Resident #173 had some dementia but was going to be placed in assisted living at the point that the home sells.Interview on 8/20/25 at 11:21 AM with LPN #9, Regional Director of Admissions, identified the admission process for the secured unit involved review of the hospital stay/discharge for residents discharging for a clinical review to make sure they are appropriate for the building. LPN #9 indicated she would have a conversation with the families or case manager, and with the resident if they are alert and oriented, in the hospital prior to admission and explain the unit and the services they offer. LPN #9 identified that the hospital makes the recommendation that the resident requires the secured unit. LPN#9 identified criteria to include a diagnosis of dementia, a wander risk, not easily redirectable, not able to keep safe on the regular units. LPN #9 indicated that the placement was made prior to admission, that she had only participated in 2 placements, and that the decision for admission was not documented in the clinical chart, but rather an email thread in the hospital system.Interview on 8/21/25 at 10:54 AM with LMSW and LPN#7 (MDS), identified they set up the 72 hour meeting after admission and indicated the secured unit placement conversation happens prior to admission and no conversation occurs at the 72 hour meeting. LPN#7 identified that they also set up a 14 day meeting and go over with the resident/representative about being on the secured unit. LPN #7 could not identify where this conversation was documented.Interview on 8/21/25 at 11:27 with RN #4 identified that she assisted with the input of the care plans and after a recent IDT meeting, RN #4 was directed by the DNS to input items related to the secured unit. Reviewed Residents #32, #69, #161 and #173 care plan items added and status and indicated that the interventions were not appropriate or resident specific and indicated she was provided a template for the input into the care plan.Interview on 8/21/25 at 11:35 AM with the DNS identified the care plans were altered this week after a conversation with RN #9 that indicated each resident residing on the secured unit had to have a care plan identifying the placement. The DNS identified they had a template but realized that the care plan template was not patient specific and that the DNS then directed social work to go through and review the care plans to make sure they were patient specific. The DNS indicated the follow-through for the secured unit was a work in progress and that the facility are still calling families and are still touching base regarding permissions for the placement and remaining on the unit. The DNS identified the implementation was started the day after the surveyor started asking questions. A Secured Locked Unit admission policy, directed that decisions regarding an admission to the secured unit, will involve input from the resident's family, the IDT review and appropriate verbal consent from the resident's legal representative, family or power of attorney. It further indicated there was criterion for placement on the secured unit if any or more of the following were met; documented cognitive impairment, exit seeking risk, safety concerns, benefit from a structured monitored environment, interdisciplinary team review, which included nursing, physician/NP, social work and therapy and informed verbal consent, from the resident or legal guardian. Which should include an explanation of the secured unit, including purpose, risks and resident rights.

Based on review of facility documentation, review of facility policy, and interviews during a review of the Infection Control Program, the facility failed to ensure environmental rounds were conducted/completed monthly, the facility failed to ensure infection surveillance data collection reports and analysis of infection trends within the facility were completed monthly, and failed to follow the policy and procedural measures developed by the facility to prevent the growth of Legionella and other water borne pathogens in the building water system. The findings include:1. Review of the infection control environmental round documentation for the past two years with the Infection Preventionist (RN #7) and the DNS on 8/19/25 at 1:00 PM failed to identify documentation of monthly environmental rounds that were completed for October 2024 and January of 2025. Interview with the Infection Preventionist (RN #7) and the DNS on 8/21/25 at 12:23 PM identified they were unable to locate any documentation for environmental rounds completed for October 2024 and January of 2025. RN #7 and the DNS identified that environmental rounds are completed monthly and it was the responsibility of the previous infection preventionist nurse to ensure they were completed as the DNS only started working at the facility in February of 2025 and only RN #7 started working at the facility in March of 2025.Review of the Environmental Rounds policy identified the infection control professional or his/her designee, charge nurses, supervisors, and department heads on their own units/departments complete environmental rounds on a regular basis. The policy further identified the environmental survey worksheets would be retained for possible review by survey teams to illustrate the improvement of quality of life within the facility.Review of the Compliance Rounds policy identified the Infection Preventionist is responsible for conducting periodic compliance rounds throughout the facility. 2. Review of the infection control program for the period of January 2024 to August 2025 with the Infection Preventionist (RN #7) and the DNS on 8/21/25 at 12:23 PM failed to provide documentation of monthly surveillance infection reports and analysis of infection trends were completed for the period of January 2024 to May 2024 and for the period of July 2024 to September 2024.Interview with the Infection Preventionist (RN #7) and the DNS on 8/21/25 at 12:23 PM identified they were unable to locate any of the monthly surveillance infection reports and analysis of infection for the period of January 2024 to May 2024 and for the period of July 2024 to September 2024 after searching thoroughly throughout the facility. RN #7 identified the monthly report and analysis data included the rate of healthcare/facility acquired infections and community acquired infections within the facility, and at the end of each month the total infection rate is calculated using a formula. They identified it was the responsibility of the infection preventionist nurse to track, identify and analyze infection rates within the facility monthly.Review of the Surveillance for Infections policy is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associate infections, to guide appropriate interventions, and to prevent future infections. The policy further identified monthly collection of information from individual resident infection reports and enter line listing of infections by resident for the entire month; and summarize monthly data for each nursing unit by site and by pathogen and monthly/quarterly identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. 3. Review of the facility Water Management Plan/Program for the period of January 2024 to August 2025 with the Administrator, Maintenance #2 and Maintenance #3 (Director of Maintenance at another facility) on 8/20/25 at 1:29 PM identified the facility water management plan included flushing of not regularly used water pipes and locations include the soiled utility room, medication room sinks, shower tubs twice monthly, annual water sampling and daily water temperature checks. Review of the flushing log for the period of January 2024 to August 2025 failed to identify flushes were completed in the identified locations and documented twice for January 2025, February 2025 and July 2025.Interview with the Maintenance #3 staff on 8/20/25 at 1:29 PM identified the facility flushing plan had changed in January of 2025 from monthly to twice a month. He identified that he was the one flushing the locations that were identified as not commonly used but went on family medical leave in May 2025 and had just returned to work on 8/18/25.Interview with the Administrator on 8/21/25 at 11:13 AM identified the facility flushing plan for the water management plan was to flush the identified locations twice monthly. He further identified he was not working at the facility during those timeframes and was unable to state why the flushes were not completed.Although a request was made on 8/20/25 at 1:29 PM for their contracted company water management binder in which the Annual Water Management Plan Revision and Update dated 10/12/24 made reference to, the facility failed to provide the water management plan binder provided by their contracted company. Review of the Annual Water Management Plan Revision and Updates dated 10/12/24 in which the Administrator, Maintenance #2 and Maintenance #3 (Director of Maintenance at another facility) identified this as the current revision of the water management plan which identifies the facility is conducting and documenting flushing records and shall continue documentation to establish compliance in all areas of the plan. The plan further identifies where a dead leg cannot be avoided, the plumbing design should consider a means for flushing the dead leg or locating it in line with a downstream fixture.Review of the Legionella Water Management Program policy identifies situations that can lead to Legionella growth such as construction, water breaks, water temperature fluctuations, water pressure changes and water stagnation and identifies specific measures used to control the introduction and /spread of legionella for example temperature, disinfectants and for documentation of the program.

Based on review of facility documentation, review of facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to ensure the antibiotic surveillance tracking report of antibiotic usage and outcome was collected and documented for analysis. The findings include: Review of the antibiotic stewardship program for the past two years with the Infection Preventionist (RN #7) and the DNS on 8/21/25 at 12:23 PM failed to provide any documentation related to antibiotic surveillance data for the period of January 2024 to May 2024 and for July 2024 to September 2024. The facility also failed to provide documentation that a quarterly review of antibiotic usage for the first, second, and third quarters of 2024 and the first and second quarter of 2025 was presented at the quarterly medical staff meeting.Interview with the RN #7 and the DNS on 8/21/25 at 12:23 PM identified they were not working at the facility during the time frame and were only able to locate the monthly Antibiotic surveillance tracking report for June 2024, and for October to December of 2024. In addition, the DNS identified she was unable to locate any infection control reports which included the antibiotic stewardship program that was presented at the quarterly medical staff meeting that was held in the first, second, and third 2024 and for the first and second quarters in 2025. RN #7 identified the antibiotic surveillance report is tracked monthly which is included in the infection surveillance report and is presented at the quarterly medical staff meeting by the infection preventionist. RN #7 identified it would have been the responsibility of the previous IP to track and complete the antibiotic surveillance usage report monthly as it was a part of the monthly infection surveillance report, which is then presented at the quarterly medical staff meeting.Review of the Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes policy identified antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.Review of the Infection Control and Control Program policy identified culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities and data gathered during surveillance is used to oversee infections and spot trends. The policy further identified monthly rates can then be plotted graphically or otherwise compared side-by-side to allow for trends and comparison.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure the residents had a safe, clean, comfortable environment. The findings included:1. Observation on 8/18/25, 8/19/25 and 8/20/25 identified the resident unit located on the first floor smelled of urine. The walls and baseboards in the hallways contained rust-colored stains, and peeling wallpaper. The floors were sticky in some areas making it hard to lift your feet off the floor. The water fountain in the hallway contained standing water in the drain that was brownish black in color. Several resident rooms (101, 104, 105, 108, 110, 118, 119 and 238) presented with peeling wallpaper that had a black substance on the back of the wallpaper and on the wall. The black substance was also noted on the wall underneath the air conditioning (AC) units. Some of the rooms had exposed inner wall and insulation around the AC units, and some were missing molding that exposed the insulation and wiring in the wall. In addition, some of the baseboard covers were detached from the wall, and holes in the wall noted with exposed insulation and a black substance. Interview on 8/20/2025 at 8:05 AM with LPN# 11 identified that the water fountain had not worked since prior to COVID and isn't cleaned regularly. LPN #11 identified that there was a housekeeper on the unit daily, but the unit had some residents with wandering and other behaviors that make it difficult to keep up with. Interview on 8/21/25 at 9:15 AM with RN#3 identified she would speak with the Administrator regarding the smell and cleanliness of the unit and indicated she noticed the floor was sticky in some areas and noted she had addressed this with the housekeeper. Interview on 8/21/25 at 9:34 AM with the Administrator and observation of the 1st floor nursing unit identified that the water fountain would be removed that day and indicated the dirty standing water could potentially be a safety concern for ambulatory residents with lower cognitive status or safety awareness. During a tour of the unit with the Administrator, the black growth and exposed insulation in the rooms as well as the residue on the walls and molding in the hallways was pointed out to him. The Administrator indicated he would assign an additional housekeeper to the unit. Interview on 8/21/2025 at 1:53 PM with the Director of Maintenance for another facility under the Civita umbrella, identified that any black substance should be treated with a bleach mixture that contained a cleaner for fungus growth. The Director of Maintenance could not identify if any of the black substance had been treated, nor could he identify when the air conditioning units were last cleaned or serviced but noted that the AC units should be cleaned. Interview on 8/21/2025 at 2:06 PM with Maintenance Worker #2 identified the AC units are cleaned one time in the spring but failed to provide documentation of when the cleaning was done. Maintenance Worker #2 identified that the water fountain would be removed from the unit, and the facility had directed an additional housekeeper for cleaning. Subsequent to surveyor inquiry, the water fountain was removed from the hallway and the plumbing secured. 2. Observation on 8/15/25 at 9:45 AM identified the resident lounge on the Chateaux unit was warm and humid, the air conditioner located in the wall was not functioning and the television was out of order. Interview on 8/15/25 at 10:00 AM with Resident #76 identified the temperature in the lounge on the second floor (Chateux) was so hot that residents do not want to frequent the lounge to relax like they use to or to watch TV because it was too hot and the TV was broken. Resident #76 further noted that it had been like that for greater than two months and all they were told was that they were working on quotes. Resident #76 identified that he/she was frustrated about the length of time the AC was not working. Interview on 8/15/25 at 10:30 AM with the Maintenance Director from another Civita facility who noted that he visits the facility monthly to maintain maintenance because the facility did not have a maintenance director. He identified that he was aware of the broken AC unit and had informed Resident #76 that it was an electrical issue that required an electrician to fix. Interview on 8/19/25 at 9:30 AM with the Administrator identified that the AC unit had been broken for several weeks and note they had a new AC unit but had not installed it because he was told it was an electrical issue, and they were working on quotes to get the electrical issue repaired. Additionally, he identified that the facility was undergoing a change in ownership and expressed that it was his understanding he had until the change of ownership was completed to fix the issue. Interview on 8/21/25 at 1:30 PM with the Maintenance Assistant identified he had been on medical leave since May 2025 and returned 8/18/25 and noted that prior to his medical leave there was problems with the HVAC (Heating ventilation and Cooling) system in the building and currently there is a roof top unit that is not working properly. He also noted that he was aware that the AC in the lounge had been out for a couple of months and they tried to reset the breaker, and it tripped the breaker. He further noted that from what he has seen there has been a lot of quotes received but not much work completed, and the electrical company had been there that week to fix the breaker for the AC unit after the state survey team entered the facility. Interview on 8/21/25 at 2:00 PM with the Administrator identified that an electrical company had been there that week to repair the breaker for the resident lounge, and the new AC was installed. Interview on 8/21/25 at 2:10 PM with the Assistant Administrator identified that he started at the end of January and that the AC in the lounge had been an ongoing issue for about 4-5 weeks along with the rooftop AC unit which they had been working on. He noted that the plan had been to have an electrical crew come out before October 1st. Although a policy regarding temperature/environment was requested one was not received.

Based on clinical record reviews and interviews for 6 of 6 sampled residents (Residents #31, #45, #49, #56, #62, and #64) reviewed for resident assessment, the facility failed to ensure quarterly MDS assessments were completed timely. The findings include:Resident #31 had a quarterly MDS assessment dated [DATE], which means the next quarterly MDS assessment should have been dated 7/1/25 and completed by 7/15/25; however, the assessment was not completed until 8/20/25 making it 35 days late.Resident #45 had a quarterly MDS assessment dated [DATE], which means the next quarterly MDS assessment should have been dated 7/1/25 and completed by 7/15/25; however, the assessment was not completed until 8/22/25 making it 37 days late.Resident #49 had a quarterly MDS assessment dated [DATE], which means the next quarterly MDS assessment should have been dated 6/26/25 and completed by 7/10/25; however, the assessment had not been completed until 8/20/25 making it 40 days late.Resident #56 had a quarterly MDS assessment dated [DATE], which means the next quarterly assessment should have been dated 6/9/25 and completed by 6/23/25; however, the assessment had not been completed until 8/20/25 making it 57 days late.Resident #62 had a quarterly MDS assessment dated [DATE], which means the next quarterly assessment should have been dated 7/8/25 and completed by 7/22/25; however, the assessment had not been completed until 8/22/25 making it 21 days late.Resident #64 had a quarterly MDS assessment dated [DATE], which means the next quarterly assessment should have been dated 7/9/25, and completed by 7/23/25; however, the assessment had not been completed until 8/22/25 making it 29 days late.Interview with LPN #7 (MDS Coordinator) on 8/20/25 at 10:45 AM identified she is responsible for completing the MDS sections and RN #2 (Regional MDS Coordinator) is responsible for signing the RN MDS completion and submitting the completed MDS. She identified that the quarterly MDS assessment need to be signed off and completed within 14 days by an RN after setting the ARD (Assessment Reference Date). In addition, she acknowledged that the MDS assessments were late because the full-time RN MDS coordinator left 2 months ago and she only receives help remotely from another MDS Coordinator between 6 to 8 hours per week which is not enough help to complete the MDS assessment timely. She further identified that RN #2 was aware that she was getting behind with the completion of the MDS assessments.An attempt to interview RN #2 was unsuccessful. The Resident Assessment Instrument 3.0 user manual identified that the resident's assessment must be completed no later than the set assessment reference date (ARD) + 14 calendar days to be considered timely.

Based on review of facility documentation, review of facility policy, and staff interviews for two of three nurse aides (NA #4 and NA #5), the facility failed to complete an annual performance evaluation. The findings include:Review of NA #4's personnel file identified a hire date of 1/31/22. Further review identified that the last performance evaluation was completed on 5/26/23. The facility failed to identify that a yearly performance evaluation was completed for 2024 and 2025.Review of NA #5's personnel file identified a hire date of 8/14/2002. Further review identified that the last performance evaluation on file was dated 8/20/2018. The facility failed to identify that a yearly performance evaluation was completed for 2023, 2024 and 2025.Interview with the DNS on 8/20/25 at 1:25 PM identified that each employee should have a performance evaluation completed yearly based on their date of hire yearly anniversary. She identified that human resources makes the notification of when the performance evaluation is due and the yearly evaluation is then distributed to the nursing supervisor to complete. Human Resources is responsible for ensuring the yearly performance evaluations are completed and in the employee record. She further identified that the facility did not currently have a human resource person. The How to Complete the Performance Evaluation policy identified that the facility reviews and summarizes the employee counseling session to identify a trend and pattern. The facility also reviews the job description performance rating with the employee to ensure the employee understands the performance rating for the function of their position and the performance evaluation is filed in accordance with facility policy.

Based on observation, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident#32, and Resident #173) reviewed for food, the facility failed to ensure the food tray ticket were accurate and fruit was available to the resident. The findings include:Resident #32's diagnoses included Parkinson disease, dementia, dysphagia, and diabetes mellitus.The quarterly MDS assessment dated [DATE] identified Resident #32 was cognitively intact, required set-up help for eating, was on therapeutic diet and received regular consistency foods. The care plan dated 5/16/25 identified Resident #32 had a potential for alteration in nutritional status related to therapeutic diet, dysphagia and diabetes mellitus. The care plan interventions directed to ensure accurate diet as ordered, report any changes/concern to the physician, offer snack as indicated, and weigh as ordered.The current monthly physician's order directed to give regular consistency and carbohydrate-controlled diet.During the resident council meeting conducted on 8/18/25 at 1:00 PM, the resident brought up a concern regarding the availability of bananas and oranges. Although the residents had been told that bananas and oranges were always available, they are frequently not available when requested.Observation on 8/20/25 at 8:06 AM identified Resident #32's meal ticket identified he/she should have 1 serving of oatmeal, 1/2 cup of hashbrowns, 1 slice of toast, 1 serving of diet jelly, 1 piece of margarine, 1 serving of coffee with creamer, 1 serving of yogurt, 1 banana, 1 packet of salt and pepper and 4 ounces of juice; however, there was no banana noted on the resident's tray of food. Resident #172's diagnosis included dementia, hypertension, and diabetes mellitus.The admission MDS assessment dated [DATE] identified Resident #172 had moderate cognitive impaired, required set-up help with eating and was on a regular consistency therapeutic diet.The care plan dated 7/17/25 identified Resident #172 had a potential for alteration in nutritional status related to therapeutic diet and weight loss. The care plan interventions directed to ensure accurate diet as ordered, report any changes/concern to the physician, offer snack as indicated, and weight as ordered.The current monthly physician's order directed to give regular consistency and carbohydrate-controlled diet.Observation on 8/20/25 at 8:12 AM identified Resident #172's meal ticket identified that he/she should have 3 ounces of scrambled egg, 1 1/4 cup of rice Krispies cereal, 1/2 cup of hashbrowns, 1 slice of toast, 1 serving of diet jelly, 1 piece of margarine, 2 serving of coffee with sugar substitute, 1 packet of salt and pepper, 1 banana, 4 ounces of juice, and 8 ounces of skim milk; however, there was no banana noted on the resident's tray of food.Interview with the Food Service Director (FSD) on 8/20/25 at 11:30 AM identified that bananas and oranges are always available to all residents. He identified that the resident tray ticket indicates whether a banana and/or orange were requested. He identified that the resident should receive the food items identified on the meal ticket. The FSD further noted they had run out of bananas. He further identified that he had decreased the order of bananas from 80 pounds to 60 pounds in June 2025 because they frequently go bad.Review of facility Planning and Food Service policy identified that the facility would provide a varied and balance diet for all residents in accordance with federal, state and local regulations, professional dietary standards, and resident preferences. Menus would be planned, reviewed, and updated to meet the nutritional and therapeutic need of the residents.

Based on observation, review of the clinical records, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident #151) observed with medications left unattended at the bedside, and (Resident #178) on controlled anti-anxiety medication, the facility failed to ensure that medications were administered and failed to ensure documentation entered on the medication administration record was in accordance with professional standards of practice. The findings include:1. Resident #151's diagnoses included heart attack, stroke, benign neoplasm of the spinal cord and paralysis of the lower body.The admission MDS assessment dated [DATE] identified Resident #151 was cognitively intact, required set-up assistance for meals and oral hygiene, and was dependent on staff for toileting, showering, upper/lower body dressing and personal hygiene.The care plan dated 6/3/25 identified Resident #151 required assistance with dressing, hygiene, eating, bathing and toileting and required a total mechanical lift with the assistance of two for transfers. Interventions included providing set-up supervision and/or assistance as needed. Observation on 8/19/25 at 9:46 AM identified Resident #151 in bed, and a medication cup containing medications located on an overbed table in front of the resident. The nurse was not in the room and Resident #151 proceeded to self-administer the medications. Interview with Resident #151 at the time of the observation identified that it takes him a while take his/her medications, so the nurse leaves the medications at the bedside. Resident #151 further identified that he/she does not have a problem taking the medications but does takes them one at a time which takes a long time. Interview with LPN #1 on 8/19/25 at 9:48 AM identified that she had poured the medications and brought them to the resident's room at which time, he/she asked her to heat up some hot cereal. She noted that she left the medications at the bedside and left the room to heat the cereal up. She further identified that she should not have the medications at the bedside and that Resident #151 was not assessed to self-administer his/her medications. In addition, LPN #1 verified that she had prepared the following medications for administration: 1. Gabapentin (anticonvulsant) 100 milligrams (mg) 1 capsule2. Cholecalciferol (Vitamin D3) 25 micrograms (mcg) 1 tablet3. Dexamethasone (corticosteroid) 2mg 1 tablet4. Acidophilus (probiotic) 1 capsule5. Vitamin C 500mg 1 tablet6. Multivitamin with minerals 1 tablet7. Prevagen (helps with mild memory loss) extra strength 1 tablet8. Aspirin 81mg delayed release 1 tablet9. Linezolid (antibiotic) 600mg 1 tablet Interview on 8/21/25 at 9:19 AM with the Nursing Supervisor (RN #4) identified LPN #1 was distracted and nervous, and when the resident asked for the cereal to be heated up, LPN #1 mistakenly left the medications at bedside. RN #4 further identified that LPN #1 had been re-educated and should have asked a NA to re-heat the cereal while she was in the process of medication administration. She further identified that medications should not be left at the bedside. The core principles of the five Rights of medication administration include the right patient, the right drug, the right dose, the right route and the right time. Also included is the observation of the patient while they take the medication that was poured by the nurse to ensure the medications are consumed as ordered. 2. Resident #178 was admitted to the facility from an acute care hospital on 6/25/25 with diagnoses that included depression, and anxiety disorder.The nursing admission assessment dated [DATE] identified Resident #178 was alert and oriented to person, place and time, had no impairments to upper or lower extremities and utilized a wheelchair for mobility.The care plan dated 6/26/25 identified Resident #178 required assistance with dressing, hygiene, eating, bathing and toileting with interventions directed to provide set-up, supervision and or assistance with activities of daily living (ADLs) as needed. The care plan further identified Resident #178 received psychotropic medication related to anxiety and depression. The physician order dated 6/26/25 directed to administer Alprazolam extended release (ER) (24hr) 1milligram (mg) tablet once daily at 9:00 AM for anxiety disorder.Review of the electronic medication administration record (eMAR) for the month of June 2025 identified Alprazolam ER 1mg tablet was administered to Resident #178 on 6/26/25 at 10:12 AM by LPN #5.Review of Resident #178's controlled disposition record for Alprazolam ER 1mg tablet identified that the medication was delivered to the facility on 6/27/25. Review of the facility's emergency medication supply inventory list failed to identify the facility stocked Alprazolam ER 1mg tablet as part of their emergency supply of medications. Review of the controlled medication transactions per patient for the period of 6/1/25 through 6/26/25 facility failed to identify any residents with an order for Alprazolam ER 1mg tablets.Interview with the Charge Nurse (LPN #5) on 8/19/25 at 11:20 AM after a review of the controlled disposition record for the Alprazolam ER 1 mg for Resident #178, she identified that the medication arrived to the facility on 6/27/25. She acknowledged that she signed the medication administration record on 6/26/25 indicating that the medication had been administered to Resident #178, but she could not identify where she obtained the medication or if the medication was actually administered. In addition, LPN #5 noted that when a medication is unavailable, she would normally notify the nursing supervisor and if the resident needed the medication emergently, she identified that she would borrow the medication from another resident. Interview with the Pharmacist (Pharmacist #3) from the pharmacy that supplies the medications to the facility on 8/19/25 at 12:05 PM identified the pharmacy received a prescription for Alprazolam ER 1mg tablet once daily on 6/26/25 and the medication was delivered to the facility on 6/27/25. Interview with the DNS on 8/19/25 at 2:44 PM identified that when a resident's medications are not available, the nurses should not borrow from another resident. She identified that if medication is unavailable, the charge nurse should notify the supervisor, the pharmacy should be contacted, the emergency supply of the medication should be checked, and the physician should be notified. Interview with the DNS on 8/20/25 at 8:30 AM identified she reviewed the controlled disposition reports for the facility for the time period of 6/1/25 through 6/26/25 and was unable to identify a resident in the facility on Alprazolam ER 1mg tablet at the time LPN #5 signed the eMAR indicating that the medication was administered to Resident #178 as ordered. She also identified that that medication was not a medication that the facility kept as part of their emergency supply of medications, thus LPN #5 could not have administered the medication and the eMAR documentation was incorrect. Review of the Medication Shortage/Unavailable Medications identified when medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and pharmacy provider.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for three sampled residents (Residents #1, #66 and #123) reviewed for pressure ulcer, the facility failed to ensure skin checks were being completed prior to the identification of a pressure ulcer and an assessment of a skin issue following identification as well as a provider order implemented and failed to ensure the low air loss mattress was set according to the physician's orders The findings include: 1. Resident #1's diagnoses included muscle weakness, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, and difficulty in walking. The quarterly MDS assessment dated [DATE] identified Resident #1 was cognitively intact, had no behaviors, required substantial maximal assist with bed mobility, partial moderate assistance with transfers, substantial/moderate to partial/moderate assistance for dressing and substantial maximal assistance with personal hygiene. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 9/25/24 identified Resident #1 was at risk for skin breakdown due to decreased mobility. Interventions directed to encourage to get out of bed as needed, nutritional supplements as ordered skin checks and skin treatment as ordered. Review of the skin assessments failed to identify weekly skin assessment being completed prior to 11/19/24. The 11/19/24 skin assessment identified 0 for no skin issues. Physician's order dated 11/1/24 directed Skin check weekly on Tuesday 7-3 shift. The nurse's note dated 11/10/24 identified area on right inner buttocks opened wound measures 1cmx1cm no drainage. Information written in APRN book. Supervisor updated. Interview on 8/20/25 at 11:49 AM with RN#6 identified she was the supervisor on duty the night on 11/10/24 when the area was noted to be identified. She did not recall being notified of the open area, and if she was notified, she would not put the information into the APRN book, she would contact the on-call provider who would place an order, and the care plan would have been updated. If she completed an assessment of the resident she would document that via a progress note. Interview on 8/20/25 at 10:48AM with APRN #2 identified she would frequently be updated if there was something that needed to be seen or a treatment started prior to the wound physician coming to the facility. Review of the clinical record identified the first time she noted the wound in a note was not until 12/20/24 and if she had been made aware, ordered a treatment, or assessed the wound prior to then she would have documented it. Interview on 8/20/25 at 2:20PM with MD#2 identified that in the wound management detail provided by the facility the right buttock area was identified as a stage III on 11/10/24 and healed by him on 11/22/24 at 1:28PM. MD#2 identified he would not have healed an area in which he had not yet consulted on. Following a review of his notes and text messages to the Wound Nurse RN#8 at the facility at this time identified he never ordered the area to be healed as he had not yet consulted on it nor had text any orders for treatment or healing. If he had assessed the area it would have been found in his wound notes. The area was not mentioned in his wound notes until 12/8/24 when it was identified as a new pressure wound to the right buttock. When MD#2 first saw the wound it was on 12/8/24 and it was identified to be Stage 3 pressure ulcer measuring 1.5cmx1.5cmx0.2cm with a moderate amount of serous exudate. If MD#2 would have been notified of the open area on 11/10/25 he would have ordered a treatment typically of Triad Paste if it was MASD or Calcium Alginate Dry with a dry clean dressing if the area was noted to be an open area. Interview on 8/21/25 at 9:44AM with wound nurse RN#8 identified she did not observe the wound noted on 11/10/24. She was not the nurse who discovered the area, and she did not work on Sunday's therefore she was not there that day to assess it. She also would not complete the assessments in the absence of the wound physician, and she followed him for wound rounds on Fridays. The new orders that were placed into the computer were only orders that she received from him. Everything they saw were documented in the weekly wound progress notes. If there was a wound that was not documented in the weekly progress notes then it was not seen due to the fact the wound physician would document each wound that he observed/assessed. When asked as to why the observation detail was noted as healed by the wound physician under an assessment with her name on it she stated that those details can be edited in the system and when she left she left her login information with the DNS and unless the wound physician had seen it and documented it she would not document it as healed. Review of physicians ordered identified no treatment was ordered following the identification of the open area on the buttocks on 11/10/24 Review of the Skin Assessment policy directed change in the resident's skin should be documented as part of the resident's record, any change in condition if identified, documentation in the record of MD notification if new skin alteration noted with change of plan of care. 2. Resident #66's diagnoses included Alzheimer's disease, dementia with agitation and depression. The annual MDS assessment dated [DATE] identified Resident #66 was severely cognitively impaired, nonverbal, had no behaviors, was non-ambulatory, dependent on staff for transfers, was at risk for skin breakdown and had pressure relieving devices for the bed and chair. A Braden scale assessment (used for predicting the risk of developing pressure ulcers) dated 3/1/25 identified Resident #66 was determined to be at a high risk for the development of pressure ulcers with a score of 11 (a score of 19 or higher indicates not at risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 9 or less very high risk). A physician's order dated 5/27/25 directed Resident #66's air mattress be set at 160 lbs. and check function and settings every shift. The care plan dated 5/29/25 identified Resident #66 had a re-opened stage 3 wound to the coccyx, with interventions that included setting the air mattress to 160 and checking function every shift, turning and positioning every 2-3 hours, and observing the affected area for signs and symptoms of infection or deterioration. Observation on 8/15/25 at 12:12 PM identified Resident #66 was in bed, and the low air loss (LAL) mattress was set at 360 lbs. Observation on 8/19/25 at 9:53 AM identified the resident's LAL was set at 360. Observation on 8/20/25 at 12:10 PM identified the resident's LAL was set to 125. Interview and observation on 8/20/25 at 2:48 PM with the Nursing Supervisor (RN #3) identified the low air loss mattress was set to 125 lbs. RN #3 identified they had residents who wanderer and suggested they could have changed the setting on the bed. She further identified that the mattress should be set according to the resident's weight. RN #3 checked the physician's orders and identified that the mattress should be set at 160 pounds (lbs.). Interview on 8/20/25 at 2:53 PM with LPN #2 identified that when she checks the mattress, she checks that it is inflated, she does not look at the settings. She further identified that she had checked the mattress that day and had signed it off in the treatment administration record. Review of the Pressure Ulcers/Skin Breakdown policy directed, that the physician will order pertinent treatments for treating a wound, for example, pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical ointments. 3. Resident #123's diagnoses included left upper arm wound, protein -calorie malnutrition, pressure ulcer stage 3 to buttocks and anemia. The admission MDS assessment dated [DATE] identified Resident #123 was cognitively intact, required moderate assistance with dressing, bathing, personal hygiene, bed mobility, transfers, ambulation, and utilized a manual wheelchair requiring moderate assistance for mobility. The assessment further identified Resident #123 was at risk for the development of pressure ulcers and had one stage 3 pressure ulcer and an open lesion present on admission; and utilized a pressure reducing device for the bed. The care plan dated 7/25/25 identified Resident #123 had a stage 3 pressure ulcer to the right buttock, and a cancerous lesion to the left upper arm with interventions that included the utilization of a pressure reducing mattress, and to encourage and assist with frequent turning and repositioning. The physician's order dated 7/25/25 directed the air mattress setting to be at 150 pounds (lbs.) and to check the function and placement every shift. Resident #123's weight record identified his/her weight was 119 lbs. on 8/8/25. The Wound Nurse's note (RN #7) dated 8/15/25 at 2:31PM identified that the stage three to the buttocks was resolved. The Wound Physician's (MD#2) note dated 8/17/25 at 12:48 PM identified Resident #123 had a carcinoma to the left upper arm that was a full thickness wound that measured 12 centimeters (cm) in length by 10 cm in width by 0.5 cm in depth with a moderate amount of serous drainage and 75-99 percent (%) slough. The note further identified that the resident had a pressure redistribution mattress per facility protocol. Observations on 8/18/25 at 9:52 AM and on 8/19/25 at 9:40 AM and 11:32 AM identified Resident #123 in the bed positioned on his/her back with the pressure mattress set to a weight of 320 pounds. A review of the electronic Medication Administration Record/Treatment Administration Record (eMAR/eTAR) for August 2025 identified LPN #5 who worked the day shift on signed that the air mattress setting was set to 150 lbs. on 8/18/25 and 8/19/25 on the day shift. Interview and observation on 8/19/25 at 2:55 PM with the Charge Nurse LPN #5 identified Resident #123 in bed positioned on his/her back with the pressure mattress on and set to a weight of 320 pounds. LPN #5 identified she had checked the mattress setting earlier and it was at 320 pounds, and she thought it was correct. Interview with the Nursing Supervisor (RN #4) on 3/19/25 at 3:15 PM identified the mattress should be set based on the resident's weight. She indicated if the resident's weight was 126 pounds, then the 150 setting would be good as the mattress cannot be set at the resident's exact weight. Interview with the Wound Nurse (RN #7) on 8/20/25 at 10:58 AM identified Resident #123 is on an alternating air loss mattress which is set based on the resident's current weight. She identified that even though Resident #123 stage 3 pressure ulcer to the buttocks recently healed on 8/8/25, he/she still had a cancerous wound to his/her left upper extremity and would remain using the alternate air mattress to prevent new and further skin breakdown. RN #7 identified a setting of 320 was hard and could cause pain that could contribute to the development of a pressure ulcer. Interview with the DNS on 8/20/25 at 11:09 AM identified she expects the mattress to be set according to the physician's order, and the nurses should check the setting of the mattress prior to signing off in the eMAR/eTAR. The DNS added that the nurse aides are supposed to check the setting of the mattress likewise the nurses. Interview with the Wound Physician (MD #2) on 8/20/25 at 2:50 PM identified Resident #123 was on an alternate air mattress for protection and prevention of skin breakdown on elbows, hips, heels, back and buttocks, given the resident had a thinner weight. MD #2 identified a setting of 320 pounds was inappropriate for Resident #123 as a setting of 320 lbs. would make the mattress hard making the intervention not effective. MD #2 identified the setting on the mattress is set based on the resident's weight. Review of the Pressure Ulcers/Skin Breakdown policy identifies in the treatment/management section that a physician will order pertinent treatments for treating a wound for example, pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents.

Based on clinical record review, review of facility documentation, and interviews for two of four sampled residents (Resident #111 & 133) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during resident transport to prevent an accident and failed to ensure adequate supervision was provided to prevent resident from smoking in the facility ground after repeated non-compliance with non-smoking policy. The findings include:1. Resident #111's diagnoses included Alzheimer's disease, congestive heart failure, and Parkinson's disease. The annual MDS assessment dated [DATE] identified Resident #111 had moderate cognitive impairment, required extensive assistance with bed mobility, dressing, toileting, hygiene, and transfers, and required staff assistance with wheelchair mobility. The facility's accident and incident report dated 4/22/25 at 10:45 AM identified a nurse aide was assisting Resident #111 with wheelchair mobility when he/she slid from the wheelchair to the floor.The nurse's note dated 4/22/25 at 11:27 AM written by RN #1 (unit manager) identified Resident #111 slid from the wheelchair while being transferred to the bathroom, did not sustain injuries and denied pain related to the fall. The care plan dated 4/23/25 identified Resident #111was at risk for falls related to weakness, history of falls and required assistance with wheelchair mobility. Care plan interventions directed to ensure resident is properly position in the wheelchair prior to transport, Should not sit on a blanket while in a wheelchair to prevent sliding, ensure call light within reach, provide assistance with bed mobility, transfers, ambulation, and wheelchair mobility as needed, and physical therapy and/or occupational therapy evaluation as needed.The therapy referral form dated 4/23/25 identified Resident #111 slid from the wheelchair while being wheeled by a nurse aide. The therapy screen also identified Resident #111 was receiving physical therapy and recommended to ensure the wheelchair leg rests are in place to ensure proper positioning while sitting in the wheelchair.The current monthly physician's order dated 8/8/25 identified Resident #111 needed assistance from staff with wheelchair mobility.Interview with RN #1 on 8/19/25 at 11:45 AM identified NA #3 was transporting Resident #111 to the bathroom, when the resident slid from the wheelchair to the floor in his/her room. She identified that she made a referral for physical therapy to address proper wheelchair positioning. Further, RN #1 identified Resident #111 typically needed assistance from the staff for wheelchair mobility and noted that she could not recall whether the leg rests were in place at the time of his/her fall. She also noted that it would be unlikely for Resident #111 to slide from the wheelchair when the leg rests are utilized during transport. Interview with the Occupational Therapist/Rehabilitation Director (OT #1) on 8/19/25 at 12:10 PM identified that she received a therapy screen for Resident #111 related to a fall from the wheelchair. She identified that Resident #111 was receiving physical therapy services at the time of his/her fall. She also identified that she recommended that the leg rests be used to ensure the resident positioned properly while sitting in the wheelchair. She further identified that the use of the wheelchair leg rests ensure and promote the resident's ideal position while seated in a wheelchair and to prevent sliding from the wheelchair.Attempts to interview NA #3 were unsuccessful.A request was made for a policy that addressed wheelchair transportation, but the facility did not provide the surveyor with the policy. 2. Resident #133's diagnoses included malignant neoplasm of the stomach, malnutrition, bipolar disorder, and nicotine dependence.The quarterly MDS assessment dated [DATE] identified Resident #133 had intact cognition and was independent with dressing, hygiene, transfer, and ambulation without assistive devices.The resident care plan dated 5/6/24 identified Resident #133 had a strong smell of smoke; 2 lighters found in his/her room, refused smoking cessation and was observed smoking outside on the facility grounds. The care plan interventions directed to search room as needed with resident permission, initiate 1:1 supervision when room search refused, educated resident on safety protocol regarding smoking, non-smoking policy reviewed with the resident, and nicotine patch as ordered.The physician's orders directed leave of absence with responsible party and/or family member and independent with ambulation without assistive devices.A review of the nursing progress notes from 5/5/24 to 8/20/25 identified the following occurrences of non-compliance with smoking:A nursing note dated 5/5/24 at 8:59 PM identified Resident #133's room had a strong smell of cigarette smoke, and the nursing supervisor was made aware. The note further identified Resident #133 became agitated during a conversation about safety in the facility related to smoking.A nursing note dated 9/11/24 at 3:57 PM identified Resident #133 was observed smoking outside on facility grounds and was educated regarding the non-smoking policy. A room search was completed, and no smoking material was found.A nursing note dated 9/16/24 at 8:57 PM identified Resident #133 was observed smoking outside on facility grounds and refused to identify where the cigarette and lighter came from. A room search was completed, and a lighter was found but no cigarettes.A nursing note dated 10/10/24 at 3:35 PM identified Resident #133 handed over a cigarette to the Administrator and requested to transfer to a smoking facility. A room search was completed with no contraband found. Resident #133 was educated regarding the smoking policy and offered smoking cessation but refused.A nursing note dated 11/4/24 at 3:40 PM identified Resident #133 was observed smoking outside on facility grounds. A room search was done with the resident's permission, and no contraband was found.A nursing note dated 7/11/25 at 10:27 PM identified Resident #133 returned from a leave of absence and immediately went outside. He/she was then observed smoking in the facility's parking lot. The DNS directed to send the resident to the hospital to be evaluated but Resident #111 refused and was then placed on 1:1 supervision. After Resident #133 non-compliance with facility nonsmoking rules, the facility provided Resident #133 the review of no smoking policy acknowledge form dated 5/6/24 identified Resident #133 had received an acknowledgement that the facility has a strict non-smoking policy and understand that if you are currently a smoker and would like an assistance to stop smoking. A smoking cessation program would be available to the resident and will be supervise and managed by the physician. Resident #133 also received and acknowledge that smoking in the facility ground was not allowed, keeping any type of smoking material/cigarette in the room was not allowed, receiving smoking material is not allowed, non-compliance to the non-smoking policy may subject to periodic search, and repeated non-compliance to the non-smoking policy may be necessity to be discharged to ensure other resident safety. Resident #133 were again educated and presented the no smoking policy acknowledgement form dated 9/11/24, 10/11/24, 11/4/24, and 7/11/25 of each non-compliance with facility smoking rulesThe physician's order dated 8/14/25 directed to apply a nicotine patch 7mg/24 hour once a day until 8/28/25.Interview with SW#1 (Social Worker) on 8/18/25 at 2:45 PM identified Resident #133 was alert, oriented, independent with ambulation, and could leave the facility any time he/she wishes. She identified that Resident #133 was being referred to be discharged to the community and/or discharged to another skilled facility that allowed smoking. She further identified that Resident #133 had an episode of non-compliance with the smoking policy and was observed smoking on facility grounds on 7/11/25. SW#1 further identified that Resident #111 refused to disclose where the smoking materials came from but noted Resident #133 frequently goes out of the facility. A room search was conducted when he/she comes back from leave of absence with the resident permission. Interview on 8/19/25 at 9:35 AM with the DNS in the presence of the Administrator identified the facility is non-smoking and smoking is not allowed on the grounds. She also identified that the facility would not offer a bed to a potential resident who wished to smoke, and residents with a history of smoking are offered smoking cessation and education. She further identified that Resident #133 had an episode of non-compliance on 7/11/25 when he/she was observed smoking outside on facility grounds. Further, she noted that she instructed the nursing supervisor to send the resident to the hospital, but Resident #133 refused. She further noted that the facility was actively looking for a safe alternative living arrangement for Resident #133. In addition, the DNS identified Resident #133 refused the offer of a nicotine patch but agreed to smoking cessation. The DNS identified that she had no prior knowledge of Resident #133's previous non-compliance related to smoking on facility grounds because it was prior to her employment with the facility. The smoking policy identified smoking is not allowed within the facility or on the property.

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs was in place to sufficiently enable an accurate reconciliation of all controlled medications. The findings include:Interview with the DNS on 8/20/25 at 1:10 PM identified that she conducts a biweekly audit of the narcotic signature sheets. Review of the audit sheets identified the DNS conducted all the audits from April through August.Observation and review of the narcotic reconciliation binders on 8/21/2025 at 3:33 PM with the DNS identified the facility has a binder that they keep duplicate copies of the controlled drug receipt/proof of use/disposition forms to compare to narcotics in use in the facility. The dates noted on the duplicate copies ranged from 2023 through 8/20/25 and all duplicate forms in the book had not been reconciled and appeared to still be outstanding Interview on 8/21/25 at 3:36 PM with the DNS identified the narcotic audit is completed twice a month and indicated the process for the reconciliation is to take the duplicate binder to each of the medication carts, count the carts and verify that the medication sheets in the carts were also present in the duplicate binder. The DNS identified that the duplicate binder had been in use prior to her taking her position and many of the narcotics were not accounted for when she took over the position in February 2025. The DNS indicated that when she does complete the narcotic reconciliations, she does not utilize the duplicate binder as a guide and therefore there are outstanding duplicate sheets that she does not know the reconciliation status of.The DNS identified that of the 30 medication forms (randomly picked by the surveyor to review whether they were in use in the facility, destroyed, returned or unaccounted for) there were some dated prior to her taking over the position and might be difficult to locate. Interview on 8/21/2025 at 5:12 PM with the Administrator identified he was not aware the reconciliations were not being completed appropriately but indicated the reconciliations were being completed bimonthly. A message was left on 8/21/2025 at 5:13 PM with the pharmacy consultant but no return call was received. Interview on 8/21/25 at 5:30 PM with the DNS identified that 25 of the 30 flagged outstanding controlled substance forms were located in the narcotic destruction logs sent home with the resident or destroyed. The medications not able to be located/reconciled were as listed below:1. Amphet/dextrin cap 50 mg ER quantity of 15 received on 8/22/2024 at the facility.2. Hydromorphone HCL 2 mg tab quantity of 120 received on 7/30/25 by the facility.3. Pregabalin cap 150 mg Quantity of 60 received on 11/14/24 by the facility.4. Oxycodone IR 5mg tab Quantity of 30 received on 12/19/24 by the facility.5. Oxycodone IR 5 mg tab Quantity of 30 received on 10/31/24 by the facility.6. Clonazepam 0.5mg tab Quantity of 45 received on 11/12/24 by the facility. #15 were reconciled but there are #30 outstanding. The facility policy for Inventory of control of dugs identified the director of nursing or his/her nursing supervisor designee shall conduct unannounced documented audits of all controlled substance stock on all units at least twice a month. The policy identified that the controlled substances be counted per facility policy and in accordance with state regulations and in the event of significant loss/theft the appropriate agencies will be notified and indicated the consultant pharmacist and facility administration will routinely audit controlled medications. The facility policy for best practice for medication dispensing regarding scheduled II Narcotics identified any ordered narcotic/controlled substance that is delivered to a facility, signed for and accepted by an authorized person may not be returned to the pharmacy for any reason and indicated that if a patient is discharge home or transferred to a hospital, any ordered, dispensed, and delivered narcotic/controlled substance must not be accepted at time of delivery. Additional policy provided by the facility was from the state department of consumer protection drug control division and identified audits of all controlled substance stock on all units at least twice a month and indicated that required receipt records for patients' controlled substance stock must be separately maintained and required disposition records for patients' controlled substance stock must be separately maintained, and required destruction records shall be maintained whenever partial or individual doses of controlled substance stock are discarded by nursing personnel.

Based on observation, review of facility policy/procedures and interviews, the facility failed to ensure expired or discontinued medications were removed from the medication cart according to facility policy. The findings include:Observation on 8/20/25 at 6:49 AM with LPN #6 identified the medication cart contained the following expired medications: 1. Lisinopril tab 10 mg (18 tablets) with an expiration date of 8/1/252. Gabapentin 300mg (1 capsule) with an expiration date of 7/1/253. Gabapentin 100mg 2 (30 capsules) with an expiration date of 7/31/254. Gabapentin 100mg (28 capsules) with an expiration date of 7/31/255. Gabapentin 100mg (25 capsules plus an additional three bubble packs of capsules totaling 90 capsules) with an expiration date of 8/1/25 Interview on 8/20/2025 at 6:52 AM with LPN #6 identified that someone in the facility is responsible for removing expired medications from the medication carts. LPN#6 indicated she was not responsible for removing expired medications. Interview on 8/20/2025 at 7:06 AM with LPN #4 identified the pharmacy consultant goes through the carts every month and removes all of the medications that are expired or discontinued. Interview on 8/20/2025 at 7:36 AM with the RN Supervisor (RN #3) identified she was unsure of the protocol for the storage/removal of expired medications from the active medication supply but would review the protocol.Interview on 8/21/25 at 3:36 PM with the DNS identified that the pharmacist is at the facility once monthly and removes expired medications in the cart if she sees it but noted that the nurses are responsible for ensuring their carts are in order and to remove expired or discontinued medications.Interview on 8/21/2025 at 5:03 PM with Pharmacist #2 identified that when medication is discontinued or expired, or if the resident leaves the facility the medication should be removed from the medication cart. She indicated that if a medication is on hold or discontinued it might remain in the cart in case it is needed again. She further identified she was at the facility approximately a week ago but did not conduct any cart audits that day and indicated the last cart audits she completed were in June 2025. The facility policy for storage of medications identified that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Additional policy provided by the facility was from the state department of consumer protection drug control division and identified patient medications which are discontinued, unauthorized or no longer needed for other reasons should be immediately removed from nursing unit locations and properly documented and stored while awaiting appropriate disposition.

Based on record review and staff interviews the facility failed to ensure residents were free from abuse for three (3) of five (5) residents (Resident ID # 2, #3 and #7). The facility failed to ensure interventions were in place to address verbal altercations which occurred prior to a physical altercation between Resident #1 and Resident #2, and for Resident #3 and #7 the facility failed to ensure the residents were free from physical and psychosocial abuse. The findings included: 1. Resident #1 had diagnoses which included schizoaffective disorder, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1, had a Brief Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, was independent with Activities of Daily Living (ADL) including ambulation, did not present with hallucinations or delusions, and did not exhibit any physical, verbal or behavioral symptoms directed toward others. Review of Resident #1's care plan dated 2/11/24 identified Resident #1 had a potential for alteration in mood due to diagnoses of anxiety, bipolar, and schizoaffective disorders and received psychotropic medications with interventions that directed to provide support, medication administration as ordered, and to be alert to a decline in mood/behavior. Resident #2 had diagnoses which included cerebral infarction, hemiplegia affecting left, nondominant side, and adjustment disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required substantial assistance with ADL's and was non-ambulatory. Review of Resident #2's Care Plan dated 12/19/23 identified a risk for alterations in mood/behavior related to depressive episodes and anxiety disorder with interventions that directed to encourage resident to verbalize feelings and fears, to spend time talking to the resident, and to allow expression of feelings. Review of Social Worker (SW) #1's note dated 12/19/23 identified Resident #2 had concerns with his roommate (Resident #1), wanted to move to another room, and that SW #1 would assist. No further documentation about the room change was identified and the facility census on 2/15/24 identified Resident #2 remained in the room with Resident #1. Review of a nurse's note dated 2/15/24 at 8:58 AM identified that Resident #2 alleged that Resident #1 had stuck him/her in the face, the resident had a swollen bloody lip. Review of the Facility Licensing and Investigations Section Reportable Event form dated 2/15/24 identified that Resident #1 punched Resident #2 in the face because Resident #1 thought Resident #2 was the devil. The residents were immediately separated, and Resident #1 was transported to the hospital. Review of the police report dated 2/15/24 at 8:16 AM identified a physical altercation occurred between two roommates, Resident #1 and Resident #2. Interview with Resident #2 identified that Resident #1 came out of the bathroom, charged at Resident #2, and began punching him/her in the face. The police report further identified that Resident #1 then fell on top of Resident #2, causing a head-to-head collision, and a minor cut was observed on Resident #2's bottom lip. The police report noted in an interview with Resident #1 identified that he hit Resident #2 because he/she thought Resident #2 was the devil. Resident #1 was transferred to the hospital for evaluation. Review of a hospital discharge summary dated 2/15/24 identified that Resident #1 denied suicidal or homicidal ideation and did not meet the criteria for inpatient psychiatric hospitalization and was sent back to the skilled nursing facility. A nurse's note dated 2/15/24 at 10:53 PM identified that Resident #1 had returned from the hospital and moved to a different room, (with no roommate) and no behaviors were noted. Interview with Resident #2 on 10/2/24 at 8:52 AM identified he/she had requested a room change in December 2023 as he/she felt his roommate (Resident #1) was mentally unstable. Resident #2 identified feeling uncomfortable with the living situation and was concerned for his/her safety as he/she was unsure when a situation would become violent. Resident #2 further indicated he/she informed the Social Worker that he/she did not want to share a room with Resident #1 any longer and was told there were no rooms available. Resident #2 indicated he/she had to deal with the situation and tried to ignore Resident #1's verbal outbursts as the room change did not occur. Interview with Licensed Practical Nurse (LPN) #1 on 9/30/24 at 11:04 AM identified he/she did not witness the incident between Resident #1 and Resident #2 on 2/15/24, however had gone to the residents' room and saw Resident #2 sitting on the edge of his/her bed, bleeding from the mouth, crying, and visibly upset. LPN #1 further identified Resident #2 had reported he/she was attacked and did not retaliate due to weakness from his/her stroke and fear of getting into trouble. LPN #1 indicated Resident #1 was placed on one-to -one supervision until sent to the emergency room for further evaluation. Interview with Social Worker (SW) #1 on 10/1/24 at 3:03 PM identified Resident #1 would frequently make negative and racist remarks to Resident #2 prior to the 2/15/24 incident. These remarks consisted of Resident #1 calling Resident #2 evil, the devil, racist remarks, and complaining about him/her leaving the bathroom unclean, however, there were no physical altercations were noted prior to 2/15/24. SW #1 indicated he/she had informed Administrator #2 (previous administrator) of their first argument, she could not recall the exact date, she identified it was sometime in December 2023. SW #1 further identified he/she did not move Resident #2 at that time of his/her request on 12/19/23 because he/she thought there were no empty beds available. SW #1 identified that the arguments between Resident #1 and Resident #2 had continued and after the second argument which SW #1 estimated had occurred sometime in January 2024, he/she again informed Administrator #2, and was instructed to move one of the residents to a new room, however both residents refused to move. SW#1 further identified that she did not document the ongoing arguments in the clinical record and was unsure why. Interview with Administrator #2 (Administrator in place at the time of the incident) on 10/1/24 at 4:02 PM identified he/she remembered the altercation between Resident #1 and Resident #2 on 2/15/24, however could not recall being informed that any verbal exchanges/concerns between the two residents occurred prior to the 2/15/24 incident. Administrator #2 identified anytime a physical or verbal incident had taken place, the resident's room would immediately be changed. Interview with the Administrator #1 (current administrator) 10/3/24 AT 9:30 AM identified rooms were available on the long-term care unit in December 2023. Interview with the Director of Nurses (DON) on 10/1/24 at 9:12 AM identified that Resident #1 was cleared psychiatrically on 2/15/24 and sent back to the facility and placed into a private room. The DON stated that she was not aware of any of the verbal exchanges that occurred between Resident #1 and Resident #2 prior to the 2/15/24 incident and was not informed by SW #1 that this was occurring. The DON further identified he/she would have immediately separated the residents had she known the verbal exchanges were taking place as it created an unsafe situation and would have also involved different disciplines to support/inquire about the issue and hopefully resolve it. 2. Resident #7 had diagnoses that included schizophrenia, generalized anxiety disorder, and congestive heart failure. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and was independent with ADLs and ambulation. Review of Resident #7's Care Plan dated 4/3/24 identified an alteration in mood state with interventions that directed to monitor for irritability, anxiety, depression, and any mood changes. A nurse's note dated 6/9/24 at 3:43 PM Resident #1 was noted to hit staff and a resident, 911 and a doctor strong (an emergency code for immediate assistance) was called. Resident #1 broke free from staff and hit another resident in the head. Review of the Facility Licensing and Investigations Section Reportable Event form dated 6/9/24 at 3:30 PM identified Resident #7 was standing at the nurse's station when he/she was punched on the side of the face by Resident #1. Resident #7 was assessed and no injuries were identified and Resident #1 was transferred to the hospital. Review of the police report dated 6/9/24 at 4:01 PM identified a physical altercation between a resident and staff member, where Resident #1 had a mental episode and jumped on LPN #2's back and then punched another resident in the face. The report further indicated Resident #1 was calm, in the presence of staff, sitting in a wheelchair upon police arrival to the facility. The report identified Resident #1 was transported to the hospital following the incident. Review of a care plan dated 7/1/24 identified that the resident had been hospitalized after hitting a resident and a staff member and had returned to the facility on [DATE] and was placed on one-to-one supervision until 7/11/24, when every fifteen-minute checks were initiated. Although the hospital discharge summary for the hospital stay from 6/9/24-7/1/24 was requested it was not provided. Interview with Resident #7 on 10/3/24 at 1:50 PM identified he/she was hit in the head, back and arms by Resident #1 on 6/9/24, that Resident #1 had punched him/her hard, called him/her a demon, and threatened to kill me. Resident #7 further identified that he/she still has flashbacks of the incident and was frightened after the incident. Interview with LPN #2 on 10/2/24 at 3:40 PM identified he/she had walked into the unit at 3:00 PM on 6/9/24, and walked into the nurse's station to receive report, and that Resident #1 had followed him and started hitting him with his/her fist in the back and then on the chest. LPN #2 further identified the floor staff assisted in separating the resident from LPN #2 and had placed Resident #1 in a wheelchair in front of the nurse's station under the supervision of staff. LPN #2 indicated he/she stepped away from the incident and was at the elevator when he/she heard commotion at the nurse's desk and heard Resident #1 had hit Resident #7. Interview with Nurse Aide (NA) #1 on 10/2/24 at 10:12 AM identified witnessing Resident #1 hitting LPN #2 on 6/9/24 and that, five (5) staff members separated Resident #1 from LPN #2, Resident #1 was placed in a wheelchair near the nurse's station under staff supervision. NA #1 identified staff had attempted to calm Resident #1 down, but Resident #1 had gotten up from the wheelchair, and ran into a resident ' s room, grabbed an overbed table, and brought it into the hallway as Resident #7 was approaching the nurse's station. Resident #1 then broke away from staff and ran over to Resident #7 started hitting Resident #7 in the head and calling him/her a demon. NA #1 further indicated Resident #7 was crying following the incident and was taken to his/her room where he/she remained until Resident #1 was transferred out of the facility. Interview with the Regional Clinical Consultant on 10/3/24 at 3:00 PM identified that Resident #1 had an extended hospital stay and upon return was placed on one-to-one supervision until 7/11/24, the resident had not exhibited behaviors so the interdisciplinary team decided every 15 minute checks was appropriate, the resident then was on every 30 minute checks and then every hour checks until they were discontinued due to a hospital stay for another physical altercation with a resident on 9/13/24. 3. Resident #3 had diagnoses which included disorganized schizophrenia, anxiety disorder, and encephalopathy. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12) indicative of moderately impaired cognition, did not exhibit physical or verbal behaviors towards others, and was independent with ADLs. Review of the Care Plan dated 7/25/24 identified Resident #3 had memory loss, impaired cognition, and was at risk for communication impairment with interventions that directed to face resident when speaking, and if resident was restless/agitated, to reapproach later in a calm, soothing manner. Review of the Facility Licensing and Investigations Section Reportable Event form dated 9/13/24 identified that Resident #1 attacked Resident #3 and was punching him/her in the face. Both residents were assessed, and no injuries were noted. Review of the police report dated 9/13/24 at 9:51 AM identified an altercation between Resident #1 and Resident #3 where Resident #1 had punched Resident #3 in the head and a scuffle had ensued. The report further indicated Resident #3 had identified Resident #1 had struck him/her in the head for no reason while he/she was walking by and threatened that he/she was going to get a gun and come back and shoot Resident #1. When the police officer asked Resident #1 what had occurred, Resident #1 responded, I saw the devil in that person. Both residents were sent to the emergency room for further evaluation. Interview with Occupational Therapist (OT) #1 on 9/30/24 at 2:46 PM identified that on 9/13/24, he was following Resident #1 with a wheelchair as he/she was walking in the hallway and had passed by Resident #3 who was ambulating in the hallway in the opposite direction when Resident #1 punched Resident #3. OT #1 further indicated Resident #3 retaliated and punched back at Resident #1. OT #1 identified the staff were able to successfully separate the two residents and that Resident #1 had stated Resident #3 was the devil. Both residents were sent to the emergency room for further evaluation. Interview with the Administrator on 10/3/24 at 5:10 PM identified that she was the administrator when the incident on 9/13/24 occurred. Resident #1 was sent to the hospital and subsequently transferred to another facility better suited for the resident's needs. The administrator further identified that the facility has zero tolerance any form of abuse. Review of the abuse policy identified that the residents in the facility will be free from abuse.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews, for one of two sampled residents (Resident #375) reviewed for pain management, the facility failed to administer pain medication when the resident made a request to be medicated. The findings include: Resident #375 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), cellulitis (infection of the skin) of right lower limb, and chronic pain syndrome. The admission MDS assessment dated [DATE] identified Resident #375 had moderately impaired cognition, required minimal assistance with personal hygiene and required the assistance of two staff members with dressing, positioning, and transfers. The assessment further noted that the resident had an almost constant presence of pain. The care plan dated 11/12/23 identified Resident #375 was at risk for pain with interventions that included: administer pain medication as indicated and observe for vocal complaints of pain and non-verbal sounds such as crying, moaning, or groaning. A physician's order dated 11/22/23 directed to administer Oxycodone (opioid) 20 milligram (mg) by mouth every 4 hours as needed for moderate to severe pain. Interview on 12/05/23 at 3:00 PM with Resident #375 identified that the for two days of the previous week, the facility did not have his/her pain medication available. Resident #375 further identified that he/she felt like he/she was losing his/her mind due to the level of pain. A nurse's note dated 11/29/23 at 8:39 AM identified Resident #375 complained of pain at 6:45 AM, was screaming, and was told that the medication had not arrived from the pharmacy and was not in the facility's emergency medication supply. In addition, the note identified that the resident declined to be sent to the emergency room and conveyed that they would not help her and would just say that the emergency room is not for pain management. A review of the audit report for the Omnicell machine (an automatic medication dispensing system) which is used to store the facility's emergency supply of medications and requires the nurses to log in with personal log in information. The audit identified that the DNS and the ADNS logged into the system on 11/29/23 at 12:15 PM and noted that the facility had 20 tablets of Oxycodone 10mg available at that time. The audit report identified that the DNS and the ADNS were the only staff that logged into the system on 11/29/23. A progress note written by APRN #1 dated 11/29/23 at 2:40 PM identified she was asked to see Resident #375 for agitation, a pain level of 10 out of 10 (based on a pain scale of 1-10 with 10 being the highest level) for back and lower extremities, increased agitation and crying out for pain medication. The note further identified that the order previous order for Oxycodone was renewed, and a script faxed to the pharmacy. A nurse's note dated 11/29/23 at 10:08 PM identified that the Oxycodone was delivered from the pharmacy at 9:30 PM and the resident was administered the pain medication (approximately 15 hours from the time the resident requested the medications and was noted to have a pain level of 10). Review of the medication administration record (MAR) identified that the resident was medicated as requested according to the physician's orders on 11/28/23, thus did not go two days without pain medication. Interview on 12/11/23 at 3:12 PM with the Nursing Supervisor (RN #7) who was the 11:00 PM to 7:00 AM shift supervisor working on 11/29/23 identified that the charge nurse reported Resident #375 requested pain medication and that the resident did not have any available. She further noted that she checked the Omnicell for Oxycodone but there was none available. She did not explain how she accessed the Omnicell without logging into the system (which is necessary to ascertain the availability of any of the emergency medications). Interview with the DNS on 12/11/23 at 2:44 PM identified she was notified on 11/29/23 that Resident #375 and the emergency box was out of Oxycodone. The DNS indicated that she checked the emergency box and Oxycodone was available. The DNS further indicated that if a resident is out of a medication the emergency supply should be checked. The DNS identified that there should not have been a delay with medicating Resident #375 because the Oxycodone was available. The DNS did not explain why the medication was not administered to the resident when she accessed the Omnicell and determined that it contained 20 tabs of Oxycodone 10mg. Review of the facility's policy on Medication Shortage/Unavailable Medication identified that if the next available delivery of the medication will result in a missed or delayed dose of the resident's medication, the medication should be taken from the emergency medication supply.

Based on clinical record review, observations, facility documentation review, facility policy review and interviews for one of two residents (Resident #90) reviewed for accidents, the facility failed to ensure staff supported the resident's head, neck, and back in accordance with facility policy during a mechanical lift (Hoyer) transfer to prevent a fall with injury. The findings include: Resident #90's diagnoses included [CONDITION(S)] with [CONDITION(S)] and [CONDITION(S)]. The quarterly MDS assessment dated [DATE] identified Resident #90 had severe cognitive impairment, no behavioral symptoms, was non-ambulatory, required total assistance of two staff for bed mobility and transfers, and had limited bilateral upper extremities range of motion. The Resident Care Plan (RCP) dated 7/28/2021 identified Resident #90 was at risk for falls due to weakness, abnormal posture and utilized a total mechanical lift for transfers with assist of two. Interventions directed to provide assistance with bed mobility, and transfers. Physician's monthly orders dated 8/10/2021 directed to transfer Resident #90 utilizing a Hoyer lift with assist of two and identified that Resident #90 utilized a tilt in space customized wheelchair with a pelvic positioning belt. Review of facility reportable event report dated 8/27/2021 at 1:10 PM identified during a Hoyer lift (mechanical lift) transfer with two nurse aides present, Resident #90 slid off the Hoyer lift pad, hit her/his head on the frame of the Hoyer lift and landed on his/her buttocks on the floor. The Hoyer pad remained attached to the Hoyer lift when the fall occurred. The report further identified that the resident was immediately seen by the APRN and sent to the hospital emergency department for evaluation. Review of NA #1's written statement identified that she supported Resident #90's legs during the Hoyer lift transfer when Resident #90 moved to the right side and fell to the floor. Review of NA #3's written statement identified that she was operating the Hoyer lift and supporting Resident #90's head during the Hoyer lift transfer, and Resident #90 moved to the right side and fell to the floor. Review of the hospital documentation identified that Resident #90 was admitted to the hospital on 8/27/2021 and had a Computerized Tomography (CT) Scan of the head and cervical spine. CT scan results identified Resident #90 had a comminuted acute fracture of the anterior arch of cervical vertebrae #1 (C1), extending into the bilateral lateral masses, and an acute fracture of the left superior articular facet of cervical vertebrae #2 (C2). Nurse's note dated 8/28/2021 at 12:24 PM identified Resident #90 returned to the facility at 10:30 AM via stretcher, was alert and responsive, and denied pain. The note further indicated that Resident #90 had a C1 and C2 fracture and was wearing a Miami J neck collar. Review of Physicians order dated 8/28/2021 directed Resident #90 was to wear a Miami J collar at all times. The order further directed the charge nurse to be present with two (2) NAs for all Hoyer lift transfers. Interview and facility documentation review with NA #3 on 9/7/2021 at 2:48 PM identified that during Resident #90's Hoyer lift transfer from the bed to the wheelchair on 8/27/2021, she was standing at the Hoyer lift controls while NA #1 supported Resident #90's legs for balance. When Resident #90 was lifted off the bed, she indicated that Resident #90's upper body was not supported. She further indicated that when Resident #90 was in the air in the Hoyer sling over the floor, she moved the Hoyer lift to turn the Hoyer lift in the room and she reached away for a moment (leaving Resident #90's upper body without guidance or support from her) to bring the wheelchair into position for completing the transfer. While Resident #90's upper body had no support provided by NA #3, Resident #90 leaned toward the right and fell out of the Hoyer sling to the floor. Interview and observation of a re-enactment demonstration of the transfer with NA #1 and NA #3 on 9/9/2021 at 1:25 PM identified that Resident #90's wheelchair was not placed near the bed prior to raising Resident #90 off the bed with the Hoyer lift. The demonstration identified Resident #90 was lifted off the bed and the Hoyer lift was parallel to the bed when NA #3 stepped away from Resident #90 (Resdient #90 was in the air over the floor), and Resident #90's upper body was without any staff support in the Hoyer lift sling. NA #3 indicated that when she moved away from Resident #90 to bring the wheelchair close to Resident #90, Resident #90 moved to the right side and fell to the floor. Interview with NA #1 on 9/21/21 at 2:38 PM identified that she supported Resident #90's legs while NA #3 operated the Hoyer lift, and NA #3 did not provide upper body support to Resident #90 during the transfer. She indicated that after Resident #90 was lifted off the bed and was in the air (in the Hoyer sling) over the floor, NA #3 was not holding onto Resident #90's upper body. She identified that when Resident #90 was in the air, NA #3 attempted to bring the wheelchair into position, and Resident #90's upper body had no support provided by NA #3. She further indicated that Resident #90 moved when she and NA #3 tried to reposition him/her in the sling while in the air and when his/her upper body was not provided support by NA #3, Resident #90 tilted to the right and fell out of Hoyer lift onto the floor. Interview with the Director of Nursing (DON) on 9/21/2021 at 3:20 PM identified that NA #3 failed to support Resident #90's upper body during the Hoyer lift transfer on 8/27/2021, in accordance with facility policy, and Resident #90 fell to the floor. She indicated that Resident #90 required more support during transfers than two (2) staff were able to provide. The DON identified that since the fall on 8/27/2021 additional supervision was provided for Resident #90 for all transfers to ensure safety. The care plan was updated to direct all transfers were performed by three (3) staff, and the third person must be the charge nurse. She further indicated that staff should have provided support to Resident #90's upper body during the transfer. Review of the facility Safe Lifting and Movement Policy dated 9/2017, directed in part, that only staff with documented trained on the safe use of the machines will be allowed to lift or move residents. Review of the facility Lifting Machine, Using a Mechanical Policy, dated July 2017, directed in part to assess the resident's current condition, including can the resident understand and follow instructions, does the resident express fear, appear anxious, is agitated, resistant or combative. The Policy further directed to attach the sling straps to the sling bar, make sure the sling is securely attached to the clips and properly balanced. Further the Policy directed to make sure the resident's head, neck and back are supported. and to support the resident as he/she is moved.

Based on clinical record review and staff interview for one of four sampled residents, (Resident #244), who was reviewed for accidents, the facility failed to ensure that the resident was transferred in accordance with their individualized plan of care to prevent an injury. The findings include: Resident #244's [DIAGNOSES REDACTED]. The minimum data sets dated 8/25/11 and 11/24/11 indicated that the resident was severely impaired cognitively and totally dependent on 2 staff for transfers. The care plan dated 12/2/11 directed that the resident be transferred via Hoyer lift with assist of two staff. A facility report dated 12/22/11 indicated that the resident sustained [REDACTED]. Although attempts were made, an interview with Nurse Aide #6 was not obtained. Interview with NA#8 indicated that he/she was not aware that NA#6 transferred Resident #244 without out the benefit of two persons until NA#6 called him/her to the room and informed him/her that the resident had been injured. Interview with RN #6 on 5/22/12 at 10:30 AM indicated that he/she was called to assess the resident after the transfer and was told by NA#6 that he/she attempted to transfer the resident without help and that during the transfer the resident right leg was struck on the Hoyer lift sustaining the laceration. Interview with the DNS on 5/22/12 at 12:30 PM indicated that the NA#6 was terminated subsequent to the injury. The DNS indicated that NA#6 should have transferred the resident according to the facility's policy and the resident's care plan.