Every finding on record at Cobalt Lodge Health Care and Rehabilitation Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #8) reviewed for accidents, the facility failed to ensure a safe transfer via a hoyer lift when the hoyer lift got caught under the wheelchair and was jerked by a nurse aide causing Resident #8 to fall from the wheelchair to the floor. As a result, Resident #8 sustained an acute L5 endplate fracture (a break in the top or bottom cartilage layer of the L5 vertebra). The findings include: Resident #8 was admitted to the facility in August 2018 with diagnoses that included Parkinson's Disease without dyskinesia, COPD, bipolar disorder, obesity, and schizoaffective disorder.The quarterly MDS dated [DATE] identified Resident #8 had intact cognition and required supervision or touching assistance with sitting to standing and chair/bed-to-chair transfers.The care plan dated 2/14/25 identified Resident #8 was at risk for falls related to weakness at times, the use of antidepressants, and other risk factors including osteoporosis and Parkinson's Disease, with interventions that included ensuring the resident's needs were evaluated and supplied, (appropriate adaptive equipment or devices, as needed) and on-going reevaluation as needed for continued appropriateness to ensure the least restrictive device.A physician's order dated 3/24/25 directed to transfer the resident via a hoyer lift with the assistance of 2 staff. A Reportable Event Form dated 3/25/25 identified that on 3/25/25 at 11:00 AM, Resident #8 slipped out of the wheelchair into a sitting position on the floor after transfer. No injury was noted; Resident #8 denied pain/discomfort.A Psychiatric Evaluation and Consultation dated 3/26/25 identified Resident #8 was seen in his/her room and was calm and cooperative. Resident #8 reported having back pain/spasms which he/she shared with nursing, and it was related to the hoyer lift. The APRN note dated 3/27/25 identified Resident #8 presented today for comprehensive nursing facility evaluation after Emergency Medical Services (EMS) was called due to increased back pain that had not been relieved by previously prescribed Baclofen. Resident #8 reported a pain score of 5 out of 10 today, which represents a significant increase in pain from his/her score of zero out of 10 during on 3/26/25. Due to inadequate pain control with Baclofen, Flexeril 5mg every 8 hours, as needed, has been initiated to address the resident's back pain symptoms. The pain was limiting his/her mobility and potentially contributing to deconditioning.The nurse's notes dated 3/25/25 through 3/27/25 failed to reflect information about the fall that occurred on 3/25/25, failed to reflect that an RN assessment had been completed at the time of the fall, failed to identify documentation of ongoing nursing assessments, provider notification or date/time of the resident's hospital transfer.The hospital Discharge summary dated [DATE] identified that Resident #8 had a past medical history of morbid obesity, that the resident was bed bound at baseline and required a hoyer lift for transfers. Resident #8 was admitted on [DATE] after presenting for an acute onset of back pain. Four days prior to admission Resident #8 had been dropped from a hoyer lift. A CT scan of the Lumbar spine showed an acute L5 endplate fracture, also possibly at S1 (sacrum). No other acute findings were noted on workup, and the resident was admitted for treatment of intractable lower back pain. Resident #8 continued to report pain worse than his/her baseline but was better controlled, anticipating this will continue to improve, Resident #8's pain medication could be gradually weaned back down to his/her home regimen. Resident #8 was discharged in stable condition on 3/30/25 back to the facility.The nurse's note dated 3/30/25 at 7:17 PM identified that Resident #8 was re-admitted to facility from the hospital via stretcher and accompanied by two EMT attendants, at 5:28 PM. Resident #8 was admitted to hospital on [DATE] for intractable low back pain and was discharged with the following diagnosis: closed compression fracture of L5 lumbar vertebra and a closed fracture of an unspecified portion of the sacrum.Interview with the DNS on 6/1/26 at 9:18 AM identified that she was not the DNS at the time of the fall on 3/25/25, but she did work at the facility as a Nursing Supervisor and ADNS. Based on the facility's investigation, (including staff interviews and video footage that was no longer available for review) it was identified that on 3/25/25, 2 nurse aides (NA #1 and NA #2) had transferred Resident #8 out of bed into a wheelchair via a hoyer lift. Resident #8 was seated in the wheelchair and the hoyer was snagged under the wheelchair so one of the nurse aides, in an attempt to remove the hoyer from under the wheelchair, jerked the hoyer lift, causing the wheelchair to pull out from under Resident #8, resulting in Resident #8 falling from the wheelchair to the floor.Interview with NA #1 on 6/1/26 at 2:53 PM identified that on 3/25/25, she and NA #2 (who no longer works at the facility) were transferring Resident #8 from the bed to a large wheelchair that she believed was brought in from the resident's home. NA #1 indicated that she had been operating the hoyer lift, and that Resident #8 was safely transferred into the wheelchair, fully seated, and was unhooked from the hoyer pad. NA #1 indicated that the legs of the hoyer were stuck under the wheelchair and were opened all the way and the wheelchair was too wide for that hoyer lift. NA #1 further indicated that NA #2 first attempted to pull the lift slowly from under the chair, but because it was jammed, he yanked it, jerking the chair which caused Resident #8 to slide to the floor. NA #1 identified that she was on the other side of the hoyer lift and was not aware that NA #2 was going to yank the lift. NA #1 indicated the nurse was notified of the incident, but she could not recall who the nurse was, and that while she had completed hoyer lift competency evaluations in the past, she did not anticipate that Resident #8's wheelchair was going to be too wide for that hoyer lift and subsequent to the incident, in-services were completed, and Resident #8 was made a 3 person assist during a hoyer transfers.Interview with the Medical APRN (APRN #1) on 6/2/26 at 10:01 AM identified that she was not the medical provider servicing the facility at the time of the incident, and she could not attest to any details of the incident, but she would expect the nursing staff to complete a safe hoyer transfer, in accordance with the facility's policy and procedure.Interview with Resident #8 on 6/2/26 at 2:16 PM identified that on 3/25/25, he/she was being transferred on the hoyer lift and the kid (NA #2) pushed a board thing and he/she took a long fall to the floor, hitting his/her coccyx area and fracturing 3 bones in that area. Resident #8 indicated that he/she knew right away that something had broken because he/she was in a lot of pain. Resident #8 indicated that the facility staff wanted him/her to go to the hospital, but he/she refused initially, but knew a few days later that he/she had to go.Interview with the DNS on 6/2/26 at 2:46 PM identified that based on the facility investigation, the hoyer lift was not being operated properly. The DNS indicated her expectation would be that NA #2 should have called the RN Supervisor or other nursing staff members for help and not to have yanked the wheelchair or the hoyer lift.Based on facility documentation, NA #2 was terminated from the facility and unavailable for an interview.Although attempted, an interview with the Charge Nurse (LPN #4) who worked on 3/25/25 during the 7:00 AM - 3:00 PM shift was not obtained.The Fall policy, dated 2/24/24 directs the facility to have a program designed to identify those residents at risk for falls and investigate all falls in order to reduce injury and prevent future falls. In the event of a fall, an investigation of the fall will be implemented to determine what might have caused the fall and appropriate interventions to reduce the risk of recurring. The interdisciplinary team (IDT) will review each fall, the circumstances surrounding the fall, interventions to prevent the recurrence of falls, and any needed equipment or further assessment necessary to prevent future falls. Following a fall the facility will complete a reportable event form, initiate an investigation if the fall was not witnessed, discuss falls with the IDT, develop and review fall interventions, update individualized resident care plans within 72- hours of a fall with interventions, and notification to the resident's responsible party and physician.The hoyer Lift Transfer Device policy, undated, directs the facility to utilize mechanical lifting devices (hoyer lifts, sit-to-stand lifts Serita lifts, etc) according to orders, care plan, manufacturer instructions, and staff competency training. Residents requiring mechanical lift transfers shall not be manually lifted except during emergencies.

Based on observations, review of facility documentation, facility policy and interviews, the facility failed to ensure that the nourishment room ice machine had regular preventative maintenance and cleaning. The findings include:During a review of the infection prevention program with RN #1 on 6/1/26 at 8:27 AM, RN #1 identified he was not aware of any mitigation strategies related to Legionella or other waterborne pathogens within the facility.Review of the facility Legionella mitigation plan dated 11/2017 identified that system maintenance of the facilities water system included ice making machines would be cleaned quarterly and sanitized yearly and that a log would be attached to the side of the ice machine.Observation of the resident nourishment room ice machine on 6/2/26 at 7:30 AM identified an auto dispensing ice machine. Interview with the Maintenance Director on 6/3/26 at 7:14 AM identified that the facility had 2 ice machines in place: one located in the facility kitchen, and one located in the facility nourishment room. The Maintenance Director identified that the ice machine located in the kitchen was regularly cleaned and maintained by maintenance staff at least monthly, but the ice machine located in the nourishment room was self-contained and had not had any maintenance or cleaning since it was installed, approximately 2-3 years ago, and had been in use continuously throughout that time. The Maintenance Director also identified that since the machine was self-contained, and that self-containment included a water filter inside of the machine that required changing and service, a specialty technician would be required to conduct the outstanding preventative maintenance and cleaning. The Maintenance Director indicated he had discussed the issue with the Administrator multiple times, but it was never addressed. The Maintenance Director identified that the preventative maintenance and cleaning was supposed to be done at least every 6-12 months to ensure that the ice machine was clean and sanitary and to mitigate waterborne organisms. Interview with the Administrator on 6/3/26 at 8:00 AM identified he had been notified by the Maintenance Director that the nourishment room ice machine needed to have service for preventative maintenance and cleaning, but that he had a lot of other issues going on including a renovation project and he did not address the issue. Although requested, the facility failed to provide the preventative maintenance guide and manual for the nourishment room ice machine. The facility policy on kitchen equipment maintenance directed that all kitchen equipment would be maintained in a safe, clean, and operable condition to support sanitary food service, protect residents from foodborne illness and injury, and comply with applicable Connecticut and federal long term care requirements. The policy also directed that the facility would maintain kitchen equipment according to manufacturer's instructions, infection prevention and food safety standards, and facility preventative maintenance schedules. The policy further directed that for cleaning, sanitization, and infection prevention, ice machines would be cleaned, sanitized, and maintained according to the manufacturer's instructions and facility schedule.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems were implemented per the facility policy; and failed to ensure that surveillance monitoring was maintained related to an outbreak (GI) from December 2024; and failed to ensure that surveillance monitoring and tracking of residents that required TBP was maintained from 12/2024 - 8/2025. The findings include:1. During a review of the infection prevention program on 6/1/26 at 8:27 AM, RN #1 (the facility's current IP) identified he was not aware of any infection prevention standards related to Legionella, including if the facility had a mitigation plan in place, or the IP role if Legionella was identified within the facility's water system. RN #1 identified that the maintenance department addressed any issues with the building's water system and he was not involved in any monitoring or tracking of Legionella mitigation strategies for the facility. RN #1 further identified he was not aware of the current infection prevention standards related to Legionella mitigation and also identified that he was unsure of what a suspected outbreak related to Legionnaire's disease would include or what testing would be required. Interview with the DNS on 6/1/26 at 12:00 PM identified that there had been multiple IPs in place from 2024 until 9/2025 when RN #1 filled the position. The DNS identified she was aware that RN #1 did not have any recent IP education and that she was not included in the hiring process for the IP, and that the Administrator alone was responsible for reviewing RN #1's credentials and that RN #1 was a contracted part time employee who did not work directly for the facility. Interview with the Maintenance Director on 6/1/26 at 3:00 PM identified that he was not aware of any testing or mitigation strategies for the facilities water system for Legionella or any other waterborne pathogens. The Maintenance Director identified that the Administrator did not allow the maintenance department to address any issues with the buildings water system and that the Administrator was solely in charge of the water management program for the facility.Interview with the Administrator on 6/1/26 at 3:30 PM Identified that he was in charge of the Legionella and waterborne pathogen mitigation plan for the facility however, due to multiple issues, he had not implemented any mitigation strategies for the facility water system related to Legionella or any other waterborne pathogens since 1/8/25 when he completed a Legionella test due to a deficiency cited as part of the prior annual recertification survey. The Administrator identified that he could not provide any additional information as to why there were no mitigation strategies implemented. Review of the Legionella plan identified mitigation strategies dated 11/2017 which included the following.Hot water heaters were to be drained of sediment and recorded as being done in a log twice yearly.Pressure vessels were to be drained of sediment and to be recorded as being done twice yearly.Ice making machines were to be cleaned quarterly and sanitized yearly per the manufacturer's instructions with a log attached to the side of the machine.Shower heads, hoses, eye wash stations, and aerators were to be removed, cleaned, and soaked in a chlorine bleach solution on a monthly basis and recorded in a log as being done.Interview with the Maintenance Director on 6/2/26 at 7:00 AM identified he was not aware of any of the mitigation strategies outlined in the November 2017 plan. The Maintenance Director identified that there was a Legionella mitigation plan book, but the Administrator kept this in his office and he had been told multiple times that the Administrator handled the water management plan for the facility. Interview with the DNS on 6/3/26 at 8:20 AM identified that she was not aware that RN #1 did not have education related to the current infection prevention standards related to Legionella mitigation as part of the infection prevention program. The DNS identified that she would need to discuss the issue with the Administrator.Interview with the Administrator and DNS on 6/3/26 at 9:29 AM identified that the facility did have a policy regarding mitigation of Legionella and other waterborne pathogens. The Administrator identified due to other issues he had to address including a facility renovation he did not address any further mitigation of Legionella or other waterborne pathogens within the facility outside of the single test completed in January 2025. The Administrator also identified that he had specifically instructed the Maintenance Director not to address anything related to the facility water system or water quality and that the Administrator alone would be responsible for water management. The facility policy for the Legionella water management program directed that the facility was committed to the prevention, detection, and control of waterborne contaminants including Legionella. The policy further directed that as part of the infection prevention and control program the facility had a water management program which was overseen by the water management team and that team included at least the following personnel:Infection Preventionist.Administrator.The medical director (or designee).Maintenance Diirector.Environmental Services Director. The policy further directed that the water management program was to identify areas in the water system where Legionella bacteria could grow and spread and to reduce the risk of Legionnaires disease and that the water management program included elements including an interdisciplinary water management team; a detailed description and diagram of the facilities water system; identification of areas in the water system that could encourage growth and spread of Legionella and other waterborne bacteria; the identification of situations that could lead to Legionella growth including construction, the presence of biofilm, scale, or sediment, water stagnation, and inadequate disinfection; specific measures used to control the introduction and Oregon spread of Legionella; Documentation of the program, and a plan when control limits were not met or control measures were not effective. The policy also directed that the water management program would be reviewed at least annually or sooner if any of the following occurred: when control limits were not consistently met and any changes in laws, regulations, standards, or guidelines. The policy on Legionella surveillance and detection directed that it was the policy of the facility to include Legionella and Legionnaires disease as part of its infection surveillance activities. 2. Review of an outbreak reportable event form reported to the state agency on 12/26/24 by the prior DNS, DNS #2, identified a gastrointestinal outbreak which involved a total of 7 residents and one staff member with symptoms that included vomiting and loose stools. Further review of the reportable event form identified that one resident required hospitalization due to symptoms. During a review of the infection prevention program with RN #1 on 6/1/26 at 8:27 AM, RN #1 identified he was unable to provide any line lists or infection surveillance regarding the gastrointestinal outbreak from 12/20/24 including the residents or staff member involved or when the outbreak resolved with any testing to determine the causative organism. The facility policy on the infection prevention and control program directed that outbreak management included documenting information about an outbreak and monitoring for reoccurrences in managing affected residents.The facility policy on outbreak of communicable diseases directed that the IP and DNS were responsible for managing surveillance data, monitoring ill residents and staff, initiating mission based precautions as appropriate, and communicating with the medical director and attending physicians. 3. During a review of the infection prevention program with RN #1 on 6/1/26 at 8:27 AM, a request was made to provide transmission based precautions surveillance data and tracking for any residents of the facility from the last annual recertification date of 11/19/24 through 8/25/25 when RN #1 became the IP for the facility. RN #1 identified he was unable to locate any line lists for any residents who required transmission based or enhanced barrier precautions for the requested time frame and was only able to provide documentation from when he became the IP beginning on 8/25/25.Interview with the DNS on 6/1/26 at 12:00 PM identified that there had been multiple IPs in place from 2024 until September 2025 when RN #1 filled the position. The DNS further identified she was unsure if any surveillance documentation had been maintained due to multiple infection preventionists being in that role since 11/2024 including coverage by two prior DNSs. The DNS identified she was aware that RN #1 did not have any recent IP education and that she was not included in the hiring process for the IP, and that the Administrator alone was responsible for reviewing RN #1's credentials and that RN #1 was a contracted part time employee who did not work directly for the facility. The DNS also identified that she had identified issues with RN #1's lack of standardized infection surveillance for antibiotic use. Although requested the facility failed to provide a policy on transmission-based precautions.The facility policy on outbreak of communicable diseases directed that the IP and DNS were responsible for managing surveillance data, monitoring ill residents and staff, initiating is mission-based precautions as appropriate, and communicating with the medical director and attending physicians.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure that the QAPI plan included ensuring good faith efforts to correct the water management deficiencies cited during the previous recertification survey. The findings include:Review of the findings from the previous annual recertification survey on 11/19/24 identified issues related to implementation of measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems.Following review of the infection prevention program on 6/1/26, ongoing issues were identified related the implementation of measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems.Interview with the Administrator and DNS on 6/3/26 at 9:29 AM identified during a review of the QAPI plan the Administrator indicated he was responsible for implementing the plan of correction related to Legionella and other waterborne pathogen mitigation identified by the previous annual recertification survey on 11/19/24. The Administrator identified that the facility did have a policy regarding mitigation of Legionella and other waterborne pathogens at that time but they had not been implemented, and that the plan of correction included obtaining Legionella testing which was completed on 1/8/25 which included 2 sample sites and both were negative. The Administrator further identified that following the completion of the testing, he did not implement any further mitigation strategies. The Administrator further identified that he did not discuss or review any issues related to water quality or mitigation of Legionella and other opportunistic waterborne pathogens at any time with the QAPI committee following the last annual recertification survey. The Administrator also identified that he had specifically instructed the Maintenance Director not to address anything related to the facility water system or water quality and that the Administrator alone would be responsible for water management. The DNS identified the QAPI plan did not identify the issues regarding Legionella or waterborne pathogen management, and that good faith efforts had not been made to correct the issue. The facility policy on quality assurance performance improvement directed that the facility would have an active quality assurance performance improvement committee that would meet on a monthly basis and that the committee would be responsible to review information received from, but not limited to, members of the committee, staff, residents and or families. The policy also directed areas in need of improvement should be reviewed for possible changes in policy, procedure, and or system repairs and that committee members included the administrator, director of nurses, and maintenance director. The policy also directed that the primary purpose was to ensure quality care and services were provided to all residents of the facility. The policy also directed responsibilities of the committee included identifying areas of concerns in each department related to current or ongoing issues; developing plans of action and or to delegate to a subcommittee; and to ensure plans of action were implemented and monitored so that revisions may be made to plans as necessary.

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure that dishes, utensils, and all other kitchenware were cleaned in a sanitary manner following an identified dishwasher failure; and failed to address temperature issues with the dishwasher per facility policy; and failed to ensure that kitchen equipment was maintained in a clean and sanitary manner; and failed to ensure that the dry storage area was maintained in a clean and sanitary manner; and failed to ensure that the facility's 3 day emergency food supply was stored in a clean and sanitary manner; and failed to ensure that the nourishment refrigerator and freezer temperatures were monitored, that food items were dated and labeled, and expired items were disposed of to prevent the potential for foodborne illness. The findings include: 1. Observation during an initial tour of the kitchen area on 5/31/26 at 7:20 AM identified Dietary [NAME] #1 and Dietary Aide #1 preparing items for breakfast. Dietary [NAME] #1 was observed preparing food items at the stove, and Dietary Aide #1 was observed wrapping paper napkins around silver spoons and forks. Observation of the dishwasher area identified a cart that contained multiple basins of soiled plates and cups. Interview with Dietary [NAME] #1 during this observation identified the plates and cups were from the evening prior, that the facility did not have a designated employee to wash dishes, and she or Dietary Aide #1 were responsible to wash the dishes once they had time, which would be after breakfast was served.Follow up observation and interview with Dietary [NAME] #1 on 5/31/26 at 10:09 AM identified that the facility low temperature dishwasher was not operational. Dietary [NAME] #1 was observed hand washing and rinsing plastic bowls used for breakfast in a 3 bay sink and then attempting to submerge the bowls under approximately 1 inch depth of a liquid solution, which she identified as sanitizing solution, in the 3rd sink for approximately 1-2 seconds. Dietary [NAME] #1 identified that she was handwashing the dishes with detergent due to the facility's dishwasher not working since sometime the week prior, and that the 3rd sink was used to hold the sanitizing solution but that the drain for the sink was also not working. Dietary [NAME] #1 identified she had been instructed by the Administrator to continue to use the regular facility dishes and utensils for residents and then wash and sanitize the items after each meal. Dietary [NAME] #1 also identified that this was the first time an incident with the dishwasher had occurred, and that she had not been provided any training regarding handwashing and sanitizing but did recall she was not to rinse off the sanitizing solution from the dishes.Interview with the Administrator on 5/31/26 at 10:15 AM identified that he believed the dishwasher stopped functioning on 5/28/26 and that the facility did not use paper products and had been handwashing the dishware items since that time to ensure that the residents' dignity was maintained (this is in conflict with dietary staff interview). The Administrator identified that all the facility dietary staff were aware of the emergency protocols that were in place following the breakdown of the dishwasher, including the proper use of sanitizing solution after washing and rinsing of all dishware.Interview with the Maintenance Director on 5/31/26 at 10:20 AM identified he was notified by the Dietary Director that the dishwasher was not functioning properly on 5/27/26 at 1:48 PM. The Maintenance Director identified that the dishwasher would either not start, or following start of a cycle, would continuously run and not shut off. The Maintenance Director identified at that time the facility contacted a technician and requested service, and that the dishwasher was not operational. The Maintenance Director identified that the issue was initially addressed by the technician for the dishwasher, however it then required a plumber to be called on 5/29/26 when it was discovered a water pressure valve issue to the dishwasher was the problem. The Maintenance Director identified that the valve had been ordered by the plumber but there was not estimated date of when the part would arrive and the dishwasher would be fixed. Interview with the Dietary Director on 5/31/26 at 12:04 PM identified she began working for the facility at the end of March 2026. The Dietary Director identified that all dietary staff should have knowledge of how to implement emergency protocols if the dishwasher was not operational, however she had not provided any education to the staff regarding the facility's policy regarding emergency procedures for a dishwasher malfunction, and that she also was not aware that the regular dishware was being used. The Dietary Director identified she was working when the dishwasher malfunctioned in the afternoon of 5/27/26, and from that time until at least lunch on 5/29/26, that the facility had been using paper products for resident meals. The Dietary Director identified she was not aware that dietary staff had been directed to handwash any dishware items. Review of instructions for 'Final Step Sanitizer', the sanitizing solution used by the facility, directed that to prevent cross contamination that kitchenware must be washed, rinsed with potable water and sanitized after each use and following the interruption of operation during which time contamination may have occurred. The instructions also directed that for sanitizing food contact surfaces in public eating places, dairy processing equipment, food processing equipment, utensils, and food contact articles, the following steps were to be done:Sanitize pre clean hard non porous articles using a solution of 1/4 to 1/2 ounce of the product per 5 gallons of water. Articles that could be immersed in the sanitizing solution must remain in the solution for 60 seconds and articles too large for immersion must be thoroughly wetted for 60 seconds by rinsing, spraying, or swabbing of the solution.Remove items from the solution. Drain the used solution from the surface. Allow surfaces to air dry.No potable water rinse is allowed. The facility policy on the dishwashing machine directed that it was the policy of the facility to ensure that all dishes, utensils, cookware, trays, and food- contact equipment were properly cleaned and sanitized to prevent foodborne illness and maintain compliance with federal and Connecticut regulations. The policy also directed that a commercial dishwasher should be maintained and operated according to the manufacturer specification and sanitation standards. The policy also directed that manual dishwashing would be implemented for emergency use only when the dishwashing machine was not available and included:Washing in hot detergent solutionRinsing with clean waterSanitizing by immersion in hot water for at least one minute or use of an improved chemical sanitizer at the required concentrationAllowing items to air dryThe facility policy on kitchen equipment maintenance directed that dietary and maintenance staff would receive orientation and ongoing training on safe equipment use, reporting procedures, and food safety principles. The policy further directed that competencies would be assessed initially and periodically, and retraining would occur when new equipment was introduced and when practices changed. 2. Review of the low temperature dishwasher logs identified beginning 4/29/26, logs for the water temperature was to be completed 3 times daily (breakfast, lunch, and dinner) through lunch on 5/26/26. Further review of the logs identified water temperatures were less than 120 on the following dates:4/29/26 (breakfast) 110 5/2/26 (lunch) 111 5/2/26 (dinner)115 5/3/26 (breakfast) 119 5/3/26 (dinner)110 5/4/26 (breakfast)105 5/6/26 (dinner)111 5/11/26 (breakfast)111 5/13/26 (breakfast)115 5/13/26 (lunch)111 5/15/26 (lunch)115 5/15/26 (dinner)117 (logged signed off with the initials of the Dietary Director)5/16/26 (lunch) 119 ( logged signed off with the initials of the Dietary Director)5/17/26 (breakfast) 119 5/17/26 (dinner) 119 5/18/26 (lunch) 119 5/19/26 (breakfast) 111 5/20/26 (breakfast) 110 5/21/26 (dinner) 119 5/22/26 (dinner) 119 5/23/26 (dinner) 119 5/25/26 (dinner) 119 5/26/26 (breakfast) 119 Further review of the dishwasher temperature logs failed to identify any documentation related to monitoring of the chemical sanitizer concentration. Interview with the Dietary Director on 6/1/26 at 2:00 PM identified that she began working at the facility at the end of March 2026. The Dietary Director identified she was unable to locate any logs related to monitoring the dishwashing machine including water temperatures or chemical sanitizer concentrations. The Dietary Director identified that she implemented use of the log at the end of April 2026 and while she had observed and had herself checked the chemical sanitizer using test strips, the dietary staff did not log the results. The Dietary Director identified that she was not aware that the wash temperatures for the low temperature dishwashing machine had been below the required temperature of 120 and that the policy of the facility was to stop using the dishwasher and notify the maintenance director if there were any issues with the dishwasher. The facility policy on the dishwash washing machine directed that for a low temperature chemical sanitizing machine the minimum wash temperature was 120 F. The policy also directed that the sanitizer concentration would meet manufacturers' recommendations and would be verified with appropriate test strips. The policy further directed corrective actions if the dishwasher failed to meet the minimum or temperature or sanitizer concentration included:Stop the use of the machine immediately.Notify the Dietary Director and maintenance department.Rewash any items processed during the malfunction.Contact the dish machine vendor as necessary. 3. During a follow up tour of the kitchen with the Dietary Director on 6/1/26 at 7:10 AM observation identified a dark thick debris adhered to the base and sides of the 2 large ovens. Observation of the ovens also identified an amber colored layer of debris on the interior of the glass making it difficult to observe the interiors of the ovens with the doors closed. Interview with the Dietary Director during this observation identified that the dietary staff did not have any assigned cleaning schedule in place and that the dietary staff instead cleaned observable dirty kitchen areas as they went with no regular cleaning intervals of kitchen equipment. The Dietary Director identified she had recently been working on a weekly cleaning schedule that had not been implemented. The Dietary Director also was unable to identify the last time the facility ovens had been cleaned and could not identify if they had been cleaned since she began working for the facility at the end of 3/2026. The facility policy on kitchen equipment maintenance directed that it was the responsibility of the Dietary Director to oversee the daily equipment condition checks, sanitation practices, and preventative maintenance coordination of kitchen equipment. The policy further directed that daily operational checks would be done and any equipment that appeared unsanitary would be reported immediately and not used until evaluated. The policy also directed that all kitchen equipment would be clean and sanitized at a frequency consistent with manufacturer's instructions, food safety standards, and facility cleaning schedules. The policy also directed that nonfood contact surfaces, handles, controls, and surrounding areas would be cleaned routinely to prevent the buildup of grease, debris, dust, and spills. 4. During an initial tour of the kitchen on 5/31/26 at 7:20 AM multiple areas of the kitchen were identified to have debris and particles throughout the floor of the kitchen and the dry storage area. Observation of the dry storage area identified multiple food items located under wire racks within the dry storage area, open boxes and containers located on the shelves of the dry storage area, employee belongings and open beverages within the dry storage area, and a large round gray trash can with wheels, with debris inside of a black bag, in the dry storage area. Follow up observations of the dry storage area on 5/31/26 at 10:05 AM and 6/1/26 at 7:10 AM identified multiple food items including dried noodles, powders and other debris under the dry storage area wire racks that appeared unchanged from the previous observations. Interview with the Dietary Director on 6/1/26 at 7:10 AM identified that the dietary staff did not have any assigned cleaning schedule in place and that the dietary staff instead cleaned observable dirty kitchen areas as they went with no regular cleaning intervals of kitchen equipment. The Dietary Director identified she had recently been working on a weekly cleaning schedule that had not been implemented. Although requested, the facility failed to provide a policy regarding sanitization of the kitchen. The facility policy on kitchen equipment maintenance directed that nonfood contact surfaces, handles, controls, and surrounding areas would be cleaned routinely to prevent the buildup of grease, debris, dust, and spills. 5. Following a request to review the facility's 3-day emergency supply, interview with the Dietary Director on 6/1/26 at 2:00 PM identified that she did not have any knowledge of the facility's 3 day emergency supply. The Dietary Director further identified that she was not sure where the emergency supply was located, what was contained in the emergency supply, or if there was enough inventory for the facility residents. The Dietary Director identified she had not had time since she began employment to determine if the emergency supply was maintained, and that she would need assistance from the Administrator and Maintenance Director to locate the emergency supply. Observations and interviews on 6/1/26 at 2:12 PM with the Administrator, Maintenance Director, and Dietary Director identified multiple large canned and dry food items located in a basement area of the facility. Observation identified that the food items were positioned directly next to 4 large vertical single paned windows, approximately 1 foot in length, 2 feet in height, and positioned approximately 2 feet from the floor. Observation of the windows identified that there was no shading and direct sunlight was observed coming into the room directly on the food items. Additionally, observation of the window sill which was directly next to the level of the food items identified multiple piles of dead insects, webs and other debris, including what appeared to be leaves remnants of plastic sheeting and other items. The Administrator identified the food stock as the 3-day emergency supply. The Administrator also identified that he was aware that the food stock was placed directly next to the window but did not notice the dead insects and other debris as an issue. The Administrator identified that the food items only stayed in this area during the wintertime and that he was in the process of moving the items to a cooler air conditioned area due to summer coming and the rise in temperatures and that the items would be moved within the week. Interview with the Administrator on 6/1/26 at 2:31 PM identified he had moved the 3 day emergency supply of food from an air-conditioned basement storage room to the basement area in front of the windows earlier in the morning of 6/1/26 due to the condition of the room.Observation of the air-conditioned basement storage room with the Administrator and Maintenance Director on 6/1/26 at 2:31 PM identified a pungent odor of sewer gas upon entrance to and inside the room. Observation of the room also identified a large plumbing line located at the back of the room running from the ceiling into the cement flooring which the Maintenance Director identified was the origin of the odor throughout the room. Observation of the floor also noted multiple areas of debris within the carpeting with dirt and debris located throughout the room.Interview with the Administrator immediately following this observation identified that he did not feel storing food in this area was an issue as the items were canned and would not be impacted by the odor or the debris. Included in the 3-day emergency supply of food was three 3.24 lbs. cartons of dry potato mix and two 42 oz containers dried rolled oats. Following identification of the paper packaged items the Administrator identified that those items may not be usable due to the condition of the room. The Administrator identified that storage of the 3-day emergency food supply was an issue due to the limited space of the facility. Although requested the facility failed to provide a policy on food storage and sanitation. The facility policy on kitchen equipment maintenance directed that the facility would protect residents from foodborne illness and injury and comply with applicable Connecticut and federal long term care requirements. The policy also directed that the dietary director, maintenance director and other designated leaders would periodically review sanitation findings to identify opportunities for improvement. 6. Observation of the nourishment refrigerator on 6/2/26 at 7:24 AM identified the following. Observation of a one-gallon container of 2% milk with approximately 25% of milk remaining. Observation of the label identified a sell by date of 5/8/26 (over 3 weeks). Multiple food items including an open bag of red grapes, sour cream, cream cheese, margarine, V8 vegetable juice, 1/2 gallon container of fat free milk, a bottle of purple grape juice, container of mayonnaise, container of mustard, multiple zip lock plastic bags that appeared to contain cheese wedges, a container of chicken bouillon paste, a bottle of honey mustard salad dressing, a jar of veggie slaw, a bag of shredded chicken, and two jars of pickles that had been opened. None of the food items contained any resident identifying information including name, date received or opened, or room number. Observation of the nourishment room freezer directly below the refrigerator identified multiple items including a bag of frozen cranberries, cinnamon brioche bread, keto ice cream containers, microwave meatloaf dinners, beef burritos and a frozen half gallon of fat free milk.None of the food items contained any resident identifying information including name, date received or opened, or room number. Review of the temperature logs for the refrigerator for May and June 2026 failed to identify any documentation a freezer temperatures and also failed to identify that temperatures were recorded twice daily. Interview with the DNS on 6/3/26 at 8:20 AM identified that she was not aware that freezer temperatures were not being monitored for the freezer for the refrigerators and that it was the policy of the facility to monitor the refrigerator temps twice daily. The DNS also identified that perishable food items brought in by residents are all to be labeled with the residents name room number and date that the item was received and any unlabeled food items were to be discarded. The DNS also identified that it was the responsibility of the dietary staff and housekeeping to discard any expired or unlabeled food items and it was the responsibility of nursing to monitor the refrigerator and freezer temperatures. The facility policy on outside food directed that the purpose of the policy was to ensure that the residents personal food was stored, labeled, monitored, and consumed in a manner that promoted food safety while honoring the residents rights. The policy further directed that all resident owned perishable foods shall be labeled with the residents name, date received or open, and room number however this was optional. The policy also directed that unlabeled food items may be discarded if ownership could not be determined. The policy further directed that refrigerators would be monitored in accordance with facility policy and perishable food would be discarded by the manufacturers expiration date, seven days after opening unless manufacture instructions specified otherwise, and earlier if storage was suspected. The policy also directed that nursing, dietary, housekeeping, and other designated staff may inspect resident food storage areas periodically for spoilage, expired products, pest concerns, sanitation concerns, and that residents would be informed if food was removed due to safety concerns whenever possible and food determined to be unsafe would be discarded immediately.

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to ensure that all dietary staff were educated and competent to implement emergency procedures for cleaning and sanitizing of all dishes, utensils, and kitchenware. The findings include:Observations during an initial tour of the kitchen area on 5/31/26 at 7:20 AM identified Dietary [NAME] #1 and Dietary Aide #1 preparing items for breakfast. Dietary [NAME] #1 was observed preparing food items at the stove, and Dietary Aide #1 was observed wrapping paper napkins around silver spoons and forks. Observation of the dishwasher area identified a cart that contained multiple basins of soiled plates and cups. Interview with Dietary [NAME] #1 during this observation identified the plates and cups were from the evening prior, that the facility did not have a designated employee to wash dishes, and she or Dietary Aide #1 were responsible to wash the dishes once they had time, which would be after breakfast was served.Follow up observation and interview with Dietary [NAME] #1 on 5/31/26 at 10:09 AM identified that the facility low temperature dishwasher was not operational. Dietary [NAME] #1 was observed hand washing and rinsing plastic bowls used for breakfast in a 3 bay sink and then attempting to submerge the bowls under approximately 1 inch depth of a liquid solution, which she identified as sanitizing solution, in the 3rd sink for approximately 1-2 seconds. Dietary [NAME] #1 identified that she was handwashing the dishes with detergent due to the facility's dishwasher not working (since sometime the week prior), and that the 3rd sink was used to hold the sanitizing solution but that the drain for the sink was also not working. Dietary [NAME] #1 identified she had been instructed by the Administrator to continue to use the regular facility dishes and utensils for residents and then wash and sanitize the items after each meal. Dietary [NAME] #1 also identified that this was the first time an incident with the dishwasher had occurred, and that she had not been provided any training regarding handwashing and sanitizing of dishes/utensils but did recall she was not to rinse off the sanitizing solution from the dishes.Interview with Dietary Aide #1 on 5/31/26 at 10:11 AM identified that she had operated the facility dishwasher when dishwashing was needed, and had not received any inservice education related to emergency procedures due to the dishwasher malfunction. Interview with the Administrator on 5/31/26 at 10:15 AM identified that he believed the dishwasher stopped functioning on 5/28/26 and that the facility did not use paper products and had been handwashing the dishware items since that time to ensure that the residents' dignity was maintained (this is in conflict with interviews with dietary staff). The Administrator identified that all the facility dietary staff were aware of the emergency protocols that were in place following the breakdown of the dishwasher, including the proper use of sanitizing solution after washing and rinsing of all dishware (this is in conflict with interviews with dietary staff).Interview with the Maintenance Director on 5/31/26 at 10:20 AM identified he was notified by the Dietary Director that the dishwasher was not functioning properly on 5/27/26 at 1:48 PM. The Maintenance Director identified that the dishwasher would either not start, or following start of a cycle, would continuously run and not shut off. The Maintenance Director identified at that time the facility contacted a technician and requested service, and that the dishwasher was not operational. The Maintenance Director identified that the issue was initially addressed by the technician for the dishwasher, however it then required a plumber to be called on 5/29/26 when it was discovered a water pressure valve issue to the dishwasher was the problem. The Maintenance Director identified that the valve had been ordered by the plumber but there was no estimated date of when the part would arrive and the dishwasher would be fixed. Interview with Dietary Aide #3 on 5/31/26 at 11:30 AM identified that he had operated the facility dishwasher when dishwashing was needed but could not recall if he had been provided any education on what to do if the dishwasher malfunctioned.Interview with the Dietary Director on 5/31/26 at 12:04 PM identified she began working for the facility at the end of March 2026. The Dietary Director identified that all dietary staff should have knowledge of how to implement emergency protocols if the dishwasher was not operational, however she had not provided any education to the staff regarding the facility's policy regarding emergency procedures for a dishwasher malfunction, and that she also was not aware that the regular dishware was being used. The Dietary Director identified that she was working when the dishwasher malfunctioned in the afternoon of 5/27/26, and from that time until at least lunch on 5/29/26, that the facility had been using paper products for resident meals. The Dietary Director identified she was not aware that dietary staff had been directed to handwash any dishware items. Interview with the Administrator on 6/1/26 at 8:00 AM identified the facility had, in fact, been using paper products and disposable utensils for residents on 5/27, 5/28, and 5/29/26, and that he had instructed Dietary [NAME] #1 to use regular dishware on 5/31/26 following the survey team's entrance into the facility as he believed there would be an issue with paper product use and the dignity of the residents. The Administrator further identified that he was also not aware that the dietary staff had not had any in-service education regarding the facility policy on emergency procedures for dishwasher malfunction. Review of instructions for 'Final Step Sanitizer', the sanitizing solution used by the facility, directed that to prevent cross contamination that kitchenware must be washed, rinsed with potable water and sanitized after each use and following the interruption of operation during which time contamination may have occurred. The instructions also directed that for sanitizing food contact surfaces in public eating places, dairy processing equipment, food processing equipment, utensils, and food contact articles, the following steps were to be done:1) Sanitize pre clean hard non porous articles using a solution of 1/4 to 1/2 ounce of the product per 5 gallons of water. Articles that could be immersed in the sanitizing solution must remain in the solution for 60 seconds and articles too large for immersion must be thoroughly wetted for 60 seconds by rinsing, spraying, or swabbing of the solution.2) Remove items from the solution. Drain the used solution from the surface. Allow surfaces to air dry.3) No potable water rinse is allowed.The facility policy on the dishwashing machine directed that it was the policy of the facility to ensure that all dishes, utensils, cookware, trays, and food- contact equipment were properly cleaned and sanitized to prevent foodborne illness and maintain compliance with federal and Connecticut regulations. The policy also directed that a commercial dishwasher should be maintained and operated according to the manufacturer specification and sanitation standards. The policy also directed that manual dishwashing would be implemented for emergency use only when the dishwashing machine was not available and included:1) Washing in hot detergent solution.2) Rinsing with clean water.3) Sanitizing by immersion in hot water for at least one minute or use of an improved chemical sanitizer at the required concentration.4) Allowing items to air dry.The facility policy on kitchen equipment maintenance directed that dietary and maintenance staff would receive orientation and ongoing training on safe equipment use, reporting procedures, and food safety principles. The policy further directed that competencies would be assessed initially and periodically, and retraining would occur when new equipment was introduced and when practices changed.

Based on review of the clinical record, facility documentation, facility policy and interviews for 4 of 5 residents (Resident #1, 6, 44 and 8) reviewed for unnecessary medications, the facility failed to ensure monthly pharmacy medication regimen reviews had been completed between November 2025 and February 2026. The findings include: 1. Resident #1 was admitted to the facility in March 2025 with diagnoses that included dementia and major depressive disorder. The quarterly MDS dated [DATE] identified Resident #1 had severe cognitive impairment and was prescribed medication to manage his/her comorbidities. The care plan dated 9/7/25 identified Resident #1 had behaviors problems with cognitive impairment and anxiety. Interventions included administering medications as ordered and monitor for side effects. 2. Resident #6 was admitted to the facility in October 2025 with diagnoses that included osteoarthritis and hypertension. The quarterly MDS dated [DATE] identified Resident #6 was cognitively intact and was prescribed medication to manage his/her comorbidities. The care plan dated 11/9/25 identified Resident #6 had the potential for pain and adverse reactions related to osteoarthritis and psychotropic medication use with interventions that included administering medications as ordered and monitor/report side effects. 3. Resident #44 was admitted to the facility in September 2025 with diagnoses that included hypertension and dementia. The admission MDS dated [DATE] identified Resident #44 was severely cognitively impaired and was prescribed medication to manage his/her comorbidities. 4. Resident #8 was admitted to the facility in [NAME] 2018 with diagnoses that included type 2 diabetes mellitus, hypertensive heart and chronic kidney disease, bipolar disorder, PTSD, and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #8 had intact cognition and received insulin injections and had received medications from the following high-risk drug classes: antipsychotic, antidepressant, anticoagulant, diuretic, opioid, hypoglycemic, and anticonvulsant during the last 7 days. The care plan dated 9/27/25 identified Resident #8 was at risk for adverse reactions related to anti-psychotic medications for diagnoses of PTSD and bipolar disorder, with interventions that included attempting a GDR per facility policy and monitoring for metabolic complications, neuroleptic malignant syndrome, target behaviors, and other medication specific side effects: anticholinergic effects, arrythmias, falls and lethargy. Review of the clinical records for Resident #1, 6, 44 and 8 identified no documented medication regime reviews had been completed from November 2025 through January 2026. Interview with the DNS on 6/1/26 at 7:19 AM identified monthly medication regimen reviews were to be completed by the pharmacy consultant and then sent electronically to the facility following the review. In her former role as an ADNS, it was her responsibility to review the pharmacy recommendations upon receipt. The DNS indicated the lapse in services occurred from November 2025 through January 2026 while she was transitioning to her new role as DNS in December 2025. The DNS noticed pharmacy reviews had been completed for new admissions only followed by a large backlog of recommendations. The DNS contacted the pharmacy, and a subsequent meeting was held that identified the subcontracted pharmacy consult utilized by their pharmacy to conduct monthly medication reviews had not completed monthly pharmacy reviews from November 2025 through January 2026. The pharmacy consultant was terminated and beginning in February 2026 monthly medication regimen reviews resumed with a new pharmacy consultant. Interview with the DNS on 6/1/26 at 7:19 AM identified that she became the facility's DNS in December 2025, before that she was the RN Supervisor and ADNS. The DNS indicated that while she was the ADNS, the monthly pharmacy medication reviews were sent to the facility via fax and that she oversaw the nursing recommendations. From November 2025 through January 2026 the facility had only been receiving pharmacy medication recommendations for new admissions. The DNS further indicated that a few months ago, around March of 2026, a representative from the facility's contracted pharmacy had notified her that the Pharmacy Consultant responsible for completing the monthly regimen reviews had not been doing them. The DNS identified that she met with the leadership team from the facility's contracted pharmacy, and a new Pharmacy Consultant was assigned to the facility. The new Pharmacy Consultant immediately completed a thorough medication regimen review on all the residents, and the facility was satisfied with the services. Interview with the Pharmacy Manager on 6/2/26 at 3:10 PM identified that they use an outsourced consultant pharmacy group, and that concerns had been raised by other facilities about the services that were being provided by the Pharmacy Consultant (Pharmacist #1), so they completed an investigation which determined there were some months without documented signatures, because some months reports had not been completed, and Pharmacist #1 was released from the pharmacy group. The Pharmacy Manager indicated that there was a new Pharmacy Consultant assigned to the facility, and he completed a comprehensive review; additionally, a new triple check system was put in place to rectify the issue. Interview with the Pharmacy Manager for contracting pharmacy on 6/3/26 at 9:45 AM identified the pharmacy utilized subcontracted pharmacy consultant services to complete monthly medication regimen reviews. The Pharmacy Manager indicated she began receiving complaints beginning January 2026 that facilities had not been receiving the required monthly medication recommendations. The Pharmacy Manager contacted Supervising Pharmacy Consultant #1 from the sub-contracted service sometime in February 2026 and learned the assigned pharmacy consultant had not been completing the monthly medication reviews resulting in their termination. Once identified, a comprehensive review was completed and new systems implemented. The updated process requires verification of completeness by the pharmacy consultant, supervising pharmacy consultant, and herself before dissemination to the facility. The Pharmacy Recommendations policy directs Pharmacists will communicate any urgent or high priority recommendations immediately to the attending physician. Non-urgent recommendations will be submitted in writing or via the facilities electronic health records system. All recommendations will be addressed within a reasonable time frame, with urgent or time sensitive issues handled promptly. Once the pharmacy recommendation is implemented, nursing staff will monitor the resident for any changes in clinical status or adverse effects. The pharmacy team will follow up periodically to ensure that the recommendation has been effective and well tolerated.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure that standardized infection surveillance and assessments were initiated and completed for facility residents with suspected infections to determine the appropriateness of antibiotic usage; and failed to ensure that antibiotic surveillance monitoring was completed for multiple months in 2025 (January 2025 - June 2025). The findings include:1. During a review of the antibiotic stewardship program as part of the infection prevention program with RN #1 on 6/1/26 at 8:27 AM a request was made to review specific elements related to evaluation of antibiotic use for residents of the facility.Review of antibiotic surveillance logs from 7/2025 through 6/2026 with RN #1 on 6/1/26 at 8:27 AM failed to identify any use of standardized guidelines and symptom thresholds for specific infections to determine if antibiotic use was appropriate based on the resident symptoms and laboratory findings.Interview with RN #1 during a review of the antibiotic stewardship program identified he was not familiar with any antibiotic use criteria and identified he did his own thing. RN #1 indicated he does not utilize any criteria (i.e. McGeer's, Loeb's) and thought that APRN or maybe one of the nurses on the floor would do that. RN #1 identified he had seen documentation sheets for McGeer's criteria when he was an IP several years ago but had never utilized and was not aware of anybody in the facility who was tracking anything related to standardized infection criteria including the specific incidence or prevalence of a specific type of infection in the facility or the actual numbers of infections including those that were required antibiotic use and prescribed antibiotics based on symptoms and diagnostic findings.Interview with the DNS on 6/1/26 at 12 PM identified that there had been multiple IPs in place from 2024 until 9/2025 when RN #1 filled the position. The DNS identified she was aware that RN #1 did not have any recent IP education and that she was not included in the hiring process for the IP, and that the Administrator alone was responsible for reviewing RN #1's credentials. The DNS indicated RN #1 was a contracted part time employee who did not work directly for the facility. The DNS also identified that she had identified issues with RN #1's lack of standardized infection surveillance for antibiotic use for residents but that the issues had not been addressed. The facility policy on Antibiotic Stewardship - staff and clinician training and roles, directed that the facility would educate and train staff and practitioners about the facilities antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. The policy directed that the DNS and IP were administrative and management personnel with clinical oversight responsibilities and would receive initial orientation and ongoing training regarding the facilities antibiotic stewardship program including the rationale for judicious use of antibiotics, common clinical conditions and associated pathogens treated by the facility, how to access current facility antibiograms if available, how to access a list of antimicrobial agents available through the facility pharmacy, how to use surveillance tools to monitor infection rates antibiotic usage patterns and outcomes, how to report notable infections, how and when to gather data to present to the infection prevention and control committee for scheduled meetings and individual roles and responsibilities in maintaining antibiotic stewardship. The policy further directed that the IP would monitor overtime and report to the infection prevention committee measures of antibiotic use, antibiotic susceptibility patterns, negative outcomes or events related to antibiotic use including C diff infections, adverse drug events, and antibiotic resistance rates, and the IP would obtain educational resources and materials about antibiotic resistance and opportunities for improved antibiotic use in the facility. The facility policy on antibiotic stewardship directed that antibiotics would be prescribed and administered to residents under the guidance of the antibiotic stewardship program. The policy further directed the purpose of the antibiotic stewardship program was to monitor the use of antibiotics with residents and that training and education of staff would emphasize the importance of antibiotic stewardship and include how inappropriate use of antibiotics would affect individual residents and the overall community. Training and education would emphasize the relationship between antibiotic use and gastrointestinal disorders; Opportunistic infections including C diff and candida albicans; Medication interaction; And the evolution of drug resistant pathogens 2. During a review of the antibiotic stewardship program with RN number one on 6/1/26 at 8:27 AM, a request was made to provide antibiotic surveillance and tracking for 2025. RN #1 identified he was unable to locate any antibiotic use or tracking for any residents who require from 1/2025 - 6/2025Interview with the DNS on 6/1/26 at 12:00 PM identified that there had been multiple IPs in place from 2024 until 9/2025 when RN #1 filled the position. The DNS further identified she was unsure if any surveillance documentation had been maintained due to multiple infection preventionists being in that role since 11/2024 including coverage by two prior DNSs. The facility policy on outbreak of communicable diseases directed that the IP and DNS were responsible for managing surveillance data, monitoring ill residents and staff, initiating transmission-based precautions as appropriate, and communicating with the medical director and attending physicians.

Based on review of facility documentation and policy, the facility failed to ensure a nurse aide completed a clinical competency evaluation for mechanical (hoyer) lift transfers. The findings include: Facility documentation review identified Nurse Aide (NA #2) was hired on 1/28/25 and was terminated from the facility on 4/13/25. Interview with the DNS on 6/2/26 at 2:46 PM identified that NA #1 had completed a clinical competency for mechanical lift transfers on 1/7/25 but had no clinical competencies on file following his orientation. The DNS further identified that it would be her expectation that all nursing staff have documented competencies on file that were signed off by their preceptor prior to working on their own, and that would include a competency evaluation in operating a mechanical lift. The Staff Competencies policy directs the facility to ensure that all staff possess the necessary competencies to deliver high quality, safe and effective care to the residents. This policy outlines the competency requirements, assessment process, and ongoing development practices that promote continuous improvement in staff skills and knowledge. New hires will complete an initial competency assessment upon employment. This assessment will include: a review of qualifications, certifications, and prior experience, orientation and training specific to the facilities policies, procedures and resident care needs, direct observation of clinical skills, including hands on evaluation and simulated scenarios where appropriate, and completion of any required certification or license or verification. Ongoing competency evaluations will be reassessed at regular intervals (at least annually or more frequently as needed) which may include: observational assessments during routine tasks or direct patient care, review of performance data, including any clinical outcomes, or resident feedback, review of adherence to protocols and care plans, and skills checklists and standardized competency tests.The Facility Assessment updated 5/29/26 directs that all competencies have been based on resident population as evidenced by resident assessments, these competencies include but are not limited to understanding infection control procedures, caring for the resident with dementia, emergency procedures, fall prevention, resident transfers, and oxygen treatments. Orientations have been completed for all new staff, and staff in-services which include but are not limited to: resident abuse, fire/emergency safety, infection control, resident rights, ADL's, and proper lifting and transfers. Please cross reference F689.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #21) reviewed for nutrition, the facility failed to notify the physician and resident representative of a significant weight loss in a timely manner. The findings include:Resident #31 was admitted to the facility in July 2025, with diagnoses that included Parkinson's disease, dysphagia, and moderate protein-calorie malnutrition.The physician's order dated 7/28/25 directed to obtained monthly weights by the first week of the month on shower day. If there is an increase or decrease of 5 lbs. a re-weight must be taken. Nurse to verify all weights.The nutritional assessment dated [DATE] at 9:47 AM identified Resident #21 was receiving a carbohydrate-controlled diet with regular texture and thin liquids. The resident had an admission weight of 134 lbs. and on 11/6/25 weighed 124.0 lbs. The assessment further identified mastication difficulties, swallowing problems, and a history of oropharyngeal dysphagia. Resident #21 required assistance with feeding and was noted to have sub-optimal oral intake. Dietary supplement of ice cream with meals was in place. Will update the APRN.The weights summary dated 12/1/25 identified Resident #21 weighed 125 lbs.The weights summary dated 1/5/26 identified Resident #21 weighed 120.2 lbs.The weights summary dated 2/3/26 identified Resident #21 weighed 120 lbs.The weights summary dated 3/3/26 identified Resident #21 weighed 116.4 lbs.The weights summary dated 4/8/26 identified Resident #21 weighed 116.6 lbs.The weights summary dated 5/4/26 identified Resident #21 weighed 108 lbs.The weights summary dated 5/29/26 identified Resident #21 weighed 107 lbs.Review of these weights represented an 18 lbs. (14.4%) weight loss over approximately six months.The nutritional assessment dated [DATE] at 11:31 PM identified Resident #21 as receiving a carbohydrate-controlled diet with regular texture. Documented weight of 120.0 on 2/3/26 at 1:58 PM. Recent weight changes in 30 days 120.2, 180 days weight 135.2 (-11.09%) decrease weight loss. The assessment further identified mastication difficulties, swallowing problems, and was noted to have sub-optimal oral intake. Dietary supplement of ice cream with meals, super cereal with breakfast was in place. The physician's order dated 5/1/26 directed to obtain monthly weight by the first week of the month on shower day. If there is an increase or decrease of 5 lbs. a re-weight must be taken. Nurse to verify all weights. Further, provide diabetic/carbohydrate controlled diet minced and moist texture.The quarterly MDS dated [DATE] identified Resident #21 was moderately cognitively impaired and required supervision or touching assistance with eating.The care plan dated 5/14/26 identified Resident #21 had protein-malnutrition, recent illness, surgery/hospitalization, diabetes, muscle wasting, dysphagia, significant weight loss-unintended, poor oral intake. Interventions included monitoring weight as needed, provide menu selections, provide diet and supplements as ordered, and provide snacks as desired in accordance with diet order.The dietitian progress note dated 5/31/26 at 12:53 PM identified Resident #21 experienced significant weight loss over the previous 90-day and 180-day periods. Resident #21 remained on a minced and moist diet with thin liquids and consumed an average of 57% of meals during the review period. Interventions included to provide the physician's ordered Boost Glucose Control 237 ml three times daily., obtain laboratory studies, speech therapy re-evaluation, continue weekly weights, Magic cup supplement at lunch, and notify the APRN. The Dietitian indicated Resident #21 weight loss and decline were anticipated and unavoidable due to disease progression.Review of the clinical record failed to reflect documentation that the physician/APRN and the resident representative were notified of the weight loss.Interview and clinical record review with the DNS on 6/1/26 at 8:00 AM failed to reflect that the physician or APRN, Resident #21 and resident representative were notified of the weight loss. The DNS identified she was not aware of Resident #21's weight loss of 14.4% over approximately six months. The DNS indicated licensed nurses are responsible for reviewing resident weights and reporting weight discrepancies to the RN supervisor for follow-up assessment and reweighing. The DNS indicated that licensed nurses and nursing supervisors are responsible for notifying the physician/APRN and the resident representative of significant weight changes and that notification had not occurred for Resident #21. The DNS indicated licensed nurse staff would be educated.Interview and clinical record review with the Dietitian on 6/2/26 at 11:14 AM identified she was aware of Resident #21's weight loss. The Dietitian indicated she assessed Resident #21 on 5/31/26. The Dietitian indicated she notice Resident #21 losing weight on 2/16/26 during the quarterly assessment. The Dietitian indicated Resident #21 was on supplements. The Dietitian indicated it is the responsibility of the licensed nurse to notify the physician/APRN and the resident representative of weight changes. The Dietitian indicated she will notify the APRN regarding Resident #21's weight loss by documenting in the APRN binder on the unit.Interview with LPN #3 on 6/3/26 at 11:17 AM identified she was not aware of Resident #21's weight loss. LPN #3 indicated it is the responsibility of the licensed nurse to notify the physician/APRN and the resident representative of weight changes. LPN #3 indicated that since Resident #21's diet order was changed from regular texture to a minced and moist diet, the resident's oral intake had decreased. LPN #3 indicated that nursing staff, including nurse aides, encouraged the resident to eat and offered alternative food selections consistent with the resident's prescribed diet order.Interview with APRN #1 on 6/3/26 at 11:20 AM identified she could not recall if she was made aware of Resident #21's continued weight loss but would have documented her assessment and plan if she had been made aware.Interview with MD #1 on 6/3/26 at 12:39 PM identified he was not notified of Resident #21's weight loss. MD #1 indicated if he had been notified of the resident's weight loss, he would have documented his assessment and plan in the medical record. MD #1 indicated that licensed nurses and nursing supervisors are responsible for notifying the physician/APRN and the resident representative of significant weight changes. Subsequent to surveyor inquiry, Resident #21 and the resident representative were notified of the weight loss, and an APRN assessment was performed.Review of the facility weight policy and procedure identified the purpose was to ensure timely identification, evaluation, and management of weight changes in residents in order to prevent avoidable weight loss or gain and maintain optimal nutritional status in accordance with federal and Connecticut state regulations. All residents will be weighed on admission, weekly for four (4) weeks, and monthly thereafter, or more frequently as clinically indicated. Significant weight changes will be promptly identified, evaluated, and addressed through an interdisciplinary approach. Significant weight loss/gain notify physician/APRN, dietitian, resident and resident representatives for significant weight changes.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #38) reviewed for grievances, the facility failed to make prompt efforts to resolve a grievance, including investigating the reported concern that two residents (Resident #39 and 15) made fun of Resident #38, laughing in his/her face and telling the resident he/she was not going to get anything to eat while in the dining room. The findings include: a. Resident #38 was admitted to the facility in October 2025 with diagnoses that included Wernicke's encephalopathy (neurological condition caused by vitamin B1 deficiency) and anxiety. The quarterly MDS dated [DATE] identified Resident #38 was cognitively intact, required set up assist with eating and was independent in ambulation with a walker. The care plan dated 4/14/26 identified Resident #38 had adjustment issues related to admission affecting mood and behavior. Interventions included encouragement in activities of choice, conversation with staff and residents and opportunities to communicate feelings. Nurses note dated 5/24/26 at 2:08 PM (entered by RN #4) identified Resident #38 was upset and reporting he/she was going to eat in his/her room due to two residents making fun of him/her and laughing in his/her face. Resident #38 further reported one resident told him/her he/she was not going to get anything to eat. Resident #38 provided the names of both residents. A review of the clinical record and facility documentation did not include any further documentation of the incident or interventions that addressed to address such. Interview with Resident #38 on 5/31/26 12:17 PM identified he/she could not recall the incident. b. Resident #39 was admitted to the facility in April 2022 with diagnoses that included dementia and adjustment disorder. The quarterly MDS dated [DATE] identified Resident #39 was cognitively intact, required set up assist with eating and was independent with ambulation with a walker. The care plan dated 5/11/26 identified Resident #39 was at risk for a behavior problem of accusatory comments. Interventions that included intervening to protect the rights and safety of others, divert attention and remove from the situation to an alternate location. The clinical record did not include documentation of the incident on 5/24/26 that had been reported by Resident #38 (two residents making fun of Resident #38, laughing in his/her face and telling the resident he/she was not going to get anything to eat). c. Resident #15 was admitted to the facility in October 2025 with diagnoses that included depression and unspecified psychosis. The quarterly MDS dated [DATE] identified Resident #15 had moderate cognitive impairment, required set up assist with eating and required one person assist with locomotion using a wheelchair. The care plan dated 4/17/26 identified Resident #15 tended to be verbally aggressive related to ineffective coping skills and poor impulse control. Interventions included identifying triggers and what de-escalates and when agitated guide away from the source. The clinical record did not include documentation of the incident on 5/24/26 that had been reported by Resident #38 (two residents making fun of Resident #38, laughing in his/her face and telling the resident he/she was not going to get anything to eat). Interview with RN #4 on 5/31/26 at 2:42 PM identified she was the assigned charge nurse working from 7:00 AM to 3:00 PM shift on 5/24/26. RN #4 identified Resident #38 reported he/she was not going to eat in the dining room as Resident #39 and Resident #15 were teasing and making fun of him/her. RN #4 indicated she did not observe the interaction herself but reported it to the nursing supervisor. RN #4 was familiar with Resident #39 and Resident #15 who were observed in the past being rude towards other residents which would be reported to the nursing supervisor or DNS. RN #4 further identified she took no further action. Interview with the Director of Social Services on 5/31/26 at 2:04 PM identified she was responsible for addressing resident reported concerns and obtaining resident statements. The Director of Social Services indicated she was made aware of the resident interaction at some point during morning meeting when it was reported that two residents made Resident #38 feel uncomfortable, so he/she ate in his/her room. The Director of Social Services met with Resident #38 to discuss the interaction. Resident #38 was described as child-like and often changes the subject and did not seem bothered by the interaction. The Director of Social Services did not obtain any statements from the residents involved in the interaction and did not document any follow-up in the clinical record as Resident #38 did not seem upset by the interaction. Interview with the DNS on 5/31/26 at 2:11 PM identified the resident interaction occurred over the weekend and she was not made aware until after reviewing the 72-hour report following the weekend. The DNS indicated she spoke with the nurse, RN # 4, about the resident interaction and was informed Resident #38 wanted to eat in his room following an interaction with other residents adding Resident #38 tends not to elaborate on his/her feelings. The DNS implemented supportive care such as ensuring a staff was in the dining room during meals and a psychiatric referral. The DNS further identified she had an idea who the residents were (Resident #39 and Resident #15) who were alleged to have made fun of Resident #38 based on past known behaviors and interactions with other residents. However, she did not obtain staff or resident statements involved in the interaction and did not implement measures to address how future interactions between the residents were to be managed. Additionally, the DNS identified the three residents ate together at the same table the following meal. The DNS identified the care plans should have been updated to reflect the interaction with interventions to address further interactions between the residents. Interview with NA #3 on 6/1/26 at 6:45 AM identified he was working from 7:00 AM to 3:00 PM on 5/24/26 but could not recall if he was assigned to Resident #38 or assigned to the dining room during the shift. NA #3 indicated a staff are routinely assigned to the dining room during meals and outside of mealtimes when residents are in the room to observe for choking and behaviors, a practice has been in place since he started employment in September 2025. NA #3 further identified Resident #38 routinely ate breakfast in the dining room but preferred to eat lunch in his/her room. NA #3 has never observed any resident making fun of Resident #38 or talking about him/her. However, NA #3 was aware Resident #39 and Resident #15 frequently talk loudly about other residents in a rude and disrespectful manner in the dining room. When this is observed, NA #3 intervenes, separates and reports to the nurse. Observation and interview with Resident #38 on 5/31/26 for breakfast and 6/1/26 through 6/2/26 for breakfast and lunch identified he/she did not join other residents in the dining room for breakfast or lunch indicating a preference instead to eat in his/her room. Interview with NA #4 on 6/01/26 at 10:46 AM identified she was working from 7:00 AM to 3:00 PM on 5/24/26, was not assigned to Resident #38 and could not recall if she was assigned to the dining room during the shift but that one staff member is routinely assigned to observe meals. NA #4 indicated she did not observe any resident-to-resident interaction involving Resident #38 during the shift. NA #4 identified she did observe however, that Resident #38, who normally ate in the dining room for meals at the same table as Resident # 39, was instead eating in his/her room. NA #3 had not observed Resident #38 eating in the dining room since 5/24/26. NA #3 further identified she had observed Resident #39 being rude and disrespectful towards other residents and staff at times. When this occurs, NA #4 redirects, separates and notifies the change nurse. Interview with RN #5 on 6/02/2026 11:16 AM identified she was the assigned nursing supervisor working from 7:00 AM to 3:00 PM on 5/24/26. RN #5 indicated the resident interaction involving Residet #38 was not reported to her. However, she observed two aides (unable to recall who) having a conversation about Resident #38 not wanting to eat in the dining room because residents were mean to him/her. RN #5 observed the aides attempting to encourage Resident #38 back to the dining room while in passing but took no further steps to address the matter as the concern did not appear to rise to the level of mistreatment. Interview with PA #1 on 6/03/26 at 10:15 AM identified she observed Resident #38 in his/her room eating breakfast when he/she would normally eat in the dining room and asked him/her why. Resident #38 would not say but the impression was that the resident was hesitant to disclose why and being protective. PA #1 was notified of the interaction involving Resident #38 after this observation and met with him/her. Resident #38 would not discuss the interaction. PA #1 also met with Resident #15, inquired about the incident and indicated to him/her that a resident feeling as though they were being laughed at may feel hurtful. PA #1 further identified although Resident #38 would not have experienced actual harm from the experience, he/she could feel sad and retreat to avoid further interactions as they can be sensitive at times. PA #1 did not document her inactions with Resident #38 as he was not on her list to be seen on the day of her visit. Although requested, a policy on the grievance process was not provided.

Based on review of the clinical record, facility documentation, facility policies, and interviews for 2 of 3 (Residents #39 and 45) reviewed for abuse, the facility failed to ensure that Resident #39 was free from physical abuse by another resident, and that Resident #45 was free from sexual abuse by another resident. The findings include: 1a. Resident #39 was admitted to the facility in April 2022 with diagnoses that included mild unspecified dementia without behavioral disturbances, adjustment disorder, and mild cognitive impairment of unknown etiology. The annual MDS dated [DATE] identified Resident #39 had intact cognition and had not exhibited physical behaviors directed towards others (e.g. hitting, kicking, pushing, scratching, or abusing others sexually), verbal behaviors directed towards others (threatening, screaming, or cursing), or other behavioral symptoms not directed towards others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, screaming, or disruptive sounds), and was independent with walking 150 feet. The care plan dated 2/24/26 identified Resident #39 was at risk for a behavior problem of accusatory comments related to dementia. Triggers for accusatory behaviors included another resident in the facility with the resident's behavior de-escalated by redirection and separation. The care plan further identified that Resident #39 had impaired cognitive function/dementia or impaired thought processes related to dementia, with interventions that included cueing, reorienting, and supervising as needed. b. Resident #70 was admitted to the facility in September 2025 with diagnoses that included severe dementia with agitation, delirium due to a known physiological condition, and adjustment disorder with mixed anxiety and depressed mood. (Resident #70 no longer resides at the facility). The quarterly MDS dated [DATE] identified Resident #70 had severely impaired cognition, had not exhibited physical behaviors directed towards others, verbal behaviors directed towards others, or other behavioral symptoms not directed towards others, and required setup assistance with wheeling 50 feet with two turns in a manual wheelchair. The care plan dated 1/5/26 identified Resident #70 had impaired cognitive function/dementia or impaired thought processes related to dementia, with interventions that included cueing, reorienting, and supervising as needed. The care plan further identified that Resident #70 had the potential to be physically aggressive related to dementia and poor impulse control, with interventions that included, when resident becomes agitated: intervening before agitation escalates, guiding away from source of distress, engaging calmly in conversation, and analyzing the times of day, places, circumstances, triggers, and what deescalates the behaviors and document. The Reportable Event Form dated 3/11/26 identified that on 3/11/26 at 3:04 PM Resident #39 had an altercation in the recreation room and was struck in the face by another resident. The incident was witnessed by a family member visiting an un-involved resident. The nurse's note dated 3/11/26 at 3:35 PM identified that Resident #39 was in the recreation room during a karaoke program, one witness stated that another resident struck Resident #39 in the mouth. The residents were immediately separated and removed from the recreation room. Resident #39 was assessed for physical injury, and no physical injury or acute distress was identified related to incident. When asking Resident #39 about the events leading up to the incident, Resident #39 stated that Resident #70 was tucking in a blanket of another resident, and when Resident #39 told Resident #70 to leave the other resident alone, Resident #70 stated, don't tell me what to do, and then struck Resident #39 in the mouth. Resident #39 was offered to speak with the Psychiatric PA via telehealth and politely declined stating and indicated he/she was fine. The local Police Department, the physician, and the Administrator were notified; Resident #39 declined to have the resident representative notified as the resident was alert and oriented and able to make informed decisions. The Psychiatric Evaluation and Consultation dated 3/11/26 identified Resident #39 was involved in an altercation involving another resident, who punched him/her. Resident #39 was being protective over another resident, when the resident who punched him/her was trying to adjust a blanket on the other resident, who is often cold. Resident #39 did not want to talk to anyone about the incident The nurse's note dated 3/11/26 at 3:35 PM identified Resident #70 was observed in the recreation room during a group activity, and a witness reported that Resident #70 struck another resident in the face. Staff responded immediately and the residents were separated to prevent further contact. Resident #70 was removed from the area and placed under 1:1 observation for safety, pending a psychiatric evaluation. Resident #70 was assessed, and no acute distress was noted. When asked what occurred, Resident #70 stated, I don't know, I want to go back to karaoke. Resident #70 was informed that he/she was observed striking another resident. Resident #70 responded that the resident told me to punch him/her. Resident #70 was assessed for safety, and when asked if he/she had any intent or plan to harm him/herself or anyone else, Resident #70 denied suicidal or homicidal ideation (SI/HI). Resident #70 was asked permission to participate in a telehealth psychiatric evaluation with the facility's Psychiatric PA; he/she was agreeable. The Psychiatric Evaluation and Consultation dated 3/11/26 identified Resident #70 was seen urgently via telehealth following a resident-to-resident incident. It was reported that Resident #70 told another resident to shut up and when he/she did not, he/she hit him/her in the shoulder. In collaboration with the Nursing Supervisor and Assistant Director of Nursing, it was identified that a family member of a resident saw Resident #39 reprimand Resident #70 telling him/her to stay away from another resident. Once Resident #70 did not listen and continued to move a blanket covering the other resident in a gesture of help, Resident #39 pointed his/her finger and said, leave him/her alone, at which point, Resident #70 punched Resident #39 in the face. No complaints were noted initially from Resident #70. Once Resident #70 was asked about the argument, he/she stated that someone told him/her to hit Resident #39 (whose name he/she was not able to recall). Resident #70 said after he/she did it, he/she was blamed for it, and reported that he/she was tired of these groups playing tricks for fun, always accusing him/her, and he/she was the one getting in trouble all the time. This was a witnessed incident, where it was seen that Resident #70 punched another resident who reprimanded him/her to stop touching another resident. Resident #70 proceeded to fix another resident's blanket when Resident #39 came over and pointed a finger at him/her and told him/her to stop at which point Resident #70 punched Resident #39. Resident #70 had no recollection of the actual incident or who was involved and does not appear to be a harm to him/herself or anyone else. The facility may continue or discontinue monitoring of the patient based on their own policies. No signs and symptoms of SI/HI. Interview with LPN #2 on 6/1/26 at 3:09 PM identified that she was the Charge Nurse on 3/11/26 and could recall the incident between Residents #39 and 70 but did not witness the event. LPN #2 identified that she was working on the medication cart when the Recreation Director came out and notified her that Resident #70 had hit Resident #39; and when she assessed Resident #39, he/she denied pain and there were no marks on his/her skin. LPN #2 indicated that Resident #70 had another resident-to-resident altercation, but she could not recall which incident had occurred first. Interview with Resident #39 on 6/1/26 at 4:26 PM identified that she could recall the 3/11/26 incident very well; Resident #70 was wrapping a blanket around another resident's neck, and the other resident was getting hot, so he/she went over to get the blanket off of the other resident because the room was so hot with the heat turned on, and then Resident #70 closed fist hit him/her in the lip. Resident #39 identified that his/her lip was swollen, but he/she did not want help from any of the facility staff, as he/she dealt with it. Interview with the Recreation Director on 6/1/26 at 4:33 PM identified that Resident #70 had very advanced dementia, and while Resident #70 had gotten into a few verbal altercations with other residents because he/she would try to tell people what to do, but he could not recall hearing of or witnessing any physical altercations, prior to the 3/11/26 incident. The Recreation Director indicated that he was across the room when he heard a commotion, and when he got to the area of the incident, there was still a lot of anger there and Resident #70 had his/her fist in front of Resident #39. The Recreation Director indicated he did not see any physical contact between the 2 residents but did calm them both down and separate them. Interview with the DNS on 6/2/26 at 2:46 PM identified that it was her expectation that residents were free from abuse, and that it was the facility's job to keep residents safe. The DNS identified that following the incident Resident #39 had declined visits from the Psychiatric PA and refused to allow facility nurses complete a thorough assessment of the lip, and once Resident #70 was cleared from 1:1 observation and met with the Psychiatric PA, he/she remained on nursing checks every 15-minutes until he/she was discharged from the facility. 2a. Resident #45 was admitted to the facility in September 2019 with diagnoses that included paranoid schizophrenia and bipolar 2 disorder. The quarterly MDS dated [DATE] identified Resident #45 had severely impaired cognition, had not exhibited physical behaviors directed towards others, verbal behaviors directed towards others or other behavioral symptoms not directed towards others, and was dependent on staff assistance for rolling left to right, sitting to lying, and sitting to standing. The care plan dated 2/23/26 identified Resident #45 had an ADL self-care performance and mobility deficit related to limited mobility, behavioral symptoms, and cognitive impairment, with interventions that included getting Resident #45 out of bed after morning care to wheelchair with pelvic positioning belt and headrest per the 24-hour positioning plan. The care plan further identified that Resident #45 had impaired cognitive function/dementia or impaired thought processes related to diagnosis of dementia, with interventions that included engaging Resident #45 in simple, structured activities that avoid overly demanding tasks. b. Resident #18 was admitted to the facility in September 2025 with diagnoses that included unspecified dementia without behavioral disturbances and major depressive disorder. The quarterly MDS dated [DATE] identified Resident #18 had severely impaired cognition, had not exhibited physical behaviors directed towards others, verbal behaviors directed towards others, or other behavioral symptoms not directed towards others, and required supervision or touching assistance with wheeling 50 feet with two turns in a manual wheelchair and wheeling 150 feet in a manual wheelchair. The care plan dated 1/15/26 identified Resident #18 was an elopement risk/wanderer, had impaired safety awareness, and wanders aimlessly, with interventions that included de-escalating behaviors with redirection and distracting him/her from wandering by offering pleasant diversions, structured activities, food, and conversation. The care plan further identified Resident #18 had impaired cognitive function/dementia or impaired thought processes related to dementia, with interventions that included cueing, reorienting, and supervising, as needed. The Reportable Event Form dated 3/13/26 identified that on 3/13/26 at 2:45 PM, Resident #18 was observed inappropriately touching another resident, in the Wing 2 hallway. The nurse's note dated 3/13/26 at 4:33 PM identified that the nursing staff reported an observation of Resident #18 inappropriately touching another resident. Resident #18 was immediately removed from the area and put on 1:1 supervision, pending a psychiatric telehealth visit. Resident #18 was alert and confused. Resident #18 was unable to recall the details of the incident and was cooperative with staff. The Administrator, physician, and the responsible party were notified; behavioral monitoring remains in place, and staff were aware of increased supervision in common areas. The nurse's note dated 3/13/26 at 4:35 PM identified that nursing staff reported an observation of another resident inappropriately touching Resident #45 in the hallway, which was witnessed by the Charge Nurse, on the unit. Both residents were immediately separated, and a physical assessment was completed, with no injury. Resident #45 denied pain/discomfort, no facial grimacing or guarding present was present. Resident #45 was unable to recall details of the incident. The Administrator, physician, and responsible party were notified. Psychiatric consult was placed for follow-up; increased supervision in common areas was implemented by nursing staff and a report was filed with the state agency, per protocol. The Psychiatric Evaluation and Consultation dated 3/13/26 identified, in part, that Resident #18 was seen urgently via telehealth after a video captured him/her groping another resident seated in a wheelchair. Resident #18 was seen in his/her room and was cooperative with answering questions, but was at times sarcastic and dismissive, with no recollection of touching another resident. Once asked about inappropriately touching someone, Resident #18 became angry and denied doing such a thing and stated that he/she would never do that to anyone. Of note, as reported in previous psychiatric notes, Resident #18 had been inappropriate at times with staff and other residents. Each time due to his/her dementia, he/she forgets. Resident #18 has no recollection of the incident or who was involved; we have increased his/her medication with the hopes of mitigating his/her over sexualized energy. Resident #18 did not appear to a harm to him/herself or others. The facility may continue or discontinue monitoring of Resident #18 based on their own policies. We may consider an antipsychotic medication for this repeated behavior. Interview with the Charge Nurse (LPN #3) on 6/1/26 at 3:22 PM identified that Resident #18 had been known to have inappropriate language on occasion, like inviting people to sit on his/her lap, but she had never observed nor was she aware of any prior incidents of inappropriate touching or other any other type of sexual behaviors directed toward staff or other residents. LPN #3 indicated that Resident #18 was able to self-propel in his/her wheelchair, and that on 3/13/26 she had stepped away from the nurse's station for no more than 5 minutes; when she returned she observed Resident #18 wheelchair close to Resident #45's wheelchair, and Resident #18 was fondling Resident #45's left breast with his/her right hand. LPN #3 indicated that while Resident #45 was awake during the incident, he/she did not appear to be having a reaction one way or another; LPN #3 separated Resident #18 and #45 and reported the incident immediately to the DNS. Interview with the Nursing Supervisor (RN #3) on 6/1/26 at 4:22 PM identified that she did not observe the incident that took place on 3/13/26 between Residents #18 and 45, but she was with Resident #18 during the telehealth visit with the Psychiatric APRN following the incident, and that during the telehealth visit, Resident #18 could not recall the event. Interview with the DNS on 6/2/26 at 2:46 PM identified that it was her expectation that residents were free from abuse, and that it was their job to keep residents safe. The DNS further identified that they do have a large dementia population at the facility, and following the 2 reportable events that were close together (3/11/26 and 3/13/26), the facility invited Supportive Care Services to provide staff reeducation on how to manage dementia related behaviors. The DNS further indicated that Supportive Care has been invited to provide additional in-services to the facility staff related to managing care for dementia residents. The DNS identified that Resident #18 remained on nursing checks every 15-minutes and that he/she was care planned to have supervision while in common areas and to be redirected if he/she was in close proximity to Resident #45 or any other vulnerable residents. The facility's Resident Rights policy directs the facility to follow and adhere to the Resident [NAME] of Rights. The [NAME] of Rights is given to staff, residents, and families to ensure compliance. At a minimum, federal law specifies that nursing homes must protect and promote the rights of each resident. Residents have the right to be free from abuse and neglect, including verbal, sexual physical, and mental abuse. The facility's Abuse and Neglect policy directs that residents have the right to be free from abuse, corporal punishment, involuntary seclusion, and psychosocial harm. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The types of abuse include verbal abuse, sexual abuse, physical abuse, mental abuse, and voluntary seclusion, and psychosocial harm.

Based on review of the clinical record, facility documentation, facility policies, and interviews for 1 of 5 residents (Resident #8) reviewed for accidents, the facility failed to ensure an RN assessment was completed after the resident fell out of the wheelchair after a hoyer lift transfer and sustained a fracture; and for 1 of 4 residents (Resident #57) reviewed for hospitalization, the facility failed to ensure ongoing neurological assessments were completed for a resident with a suspected head injury. The findings include: 1. Resident #8 was admitted to the facility in August 2018 with diagnoses that included Parkinson's Disease without dyskinesia, COPD, bipolar disorder, obesity, and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #8 had intact cognition and required supervision or touching assistance with sitting to standing and chair/bed-to-chair transfers. The care plan dated 2/14/25 identified Resident #8 was at risk for falls related to weakness at times, the use of antidepressants, and other risk factors including osteoporosis and Parkinson's Disease, with interventions that included ensuring the resident's needs were evaluated and supplied, (appropriate adaptive equipment or devices, as needed) and on-going reevaluation as needed for continued appropriateness to ensure the least restrictive device. A physician's order dated 3/24/25 directed to transfer the resident via a hoyer lift with the assistance of 2 staff. A Reportable Event Form dated 3/25/25 identified that on 3/25/25 at 11:00 AM, Resident #8 slipped out of the wheelchair into a sitting position on the floor after transfer. No injury was noted; Resident #8 denied pain/discomfort. The nurse's notes dated 3/25/25 through 3/27/25 failed to reflect information about the fall on 3/25/25 and failed to reflect that an RN assessment had been completed at the time of the fall. The hospital Discharge summary dated [DATE] identified that Resident #8 had a past medical history significant for atrial fibrillation, chronic hypoxic respiratory failure, morbid obesity, and he/she was bed bound at baseline, requiring a hoyer lift. Resident #8 was admitted on [DATE] after presenting for an acute onset of back pain. Four days prior to hospital admission, Resident #8 had been dropped from a hoyer lift. A CT scan of the Lumbar spine showed an acute L5 endplate fracture, also possibly at S1(sacrum). No other acute findings were noted on workup, and he/she was admitted for treatment of intractable lower back pain. Resident #8 continued to report pain worse than his/her baseline but was better controlled, anticipating this will continue to improve, Resident #8's pain medication could be gradually weaned back down to his/her home regimen. Resident #8 was discharged in stable condition on 3/30/25 back to the facility. The nurse's note dated 3/30/25 at 7:17 PM identified that Resident #8 was re-admitted to facility from the hospital at 5:28 PM. Resident #8 had been admitted to hospital on [DATE] for intractable low back pain and was discharged with the following diagnosis: closed compression fracture of L5 lumbar vertebra and a closed fracture of an unspecified portion of the scrum. Per discharge paperwork, a CT scan of the Lumbar spine performed at the hospital showed an acute L5 endplate fracture, also possible S1, no other acute findings were noted at the hospital. Medications were reviewed with the on-call provider; continue to monitor per care plan and report any issues or concerns to physician/APRN. Interview with the DNS on 6/1/26 at 9:18 AM identified that based on the facility's investigation, (including video footage that was no longer available for review) it was identified that on 3/25/25, 2 nurse aides (NA #1 and NA #2) had transferred Resident #8 out of bed via the hoyer lift into a wheelchair. Resident #8 was seated in the chair and the hoyer was snagged under the wheelchair so one the nurse aides, in an attempt to remove the hoyer lift from under the wheelchair jerked the lift, causing the wheelchair to pull out from under Resident #8, who then fell from the chair to the floor. Review of the clinical record with the DNS on 6/1/26 at 4:49 PM failed to identify that an RN assessment had been completed after Resident #8 fell out the wheelchair after the hoyer lift transfer on 3/25/25. Interview with the DNS on 6/1/26 at 4:49 PM identified that she was the Nursing Supervisor at the time of the incident on 3/25/25 and that she was upstairs during morning report, and while she could not recall all of the details of the event, she remembered coming downstairs and Resident #8 had already been hoyered back up by the nurse aides and therapy. The DNS indicated that Resident #8 had recently been hospitalized for a medical condition but was working with the Psychiatric PA due to a history of bi-polar, and was also coming out of a manic phase. The DNS indicated it was hard to identify if Resident #8 was screaming in pain or was screaming due to his/her psychiatric state, fear, or anxiety. The DNS identified that she could not recall if she had assessed Resident #8 because the event took place in March of 2025, but she should have completed and documented her assessment in the clinical record, and she would expect additional nursing assessments to be have been completed every shift for 72 hours, or case by case if a resident required more monitoring. Interview with the Medical APRN (APRN #1) on 6/2/26 at 10:01 AM identified that she was not the medical provider servicing the facility, at the time of the incident, and she could not attest to any details of the incident but following a witnessed fall not involving a head strike she would expect nursing assessments and vital signs to be completed every shift for 72-hours. APRN #1 indicated that immediately following a fall an RN assessment should be completed to look for pain, deformities, and head injuries; the medical provider should be notified of the fall and any assessment findings, as they may choose to order diagnostics. Interview with Resident #8 on 6/2/26 at 2:16 PM identified that on 3/25/25, he/she was being transferred on the hoyer lift and the kid (NA #2) pushed a board thing and he/she took a long fall to the floor, hitting his/her coccyx area and fracturing 3 bones in that area. Resident #8 indicated that he/she knew right away that something had broken because he/she was in a lot of pain. Resident #8 indicated that the facility staff wanted him/her to go to the hospital, but he/she refused initially, but knew a few days later that he/she had to go. Although attempted, an interview with the Charge Nurse (LPN #4) who worked on 3/25/25 during the 7:00 AM - 3:00 PM shift was not obtained. The Assessment of Acutely Ill Resident policy directs that any resident who presents with a change in condition will be assessed according to their presenting problem, symptom, or complaint. Only physicians and licensed personnel will assess residents. The nursing supervisor will be informed of all changes in condition of residents regardless of the assessment findings. Documentation of abnormal findings should be noted in the clinical record. The physician will be notified of any resident who is in distress and be informed of the assessment findings. The Accident and Injury policy directs any accident or injury found will be immediately reported to the charge nurse or supervisor, nursing staff will thoroughly and promptly complete the accident and injury report to properly follow up the nurse shall complete the following: identify the accident and injury, update the resident care plan with appropriate interventions, create new orders for treatment, open and complete relevant evaluations, collect witness statements, fill out proper consultations, create a progress note, and complete the accident and injury packet and submit to the a DNS or DNS. Depending on accident and injury, a reportable event may be needed. In which case the director of nursing shall be contacted immediately. 2. Resident #57 was admitted to the facility in June 2025 with diagnoses that included a history of cellulitis of the lower limb and schizophrenia. Resident #57 was self-responsible. The quarterly MDS dated [DATE] identified Resident #57 was cognitively intact, independent with bed mobility, transfers and was mobile with the assistance of a motorized wheelchair. The care plan dated 4/3/26 identified Resident #57 had a diagnosis of schizophrenia and accusatory behaviors. Interventions included administration and monitoring medications, and discussing the inappropriateness of behavior and what is acceptable. Nurse's note dated 4/28/26 at 7:08 PM completed by RN #3 identified Resident #57 was out on a leave of absence (LOA) from the facility earlier in the day and contacted the facility on the way back to report he/she had hit his/her head when getting lifted into the van and requested a hospital transfer for further evaluation. The APRN was notified and orders were obtained to transfer Resident #57 if preferred. Upon return from the facility, Resident #57 subsequently refused the hospital transfer reporting he/she was ok. Vital signs were stable with no complaints of headaches for the remainder of the shift. Nurse's note dated 4/30/26 at 7:18 PM completed by RN #3 identified Resident #57 refused his/her shower reporting he/she was going to call 911 due to pain that had not subsided (no documentation from what site). Resident #57 was reminded he/she could have gone to the hospital on 4/28/26 when the original incident occurred but that he/she decided not to but that he/she could go now if that was what was preferred. Nurse's notes dated 4/28/26 through 4/29/26 did not include an initial or ongoing neurological assessment following the reported head injury. Nurses note dated 5/1/26 at 2:13 PM identified Resident #57 reported hitting his/her head on 4/29/26 while navigating his/her wheelchair onto the van. Resident #57 initially requested to go to the hospital and then refused and subsequently earlier in the day and then refused. Resident #57 was calling 911 requesting an ambulance to be transferred. There were no signs of injury to the forehead and Resident #57 was alert/oriented at baseline with delusional behaviors that were not increased from baseline. Resident #57 also had swelling to the left lower extremity with noted erythema (redness) and was warm and tender to touch. EMS was provided with a detailed history and the APRN was notified of the transfer. Situation, Background, Assessment, Recommendation (SBAR) Communication Form and progress note dated 5/1/26 identified Resident #57 independently went out and reported hitting his/her head when being picked up. Resident #57 was offered a hospital transfer on two previous occasions but refused. Resident #57 called 911 despite being offered hospital transfer. Resident #57 was paranoid and accusatory at times and recently deemed independent by probate court following conservatorship. Resident #57 was assessed as having worsening behavioral symptoms and was being transferred to the hospital for further evaluation. Hospital Discharge summary dated [DATE] identified Resident #57 was admitted for questionable cellulitis of the left lower extremity and head injury following two self-reported episodes of head trauma, the most recent while operating his/her motorized wheelchair. A CT scan of the head identified no acute intercranial abnormalities. Resident #57 was discharged with antibiotics for treatment of a left lower leg cellulitis and recommendations to resume diuretics. Interview with the DNS on 6/1/26 at 1:55 PM identified neurological assessments should be conducted with every suspected head injury according to policy. The DNS further identified no accident and incident report was located related to the incident. Interview with RN #3 on 6/1/26 at 3:05 PM identified she was the assigned nursing supervisor on 4/28/26 and 4/30/26 when Resident #57 reported a head injury. RN #3 indicated for any suspected head injury, a neurological assessment form is completed for neurological checks to be completed consecutively at specified intervals for forty-eight hours. RN #3 further identified she could not recall if she initiated neurological checks when Resident #57 reported a suspected head injury but would have documented if she had. RN #3 further identified she did not complete ongoing neurological assessments following reports of a suspected head injury. Review of the facility policy for Head Injury directed for a suspected head injury, vital signs will be taken immediately upon assessment and until stable. Neurological checks will be assessed consecutively as follows: Every 15 minutes for 1 hour. Every 30 minutes for 2 hours. Every 2 hours for 8 hours. Every 4 hours for 16 hours. Every 8 hours/every shift for 48 hours. An accident and incident report must be completed in its entirety, documented in the clinical record with recorded vital signs and neurological signs on the Neuro/Vital Signs sheet of the next 48 hours.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure that a qualified IP was in place for multiple months in 2025 and failed to ensure that the facility IP had education and training on current infection prevention standards. The findings include: Interview with RN #1 (the facility's current IP) on 6/1/26 at 8:27 AM identified he assumed the role at the beginning of 9/2025. RN #1 further identified while he had functioned as an IP in the past, he had not worked in any direct care setting for several years. RN #1 identified he worked as the facility IP from 2014 - 2017 and then became the DNS from 2017 until 9/2020 when he left. RN #1 identified while he was the DNS in 2020, the Covid pandemic began. RN #1 further identified after leaving the facility in 9/2020, he rarely worked as an RN in any direct care setting. RN #1 also identified that he had not had any training or education on infection prevention protocols and standards since he completed his IP certification in 2016, prior to assuming the role of the IP in 9/2025, or any time after. Further review of current infection prevention standards in long term care facilities with RN #1 identified he was not aware of any infection prevention standards related to Legionella, including if the facility had a mitigation plan in place, or the IP role if Legionella was identified within the facility's water system. RN #1 identified that the maintenance department addressed any issues with the building's water system and he was not involved in any monitoring or tracking of legionella mitigation strategies for the facility. Interview with the DNS on 6/1/26 at 12:00 PM identified that there had been multiple IPs in place from 2024 until 9/2025 when RN #1 filled the position. The DNS identified she was aware that RN #1 did not have any recent IP education. The DNS also identified that she had identified issues with RN #1's lack of standardized infection surveillance for antibiotic use for residents but that the issues had not been addressed. Subsequent to surveyor inquiry, the facility identified the following regarding IP coverage prior to RN #1's employment:DNS #2 provided coverage of the IP program from 11/13/24-1/5/25 and had an IP certification. During this time the facility did not have a designated IP.LPN #5 was the designated IP from 1/6/25 - 2/4/25. LPN #5 had no specialized IP training or IP certification prior to or during her employment at the facility.DNS #2 provided coverage of the IP program from 2/5/25 - 2/16/25. During this time the facility did not have a designated IP.RN #6 was the designated IP from 2/17/25 - 5/22/25. RN #6 had no specialized IP training or IP certification prior to her employment at the facility. RN #6 obtained IP certification on 5/12/25. DNS #1 provided coverage of the IP program from 5/22/25 - 8/25/25. The facility failed to provide any documentation that DNS #1 had any specialized IP training or certification. During this time the facility did not have a designated IP.RN #1 was the designated IP beginning 8/25/25. Review of RN #1's resume identified he had not had any education or training related to infection prevention since 2016. Interview with the Administrator and DNS on 6/3/26 at 9:29 AM identified that the Administrator was responsible for contracting RN #1 to work at the facility, and identified he was not aware that RN #1 did not have any recent education as an IP or in current infection prevention standards for long term care facilities. The Administrator also identified that he contracted RN #1 as the IP due to multiple issues with hiring and retaining a designated IP for the facility. The facility job description for the infection preventionist nurse directed that the primary function of the nurse was to be responsible for the day-to-day operation of a surveillance program under the direction of the infection control committee to maintain a safe environment for our facility personnel and residents. The policy also directed that the duties of the infection preventionist nurse included maintaining a working knowledge of and enforcing all infection control policies and procedures and maintaining compliance with all state and federal regulatory requirements.The facility policy on the infection prevention and control program (IPCP) directed that the IPCP was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy further directed that coordination and oversight of the IPCP would be overseen by an infection prevention specialist, and the qualifications and responsibilities of the infection prevention specialist were outlined in the infection preventionist job description.

Based on observation, review of facility policy and interview, the facility failed to ensure that resident medical records systematically organized and were stored in a manner to safeguard against loss, destruction, and unauthorized use. The findings include: During a tour of the basement storage area with the Administrator and Maintenance Director on 6/1/26 at 2:31 PM over 20 banker sized boxes containing multiple resident records including financial information, resident face sheets and census data, as well as progress notes and other confidential information were identified. Multiple off white file folders (over 100 file folders) containing resident medical records located in multiple areas throughout room were observed. Additionally, multiple stacks, without file folders or boxes, of resident medical records were observed directly on the floor, as well as spread out random single face sheets of multiple residents. Observation of a metal file storage area in right corner area of the room visible upon entrance identified 6 large 5 drawer metal file cabinets. The bottom drawer of one of the cabinets was observed pulled fully open with multiple off white file folders (25 file folders) containing resident medical records. Observation of the room identified that the entrance of the room to the basement from inside the building was secured by a padlock, however an additional door outside the building and located along the left wall of the room appeared to have a round doorknob with built in turn style lock. The door also was observed to have multiple bags of dry concrete mix packed against the bottom, which the Administrator identified were place due to a gap between the base of the door and the frame of the door. Observation also identified multiple vertical single paned windows, approximately 1 foot in length, 2 feet in height, and positioned approximately 2 feet from the floor, along the left side of the basement wall with curtains placed. The windows did not appear to be tempered or have additional locking mechanisms in place. Further observation identified that 3 of the windows were completely exposed with no curtains or shielding of view allowing direct viewing of the room and its contents from outside the building, which was located a gravel driveway and parking area. Interview with the Administrator immediately following these observations identified that he had been attempting to organize the medical records since the Covid pandemic, but due to other issues he had to address including a facility renovation and other issues, he had not had time to address the records. The Administrator also identified that since the interior access door had a padlock on it, he felt the area was secured. The Administrator identified that the 3 open windows would allow viewing of the room from outside, and he would have the Maintenance Director place curtains to block viewing into the room. The facility policy on medical records directed that the purpose of the policy was to establish guidelines for the creation, maintenance, use, disclosure, and retention of medical records in accordance with federal and Connecticut State regulations, to ensure confidentiality, accuracy, and timely access to health information for residents. The policy further directed that a complete and accurate medical record would be maintained for each resident and that records would be confidential, securely stored, and accessible only to authorized personnel. The policy also directed that records would be maintained for seven years after discharging death and that destruction of records must be in a manner for protected health information which included shredding or certified disposal of records.

Based on a review of clinical records, facility documentation, policy, and staff interviews for one of three sampled residents (Resident #1) who was dependent on staff for transfers and toileting, the facility failed to ensure the nurse aide care card was updated to reflect the resident's current non-ambulatory status. This lapse resulted in a fall with significant injury to Resident #1, who was then treated for a traumatic subarachnoid hemorrhage (internal bleeding into the space between the brain and the membranes that cover it), a right femoral neck fracture (broken thigh bone that required surgery), and a right distal clavicle fracture.The findings include:Resident #1's diagnoses included unsteadiness on feet, polyneuropathy, atrial fibrillation, and cognitive communication deficit. The physician's order dated 5/28/25 directed Resident #1 to ambulate with rehabilitation staff only. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating Resident #1 had some memory recall deficits, required maximum assistance of one (1) for transfers and toileting, moderate assistance of one (1) for bed mobility, and was non-ambulatory. A physician's order dated 8/29/25 identified Resident #1 was not functionally ambulatory. The Resident Care Plan dated 8/29/25 identified Resident #1 had a self-care deficit and was at risk for falls. Interventions directed to assist the resident with daily living skills, keep the call bell within the resident's reach, and provide the assistance of one (1) for transfers. Upon further review, the care plan failed to identify Resident #1's ambulation status. The social service note dated 9/11/25 at 3:05 PM identified a care plan meeting was held with Resident #1's spouse. The note indicated Resident #1 was not receiving therapy at this time and had recently been discharged at the beginning of the month. The note identified Resident #1 was not functionally ambulatory and utilized a wheelchair for mobility. The undated nurse aide care card that was in place on 9/12/25 identified assistive devices Resident #1 used, a walker and wheelchair and had required assistance of one (1) for transfers. The care card failed to identify Resident #1's ambulation status or that Resident #1 was non-ambulatory. The nurse's note dated 9/12/25 at 8:11 PM identified the 3-11PM nursing supervisor, Registered Nurse (RN) #1, was called to Resident #1's room at 10:00 PM. The note identified a nurse aide, Nurse Aide (NA) #1, was transferring Resident #1 and Resident #1 lost his/her balance and fell forward. The note indicated Resident #1 was laying on his/her right side with his/her right arm extended underneath his/her head and blood was noted, Emergency Medical Services (EMS) was called, and Resident #1 was transferred to the hospital. In a written statement dated 9/12/25 NA #1, who had been assigned as Resident #1's caregiver identified Resident #1 was in front of him with the walker ambulating to the bathroom, as they passed by the bathroom door Resident #1 reached over to turn on the lights, putting his/her weight on the walker causing the walker to topple over. The Emergency Department note dated 9/13/25 identified Resident #1 was ambulating to the bathroom with a caregiver behind him/her when Resident #1 fell forward striking his/her head on the ground. The hospital discharge paperwork dated 9/17/25 identified Resident #1 was diagnosed and treated for a traumatic subarachnoid hemorrhage, right femoral neck fracture and right distal clavicle fracture. The nurse's note dated 9/17/25 at 8:59 PM identified Resident #1 returned to the facility. The note indicated Resident #1 had surgery on the right hip on 9/15/25 and a mediplex dressing was in place and to remain on the surgical site until follow-up on 9/29/25 with the orthopedic surgeon. The facility summary report dated 9/18/25 identified it was determined Resident #1 had been recently made non-ambulatory by physical therapy (PT) and the care card was not updated to reflect the change. Interview with the Physical Therapist (PT) #1 on 9/26/25 at 12:20 PM identified she had treated Resident #1 for therapy services at which time Resident #1's ambulation status was to ambulate with therapy staff only and Resident #1 was discharged from physical therapy services on 8/29/25. PT #1 explained at the time of discharge Resident #1 required assistance from one (1) staff member for transfers and was non-ambulatory. PT #1 identified on 8/29/25 she entered a status change to not functionally ambulatory into the physician orders and communicated the change with the nursing staff. PT #1 identified due to Resident #1 suffering a subdural hematoma and subsequent deconditioning, Resident #1's status has deteriorated since the fall and now requires a Hoyer lift for transfers and staff support for sitting. Interview with the Director of Nursing (DON) on 9/26/25 at 1:00 PM identified once a resident's ambulation status was on the physician's orders, the nurse was responsible to update the nurse aide care card. The DON stated the nurse aide care card for Resident #1 failed to identify Resident #1's ambulation status prior to, and after the change on 8/29/25 and only identified Resident #1 having a wheelchair and walker for adaptive equipment, the care card section for ambulation was left blank. The DON identified in her interview with NA #1 he identified when he entered Resident #1's room he saw both the wheelchair and walker and therefore assisted Resident #1 out of bed utilizing the walker to ambulate to the bathroom and NA #1 reported Resident #1 was in front of him and he did not use a gait belt. Attempts to interview RN #1 and NA #1 were unsuccessful. Review of the Resident Transfer and Ambulation Policy directed that care plans must reflect the resident's current functional status transfer method, and ambulation ability. The policy further identified that a gait belt was to be utilized unless contraindicated.

Based on clinical record reviews, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #2) who was transferred to the hospital, the facility failed to provide the resident and responsible party with the correct transfer and discharge documents and readmit the resident when the resident was ready for discharge from the hospital. The findings include:Based on clinical record reviews, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #2) who was transferred to the hospital, the facility failed to provide the resident and responsible party with the correct transfer and discharge documents and readmit the resident when the resident was ready for discharge from the hospital. The findings include: Resident #2's diagnoses included dementia, anxiety, and a history of alcohol abuse. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily living. The Resident Care Plan dated 6/28/25 identified Resident #2 as a long-term resident at the facility. Interventions aimed at encouraging family participation, to encourage the resident to participate in activities, inform the family of any changes, and social services to provide one (1) to one (1) support as needed. The nurse's note dated 8/31/25 at 8:41 PM identified Resident #2 had eloped from the facility and was found by the police walking along the road, although Resident #2 appeared unharmed, Resident #2 was sent to the hospital to be evaluated and treated and Resident #2's conservator was updated. Review of the clinical record failed to identify a bed hold notice was issued to Resident #2 and/or the conservator. Review of the clinical record failed to identify that a discharge summary was completed for Resident #2. The discharge notice given to Resident #2 identified the notice was dated 9/19/25 and Resident #2 had been discharged on 9/1/25. Interview with the hospital Social Worker (Person #2) on 9/26/25 at 2:58 PM identified she received written documentation from the Resident #2's Conservator (Person #3) regarding the meeting he/she had with the facility on 9/8/25 to discuss a safe discharge plan for Resident #2. Person #2 indicated he/she received a copy of the letter Person #3 received from the facility on 9/10/25 which indicated the facility's refusal to take Resident #2 back. Person #2 identified Resident #2 remained in the hospital under observation because they had not found placement for Resident #2. Interview with an Ombudsman from the Long-Term Care Ombudsman Program (Person #1) on 9/29/25 at 10:30 AM identified she had multiple conversations with the administrator at the facility regarding the discharge process. Person #1 identified she informed the administrator he needed to initiate a consultative process and then follow the involuntary discharge process if the facility still determined they wanted to discharge Resident #2. Person #1 explained she informed the administrator they would have to take Resident #2 back to the facility while the Conservator filed an appeal and wait for the appeal hearing. Person #1 stated training was offered to all nursing homes regarding changes to the discharge process, with the new process a discharge notice needed to be issued to a resident, conservator and filed with Person #1 the same day of discharge, and the facility failed to do this. Person #1 stated discharges cannot be back dated, he/she explained this to the administrator, and sent an email with this information to the administrator on 9/16/25. Person #1 identified as of 9/29/25 Resident #2 remains in the hospital on observation status, and the facility has continued to refuse to take Resident #2 back despite education on the regulations. Interview with Person #3 on 9/29/25 at 1:45 PM identified when Resident #2 initially eloped from the facility he/she was told Resident #2 climbed out of a window but was not given all the information leading up to the event. Person #3 explained he/she was initially concerned about Resident #2 returning to the facility and wanted Resident #2 evaluated at the hospital and after learning the details surrounding the reasons Resident #2 eloped, Person #3 felt it was in the best interest for Resident #2's safety and well-being for him/her to return to the facility and Person #3 met with facility staff the beginning of the week following the elopement. Person #3 explained he/she was unable to recall anyone saying Resident #2 was discharged and would need to apply for a readmission. Person #3 identified he/she had conversations with the facility staff regarding safety measurements and was ready to pay for one (1) to one (1) staff while establishing a safe plan. Person #3 stated he/she received a letter from the facility on 9/10/25 indicating they would not allow Resident #2 to return to the facility, so he/she has filed an appeal on behalf of Resident #2 to allow Resident #2 to return to the facility. Person #3 identified although a bed hold was not issued, Resident #2's bed was still open, and Resident #2's belongings were still at the facility. Person #3 indicated he/she did not sign discharge paperwork. Interview with the administrator on 9/29/25 at 2:00 PM identified the facility received communication in the hospital portal system dated 9/1/25 which indicated Resident #2's conservator did not want Resident #2 to return to the facility, therefore, the facility did not issue a bed hold notice. The administrator identified Person #3 later requested to allow Resident #2 to return to the facility, so Person #3 met with the facility on 9/8/25 and discussed various options to help keep Resident #2 safe. The administrator explained a follow-up meeting was scheduled for 9/10/25 to finalize the return, the facility held a meeting with other staff members, and they determined they would not be able to keep Resident #2 safe. The administrator explained he issued a discharge notice to Resident #2 and Person #3 on 9/19/25 with a discharge date of 9/1/25. The administrator identified he had spoken to Person #1 regarding the discharge and filed the discharge notice with Resident #2, Person #3, and Person #1's office only after learning that he should have filed the discharge notice on 9/1/25. The administrator acknowledged Person #1 sent him the regulations and a slide presentation on 9/16/25 outlining the discharge process and the facility's responsibility regarding discharge. The administrator identified he has not requested a consultative process meeting with the hospital and has continued to refuse to allow Resident #2 to return to the facility while in the appeal process. The administrator indicated he has received notice of a hearing regarding the appeal of discharge filed by the conservator on behalf of the resident. Review of the Resident Rights Policy identified the resident had the right to appeal a transfer or discharge to the state and the facility must safely and orderly transfer or discharge the resident and give the resident proper notice of bed-hold and/or readmission requirements.Review of the Bed Hold Policy identified upon transfer to a hospital the notice will be given to the resident and the facility will send the notice to the hospital with the resident. Documentation will be noted in the medical record that the [NAME] was sent with the resident. A notice will also be sent to the party responsible as soon as possible. The policy further identified the facility will contact the hospital on the day the resident is admitted and ask the hospital if, and when the resident is expected to return to the facility. Documentation from that contact will be maintained in the medical record. If the resident is hospitalized for more than seven (7) days, the facility will repeat the above process and document it. For private pay residents the facility must reserve the bed if payment is available.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Resident #8 and #4) who were identified to be at risk for elopement, the facility failed to develop a care plan and implement interventions when it was identified that Resident #8 was at risk for elopement and failed to implement their Elopement policy when the resident was discovered missing. The failures resulted in the finding of Immediate Jeopardy. For Resident #4 who was at risk of elopement, the facility failed to ensure a Wanderguard alarmed door was shut and latched completely to prevent the resident from exiting out the door and into the parking lot, subsequently falling and sustaining injuries. For one (1) of three (3) sampled residents (Resident #5) who were dependent on staff for transfers, the facility failed to ensure the resident was transferred by two (2) person assistance via a mechanical lift per the physician's order to prevent a fracture. The findings include:: 1.Resident #8's diagnoses included dementia without behavioral disturbances, adjustment disorder with mixed anxiety and depressed mood, history of alcohol abuse, restlessness and agitation. The Wandering Risk Scale dated 6/9/25 identified Resident #8 was at risk for wandering. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) indicative of severe impaired cognition and was independent with transfers and ambulating. The Resident Care Plan (RCP) dated 6/26/25 identified that Resident #8 had impaired cognitive function and impaired thought processes due to dementia. Interventions directed to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion and monitor, document and report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness and difficulty expressing self. Review of the clinical record failed to identify a care plan was developed and interventions were put into place when Resident #8 was identified to be at risk for wandering on 6/9/25. Review of the nurse's note dated 8/31/25 at 8:41 PM, written by the Director of Nursing (DON), identified just after 8:00 PM she received a call from the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, staff were unable to find Resident #8 in the facility. The supervisor identified staff were searching for Resident #8 and found the window and screen in Resident #8's bedroom open. The DON instructed the supervisor to call the police, and all available staff were notified to aid in the search. The note identified a call was received at 11:33 PM that a neighboring town police department found Resident #8 walking along a road, Resident #8 was noted to be alert and stated that he/she was just going for a walk. The note indicated Resident #8 was in the presence police officers and Emergency Medical Services (EMS) when the DON and Administrator arrived on scene and although Resident #8 appeared to be unharmed, Resident #8 was sent to the hospital for evaluation, and the conservator was updated. The police report dated 8/31/25 identified that at 8:42 PM the police were dispatched to the facility for reports of a missing person and upon arrival they spoke with the nursing supervisor, RN #1, who stated Resident #8 walked away from the facility. RN #1 reported Resident #8 was last seen by staff at around 7:00 PM (1 hour and 42 minutes prior) in his/her room and when Resident #8's room was checked, the window was noted to be open. Interview with the charge nurse, Licensed Practical Nurse (LPN) #1, on 9/3/25 at 3:05 PM identified on 8/31/25 she checked on Resident #8 at the start of the 3-11PM shift and interacted with Resident #8 around 4:30 PM when she administered medications to him/her. LPN #1 identified at around 6:50 PM she went to check on Resident #8 again and was unable to locate Resident #8 in his/her room or the common areas. LPN #1 stated she asked a nurse aide, Nurse Aide (NA) #2, and other co-workers if they had seen Resident #8 and they reported they had not, so they all did a quick interior search of the building and were unable to locate Resident #8. LPN #1 indicated she and NA #2 notified the nursing supervisor, RN #1, at 7:00 PM Resident #8 was unable to be located. LPN #1 identified after notifying RN #1, a missing person's code was never called, and the police did not arrive at the facility until after 8:00 PM. Interview with RN #1 on 9/3/25 at 1:25 PM identified on 8/31/25 it was very busy and could not recall if LPN #1 or NA #2 had reported to her around 7:00 PM they were unable to locate Resident #8 and thought it was more around 8:25 PM. RN #1 said she checked the recreation room, therapy room and the exterior of the building, but was unable to locate Resident #8. RN #1 identified when she checked Resident #8's room she saw the window was open and the screen was pushed up. RN #1 identified she then called the DON at 8:41 PM (over 1.5 hours after it was identified Resident #8 was missing and sixteen (16) minutes after she started searching) and was directed by the DON to call the police. RN #1 reported she did not call an elopement code because she thought everyone was aware Resident #8 was missing. RN #1 did not call the DON or police immediately because she was unsure of what to do and wanted to first look for Resident #8 herself. RN #1 identified although she was uncertain of what time she was originally notified Resident #8 was missing, she should have called the police and then the DON immediately. Interviews with LPN #2, NA #2, NA #3 and NA #4 on 9/3/25 identified they were made aware Resident #8 could not be located between 7:00 and 7:30 PM and identified although they saw RN #1 looking for Resident #8, a missing person code was never called. Interview with the DON on 9/3/25 at 1:58 PM identified Resident #8 was not exhibiting exit seeking behaviors or voiced the desire to leave prior to 8/31/25. The DON identified on 8/31/25, RN #1 first called her at 8:41 PM reporting they could not find Resident #8 and RN #1 identified she had not called the police, so she directed RN #1 to do so. The DON identified she received a call at approximately 11:33 PM reporting Resident #8 had been found in a nearby town at a business 4.4 miles away (a very dangerous busy road with no sidewalks and at times is a 4-lane highway). The DON identified Resident #8 had no obvious injuries but was transferred to the Emergency Department (ED) for an evaluation, where he/she remained as of 9/3/25. The DON explained through her investigation it was identified Resident #8 was noted to be missing at 7:00 PM, but RN #1 did not call the police and did not contact her until 8:41 PM (1 hour and 41 minutes later). Re-interview with the DON on 9/4/25 at 8:50 AM identified although the Wandering Risk Scale dated 6/9/25 identified Resident #8 was at risk for elopement, Resident #8 did not utilize a wanderguard, and had no history of exit seeking or wandering behaviors that she was aware of. The DON identified that for any resident at risk for elopement, a care plan should be developed with interventions to prevent elopement and identified a care plan was not initiated for Resident #8. Review of the Wanderguard policy (undated) directed, in part, that all residents are assessed on admission and quarterly for the potential to wander away from the facility. If the resident is deemed at risk for wandering, a Wanderguard signaling device will be placed on their wrist or ankle after consent for the device is obtained from the family. If a resident is found to be missing from the building the person who is unable to locate the resident will institute the policy for elopement of a resident. Review of the Elopement policy dated 11/7/24 directed, in part, that when a resident is discovered missing, the following protocols will be followed: A head count of all residents in the building will be done. If the resident has not been signed out in the LOA book a thorough search of the building will begin and the charge nurse on the unit will announce over the intercom Code Silver and the Wing number. Staff will report to the wing number that was announced to receive the name of the resident. Staff assigned to each unit will check ALL resident rooms and bathrooms and all common areas as well as all locked areas and basement areas. At the time the search is instituted in the building, staff members will be assigned to begin a thorough search of the grounds. The following people will be notified once the grounds search is completed or within 20 minutes of the resident's noted disappearance: Administrator, DNS, Resident's responsible party, the provider, the Medical Director and the local police. Staff will be assigned to look for the resident in the area 1/4 to 1 mile from the facility and when the resident is located, the Charge Nurse will announce Code Silver all clear. 2. Resident #4's diagnoses included Alzheimer's disease with early onset, muscle weakness, lack of coordination and cognitive communication deficit. The Resident Care Plan dated 7/24/25 identified Resident #4 was an elopement risk and wandered aimlessly. Interventions directed to identify patterns of wandering and intervene as appropriate, distract the resident from wandering by offering pleasant diversions, structures activities, food, conversation, television and books, assess for fall risk and the resident utilized a Wanderguard (a security device utilized to prevent residents who are at risk for elopement from wandering) to the right lower extremity. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen indicating Resident #4 was alert and oriented to person, place, and time and required supervision assistance for bed mobility, transfers and ambulating. The nurse's note dated 8/22/25 identified that at 6:55 PM the 3-11PM Nursing Supervisor, Registered Nurse (RN) #2, was in the front of the building and observed Resident #4 running past the front porch on the asphalt and when Resident #4 looked backwards, Resident #4 subsequently fell on his/her left side. The note indicated Resident #4 was bleeding from the left side of the head and around the left eye and an abrasion (superficial injury caused by scraping or rubbing) was noted above the left eye. The note identified 911 was called, the Medical Director (MD #1) was contacted and in agreement with transferring Resident #4 to the hospital for further evaluation. The note identified the wanderguard on Resident #4's ankle was intact and functioning appropriately. The hospital Emergency Department (ED) note dated 8/22/25 identified Resident had head lacerations (cuts in the skin) around the left eye and was complaining of significant left thumb pain. The x-ray of the left thumb was negative for a fracture and the head CT (computed tomography) scan results identified a two (2) millimeter left frontal subdural hematoma (a collection of blood that accumulates near the brain) and small subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover/protect it) in the left frontal lobe as well as a nondisplaced fracture through the left frontal sinus and posterior wall of the sinus and a left periorbital (tissue surrounding the eye and eyelid) hematoma. The Facility Summary Report dated 8/25/25 in follow-up to the 8/22/25 incident identified Resident #4 was able to exit the facility by way of a Wanderguard alarmed door that was not closed and latched completely, reporting the door system and Wanderguard did alarm after Resident #4 exited the door. Interview with the Director of Nursing (DON) on 9/2/25 at 3:25 PM identified she viewed security footage after the incident which showed a nurse aide, Nurse Aide (NA) #11, going through the alarmed doors onto Wing-1 from the kitchen area and she could see the door bounced and did not close completely and once NA #11 went through the doors, he did not ensure the door was completely closed before walking away. The camera footage identified a few seconds after NA #11 entered the unit, Resident #4 exited his/her room, looked down the hall and then exited the unit through the double doors that were not completely shut and was able to then exit the building through a slider door which exited into the parking lot. The DON identified once Resident #4 went through the double doors out of the unit, the doors appeared to shut, the Wanderguard alarm started going off, and she stated although NA #5 responded, by the time NA #5 deactivated the alarm, Resident #4 was already about seventy (70) feet into the parking lot. The DON explained when NA #5 approached the sliding doors and called Resident #4's name, Resident #4 looked back, continued running and then subsequently fell forwards onto the ground. The DON identified NA #11 should have ensured the doors closed completely behind him and the light turned red indicating the doors were locked. Interview with nurse aide, Nurse Aide (NA) #11, on 9/3/25 at 11:54 AM identified on 8/22/25 he entered Wing-1 through the double doors after bringing the trash out. NA #11 stated although he thought the door shut all the way, he did not hear the lock engage and did not check the light to ensure it turned red, which would indicate the door was locked. NA #11 identified he turned left down the hall and as he approached the nurse's station, he heard the door start alarming, so he turned around and as he approached the double doors, NA #5 was already at the door entering the code into the keypad to turn off the alarm. NA #11 explained once NA #5 entered the code, they realized the Wanderguard alarm was also going off, so they disengaged it, went through the double doors and ran to the slider door where they observed Resident #4 in the parking lot near the front porch. NA #11 reported prior to the 8/22/25 incident although he was unaware of any previous issues with the double doors, he should have ensured the doors locked prior to walking away. Interview with the Director of Maintenance on 9/4/25 at 11:45 AM identified there have been issues with the Wing-1 double doors (which are fire doors) since September 2024, reporting that the doors are opened and closed at least 500 times per day and the hardware was not meant for that, explaining every time the door slams, it loosens the hardware, they adjust it and the door will work normally for a few days and then will start to not close again and he has communicated his concerns with the owners. The Director of Maintenance explained the double doors have always been timed with a delay of thirty (30) seconds before they alarm when the door was not shut completely and he had no service records from outside companies coming to inspect the doors and it was the owner's responsibility to call them. Interview with NA #5 on 9/4/25 at 2:34 PM identified there had been ongoing issues with the Wing-1 double doors, reporting they often did not shut completely, and the alarms would go off numerous times per shift. Interview with Owner #1 on 9/4/25 at 3:06 PM identified although there have been ongoing issues with the Wing-1 double doors, the facility has not had a vendor come in to inspect the door thus far. Review of the Accident and Injury policy dated 10/10/23 directed, in part, that the facility is responsible to ensure the safety of the residents and prevent possible accidents and injuries. 3. Resident #5's diagnoses included dementia with behavioral disturbances, Parkinson's disease (a movement disorder of the central nervous system that worsens over time) and osteoarthritis (a joint disease that causes pain, stiffness and swelling of the affected joints). A physician's order dated 3/4/24 directed to transfer Resident #5 with an assist of two (2) utilizing a mechanical lift. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) indicating Resident #5 rarely made decision regarding tasks of daily life and was dependent on staff assistance for bed mobility and transfers. The Resident Care Plan dated 8/21/25 identified Resident #5 had impaired physical mobility. Interventions directed to provide two (2) person assistance for transfers with the Hoyer (mechanical) lift and following therapy recommendations. The nurse's note dated 8/24/25 at 8:00 PM and written by the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, identified a nurse aide, Nurse Aide (NA) #11, reported to her Resident #5 was complaining of left knee and left hip pain. The note identified that upon assessment, Resident #5 was noted to complain of pain with light touch, and minimal movement and had the pain since he/she was put to bed the previous night (8/23/25) and was unable to recall if he/she had sustained a fall. The note identified an eight (8) centimeter (cm) by 8.5 cm blueish bruise was present on the left shin area. The note indicated Resident#5's family and provider were notified, and an order was obtained to transfer Resident #5 to the Emergency Department (ED) for evaluation at 6:55 PM accompanied by Emergency Medical Services (EMS). The hospital Emergency Department note dated 8/24/25 identified Resident #5 arrived appearing uncomfortable but in no acute distress, with an obvious deformity of the left lower extremity, swelling at the proximal femur (upper part of the thigh bone closer to the hip joint), and internal rotation and shortening of the leg suggesting an open fracture. The note identified an x-ray of the left femur was obtained and resulted with a significant left femur periprosthetic fracture (a fracture occurring around a previously implanted artificial hip joint) and per the Orthopedic physician Resident #5 was transferred to a trauma center, where surgery was to be performed (Open Reduction and Internal Fixation) to the left femur on 8/25/25. Review of the facility Summary Report dated 8/29/25 in follow-up to the 8/24/25 incident identified through the investigation it was identified an agency nurse aide, NA #1, transferred Resident #5 back to bed on 8/23/25 by bear hugging Resident #5, NA #1 pulled Resident #5 up by the pants, was able to pick Resident #5 up and then place him/her back to bed. The report identified the nurse aide assignment sheet listed Resident #5 as requiring a Hoyer lift for transfers. Review of the Nurse Aide Care Card (undated) identified Resident #5 required the assistance of two (2) staff and a Hoyer lift for all transfers. Interview with NA #1 on 9/3/25 at 9:38 AM identified on 8/23/25 she brought Resident #5 into his/her room to put Resident #5 to bed and although she noticed a Hoyer pad in the room, she was not aware Resident #5 required two (2) staff and a Hoyer-lift for transfers because she did not look at the assignment sheet or the care card first. NA #1 explained she locked the wheelchair, stood facing Resident #5, assisted Resident #5 to a standing position without another staff member's assistance and without the use of a gait belt, bear hugged Resident #5 using both hands to hold onto the back of Resident #5's pants and then she quickly pivoted Resident #5, sat Resident down on the bed, kept one hand on the back of the pants and used the other arm to pull the legs up onto the bed into a laying position and Resident #5 did not appear to be in any pain after the transfer. NA #1 stated when she arrived at the facility for her shift several days later (8/25/25) staff alerted her she put Resident #5 in his/her roommate's bed mixing up the residents and she did not look at their name bracelets. NA #1 identified prior to caring for any resident, she should ensure she has the correct resident and check the resident's care card prior to providing any care to a resident for safe practices. Interview with the Medical Director (MD #1) on 9/3/25 at 9:51 AM identified for Resident #5 to have sustained a periprosthetic fracture of the left femur, forceful twisting, a fall or some type of trauma would have had to occur and torque, or impact would be required. MD #1 identified it is unlikely for a resident who required a Hoyer lift for transfer, was non-ambulatory and could not bear his/her own weight, was able to turn and pivot his/her feet independently to back up to the bed safely while NA #1 was holding Resident #5 up as she reported. MD #1 identified NA #1 should have followed the physician's order directing two (person assistance and a Hoyer lift for transfers, stating if that had been followed it could have prevented Resident #5's injury. Interview with NA #12 on 9/3/25 at 10:24 AM identified she worked alongside NA #1 on 8/23/25 on the 3-11PM shift and explained NA #1 did not ask for her assistance with Resident #5 that night. NA #12 indicated the next time she worked with NA #1 (on 8/25/25) she communicated to NA #1 Resident #5 sustained an injury and NA #1 was the last person to transfer Resident #5 on 8/23/25. NA #12 identified NA #1 reported to her that she, NA #1, did not know Resident #5 utilized a Hoyer lift and admitted to her she transferred Resident #5 by herself. Interview with the 11PM-7AM Nursing Supervisor, RN #3 on 9/3/25 at 1:18 PM identified she cared for Resident #5 on 8/23/25 into 8/24/25, and she immediately noticed upon arriving for her shift Resident #5 was in Resident #6's bed and Resident #6 was in Resident #5's bed but that they appeared comfortable, so she left them. Interview with the Director of Nursing (DON) on 9/3/25 at 10:45 AM identified through her investigation, NA #1 was the last person to transfer Resident #5 prior to him/her complaining of pain. The DON explained NA #1 admitted to transferring Resident #5 independently. The DON identified all nurse aides are expected to verify who each resident is, as well as check their care card prior to providing any care to a resident, explaining NA #1 should not have transferred Resident #5 independently and if she had requested the assistance of a second staff and followed the care card, it could have prevented Resident #5's injury. Review of the Resident Transfer and Ambulation policy (undated) directed, in part, that residents will be assessed on admission for transfer and ambulation status and staff will use appropriate assistive devices and techniques as indicated. Safe transfers and ambulation require the participation of trained staff using proper body mechanics, equipment and fall-prevention measures. Staff should apply a gait belt for all transfers unless contraindicated and use proper body mechanics. Although requested, a facility policy for resident Care Cards was not provided.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #7) who were reviewed for an allegation of abuse, the facility failed to ensure the resident was free from physical abuse when the resident's behavior escalated and a staff member pushed the resident to the floor resulting in a fracture. The findings include:Resident #7's diagnoses included vascular dementia with psychosis (condition where cognitive decline caused by damage to blood vessels in the brain is accompanied by psychotic symptoms) and major depressive disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) indicating Resident #7 rarely made decision regarding tasks of daily life and required moderate assistance with transfers and ambulating. The Resident Care Plan dated 7/29/25 identified Resident #7 has impaired cognition or impaired thought processes related to dementia. Interventions directed to reorient and supervise the resident as needed and provide the resident with necessary cues and stop care if the resident becomes agitated. The nurse's note dated 8/29/25 at 6:15 PM identified the Director of Nursing (DON) was called to the dining room regarding reports that Resident #7 lunged at a staff member, Licensed Practical Nurse (LPN) #4, with a fork and then Resident #7 fell. The note indicated Resident #7 refused to be assessed for injuries, was removed from the dining room and supervised by the DON until Emergency Medical Technicians (EMTs) arrived to transfer Resident #7 to the hospital for further evaluation. The hospital Emergency Department (ED) note dated 8/29/25 identified Resident #7 was brought to the ED for increased agitation and altered mental status after Resident #7 tried to poke a staff member with a fork resulting with Resident #7 falling. The note identified Resident #7 had swelling, tenderness and deformity noted to the right wrist, an x-ray was obtained and resulted with fractures to the right distal (furthest from the body's center/midline) radius and ulna (the bones of the lower arm between the elbow and the wrist) which required reduction (a medical procedure to realign the bones into the correct anatomical position) and the arm was splinted. The note also identified Resident #7 was found to have a Urinary Tract Infection (UTI), was started on antibiotics and admitted to the hospital. Interview and review of the video surveillance of the 8/29/25 incident with the DON on 9/3/25 at 12:45 PM identified around 5:54 PM Resident #7 was observed to be sitting at a table in the front corner of the dining room when Resident #7 stood up and LPN #4 came walking towards him/her. The DON indicated Resident #7 was noted to have a fork in his/her right hand down by their side at hip level. The DON explained LPN #4 appeared to [NAME] forward towards Resident #7, LPN #4 could be seen swinging at Resident #7 multiple times and when Resident #7 fell to the floor, LPN #4 leaves and walks out of the dining room. The DON identified Resident #7 was not observed with his/her right arm extending the fork towards LPN #4 and the fork was not raised higher than Resident #7's naval. The DON identified the cameras have no sound and LPN #4 reported to her Resident #7 was cursing so he approached Resident #7 to request he/she stop, the incident took place and LPN #4 subsequently said he pushed Resident #7 in self-defense. The DON explained LPN #7 ws suspended pending investigation and LPN #4 should never have approached Resident #7 knowing Resident #7 was agitated and should have backed up if he thought Resident #7 was threatening him with the fork and not continued to walk towards Resident #7 and he should not have pushed or made contact with Resident #7. The DON identified had LPN #4 not resigned following the incident, they would have terminated his employment. Interview with NA #12 on 9/3/25 at 1:05 PM identified Resident #7 had been confused and argumentative prior to going to the dining room for dinner on 8/29/25. NA #12 explained just prior to the incident Resident #7 had been swearing and making inappropriate comments and LPN #4 requested that he/she stop swearing at which time LPN #4 and Resident #7 started arguing back and forth. NA #12 identified Resident #7 then stood up with a fork in his/her hand and LPN #4 started walking towards Resident #7 and jerked his body towards Resident #7 in a threatening manner and stated, go ahead. NA #12 identified although Resident #7 did not raise the fork up towards LPN #4, LPN #4 pushed Resident #7 to the floor and then walked out of the room. Interview with LPN #4 on 9/4/25 at 9:41 AM identified that on 8/29/25 he was in the dining room administering another resident medication when Resident #7 started swearing, he asked Resident #7 to stop swearing and told him/her to relax and Resident #7 then stood up at the table with a fork in his/her hand and threatened to stab him with the fork. LPN #4 denied arguing with Resident #7 however he did continue to walk towards Resident #7 and Resident #7 lunged at him with the fork, lost his/her balance and then fell on the floor. LPN #4 was unable to explain why he engaged with Resident #7 when he knew Resident #7 was agitated instead of requesting additional assistance. Review of the Abuse and Neglect policy dated 9/2021 directed, in part, that residents have the right to be free from abuse. Residents will not be subjected to abuse by anyone, including, but not limited to facility staff.

Based on review of facility documentation, facility policy and interviews for five (5) sampled Nurse Aides (NA #6, #7, #8, #9 and #10), the facility failed to ensure the nurse aides received at least twelve (12) hours of in-service training annually. The findings include:Review of NA #6, #7, #8, #9 and #10's personnel files failed to reflect documentation the nurse aides received annual in-service training. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on [DATE] at 10:00 AM identified the facility has been without a Staff Development Coordinator since [DATE], stating she was terminated for not completing requirements of the job. They reported annual in-service training had not been completed since at least 12/2024, and they could not locate in-service records from the past year. They identified that nurse aide in-service training was to be completed on orientation and then annually. Review of the facility Training Policy directed, in part, that all employees are required to complete annual in-service education to comply with state and federal regulations and ensure they remain up to date with best practices. Job specific training is based on their roles, for nurses and aides medication administration, wound care, care planning, CPR/first aid, and infection control practices.

Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for 1 of 1 sampled resident reviewed for pain (Resident #4) , the facility failed to follow Resident #4's plan of care for bed mobility, and for 1 of 1 sampled residents reviewed for range of motion (Resident #7), the facility failed to ensure nails were groomed in a manner to prevent skin breakdown and for 2 of 5 sampled residents reviewed for antipsychotic medication (Resident #25 and Resident #35), the facility failed to follow physician orders [REDACTED]. The findings include: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum (MDS) data set [DATE] identified Resident #4 with intact cognition and requiring extensive assistance of 2 staff for bed mobility, dressing, and personal hygiene and dependent on staff for transfers and toileting. The Resident Care Plan (RCP) dated 6/21/18 identified Resident #4 as having a self-care performance deficit related to chronic right leg pain and right side weakness after a stroke. Interventions included extensive assist of 2 staff to turn and reposition in bed. A nurses note dated 6/30/18 at 7:10 PM identified Resident #4 was involved in an incident with a NA. The nurses note further identified that all parties were notified. (No other details were provided in the nurses note) Review of a Reportable Event form dated 6/30/18 identified Resident #4 stated NA #1 pushed him/her hard and hurt him/her, resulting in knee pain when he/she was being turned by NA #1 who was providing incontinence care. The investigation follow up dated 7/2/18 identified Resident #4 was sent to the Emergency Department and X-rays were negative for a fracture. The care plan and the care card identified Resident #4 was an assist of 2 for care. Abuse was unsubstantiated. NA #1 was terminated for not following the plan of care for utilizing 2 staff members to turn Resident # 4 in bed. Interview with the assistant administrator on 9/14/18 at 1:30 PM identified he/she was the acting administrator on 6/30/18. He/she further identified, after the incident was investigated the facility determined that it was not abuse but the NA #1 did not follow the plan of care to utilize 2 staff members to turn the resident. He/she further identified NA #1 was terminated by the facility for failing to provide care to Resident #4 per the plan of care for not utilizing 2 staff members to turn Resident #4. Interview with NA #1 on 9/14/18 at 2:00 PM identified he/she turned Resident #4 without the benefit of assistance by another staff person because he/she thought the resident care card identified Resident #4 was an assist of one for turning. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Orthotic wearing schedule dated 2/14/17 directed to apply a right air resting hand splint, on with morning care, off with evening care. The wearing schedule further identified to store the orthotic splint, between uses, in the top dresser drawer and to wash the orthotic cover at least monthly, air dry, and hand wash only. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The physician order [REDACTED].#7's right hand, due to build up of bacteria and sweat every night. A quarterly Minimum (MDS) data set [DATE] identified Resident #7 had severely impaired cognition, required total assistance with activities of daily living, had functional limitation in range of motion to the upper extremity (shoulder, elbow, wrist, hand) on 1 side. The care plan dated 7/21/18 identified Resident #7 had a right hand contracture due to a [MEDICAL CONDITION]. Interventions included for Resident #7 to allow staff to don a right elbow extension splint at hours of sleep and remove at morning care but failed to include the physician order [REDACTED]. Observation of Resident #7 on 9/13/18 at 2:23 PM identified Resident #7 sitting in a custom wheelchair in the recreation room, without the benefit of a right hand splint and/or any device to the right hand. The NA care card directed a right resting hand splint on with morning care, off with evening care. Visual and/or a bedside kardex directed carrot device to the right hand. Remove to check skin integrity and to wash and dry completely twice daily and as needed. Interview with NA #2 on 9/13/18 at 2:28 PM identified that NA #2 did not remember to apply the right resting hand splint after completing morning care. Interview with LPN #1 on 9/13/18 at 2:35 PM identified that Resident #7 was to have a splint in his/her right hand or the NA can use a carrot. The carrot was in Resident #7's dresser drawer. Interview with Occupational Therapist (OT) #1 on 9/13/18 at 2:38 PM identified that Resident #7 was to have the air resting hand splint on after morning care and off at evening care. Resident #7 should have the hand splint in place, however NA could use the carrot splint if they needed to wash the air hand splint. Observation of Resident #7 ' s right palm with OT #1 at the time of the interview identified an indentation measuring approximately 0.5 cm with open area measuring approximately 0.1 by 0.1 by 0.1 cm with scant amount of clear drainage. The right hand middle digit fingernail was approximately 1.5 cm long with jagged edges and when contracted, alligned with the indentation and skin breakdown. Interview with RN #1 on 9/13/18 at 2:49 PM identified Resident #7's fingernails were to be trimmed every Friday on his/her shower day. Interview and observation of Resident #7 with LPN #1 on 9/13/18 at 2:49 PM identified that LPN #1 cut Resident #7 ' s fingernails 2 weeks ago with the NA. Resident #7's right hand fingernails were longer then the left hand fingernails especially the middle digit fingernail, and middle digit fingernail was digging into Resident #7's right palm. LPN #1 further identified that Resident #7 had the same problem in the past. Subsequent to surveyor inquiry the physician was updated on 9/13/18 at 3:45 PM. physician's orders [REDACTED]. Nurses notes dated 9/13/18 at 3:08 PM identified that Resident #7 was noted to not have the right hand carrot or palm splint on during the shift. The right middle finger nail was not properly trimmed. The nurses note further identified Resident #35's palm was moist and had an indentation and/or open area measuring 10 mm by 1 mm by 1mm. OT progress note dated 9/13/18 identified Resident #35 was referred for OT services due to a new onset of a missing right air resting hand splint. The splinting vendor was contacted for replacement. OT note further identified that Resident #35 was identified with current skin breakdown to right palm presumably caused by elongated middle digit fingernail. OT to assess appropriate fit of replacement splint upon delivery when cleared by nursing due to impaired skin integrity. 3. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 12/29/17 identified Resident #25 used [MEDICAL CONDITION] medications related to [DIAGNOSES REDACTED]. Interventions included to monitor and/or document and/or report as needed any adverse reactions of [MEDICAL CONDITION] medication The 5-day Minimum Data Set ((MDS) dated [DATE] identified Resident #25 had no cognitive impairment, required extensive assistance with transfers, locomotion on the unit and limited assistance with walking in the room. The MDS further identified Resident #25 received [MEDICAL CONDITION] medication. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Interview and clinical record review the with DNS on 9/14/18 at 2:30 PM, failed to provide documentation that orthostatic blood pressures were consistently monitored as per physician order. Subsequent to surveyor inquiry on 9/14/18 at 5:09PM, the physician was notified and a new order was obtained to discontinue orthostatic blood pressure monthly due to resident refusal (however no documentation was provided regarding Resident # 25's previous refusals to have orthostatic blood pressure monitored). 4. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified Resident #35 had severely impaired cognition, was independent with activities of daily living, and received antipsychotic medication. The care plan dated 5/29/18 identified Resident #35 used [MEDICAL CONDITION] medications related to a [DIAGNOSES REDACTED]. The care plan further identified a problem with having a potential for falls related to chronic back pain, and syncopal episode while outside, with the last fall dated 8/20/18. Interventions directed independent ambulation with rolling walker. A psychiatry progress note dated 7/2/18 identified that Resident #35 was observed with periods of increased confusion, disruptive behavior toward others (in and out of rooms) due to increased confusion and paranoia. Resident #35 exhibited increased confusion later in the day, and was intrusive and disruptive. Recommendations directed to begin Quetiapine 25 mg by mouth, once daily at 5:00 PM, and re-assess in 2 weeks. Family in agreement with this plan. A nurses note dated 7/14/18 at 5:35 PM identified that the physician was notified of psychiatry recommendations for Quetiapine 25 mg, give 1 tablet by mouth in the evening related to [MEDICAL CONDITION] with behavioral disturbance (12 days after psychiatry recommendations). A physician's orders [REDACTED]. Interview and clinical record review with DNS on 9/17/18 at 2:20 PM identified that recommendations were placed in the physician's book and/or binder, however the physician was on vacation. In addition, the DNS indicated that there was a covering physician, however the covering physician did not review the recommendations placed in the book and/or binder.

Based on clinical record review, review of facility policy and procedures and interviews for one of two sampled residents reviewed for death, (R# 64), the facility failed to notify the physician of a change in condition in a timely manner and as per facility policy. The findings include: Resident #64 was admitted on [DATE] with [DIAGNOSES REDACTED]. A 72- hour admission note dated 8/24/12 (3-11) identified the resident stated he/she had no BM's since before 8/20/12. At 4:45 PM, MOM 30 cc was administered with no results. Nurse's note dated 8/24/12 identified the resident's abdomen as hard, non-tender to touch, positive bowel sounds on all four quadrants. physician's orders [REDACTED]. more shifts consecutively. Review of the MAR indicated [REDACTED]. On 8/25/12 [MEDICATION NAME] 10 mg suppository was administered with no results. MOM was administered on 8/29/12 with no results and on 8/31/12 [MEDICATION NAME] was administered with no results and on 9/3/12, MOM was administered with no results. Review of nurse's notes dated 8/29, 8/31, 9/02, and 9/4/12 identified episodes of nausea and vomiting with [MEDICATION NAME] administered. Nurse's note dated 9/04/12 at 3:45 PM identified resident's vomiting and constipation reported to MD, abdominal X-ray ordered. Results of Abdominal 1 V/KUB indicates nonspecific gas pattern with modest to moderate constipation. Review of the MAR failed to reflect that MOM was administered until 9/05/12 with results noted as a large stool. Nurse's note dated 9/6/12 at 2:45 PM identified resident as lethargic, clear liquid diet continued and complaining of upper stomach discomfort and no BM on the shift. Resident requesting to go to ER for evaluation. Resident transported to ER at 10:30 AM. A hospital discharge summary identified the resident was admitted on [DATE] and discharged on [DATE]. Admitting primary [DIAGNOSES REDACTED]. Review of MAR from 8/28/12 to 9/04/12 (22 shifts), identified the resident with no bowel movements, with no bowel regimen implementation as per physician orders [REDACTED]. On 9/04/12 the resident was noted with a large stool. Interview with the DON on 1/07/12 at 12:45 PM identified that the physician should be notified when the resident does not have a bowel movement after [MEDICATION NAME] suppository is administered. Interview with MD#1 on 1/07/12 at 2:15 PM identified that the bowel regime is individualized and dependent on the resident and indicated he did not recall whether he was notified when the resident failed to have a BM in 3 days and indicated he would have to review the clinical record. Although physician orders [REDACTED]. and physician progress notes [REDACTED]. Review of the facility's Bowel Regime policy identifies that on the second day of no bowel movement the resident will be given 30 cc milk of MOM on the 3-11 shift. If there is no bowel movement by the following day ( no bowel movement in 3 days) a second dose of 30 cc of MOM will be administered on the 3-11 shift. If there is no bowel movement by the following morning at 6 am, a [MEDICATION NAME] suppository will be administered by the 11-7 nurse. If there are no results later that morning from the suppository then a Fleet enema will be given on the 7-3 shift. Review of the clinical record failed to reflect that the facility implemented their policy.

Based on clinical record review, review of facility policy and procedures and interviews for one of two sampled residents reviewed for death, (R# 64), the facility failed to provide care and services to maintain the highest practical physical and mental well-being. The findings include: Resident #64 was admitted on [DATE] with [DIAGNOSES REDACTED]. A 72- hour admission note dated 8/24/12 (3-11) identified the resident stated he/she had no BM's since before 8/20/12. At 4:45 PM, MOM 30 cc was administered with no results. Nurse's note dated 8/24/12 identified the resident's abdomen as hard, non-tender to touch, positive bowel sounds on all four quadrants. physician's orders [REDACTED]. more shifts consecutively. Review of the MAR indicated [REDACTED]. On 8/25/12 [MEDICATION NAME] 10 mg suppository was administered with no results. MOM was administered on 8/29/12 with no results and on 8/31/12 [MEDICATION NAME] was administered with no results and on 9/3/12, MOM was administered with no results. Review of nurse's notes dated 8/29, 8/31, 9/02, and 9/4/12 identified episodes of nausea and vomiting with [MEDICATION NAME] administered. Nurse's note dated 9/04/12 at 3:45 PM identified resident's vomiting and constipation reported to MD, abdominal X-ray ordered. Results of Abdominal 1 V/KUB indicates nonspecific gas pattern with modest to moderate constipation. Review of the MAR failed to reflect that MOM was administered until 9/05/12 with results noted as a large stool. Nurse's note dated 9/6/12 at 2:45 PM identified resident as lethargic, clear liquid diet continued and complaining of upper stomach discomfort and no BM on the shift. Resident requesting to go to ER for evaluation. Resident transported to ER at 10:30 AM. A hospital discharge summary identified the resident was admitted on [DATE] and discharged on [DATE]. Admitting primary [DIAGNOSES REDACTED]. Review of MAR from 8/28/12 to 9/04/12 (22 shifts), identified the resident with no bowel movements, with no bowel regimen implementation as per physician orders [REDACTED]. On 9/04/12 the resident was noted with a large stool. Interview with the DON on 1/07/12 at 12:45 PM identified that the physician should be notified when the resident does not have a bowel movement after [MEDICATION NAME] suppository is administered. Interview with MD#1 on 1/07/12 at 2:15 PM identified that the bowel regime is individualized and dependent on the resident and indicated he did not recall whether he was notified when the resident failed to have a BM in 3 days and indicated he would have to review the clinical record. Although physician orders [REDACTED]. and physician progress notes [REDACTED]. Review of the facility's Bowel Regime policy identifies that on the second day of no bowel movement the resident will be given 30 cc milk of MOM on the 3-11 shift. If there is no bowel movement by the following day ( no bowel movement in 3 days) a second dose of 30 cc of MOM will be administered on the 3-11 shift. If there is no bowel movement by the following morning at 6 am, a [MEDICATION NAME] suppository will be administered by the 11-7 nurse. If there are no results later that morning from the suppository then a Fleet enema will be given on the 7-3 shift. Review of the clinical record failed to reflect that the facility implemented their policy.

Based on clinical record review, observation and interviews for two of three sampled residents reviewed for accidents (R#13, R#32) the facility failed to implement measures to prevent an accident. The findings include: 1. Resident #13 was admitted with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated R#13 as moderately impaired, with short and long term memory deficits and requiring extensive assistance of 2 persons with transfers, and extensive assistance of one person for hygiene. In addition the resident exhibited resistive behaviors during care. A RCP dated 9/12 identified the resident with combative behaviors with interventions to apply when R#13 exhibited combative or resistive behaviors. According to facility documentation/investigation dated 10/14/12 identified that NA#1 was providing care and put R#13's pants on with R#13 exhibiting resistive behaviors. NA#1 and NA#2 placed R#13 transferred the resident via Hoyer into his/her custom wheelchair. R#13 was then transported to the dining room for dinner. At approximately 5:45 PM, R#13 complained of left knee pain and was evaluated by LPN#2 and the RN#1 at which time there was no bruising, redness or swelling. R#13 was medicated for pain with good effect. At approximately 8;00 PM R#13 was provided evening care by NA#1 at which time R#13's knee was noted to have a quarter sized bruise on his/her left knee. Subsequent assessments identified R#13's knee continued to exhibit bruising and swelling. An X-ray was obtained on 10/15/12 which identified a left knee patellar fracture with age indeterminate. R#13 was evaluated in the emergency department (ED) at Facility #2 and readmitted to Facility #1 with recommendations to maintain the knee immobilizer, treat symptoms of pain and follow up with orthopedics. A consultation with orthopedics dated 10/19/12 indicated the left knee injury was from a direct blow or resisted contraction bending. 2. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A RCP dated 10/26/12 identified a potential for falls related to decreased mobility. Interventions included to transfer with sling with the assistance of two staff members to the adaptive wheelchair. A nurse's narrative note dated 12/29/12 identified that R#32 slid out of the customized wheelchair at 7:30 PM and the nurse aide lowered the resident to the floor without injury. The note further reflected that the resident was transferred to the bed with assistance of two staff members. Interview with NA#6 on 1/7/13 at 2:00 PM identified she washed the resident's upper body while he/she was sitting in the customized wheelchair. NA#6 indicated that she then removed the lap tray to wash the resident's bottom, the resident became stiff and she had to lower R#32 to the floor. Interview with the DNS on 1/07/13 at 2:30 PM identified that the nurse aide had acted inappropriately in washing the resident in the wheelchair and removing the lap tray without assistance.

Based on clinical record review, review of facility policy, review of the hospital clinical record and interviews for one sampled resident (Resident #52) who had a history of [REDACTED]. The findings include: Resident #52's [DIAGNOSES REDACTED]. The nutrition and hydration assessment dated [DATE] identified that Resident #52 was a moderate nutritional risk and with daily fluid requirements of 1800 cubic centimeters (cc). The physician's orders [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #52 had memory deficits both short and long term, moderate cognitive impairments, was independent with eating, and with no dehydration noted in the past seven days. The Resident Care Plan (RCP) dated 5/4/10 identified a potential for alteration in nutrition and/or hydration related to [MEDICAL CONDITIONS] and diuretic use. Interventions directed dietary and nursing to monitor food and fluid intake, notify the physician per policy and proceed with steps per the Intake & Output (I & O) protocol. Review of the BMP blood work results dated 3/26/10 identified the Blood Urea Nitrogen (BUN) was 46 mg/dL (normal 7-28 mg/dL) and the serum Creatinine was 1.6 md/dL (normal 0.3-1.2 mg/dL). The BMP results dated 6/15/10 identified that the BUN was 74 mg/dL, the serum Creatinine was 1.9, and the results had been faxed to the physician. Review of the flow sheet records from 6/1/10 through 7/9/10 (thirty-nine days) identified that Resident #52's average fluid intake with meals was 25% and had exceeded 50% at only four meals. Review of the clinical record from 6/1/10 through 7/9/10 failed to reflect that Resident #52 had been monitored and/or assessed for signs and symptoms of dehydration, i.e. skin turgor and quantitative intake and output measurements. The nurse's note dated 7/9/10 at 7:00 PM identified that Resident #52 appeared weak and had vomited a large amount of bile colored liquid. The 8:30 PM note identified that the resident was found listless, eyes were sunken, the voice was very weak and the resident's mouth was dry. Vital signs identified a blood pressure was 112/65, pulse 94 to 100 beats per minute, respirations 16 breaths per minute, temperature 97.6 degrees Fahrenheit and a pulse oximetry of 94% on room air. Subsequent to physician notification Resident #52 was transferred to the emergency department and admitted to the hospital. Review of the emergency department priority/follow up report dated 7/10/10 identified that the chief complaint was dehydration and that the resident presented with a decreased oral intake, vomiting, decreased activity and altered mental status. The physical examination identified that the resident had a dehydrated appearance, was lethargic, eyes were sunken and the mucous membranes were dry. Initial blood work identified that the BUN was 99 and the Creatinine was 2.8. The impression was dehydration, [MEDICAL CONDITION] and urinary tract infection. The hospital discharge summary dated 7/13/10 identified that the discharge [DIAGNOSES REDACTED]. The summary further identified that the resident's condition improved with the administration of intravenous fluids and Resident #52 returned to the nursing facility on 7/13/10. Review of the facility's Intake and Output policy directs that one of the conditions that necessitate the need for I & O is poor oral intake. Review of the clinical record with the Assistant Director of Nursing Services (ADNS) on 9/1/10 at 10:30 AM and 9/2/10 at 10:00 AM identified that on 6/15/10 when the laboratory results were elevated from the results of 3/26/10, no interventions were implemented to address the resident's risk of dehydration. Interview with Resident #52's attending physician on 9/2/10 at 11:00 AM identified that intravenous fluids should probably have been initiated to avoid the dehydration that occurred on 7/10/10.